This is a summary of what our plan covers and what you pay. It does not list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, please refer to the Evidence of Coverage, this legal member contract is the primary source of the coverage information and supersedes all other information.
2024 Medical BenefitsCovered Services | What You Pay |
Physician Services / Doctor Office Visits | PCP - $0 Specialist - $40 |
Annual Wellness Visit | $0 |
Telehealth Benefit | PCP - $0 Specialist - $15 |
Preventive Health Screenings | $0 |
Inpatient Hospital Care | $375 Days 1-5, $0 Days 6-90 |
Outpatient Diagnostic Tests and Therapeutic Services & Supplies | Diagnostic labs & x-rays $0 Advanced Radiology - $150 |
Emergency Care | $100 |
Ambulance Services | $100 |
Urgently Needed Services | $25 |
Convenient Care | Per visit: $25 CVS Minute Clinics only |
OTC Allowances | $150 per quarter |
Flex Card | $1000 per year for dental, hearing or vision related services and home fitness equipment purchases |
Outpatient Hospital Observation | $325 |
Outpatient Surgery | ASC - $175 Hospital $325 |
Outpatient Mental Health Care | Individual or Group - $20 |
Outpatient Substance Abuse Services | Individual or Group - $20 |
Durable Medical Equipment (DME) and Related Supplies | 15%-20% coinsurance |
Prosthetic Devices and Related Supplies | 20% coinsurance |
Medicare Part B Prescription Drugs | 20% coinsurance (including chemotherapy) |
Services to Treat Kidney Disease | 20% coinsurance |
Pulmonary Rehabilitation Services | $15 |
Cardiac Rehabilitation Services | $35 |
Chiropractic Services | $15 |
Acupuncture | $15 |
Podiatry Services | $40 |
Home Health Agency Care | $0 |
Inpatient Mental Health Care | $375 Days 1-5, $0 Days 6-90 |
Medical Nutrition Therapy | $0 |
Dental Services | $40 copayment |
Preventative Dental | Included |
Comprehensive Dental | 0% coinsurance up to $3,500 combined preventive & comprehensive benefit maximum |
Diabetes Self Management Training, Diabetic Services and Supplies | 0% - 20% coinsurance |
Immunizations | $0 |
Transportation | Not included |
Smoking Cessation | $0 |
Hearing Services | $0 for exams and $750 per ear towards the cost of hearing aid(s) every 3 years |
Vision Care | $0-$40 and $175 plan allowance per year |
LiveWell Rewards | Included |
The monthly fee you pay the plan for your health care. The amount shown does not include the Part B premium you already pay to the government.
Plan | Monthly Premium |
Thrive | $0 |
This table gives you basic information about the prescription drug benefits that are available with some of our plans. For more details, see the Comprehensive Formulary (PDF) in the Plan Documents section
There is no deductible for KelseyCare Advantage drugs on tiers 1, 2, 6, formulary insulins, or formulary vaccines. You will pay a yearly deductible of $100 on Tiers 3, 4 and 5 drugs. You must pay the full cost of your Tiers 3, 4, and 5 drugs until you reach the plan’s deductible amount.
After you pay your yearly deductible, you pay the following until your total yearly drug cost reach $5,030. Total yearly drug costs are the total drug cost paid by both you and our Part D plan. You may get your drugs at network retail and mail-order pharmacies.
Preferred Retail Cost-Sharing* | |||
Tier | 30-Day Supply | 60-Day Supply | 90-Day Supply |
Tier 1 (Preferred Generic) | $0.00 | $0.00 | $0.00 |
Tier 2 (Generic) | $5.00 | $10.00 | $13.00 |
Tier 3 (Preferred Brand) | $45.00 | $90.00 | $113.00 |
Tier 4 (Non-Preferred Drug) | $90.00 | $180.00 | $225.00 |
Tier 5 (Specialty Tier) | 31% | N/A | N/A |
Tier 6 (Select Care Drugs) | $0.00 | $0.00 | $0.00 |
Covered Insulins | $35.00 | $70.00 | $87.50 |
* The preferred cost-sharing pharmacies in the Greater Houston area include Kelsey Pharmacy, HEB, CVS retail locations and CVS Caremark Mail Service.
Standard Retail Cost-Sharing | |||
Tier | 30-Day Supply | 60-Day Supply | 90-Day Supply |
Tier 1 (Standard Generic) | $7.00 | $14.00 | $21.00 |
Tier 2 (Generic) | $15.00 | $30.00 | $45.00 |
Tier 3 (Standard Brand) | $47.00 | $94.00 | $141.00 |
Tier 4 (Non-Standard Drug) | $100.00 | $200.00 | $300.00 |
Tier 5 (Specialty Tier) | 31% | N/A | N/A |
Tier 6 (Select Care Drugs) | $0.00 | $0.00 | $0.00 |
(Select Insulins*) | $35.00 | $70.00 | $105.00 |
You won’t pay more than $35 for a one-month supply of each covered insulin product regardless of the cost-sharing tier, even if you haven’t paid your deductible.
The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $5,030. KelseyCare Advantage offers additional gap coverage for drugs on Tiers 1, 2, 6, insulins, and vaccines. You will continue to pay the initial coverage stage copays for these products. Refer to the tables above to determine your copays for these products.
After you enter the coverage gap, you pay 25% of the plan’s negotiated price for covered drugs on Tiers 3, 4, and 5 until your out-of-pocket costs total $8,000, which is the end of the coverage gap. Not everyone will enter the coverage gap.
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $8,000, you pay the greater of:
Select Care Drugs Tier
KelseyCare Advantage is ensuring you have easy access to many of the vaccines you need and drugs you take to treat high blood pressure, high cholesterol and diabetes – all at a $0 copay!
Tier 6 covers Medicare Select Care Drugs at a $0 copay, all year long, at any network pharmacy including:
Vaccines
33 vaccinations that protect you from serious disease and illness.
Maintenance Medications
46 generic oral medications prescribed most to help you manage chronic conditions. Tier 6 drugs are covered at $0 copay all year, including during the Medicare Coverage Gap.
Excluded Drug Coverage
We offer additional coverage of some prescription drugs not normally covered in a Medicare prescription drug plan (enhanced drug coverage). This includes coverage of certain drugs excluded from Medicare Part D Coverage.
As part of the plan's enhanced drug coverage for Calendar Year 2024, the excluded drugs sildenafil 25 MG, 50 MG and 100 MG Tablet, folic acid 1 MG Tablet, ergocalciferol (vitamin D2) 1.25 MG Capsule, vitamin B12 1000 MCG/ML Injection are covered on tier 2. Payments you make for excluded drugs are not included in your out-of-pocket costs.
The covered excluded drugs in 2024 are listed below
Drug Name | Tier | Drug Restrictions |
sildenafil 25 MG, 50 MG and 100 MG Tablet | 2 | Quantity Limit of 6 Tablets every 30 days |
folic acid 1 MG Tablet | 2 | Quantity Limit of 30 Tablets every 30 days |
ergocalciferol (vitamin D2) 1.25 MG Capsule | 2 | Quantity Limit of 4 Capsules every 28 days |
vitamin B12 1000 MCG/ML Injection | 2 | Quantity Limit of one vial every 30 days |
The amount you pay when you fill a prescription for these drugs does not count towards drug cost for entering the Coverage Gap Stage nor does it contribute to entering the Catastrophic Coverage Stage.
You must maintain your Medicare Part B coverage to be a member of any Medicare Advantage plan. Most people will pay the standard Part B premium amount. Please call Social Security at 1-800-772-1213 for information about your Part B premium.