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2018 Medicare Advantage Plan Benefit Details for the Kaiser Permanente Medicare Plus Std w/Part D (AB) (Cost)

2018 Medicare Advantage Plan Details
Medicare Plan Name:Kaiser Permanente Medicare Plus Std w/Part D (AB) (Cost)
Location:Fairfax, Virginia
Plan ID:H2150 - 009 - 0     Click to see other plans
Member Services:1-888-777-5536 TTY users 711
— Enrollment Options —
Medicare Contact Information:1-800-MEDICARE (1-800-633-4227)
TTY users 1-877-486-2048
Medicare plan advice at no cost from licensed insurance agents.  Call: 888-205-9813 / TTY 711
Monday-Friday, 8am-9pm   Saturday, 9am-6pm ET

Email a copy of the Kaiser Permanente Medicare Plus Std w/Part D (AB) (Cost) benefit details
— Medicare Plan Features —
Monthly Premium:$30.00 (see Plan Premium Details below)
Annual Deductible:$300 (Tier 1, 2, 3, 5 and 6 excluded from the Deductible.)
Annual Initial Coverage Limit (ICL):$3,750
Health Plan Type:Cost
Maximum Out-of-Pocket Limit for Parts A & B (MOOP):$6,000
Gap Coverage:Yes
Total Number of Formulary Drugs:6,095 drugsBrowse the Kaiser Permanente Medicare Plus Std w/Part D (AB) (Cost) 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:
Number of Drugs per
Plan's Pharmacy Search:http://kp.org/directory
Plan Offers Mail Order:Yes
Number of Members enrolled in this plan in Virginia:769 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:
Part C
Part D Base
Part D Supplemental
Monthly Premium with Extra Help Low-Income Subsidy (LIS):100%
Monthly Part D Premium with LIS:$4.50$8.90$13.20$17.60
Total Monthly Premium with LIS (Parts C & D):$4.50$8.90$13.20$17.60
— Plan Health Benefits —
** Benefit Highlights **
Important Note This plan does not charge an annual deductible for all drugs. The $300.00 annual deductible only applies to drugs on certain tiers.
Monthly health plan premium $8.00
Monthly drug plan premium $22.00
Total monthly premium $30.00
Health plan deductible $0
Other health plan deductibles? In-Network: No
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs) $6,000 In-network
Optional Supplemental Benefits? No
Inpatient hospital coverage $850 per stay
Outpatient hospital coverage $250 per visit
Doctor visits Primary: $20 per visit Specialist: $45 per visit
Preventive care $0 copay
Emergency care/Urgent care Emergency: $75 per visit (always covered) Urgent care: $45 per visit (always covered)
Diagnostic procedures/lab services/imaging Diagnostic tests and procedures: $0 copay Lab services: $0 copay Diagnostic radiology services (e.g., MRI): $150 Outpatient x-rays: $20
Mental health services $850 per stay Outpatient group therapy visit with a psychiatrist: $10 Outpatient individual therapy visit with a psychiatrist: $20 Outpatient group therapy visit: $10 Outpatient individual therapy visit: $20
Skilled Nursing Facility $0 for days 1 through 20 $160 for days 21 through 100
Rehabilitation services Occupational therapy visit: $40 Physical therapy and speech and language therapy visit: $40
Ambulance $275
Transportation Not covered
Foot care (podiatry services) Foot exams and treatment: $45 Routine foot care: Not covered
Medical equipment/supplies Durable medical equipment (e.g., wheelchairs, oxygen): 20% per item Prosthetics (e.g., braces, artificial limbs): 20% per item Diabetes supplies: $0 copay
Wellness programs (e.g., fitness, nursing hotline) Covered
Medicare Part B drugs Chemotherapy: $0-47 Other Part B drugs: $0-47
Dental Services Preventive dental -
Cleaning Covered under office visit
There may be limits on how much the plan will provide.
Dental x-ray(s) Covered under office visit
There may be limits on how much the plan will provide.
Fluoride treatment Covered under office visit
There may be limits on how much the plan will provide.
Office visit $30.00
Oral exam Covered under office visit
There may be limits on how much the plan will provide.
Comprehensive dental -
Diagnostic services $11-69
Endodontics $47-1,047
Extractions $72-429
Non-routine services $0-55
Periodontics $33-836
Prosthodontics, other oral/maxillofacial surgery, other services $40-3,658
Restorative services $40-755
Vision Services Contact lenses 85%

Eyeglass frames Not covered

Eyeglass lenses Not covered

Eyeglasses (frames and lenses) 75%

Other Not covered

Routine eye exam $20-45

Upgrades Not covered
Hearing Services Fitting/evaluation Not covered

Hearing aids - inner ear Not covered

Hearing aids - outer ear Not covered

Hearing aids - over the ear Not covered

Hearing exam $45

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