** Cost ** |
Premium and Other Important Information |
* Depending on your level of Medicaid eligibility you may not have any cost-sharing responsibility for original Medicare services |
$0 monthly plan premium in addition to your monthly Medicare Part B premium.* |
$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 |
* Depending on your level of Medicaid eligibility you may not have any cost-sharing responsibility for original Medicare services |
$0 monthly plan premium in addition to your monthly Medicare Part B premium.* |
$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. |
$0 copay |
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. |
$0 copay |
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. |
$0 copay for SNF services |
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. |
$0 copay for each Medicare-covered primary care doctor visit.* |
$0 copay for each Medicare-covered specialist visit.* |
Chiropractic Services |
Authorization rules may apply. |
$0 copay for each Medicare-covered chiropractic 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. |
Podiatry Services |
Authorization rules may apply. |
$0 copay for each Medicare-covered podiatry visit* |
Medicare-covered podiatry visits are for medically-necessary foot care. |
Outpatient Mental Health Care |
Authorization rules may apply. |
$0 copay for each Medicare-covered individual therapy visit* |
$0 copay for each Medicare-covered group therapy visit* |
$0 copay for each Medicare-covered individual therapy visit with a psychiatrist* |
$0 copay for each Medicare-covered group therapy visit with a psychiatrist* |
$0 copay for Medicare-covered partial hospitalization program services* |
Outpatient Substance Abuse Care |
Authorization rules may apply. |
$0 copay for Medicare-covered individual therapy visits* |
$0 copay for Medicare-covered group substance abuse outpatient treatment visits* |
Outpatient Services |
Authorization rules may apply. |
$0 copay for each Medicare-covered ambulatory surgical center visit* |
$0 copay for each Medicare-covered outpatient hospital facility visit* |
Ambulance Services |
Authorization rules may apply. |
$0 copay for Medicare-covered ambulance benefits.* |
Emergency Care |
$0 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. |
Urgently Needed Care |
$0 copay for Medicare-covered urgently-needed-care visits* |
Outpatient Rehabilitation Services |
Authorization rules may apply. |
$0 copay for Medicare-covered Occupational Therapy visits* |
$0 copay for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits* |
** Outpatient Medical Services and Supplies ** |
Durable Medical Equipment |
Authorization rules may apply. |
0% of the cost for Medicare-covered durable medical equipment* |
Prosthetic Devices |
Authorization rules may apply. |
0% of the cost for Medicare-covered prosthetic devices* |
Diabetes Programs and Supplies |
Authorization rules may apply. |
$0 copay for Medicare-covered Diabetes self-management training* |
0% of the cost for Medicare-covered Diabetes monitoring supplies* |
0% of the cost for Medicare-covered Therapeutic shoes or inserts* |
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* |
$0 copay for Medicare-covered diagnostic radiology services(not including X-rays)* |
$0 copay for Medicare-covered therapeutic radiology services* |
** Preventive Services ** |
Cardiac and Pulmonary Rehabilitation Services |
Authorization rules may apply. |
$0 copay for: |
- Medicare-covered Cardiac Rehabilitation Services*
|
Medicare-covered Intensive Cardiac Rehabilitation Services* |
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. Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare. |
Authorization rules may apply. |
The plan covers the following supplemental education/wellness programs: |
|
Nutritional Education |
Nursing Hotline |
$0 copay for Non-Medical Transitional Residential Recovery Services. Contact plan for details. |
Kidney Disease and Conditions |
Authorization rules may apply. |
$0 copay for Medicare-covered renal dialysis* |
$0 copay for Medicare-covered kidney disease education services* |
Outpatient Prescription Drugs |
$0 yearly deductible for Medicare Part B drugs.* |
$0 copay for Medicare Part B chemotherapy drugs and other Part B 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) providers.
|
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 you the plan and Medicare. |
Your provider must get prior authorization from Senior Advantage Medicare Medi-Cal Plan South (HMO SNP) 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 Senior Advantage Medicare Medi-Cal Plan South (HMO SNP) approves the exception you will pay the generic cost share for generic drugs and the brand cost share for brand drugs. |
You pay a $0 annual deductible. |
Depending on your income and institutional status you pay the following: For generic drugs (including brand drugs treated as generic) either: - A $0 copay or
- A $1.15 copay or
- A $2.65 copay
For all other drugs either: - A $0 copay or
- A $3.50 copay or
- A $6.60 copay.
|
Please note that brand drugs must be dispensed incrementally in long-term care facilities. Generic drugs may be dispensed incrementally. Contact your plan about cost-sharing billing/collection when less than a one-month supply is dispensed. |
After your yearly out-of-pocket drug costs reach $4 750 you pay a $0 copay. |
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 Senior Advantage Medicare Medi-Cal Plan South (HMO SNP). |
Depending on your income and institutional status you will be reimbursed by Senior Advantage Medicare Medi-Cal Plan South (HMO SNP) up to the plan’s cost of the drug minus the following: For generic drugs purchased out-of-network (including brand drugs treated as generic) either: - A $0 copay or
- A $1.15 copay or
- A $2.65 copay
For all other drugs purchased out-of-network either: - A $0 copay or
- A $3.50 copay or
- A $6.60 copay.
|
After your yearly out-of-pocket drug costs reach $4 750 you will be reimbursed in full for drugs purchased out-of-network. |
Dental Services |
Authorization rules may apply. |
$0 copay for Medicare-covered dental benefits* |
$10 copay for a visit that includes: |
|
up to 2 cleaning(s) every six months |
dental x-rays |
Plan offers additional comprehensive dental benefits. |
Hearing Services |
Authorization rules may apply. |
In general supplemental routine hearing exams and hearing aids not covered. |
$0 copay for Medicare-covered diagnostic hearing exams* |
** Additional Benefits ** |
Vision Services |
Authorization rules may apply. |
$0 copay for - one pair of Medicare-covered eyeglasses or contact lenses after cataract surgery *
|
|
contacts |
$0 copay for Medicare-covered exams to diagnose and treat diseases and conditions of the eye.* |
$0 copay for supplemental routine eye exams |
$275 plan coverage limit for eye wear every two years. |
Over-the-Counter Items |
The plan does not cover Over-the-Counter items. |
Transportation |
This plan does not cover supplemental routine transportation. |
Acupuncture |
Authorization rules may apply. |
$0 copay per acupuncture visit |
** Inpatient Care ** |
Inpatient Hospital Care |
No limit to the number of days covered by the plan each hospital stay. |
$0 copay |
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. |
$0 copay for each Medicare-covered primary care doctor visit.* |
$0 copay for each Medicare-covered specialist visit.* |
Outpatient Services |
Authorization rules may apply. |
$0 copay for each Medicare-covered ambulatory surgical center visit* |
$0 copay for each Medicare-covered outpatient hospital facility visit* |
Ambulance Services |
Authorization rules may apply. |
$0 copay for Medicare-covered ambulance benefits.* |
** Outpatient Medical Services and Supplies ** |
Durable Medical Equipment |
Authorization rules may apply. |
0% of the cost for Medicare-covered durable medical equipment* |
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* |
$0 copay for Medicare-covered diagnostic radiology services(not including X-rays)* |
$0 copay for Medicare-covered therapeutic radiology services* |
** Additional Benefits ** |
Over-the-Counter Items |
The plan does not cover Over-the-Counter items. |
Transportation |
This plan does not cover supplemental routine transportation. |