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Kaiser Permanente Contra Costa Medicare health plans & rates for 2016

 

5 stars

This plan received Medicare's highest possible rating (5 stars) for 2016*

Kaiser Permanente Senior Advantage (HMO) Individual plans

Areas covered by this plan are noted beneath the tables.

2016 benefits highlights


Effective January 1, 2016, to December 31, 2016

Premiums and Benefits

Kaiser Permanente Senior Advantage
Contra Costa (HMO)

DESCRIPTION

YOU PAY

Monthly Premium

$86

Annual Maximum Out-of-Pocket

$4,400

Annual Deductible

None

Doctor Office Visit Copay

$25 Primary / $25 Specialist

Emergency Room Copay

$75

Urgent Care Copay

$25

Preventive Services1

No charge

Inpatient Hospitalization

$275 per day for days 1–7 of your stay.

Thereafter, no charge for the remainder of your stay.

Outpatient Surgery Copay

$250

Skilled Nursing Facility Copay
Up to 100 days per benefit period

$0 per day for days 1–20
$50 per day for days 21–100

Lab, X-ray, Imaging Copay

$35 Lab, $60 X-ray, $60 - $205 Ultrasound, MRI, PET, CT scans

Durable Medical Equipment

20% coinsurance

Ambulance Service
Per one-way trip

$200 copay

For more information about benefits, please view the 2016 Summary of Benefits.

These plans include Medicare Part D prescription drug coverage. Copay and coinsurance amounts below are for up to a month’s 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.2

Premiums and BenefitsSenior Advantage Contra Costa (HMO)

Part D Prescription Drug Coverage

DESCRIPTION

YOU PAY

(copay or coinsurance)

Initial Coverage Stage

(for up to a 30-day supply)

 

When the annual total drug costs paid by you and any Part D plan reach $3,310, you move into the Coverage Gap Stage.

$5 preferred generic

$15 generic

$45 preferred brand name

$95 nonpreferred brand name

25% coinsurance for specialty

$0 injectable Part D vaccines

Coverage Gap Stage

(for up to a 30-day supply)

 

If your annual out-of-pocket costs reach $4,850, you move into the Catastrophic Coverage Stage.

$5 preferred generic

$15 generic

You pay 45% for brand-name & specialty drugs (including a portion of the dispensing fee)

$0 injectable Part D vaccines

Catastrophic Coverage Stage

When your annual out-of-pocket costs exceed $4,850, you pay lower cost shares for the remainder of the calendar year.

$5 generic

$12 brand name & specialty

$0 injectable Part D vaccines

Our Mail-Order Pharmacy2
(Restrictions & limitations may apply)

2 copays for up to a 100-day supply

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.
1$0 copay for all preventive services covered under Original Medicare at zero cost sharing.
2For certain drugs, you can get prescription refills mailed to you through our Kaiser Permanente mail-order pharmacy. You should receive them within 10 business days. If not, please call 1-888-218-6245 (TTY 711), Monday through Friday, 8 a.m. to 6 p.m.

See which areas♦ are covered by this plan.

2016 Summary of Benefits

The Summary of Benefits is a great resource for plan information, including:

  • the monthly premium, annual deductible, and other yearly out-of-pocket costs
  • a summary ofcovered medical and hospital benefits, and prescription drugs
  • optional benefits (you must pay an extra premium for these benefits)

Summary of Benefits for Contra Costa county plan♦.
Also available in Spanish (en español)♦.

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 2016. Kaiser Permanente contract #H0524.

Benefits, premiums and/or copayments/coinsurance may change on January 1 of each year.

This information is not a complete description of benefits. Contact the plan for more information. 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 Senior Advantage Medicare Medi-Cal Plan (HMO SNP)

If you are eligible for both Medicare and full benefits under Medi-Cal, you may qualify for the Kaiser Permanente Senior Advantage Medicare Medi-Cal Plan.

  • no monthly premiums
  • no copayments for medical services, including doctor office visits with primary care physicians and specialists
  • Medicare Part D drug coverage for generic and brand-name drugs ― with very low copayments

For benefits details, see the Kaiser Permanente Senior Advantage Medicare Medi-Cal Plan Summary of Benefits♦, also available in Spanish (en español)♦, and Evidence of Coverage♦, also available in Spanish (en español)♦.

Note: Our Kaiser Permanente Senior Advantage Medicare Medi-Cal Plan is available to individual plan members only. If you are a member of a Kaiser Permanente plan through your employer or Labor & Trust organization and are interested in this plan, call us to find out how to qualify.

Anyone who has full benefits under Medi-Cal and Medicare Parts A and B, including some people under the age of 65 with disabilities, may apply.

Premiums, copays, coinsurance/cost sharing, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.

Kaiser Permanente is an HMO SNP plan with a Medicare contract and a contract with the Medi-Calprogram. Enrollment in Kaiser Permanente depends on contract renewal.

Benefits, premiums and/or copayments/coinsurance may change on January 1 of each year.

This information is not a complete description of benefits. Contact the plan for more information. 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.

2016 Kaiser Permanente Medicare Part D formulary

This comprehensive formulary is a list of covered Part D drugs used for prescription therapies, which are an important part of a quality treatment program. The formulary is selected by a team of Kaiser Permanente health care providers. Our formulary includes all drugs covered under Medicare Part D according to Medicare requirements.

Download the Kaiser Permanente comprehensive formulary♦.
Also available in Spanish (en español)♦.

This formulary is effective as of 01/2016.

Using the formulary

There are 3 ways to find your Part D drug and the tier level it’s in.

  • Search tool:
    • Windows: Hold down the Control and “F” key to call up the search box. Type the name of your drug in this search box, and press “Enter”.
    • Mac: Hold down the Command and “F” keys to call up the search box. Type the name of your drug in this search box, and press “Enter”.
  • Index (alphabetical): The index lists all brand-name and generic drugs in alphabetical order.
  • Medical condition: Drugs are grouped alphabetically by medical condition they address. Look under drug category name if you know what condition your drug treats. For example, drugs that treat heart conditions are listed under “Cardiovascular Drugs.”

Our plan usually covers all drugs listed in the formulary, as long as:

  • The drug is medically necessary.
  • Your prescription is written by a Kaiser Permanente or affiliated health care provider.
  • Your prescription is filled at a Kaiser Permanente or affiliated pharmacy.
  • Other plan rules are followed.

We cover both brand-name drugs and generic drugs. Both have the same active-ingredient formulas and are rated by the Food and Drug Administration (FDA) to be equally safe and effective, but generic drugs usually cost less.

Tier Levels

Each drug is assigned a drug tier level:

Tier 1 — preferred generic drugs
Tier 2 — generic drugs
Tier 3 — preferred brand-name drugs
Tier 4 — non-preferred brand-name drugs
Tier 5 — specialty-tier drugs
Tier 6 — injectable Part D vaccines (given as shots)

What You’ll Pay

What you’ll pay for prescriptions depends on your coverage stage, the pharmacy you go to, 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 coverage, including your cost-sharing amounts.

If you have an employer-sponsored group plan, your Part D benefits and coverage may be different. Check your group Evidence of Coverage or other plan materials for details.

Learn how to fill your prescriptions in your Evidence of Coverage.

Changes to the formulary

The formulary on this page is updated regularly and will reflect any changes that may happen during the year.

Drugs you already take usually won’t be affected by these changes. They’ll be covered at the same cost through the end of the coverage year, unless the FDA decides they’re no longer safe or effective, or a new, less expensive generic version comes out.

If your drug coverage is ever affected by a change to the formulary, we’ll either tell you 60 days before the change or give you a 60-day supply when you ask for a refill. Examples of changes that could affect you include:

  • Removing a drug from our formulary
  • Adding a requirement for prior authorization♦ (pre-approval by your doctor or our plan)
  • 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.

Kaiser Permanente will let you know about these changes through the Provision of Notice (coming soon) or Explanation of Benefits, which will also detail all your pharmacy transactions and annual accumulations.

For current information about drugs covered by Kaiser Permanente, contact us 7 days a week, 8.a.m. to 8 p.m. at:

1-800-443-0815 (toll free) TTY 711
Spanish:1-800-788-0616 (toll free) TTY 711
Chinese dialects: 1-800-757-7585 (toll free) TTY 711

Getting an exception to the formulary

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

  • Ask your Kaiser Permanente or affiliated health care provider to prescribe a similar drug on our formulary.
  • Ask us to waive restrictions such as prior authorization.
  • Ask us to cover certain Part D formulary drugs at a lower cost-sharing level, as long as the drug is not on the specialty tier (Tier 5) and meets certain conditions.

Exceptions are only approved when alternative drugs on our formulary, lower-tiered drugs, or adding usage restrictions would not be effective or would be harmful.

If you or your doctor ask for an exception, you may give us 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.

If waiting up to 72 hours could be harmful to your health, you or your Kaiser Permanente or affiliated health care provider can ask for an expedited (fast) exception. If the fast request is approved, we’ll make a decision within 24 hours of getting your prescribing doctor’s supporting statement.

If you can’t get a supporting statement from your doctor, you may ask for a coverage determination, which is a decision we make about whether we will cover a Medicare Part D drug and the amount you’ll need to pay.

Note: You can only request an exception for drugs considered Medicare Part D prescription drugs by the Centers for Medicare & Medicaid Services (CMS), and you can’t get brand-name drugs at the generic cost-sharing tier.

For more information about asking for exceptions, including the appeals process, please see your Evidence of Coverage.

For complete information on how to ask for a coverage determination, please see your Evidence of Coverage or go to our section on grievances, coverage determinations, and appeals.

Kaiser Permanente’s transition process for medications

In the rare case that you’re taking a Medicare Part D drug that’s not on our formulary or may need approval from us before we can fill your prescription, talk to your Kaiser Permanente or affiliated doctor about switching to one that is covered, or requesting an exception. We may be able to cover your current drug during your first 90 days as a new member or for existing members, the first 90 days of the calendar year.

If your ability to get your drugs is limited, we’ll cover a 30-day supply (unless your prescription is for fewer days) when you go to a Kaiser Permanente or affiliated pharmacy. An additional refill may be covered if medically necessary, but we may not pay for the drug after that.

If you reside in a long-term care facility, you may get refills until we give you a transition supply for up to 98 days, consistent with the dispensing increment and day supply written on your prescription. We’ll cover more than 1 refill for the first 90 days as a member of our plan. If you need a drug that’s not on our formulary, or if your ability to get it is limited, but you’re past the first 90 days of membership in our plan, we’ll cover a 31-day emergency supply (unless your prescription is for fewer days) as medically necessary while you ask for an exception.

Drugs prescribed during a covered stay in a hospital or skilled nursing facility are covered under your medical benefit rather than your Medicare Part D prescription drug coverage. After you’re released from care, many outpatient prescription drugs will be covered under your Medicare Part D coverage, as long as they’re filled at a Kaiser Permanente or affiliated pharmacy.

Since coverage is different depending on where you get your medication, certain drugs covered under your medical benefit might not be covered by Medicare Part D. You’ll have to pay full price unless you have additional coverage (for example, employer-sponsored group coverage).

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

 
Kaiser Permanente and affiliated pharmacies

You can only get your prescription drug benefit at Kaiser Permanente or affiliated pharmacies, except in non-routine situations. Fill your prescriptions at any Kaiser Permanente or affiliated pharmacy or through our mail-order service. We operate our own pharmacies and contract with affiliated pharmacies that meet or exceed CMS requirements for pharmacy access in your area. The Kaiser Permanente pharmacy network has 247 pharmacies in the California region.

To locate a Kaiser Permanente or affiliated pharmacy near you, please see our Pharmacy Directory♦. Also available in Spanish (en español)♦.

You may contact Member Services to request a printed version.

You also may search online for a convenient pharmacy location.

To fill a prescription at a Kaiser Permanente or affiliated pharmacy, you must show your Kaiser Permanente Senior Advantage (HMO) ID card and photo ID. This is in order to receive your prescription at your Medicare Part D Cost Share. If you don’t have your ID card or if you got the prescription from a non-plan, non-affiliated provider as part of covered emergency care or out-of-area urgent care, you may have to pay full price.

If this happens, ask us to pay you back for our share of the cost by submitting a paper claim. Learn how to submit a claim in your Evidence of Coverage.

You’ll get an Explanation of Benefits (EOB) by mail each month you use your Medicare Part D benefits. (See an example of the EOB or sign up to get your EOB electronically). The EOB lists all Medicare Part D purchases from the previous month, including your total out-of-pocket expenses and year-to-date drug costs. Your EOB will also reflect any changes to the formulary within the last 60 days.

Out-of-network pharmacy coverage

Prescriptions filled at an out-of-network pharmacy will only be covered when a Kaiser Permanente or affiliated pharmacy is not available or under limited circumstances.

For example, if you get sick while traveling within the United States and its territories, but outside one of our service areas, we may cover prescriptions filled out-of-network according to our Part D formulary guidelines. If a Medicare Part D drug is prescribed as part of covered out-of-network emergency care or out-of-area urgent care, we’ll cover up to a 30-day supply.

Note: Prescriptions prescribed and provided outside the United States as part of covered emergency or urgent care are covered up to a 30-day supply. However, they’re not covered under Medicare Part D, so payments don’t count toward reaching the catastrophic coverage threshold. Catastrophic drug coverage limits the amount you’ll pay out-of-pocket for Medicare Part D drugs each year.

Medicare Part D prescriptions filled at an out-of-network pharmacy will also be covered in the following situations:

  • You need the drug right away and there is no 24-hour Kaiser Permanente or affiliated pharmacy within a reasonable driving distance.
  • Your drug is not regularly stocked at an accessible Kaiser Permanente or affiliated pharmacy or available through our mail-order service.
  • You are not able to get drugs from a Kaiser Permanente or affiliated pharmacy during a disaster.

In these situations, you’ll have to pay the full cost when you fill the prescription and ask to be paid back for our share by submitting a paper claim.

To learn more about out-of-network pharmacy coverage and find out how to file a paper claim, see your Evidence of Coverage.

Rx refills and mail-order services

Save time and energy by ordering most prescription refills:

If you haven’t already, you’ll need to register for a secure kp.org account to refill prescriptions online.

Most prescription refills can be mailed to you at no extra charge. Sign up for mail-order services at your Kaiser Permanente pharmacy or by calling the number on your prescription label.

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

  • Call our mail-order service at 1-888-218-6245 (toll free) or TTY 711, Monday through Friday, 8 a.m. to 6 p.m., follow the voice prompts and choose the mail delivery option.

Mail-order services

When you order refills by mail, there’s no charge for postage and your costs could be lower when you order a 3-month supply. Look in your Evidence of Coverage for details.

Most covered Medicare Part D drugs can be refilled by mail, but there are some exceptions, such as:

  • Drugs that are time - or temperature-sensitive
  • Drugs identified as unmailable
  • Certain high-cost drugs
  • Drugs that require a health professional’s care or observation

Availability is subject to change at any time without notice. Please ask your Kaiser Permanente or affiliated pharmacy or mail-order pharmacy if your prescription is available by mail.

Note: Drugs ordered through a mail-order service other than Kaiser Permanente are not covered.

Please contact us 10 days before you run out of your medications to make sure your next mail order refill is shipped to you in time. Allow up to 10 days for delivery. If your prescription is late, please call the Kaiser Permanente Mail Order Pharmacy at 1-888-218-6245 or TTY 711, Monday through Friday 8 a.m. to 6 p.m., or the number on your prescription label for help. If you have no refills left, it may take an additional 72 hours.

You’ll find more information about our mail-order service in your Pharmacy Directory or 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. It’s an extra service offered at no additional cost to members who qualify. Developed by a team of pharmacists and doctors to help us give you better care, this program connects you and your doctor with specially trained pharmacists who make sure that all the medications you take are necessary, safe, and effective.

Am I eligible for the MTM program?

The 3 factors below determine whether you’re eligible:

1. You have 3 or more of these health conditions:

  • High cholesterol
  • High blood pressure
  • Coronary artery disease
  • Diabetes
  • Stroke
  • Rheumatoid arthritis
  • Chronic obstructive pulmonary disease
  • Osteoporosis
  • Chronic non-cancer pain

2. You take 5 or more of these Part D medications:

  • Drugs for high cholesterol (for example, atorvastatin)
  • Drugs for high blood pressure (for example, lisinopril or hydrochlorothiazide)
  • Drugs for diabetes (for example, metformin or insulin)
  • Drugs for rheumatoid arthritis (for example, etanercept)
  • Bronchodilators (for example, albuterol)
  • Inhaled corticosteroids (for example, bethamethasone)
  • Osteoporosis agents (for example, alendronate)

3. You spend more than $3,507 per year on Part D medications.

If you think you might qualify, please complete this Personal Medication form♦ and share it with your Kaiser Permanente or affiliated provider.

How will I know if I qualify for the MTM program?

You or your authorized representative will get a letter asking you to set up a comprehensive medication review (CMR) with one of our pharmacists. You may also get a follow-up reminder by phone.

Most CMRs are done over the phone and take 15 to 20 minutes. In some cases, we may also need to do a 10 to 15 minute targeted medication review.

We’ll ask about your prescription medications and any over-the-counter, herbal, or dietary supplements you take. We’ll look for ways to reduce side effects, prevent harmful drug interactions, and lower drug costs. We’ll give you an action plan based on your needs to help you get the most out of your medications.

We recommend taking advantage of this service if you qualify. Remember, you don’t need to pay anything extra to take part.

For more information, see this MTM flyer♦. You may also contact Member Services at 1-800-443-0815 (TTY 711), 7 days a week, 8 a.m. to 8 p.m. for more details about this free service.

Extra Help for Medicare Part D drugs

Are you a Kaiser Permanente Senior Advantage (HMO) member with limited income and resources? If so, you may qualify for Extra Help, a Medicare program that helps you pay for prescription drugs.

If you’re eligible, Medicare could pay for some or most of your drug costs, including monthly prescription drug premiums, annual deductibles, and coinsurance. Plus, some may not have to pay the coverage gap cost sharing or a late enrollment penalty. Many people qualify for these savings and don’t even know it.

Visit the BenefitsCheckUp website† to see if you might be eligible for Extra Help and to find out about other ways to save money.

You can also call:

  • Our Member Services department at 1-800-443-0815 (toll free) or TTY 711, 7 days a week, 8 a.m. to 8 p.m.

  • 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 getting 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 Medicare website.

You may also visit your Member Services Department, located in most Kaiser Permanente medical facilities for help.

How much will I pay?

Here’s how your costs will change if you qualify for the same level of help next year.

If you pay this much this year (2015)

You will pay this much next year (2016)

$0 deductible$0 deductible
$66 deductible$74 deductible
$1.20 for generics and brands that are treated as generics
$3.60 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
$2.95 for generics and brands that are treated as generics
$7.40 for brand-name drugs
No more than 15% coinsurance for all drugsNo more than 15% coinsurance for all drugs

Note: If the 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, you’ll pay the lower amount. The amount of Extra Help you get determines your monthly plan premium and your prescription drug cost sharing. For details, refer to the “Evidence of Coverage Rider for Those Who Receive Extra Help Paying for Their Prescription Drugs.”

You may get a letter from Medicare or Social Security about your 2016 eligibility for Extra Help. Please read it carefully. If you don’t know what 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.

Call Senior Advantage Member Services to ask whether you qualify for assistance through the Kaiser Permanente Senior Advantage Medicare Medi-Cal Plan (HMO SNP).

2016 Extra Help premium summary chart

The tables below show what your monthly plan premium will be if you get Extra Help. This does not include a Medicare Part B premium. You must keep paying your Medicare Part B premium and other applicable premium(s), unless they’re paid by Medicaid or another third party.

Monthly premiums*

Your level of extra help

Contra Costa County Plan

Senior Advantage Medicare Medi-Cal Plan in Northern California

100%

$86.00$0

75%

$86.00$0

50%

$86.00$0

25%

$86.00$0

* 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.

Best Available Evidence

If you think you’re eligible for Extra Help and you are not paying the correct monthly premium or costs for your drugs you may be able to correct your Medicare records by providing us with information known as best available evidence (BAE).

Acceptable examples of BAE documents include:

  • Your state Medicaid card
  • Your Extra Help Social Security award letter
  • Supplemental Security Income 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

When we receive and verify your BAE, we’ll notify Medicare and update our records within 3 business days. You may bring your BAE document to the pharmacy during this time so we can charge you the appropriate cost-sharing amount until Medicare updates its records.

If you’re in a long-term care facility, you can choose someone to represent you. Your appointed representative can provide one of these BAE examples:

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

You or your appointed representative can provide a copy of your BAE document with your Health/Medical Record number in the following ways:

  • Mail it to:

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

  • Fax it to 1-877-528-8579 (toll free)
  • Or you may bring it to your local Member Services Department.

If you have questions about BAE or need help getting documented proof, please call Member Services at 1-800-443-0815 (toll free) or TTY 711, 7 days a week, 8 a.m. to 8 p.m. You also can visit the CMS Best Available Evidence page.†

Quality Assurance and Drug Utilization Management

Kaiser Permanente has established quality assurance measures to prevent medication errors and harmful drug interactions, and to improve medication use.

We practice and uphold pharmacy policies and procedures at standards required by state and federal laws. These include:

  • Drug utilization reviews are performed before each new prescription is given out to check for issues like drug-drug interactions and drug-allergy interactions
  • Computerized systems regularly examine records to identify drug therapy problems among Senior Advantage (HMO) members
  • Medication error identification and reduction systems
  • Reporting our quality assurance practices to the Centers for Medicare & Medicaid Services

If you have a complaint about your Kaiser Permanente care, you 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 can file a complaint with the local QIO by writing to:

Livanta
BFCC – QIO Program
9090 Junction Drive, Suite 10
Annapolis Junction, MD 20701

Or contact the QIO at 1-877-588-1123 or TTY 711.

Drug Utilization Management

Kaiser Permanente has requirements, restrictions, or limits on some covered prescription drugs. They’re established by a team of doctors and pharmacists to manage costs and make sure members use these drugs safely and effectively that comply with FDA and Medicare guidelines.

For example, you may need to get an approval (prior authorization) from us before you fill certain prescriptions. If you don’t get an approval, we may not cover the drug.

Drugs needing our approval♦ could be covered under Medicare Part B or Part D or Medicare Part A or Part D, depending on the situation. More details from your prescriber might be required to make that decision.

You may need to get an approval for certain Part D drugs when used in hospice settings, which are health care facilities for people who are terminally ill. Hospice providers can complete this form♦ if necessary.

Note: Our plan may limit the day supply of certain drugs that will be covered. For example, extended day supplies (over 1 month) are limited for some drugs. Also, if there is a shortage in the marketplace, we may fill your prescription for a limited quantity.

To find out if your drug is subject to these requirements or limits, check the Kaiser Permanente comprehensive formulary.

Grievances, coverage determinations, and appeals

Grievances

Let us know right away if you have questions, concerns, or problems related to your covered services or care by contacting Member Services at 1-800-443-0815 (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 complaint about the quality of your care. It doesn’t involve coverage or payment disagreements.
  • A coverage determination is adecision about whether a drug prescribed for you will be covered by us and the amount you’ll need to pay for it.
  • An appeal can be made if you disagree with our decision to deny a request about your Part D drugs.

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

Coverage determinations

A coverage determination may be requested by you, your appointed representative, your Kaiser Permanente or affiliated doctor, or another prescriber. You can only ask for a coverage determination for a drug you haven’t gotten yet.

The CMS coverage determination form♦ makes it easy to provide evidence supporting your request. You don’t have to use the form, but your request must include all the information from the form.

You can ask for a coverage determination in the following ways:

  • By calling the Part D Unit phone line at 1-866-206-2973 (toll free) or TTY 711, from 8:30 a.m. to 5 p.m., 7 days a week
  • By faxing the completed form or information to the Part D Unit fax line at 1-866-206-2974
  • By mailing the completed form or information to:

Kaiser Permanente
Attention: Medicare Part D Review
P.O. Box 23170
Oakland, CA 94623-0170

  • By delivering the completed form or information or making a request in person at your local Member Services department at a Kaiser Permanente location.

If you appoint a representative to act on your behalf, you must both sign and date a statement giving that person legal permission to act as your appointed representative♦.

The decision about whether your drug will be covered can be a standard decision, made within 72 hours after receipt of your doctor’s supporting statement, or an expedited decision, made within 24 hours.

Note: The decision time frame doesn’t begin until we get the completed and signed statement.

An expedited decision will only be granted if your Kaiser Permanente or affiliated doctor confirms that waiting 72 hours could seriously harm your health or compromise your ability to regain maximum function.

If your request for an expedited decision is made by or supported by your doctor, we will automatically follow the 24-hour time frame. If you make the request yourself and we do not grant it, the standard 72-hour time frame will apply.

If we deny your expedited review by phone and you disagree with our decision, you can ask for a 24-hour expedited grievance at that time. Otherwise, we’ll send a letter within 3 calendar days explaining 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 believe you were incorrectly charged through our coverage determination process, you may submit a reimbursement request. Once we receive it, we’ll respond within 14 calendar days. If approved, payment will be made within 14 calendar days as well.

To ask questions or check on the status of a request, please call Member Services.

Appeals

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

You must file your request in writing by mailing it to the address on your denial notice. An expedited (fast) request may also be filed in writing, or by contacting us by telephone or fax at the numbers provided in your coverage determination denial letter.

You also have the right to give us new information supporting your appeal in writing, by telephone or fax, or by hand delivering it to your local Member Services department.

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

You can either file a standard request in writing or an expedited request filed in writing or by telephone or fax using the contact information listed in your coverage determination denial letter.

You can also complete the coverage redetermination form♦ and fax it to the Part D Unit fax line at 1-866-206-2974 or mail it to the following address:

Kaiser Permanente
Attention: Medicare Part D Review
P.O. Box 23170
Oakland, CA 94623-0170

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.

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

Who to contact for inquiries

If you have questions or concerns about services or the care you get, problems with a particular Medicare Part D drug, or need help getting a representative to handle your coverage determination or appeal, you may submit a complaint online or call Member Servicesat 1-800-443-0815 (toll free) or TTY 711, 7 days a week, from 8 a.m. to 8 p.m., or visit the Member Services department at your local Kaiser Permanente facility. To send a complaint directly to Medicare, you may use the online Medicare Complaint Form. † 

Total number of grievances, appeals, and exceptions

You can access a summary of the appeals and grievances other plan members have filed with Kaiser Permanente by calling Member Services.

Reporting suspected fraud

We encourage members, vendors and others to let us know if anything happens at Kaiser Permanente that could be unlawful. If we know about it, we can take action.

If you believe you’ve experienced fraud, or you become aware of fraud, waste, or abuse 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

Mail

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

Your options upon disenrollment

If you leave Kaiser Permanente Senior Advantage (HMO), you have other prescription drug coverage options:

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

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

Disenrollment from a 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, 7 days a week. Or visit the Medicare website. †

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

2016 Evidence of Coverage (EOC)

Kaiser Permanente Senior Advantage (HMO) and Senior Advantage Medicare Medi-Cal (HMO SNP)

2016 EOC for Senior Advantage Individual Plan (HMO)
Also available in Spanish (en español)♦.

2016 EOC for Senior Advantage Medicare Medi-Cal plan (HMO SNP)
Also available in Spanish (en español)♦. 

Interpreter services

We have interpreters available at no cost for more than a dozen languages, and they are just a toll-free phone call away.

Learn more about our multi-language interpreter services for Senior Advantage plans♦.

Learn more about our multi-language interpreter services for Senior Advantage Medicare-Medi-Cal plan♦.

Contact information
  • Prospective members may call our licensed sales specialists for more information about Senior Advantage (HMO) at 1-800-443-0815 (toll free) or TTY 711, 7 days a week, 8 a.m. to 8 p.m.  For information in Spanish, please call us at 1-800-788-0616 (toll free) or TTY 711, 7 days a week, 8 a.m. to 8 p.m.
  • Current members asking for health plan benefit information or who have questions about Medicare prescription drug expenses or who need materials in an alternate format or language may call Member Services at 1-800-443-0815 or TTY 711, 7 days a week, 8 a.m. to 8 p.m.
  • Or mail any written correspondence to:
    Kaiser Foundation Health Plan, Inc.
    393 E. Walnut St.
    Pasadena, CA 91188-8514

  • 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, premiums and/or copayments/coinsurance may change on January 1 of each year.

The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.

This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply.

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

Anyone who has full benefits under Medi-Cal and Medicare Parts A and B, including some people under the age of 65 with disabilities, may apply. Premiums, copays, coinsurance/cost sharing, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.

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
Also available in Spanish (en español)♦.

Medicare Part D prescription drug abridged formulary
Also available in Spanish (en español)♦.

Advantage Plus brochure

Summary of Benefits


Summary of Benefits for Contra Costa county plan
Also available in Spanish (en español)♦.

Senior Advantage Medicare Medi-Cal Plan Summary of Benefits
Also available in Spanish (en español)♦.

Evidence of Coverage

 

2016 Senior Advantage Evidence of Coverage  Northern California
Also available in Spanish (en español)♦.

2016 Senior Advantage Evidence of Coverage Medicare Medi-Cal plan
Also available in Spanish (en español)♦.

Multi-language interpreter services for Senior Advantage plan♦.

Multi-language interpreter services for Senior Advantage Medicare-Medi-Cal plan♦.

Annual Notices of Changes


2016 Annual Notices of Changes for Senior Advantage Individual Plan (HMO) Contra Costa county plan
Also available in Spanish (en español)♦.

2016 Annual Notices of Changes for Senior Advantage Medicare Medi-Cal plan
Also available in Spanish (en español)♦.

Enrollment forms


Kaiser Permanente Senior Advantage Individual plan enrollment form
Also available in Spanish (en español)♦.

Advantage Plus enrollment form♦.

Directories


Provider directory
Also available in Spanish (en español)♦.

Pharmacy directory
Also available in Spanish (en español)♦.

You can also search for Kaiser Permanente doctors and pharmacies using our online directory♦. If you would like a directory sent to you by mail, contact Member Services, or email us at mscc@kp.org. Be sure to include “directory request” in the subject line and your name, full address, and which directory you’re requesting in the body of the email.

Map of facilities♦.

For a healthier, more vibrant you

Add dental, hearing, extra vision and fitness benefits


Enhance your health and well–being by combining the affordable benefits of Advantage Plus with your Kaiser Permanente Senior Advantage (HMO) plan.

Only $20 a month* added to your Senior Advantage premium gets you Advantage Plus coverage. You’ll get dental, hearing aid, additional eyewear, and the Silver&Fit fitness benefit.

The Silver&Fit® fitness benefit helps you get and stay active. Choose a fitness facility membership or the Silver&Fit home exercise program at no additional cost.

When you can enroll


You can enroll in Advantage Plus which includes Silver&Fit at the same time or within 30 days you enroll in a Kaiser Permanente Senior Advantage (HMO) plan.

  • If you are enrolling in Senior Advantage either as a new member or because you have moved to a different Kaiser Permanente service area, you may add Advantage Plus within 30 days of your enrollment. Coverage is typically effective the first day of the month following the date we receive your completed enrollment form.

  • If you are already a Senior Advantage member, you may add Advantage Plus during the annual election period October 15 – December 7 for coverage to become effective on January 1, 2016. If you don’t enroll during the annual election period, you have until March 31, 2016 to enroll. Coverage is typically effective the first day of the month following the date we receive your completed enrollment form.

Get started today


To learn more about the Advantage Plus benefits, download the Advantage Plus brochure♦.

When you are ready to enroll, download the enrollment form♦, fill it out, and mail it in.

Coverage is effective the first day of the month following the date we receive your completed enrollment form.

We're here to help


If you have questions, call one of our licensed sales specialists at 1-877-372-1792 (toll free) or TTY 711 for the hearing/speech impaired, 8 a.m. to 8 p.m., 7 days a week.

You must be enrolled in a Kaiser Permanente Senior Advantage individual plan to be eligible to enroll in the Advantage Plus optional benefits package. Advantage Plus optional supplemental benefits package is not available under the Medicare Medi-Cal plan.

Benefits, premiums and/or copayments/coinsurance may change on January 1 of each year.

This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply.

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

The Silver&Fit Program is provided by American Specialty Health Fitness, Inc., a subsidiary of American Specialty Health Incorporated (ASH). All programs and services are not available in all areas. Silver&Fit, The Silver Slate, and the Silver&Fit Signature Series Classes are federally registered trademarks of ASH. Other names and logos may be trademarks of their respective owners.


♦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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