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Northern California

A plan that makes Medicare complete

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

Our plan includes Medicare Part D prescription drug coverage. The cost of your Medicare prescription drug coverage is included in your monthly plan premium.

View the details below to see why Kaiser Permanente Senior Advantage stands apart. Then when you’re ready,enroll in a Kaiser Permanente Medicare Plan online.

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

Kaiser Permanente Senior Advantage Individual Plan

2010 benefit highlights

Santa Clara County

Effective January 1 to December 31, 2010

You pay
Monthly Premium$74 in addition to your monthly Medicare Part B premium
Annual medical deductibleNone
Plan benefitYou pay
Office visit$30 per visit
Medicare prescription drug coverage (Part D)
Initial coverage: Until the total cost of your Part D—covered drugs1 paid by you and us (or any other Part D plan) reaches $2,830 in 2010, you will pay
  • formulary generic drugs—up to a 30-day supply
  • formulary brand-name drugs—up to a 30-day supply
  • formulary specialty-tier drugs—up to a 30-day supply








$10


$45


25% coinsurance
Coverage gap: Once the total cost of your Part D—covered drugs paid by you and us (or any other Part D plan) reaches $2,831 in 2010, you will pay
  • formulary generic drugs—up to a 30-day supply
  • formulary brand-name and specialty-tier drugs






$10


Full pharmacy price (100%)
Catastrophic coverage: If your out-of-pocket expenses (copayments, coinsurance, and payments for full-price drugs) reach $4,550 in 2010, you will pay
  • formulary generic drugs
  • formulary brand-name and specialty-tier drugs






$5 per Rx
$12 per Rx
Refraction eye exams$30 per visit
Eyeglasses/contact lenses
  • eyeglasses and contact lenses every two years
  • eyeglasses and contact lenses following cataract surgery

$120 credit

$0
X-Rays$25 per encounter
Laboratory tests$25 per encounter
Emergency room—worldwide coverage$50 per visit (In-network and out-of-network: If you are admitted to the hospital within 24 hour(s) for the same condition, you pay $0 for the emergency room visit)
Outpatient surgery$175 per procedure
Inpatient hospital care$225 per day for days 1-7
Skilled nursing facility care (up to 100 days per benefit period)
  • for days 1-20 per benefit period
  • for days 21-100 per benefit period



$0 copay per day

$100 copay per day
Ambulance service—when medically necessary$300 per trip
Durable medical equipment20% coinsurance
Annual out-of-pocket maximum for certain services—The maximum amount you will pay for services covered by Medicare parts A and B in a calendar year. Thereafter, the services are provided at no charge for the rest of that year.$3,400

HIV screening: For people who ask for an HIV screening test or who are at increased risk for HIV infection, we cover one screening exam every 12 months. For women who are pregnant, we cover up to three screening exams during a pregnancy.

1Calculated using prices set by the pharmacy.


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


Rx drug formulary

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


Save money on Rx refill by mail

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


2010 Summary of Benefits

This document provides an overview of the plans benefits and includes:

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

View the Summary of Benefits

This information may be available in a different format, including Spanish, Chinese, Braille, large print, electronic text file, and audio tapes.  Please call our Member Service Call Center toll free at 1-800-443-0815 (TTY 1-800-777-1370 for the hearing/speech impaired), seven days a week, 8 a.m. to 8 p.m. if you need plan information in another format or language.

Es posible que se pueda obtener esta información en un formato diferente, incluido en español, chino, braille, letra grande, archivo de texto electrónico,y cintas de audio. Por favor llame a nuestra Central de Llamadas de Servicio a los Miembros al número sin costo 1-800-443-0815 (TTY 1-800-777-1370 para las personas con problemas de audición/del habla), los siete días de la semana, de 8 a.m. a 8 p.m. si necesita información acerca del plan en otro formato o idioma.


2010 Evidence of Coverage

This document provides comprehensive benefit information and explains:

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

View the Evidence of Coverage

This information may be available in a different format, including Spanish, Chinese, Braille, large print, electronic text file, and audio tapes.  Please call our Member Service Call Center toll free at 1-800-443-0815 (TTY 1-800-777-1370 for the hearing/speech impaired), seven days a week, 8 a.m. to 8 p.m. if you need plan information in another format or language.

Es posible que se pueda obtener esta información en un formato diferente, incluido en español, chino, braille, letra grande, archivo de texto electrónico,y cintas de audio. Por favor llame a nuestra Central de Llamadas de Servicio a los Miembros al número sin costo 1-800-443-0815 (TTY 1-800-777-1370 para las personas con problemas de audición/del habla), los siete días de la semana, de 8 a.m. a 8 p.m. si necesita información acerca del plan en otro formato o idioma.

Note: If you have health care coverage through an employer or trust fund, please contact your benefits administrator for information about your group plan or go to the Kaiser Permanente employer-sponsored plans page.


Advantage Plus—dental, hearing, and extra vision benefits

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

2010 Advantage Plus benefits include:

  • dental—no charge for cleanings and oral exams; no charge for most X-Rays and comprehensive periodontal evaluations; coverage for periodontics and dentures
  • hearing—coverage for up to $700 in hearing aids ($350 per hearing aid per ear) every three years
  • vision—an additional $150 to apply to your eyewear purchase every two years. Combined with your other Senior Advantage plan eyewear coverage of $120, this gives you a total of up to $270.

If you are already a Senior Advantage member, you may enroll in Advantage Plus today. For more information, see the Advantage Plus enrollment brochure♦.


Senior Advantage Medicare Medi-Cal Individual Plan

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 Senior Advantage Medicare Medi-Cal Plan Summary of Benefits♦ and Evidence of Coverage♦.

Please note: Our 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 our Senior Advantage Medicare Medi-Cal plan, you should call us to find out how to qualify for this plan.


Meetings and events near you

Get to know Kaiser Permanente at one of our informational meetings in your area.

  • Get answers to all your Medicare questions.
  • Learn about Kaiser Permanente Senior Advantage and the many benefits of membership.
  • Meet some of our health care professionals and get tips to help you stay healthy.

Upcoming meetings and events schedule



*You must be a Kaiser Permanente Senior Advantage Individual Plan member to apply. You must continue to pay your Medicare Part B premium and any other applicable Medicare premiums.

See the Evidence of Coverage♦ for more information about dental, hearing, and vision services provided.

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

This information may be available in a different format, including Spanish, Chinese, Braille, large print, electronic text file, and audio tapes.  Please call our Member Service Call Center toll free at 1-800-443-0815 (TTY 1-800-777-1370 for the hearing/speech impaired), seven days a week, 8 a.m. to 8 p.m. if you need plan information in another format or language.

Es posible que se pueda obtener esta información en un formato diferente, incluido en español, chino, braille, letra grande, archivo de texto electrónico,y cintas de audio. Por favor llame a nuestra Central de Llamadas de Servicio a los Miembros al número sin costo 1-800-443-0815 (TTY 1-800-777-1370 para las personas con problemas de audición/del habla), los siete días de la semana, de 8 a.m. a 8 p.m. si necesita información acerca del plan en otro formato o idioma.




Anyone who has Medicare Parts A and B, including some people under the age of 65 with disabilities, may apply. You must reside in the Kaiser Permanente service area in which you enroll. You must continue to pay your Medicare Part B premium and any other applicable Medicare premium(s). Eligible Medicare beneficiaries may enroll in a Medicare Health Plan and/or Medicare Prescription Drug Plan only during specific times of the year. For more information, please contact Kaiser Permanente. Except for emergency care, urgent care when our network is not available, or out-of-area dialysis care, a Kaiser Permanente Plan provider must authorize or provide covered services, including referrals to specialists. If you obtain any other care from non-Plan providers, neither Medicare nor Kaiser Permanente will be responsible for the costs. Services received under the Travel Benefit (if applicable) do not need to be authorized or provided by Kaiser Permanente.

This plan includes Medicare Part D prescription drug coverage and is only available to Kaiser Permanente Senior Advantage members. You may only be enrolled in one Part D plan at a time, which means you will be disenrolled from any other Part D plan when your coverage under this plan becomes effective.

This plan uses a formulary, which lists covered drugs. In most cases, you must obtain covered drugs at one of our pharmacies listed in our pharmacy directory or through our mail order service. You can get a copy of the directory at www.kp.org/seniormedrx or by calling us toll free at 1-866-973-4588, TTY/TDD 1-888-758-6054, 8 a.m. to 8 p.m., seven days a week.

Kaiser Permanente is a Medicare Advantage organization with a Medicare contract that is renewed annually. Coverage beyond the end of the contract year is not guaranteed. You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for getting Extra Help, call: a. 1-800 MEDICARE (1-800-633-4227) (toll free). TTY/TDD users should call 1-877-486-2048 (toll-free TTY), 24 hours a day, 7 days a week; b. The Social Security office at 1-800-772-1213 (toll free) between 7 a.m. and 7 p.m., Monday through Friday. TTY/TDD users should call 1-800-325-0778 (toll-free TTY); or c. Your state Medicaid office.



Yes, I am ready to enroll!

  

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(toll free) (TTY 711)
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