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Hawaii

Plans that make Medicare complete

With Kaiser Permanente Senior Advantage (HMO), you get one plan that takes care of the whole you. We offer more coverage and more benefits than Original Medicare—and that’s just the beginning.

View the details below to see why Kaiser Permanente Senior Advantage (HMO) stands apart. Then when you’re ready, enroll online now.

For additional information about Kaiser Permanente Medicare plans or plans’ ratings, visit the Medicare Web site.


Kaiser Permanente Senior Advantage (HMO) Individual Plan

2010 benefit highlights

Effective January 1 to December 31, 2010

Basic PlanEnhanced Plan
Monthly Premium$0 in addition to your monthly Medicare Part B premium$116 in addition to your monthly Medicare Part B premium
Annual medical deductibleNoneNone
Plan benefitBasic PlanEnhanced Plan
Office visit$25 per visit$10 per visit
Medicare prescription drug coverage (Part D)
Initial coverage: Until the total cost of your Part D—covered drugs1 paid by you and us (or any other Part D plan) reaches $2,830 in 2010, you will pay
  • formulary generic drugs—up to a 30-day supply
  • formulary brand-name drugs—up to a 30-day supply
  • formulary specialty-tier drugs—up to a 30-day supply









$10


$40


$25% specialty









$10


$40


25% specialty

Coverage gap: Once the total cost of your Part D—covered drugs paid by you and us (or any other Part D plan) reaches $2,830 in 2010, you will pay
  • formulary generic drugs—up to a 30-day supply
  • formulary brand-name and specialty-tier drugs
  • formulary specialty-tier drugs






$10


100% brand

100% specialty







$10


100% brand

100% specialty

Catastrophic coverage: If your out-of-pocket expenses (copayments, coinsurance, and payments for full-price drugs) reach $4,550 in 2010, you will pay
  • formulary generic drugs
  • formulary brand-name drugs
  • formulary specialty-tier drugs






$4 per Rx
$10 per Rx

$10 per Rx







$4 per Rx
$10 per Rx

$10 per Rx

Routine eye exams$30 per visit$10 per visit
Hearing tests$30 per visit$10 per visit
Diagnostic tests, X-Rays, and laboratory services$25 for Medicare-covered diagnostic procedures and tests; $25 for most X-Rays; $100 for MRI, CT, and PET; $0 for Medicare-covered lab services.$10 for Medicare-covered diagnostic procedures and tests; $10 for most X-Rays; $50 for MRI, CT, and PET; $0 for Medicare-covered lab services.
Inpatient hospital care

Days 1-12: $175 per day
Days 13+: $0 per day

$0
Outpatient surgery$25 to $175 for each Medicare-covered ambulatory surgical center visit$10 for each Medicare-covered ambulatory surgical center visit
Annual out-of-pocket maximum for certain services2—The maximum amount you will pay for services covered by Medicare parts A and B in a calendar year. Thereafter, the services are provided at no charge for the rest of that year.$3,400$3,000

1Calculated using prices set by the pharmacy.
2Only certain covered services apply to this annual out-of-pocket maximum as described in the Evidence of Coverage. For example, Medicare Part D drugs do not count toward this maximum.

Please note: You must reside on Oahu, Maui, or the Big Island (except in ZIP codes 96718, 96772, and 96777) to join Kaiser Permanente Senior Advantage (HMO).


For full information on Kaiser Permanente benefits, please see the Evidence of Coverage below or call 1-877-269-9821 (toll free) or 1-888-758-6054 (toll-free TTY for the hearing/speech impaired), 8 a.m. to 8 p.m., seven days a week.


Rx drug formulary

Are your prescriptions covered by Kaiser Permanente? See the latest formulary of covered drugs for your region.


Save money on Rx refill by mail

When you refill a prescription by mail, you can get up to a 90-day supply from a plan pharmacy for only two copayments, instead of three copayments (restrictions and limitations may apply). A small number of drugs cannot be mailed; plan pharmacies can give you details.


2010 Summary of Benefits

This document provides an overview of the plan’s benefits and includes:

  • a comparison of our benefits to the Original Medicare plan benefits
  • information about the plan’s monthly premium, annual deductible, and other yearly out-of-pocket costs
  • service areas, listed by ZIP code
  • information on eligibility, choice of doctor, and prescription drugs

Summary of Benefits for Kaiser Permanente Senior Advantage (HMO) Basic Plan and Enhanced Plan


2010 Evidence of Coverage

Provides comprehensive benefit information and explains:

  • what is covered by our plan and what isn’t covered
  • how to get the care you need or prescriptions refilled
  • what to do if you’re unhappy with our services
  • how to leave our plan and other Medicare options that are available

Evidence of Coverage for Kaiser Permanente Senior Advantage (HMO) Individual Plan


2010 Provider Directory

Find contact information for clinics, primary care physicians, specialists, pharmacies, and other health providers in your area.

Kaiser Permanente Senior Advantage (HMO) Medicare Provider Directory


Advantage Plus—dental, hearing, and vision benefits

Add more coverage to your Kaiser Permanente Senior Advantage (HMO) plan. Kaiser Permanente Senior Advantage (HMO) Individual Plan members can enroll in our Advantage Plus option for an additional $20 each month* 

2010 Advantage Plus benefits include:

  • dental—cleanings at 75 percent coverage and examinations at 90 percent coverage; most X-rays are at 80 percent coverage
  • hearing—$500 credit to purchase up to two hearing aids every three years
  • vision—$100 credit to purchase one pair of prescription eyeglasses or one order of contact lenses every two years

If you are already a Kaiser Permanente Senior Advantage (HMO) member, you may be eligible to enroll in Advantage Plus today. For more information, see the Advantage Plus enrollment brochure♦.


Silver and FitTM fitness and healthy aging program

Exercise is good for you—at any age. The Silver and Fit program is designed specifically to help you achieve better health through regular exercise and includes the following benefits:

  • free membership at a local, participating fitness facility
  • group exercise classes designed for Silver and Fit members
  • a healthy aging educational kit
  • social events with other Silver and Fit members
  • access to the Silver and Fit Web site which has a wide range of tools and resources
  • optional Silver and Fit home fitness programs for members who prefer to exercise at home
  • The Silver Slate® quarterly newsletter

Read more about the Silver and Fit program♦.

Silver and Fit is provided by American Specialty Health Networks, Inc. and Healthyroads, Inc., subsidiaries of American Specialty Health Incorporated (ASH). Silver and Fit, the Silver and Fit logo, and The Silver Slate are federally registered trademarks of ASH.




*You must be a Kaiser Permanente Senior Advantage (HMO) Individual Plan member to apply and continue to pay applicable Kaiser Permanente Senior Advantage (HMO) and Medicare Part B premiums.

For details about hearing and vision services for Kaiser Permanente Senior Advantage (HMO) Individual Plan members, see our benefits chart above.

♦You will need the free Adobe Acrobat Reader to read this file.




Yes, I am ready to enroll!

  

Get answers


To learn more about Kaiser Permanente Medicare health plans and services,

Call 1-877-852-5081
(toll free) (TTY 711)
8 a.m. to 8 p.m.,
7 days a week, to:

Speak to a licensed sales specialist

Schedule a personal appointment with a local sales specialist

RSVP online for a Medicare Straight-Talk Seminar in your neighborhood

Have us call you


KP members turning 65 and over:
Keep a good thing going.