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2015 Medicare Advantage Plan Benefit Details for the Kaiser Permanente Senior Advantage Essential Plus (HMO) in HI - H1230-006-0
This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.

2015 Medicare Advantage Plan Details
Medicare Plan Name:Kaiser Permanente Senior Advantage Essential Plus (HMO)
Location:Hawaii, Hawaii     Click to see other locations
Plan ID:H1230 - 006 - 0     Click to see other plans
Member Services:1-800-805-2739 TTY users 711
— 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
Email a copy of the Kaiser Permanente Senior Advantage Essential Plus (HMO) benefit details
— Medicare Plan Features —
Monthly Premium:$160.00 (see Plan Premium Details below)
Annual Deductible:$0
Annual Initial Coverage Limit (ICL):$2,960
Health Plan Type:Local HMO
Maximum Out-of-Pocket Limit for Parts A & B (MOOP):$3,400
Additional Gap Coverage?Yes, some additional gap coverage.
Total Number of Formulary Drugs:5,825 drugsBrowse the Kaiser Permanente Senior Advantage Essential Plus (HMO) Formulary
This plan has 6 drug tiers. See cost-sharing for all pharmacies and tiers. 
Formulary Drug Details:Tier 1Tier 2Tier 3Tier 4Tier 5
• Preferred Pharmacy
  Cost-Sharing during
  initial coverage phase:		$6.00$10.00$45.00$75.0025%
• Number of Drugs per
  Tier:		12225494602235409
Plan's Pharmacy Search:http://www.kp.org/seniormedrx
Plan Offers Mail Order?Yes
Number of Members enrolled in this plan in Hawaii, Hawaii:1,636 members
Number of Members enrolled in this plan in (H1230 - 006):1,671 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: Insufficient data to rate this plan.
• Member Experience Rating: 5 out of 5 Stars.
• Drug Cost Accuracy Rating: 5 out of 5 Stars.
— Plan Premium Details —
The Monthly Premium is Split as Follows: ❔
Total
Premium		Part C
Premium		Part D Base
Premium		Part D Supplemental
Premium
$160.00$126.20$18.20$15.60
Monthly Premium with Extra Help Low-Income Subsidy (LIS): ❔100%
Subsidy		75%
Subsidy		50%
Subsidy		25%
Subsidy
Monthly Part D Premium with LIS:$15.60$20.10$24.70$29.20
Total Monthly Premium with LIS (Parts C & D):$141.80$146.30$150.90$155.40
— Plan Health Benefits —
** Cost **
Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services
$160 per month. In addition you must keep paying your Medicare Part B premium.
This plan does not have a deductible.
Yes. Like all Medicare health plans our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care.
Your yearly limit(s) in this plan:
  • $3 400 for services you receive from in-network providers.
If you reach the limit on out-of-pocket costs you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year.
Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs.
Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply.
** Doctor and Hospital Choice **
Acupuncture and Other Alternative Therapies
Not covered
** Extra Benefits **
Inpatient Mental Health Care
For inpatient mental health care see the "Mental Health Care" section.
Outpatient Prescription Drugs
For Part B drugs such as chemotherapy drugs1:  $10-45 copay depending on the drug
Other Part B drugs1:  $10-45 copay depending on the drug
You pay the following until your total yearly drug costs reach $2 960. Total yearly drug costs are the total drug costs paid by both you and our Part D plan.
You may get your drugs at network retail pharmacies and mail order pharmacies.
Standard Retail Cost-Sharing
TierOne-month supplyThree-month supply
Tier 1 (Preferred Generic)$6 copay$18 copay
Tier 2 (Non-Preferred Generic)$10 copay$30 copay
Tier 3 (Preferred Brand)$45 copay$135 copay
Tier 4 (Non-Preferred Brand)$75 copay$225 copay
Tier 5 (Specialty Tier)25% of the cost25% of the cost
Tier 6 (Vaccines)$0Not Offered
Standard Mail Order Cost-Sharing
TierOne-month supplyThree-month supply
Tier 1 (Preferred Generic)$6 copay$12 copay
Tier 2 (Non-Preferred Generic)$10 copay$20 copay
Tier 3 (Preferred Brand)$45 copay$90 copay
Tier 4 (Non-Preferred Brand)$75 copay$150 copay
Tier 5 (Specialty Tier)25% of the cost25% of the cost
If you reside in a long-term care facility you pay the same as at a retail pharmacy.
You may get drugs from an out-of-network pharmacy at the same cost as an in-network pharmacy.
Most Medicare drug plans have a coverage gap (also called the "donut hole"). This means that there's a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $2 960.

After you enter the coverage gap you pay 45% of the plan's cost for covered brand name drugs and 65% of the plan's cost for covered generic drugs until your costs total $4 700 which is the end of the coverage gap. Not everyone will enter the coverage gap.

Under this plan you may pay even less for the brand and generic drugs on the formulary. Your cost varies by tier. You will need to use your formulary to locate your drug's tier. See the chart that follows to find out how much it will cost you.
Standard Retail Cost-Sharing
TierDrugs CoveredOne-month supplyThree-month supply
Tier 1 (Preferred Generic)All$6 copay$18 copay
Tier 2 (Non-Preferred Generic)All$10 copay$30 copay
Tier 6 (Vaccines)All$0Not Offered
Standard Mail Order Cost-Sharing
TierDrugs CoveredOne-month supplyThree-month supply
Tier 1 (Preferred Generic)All$6 copay$12 copay
Tier 2 (Non-Preferred Generic)All$10 copay$20 copay
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4 700 you pay the following:
TierYour cost
Tier 1 (Preferred Generic)$4 copay
Tier 2 (Non-Preferred Generic)$4 copay
Tier 3 (Preferred Brand)$10 copay
Tier 4 (Non-Preferred Brand)$10 copay
Tier 5 (Specialty Tier)$10 copay
Tier 6 (Vaccines)$0
** Important Information **
Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services
$160 per month. In addition you must keep paying your Medicare Part B premium.
This plan does not have a deductible.
Yes. Like all Medicare health plans our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care.
Your yearly limit(s) in this plan:
  • $3 400 for services you receive from in-network providers.
If you reach the limit on out-of-pocket costs you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year.
Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs.
Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply.
** Outpatient Care and Services **
Acupuncture and Other Alternative Therapies
Not covered
Ambulance Services
20% of the cost
Chiropractic Care
Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position):  $15 copay
Dental Services
Limited dental services (this does not include services in connection with care treatment filling removal or replacement of teeth):  $25 copay
Diabetes Supplies and Services
Diabetes monitoring supplies:  You pay nothing
Diabetes self-management training:  You pay nothing
Therapeutic shoes or inserts:  20% of the cost
Diagnostic Tests, Lab and Radiology Services, and X-Rays
Diagnostic radiology services (such as MRIs CT scans):  $25-125 copay depending on the service
Diagnostic tests and procedures:  $25 copay
Lab services:  $5 copay
Outpatient x-rays:  $25 copay
Therapeutic radiology services (such as radiation treatment for cancer):  $25 copay
Doctor’s Office Visits
Primary care physician visit:  $0-15 copay depending on the service
Specialist visit:  $25 copay
Durable Medical Equipment (wheelchairs, oxygen, etc.)
20% of the cost
Emergency Care
$65 copay
If you are admitted to the hospital within 24 hours you do not have to pay your share of the cost for emergency care. See the "Inpatient Hospital Care" section for other costs.
Foot Care (podiatry services)
Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions:  $25 copay
Hearing Services
Exam to diagnose and treat hearing and balance issues:  $15 copay
Routine hearing exam:  $15 copay
Home Health Care
You pay nothing
Mental Health Care
Inpatient visit:
Our plan covers an unlimited number of days for an inpatient hospital stay.
  • $225 copay per day for days 1 through 6
  • You pay nothing per day for days 7 through 90
  • You pay nothing per day for days 91 and beyond
    • Outpatient group therapy visit:  $15 copay
    Outpatient individual therapy visit:  $25 copay
    Outpatient Rehabilitation Services
    Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks):  $15 copay
    Occupational therapy visit:  $15 copay
    Physical therapy and speech and language therapy visit:  $15 copay
    Outpatient Substance Abuse
    Group therapy visit:  $15 copay
    Individual therapy visit:  $25 copay
    Outpatient Surgery
    Ambulatory surgical center:  $225 copay
    Outpatient hospital:  $15-225 copay depending on the service
    Over-the-Counter Items
    Not Covered
    Prosthetic Devices (braces, artificial limbs, etc.)
    Prosthetic devices:  20% of the cost
    Related medical supplies:  20% of the cost
    Renal Dialysis
    You pay nothing
    Transportation
    Not covered
    Urgently Needed Care
    $15-65 copay depending on the service
    Vision Services
    Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening):  $15 copay
    Routine eye exam:  $15 copay
    Eyeglasses or contact lenses after cataract surgery:  20% of the cost
    ** Hospice **
    Hospice
    You pay nothing for hospice care from a Medicare-certified hospice. You may have to pay part of the cost for drugs and respite care.
    ** Preventive Care **
    Preventive Care
    You pay nothing
    Our plan covers many preventive services including:
    • Abdominal aortic aneurysm screening
    • Alcohol misuse counseling
    • Bone mass measurement
    • Breast cancer screening (mammogram)
    • Cardiovascular disease (behavioral therapy)
    • Cardiovascular screenings
    • Cervical and vaginal cancer screening
    • Colonoscopy
    • Colorectal cancer screenings
    • Depression screening
    • Diabetes screenings
    • Fecal occult blood test
    • Flexible sigmoidoscopy
    • HIV screening
    • Medical nutrition therapy services
    • Obesity screening and counseling
    • Prostate cancer screenings (PSA)
    • Sexually transmitted infections screening and counseling
    • Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease)
    • Vaccines including Flu shots Hepatitis B shots Pneumococcal shots
    • "Welcome to Medicare" preventive visit (one-time)
    • Yearly "Wellness" visit
    Any additional preventive services approved by Medicare during the contract year will be covered.
    ** Inpatient Care **
    Inpatient Hospital Care
    Our plan covers an unlimited number of days for an inpatient hospital stay.
    • $225 copay per day for days 1 through 6
    • You pay nothing per day for days 7 through 90
    • You pay nothing per day for days 91 and beyond
      • Inpatient Mental Health Care
      For inpatient mental health care see the "Mental Health Care" section.
      Skilled Nursing Facility (SNF)
      Our plan covers up to 100 days in a SNF.
      • You pay nothing per day for days 1 through 20
      • $50 copay per day for days 21 through 100
        • Outpatient Prescription Drugs
        For Part B drugs such as chemotherapy drugs1:  $10-45 copay depending on the drug
        Other Part B drugs1:  $10-45 copay depending on the drug
        You pay the following until your total yearly drug costs reach $2 960. Total yearly drug costs are the total drug costs paid by both you and our Part D plan.
        You may get your drugs at network retail pharmacies and mail order pharmacies.
        Standard Retail Cost-Sharing
        TierOne-month supplyThree-month supply
        Tier 1 (Preferred Generic)$6 copay$18 copay
        Tier 2 (Non-Preferred Generic)$10 copay$30 copay
        Tier 3 (Preferred Brand)$45 copay$135 copay
        Tier 4 (Non-Preferred Brand)$75 copay$225 copay
        Tier 5 (Specialty Tier)25% of the cost25% of the cost
        Tier 6 (Vaccines)$0Not Offered
        Standard Mail Order Cost-Sharing
        TierOne-month supplyThree-month supply
        Tier 1 (Preferred Generic)$6 copay$12 copay
        Tier 2 (Non-Preferred Generic)$10 copay$20 copay
        Tier 3 (Preferred Brand)$45 copay$90 copay
        Tier 4 (Non-Preferred Brand)$75 copay$150 copay
        Tier 5 (Specialty Tier)25% of the cost25% of the cost
        If you reside in a long-term care facility you pay the same as at a retail pharmacy.
        You may get drugs from an out-of-network pharmacy at the same cost as an in-network pharmacy.
        Most Medicare drug plans have a coverage gap (also called the "donut hole"). This means that there's a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $2 960.

        After you enter the coverage gap you pay 45% of the plan's cost for covered brand name drugs and 65% of the plan's cost for covered generic drugs until your costs total $4 700 which is the end of the coverage gap. Not everyone will enter the coverage gap.

        Under this plan you may pay even less for the brand and generic drugs on the formulary. Your cost varies by tier. You will need to use your formulary to locate your drug's tier. See the chart that follows to find out how much it will cost you.
        Standard Retail Cost-Sharing
        TierDrugs CoveredOne-month supplyThree-month supply
        Tier 1 (Preferred Generic)All$6 copay$18 copay
        Tier 2 (Non-Preferred Generic)All$10 copay$30 copay
        Tier 6 (Vaccines)All$0Not Offered
        Standard Mail Order Cost-Sharing
        TierDrugs CoveredOne-month supplyThree-month supply
        Tier 1 (Preferred Generic)All$6 copay$12 copay
        Tier 2 (Non-Preferred Generic)All$10 copay$20 copay
        After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4 700 you pay the following:
        TierYour cost
        Tier 1 (Preferred Generic)$4 copay
        Tier 2 (Non-Preferred Generic)$4 copay
        Tier 3 (Preferred Brand)$10 copay
        Tier 4 (Non-Preferred Brand)$10 copay
        Tier 5 (Specialty Tier)$10 copay
        Tier 6 (Vaccines)$0
        ** Outpatient Care **
        Diabetes Supplies and Services
        Diabetes monitoring supplies:  You pay nothing
        Diabetes self-management training:  You pay nothing
        Therapeutic shoes or inserts:  20% of the cost
        Foot Care (podiatry services)
        Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions:  $25 copay
        Hearing Services
        Exam to diagnose and treat hearing and balance issues:  $15 copay
        Routine hearing exam:  $15 copay
        ** Outpatient Medical Services and Supplies **
        Outpatient Substance Abuse
        Group therapy visit:  $15 copay
        Individual therapy visit:  $25 copay
        Prosthetic Devices (braces, artificial limbs, etc.)
        Prosthetic devices:  20% of the cost
        Related medical supplies:  20% of the cost
        ** Additional Benefits **
        Inpatient Mental Health Care
        For inpatient mental health care see the "Mental Health Care" section.
        ** Cost **
        Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services
        Package 1: Advantage Plus
        Benefits include:
        • Preventive Dental
        • Eyewear
        • Hearing Aids
        Additional $22.00 per month. You must keep paying your Medicare Part B premium and your $160 monthly plan premium.
        This package does not have a deductible.
        No. There is no limit to how much our plan will pay for benefits in this package.
        ** Important Information **
        Package 1: Advantage Plus
        Benefits include:
        • Preventive Dental
        • Eyewear
        • Hearing Aids
        Additional $22.00 per month. You must keep paying your Medicare Part B premium and your $160 monthly plan premium.
        This package does not have a deductible.
        No. There is no limit to how much our plan will pay for benefits in this package.




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