2015 Summary of Benefits Kaiser Permanente Senior Advantage (HMO) Group Plan Including Medicare Part D Prescription Drug Benefit Information Kaiser Foundation Health Plan, Inc. Northern and Southern California Regions A nonprofit corporation Health Maintenance Organization (HMO) January 1, 2015, through December 31, 2015 60254234
Kaiser Permanente Senior Advantage (HMO) (a Medicare Advantage Health Maintenance Organization (HMO) offered by KAISER FOUNDATION HP, INC. with a Medicare contract). Summary of Benefits January 1, 2015 December 31, 2015 This booklet gives you a summary of what we cover. To get a complete list of your Kaiser Permanente Senior Advantage (HMO) benefits, please refer to your Evidence of Coverage (EOC). Contact your employer or trust fund or call Kaiser Permanente Senior Advantage (HMO) and ask for the Evidence of Coverage. You have choices about how to get your Medicare benefits One choice is to get your Medicare benefits through Original Medicare (fee-forservice Medicare). Original Medicare is run directly by the Federal government. Another choice is to get your Medicare benefits by joining a Medicare health plan (such as Kaiser Permanente Senior Advantage (HMO)), which is made available through your employer or trust fund. However, if you enroll in Original Medicare alone, you may endanger the coverage you receive through your employer or trust fund, and your benefits may be reduced. For information about the benefits available through your employer or trust fund, please see your EOC. No matter what you decide, you are still in the Medicare Program. Your employer or trust fund may restrict when you may join or leave its plan. Usually this is connected to your employer or trust fund's annual enrollment period. Please call your employer or trust fund for more information about enrollment periods. Tips for comparing your Medicare choices As a member who receives Kaiser Permanente Senior Advantage (HMO) coverage through an employer or trust fund, you will receive all of the benefits that the Original Medicare plan offers, plus additional benefits purchased for you by your employer or trust fund, which may change from year to year. Please see the enclosed Kaiser Permanente Senior Advantage (HMO) Summary of Benefits for benefits you receive through your employer or trust fund. If you want to know more about the coverage and costs of Original Medicare, look in your current Medicare & You handbook. View it online at http://www.medicare.gov or get a copy by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. Kaiser Permanente Senior Advantage Group Plan 2015 Summary of Benefits 1
Sections in this booklet Things to Know About Kaiser Permanente Senior Advantage (HMO) Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services Covered Medical, Hospital Benefits, and Prescription Drug Benefits This document is available in other formats such as Braille and large print. This document may be available in a non-english language. For additional information, call us at 1-800-777-1238. Este documento puede estar disponible en otros idiomas aparte del inglés. Si desea información adicional, por favor llámenos al 1-800-777-1238. Things to Know About Kaiser Permanente Senior Advantage (HMO) Hours of Operation You can call us 7 days a week from 8:00 a.m. to 8:00 p.m. Pacific time. Kaiser Permanente Senior Advantage (HMO) Phone Numbers and Website If you are a member of this plan, call toll-free 1-800-443-0815. If you are not a member of this plan, call toll-free 1-800-777-1238. Our website: kp.org/medicare Who can join? To join Kaiser Permanente Senior Advantage (HMO), you must be enrolled in Medicare Part B or have both Medicare Part A and Medicare Part B and live in our service area. In Northern California, the service area for this plan includes: Alameda, Amador*, Contra Costa, El Dorado*, Fresno*, Kings*, Madera*, Marin, Mariposa*, Napa*, Placer*, Sacramento, San Francisco, San Joaquin, San Mateo, Santa Clara*, Solano, Sonoma*, Stanislaus, Sutter*, Tulare*, Yolo*, and Yuba*. * denotes partial county Amador County: 95640, 95669. 2 Kaiser Permanente Senior Advantage Group Plan 2015 Summary of Benefits
El Dorado County: 95613 14, 95619, 95623, 95633 35, 95651, 95664, 95667, 95672, 95682, 95762. Fresno County: 93242, 93602, 93606 07, 93609, 93611 13, 93616, 93618 19, 93624 27, 93630 31, 93646, 93648 52, 93654, 93656 57, 93660, 93662, 93667 68, 93675, 93701 12, 93714 18, 93720 30, 93737, 93740 41, 93744 45, 93747, 93750, 93755, 93760 61, 93764 65, 93771 79, 93786, 93790 94, 93844, 93888. Kings County: 93230, 93232, 93242, 93631, 93656. Madera County: 93601 02, 93604, 93614, 93623, 93626, 93636 39, 93643 45, 93653, 93669, 93720. Mariposa County: 93601, 93623, 93653. Napa County: 94503, 94508, 94515, 94558 59, 94562, 94567, 94573 74, 94576, 94581, 94589 90, 94599, 95476. Placer County: 95602 04, 95626, 95648, 95650, 95658, 95661, 95663, 95668, 95677 78, 95681, 95692, 95703, 95722, 95736, 95746 47, 95765. Santa Clara County: 94022 24, 94035, 94039 43, 94085 89, 94301 06, 94309, 94550, 95002, 95008 09, 95011, 95013 15, 95020 21, 95026, 95030 33, 95035 38, 95042, 95044, 95046, 95050 56, 95070 71, 95076, 95101, 95103, 95106, 95108 13, 95115 36, 95138 41, 95148, 95150 61, 95164, 95170, 95172 73, 95190 94, 95196. Sonoma County: 94515, 94922 23, 94926 28, 94931, 94951 55, 94972, 94975, 94999, 95401 07, 95409, 95416, 95419, 95421, 95425, 95430 31, 95433, 95436, 95439, 95441 42, 95444, 95446, 95448, 95450, 95452, 95462, 95465, 95471 73, 95476, 95486 87, 95492. Sutter County: 95626, 95645, 95648, 95659, 95668, 95674, 95676, 95692, 95836 37. Tulare County: 93238, 93261, 93618, 93631, 93646, 93654, 93666, 93673. Yolo County: 95605, 95607, 95612, 95616 18, 95645, 95691, 95694 95, 95697 98, 95776, 95798 99. Yuba County: 95692, 95903, 95961. In Southern California, the service area for this plan includes: Kern*, Los Angeles*, Orange, Riverside*, San Bernardino*, San Diego*, and Ventura*. * denotes partial county Kern County: 93203, 93205 06, 93215 16, 93220, 93222, 93224 26, 93238, 93240 41, 93243, 93250 52, 93263, 93268, 93276, 93280, 93285, 93287, 93301 09, 93311 14, 93380, 93383 90, 93501 02, 93504 05, 93518 19, 93531, 93536, 93560 61, 93581. Los Angeles County: 90001 84, 90086 91, 90093 96, 90099, 90189, 90201 02, 90209 13, 90220 24, 90230 33, 90239 42, 90245, 90247 51, 90254 55, 90260 67, 90270, 90272, 90274 75, 90277 78, 90280, 90290 96, 90301 12, 90401 11, 90501 10, 90601 10, 90623, 90630 31, 90637 40, 90650 52, 90660 62, 90670 71, 90701 03, 90706 07, 90710 17, 90723, 90731 34, 90744 49, 90755, 90801 10, 90813 15, 90822, 90831 35, 90840, 90842, 90844, 90846 48, 90853, 90895, 90899, 91001, 91003, Kaiser Permanente Senior Advantage Group Plan 2015 Summary of Benefits 3
91006 12, 91016 17, 91020 21, 91023 25, 91030 31, 91040 43, 91046, 91066, 91077, 91101 10, 91114 18, 91121, 91123 26, 91129, 91182, 91184 85, 91188 89, 91199, 91201 10, 91214, 91221 22, 91224 26, 91301 11, 91313, 91316, 91321 22, 91324 31, 91333 35, 91337, 91340 46, 91350 57, 91361 62, 91364 65, 91367, 91371 72, 91376, 91380 87, 91390, 91392 96, 91401 13, 91416, 91423, 91426, 91436, 91470, 91482, 91495 96, 91499, 91501 08, 91510, 91521 23, 91526, 91601 12, 91614 18, 91702, 91706, 91709, 91711, 91714 16, 91722 24, 91731 35, 91740 41, 91744 50, 91754 56, 91765 73, 91775 76, 91778, 91780, 91788 93, 91801 04, 91896, 91899, 93243, 93510, 93532, 93534 36, 93539, 93543 44, 93550 53, 93560, 93563, 93584, 93586, 93590 91, 93599. Riverside County: 91752, 92201 03, 92210 11, 92220, 92223, 92230, 92234 36, 92240 41, 92247 48, 92253, 92255, 92258, 92260 64, 92270, 92276, 92282, 92320, 92324, 92373, 92399, 92501 09, 92513 19, 92521 22, 92530 32, 92543 46, 92548, 92551 57, 92562 64, 92567, 92570 72, 92581 87, 92589 93, 92595 96, 92599, 92860, 92877 83. San Bernardino County: 91701, 91708 10, 91729 30, 91737, 91739, 91743, 91758 59, 91761 64, 91766, 91784 86, 91792, 92305, 92307 08, 92313 18, 92321 22, 92324 25, 92329, 92331, 92333 37, 92339 41, 92344 46, 92350, 92352, 92354, 92357 59, 92369, 92371 78, 92382, 92385 86, 92391 95, 92397, 92399, 92401 08, 92410 11, 92413, 92415, 92418, 92423, 92427, 92880. San Diego County: 91901 03, 91908 17, 91921, 91931 33, 91935, 91941 46, 91950 51, 91962 63, 91976 80, 91987, 92007 11, 92013 14, 92018 27, 92029 30, 92033, 92037 40, 92046, 92049, 92051 52, 92054 58, 92064 65, 92067 69, 92071 72, 92074 75, 92078 79, 92081 85, 92091 93, 92096, 92101 24, 92126 32, 92134 40, 92142 43, 92145, 92147, 92149 50, 92152 55, 92158 61, 92163, 92165 79, 92182, 92186 87, 92190 93, 92195 99. Ventura County: 90265, 91304, 91307, 91311, 91319 20, 91358 62, 91377, 93001 07, 93009 12, 93015 16, 93020 22, 93030 36, 93040 44, 93060 66, 93094, 93099, 93252. Which doctors, hospitals, and pharmacies can I use? Kaiser Permanente Senior Advantage (HMO) has a network of doctors, hospitals, pharmacies, and other providers. If you use the providers that are not in our network, the plan may not pay for these services. You must generally use network pharmacies to fill your prescriptions for covered Part D drugs. You can see our plan s provider directory at our website (kp.org/medicare). You can see our plan s pharmacy directory at our website (http://www.kp.org/seniorrx). Or, call us and we will send you a copy of the provider and pharmacy directories. What do we cover? Like all Medicare health plans, we cover everything that Original Medicare covers and more. 4 Kaiser Permanente Senior Advantage Group Plan 2015 Summary of Benefits
Our plan members get all of the benefits covered by Original Medicare. For some of these benefits, you may pay more in our plan than you would in Original Medicare. For others, you may pay less. Our plan members also get more than what is covered by Original Medicare. Please see the enclosed Kaiser Permanente Senior Advantage (HMO) Summary of Benefits for benefits you receive through your employer or trust fund. We cover Part D drugs. In addition, we cover Part B drugs such as chemotherapy and some drugs administered by your provider. You can see the complete plan formulary (list of Part D prescription drugs) and any restrictions on our website, http://www.kp.org/seniorrx. Or, call us and we will send you a copy of the formulary. How will I determine my drug costs? Our plan groups each medication into one of six tiers. You will need to use your formulary to locate what tier your drug is on to determine how much it will cost you. The amount you pay depends on the drug s tier and what stage of the benefit you have reached. Kaiser Permanente Senior Advantage Group Plan 2015 Summary of Benefits 5
Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services How much is the monthly premium? Your group will notify you about your group's premium and the amount you will be expected to pay. If you have any questions about your contribution toward your group's premium, please contact your group's benefits administrator. In addition, you must keep paying your Medicare premium(s). How much is the deductible? Is there any limit on how much I will pay for my covered services? Please see the enclosed Kaiser Permanente Senior Advantage (HMO) Summary of Benefits to find out what the yearly limit is for your group's plan. Yes. Like all Medicare health plans, our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care. Please see the enclosed Kaiser Permanente Senior Advantage (HMO) Summary of Benefits to find out what the yearly limit is for your group's plan. If you reach the limit on out-of-pocket costs, you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year. Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs. Kaiser Permanente is an HMO plan with a Medicare contract. Enrollment in Kaiser Permanente depends on contract renewal. Covered Medical, Hospital Benefits, and Prescription Drug Benefits Please see the enclosed Kaiser Permanente Senior Advantage (HMO) Summary of Benefits for your group's benefits. 6 Kaiser Permanente Senior Advantage Group Plan 2015 Summary of Benefits
Additional information about Kaiser Permanente Senior Advantage (HMO) Covered services are provided in accord with Medicare coverage guidelines. Please see the Evidence of Coverage (EOC) for complete details, including other coverage limitations and exclusions. Getting care You must get covered services from plan providers except for authorized referrals, emergency care, and out-of-area urgent or dialysis care or as otherwise described in the EOC. Case management We have case management programs if you are managing many chronic conditions. Nurses, social workers, and your physician partner to meet your needs. They educate and teach self-care skills to help you manage your health. Please ask your physician for details. Grievances & appeals You can ask us to provide or pay for an item or service you think should be covered. If we deny your request, you can ask us to reconsider. You may ask for a fast decision if you think waiting could put your health at risk. If your doctor makes or supports the fast request, we will expedite our decision. If you have an issue unrelated to coverage, you can file a grievance with us. Please see the EOC for details. Privacy We protect the privacy of protected health information. Please see the EOC or view our Notice of Privacy Practices on kp.org to learn more. Kaiser Permanente Senior Advantage Group Plan 2015 Summary of Benefits 7
Multi-language Interpreter Services English: We have free interpreter services to answer any questions you may have about our health or drug plan. To get an interpreter, just call us at 1-800-443-0815. Someone who speaks English/Language can help you. This is a free service. Spanish: Tenemos servicios de intérprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos. Para hablar con un intérprete, por favor llame al 1-800-443-0815. Alguien que hable español le podrá ayudar. Este es un servicio gratuito. Chinese Mandarin: 我 们 提 供 免 费 的 翻 译 服 务, 帮 助 您 解 答 关 于 健 康 或 药 物 保 险 的 任 何 疑 问 如 果 您 需 要 此 翻 译 服 务, 请 致 电 1-800-443-0815 我 们 的 中 文 工 作 人 员 很 乐 意 帮 助 您 这 是 一 项 免 费 服 务 Chinese Cantonese: 您 對 我 們 的 健 康 或 藥 物 保 險 可 能 存 有 疑 問, 為 此 我 們 提 供 免 費 的 翻 譯 服 務 如 需 翻 譯 服 務, 請 致 電 1-800-443-0815 我 們 講 中 文 的 人 員 將 樂 意 為 您 提 供 幫 助 這 是 一 項 免 費 服 務 Tagalog: Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot. Upang makakuha ng tagasaling-wika, tawagan lamang kami sa 1-800-443-0815. Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog. Ito ay libreng serbisyo. French: Nous proposons des services gratuits d'interprétation pour répondre à toutes vos questions relatives à notre régime de santé ou d'assurance-médicaments. Pour accéder au service d'interprétation, il vous suffit de nous appeler au 1-800-443-0815. Un interlocuteur parlant Français pourra vous aider. Ce service est gratuit. Vietnamese: Chúng tôi có dịch vụ thông dịch miễn phí để trả lời các câu hỏi về chương sức khỏe và chương trình thuốc men. Nếu quí vị cần thông dịch viên xin gọi 1-800-443-0815 sẽ có nhân viên nói tiếng Việt giúp đỡ quí vị. Đây là dịch vụ miễn phí. German: Unser kostenloser Dolmetscherservice beantwortet Ihren Fragen zu unserem Gesundheits- und Arzneimittelplan. Unsere Dolmetscher erreichen Sie unter 1-800-443-0815. Man wird Ihnen dort auf Deutsch weiterhelfen. Dieser Service ist kostenlos. Korean: 당사는 의료 보험 또는 약품 보험에 관한 질문에 답해 드리고자 무료 통역 서비스를 제공하고 있습니다. 통역 서비스를 이용하려면 전화 1-800-443-0815 번으로 문의해 주십시오. 한국어를 하는 담당자가 도와 드릴 것입니다. 이 서비스는 무료로 운영됩니다. Y0043_N009556 accepted 60134608 CA
Russian: Если у вас возникнут вопросы относительно страхового или медикаментного плана, вы можете воспользоваться нашими бесплатными услугами переводчиков. Чтобы воспользоваться услугами переводчика, позвоните нам по телефону 1-800-443-0815. Вам окажет помощь сотрудник, который говорит по-pусски. Данная услуга бесплатная. Arabic: ا ننا نقدم خدمات المترجم الفوري المجانية للا جابة عن ا ي ا سي لة تتعلق بالصحة ا و جدول الا دوية لدينا. للحصول على مترجم فوري ليس عليك سوى الاتصال بنا على 5180-344-008-1. سيقوم شخص.بمساعدتك. هذه خدمة مجانية ما يتحدث العربية Hindi: हम र स व स थ य य दव क य जन क ब र म आपक कस भ प रश न क जव ब द न क लए हम र प स म फ त द भ षय स व ए उपलब ध ह. एक द भ षय प र प त करन क लए, बस हम 1-800-443-0815 पर फ न कर. क ई व य क त ज हन द ब लत ह आपक मदद कर सकत ह. यह एक म फ त स व ह. Italian: È disponibile un servizio di interpretariato gratuito per rispondere a eventuali domande sul nostro piano sanitario e farmaceutico. Per un interprete, contattare il numero 1-800-443-0815. Un nostro incaricato che parla Italianovi fornirà l'assistenza necessaria. È un servizio gratuito. Portugués: Dispomos de serviços de interpretação gratuitos para responder a qualquer questão que tenha acerca do nosso plano de saúde ou de medicação. Para obter um intérprete, contacte-nos através do número 1-800-443-0815. Irá encontrar alguém que fale o idioma Português para o ajudar. Este serviço é gratuito. French Creole: Nou genyen sèvis entèprèt gratis pou reponn tout kesyon ou ta genyen konsènan plan medikal oswa dwòg nou an. Pou jwenn yon entèprèt, jis rele nou nan 1-800-443-0815. Yon moun ki pale Kreyòl kapab ede w. Sa a se yon sèvis ki gratis. Polish: Umożliwiamy bezpłatne skorzystanie z usług tłumacza ustnego, który pomoże w uzyskaniu odpowiedzi na temat planu zdrowotnego lub dawkowania leków. Aby skorzystać z pomocy tłumacza znającego język polski, należy zadzwonić pod numer 1-800-443-0815. Ta usługa jest bezpłatna. Japanese: 当 社 の 健 康 健 康 保 険 と 薬 品 処 方 薬 プランに 関 するご 質 問 にお 答 えするため に 無 料 の 通 訳 サービスがありますございます 通 訳 をご 用 命 になるには 1-800-443-0815 にお 電 話 ください 日 本 語 を 話 す 人 者 が 支 援 いたします これは 無 料 のサービス です
Kaiser Foundation Health Plan, Inc. 393 E. Walnut St. Pasadena, CA 91188-8514 Member Service Contact Center 1-800-443-0815 (TTY 711) toll free Seven days a week, 8 a.m. to 8 p.m. kp.org/medicare Please recycle.