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Kaiser Permanente Maryland, Virginia and Washington, DC Medicare health plans & rates for 2014

Quality and convenience

Kaiser Permanente’s highly rated Medicare health plan provides convenient, coordinated care thanks to our all-in-one approach.*

Areas covered by this plan are noted beneath the following tables.

Kaiser Permanente Medicare Plus (Cost) Individual plans

2014 benefits highlights

Effective January 1, 2014, to December 31, 2014

Premiums and BenefitsMedicare Plus Standard Option with Part D A&B (Cost)Medicare Plus High Option with Part D A&B (Cost)
DescriptionYou PayYou Pay
Monthly Premium $15$113
Maximum Out-of-Pocket $3,400$3,400
Annual DeductibleNoneNone
Doctor Office Visit$20 Primary / $30 Specialist$10 Primary / $20 Specialist
Preventive Services1 No chargeNo charge
Inpatient Hospitalization
Per benefit period
$600$250
Outpatient Surgery$175$100
Skilled Nursing Facility
Per benefit period
$0 per day, Days 1–20
$100 per day, Days 21–100
$0 per day, Days 1–20
$88 per day, Days 21–100
Lab, X-Ray, Imaging$0 Lab, $0 X-Ray, $0-50 MRI, PET, CT scans$0 Lab, $0 X-Ray, $0 MRI, PET, CT scans
Durable Medical Equipment20% coinsurance20% coinsurance
Emergency Room/Urgent Care$65 ER / $30 Urgent Care$65 ER / $20 Urgent Care
Ambulance Service$150 copay$100 copay

1$0 copay for all preventive services covered under Original Medicare at zero cost sharing.

For a more complete listing of plan benefits, please view the 2014 Summaries of Benefits.

These plans include Medicare Part D prescription drug coverage. Copay and coinsurance amounts below are for up to a one month supply. You can save on most refills of a 3-month supply through our mail order pharmacy and have them mailed to your home at no extra charge.

Premiums and BenefitsMedicare Plus Standard Option with Part D A&B (Cost)Medicare Plus High Option with Part D A&B (Cost)
Part D Prescription Drug Coverage
DescriptionYou PayYou Pay
Initial Coverage Stage
(for up to a 30-day supply from an in-network preferred pharmacy)

When the total drug costs paid by you and the plan reach $2,850, you move into the Coverage Gap.
$7 preferred generic$5 preferred generic
$28 nonpreferred generic$10 nonpreferred generic
$40 preferred brand-name$40 preferred brand-name
$90 nonpreferred brand-name$75 nonpreferred brand-name
25% coinsurance for specialty25% coinsurance for specialty
$0 injectable Part D vaccines$0 injectable Part D vaccines
Coverage Gap Stage
(for up to a 30-day supply from an in-network preferred pharmacy)

If your annual out-of-pocket costs reach $4,550, you move into Catastrophic Coverage.
72% of the plan’s cost for all generic drugs$5 preferred generic
You pay 47.5% for all brand-name & specialty drugs (including a portion of the dispensing fee)$10 nonpreferred generic
You pay 47.5% for all brand-name & specialty drugs (including a portion of the dispensing fee)
47.5% injectable Part D vaccines$0 injectable Part D vaccines
Catastrophic Coverage Stage
(per prescription)

When your annual out-of-pocket costs exceed $4,550, you pay lower cost shares for the remainder of the calendar year.
$5 all generic$4 all generic
$15 all brand-name & specialty$12 all brand-name & specialty
$0 injectable Part D vaccines$0 injectable Part D vaccines
Our Mail Order Pharmacy
(Restrictions & limitations may apply)
Two copays for up to a 90-day supplyTwo copays for up to a 90-day supply

See which areas♦ are covered by this plan.

2014 Summary of Benefits

The Summary of Benefits is a great resource for information about the plan’s medical or prescription drug benefits, including:

  • a comparison of our benefits to the Original Medicare plan benefits
  • information about monthly premium and other yearly out-of-pocket costs
  • information on eligibility, choice of doctor, and prescription drugs

Kaiser Permanente Medicare Plus Standard and High Option plans with Part D for those with Medicare Parts A&B

Kaiser Permanente Medicare Plus Basic, Standard, and High Option plans without Part D for those with Medicare Parts A&B

Kaiser Permanente Medicare Plus Basic Option without Part D for those with Part B only

Kaiser Permanente Medicare Plus Standard Option with Part D for those with Part B only

Note: If you have health care coverage through an employer or trust fund, please contact your benefits administrator for information about your group plan.

 

* Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next. Centers for Medicare & Medicaid Services Health Plan Management System, Plan Ratings 2014. Kaiser Permanente contract #H0524, #H0630, #H1170, #H1230, #H2150, #H9003.

Benefits, formulary, pharmacy network, provider network, premium and/or copayments/co-insurance may change on January 1 of each year.

The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Limitations, copayments, and restrictions may apply.

You must continue to pay your Medicare Part B premium and any other applicable Medicare premium(s), if not otherwise paid by Medicaid or another third party.

Kaiser Permanente Medicare Plus (Cost) for employer groups

Kaiser Permanente has a variety of Medicare Plus plans available to employer groups. If you get health coverage through your employer, talk to your group benefits administrator to see if there is a Kaiser Permanente Medicare Plus plan available to you. Employer plans may have different benefits and premiums than other plans described here.

If you are a Medicare-eligible federal government retiree, you may enroll in Kaiser Permanente Medicare Plus for Federal Members. It’s a great value because you keep your Kaiser Permanente federal plan but, for the same premium, you pay lower copays than active employees. What’s more:

  • no copays for preventive care under both the High and Standard Option plans
  • no copays on the High Option plan for other office visits
  • reduced copays on both plans for most other services such as chiropractic, vision care, prescription drugs, and many other benefits.

To request a copy of the Medicare Plus for Federal Employees Summary of Benefits, please contact 1-866-415-0785 (TTY 711) for a Kaiser Permanente Medicare health plan consultant Monday through Friday, 9 a.m. to 5 p.m. Dialing this number will direct you to a licensed sales specialist.

 

Benefits, formulary, pharmacy network, provider network, premium and/or copayments/co-insurance may change on January 1 of each year.

The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Limitations, copayments, and restrictions may apply.

You must continue to pay your Medicare Part B premium and any other applicable Medicare premium(s), if not otherwise paid by Medicaid or another third party.

Our Medicare Part D drug formulary is a list of the prescription drugs that are approved for coverage by Kaiser Permanente's Medicare health plan. Learn more about our Part D drug formulary below.

2014 Kaiser Permanente Medicare Part D formulary

The Kaiser Permanente comprehensive formulary is a list of covered Part D drugs representing the prescription therapies believed to be a necessary part of a quality treatment program. The formulary is selected in consultation with a team of Kaiser Permanente health care providers. Our formulary includes all drugs that can be covered under Medicare Part D according to Medicare requirements.

Download the Kaiser Permanente comprehensive formulary.♦

This formulary will be effective 03/2014.

Download the enhanced formulary list for group members

Using the formulary

After downloading the formulary, there are several ways to find your Part D drug and the tier level it is in.

  • Medical condition. If you know the condition treated by your drug, you can look under category name. For example, drugs used to treat a heart condition are listed under “Cardiovascular Drugs.”
  • Alphabetical listing. If you are not sure of the category, look in the index, which provides an alphabetical list of all brand-name and generic drugs in the formulary.
  • Search. Use Control + “F” (hold down the Control and “F” keys) to call up the search box. Type in the name of your drug and press “Enter” to be taken to its listing in the formulary.

Our plan will generally cover any drug listed on our formulary as long as:

  • your benefit plan includes Part D prescription drug coverage
  • the drug is medically necessary
  • the prescription is filled at a Kaiser Permanente or affiliated pharmacy
  • other plan rules are followed

We cover both brand-name drugs and generic drugs. Generic drugs have the same active-ingredient formula as a brand-name drug. Generic drugs usually cost less than brand-name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand name drugs.

Each Part D drug on our formulary is assigned a drug tier level:

Tier 1 — preferred generic drugs
Tier 2 — nonpreferred generic drugs
Tier 3 — preferred brand-name drugs
Tier 4 — nonpreferred brand-name drugs
Tier 5 — specialty-tier drugs
Tier 6 — injectable Part D vaccines

Generally, the cost sharing you will pay for your drugs depends on your coverage stage, the type of pharmacy where you purchase your drugs, and your drug’s cost-sharing tier on our formulary. Please refer to your Evidence of Coverage for the details about your Medicare Part D prescription drug coverage, including your cost-sharing amounts.

If you are in an employer-sponsored group plan, your Part D benefits and coverage may be different. You should check your group Evidence of Coverage or other plan materials for details.

For information on how to fill your prescriptions, please review your Evidence of Coverage.

Changes to the formulary

Kaiser Permanente may add or remove drugs from the formulary during the year. The formulary on this page is the most current.

Generally, if you are taking a drug that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the coverage year except when a new, less expensive generic drug becomes available or if we receive information from the FDA that a drug is no longer safe or effective.

Other types of formulary changes, such as removing a drug, will not affect members currently taking the drug. The drug will remain available at the same cost for the remainder of the coverage year.

We will notify members affected by changes at least 60 days before the date that the change becomes effective, or at the time the member requests a refill of the drug (at which time the member will receive a 60-day supply of the drug). Examples of changes include the following:

  • removing drugs from our formulary
  • adding prior authorization
  • moving a drug to a higher cost-sharing tier

If the FDA deems a drug on our formulary to be unsafe, or if the drug’s manufacturer removes the drug from the market, we immediately will remove the drug from our formulary and notify members who take the drug.

We also will notify you of formulary changes through the Provision of Notice or Explanation of Benefits, which will detail all your pharmacy transactions and annual accumulations.

For current information about the drugs covered by Kaiser Permanente, contact us 7 days a week, 8 a.m. to 8 p.m. at: 1-888-777-5536 (toll free) TTY 711

Getting an exception to the formulary

If there are certain restrictions or limitations on a Part D drug, you can:

  • Ask your Kaiser Permanente or affiliated provider to prescribe a similar drug that is included on our formulary.
  • Ask us to waive coverage restrictions such as a prior authorization on your Part D drug.
  • Ask us to cover a Part D formulary drug at a lower cost-sharing level if this drug is not on the specialty tier (Tier 5), subject to our tiering exception process. If approved, this would lower the amount you may pay for your drug.

Generally we will only approve your request for an exception if the alternative drugs included on our formulary, the lower-tiered drug, or additional utilization restrictions would not be as effective in treating your condition or would cause you to have adverse medical effects.

When you are requesting a utilization restriction or tiering exception, you or your Kaiser Permanente or affiliated provider should submit a physician statement supporting your request.

Generally, we must make our decision within 72 hours of getting your request for a coverage decision as long as we have your prescribing physician’s supporting statement.

You can request an expedited (fast) exception if you or your Kaiser Permanente or affiliated provider believes that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get your prescribing physician’s supporting statement.

Note: You can request an exception only for drugs that are considered Medicare Part D prescription drugs by the Centers for Medicare & Medicaid Services (CMS). You cannot get an exception for drugs that are excluded under Medicare Part D or for obtaining a brand-name drug (Tier 3) at the cost sharing that applies to generic drugs.

Please refer to your Evidence of Coverage for more information about requesting exceptions, including the appeals process.

If your Kaiser Permanente or affiliated provider does not grant a utilization or tiering exception, you may request a coverage determination, which is an initial decision we make about whether we will cover a Medicare Part D drug and the amount you are required to pay.

For complete information on how to request a coverage determination, please refer to the Evidence of Coverage or go to our section on grievances, coverage determinations, and appeals.

Kaiser Permanente’s Transition Process for Medications

In rare cases, you might be taking Medicare Part D drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it may be limited. For example, you may need a prior authorization from us before you can fill your prescription.

If this is the case, you should talk to your Kaiser Permanente or affiliated provider about switching to an appropriate drug that we cover. Your Kaiser Permanente or affiliated provider also may request a utilization or tiering exception for the drug you take. We may cover your drug in certain cases during the first 90 days you are a new member of our plan.

If your ability to get your drugs is limited, we will cover a temporary 1-month supply (unless you have a prescription written for fewer days) when you go to a Kaiser Permanente or affiliated pharmacy. After your first 1-month supply, we may cover an additional refill, as medically necessary. After you have used these refills, we will not pay for these drugs.

If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with up to a 98-day transition supply, consistent with the dispensing increment (unless you have a prescription written for fewer days). We will cover more than 1 refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary, or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, then we will cover a 31-day emergency supply of that drug (unless you have a prescription written for fewer days) while you pursue an exception.

If, as a current member of our plan, you have a covered inpatient stay in the hospital or in a skilled nursing facility, then drugs you obtain during your stay will be covered under your medical benefit rather than your Medicare Part D prescription drug coverage. When you are discharged home or to a custodial level of care at a long-term care facility, many outpatient prescription drugs you obtain at a pharmacy will be covered under your Medicare Part D coverage.

Because coverage is different depending on where you obtain the drug, it is possible that a drug covered under your medical benefit might not be covered by Medicare Part D (for example, over-the-counter drugs, or cough medicine). If this happens, you will have to pay full price for that drug unless you have other coverage (for example, employer-sponsored group coverage).

Please refer to your Evidence of Coverage for more information about our transition policy and drugs not covered by Medicare Part D.

Kaiser Permanente and affiliated pharmacies

You must use a Kaiser Permanente or affiliated pharmacy to get your prescription drug benefit except in limited, non-routine circumstances. Generally, you may find a pharmacy at the Kaiser Permanente medical office or center where you see your primary care provider or specialist. However, you can fill or refill a prescription at any Kaiser Permanente or affiliated pharmacy or through our mail-order pharmacy service.

We operate our own pharmacies and contract with affiliated pharmacies that equal or exceed CMS requirements for pharmacy access in your area. The Kaiser Permanente pharmacy network has 29 pharmacies in the Mid-Atlantic States region.

To locate a Kaiser Permanente or affiliated pharmacy nearest you, please refer to our Pharmacy Directory

To fill your prescription at a Kaiser Permanente or affiliated pharmacy, you must show your Kaiser Permanente Medicare Plus Member ID card and photo identification to receive it at your Medicare Part D cost share. If you do not have your ID card with you when you fill your prescription, or if you receive a prescription from a non-Plan, non-affiliated provider in conjunction with covered emergency care or out-of-area urgent care, then you may have to pay the full cost of the prescription.

If this happens, you can ask us to reimburse you for our share of the cost by submitting a paper claim to us. To find out how to submit a claim, see your Evidence of Coverage. 

You will receive a statement by mail called the Explanation of Benefits (EOB) for any month you use your Medicare Part D benefits. (See an example of the EOB and find out more about how to receive your EOB electronically.) The EOB will list all Medicare Part D transactions from the previous month and display what you’ve spent (total out-of-pocket expenses) and what your total drug costs are year-to-date. If there are formulary changes within a 60-day period, we will notify you by mail through a Provision of Notice or your Explanation of Benefits.

Out-of-network pharmacy coverage

Generally, we only cover drugs filled at an out-of-network pharmacy in limited, non-routine circumstances when a Kaiser Permanente or affiliated pharmacy is not available.

For example, if you are traveling within the United States and its territories but outside the service area and you become ill or run out of your covered drugs, we will cover prescriptions filled at an out-of-network pharmacy in limited circumstances according to our Part D formulary guidelines.

If you need a Medicare Part D prescription drug in conjunction with covered out-of-network emergency care or out-of-area urgent care, we will cover up to a 30-day supply from an out-of-network pharmacy.

Note: Prescription drugs prescribed and provided outside of the United States and its territories as part of covered emergency or urgent care are covered up to a 30-day supply in a 30-day period. These drugs are not covered under Medicare Part D; therefore, payments for these drugs do not count toward reaching the catastrophic coverage stage.

We also will cover Medicare Part D drugs on our formulary that you obtain at an out-of-network pharmacy if one or both of the following applies:

  • You are unable to obtain a covered drug in a timely manner within our service area because there is no Kaiser Permanente or affiliated pharmacy within a reasonable driving distance that provides 24-hour service. We may not cover your prescription if a reasonable person could have purchased the drug at a Kaiser Permanente or affiliated pharmacy during normal business hours.
  • You are trying to fill a prescription for a drug not regularly stocked at an accessible Kaiser Permanente or affiliated pharmacy or available through our mail-order pharmacy (including high-cost drugs)

In these situations, you will have to pay the full cost (rather than paying just your Medicare Part D cost share) when you fill your prescription. You can ask us to reimburse you for our share of the cost by submitting a paper claim.

For complete information about out-of-network pharmacy coverage or how to file a paper claim, please refer to your Evidence of Coverage.

Rx refills and mail-order services

Save time and energy by conveniently ordering prescription refills online, by mobile app, or by calling the phone number on your prescription label.

Prescription refills can be mailed to your home at no extra charge or you may designate the Kaiser Permanente or affiliated pharmacy where you want to pick up and pay for your prescription.

To order online, you will need to register for a secure kp.org account if you have not done so already. (You also can set up mail-order services at your Kaiser Permanente or affiliated pharmacy.)

Once you have registered, you can order prescription refills online, either through kp.org or by using our mobile app (available for download at Google Play™ and the Apple App Store).

If you don’t want to order online, you can:

  • Call our EZ Refill Line at 1-800-700-1479 (toll free), 24 hours a day, 7 days a week, or TTY 703-466-4805, Monday through Friday, 8 a.m. to 7 p.m. Select the mail-delivery option when prompted.
  • Fax your refill request to 703-466-4901 or toll free 877-260-0012.
  • Mail your prescription refill request on a mail-order form that is available at any Kaiser Permanente pharmacy.

Mail-order services

When you order prescription refills by mail, there’s no extra charge for postage and your costs may be lower for a 3-month supply. Please look in your Evidence of Coverage for details.

Most covered Medicare Part D drugs can be refilled using our mail-order service, but there are some exceptions. Certain drugs that require special handling or packaging are not provided through our mail-order service, such as:

  • drugs that are time- or temperature-sensitive
  • drugs that we identify as unmailable
  • certain high-cost drugs
  • drugs that require professional administration or observation

Items available through our mail-order service are subject to change at any time without notice and may be subject to state and other licensing restrictions. Please check with your Kaiser Permanente or affiliated pharmacy or mail-order pharmacy if you have a question about whether or not your prescription can be mailed.

Note: Prescription drugs that you get through a mail-order service other than Kaiser Permanente are not covered.

Please allow up to 3-5 business days for delivery of your prescription by mail. If you have no refills left, it may take an additional 48 hours for us to contact your Kaiser Permanente or affiliated provider to confirm your prescription refill.

If your mail-order prescription is delayed, please contact the number listed on the prescription label on the bottle or call 1-800-733-6345 (toll free) for assistance Monday through Friday 8 a.m. to 7 p.m.

For more information about our mail-order services, please look in your Evidence of Coverage.

Medicare medication therapy management

Kaiser Permanente provides a medication therapy management (MTM) program for current Medicare Part D members who have multiple medical conditions for which they are taking a number of prescription drugs and meet an annual medication cost threshold.

The MTM program is not a benefit, but is an extra service offered at no additional cost to eligible members who qualify. This program has been developed for Kaiser Permanente by a team of pharmacists and doctors to help us provide better care for our members. Specially trained pharmacists will work with you and your doctor to ensure that the medications you take are necessary, safe, and effective. Our pharmacists will be able to help you over the phone.

Am I eligible for the MTM Program?

The following will determine if you are eligible for the MTM program:

If you have three (3) or more of the following medical conditions:

  • high cholesterol
  • high blood pressure
  • coronary artery disease
  • diabetes
  • stroke
  • rheumatoid arthritis
  • chronic obstructive pulmonary disease
  • osteoporosis

If you are taking five (5) or more of the following Part D medications:

  • drugs for high cholesterol (e.g. atorvastatin)
  • drugs for high blood pressure (e.g. lisinopril, hydrochlorothiazide)
  • drugs for diabetes (e.g. metformin, insulin)
  • drugs for rheumatoid arthritis (e.g. etanercept)
  • bronchodilators (e.g. albuterol)
  • inhaled corticosteroids (e.g. bethamethasone)
  • osteoporosis agents (e.g. alendronate)

You spend more than $3017 per year on Part D medications.

You may complete this Personal Medication form♦ for your records and to share with your Kaiser Permanente or affiliated provider. Or we may contact you and ask you to complete one over the phone.

How will I know if I qualify?

You or your authorized representative will receive a letter describing our MTM program with a phone number to call to set up your Comprehensive Medication Review (CMR) with our pharmacist. You may also receive a follow-up reminder by phone or through an automated voice message system.

During the CMR call, our staff will ask about your prescription medications you take along with any over-the-counter medications, herbal and/or dietary supplements.

The pharmacist will review your medications and determine if there are any medication-related opportunities (such as reducing side effects, harmful drug interactions or lower drug costs). You will receive an individualized, written summary that includes a personal medication list and medication action plan that will help you get the most out of your medications.

Your current medications will be updated in our electronic medical record, which will be readily available and accessible to your doctor and others on your health care team.

We recommend that you take full advantage of this MTM service if you qualify. Remember, you don’t need to pay anything extra to participate. Please call our Member Services for more information.

Please review this MTM flyer♦ or contact Kaiser Permanente Medicare Plus for more details about qualifying for this free program.

Extra help for Medicare Part D drugs

Are you a Kaiser Permanente Medicare Plus (Cost) member with limited income and resources?

People with limited incomes may qualify for extra help to pay for their prescription drug costs: the low-income subsidy, or LIS.

If eligible, Medicare could pay for up to 75 percent or more of your drug costs including monthly prescription drug premiums, annual deductibles, and coinsurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don’t even know it.

We can help you find out if you are eligible. If you qualify, you may have lower monthly premiums for the prescription drug coverage under your Kaiser Permanente plan. You also may have lower cost sharing for your prescriptions. Visit our BenefitsCheckUp website† to see if you might be eligible for the LIS — and for other programs that can help you save money and cover everyday expenses.

You also may call:

  • Member Services at 1-888-777-5536 (toll free) or TTY 711, 7 days a week, from 8 a.m. to 8 p.m., or call:
  • Social Security at 1-800-772-1213 (toll free) between 7 a.m. and 7 p.m., Monday through Friday, or 1-800-325-0778 (toll-free TTY for the hearing/speech impaired). Or visit the Social Security website†.
  • your state Medi-Cal office

For general information about extra help, please call 1-800-MEDICARE (1-800-633-4227) (toll free), or 1-877-486-2048 (toll-free TTY for the hearing/speech impaired), 24 hours a day, 7 days a week. Or visit the Medicare website†.

How much will I pay?

If you continue to qualify for the same level of help next year, then the table tells you how your prescription costs will change.

If you pay this much this year (2013)You will pay this much next year (2014)
$0 deductible$0 deductible
$66 deductible$63 deductible
$1.15 for generics and brands that are treated as generics
$3.50 for brand-name drugs
$1.20 for generics and brands that are treated as generics
$3.60 for brand-name drugs
$2.65 for generics and brands that are treated as generics
$6.60 for brand-name drugs
$2.55 for generics and brands that are treated as generics
$6.35 for brand-name drugs
No more than 15% coinsurance for all drugsNo more than 15% coinsurance for all drugs

Note: If the copayment, coinsurance, or deductible amount listed in your “Evidence of Coverage Rider for Those Who Receive Extra Help Paying for Their Prescription Drugs” is less than the amount listed above, then you will pay the lower amount.

The amount of extra help you get will determine your total monthly plan premium and your prescription drug cost sharing as a member of the Kaiser Permanente Medicare Plus plan. For details, refer to the “Evidence of Coverage Rider for Those Who Receive Extra Help Paying for Their Prescription Drugs.”

You may get (or may have gotten) a letter from Medicare or Social Security about your 2014 eligibility for extra help. Read this information carefully. If you don’t know what level of extra help you qualify for, you can call 1-800-MEDICARE (1-800-633-4227) (toll-free), or 1-877-486-2048 (toll-free TTY for the hearing/speech impaired), 24 hours a day, 7 days a week.

2014 LIS premium summary chart

The tables below show you what your monthly plan premium will be if you get extra help. (This does not include any Medicare Part B premium you may have to pay.) The monthly plan premiums listed include coverage for both medical services and prescription drug benefits. . You must continue to pay your Medicare Part B premium and any other applicable Medicare premium(s), if not otherwise paid by Medicaid or another third party.

Your level of extra helpMonthly premium for High Option with Part D (AB)Monthly premium for Standard Option with Part D (AB)Monthly premium for Standard Option with Part D (B only)
100%$82.20$12.90$347.20
75%$89.90$13.40$354.90
50%$97.60$13.90$362.60
25%$105.30$14.50$370.30

Best available evidence

If you think you are eligible for Medicare’s extra help and that you are not paying the correct monthly premium or costs for your drugs, you or your appointed representative may be able to correct your Medicare records by providing us with information, known as best available evidence (BAE), about your eligibility for extra help.

When we receive and verify your BAE, we will share it with Medicare and also update our records within three business days. You also will need to provide the information to a Kaiser Permanente or affiliated pharmacy when you obtain prescriptions so that we can charge you the appropriate cost-sharing amount until Medicare updates its records to reflect your current status.

Acceptable examples of BAE documents include copies of the following:

  • your state Medicaid card
  • your extra help Social Security award letter
  • Supplemental Security Income (SSI) Notice of Award with an effective date
  • a state document that confirms your active Medicaid status
  • other official state documentation showing your Medicaid status
  • a Home and Community-Based Services (HCBS) Notice that includes your name and HCBS eligibility date

For members who are institutionalized or in a long-term care facility, an appointed representative can provide a copy of the following BAE examples:

  • a remittance from the facility showing Medicaid payment for a full calendar month with that individual’s name on the statement
  • a copy of a state document that confirms Medicaid payment to the facility for a full calendar month on behalf of the individual
  • a screen printout from the state's Medicaid information system showing that individual's institutional status based on at least a full calendar month stay for Medicaid payment purposes

You or your appointed representative can mail a copy of your BAE document with your medical or health record number to:

Kaiser Permanente
California Service Center
Attn: Best Available Evidence
P.O. Box 232407
San Diego, CA 92193-2407

Or you may fax it to 1-877-528-8579 (toll free).

Or you may bring it to your local Member Services department.

If you have additional questions about BAE or need assistance if you don’t have documentation, please call Member Services Department or visit the CMS Best Available Evidence page†

Quality assurance and Drug utilization management

Quality assurance

Kaiser Permanente has established quality assurance measures and systems to reduce medication errors and adverse drug interactions, and improve medication use.

We have policies and procedures that define standards for pharmacy practice as required by state and federal laws. They include:

  • drug utilization review systems designed to ensure that a review of your drug therapy is performed before each prescription is dispensed, to check for issues such as potential drug therapy problems, drug-drug interactions, and drug-allergy interactions
  • computerized drug utilization review systems designed to ensure ongoing periodic examination of prescription data and other records in order to identify drug therapy problems among Medicare Plus members
  • medication error identification and reduction systems
  • reporting of our quality assurance practices to the Centers for Medicare & Medicaid Services (CMS)

For quality-of-care issues, an enrollee may file a grievance with Kaiser Permanente, a written complaint with the quality improvement organization (QIO), or both. The QIO review of a quality-of-care issue is separate and distinct from Kaiser Permanente's Medicare Part D grievance procedures. You may file a complaint with the local QIO by writing to:

QIO for District of Columbia and Maryland:
Delmarva Foundation for Medical Care
9240 Centreville Road
Easton, MD 21601

You may contact the QIO at 410-822-0697 or toll-free at 1-800-999-3362 (TTY 711) from 8 a.m. to 5 p.m., Monday through Friday.

QIO for Virginia
Virginia Health Quality Center
9830 Mayland Drive, Suite J
Richmond, VA 23233

You may contact the QIO at 804-289-5320 or toll-free 1-800-545-3814 (TTY 711), from 8 a.m. to 5 p.m., Monday through Friday.

Drug utilization management

Kaiser Permanente may have requirements, restrictions, or limits on certain covered prescription drugs for coverage. These are developed by a team of doctors and pharmacists to control drug plan costs and to help ensure that our members use the drugs safely and in the most effective way.

This means that you may need to get prior authorization from us for certain drugs before you fill your prescriptions. If you don’t get approval, we may not cover the drug.

Drugs needing prior authorization may be covered under Medicare Part B or Part D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. Prior authorization may also apply to drugs in which treatment for the medical condition will determine if the drug is non-Part D (excluded) or covered.

Note: For certain drugs, we may limit the amount of an extended day supply (amounts that exceed a one month supply) that you can receive. Also, if there is a shortage in the marketplace, we may charge 1 Part D cost share for a limited quantity.

You can find out if your drug is subject to these requirements or limits by looking in the Kaiser Permanente comprehensive formulary.

Reporting suspected fraud

We encourage our members, as well as our vendors and others, to let us know of any situation at Kaiser Permanente that may be unlawful. If we know about such a situation, we can investigate and take action to protect our members and our health care resources.

If you believe you've experienced fraud (or are aware of a fraud, waste, or abuse matter involving Kaiser Permanente members or resources), please contact Member Services.

You can also contact Medicare for fraud-related questions and concerns at:

Phone
1-800-HHS-TIPS (1-800-447-8477) (toll free)

Fax
1-800-223-8164 (toll free)

TTY (toll-free for the hearing/speech impaired)
1-800-377-4950

Email
HHSTips@oig.hhs.gov

Mailing address
Office of Inspector General
Department of Health and Human Services
Attn: HOTLINE
330 Independence Ave., SW
Washington, DC 20201

Grievances, coverage determinations, and appeals

We encourage you to let us know right away if you have questions, concerns, or problems related to your covered services or the care you receive by contacting Member Services at 1-888-777-5536 (toll free) or TTY 711, 7 days a week, from 8 a.m. to 8 p.m.

Representatives will help determine how your concern should be handled — as a grievance, a coverage determination, or an appeal.

  • A grievance is a type of complaint about our plan or one of our Kaiser Permanente or affiliated providers or pharmacies that concerns the quality of your care. It does not involve coverage or payment disputes.
  • A coverage determination is an initial decision we make about whether a drug prescribed for you is covered by us and the amount you are required to pay.
  • An appeal can be made if you disagree with a decision to deny a request for Part D drugs, or a decision to deny payment for drugs.

We will respond to your concerns as quickly as possible through our coverage determination and appeals process, which is detailed below and also in your Evidence of Coverage.

Coverage determinations

A coverage determination may be requested by you, your appointed representative, your Kaiser Permanente or affiliated provider, or other prescriber.

If you name someone to act on your behalf as your appointed representative, then you and that person must sign and date a statement that gives the person legal permission to act as your appointed representative♦.

To request an exception, you, your appointed representative, your Kaiser Permanente or affiliated provider, or other prescriber may use the CMS coverage determination form♦ to provide substantiation supporting your request. Use of this form is not required as long as the information from the form is included in the request.

A coverage determination may be requested in the following ways:

  • by calling Member Services at 1-888-777-5536 or TTY 711, 7 days a week, 8 a.m. to 8 p.m.
  • by faxing the completed form or information to 301-879-6177
  • by mailing the completed form or information to:

Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc.
Attn: Medicare Appeals and Grievances Unit
2101 East Jefferson St.
Rockville, MD 20852

A decision about whether we will cover a drug can be either a standard decision, which is made within 72 hours after receipt of your physician’s supporting statement (only for drugs which you have not yet received), or an expedited (fast) decision, which is made within 24 hours. Note: The decision time frame does not begin until our plan receives the completed and signed statement.

You can ask for an expedited decision only if your Kaiser Permanente or affiliated provider states that waiting for a standard decision could seriously harm your life, health, or ability to regain maximum function. Expedited decisions apply only if you are requesting coverage for drugs that you have not received.

You may also submit reimbursement requests for Part D drugs purchased at an out-of-network pharmacy or if you believe you were incorrectly charged through our coverage determination process. We will notify you of our decision within 14 calendar days of receipt of your request. If we approve your request, payment will be made within 14 calendar days as well.

If the request for an expedited review is made by or supported by your prescribing Kaiser Permanente or affiliated provider, we will automatically follow the fast time frames. If you make the request for an expedited review yourself and we do not grant it, we will automatically transfer your request to the standard 72-hour time frame.

If we deny your expedited review by phone, you can request a 24-hour expedited grievance at that time if you disagree with our decision. Otherwise, we will send you a letter within 3 calendar days after we call you with information on how to file the expedited grievance. It also will explain that we will automatically give you an expedited decision if you get the prescribing Kaiser Permanente or affiliated provider’s support for an expedited review.

If you or your prescribing Kaiser Permanente or affiliated provider has any questions about this process or want to check on the status of a request, please call Member Services.

Appeals

If you disagree with our coverage determination about your drug, you have the right to file an appeal, also called a plan “redetermination.” You must request an appeal within 60 days from the date of our denial notice, unless you show good cause for a delay past 60 days.

You must file your request for a standard appeal in writing at the address shown on your denial notice. You have the right to give us new information to support your appeal by telephone or fax, in writing, or by hand-delivering it to your local Member Services department.

Note: Delivery of information by hand does not mean our plan provides in-person hearings for enrollees.

An appeal may be filed either as a written standard request or as an expedited (fast) request, which may be filed in writing or by contacting us by telephone or fax at the numbers provided in your coverage determination denial letter.

You also may complete the coverage redetermination form♦ and fax it to Appeals and Grievances fax line at 1-301-816-6192 or mail it to the following address:

Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc.
Attn: Medicare Appeals and Grievances Unit
2101 East Jefferson Street
Rockville, MD 20852

A standard appeal decision will be made within 7 calendar days. If our decision is fully in your favor, we must authorize the service within 7 days and/or make the payment within 30 calendar days after we receive your appeal.

If waiting for a standard decision could seriously harm your life, health, or ability to regain maximum function, you or your prescribing Kaiser Permanente or affiliated provider may request an expedited appeal for a decision within 72 hours. The fast appeal process does not apply to denied claims for payment.

Whom to contact for inquiries

If you have questions or concerns about services or the care you receive, problems with a particular Medicare Part D prescription drug, or appointing a representative, if necessary, to handle your coverage determination or appeal, please call Member Services at 1-888-777-5536 or TTY 711 for the hearing/speech impaired, 7 days a week, from 8 a.m. to 8 p.m. You also may use the online Medicare Complaint Form† to transmit a complaint directly to Medicare.

Aggregate number of grievances, appeals, and exceptions

You may obtain a summary of information about the appeals and grievances that plan members have filed with Kaiser Permanente. To get this information, please call Member Services.

Your options upon disenrollment

If you leave Kaiser Permanente Medicare Plus, you have other options for obtaining prescription drug coverage.

  • Medicare Prescription Drug Plan (PDP). This plan adds prescription drug benefits to your Original Medicare coverage. To enroll in a Prescription Drug Plan in your area, you must be entitled to Medicare benefits under Part A and/or currently enrolled in Part B, and reside in the service area of the Prescription Drug Plan.
  • Medicare Advantage Prescription Drug Plan (MA-PD). You can join a Medicare Advantage plan with prescription drug coverage if it is available in your area, accepting new members, and if you meet the plan’s eligibility requirements.

If you choose to join a Medicare Advantage plan that offers prescription drug coverage, then you must obtain your Medicare prescription drug coverage through that Medicare Advantage plan.

Disenrollment from Medicare health plan is subject to CMS enrollment rules. For more information about disenrolling from our plan, please review Chapter 10 in your Evidence of Coverage.

For more information about your rights and responsibilities, please review Chapters 8 and 10 in your Evidence of Coverage. If you have questions about joining a Medicare Advantage plan in your area, contact 1-800-MEDICARE (1-800-633-4227) (toll free), or 1-877-486-2048 (toll-free TTY for the hearing/speech impaired), 24 hours a day, seven days a week. Or visit the Medicare website†.

Note: If you go without a Medicare drug plan or other creditable prescription drug coverage† for a continuous period of 63 days or more, you may have to pay a late enrollment penalty when you enroll in a Medicare Part D plan later.

2014 Evidence of Coverage (EOC)

Kaiser Permanente Medicare Plus (Cost) for Maryland

EOC for 2014 MD Kaiser Permanente Medicare Plus High Option Plan with Part D, A&B

EOC for 2014 MD Kaiser Permanente Medicare Plus Standard Option Plan with Part D, A&B

EOC for 2014 MD Kaiser Permanente Medicare Plus Standard Option Plan with Part D, B Only

EOC for 2014 MD Kaiser Permanente Medicare Plus High Option Plan without Part D, A&B

EOC for 2014 MD Kaiser Permanente Medicare Plus Standard Option Plan without Part D, A&B

EOC for 2014 MD Kaiser Permanente Medicare Plus Basic Option Plan without Part D, A&B

EOC for 2014 MD Kaiser Permanente Medicare Plus Basic Option Plan without Part D, B Only

Kaiser Permanente Medicare Plus (Cost) for Virginia

EOC for 2014 VA Kaiser Permanente Medicare Plus High Option Plan with Part D, A&B

EOC for 2014 VA Kaiser Permanente Medicare Plus Standard Option Plan with Part D, A&B

EOC for 2014 VA Kaiser Permanente Medicare Plus Standard Option Plan with Part D, B Only

EOC for 2014 VA Kaiser Permanente Medicare Plus High Option Plan without Part D, A&B

EOC for 2014 VA Kaiser Permanente Medicare Plus Standard Option Plan without Part D, A&B

EOC for 2014 VA Kaiser Permanente Medicare Plus Basic Option Plan without Part D, A&B

EOC for 2014 VA Kaiser Permanente Medicare Plus Basic Option Plan without Part D, B Only

Kaiser Permanente Medicare Plus (Cost) for Washington, D.C.

EOC for 2014 DC Kaiser Permanente Medicare Plus High Option Plan with Part D, A&B

EOC for 2014 DC Kaiser Permanente Medicare Plus Standard Option Plan with Part D, A&B

EOC for 2014 DC Kaiser Permanente Medicare Plus Standard Option Plan with Part D, B Only

EOC for 2014 DC Kaiser Permanente Medicare Plus High Option Plan without Part D, A&B

EOC for 2014 DC Kaiser Permanente Medicare Plus Standard Option Plan without Part D, A&B

EOC for 2014 DC Kaiser Permanente Medicare Plus Basic Option Plan without Part D, A&B

EOC for 2014 DC Kaiser Permanente Medicare Plus Basic Option Plan without Part D, B Only

Do we speak your language?

We have interpreters available, at no cost, for more than a dozen languages. Learn more about our multi-language interpreter services♦ that are just a toll-free phone call away.

Contact information
  • Current members or prospective members requesting health plan benefit information or who have questions about Medicare prescription drug expenses may call Member Services at 1-888-777-5536 or TTY 711, 7 days a week, 8 a.m. to 8 p.m.

    Or mail any written correspondence to

    Kaiser Permanente
    2101 East Jefferson St.
    Rockville, Maryland 20852

  • For questions about your medications, please consult your Kaiser Permanente or affiliated provider, or contact your local Kaiser Permanente or affiliated pharmacy at the number listed on your prescription label.
  • For more information about Medicare prescription drug coverage, call 1-800-MEDICARE (1-800-633-4227) (toll free) or 1-877-486-2048 (toll-free TTY for the hearing/speech impaired), 24 hours a day, 7 days a week. Or visit the Medicare website.

 

Benefits, formulary, pharmacy network, provider network, premium, and copayments/co-insurance may change on January 1 of each year.

The benefit information provided herein is a brief summary, not a comprehensive description of benefits. For more information contact the plan. Limitations, copayments, and restrictions may apply.

You must reside in the Kaiser Permanente Medicare health plan service area in which you enroll.

The following information describes the advantages of Kaiser Permanente so you can choose the Medicare health plan that’s right for you.

Plan documents

Medicare plan rating sheet

Medicare Part D prescription drug abridged formulary

Summary of Benefits

Kaiser Permanente Medicare Plus Standard and High Option plans with Part D for those with Medicare Parts A&B

Kaiser Permanente Medicare Plus Basic, Standard, and High Option plans without Part D for those with Medicare Parts A&B

Kaiser Permanente Medicare Plus Basic Option without Part D for those with Part B only

Kaiser Permanente Medicare Plus Standard Option with Part D for those with Part B only

Evidence of Coverage

Maryland

EOC for 2014 MD Kaiser Permanente Medicare Plus High Option Plan with Part D, A&B

EOC for 2014 MD Kaiser Permanente Medicare Plus Standard Option Plan with Part D, A&B

EOC for 2014 MD Kaiser Permanente Medicare Plus Standard Option Plan with Part D, B Only

EOC for 2014 MD Kaiser Permanente Medicare Plus High Option Plan without Part D, A&B

EOC for 2014 MD Kaiser Permanente Medicare Plus Standard Option Plan without Part D, A&B

EOC for 2014 MD Kaiser Permanente Medicare Plus Basic Option Plan without Part D, A&B

EOC for 2014 MD Kaiser Permanente Medicare Plus Basic Option Plan without Part D, B Only

Virginia

EOC for 2014 VA Kaiser Permanente Medicare Plus High Option Plan with Part D, A&B

EOC for 2014 VA Kaiser Permanente Medicare Plus Standard Option Plan with Part D, A&B

EOC for 2014 VA Kaiser Permanente Medicare Plus Standard Option Plan with Part D, B Only

EOC for 2014 VA Kaiser Permanente Medicare Plus High Option Plan without Part D, A&B

EOC for 2014 VA Kaiser Permanente Medicare Plus Standard Option Plan without Part D, A&B

EOC for 2014 VA Kaiser Permanente Medicare Plus Basic Option Plan without Part D, A&B

EOC for 2014 VA Kaiser Permanente Medicare Plus Basic Option Plan without Part D, B Only

Washington, D.C.

EOC for 2014 DC Kaiser Permanente Medicare Plus High Option Plan with Part D, A&B

EOC for 2014 DC Kaiser Permanente Medicare Plus Standard Option Plan with Part D, A&B

EOC for 2014 DC Kaiser Permanente Medicare Plus Standard Option Plan with Part D, B Only

EOC for 2014 DC Kaiser Permanente Medicare Plus High Option Plan without Part D, A&B

EOC for 2014 DC Kaiser Permanente Medicare Plus Standard Option Plan without Part D, A&B

EOC for 2014 DC Kaiser Permanente Medicare Plus Basic Option Plan without Part D, A&B

EOC for 2014 DC Kaiser Permanente Medicare Plus Basic Option Plan without Part D, B Only

Multi-language interpreter services

Enrollment form

Kaiser Permanente Medicare Plus Individual plan enrollment form

Directories

Provider directory

Pharmacy directory

Annual Notice of Changes (ANOC)

ANOC for Kaiser Permanente Medicare Plus High Option Plan with Part D, A&B

ANOC for Kaiser Permanente Medicare Plus Standard Option Plan with Part D, A&B

ANOC for Kaiser Permanente Medicare Plus Standard Option Plan with Part D, B Only

ANOC for Kaiser Permanente Medicare Plus High Option Plan without Part D, A&B

ANOC for Kaiser Permanente Medicare Plus Standard Option Plan without Part D, A&B

ANOC for Kaiser Permanente Medicare Plus Basic Option Plan without Part D, A&B

ANOC for Kaiser Permanente Medicare Plus Basic Option Plan without Part D, B Only


♦You will need the free Adobe Acrobat Reader† to read this file.
†Kaiser Permanente is not responsible for the content or policies of external Internet sites.



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