P.O.

Box 629028
EL Dorado Hills, CA 95762-9028

Earl C Wentworth PURCHASER/BU-ID: 236589/0142

12246 HORADO RD Medical Record Number:
SAN DIEGO, CA 92128-2742 00-0007172482

Rx ID: 000007172482
RxGroup: SC
RxBIN: 011172
RxPCN: SCCMS

December 5, 2024

Dear Earl C Wentworth:

Thank you for enrolling in Kaiser Permanente Prescription Drug Plan (PDP). Medicare has approved
your enrollment in Kaiser Permanente Prescription Drug Plan (PDP) beginning January 1, 2025.

How will this plan work?

Beginning January 1, 2025, you should begin using Kaiser Permanente Prescription Drug Plan (PDP)
network pharmacies to fill your prescriptions. If you use an out-of-network pharmacy except in an
emergency, Kaiser Permanente Prescription Drug Plan (PDP) may not pay for your prescriptions.
You can find network pharmacies in your area by looking in your pharmacy directory or by calling
Kaiser Permanente. You can also visit the Kaiser Permanente website at kp.org. This letter is proof of
insurance that you should show to your pharmacy until you get your Member ID card from us.

What are my costs in this plan?

If you have questions about the amount of your premium contribution, please contact your employer
group or trust fund.

Can I get help paying my premiums and other out-of-pocket costs?

People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If you
qualify, Medicare could help pay for your drug costs including monthly prescription drug premiums,
annual deductibles, and co-insurance. Additionally, those who qualify won’t have a coverage gap or
a late enrollment penalty. Many people qualify for these savings and don’t even know it. For more
information about this Extra Help, contact your local Social Security office, or call Social Security at
1-800-772-1213. TTY users should call 1-800- 325-0778. You can also apply for Extra Help online at
www.ssa.gov/medicare/part-d-extra-help. If you think you qualify for Extra Help with your prescription
drug costs, but you don’t have or can’t find proof, please contact Kaiser Permanente.

SCR (05/20/2024)
Letter ID: MDCL0002
Will I pay a late enrollment penalty as part of my premium?
The late enrollment penalty is an amount added to your monthly Medicare drug plan (Part D)
premium for as long as you have Medicare prescription drug coverage. This penalty is required
by law and is designed to encourage people to enroll in a Medicare drug plan when they are first
eligible or keep other prescription drug coverage that meets Medicare’s minimum standards. You
may owe a late enrollment penalty if you didn’t join a Medicare drug plan when you were first eligible
for Medicare Part A and/or Part B, and:

● You didn’t have other prescription drug coverage that met Medicare’s minimum standards; OR

● You had a break in coverage of at least 63 days

If we determine that you owe a late enrollment penalty, we will notify you of your new monthly
premium amount.

What if I have a Medigap (Medicare Supplement Insurance) policy?

If you have a Medigap (Medicare Supplement) policy that includes prescription drug coverage, you
must contact your Medigap Issuer to let them know that you have joined a Medicare prescription
drug plan. Your Medigap Issuer will remove the prescription drug coverage portion of your policy and
adjust your premium. Call your Medigap Issuer for details.

How will this plan work?

Beginning January 1, 2025, you must see your Kaiser Permanente doctor(s) for your health care.
This means that starting January 1, 2025, all of your health care, except emergency or urgently
needed care, or out-of-area dialysis services, must be given or arranged by a Kaiser Permanente
doctor(s). You will need to pay your plan co-payments and co-insurance at the time you get health
care services, as provided in your member materials.

This letter is proof of insurance that you should show during your doctor appointments until you get
your member card from us. This letter is also proof of your prescription drug coverage. You should
show this letter at the pharmacy until you get your member card from us.

What do I need to know about getting health care services?

You must have Medicare Part B (Medical Insurance) to be a member of Kaiser Permanente
Prescription Drug Plan (PDP), however some employer groups require both Parts A (Hospital
Insurance) and B to join a Medicare Advantage plan. Please contact your employer group with any
questions about their requirements. If you don’t have Medicare Part B and/or Part A, as required by
your employer group, we will bill you for any health care you receive from us, and neither Medicare
nor Kaiser Permanente will pay for those services.

What are my costs on this plan?

If you have questions about the amount of your premium contribution, please contact your employer
group or trust fund.

Can I get help paying my premiums and other out-of-pocket costs?

People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If you
qualify, Medicare could help pay for your drug costs including monthly prescription drug premiums,
annual deductibles, and co-insurance. Additionally, those who qualify won’t have a coverage gap or
a late enrollment penalty. Many people qualify for these savings and don’t even know it. For more
information about this Extra Help, contact your local Social Security office, or call Social Security at
1-800-772-1213. TTY users should call 1-800-325-0778. You can also apply for Extra Help online at

SCR (05/20/2024)
Letter ID: MDCL0002
www.ssa.gov/medicare/part-d-extra-help. If you think you qualify for Extra Help with your prescription
drug costs, but you don’t have or can’t find proof, please contact Kaiser Permanente.

Will I pay a late enrollment penalty as part of my premium?

What if I have a Medigap (Medicare Supplement Insurance) policy?
Now that we have confirmed your enrollment, you may cancel any Medigap or supplemental
insurance that you have. Please note that if this is the first time that you are a member of a Medicare
Advantage or Medicare Cost plan, you may have a trial period during which you have certain rights to
leave (disenroll from) Kaiser Permanente Prescription Drug Plan (PDP) and buy a Medigap policy.
Please contact 1-800-MEDICARE (1-800-633-4227) anytime, 24 hours a day, 7 days a week for
further information. TTY users should call 1-877-486-2048.

If you have any questions, please call Kaiser Permanente at 1-800-443-0815. TTY users should call
711. We are open seven days a week, 8:00 a.m. to 8:00 p.m. Please be sure to keep a copy of this
letter for your records.

Thank you.

Kaiser Permanente
California Service Center

SCR (05/20/2024)
Letter ID: MDCL0002
MDCL0002
ID:
SCR(05/20/2024)Letter
This page is intentionally left blank.
 Notice of Nondiscrimination
1126306860 CA
June 2023
Kaiser Permanente complies with applicable federal civil rights laws and does not discriminate on
the basis of race, color, national origin, age, disability, or sex. Kaiser Permanente does not exclude
people or treat them differently because of race, color, national origin, age, disability, or sex. We also:

● Provide no cost aids and services to people with disabilities to communicate effectively with
us, such as:

o Qualified sign language interpreters.

o Written information in other formats, such as large print, audio, and accessible
electronic formats.
● Provide no cost language services to people whose primary language is not English, such as:

o Qualified interpreters.

o Information written in other languages.

If you need these services, call Member Services at 1-800-443-0815 (TTY 711), 8 a.m. to 8 p.m.,
seven days a week.

If you believe that Kaiser Permanente has failed to provide these services or discriminated in another
way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance
with our Civil Rights Coordinator by writing to One Kaiser Plaza, 12th Floor, Suite 1223, Oakland,
CA 94612 or calling Member Services at the number listed above. You can file a grievance by
mail or phone. If you need help filing a grievance, our Civil Rights Coordinator is available to help
you. You can also file a civil rights complaint with the U.S. Department of Health and Human
Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal,
available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department
of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building,
Washington, DC 20201, 1-800-368-1019, 1-800-537-7697 (TDD). Complaint forms are available at
http://www.hhs.gov/ocr/office/file/index.html.

1126306860 CA
June 2023
This page is intentionally left blank.
 Form Approved
OMB# 0938-1421

Multi-language Insert
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 (TTY 711). 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 (TTY 711). 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（TTY 711）。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，1-800-443-0815（TTY 711)。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 (TTY 711). 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 (TTY 711). 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 (TTY 711). 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
（TTY 711). 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 (TTY 711) 번으로 문의해
주십시오. 한국어를 하는 담당자가 도와 드릴 것입니다. 이 서비스는 무료로 운영됩니다.
Form CMS-10802
(Expires 12/31/25)
Y0043_N00036258_C

Form CMS-10802
(Expires 12/31/25)
Y0043_N00036258_C
 Form Approved
OMB# 0938-1421

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
(TTY 711). Вам окажет помощь сотрудник, который говорит по-pусски. Данная услуга
бесплатная.

‫ للحصول على مترجم‬.‫ إننا نقدم خدمات المترجم الفوري المجانية للإجابة عن أي أسئلة تتعلق بالصحة أو جدول الأدوية لدينا‬:Arabic
‫ هذه خدمة‬.‫ سيقوم شخص ما يتحدث العربية بمساعدتك‬.1-800-443-0815 (TTY 711) ‫ ليس عليك سوى الاتصال بنا على‬،‫فوري‬
.‫مجانية‬

Hindi: हमारे स्वास्थ्य या दवा की योजना के बारे में आपके ककसी भी प्रश्न के जवाब दे ने के लिए हमारे
पास मफ् ु त दभ
ु ाषिया सेवाएँ उपिब्ध हैं. एक दभ
ु ाषिया प्राप्त करने के लिए, बस हमें 1-800-443-0815
(TTY 711). पर फोन करें . कोई व्यक्तत जो हहन्दी बोिता है आपकी मदद कर सकता है . यह एक मुफ्त
सेवा है .
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
（TTY 711). 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 (TTY 711). 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
(TTY 711). 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
(TTY 711). 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（TTY 711）
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。
Form CMS-10802
(Expires 12/31/25)
1140823727
June 2023

Form CMS-10802
(Expires 12/31/25)
1140823727
June 2023