** Cost ** |
Premium and Other Important Information |
$0 monthly plan premium in addition to your monthly Medicare Part B premium. |
Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However some people will pay higher Part B and Part D premiums because of their yearly income (over $85 000 for singles $170 000 for married couples). For more information about Part B and Part D premiums based on income call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may also call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. |
This plan covers all Medicare-covered preventive services with zero cost sharing. |
$3 400 out-of-pocket limit. |
This limit includes only Medicare-covered services. |
** Doctor and Hospital Choice ** |
Doctor and Hospital Choice |
You must go to network doctors specialists and hospitals. |
Referral required for network hospitals and specialists (for certain benefits). |
Plan covers you when you travel in the U.S. |
** Extra Benefits ** |
Prescription Drugs |
$10 to $45 copay for Part B-covered chemotherapy drugs and other Part B-covered drugs. |
$0 copay for home infusion drugs that would normally be covered under Part D. This cost-sharing amount will also cover the supplies and services associated with home infusion of these drugs. |
This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at www.kp.org/seniorrx on the web. |
Different out-of-pocket costs may apply for people who - have limited incomes
- live in long term care facilities or
- have access to Indian/Tribal/Urban (Indian Health Service).
|
Your in-network prescription coverage may be limited to the plan's service area. This means that if you travel outside the service area you may have to pay the full cost of your prescription. In certain emergencies your drugs will be covered if you get them at an out-of-network-pharmacy although you may have to pay additional charges. Contact the plan for details. |
Total yearly drug costs are the total drug costs paid by both you and the plan. |
Your provider must get prior authorization from Kaiser Permanente Senior Advantage Inland Empire (HMO) for certain drugs. |
You must go to certain pharmacies for a very limited number of drugs due to special handling provider coordination or patient education requirements that cannot be met by most pharmacies in your network. These drugs are listed on the plan's website formulary printed materials as well as on the Medicare Prescription Drug Plan Finder on Medicare.gov. |
If the actual cost of a drug is less than the normal cost-sharing amount for that drug you will pay the actual cost not the higher cost-sharing amount. |
If you request a formulary exception for a drug and Kaiser Permanente Senior Advantage Inland Empire (HMO) approves the exception you will pay Tier 2: Brand Drugs cost sharing for that drug. |
$0 deductible. |
You pay the following until total yearly drug costs reach $2 840: |
Tier 1: Generic Drugs |
Tier 2: Brand Drugs |
Tier 3: Specialty Tier Drugs |
$10 copay for a one-month (30-day) supply of drugs in this tier |
$45 copay for a one-month (30-day) supply of drugs in this tier |
25% coinsurance for a one-month (30-day) supply of drugs in this tier |
$30 copay for a 100-day supply of drugs in this tier |
$135 copay for a 100-day supply of drugs in this tier |
25% coinsurance for a 100-day supply of drugs in this tier |
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. |
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. |
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. |
Tier 1: Generic Drugs |
Tier 2: Brand Drugs |
Tier 3: Specialty Tier Drugs |
$10 copay for a one-month (31-day) supply of drugs in this tier |
$45 copay for a one-month (31-day) supply of drugs in this tier |
25% coinsurance for a one-month (31-day) supply of drugs in this tier |
Tier 1: Generic Drugs |
Tier 2: Brand Drugs |
Tier 3: Specialty Tier Drugs |
$10 copay for a one-month (30-day) supply of drugs in this tier |
$45 copay for a one-month (30-day) supply of drugs in this tier |
25% coinsurance for a one-month (30-day) supply of drugs in this tier |
$20 copay for a 100-day supply of drugs in this tier |
$90 copay for a 100-day supply of drugs in this tier |
25% coinsurance for a 100-day supply of drugs in this tier |
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. |
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. |
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. |
The plan covers all formulary generics (100% of formulary generic drugs) through the coverage gap. |
You pay the following: |
Tier 1: Generic Drugs |
$10 copay for a one-month (30-day) supply of all drugs covered in this tier |
$30 copay for a 100-day supply of all drugs covered in this tier |
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. |
Tier 1: Generic Drugs |
$10 copay for a one-month (31-day) supply of all drugs covered in this tier |
Tier 1: Generic Drugs |
$10 copay for a one-month (30-day) supply of all drugs covered in this tier |
$20 copay for a 100-day supply of all drugs covered in this tier |
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. |
After your total yearly drug costs reach $2 840 you receive limited coverage by the plan on certain drugs. You will also receive a discount on brand name drugs and generally pay no more than 93% of the plan's costs for generic drugs until your yearly out-of-pocket drug costs reach $4 550. |
After your yearly out-of-pocket drug costs reach $4 550 you pay the following: |
Tier 1: Generic Drugs |
Tier 2: Brand Drugs |
Tier 3: Specialty Tier Drugs |
$4 copay for drugs in this tier |
$12 copay for drugs in this tier |
$12 copay for drugs in this tier |
Plan drugs may be covered in special circumstances for instance illness while traveling outside of the plan's service area where there is no network pharmacy. You may have to pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy. In addition you will likely have to pay the pharmacy's full charge for the drug and submit documentation to receive reimbursement from Kaiser Permanente Senior Advantage Inland Empire (HMO). |
You will be reimbursed up to the full cost of the drug minus the following for drugs purchased out-of-network until total yearly drug costs reach $2 840: |
Tier 1: Generic Drugs |
Tier 2: Brand Drugs |
Tier 3: Specialty Tier Drugs |
$10 copay for a one-month (30-day) supply of drugs in this tier |
$45 copay for a one-month (30-day) supply of drugs in this tier |
25% coinsurance for a one-month (30-day) supply of drugs in this tier |
You will be reimbursed for these drugs purchased out-of-network up to the full cost of the drug minus the following: |
Tier 1: Generic Drugs |
Tier 2: Brand Drugs |
Tier 3: Specialty Tier Drugs |
$10 copay for a one-month (30-day) supply of all drugs covered in this tier |
You will be reimbursed up to 7% of the plan allowable cost for generic drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 550. |
You will be reimbursed up to 7% of the plan allowable cost for generic drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 550. |
You will be reimbursed up to the discounted price for brand name drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 550. |
You will be reimbursed up to the discounted price for brand name drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 550. |
After your yearly out-of-pocket drug costs reach $4 550 you will be reimbursed for drugs purchased out-of-network up to the full cost of the drug minus the following: |
Tier 1: Generic Drugs |
Tier 2: Brand Drugs |
Tier 3: Specialty Tier Drugs |
$4 copay for drugs in this tier |
$12 copay for drugs in this tier |
$12 copay for drugs in this tier |
Physical Exams |
Authorization rules may apply. |
$0 copay for routine exams. |
No plan coverage limit on the number of covered exams. |
$0 copay for the required Medicare-covered initial preventive physical exam and annual wellness visits. |
Separate Office Visit cost sharing of $15 may apply. |
Vision Services |
Authorization rules may apply. |
$0 copay for - one pair of eyeglasses or contact lenses after cataract surgery
|
up to 1 pair(s) of glasses every two years |
$0 to $15 copay for exams to diagnose and treat diseases and conditions of the eye. |
$0 copay for routine eye exams |
$100 plan coverage limit for eye wear every two years. |
Separate Office Visit cost sharing of $15 may apply. |
Dental Services |
Authorization rules may apply. |
In general preventive dental benefits (such as cleaning) not covered. However this plan covers preventive dental benefits for an extra cost (see 'Optional Benefits.') |
$15 copay for Medicare-covered dental benefits. |
** Important Information ** |
Premium and Other Important Information |
$0 monthly plan premium in addition to your monthly Medicare Part B premium. |
Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However some people will pay higher Part B and Part D premiums because of their yearly income (over $85 000 for singles $170 000 for married couples). For more information about Part B and Part D premiums based on income call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may also call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. |
This plan covers all Medicare-covered preventive services with zero cost sharing. |
$3 400 out-of-pocket limit. |
This limit includes only Medicare-covered services. |
Doctor and Hospital Choice |
You must go to network doctors specialists and hospitals. |
Referral required for network hospitals and specialists (for certain benefits). |
Plan covers you when you travel in the U.S. |
** Inpatient Care ** |
Inpatient Hospital Care (Acute) |
No limit to the number of days covered by the plan each benefit period. |
For Medicare-covered hospital stays: |
Days 1 - 10: $200 copay per day |
Days 11 - 90: $0 copay per day |
$0 copay for additional hospital days |
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital. |
Inpatient Mental Health Care |
Contact the plan for details about coverage in a Psychiatric Hospital beyond 190 days. |
For Medicare-covered hospital stays: |
Days 1 - 10: $200 copay per day |
Days 11 - 90: $0 copay per day |
$0 copay for additional hospital days |
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital. |
Skilled Nursing Facility (SNF) |
Authorization rules may apply. |
Plan covers up to 100 days each benefit period |
No prior hospital stay is required. |
For SNF stays: |
Days 1 - 20: $0 copay per day |
Days 21 - 100: $100 copay per day |
Home Health Care |
Authorization rules may apply. |
$0 copay for each Medicare-covered home health visit. |
Hospice |
You must get care from a Medicare-certified hospice. |
** Outpatient Care ** |
Doctor Office Visits |
See 'Welcome to Medicare; and Annual Wellness Visit' for more information. |
Authorization rules may apply. |
$15 copay for each primary care doctor visit for Medicare-covered benefits. |
$15 copay for each in-area network urgent care Medicare-covered visit. |
$15 copay for each specialist visit for Medicare-covered benefits. |
Chiropractic Services |
Authorization rules may apply. |
$15 copay for each Medicare-covered visit. |
Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part) if you get it from a chiropractor or other qualified providers. |
Podiatry Services |
Authorization rules may apply. |
$15 copay for each Medicare-covered visit. |
Medicare-covered podiatry benefits are for medically-necessary foot care. |
Outpatient Mental Health Care |
Authorization rules may apply. |
$15 copay for each Medicare-covered individual therapy visit. |
$7 copay for each Medicare-covered group therapy visit. |
Outpatient Substance Abuse Care |
Authorization rules may apply. |
$15 copay for Medicare-covered individual visits. |
$5 copay for Medicare-covered group visits. |
Outpatient Hospital Services |
Authorization rules may apply. |
$150 copay for each Medicare-covered ambulatory surgical center visit. |
$0 to $150 copay for each Medicare-covered outpatient hospital facility visit. |
Emergency Care |
$50 copay for Medicare-covered emergency room visits. |
Worldwide coverage. |
If you are admitted to the hospital within 24-hour(s) for the same condition you pay $0 for the emergency room visit |
Outpatient Rehabilitation Services |
Authorization rules may apply. |
$15 copay for Medicare-covered Occupational Therapy visits. |
$15 copay for Medicare-covered Physical and/or Speech and Language Therapy visits. |
$15 copay for Medicare-covered Cardiac Rehab services. |
** Outpatient Medical Services and Supplies ** |
Durable Medical Equipment |
Authorization rules may apply. |
20% of the cost for Medicare-covered items. |
Prosthetic Devices |
Authorization rules may apply. |
20% of the cost for Medicare-covered items. |
Diabetes Self-Monitoring Training, Nutrition Therapy, and Supplies |
Authorization rules may apply. |
$0 copay for Diabetes self-monitoring training. |
$0 copay for Nutrition Therapy for Diabetes. |
0% of the cost for Diabetes supplies. |
Separate Office Visit cost sharing of $15 may apply. |
** Preventive Services ** |
Bone Mass Measurement |
Authorization rules may apply. |
$0 copay for Medicare-covered bone mass measurement. |
Separate Office Visit cost sharing of $15 may apply. |
Colorectal Screening Exams |
Authorization rules may apply. |
$0 copay for Medicare-covered colorectal screenings. |
Separate Office Visit cost sharing of $15 may apply. |
$0 copay up to 1 additional screening(s) . |
Immunizations |
Authorization rules may apply. |
$0 copay for Flu and Pneumonia vaccines. |
No referral needed for Flu and pneumonia vaccines. |
$0 copay for Hepatitis B vaccine. |
Pap Smears and Pelvic Exams |
Authorization rules may apply. |
$0 copay for Medicare-covered pap smears and pelvic exams |
Separate Office Visit cost sharing of $15 may apply. |
Prostate Cancer Screening Exams |
Authorization rules may apply. |
$0 copay for Medicare-covered prostate cancer screening. |
Separate Office Visit cost sharing of $15 may apply. |
** Additional Benefits ** |
Dialysis |
Authorization rules may apply. |
$0 copay for renal dialysis |
$0 copay for Nutrition Therapy for End-Stage Renal Disease. |
Prescription Drugs |
$10 to $45 copay for Part B-covered chemotherapy drugs and other Part B-covered drugs. |
$0 copay for home infusion drugs that would normally be covered under Part D. This cost-sharing amount will also cover the supplies and services associated with home infusion of these drugs. |
This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at www.kp.org/seniorrx on the web. |
Different out-of-pocket costs may apply for people who - have limited incomes
- live in long term care facilities or
- have access to Indian/Tribal/Urban (Indian Health Service).
|
Your in-network prescription coverage may be limited to the plan's service area. This means that if you travel outside the service area you may have to pay the full cost of your prescription. In certain emergencies your drugs will be covered if you get them at an out-of-network-pharmacy although you may have to pay additional charges. Contact the plan for details. |
Total yearly drug costs are the total drug costs paid by both you and the plan. |
Your provider must get prior authorization from Kaiser Permanente Senior Advantage Inland Empire (HMO) for certain drugs. |
You must go to certain pharmacies for a very limited number of drugs due to special handling provider coordination or patient education requirements that cannot be met by most pharmacies in your network. These drugs are listed on the plan's website formulary printed materials as well as on the Medicare Prescription Drug Plan Finder on Medicare.gov. |
If the actual cost of a drug is less than the normal cost-sharing amount for that drug you will pay the actual cost not the higher cost-sharing amount. |
If you request a formulary exception for a drug and Kaiser Permanente Senior Advantage Inland Empire (HMO) approves the exception you will pay Tier 2: Brand Drugs cost sharing for that drug. |
$0 deductible. |
You pay the following until total yearly drug costs reach $2 840: |
Tier 1: Generic Drugs |
Tier 2: Brand Drugs |
Tier 3: Specialty Tier Drugs |
$10 copay for a one-month (30-day) supply of drugs in this tier |
$45 copay for a one-month (30-day) supply of drugs in this tier |
25% coinsurance for a one-month (30-day) supply of drugs in this tier |
$30 copay for a 100-day supply of drugs in this tier |
$135 copay for a 100-day supply of drugs in this tier |
25% coinsurance for a 100-day supply of drugs in this tier |
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. |
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. |
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. |
Tier 1: Generic Drugs |
Tier 2: Brand Drugs |
Tier 3: Specialty Tier Drugs |
$10 copay for a one-month (31-day) supply of drugs in this tier |
$45 copay for a one-month (31-day) supply of drugs in this tier |
25% coinsurance for a one-month (31-day) supply of drugs in this tier |
Tier 1: Generic Drugs |
Tier 2: Brand Drugs |
Tier 3: Specialty Tier Drugs |
$10 copay for a one-month (30-day) supply of drugs in this tier |
$45 copay for a one-month (30-day) supply of drugs in this tier |
25% coinsurance for a one-month (30-day) supply of drugs in this tier |
$20 copay for a 100-day supply of drugs in this tier |
$90 copay for a 100-day supply of drugs in this tier |
25% coinsurance for a 100-day supply of drugs in this tier |
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. |
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. |
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. |
The plan covers all formulary generics (100% of formulary generic drugs) through the coverage gap. |
You pay the following: |
Tier 1: Generic Drugs |
$10 copay for a one-month (30-day) supply of all drugs covered in this tier |
$30 copay for a 100-day supply of all drugs covered in this tier |
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. |
Tier 1: Generic Drugs |
$10 copay for a one-month (31-day) supply of all drugs covered in this tier |
Tier 1: Generic Drugs |
$10 copay for a one-month (30-day) supply of all drugs covered in this tier |
$20 copay for a 100-day supply of all drugs covered in this tier |
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. |
After your total yearly drug costs reach $2 840 you receive limited coverage by the plan on certain drugs. You will also receive a discount on brand name drugs and generally pay no more than 93% of the plan's costs for generic drugs until your yearly out-of-pocket drug costs reach $4 550. |
After your yearly out-of-pocket drug costs reach $4 550 you pay the following: |
Tier 1: Generic Drugs |
Tier 2: Brand Drugs |
Tier 3: Specialty Tier Drugs |
$4 copay for drugs in this tier |
$12 copay for drugs in this tier |
$12 copay for drugs in this tier |
Plan drugs may be covered in special circumstances for instance illness while traveling outside of the plan's service area where there is no network pharmacy. You may have to pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy. In addition you will likely have to pay the pharmacy's full charge for the drug and submit documentation to receive reimbursement from Kaiser Permanente Senior Advantage Inland Empire (HMO). |
You will be reimbursed up to the full cost of the drug minus the following for drugs purchased out-of-network until total yearly drug costs reach $2 840: |
Tier 1: Generic Drugs |
Tier 2: Brand Drugs |
Tier 3: Specialty Tier Drugs |
$10 copay for a one-month (30-day) supply of drugs in this tier |
$45 copay for a one-month (30-day) supply of drugs in this tier |
25% coinsurance for a one-month (30-day) supply of drugs in this tier |
You will be reimbursed for these drugs purchased out-of-network up to the full cost of the drug minus the following: |
Tier 1: Generic Drugs |
Tier 2: Brand Drugs |
Tier 3: Specialty Tier Drugs |
$10 copay for a one-month (30-day) supply of all drugs covered in this tier |
You will be reimbursed up to 7% of the plan allowable cost for generic drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 550. |
You will be reimbursed up to 7% of the plan allowable cost for generic drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 550. |
You will be reimbursed up to the discounted price for brand name drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 550. |
You will be reimbursed up to the discounted price for brand name drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 550. |
After your yearly out-of-pocket drug costs reach $4 550 you will be reimbursed for drugs purchased out-of-network up to the full cost of the drug minus the following: |
Tier 1: Generic Drugs |
Tier 2: Brand Drugs |
Tier 3: Specialty Tier Drugs |
$4 copay for drugs in this tier |
$12 copay for drugs in this tier |
$12 copay for drugs in this tier |
Dental Services |
Authorization rules may apply. |
In general preventive dental benefits (such as cleaning) not covered. However this plan covers preventive dental benefits for an extra cost (see 'Optional Benefits.') |
$15 copay for Medicare-covered dental benefits. |
Hearing Services |
Authorization rules may apply. |
In general routine hearing exams and hearing aids not covered. However this plan covers some hearing benefits for an extra cost (see 'Optional Benefits'). |
$15 copay for Medicare-covered diagnostic hearing exams |
Vision Services |
Authorization rules may apply. |
$0 copay for - one pair of eyeglasses or contact lenses after cataract surgery
|
up to 1 pair(s) of glasses every two years |
$0 to $15 copay for exams to diagnose and treat diseases and conditions of the eye. |
$0 copay for routine eye exams |
$100 plan coverage limit for eye wear every two years. |
Separate Office Visit cost sharing of $15 may apply. |
Physical Exams |
Authorization rules may apply. |
$0 copay for routine exams. |
No plan coverage limit on the number of covered exams. |
$0 copay for the required Medicare-covered initial preventive physical exam and annual wellness visits. |
Separate Office Visit cost sharing of $15 may apply. |
Health/Wellness Education |
Authorization rules may apply. |
The plan covers the following health/wellness education benefits: |
Written health education materials including Newsletters |
Nutritional Training |
Nursing Hotline |
Other Wellness Benefits |
Copays may apply for these benefits. |
$0 copay for each Medicare-covered smoking cessation counseling session. |
$0 copay for each Medicare-covered HIV screening. |
HIV screening is covered for people with Medicare who are pregnant and people at increased risk for the infection including anyone who asks for the test. Medicare covers this test once every 12 months or up to three times during a pregnancy. |
Transportation |
This plan does not cover routine transportation. |
Acupuncture |
This plan does not cover Acupuncture. |
** Cost ** |
Premium and Other Important Information |
Package: 1 - Advantage Plus: |
$20 monthly premium in addition to your $0 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits: - Preventive Dental
- Comprehensive Dental
- Eye Wear
- Hearing Aids
|
** Extra Benefits ** |
Vision Services |
$315 plan coverage limit for eye wear every two years. |
$0 copay for |
up to 1 pair(s) of glasses every two years |
Dental Services |
Plan offers additional comprehensive dental benefits. |
$0 copay for up to 2 cleaning(s) every six months |
$0 copay for oral exams |
$0 copay for dental x-rays |
** Important Information ** |
Premium and Other Important Information |
Package: 1 - Advantage Plus: |
$20 monthly premium in addition to your $0 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits: - Preventive Dental
- Comprehensive Dental
- Eye Wear
- Hearing Aids
|
** Additional Benefits ** |
Dental Services |
Plan offers additional comprehensive dental benefits. |
$0 copay for up to 2 cleaning(s) every six months |
$0 copay for oral exams |
$0 copay for dental x-rays |
Hearing Services |
$0 copay for up to 2 hearing aid(s) every three years. |
$700 plan coverage limit for hearing aids every three years. |
Vision Services |
$315 plan coverage limit for eye wear every two years. |
$0 copay for |
up to 1 pair(s) of glasses every two years |