Kaiser Permanente 2017 Summary of Benefits

1 PBP 032 H0524_17SB032 accepted 60425415 N 032 Kaiser Permanente 2017 Summary of Benefits Kaiser Permanente Senior Advantage Alameda, Napa, and San Francisco Counties Plan (HMO) Kaiser Foundation Health Plan, Inc. Northern California Region A nonprofit corporation Health Maintenance Organization (HMO) Summary of Benefits for Kaiser Permanente Senior Advantage Alameda, Napa, and San Francisco Counties Plan January 1, 2017 December 31, 2017 Kaiser Permanente Senior Advantage is a Medicare Advantage Health Maintenance Organization (HMO) offered by Kaiser Foundation Health Plan, Inc. This document is a Summary and does not include all plan rules, Benefits , limitations, and exclusions. For complete details, refer to the Evidence of Coverage (EOC), which we will send you after you enroll.

2 If you would like to review the EOC before you enroll, you can view it online at or request a copy from Member Services by calling 1-800-443-0815, seven days a week, 8 to 8 (TTY 711). Benefits Alameda, Napa, and San Francisco Counties Plan Monthly plan premium 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. You pay $86 per month. Deductible None. Your maximum out-of-pocket responsibility The amount you pay for premiums, Medicare Part D drugs, and certain services does not apply to this maximum (see the Evidence of Coverage for details). If you pay $4,400 in copays (a set amount you pay for covered services) or coinsurance (a percentage of the charges that you pay for covered services) during 2017 for services subject to the out-of-pocket maximum, you will not have to pay any more copays or coinsurance for those services for the rest of the year.

3 Inpatient hospital coverage There is no limit to the number of medically necessary inpatient hospital days. You pay $280 per day, for days 1 through 7 of a hospital stay. You pay nothing for the rest of the hospital stay. Doctor's visits Primary and specialty care You pay $35 per office visit. 1 2 1-800-777-1238, seven days a week, 8 to 8 (TTY 711) Benefits Alameda, Napa, and San Francisco Counties Plan Preventive care Please see the EOC to learn which services are covered. You pay nothing. Emergency care Our plan covers emergency care anywhere in the world. You pay $75 per Emergency Department visit. Urgently needed services Our plan covers urgent care anywhere in the world. You pay $35 per office visit. Diagnostic services, lab, and imaging Lab tests You pay $35 per encounter.

4 X-rays You pay $55 per encounter. Diagnostic tests and procedures (such as EKG) You pay $35 per encounter. Other imaging procedures (such as MRI, CT, and PET) You pay $205 per procedure except you pay $55 for ultrasounds. Hearing services Exams to diagnose and treat hearing and balance issues Routine hearing exams (Hearing aids are not covered unless you are enrolled in Advantage Plus, see the "Advantage Plus" section.) You pay $35 per office visit. Dental services Preventive and comprehensive dental coverage Not covered unless you are enrolled in Advantage Plus (see the "Advantage Plus" section). 3 Benefits Alameda, Napa, and San Francisco Counties Plan Vision services Visits to diagnose and treat diseases and conditions of the eye Routine eye exams You pay $35 per office visit.

5 Preventive glaucoma screening You pay nothing. Eyeglasses or contact lenses after cataract surgery You pay nothing up to Medicare's limit and you pay any amounts that exceed Medicare's limit. Other eyeglasses or contact lenses (covered once every 24 months) If the eyewear you purchase costs more than $75, you pay the difference. Mental health services Inpatient care (there is no limit to the number of medically necessary hospital days for specified conditions, see the EOC for details.) You pay $220 per day, for days 1 through 7 of a hospital stay. You pay nothing for the rest of the hospital stay. Outpatient group therapy You pay $17 per office visit. Outpatient individual therapy You pay $35 per office visit. Skilled Nursing Facility Our plan covers up to 100 days per benefit period.

6 A benefit period begins the day you go into a hospital or skilled nursing facility. The benefit period ends when you haven't received any inpatient hospital care (or skilled care in a SNF) for 60 days in a row. Per benefit period, you pay: $0 per day for days 1 through 20. $50 per day for days 21 through 100. Rehabilitation services Occupational, speech, or physical therapy You pay $35 per office visit. Ambulance You pay $200 per one-way trip. 4 1-800-777-1238, seven days a week, 8 to 8 (TTY 711) Benefits Alameda, Napa, and San Francisco Counties Plan Transportation Not covered. Foot care (podiatry services) Office visits to diagnose and treat injuries and diseases of the feet Routine foot care for certain medical conditions affecting the lower limbs You pay $35 per office visit.

7 Outpatient surgery for treatment of injuries and diseases of the feet You pay $250 per procedure. Medical equipment and supplies Durable medical equipment You pay 20% coinsurance. Diabetic testing supplies You pay nothing. Wellness programs Health education program (Fitness Benefits are not covered unless you are enrolled in Advantage Plus, see the "Advantage Plus" section.) You pay $35 per visit. Medicare Part B drugs A limited number of Medicare Part B drugs are covered when you get them from a network provider (see the EOC for details). Drugs that require administration by medical personnel You pay nothing. Up to a 30-day supply You pay $15 for generic drugs and $45 for brand-name drugs. Medicare Part D prescription drug coverage Initial Coverage Stage The amount you pay for drugs differs depending upon the following: The drug tier that your drug is in.

8 There are a total of six tiers, please refer to our Part D formulary to locate your drug's tier on our website at or call Member Services to request a copy at 1- 800-443-0815, seven days a week, 8 to 8 (TTY 711). The day supply you receive. For a 100-day supply, the type of network pharmacy that fills your prescription (network retail pharmacy or our mail-order pharmacy). See the Pharmacy Directory for our list of network pharmacies at The coverage stage you are in (initial, coverage gap, or catastrophic coverage stages). You pay the following copays and coinsurance shown in the chart below until your total yearly drug costs reach $3,700. Total yearly drug costs are the total drug costs paid by both you and any Part D plan during a calendar year. Tier You pay Tier 1 (Preferred Generic) $5 (up to a 30-day supply).

9 Tier 2 (Generic) $15 (up to a 30-day supply). Tier 3 (Preferred Brand) $45 (up to a 30-day supply). Tier 4 (Non-Preferred Brand) $100 (up to a 30-day supply). Tier 5 (Specialty Tier) 33% coinsurance. Tier 6 (Vaccines) $0. You can get up to a 100-day supply for many drugs, but you will pay more (a 100-day supply is not available for all drugs). For a 100-day supply of drugs in Tiers 1-4 that you get from a network retail pharmacy, you pay the copay listed above multiplied by three. For example, if you get a 100-day supply of a Tier 1 drug from a retail network pharmacy, you will pay $15 (3 x $5 copay). For a 100-day supply of drugs in Tiers 1-4 that you get from our network mail-order pharmacy, you pay the copay listed above multiplied by two. For example, if you get a 100-day supply of a Tier 1 drug from our mail-order pharmacy, you will pay $10 (2 x $5 copay).

10 Many drugs can be mailed to you through our network mail-order pharmacy (not all drugs can be mailed). If you reside in a long-term care facility, you pay the same as at a network retail pharmacy. 5 Coverage gap and catastrophic coverage stages The information above shows the copays and coinsurance for the Initial Coverage Stage. Most members do not reach the other two stages Coverage Gap Stage or the Catastrophic Coverage Stage. The Coverage Gap Stage begins if your total yearly drug costs in a calendar year (including what any plan has paid and what you have paid) reaches $3,700. During the Coverage Gap Stage for generic drugs (Tiers 1 and 2) and vaccines (Tier 6), you pay the same copays you paid during the Initial Coverage Stage or 51% coinsurance, whichever is lower.