2021 Summary of Benefits

January 1–December 31, 2021 2021 Summary of Benefits Kaiser Permanente Senior Advantage Greater Fresno Area Basic Plan (HMO) and Kaiser Permanente Senior Advantage Greater Fresno Area Enhanced Plan (HMO) H0524_21SB038046_M PBPs 038 & 046 480133546 N3846 About this Summary of Benefits Thank you for considering Kaiser Permanente Senior Advantage. You can use this Summary of Benefits to learn more about our plans. It includes information about: • Premiums • Benefits and costs • Part D prescription drugs • Optional supplemental benefits (Advantage Plus) • Who can enroll • Coverage rules • Getting care For definitions of some of the terms used in this booklet, see the glossary at the end. For more details This document is a summary of 2 Kaiser Permanente Senior Advantage plans. It doesn’t include everything about what’s covered and not covered or all the plan rules. For details, see the Evidence of Coverage (EOC), which is located on our website at kp.org/eocncal or ask for a copy from Member Services by calling 1-800-443-0815 (TTY 711), 7 days a week, 8 a.m. to 8 p.m. Have questions? • If you’re not a member, please call 1-800-777-1238 (TTY 711). • If you’re a member, please call Member Services at 1-800-443-0815 (TTY 711). • 7 days a week, 8 a.m. to 8 p.m. 1 What’s covered and what it costs *Your plan provider may need to provide a referral †Prior authorization may be required. With our Basic plan, With our Enhanced plan, Benefits and premiums you pay you pay Monthly plan premium $15 $75 Deductible None None Your maximum out-of-pocket responsibility $5,900 $4,000 Doesn't include Medicare Part D drugs Inpatient hospital coverage*† $200 per day for days 1 $160 per day for days 1 There’s no limit to the number of through 7 of your stay and through 7 of your stay and medically necessary inpatient $0 for the rest of your stay $0 for the rest of your stay hospital days. Outpatient hospital coverage $0–$150 per visit $0–$150 per visit Ambulatory Surgery Center $150 per visit $150 per visit Doctor’s visits • Primary care providers $15 per visit $5 per visit • Specialists* $25 per visit $15 per visit Preventive care* $0 $0 See the EOC for details. Emergency care $90 per Emergency $90 per Emergency We cover emergency care Department visit Department visit anywhere in the world. Urgently needed services We cover urgent care $15 per office visit $5 per office visit anywhere in the world. Diagnostic services, lab, and imaging* • A1c, LDL, certain INR, and $0 $0 glucose quantitative lab tests • All other lab tests • Diagnostic tests and procedures $15 per encounter $5 per encounter (like EKG) • X-rays $25 per encounter $15 per encounter • Other imaging procedures $150 per procedure $105 per procedure (like MRI, CT, and PET) ($25 for ultrasounds) ($15 for ultrasounds) 2 With our Basic plan, With our Enhanced plan, Benefits and premiums you pay you pay Hearing services* Evaluations to diagnose medical • per visit with a • per visit with a conditions. $15 $5 primary care provider primary care provider Hearing aids and related exams • $25 per visit with a • $15 per visit with a aren’t covered unless you sign up specialist specialist for optional benefits (see Advantage Plus for details). Dental services Not covered unless you sign Not covered unless you sign Preventive and comprehensive up for optional benefits (see up for optional benefits (see dental coverage Advantage Plus for details). Advantage Plus for details). Vision services* • $15 per visit with an • $5 per visit with an • Visits to diagnose and treat eye optometrist optometrist diseases and conditions • $25 per visit with an • $15 per visit with an ophthalmologist ophthalmologist • Routine eye exams • $15 per visit • $5 per visit • Preventive glaucoma screening and diabetic retinopathy $0 $0 services • Eyeglasses or contact lenses $0 up to Medicare’s limit, but $0 up to Medicare’s limit, but after cataract surgery you pay any amounts beyond you pay any amounts beyond that limit. that limit. • Other eyewear ($40 allowance every 24 months) If your eyewear costs more If your eyewear costs more • If you sign up for optional than $40, you pay the than $40, you pay the benefits the allowance is greater difference. difference. (see Advantage Plus for details). Mental health services • Outpatient group therapy $7 per visit $2 per visit • Outpatient individual therapy $15 per visit $5 per visit Skilled nursing facility*† Per benefit period: Per benefit period: We cover up to 100 days • $0 per day for days • $0 per day for days per benefit period. 1 through 20 1 through 20 • $100 per day for days • $100 per day for days 21 through 100 21 through 100 Physical therapy* $25 per visit $15 per visit Ambulance $200 per one-way trip $200 per one-way trip Transportation Not covered Not covered 3 With our Basic plan, With our Enhanced plan, Benefits and premiums you pay you pay Medicare Part B drugs† A limited number of Medicare Part B drugs are covered when you get them from a plan provider. See the EOC for details. • Drugs that must be administered by a health $0 $0 care professional • Up to a 30-day supply • $15 for generic drugs • $12 for generic drugs from a plan pharmacy • $47 for brand-name drugs • $47 for brand-name drugs Medicare Part D prescription drug coverage† The amount you pay for drugs will be different depending on: • The plan you enroll in (Basic or Enhanced). • The tier your drug is in. There are 6 drug tiers. To find out which of the 6 tiers your drug is in, see our Part D formulary at kp.org/seniorrx or call Member Services to ask for a copy at 1-800-443-0815 (TTY 711), 7 days a week, 8 a.m. to 8 p.m. • The day supply quantity you get (like a 30-day or 100-day supply). Note: A supply greater than a 30-day supply isn’t available for all drugs. • Whether you get your prescription filled by one of our retail plan pharmacies or our mail-order pharmacy. Note: Not all drugs can be mailed. • The coverage stage you’re in (initial, coverage gap, or catastrophic coverage stages). Initial coverage stage You pay the copays and coinsurance shown in the chart below until your total yearly drug costs reach $4,130. (Total yearly drug costs are the amounts paid by both you and any Part D plan during a calendar year.) If you reach the $4,130 limit in 2021, you move on to the coverage gap stage and your coverage changes. Drug tier Retail plan pharmacy Mail-order plan pharmacy Tier 1 (Preferred generic) • Basic plan $5 (up to a 30-day supply) $0 (up to a 100-day supply) • Enhanced plan $3 (up to a 30-day supply) $0 (up to a 100-day supply) Tier 2 (Generic) • Basic plan $15 (up to a 30-day supply) • Enhanced plan $12 (up to a 30-day supply) Tier 3 (Preferred brand-name) $47 (up to a 30-day supply) Tier 4 (Nonpreferred brand-name) $100 (up to a 30-day supply) Tier 5 (Specialty) 33% coinsurance (up to a 100-day supply) 4 Drug tier Retail plan pharmacy Mail-order plan pharmacy Tier 6 (Vaccines) $0 Not applicable When you get a 31- to 100-day supply of drugs, the copays listed above for a 30-day supply in the chart will be multiplied as follows: • If you get a 31- to 60-day supply from a retail plan pharmacy, you pay 2 copays; and you pay 3 copays if you get a 61- to 100-day supply. • If you get a 31- to 100-day supply of drugs in Tiers 2–4 from our mail-order pharmacy, you pay 2 copays. Coverage gap stage The coverage gap stage begins if you or a Part D plan spends $4,130 on your drugs during 2021. You pay the following copays and coinsurance during the coverage gap stage: Drug tier You pay Tiers 1, 2, and 6 The same copays listed above that you pay during the initial coverage stage Tiers 3, 4, and 5 25% coinsurance Catastrophic coverage stage If you spend $6,550 on your Part D prescription drugs in 2021, you’ll enter the catastrophic coverage stage. Most people never reach this stage, but if you do, your copays and coinsurance will change for the rest of 2021. You pay the following copays per prescription during the catastrophic coverage stage: Drug You pay Generic drugs $3 Brand-name drugs $12 Part D vaccines $0 Long-term care, plan home-infusion, and non-plan pharmacies • If you live in a long-term care facility and get your drugs from their pharmacy, you pay the same as at a retail plan pharmacy and you can get up to a 31-day supply. • Covered Part D home infusion drugs from a plan home-infusion pharmacy are provided at no charge. • If you get covered Part D drugs from a non-plan pharmacy, you pay the same as at a retail plan pharmacy and you can get up to a 30-day supply. Generally, we cover drugs filled at a non-plan pharmacy only when you can’t use a network pharmacy, like during a disaster. See the Evidence of Coverage for details. 5 Advantage Plus (optional benefits) In addition to the benefits that come with your plan, you can choose to buy a supplemental benefit package called Advantage Plus.

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