Disclosure form and evidence of coverage - Kaiser Permanente ...

Member Service Contact Center: toll free 1-800-443-0815 (TTY users call 711) seven days a week 8 a.m.–8 p.m.
• Emergency contraceptive pills: no charge
• The following insulin-administration devices at a
$5 Copayment for up to a 30-day supply: needles,
syringes, alcohol swabs, and gauze
Catastrophic Coverage Stage. All Medicare
prescription drug plans include catastrophic coverage for
people with high drug costs. In order to qualify for
catastrophic coverage, you must spend $4,750 out-ofpocket
during 2013. When the total amount you have
paid for your Cost Sharing reaches $4,750, you will pay
the following for the remainder of 2013:
• a $3 Copayment per prescription for insulin
administration devices and generic drugs
• a $10 Copayment per prescription for brand-name
and specialty drugs
• Injectable Part D vaccines: no charge
• Emergency contraceptive pills: no charge
Note: Each year, effective on January 1, the Centers for
Medicare & Medicaid Services may change coverage
thresholds and catastrophic coverage Copayments that
apply for the calendar year. We will notify you in
advance of any change to your coverage.
These payments are included in your out-of-pocket
costs. When you add up your out-of-pocket costs, you
can include the payments listed below (as long as they
are for Part D covered drugs and you followed the rules
for drug coverage that are explained in this "Outpatient
Prescription Drugs, Supplies, and Supplements" section):
• The amount you pay for drugs when you are in the
Initial Coverage Stage
• Any payments you made during this calendar year as
a member of a different Medicare prescription drug
plan before you joined our Plan
It matters who pays:
• If you make these payments yourself, they are
included in your out-of-pocket costs
• These payments are also included if they are made on
your behalf by certain other individuals or
organizations. This includes payments for your drugs
made by a friend or relative, by most charities, by
AIDS drug assistance programs, or by the Indian
Health Service. Payments made by Medicare's Extra
Help Program are also included
These payments are not included in your out-ofpocket
costs. When you add up your out-of-pocket costs,
you are not allowed to include any of these types of
payments for prescription drugs:
• The amount you contribute, if any, toward your
group's Premium
• Drugs you buy outside the United States and its
territories
• Drugs that are not covered by our Plan
• Drugs you get at an out-of-network pharmacy that do
not meet our Plan's requirements for out-of-network
coverage
• Prescription drugs covered by Part A or Part B
• Payments you make toward prescription drugs not
normally covered in a Medicare prescription drug
plan
• Payments for your drugs that are made or funded by
group health plans, including employer health plans
• Payments for your drugs that are made by certain
insurance plans and government-funded health
programs such as TRICARE and the Veterans
Administration
• Payments for your drugs made by a third-party with a
legal obligation to pay for prescription costs (for
example, Workers' Compensation)
Reminder: If any other organization such as the ones
described above pays part or all of your out-of-pocket
costs for Part D drugs, you are required to tell our Plan.
Call our Member Service Contact Center to let us know
(phone numbers are on the cover of this Evidence of
Coverage).
Keeping track of Medicare Part D drugs. The
Explanation of Benefits is a document you will get for
each month you use your Part D prescription drug
coverage. The Explanation of Benefits will tell you the
total amount you have spent on your prescription drugs
and the total amount we have paid for your prescription
drugs. An Explanation of Benefits is also available upon
request from our Member Service Contact Center.
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