2012 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | Kaiser Permanente Senior Advantage Basic (HMO) | ||||
Location: | Polk, Oregon Click to see other locations | ||||
Plan ID: | H9003 - 006 - 0 Click to see other plans | ||||
Member Services: | 1-877-221-8221 TTY users 1-800-735-2900 | ||||
— This plan information is for research purposes only. — Click here to see plans for the current plan year | |||||
Medicare Contact Information: | Please go to Medicare.gov or call 1-800-MEDICARE (1-800-633-4227) to get information on all of your options. TTY users 1-877-486-2048 or contact your local SHIP for assistance |
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Email a copy of the Kaiser Permanente Senior Advantage Basic (HMO) benefit details | |||||
— Medicare Plan Features — | |||||
Monthly Premium: | $39.00 (see Plan Premium Details below) | ||||
Annual Deductible: | $0 | ||||
Annual Initial Coverage Limit (ICL): | $2,930 | ||||
Health Plan Type: | Local HMO | ||||
Maximum Out-of-Pocket Limit for Parts A & B (MOOP): | $3,400 | ||||
Additional Gap Coverage? | All Generics, Few Brands | ||||
Total Number of Formulary Drugs: | 5,224 drugs | Browse the Kaiser Permanente Senior Advantage Basic (HMO) Formulary | |||
This plan has drug tiers. See cost-sharing highlights below. | |||||
Formulary Drug Details: | Tier 1 | Tier 2 | Tier 3 | Tier 4 | Tier 5 |
• Preferred Pharmacy Cost-Sharing during initial coverage phase: | cost-sharing data not available. | ||||
• Number of Drugs per Tier: | |||||
Plan's Pharmacy Search: | http://kp.org/seniorrx | ||||
Plan Offers Mail Order? | No | ||||
Number of Members enrolled in this plan in (H9003 - 006): | 10,609 members | ||||
Plan’s Summary Star Rating: | 5 out of 5 Stars. This plan qualifies for the 5-star rating Special Enrollment period. Read more. | ||||
• Customer Service Rating: | 4 out of 5 Stars. | ||||
• Member Experience Rating: | 5 out of 5 Stars. | ||||
• Drug Cost Accuracy Rating: | 5 out of 5 Stars. | ||||
— Plan Premium Details — | |||||
Monthly Premium with Extra Help Low-Income Subsidy (LIS): ❔ | 100% Subsidy | 75% Subsidy | 50% Subsidy | 25% Subsidy | |
Monthly Part D Premium with LIS: | $0.00 | $0.00 | $0.00 | $0.00 | |
— Plan Health Benefits — | |||||
** Cost ** | |||||
Premium and Other Important Information | |||||
$39 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. | |||||
$3 400 out-of-pocket limit for Medicare-covered services and select Non-Medicare Supplemental Services. Contact plan for details regarding Non-Medicare Supplemental Services covered under this limit. | |||||
** 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). | |||||
** Extra Benefits ** | |||||
Over-the-Counter Items | |||||
The plan does not cover Over-the-Counter items. | |||||
Transportation | |||||
This plan does not cover supplemental routine transportation. | |||||
** Important Information ** | |||||
Premium and Other Important Information | |||||
$39 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. | |||||
$3 400 out-of-pocket limit for Medicare-covered services and select Non-Medicare Supplemental Services. Contact plan for details regarding Non-Medicare Supplemental Services covered under this limit. | |||||
Doctor and Hospital Choice | |||||
You must go to network doctors specialists and hospitals. | |||||
Referral required for network hospitals and specialists (for certain benefits). | |||||
** Inpatient Care ** | |||||
Inpatient Hospital Care | |||||
No limit to the number of days covered by the plan each hospital stay. | |||||
For Medicare-covered hospital stays: | |||||
Days 1 - 4: $275 copay per day | |||||
Days 5 - 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 | |||||
You get up to 190 days of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital. | |||||
For Medicare-covered hospital stays: | |||||
Days 1 - 4: $275 copay per day | |||||
Days 5 - 90: $0 copay per day | |||||
Plan covers 60 lifetime reserve days. Cost per lifetime reserve day: | |||||
Days 1 - 60: $0 copay per day | |||||
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 - 100: $0 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. Your plan will pay for a consultative visit before you select hospice. | |||||
** Outpatient Care ** | |||||
Doctor Office Visits | |||||
Authorization rules may apply. | |||||
$30 copay for each primary care doctor visit for Medicare-covered benefits. | |||||
$35 copay for each in-area network urgent care Medicare-covered visit | |||||
$30 copay for each specialist visit for Medicare-covered benefits. | |||||
Chiropractic Services | |||||
Authorization rules may apply. | |||||
$20 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. | |||||
$30 copay for each Medicare-covered visit | |||||
Medicare-covered podiatry benefits are for medically-necessary foot care. | |||||
Outpatient Mental Health Care | |||||
Authorization rules may apply. | |||||
$30 copay for each Medicare-covered individual therapy visit | |||||
$15 copay for each Medicare-covered group therapy visit | |||||
$30 copay for each Medicare-covered individual therapy visit with a psychiatrist | |||||
$15 copay for each Medicare-covered group therapy visit with a psychiatrist | |||||
$137 copay for Medicare-covered partial hospitalization program services | |||||
Outpatient Substance Abuse Care | |||||
Authorization rules may apply. | |||||
$30 copay for Medicare-covered individual visits | |||||
$15 copay for Medicare-covered group visits | |||||
Outpatient Services/Surgery | |||||
Authorization rules may apply. | |||||
$250 copay for each Medicare-covered ambulatory surgical center visit | |||||
$0 to $250 copay for each Medicare-covered outpatient hospital facility visit | |||||
Ambulance Services | |||||
Authorization rules may apply. | |||||
$150 copay for Medicare-covered ambulance benefits. | |||||
Emergency Care | |||||
$65 copay for Medicare-covered emergency room visits | |||||
Worldwide coverage. | |||||
If you are immediately admitted to the hospital you pay $0 for the emergency room visit. | |||||
Urgently Needed Care | |||||
$35 copay for Medicare-covered urgently-needed-care visits | |||||
Outpatient Rehabilitation Services | |||||
Authorization rules may apply. | |||||
$30 copay for Medicare-covered Occupational Therapy visits | |||||
$30 copay for Medicare-covered Physical and/or Speech and Language Therapy visits | |||||
** Outpatient Medical Services and Supplies ** | |||||
Durable Medical Equipment | |||||
Authorization rules may apply. | |||||
0% to 20% of the cost for Medicare-covered items | |||||
Prosthetic Devices | |||||
Authorization rules may apply. | |||||
20% of the cost for Medicare-covered items | |||||
Diabetes Programs and Supplies | |||||
Authorization rules may apply. | |||||
$0 copay for Diabetes self-management training | |||||
0% of the cost for Diabetes monitoring supplies | |||||
20% of the cost for Therapeutic shoes or inserts | |||||
If the doctor provides you services in addition to Diabetes self-management training separate cost sharing of $30 may apply | |||||
'Diagnostic Tests, X-Rays, Lab Services, and Radiology Services' | |||||
Authorization rules may apply. | |||||
$0 copay for Medicare-covered lab services | |||||
$0 copay for Medicare-covered diagnostic procedures and tests | |||||
$0 copay for Medicare-covered X-rays | |||||
$125 copay for Medicare-covered diagnostic radiology services (not including X-rays) | |||||
$30 copay for Medicare-covered therapeutic radiology services | |||||
If the doctor provides you services in addition to Outpatient Diagnostic Procedures Tests and Lab Services separate cost sharing of $30 may apply | |||||
If the doctor provides you services in addition to Outpatient Diagnostic and Therapeutic Radiology Services separate cost sharing of $30 may apply | |||||
** Preventive Services ** | |||||
Cardiac and Pulmonary Rehabilitation Services | |||||
Authorization rules may apply. | |||||
$30 copay for Medicare-covered Cardiac Rehabilitation Services | |||||
$30 copay for Medicare-covered Intensive Cardiac Rehabilitation Services | |||||
$30 copay for Medicare-covered Pulmonary Rehabilitation Services | |||||
Preventive Services and Wellness/Education Programs | |||||
$0 copay for all preventive services covered under Original Medicare at zero cost sharing: | |||||
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. Please contact plan for details. | |||||
The plan covers the following supplemental education/wellness programs: | |||||
Copays may apply for these benefits. | |||||
Kidney Disease and Conditions | |||||
Authorization rules may apply. | |||||
$0 copay for renal dialysis | |||||
$0 copay for kidney disease education services | |||||
Outpatient Prescription Drugs | |||||
$0 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 kp.org/seniorrx on the web. | |||||
Different out-of-pocket costs may apply for people who | |||||
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 a Part D plan. | |||||
Your provider must get prior authorization from Kaiser Permanente Senior Advantage Basic (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 Basic (HMO) approves the exception you will pay Tier 3: Preferred Brand Drugs cost sharing for that drug. | |||||
$0 deductible. | |||||
You pay the following until total yearly drug costs reach $2 930: | |||||
Tier 1: Preferred Generic Drugs | |||||
Tier 2: Non-Preferred Generic Drugs | |||||
Tier 3: Preferred Brand Drugs | |||||
Tier 4: Non-Preferred Brand Drugs | |||||
Tier 5: Specialty Tier Drugs | |||||
Tier 6: Vaccines | |||||
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. | |||||
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: Preferred Generic Drugs | |||||
Tier 2: Non-Preferred Generic Drugs | |||||
Tier 3: Preferred Brand Drugs | |||||
Tier 4: Non-Preferred Brand Drugs | |||||
Tier 5: Specialty Tier Drugs | |||||
Tier 6: Vaccines | |||||
Tier 1: Preferred Generic Drugs | |||||
Tier 2: Non-Preferred Generic Drugs | |||||
Tier 3: Preferred Brand Drugs | |||||
Tier 4: Non-Preferred Brand Drugs | |||||
Tier 5: Specialty Tier Drugs | |||||
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. | |||||
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) few formulary brands (less than 10% of formulary brand drugs) through the coverage gap. | |||||
You pay the following: | |||||
Tier 1: Preferred Generic Drugs | |||||
Tier 2: Non-Preferred Generic Drugs | |||||
Tier 6: Vaccines | |||||
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: Preferred Generic Drugs | |||||
Tier 2: Non-Preferred Generic Drugs | |||||
Tier 6: Vaccines | |||||
Tier 1: Preferred Generic Drugs | |||||
Tier 2: Non-Preferred Generic Drugs | |||||
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. | |||||
After your total yearly drug costs reach $2 930 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 86% of the plan's costs for generic drugs until your yearly out-of-pocket drug costs reach $4 700. | |||||
Tier 1: Preferred Generic Drugs | |||||
Tier 2: Non-Preferred Generic Drugs | |||||
Tier 3: Preferred Brand Drugs | |||||
Tier 4: Non-Preferred Brand Drugs | |||||
Tier 5: Specialty Tier Drugs | |||||
Tier 6: Vaccines | |||||
After your yearly out-of-pocket drug costs reach $4 700 you pay the following: | |||||
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 Basic (HMO). | |||||
You will be reimbursed up to the plan's cost of the drug minus the following for drugs purchased out-of-network until total yearly drug costs reach $2 930: | |||||
Tier 1: Preferred Generic Drugs | |||||
Tier 2: Non-Preferred Generic Drugs | |||||
Tier 3: Preferred Brand Drugs | |||||
Tier 4: Non-Preferred Brand Drugs | |||||
Tier 5: Specialty Tier Drugs | |||||
Tier 6: Vaccines | |||||
You will be reimbursed for these drugs purchased out-of-network up to the plan's cost of the drug minus the following: | |||||
Tier 1: Preferred Generic Drugs | |||||
Tier 2: Non-Preferred Generic Drugs | |||||
Tier 6: Vaccines | |||||
Tier 3: Preferred Brand Drugs | |||||
Tier 4: Non-Preferred Brand Drugs | |||||
Tier 5: Specialty Tier Drugs | |||||
After your yearly out-of-pocket drug costs reach $4 700 you will be reimbursed for drugs purchased out-of-network up to the plan's cost of the drug minus the following: | |||||
Tier 1: Preferred Generic Drugs | |||||
Tier 2: Non-Preferred Generic Drugs | |||||
Tier 3: Preferred Brand Drugs | |||||
Tier 4: Non-Preferred Brand Drugs | |||||
Tier 5: Specialty Tier Drugs | |||||
Tier 6: Vaccines | |||||
Dental Services | |||||
In general preventive dental benefits (such as cleaning) not covered. However this plan covers preventive dental benefits for an extra cost (see 'Optional Benefits.') | |||||
$0 copay for Medicare-covered dental benefits | |||||
Hearing Services | |||||
** Additional Benefits ** | |||||
Vision Services | |||||
$0 copay for | |||||
Over-the-Counter Items | |||||
The plan does not cover Over-the-Counter items. | |||||
Transportation | |||||
This plan does not cover supplemental routine transportation. | |||||
Acupuncture | |||||
This plan does not cover Acupuncture. | |||||
** Inpatient Care ** | |||||
Inpatient Hospital Care | |||||
No limit to the number of days covered by the plan each hospital stay. | |||||
For Medicare-covered hospital stays: | |||||
Days 1 - 4: $275 copay per day | |||||
Days 5 - 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. | |||||
** Outpatient Care ** | |||||
Doctor Office Visits | |||||
Authorization rules may apply. | |||||
$30 copay for each primary care doctor visit for Medicare-covered benefits. | |||||
$35 copay for each in-area network urgent care Medicare-covered visit | |||||
$30 copay for each specialist visit for Medicare-covered benefits. | |||||
Outpatient Services/Surgery | |||||
Authorization rules may apply. | |||||
$250 copay for each Medicare-covered ambulatory surgical center visit | |||||
$0 to $250 copay for each Medicare-covered outpatient hospital facility visit | |||||
Ambulance Services | |||||
Authorization rules may apply. | |||||
$150 copay for Medicare-covered ambulance benefits. | |||||
** Outpatient Medical Services and Supplies ** | |||||
Durable Medical Equipment | |||||
Authorization rules may apply. | |||||
0% to 20% of the cost for Medicare-covered items | |||||
'Diagnostic Tests, X-Rays, Lab Services, and Radiology Services' | |||||
Authorization rules may apply. | |||||
$0 copay for Medicare-covered lab services | |||||
$0 copay for Medicare-covered diagnostic procedures and tests | |||||
$0 copay for Medicare-covered X-rays | |||||
$125 copay for Medicare-covered diagnostic radiology services (not including X-rays) | |||||
$30 copay for Medicare-covered therapeutic radiology services | |||||
If the doctor provides you services in addition to Outpatient Diagnostic Procedures Tests and Lab Services separate cost sharing of $30 may apply | |||||
If the doctor provides you services in addition to Outpatient Diagnostic and Therapeutic Radiology Services separate cost sharing of $30 may apply | |||||
** Additional Benefits ** | |||||
Over-the-Counter Items | |||||
The plan does not cover Over-the-Counter items. | |||||
Transportation | |||||
This plan does not cover supplemental routine transportation. | |||||
** Cost ** | |||||
Premium and Other Important Information | |||||
Package: 1 - Advantage Plus: | |||||
$38 monthly premium in addition to your $39 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits: | |||||
** Important Information ** | |||||
Package: 1 - Advantage Plus: | |||||
$38 monthly premium in addition to your $39 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits: | |||||
** Preventive Services ** | |||||
Dental Services | |||||
Plan offers additional comprehensive dental benefits. | |||||
$0 copay for the following preventive dental benefits: | |||||
$1 000 plan coverage limit for dental benefits every year | |||||
Hearing Services | |||||
$0 copay for up to 2 hearing aid(s) every three years | |||||
$1 000 plan coverage limit for hearing aids every three years. | |||||
** Additional Benefits ** | |||||
Vision Services | |||||
$0 copay for | |||||
$175 plan coverage limit for eye wear every two years. |