PPO. Alliance Medicare PPO H2322. hap.org/medicare. Genesee Lapeer Livingston Macomb Monroe Oakland St. Clair Washtenaw Wayne Counties

Transcription

1 hap.org/medicare PPO 2015 Summary of Benefits 2850 W. Grand Boulevard Detroit, MI hap.org/medicare Alliance Medicare PPO H2322 Individual Plan 008 Individual Plan 004 Genesee Lapeer Livingston Macomb Monroe Oakland St. Clair Washtenaw Wayne Counties January 1, December 31, Health Alliance Plan of Michigan. A Nonprofit Company. Y0076_PPO SB15 CMS Accepted 9/22/2014

2 Alliance Medicare PPO (PPO) (a Medicare Advantage Provider Organization (PPO) offered by ALLIANCE HEALTH AND LIFE INSURANCE COMPANY with a Medicare contract) Summary of Benefits January 1, December 31, 2015 There is more than one plan listed in this Summary of Benefits booklet. The booklet gives you a summary of what each plan covers and what you pay. It doesn t list every service that each plan covers or list every limitation or exclusion. To get a complete list of services we cover, call us 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-for-service 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 Alliance Medicare PPO). Tips for comparing your Medicare choices This Summary of Benefits booklet gives you a summary of what Alliance Medicare PPO covers and what you pay. If you want to compare our plans with other Medicare health plans, ask the other plans for their Summary of Benefits booklets. Or, use the Medicare Plan Finder on 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 or get a copy by calling MEDICARE ( ), 24 hours a day, 7 days a week. TTY users should call (Introduction continued on next page) 1

3 Sections in this booklet Things to Know About Alliance Medicare PPO Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services Covered Medical and Hospital Benefits Prescription Drug Benefits Optional Benefits (you must pay an extra premium for these benefits) This document is available in other formats such as large print. This document may be available in a non-english language. For additional information, call us at (888) Things to Know About Alliance Medicare PPO Hours of Operation From October 1 to March 31, you can call us 7 days a week from 8:00 a.m. to 8:00 p.m. Eastern time. From February 15 to September 30, you can call us Saturday from 8:00 a.m. to 12:00 p.m. Eastern time, Monday from 8:00 a.m. to 8:00 p.m. Eastern time, Tuesday from 8:00 a.m. to 8:00 p.m. Eastern time, Wednesday from 8:00 a.m. to 8:00 p.m. Eastern time, Thursday from 8:00 a.m. to 8:00 p.m. Eastern time, Friday from 8:00 a.m. to 8:00 p.m. Eastern time. From April 1 to September 30, you can call us Monday through Friday from 8:00 a.m. to 8:00 p.m. Eastern time. Alliance Medicare PPO Phone Numbers and Website If you are a member of this plan, call toll-free (888) If you are not a member of this plan, call toll-free (800) Our website: Who can join? To join Alliance Medicare PPO, you must be entitled to Medicare Part A, be enrolled in Medicare Part B, and live in our service area. Our service area includes the following counties in Michigan: Genesee, Lapeer, Livingston, Macomb, Monroe, Oakland, St. Clair, Washtenaw, and Wayne. Which doctors, hospitals, and pharmacies can I use? Alliance Medicare PPO has a network of doctors, hospitals, pharmacies, and other providers. If you use the providers in our network, you may pay less for your covered services. But if you want to, you can also use providers that are not in our network. 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 ( You can see our plan s pharmacy directory at our website ( 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. Our plan members get all of the benefits covered by Original Medicare. For some of these benefits, you may pay more for one of our plans 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. Some of the extra benefits are outlined in this booklet. 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, 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 five 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. Later in this document we discuss the benefit stages that occur: Initial Coverage, Coverage Gap, and Catastrophic Coverage. These benefit stages occur after you meet your deductible with Plan 004 (). 2 3

4 Mul -language Interpreter Services English: We have free interpreter services to answer any ques ns you may have about our health or drug plan. To get an interpreter, just call us at (800) (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 (800) (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 (800) (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, 請 致 電 (800) (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 (800) (TTY: 711). Maaari kayong t ulungan ng isang nakakapagsalita ng Tagalog. Ito ay libreng serbisyo. French: Nous proposons des services gratuits d'interpréta on pour répondre à toutes vos ques ns rela à notre régime de santé ou d'assurance-médicaments. Pour accéder au service d'interpréta on, il vous suffit de nous appeler au (800) (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 (800) (TTY: 711). sẽ có nhân viên nói ếng Việt giúp đỡ quí vị. Đây là dịch vụ miễn phí. German: Unser kostenloser Dolmetscherservice beantwortet Ihren Fragen zu unserem Gesundheits- und Arzneimi elplan. Unsere Dolmetscher erreichen Sie unter (800) (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 (800) (TTY: 711). 번으로 문의해 주십시오. 한국어를 하는 담당자가 도와 드릴 것입니다. 이 서비스는 무료로 운영됩니다. Russian: Если у вас Russian: возникнут Если вопросы у вас возникнут относительно вопросы страхового относительно или медикаментного страхового или медикаментного плана, вы можете воспользоваться плана, вы можете нашими воспользоваться бесплатными нашими услугами бесплатными переводчиков. услугами Чтобы переводчиков. Чтобы воспользоваться услугами воспользоваться переводчика, услугами позвоните переводчика, нам по телефону позвоните (800) нам по телефону or (800) (TTY: 711). Вам окажет (TTY: помощь 711). Вам сотрудник, окажет помощь которыйсотрудник, говорит по-pусски. который говорит по-pусски. Данная услуга бесплатная. Данная услуга бесплатная. إننا نقد مخدمات المترجم إننا الفوري نقدم المجانی خدمات ةللا جابة المترجمعن أ الفوري أسي لة تتع المجانیةلق للا جابة بالصحة عنأ أي وجدول أسي لة الا دویة تتعلق لدینا. بالصحةل حل أوصو لع جدول ىل الا دویة Arabic: لدینا. للحصول على Arabic:. سیق وم شخص ما.(. 711 سیقوم : TTY )شخص ما (711 (800) : TTY )متر orجم فوري لی سعلی (800) ك سوى مترجم الاتصال فوري بنا لیسعلى علیك سوى الاتصال بنا على. بمساعدتك. ھذه خدم. ةمجانیة یت بمساعدتك حدث. ھذه العربیةخدمة مجانیة یتحدث العربیة Italian: È disponibileitalian: un servizio È disponibile interpretariato un servizio gratuito di interpretariato per rispondere gratuito a eventuali per rispondere domandea eventuali domande sul nostro piano sanitario sul nostro e farmaceu piano sanitario co. Per e unfarmaceu interprete, co. conta Per un are interprete, il numeroconta are il numero (800) (800) or (TTY: 711). Un Un nostro incaricato che che parla Italianovi fornirà l'assistenza necessaria. l'assistenza necessaria. È un Èservizio un servizio gratuito. Portugués: Dispomos Portugués: de serviços Dispomos de interpretação de serviços gratuitos de interpretação para responder gratuitos a qualquer para responder a qualquer questão que tenha acerca questão doque nosso tenha plano acerca de saúde do nosso ou de plano medicação. de saúde Para ou de obter medicação. um intérprete, Para obter um intérprete, contacte-nos através contacte-nos do número (800) através do número or (TTY: (800) 711) Irá encontrar (TTY: 711). Irá encontrar alguém que alguém que fale o idioma fale o Português idioma Português para o ajudar. para o Este ajudar. serviço Este éserviço gratuito. é gratuito. French Creole: NouFrench genyencreole: sèvis entèprèt Nou genyen gra sèvis pou reponn entèprèt tout gra kesyon pou reponn ou ta genyen tout kesyon ou ta genyen konsènan plan medikal konsènan oswa dwòg plan medikal nou an. oswa Pou jwenn dwòg yon nou entèprèt, an. Pou jwenn jis releyon nouentèprèt, nan jis rele nou nan (800) or (TYY: (800) 711) Yon moun (TTY: ki 711). pale Kreyòl Yon moun kapab ki pale ede w. Kreyòl Sa akapab se yonede sèvis w. ki Sa gra a se yon sèvis ki gra Polish: Umożliwiamy Polish: bezpłatne Umożliwiamy skorzystanie bezpłatne z usługskorzystanie tłumacza ustnego, z usług który tłumacza pomoże ustnego, w który pomoże w uzyskaniu odpowiedzi uzyskaniu na temat odpowiedzi planu zdrowotnego na temat planu lub dawkowania zdrowotnego leków. lub dawkowania Aby skorzystać leków. z Aby skorzystać z pomocy tłumacza znającego pomocy tłumacza język polski, znającego należy zadzwonić język polski, pod należy numer zadzwonić (800) pod numer or (800) (TTY: 711). Ta usługa (TTY: jest711). bezpłatna. Ta usługa jest bezpłatna. Hindi: हम र Hindi: य दव हम र य जन क य ब र दव आपक य जन क ब भ र आपक जव ब द न भ क क जव ब द न क हम र प स म त द भ हम र षय प स सव एम उपल त दभ षय. एक सव ए द भ उपल षय. एक करन दभ क षय, बस करन क, बस (800) or (TTY: (800) 711) पर फ न (TTY: 711).. क ईपर फ न ज. क ई ब लत ह ज ब लत ह मदद कर सकत ह. मदद यह एक कर म सकत त सह. व यह ह. एक म त सव ह. Japanese: 当 社 の 健 Japanese: 康 健 康 保 当 険 社 と の 薬 健 品 康 処 健 方 康 薬 保 プランに 険 と 薬 品 関 するご 処 方 薬 質 プランに 問 にお 答 関 えするため 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 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 通 訳 をご 用 命 になるには (TTY: 711). にお 電 話 ください にお 日 本 電 語 話 を ください 話 す 人 者 日 本 語 を 話 す 人 者 が 支 援 いたします これは が 支 援 いたします これは 無 料 のサービスです 無 料 のサービスです Y0076_HMO 676 HMO Y0076_HMO POS ML INS 676 HMO POS CMSML ACCEPTED INS 09/04/2012 CMS ACCEPTED 09/04/

5 Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services QUESTIONS How much is the monthly premium? $126 per month. In addition, you must keep paying your Medicare Part B premium. $210 per month. In addition, you must keep paying your Medicare Part B premium. How much is This plan has deductibles for some hospital $150 per year for Part D prescription drugs. the deductible? and medical services. $250 per year for some in-network and out-of-network services. This plan does not have a deductible for Part D prescription drugs. Is there any Yes. Like all Medicare health plans, our plan Yes. Like all Medicare health plans, our plan limit on how protects you by having yearly limits on your out- protects you by having yearly limits on your outmuch I will pay of-pocket costs for medical and hospital care. of-pocket costs for medical and hospital care. for my covered services? Is there a limit on how much the plan will pay? Your yearly limit(s) in this plan: $3,400 for services you receive from in-network providers. $5,100 for services you receive from any provider. Your limit for services received from in-network providers will count toward this limit. 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. Our plan has a coverage limit every year for certain benefits from any provider. Contact us for services that apply. Your yearly limit(s) in this plan: $3,400 for services you receive from in-network providers. $5,100 for services you receive from any provider. Your limit for services received from in-network providers will count toward this limit. 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. Our plan has a coverage limit every year for certain benefits from any provider. Contact us for services that apply. COVERED MEDICAL AND HOSPITAL S Acupuncture and Other Alternative Therapies Ambulance 1 Not covered In-network: $75 Not covered In-network: $75 Chiropractic Manipulation of the spine to correct a Manipulation of the spine to correct a Care 1 subluxation (when 1 or more of the bones of subluxation (when 1 or more of the bones of your spine move out of position): your spine move out of position): Dental Services 1,2 In-network: $20 Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): In-network: $20-40, depending on In-network: $20 Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): In-network: $15-30, depending on Diabetes Diabetes monitoring supplies: Diabetes monitoring supplies: Supplies and Services 1 Diabetes self-management training: Diabetes self-management training: Alliance Medicare PPO is a plan with a Medicare contract. Enrollment in the plan depends on contract renewal. 6 7

6 COVERED MEDICAL AND HOSPITAL S COVERED MEDICAL AND HOSPITAL S Diabetes Therapeutic shoes or inserts: Therapeutic shoes or inserts: Supplies and Services 1 (cont d) Diagnostic Tests, Diagnostic radiology services (such as MRIs, Diagnostic radiology services (such as MRIs, Lab and CT scans): CT scans): Radiology Services, and In-network: $0-100, depending on In-network: $0-75, depending on X Rays 1,2 Diagnostic Tests, Lab and Radiology Services, and X Rays 1,2 (cont d) Therapeutic radiology services (such as radiation treatment for cancer): In-network: $25 Therapeutic radiology services (such as radiation treatment for cancer): In-network: $25 Doctor s Offce Primary care physician visit: Primary care physician visit: Visits 1 In-network: $0-20, depending on In-network: $0-15, depending on Diagnostic tests and procedures: Diagnostic tests and procedures: Specialist visit: Specialist visit: In-network: $0-100, depending on In-network: $0-75, depending on In-network: $0-40, depending on In-network: $0-30, depending on Lab services: Outpatient x-rays: In-network: $0-100, depending on Lab services: Outpatient x-rays: In-network: $0-75, depending on Durable Medical Equipment (wheelchairs, oxygen, etc.) 1 Emergency Care In-network: 20% of the cost $65 If you are immediately admitted to the hospital, you do not have to pay your share of the cost for emergency care. See the Inpatient Hospital Care section of this booklet for other costs. In-network: 20% of the cost $65 If you are immediately admitted to the hospital, you do not have to pay your share of the cost for emergency care. See the Inpatient Hospital Care section of this booklet for other costs. Worldwide coverage. Worldwide coverage. 8 9

7 COVERED MEDICAL AND HOSPITAL S COVERED MEDICAL AND HOSPITAL S Foot Care Foot exams and treatment if you have Foot exams and treatment if you have (podiatry diabetes-related nerve damage and/or meet diabetes-related nerve damage and/or meet services) 1 certain conditions: In-network: $40 certain conditions: In-network: $30 Mental Health Our plan also covers 60 lifetime reserve Our plan also covers 60 lifetime reserve Care 1,2 days. These are extra days that we cover. days. These are extra days that we cover. (cont d) If your hospital stay is longer than 90 days, you can use these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days. If your hospital stay is longer than 90 days, you can use these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days. Hearing Services Exam to diagnose and treat hearing and balance issues: Exam to diagnose and treat hearing and balance issues: In-network: $150 per day for days 1 through 5 You pay nothing per day for days 6 through 90 In-network: $125 per day for days 1 through 5 You pay nothing per day for days 6 through 90 Routine hearing exam: Routine hearing exam: Out-of-network: Out-of-network: Home Health Care In-Network Hearing aids not covered. In-network: 20% of the cost In-Network Hearing aids not covered. Mental Health Inpatient visit: Inpatient visit: Care 1,2 Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital. Our plan covers 90 days for an inpatient hospital stay. In-network: 20% of the cost Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital. Our plan covers 90 days for an inpatient hospital stay. $300 per day for days 1 through 5 You pay nothing per day for days 6 and beyond Outpatient group therapy visit: In-network: $40 Outpatient individual therapy visit: In-network: $40 Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital. $250 per day for days 1 through 5 You pay nothing per day for days 6 and beyond Outpatient group therapy visit: In-network: $30 Outpatient individual therapy visit: In-network: $30 Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital

8 COVERED MEDICAL AND HOSPITAL S COVERED MEDICAL AND HOSPITAL S Outpatient Cardiac (heart) rehab services (for a Cardiac (heart) rehab services (for a Rehabilitation 1 maximum of 2 one hour sessions per day for maximum of 2 one hour sessions per day for up to 36 sessions up to 36 weeks): up to 36 sessions up to 36 weeks): In-network: $15 Occupational therapy visit: In-network: $15 In-network: $15 Occupational therapy visit: In-network: $15 Outpatient Ambulatory surgical center: Ambulatory surgical center: Surgery 1,2 In-network: $0-100, depending on Outpatient hospital: In-network: $0-100, depending on In-network: $0-75, depending on Outpatient hospital: In-network: $0-75, depending on Physical therapy and speech and language therapy visit: Physical therapy and speech and language therapy visit: Over-the-Counter Items Not Covered Not Covered In-network: $15 In-network: $15 Outpatient Group therapy visit: Group therapy visit: Substance Abuse In-network: $40 In-network: $30 Prosthetic Devices (braces, artificial limbs, etc.) 1 Prosthetic devices: In-network: 20% of the cost Related medical supplies: Prosthetic devices: In-network: 20% of the cost Related medical supplies: In-network: 20% of the cost In-network: 20% of the cost Individual therapy visit: Individual therapy visit: In-network: $40 In-network: $30 Renal Dialysis 1 In-network: $0-25, depending on In-network: $0-25, depending on Transportation Not covered Not covered 12 13

9 COVERED MEDICAL AND HOSPITAL S COVERED MEDICAL AND HOSPITAL S Urgent Care $35 If you are immediately admitted to the hospital, you do not have to pay your share of the cost for urgent care. See the Inpatient Hospital Care section of this booklet for other costs. $35 If you are immediately admitted to the hospital, you do not have to pay your share of the cost for urgent care. See the Inpatient Hospital Care section of this booklet for other costs. Vision Services (cont d) Our plan pays up to $80 every two years for eyeglass frames from any provider. Eyeglass lenses (for up to 1 every two years): Vision Services Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): Our plan pays up to $120 every two years for eyeglass lenses from any provider. Eyeglasses or contact lenses after cataract surgery: Routine eye exam: Routine eye exam: Contact lenses (for up to 1 every two years): Our plan pays up to $80 every two years for contact lenses from any provider. Eyeglasses or contact lenses after cataract surgery: Eyeglass frames (for up to 1 every two years): 14 15

10 COVERED MEDICAL AND HOSPITAL S Preventive Care COVERED MEDICAL AND HOSPITAL S Preventive Care Preventive Care 2 Our plan covers many preventive services, including: Our plan covers many preventive services, including: Preventive Care 2 Sexually transmitted infections screening Sexually transmitted infections screening (cont d) and counseling and counseling Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease) Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease) Abdominal aortic aneurysm screening Alcohol misuse counseling Bone mass measurement Abdominal aortic aneurysm screening Alcohol misuse counseling Bone mass measurement Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots Welcome to Medicare preventive visit (one-time) Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots Welcome to Medicare preventive visit (one-time) Breast cancer screening (mammogram) Breast cancer screening (mammogram) Yearly Wellness visit Yearly Wellness visit Cardiovascular disease (behavioral therapy) Cardiovascular screenings Cardiovascular disease (behavioral therapy) Cardiovascular screenings Any additional preventive services approved by Medicare during the contract year will be covered. Any additional preventive services approved by Medicare during the contract year will be covered. Cervical and vaginal cancer screening Cervical and vaginal cancer screening Colonoscopy Colorectal cancer screenings Depression screening Diabetes screenings Fecal occult blood test Flexible sigmoidoscopy HIV screening Medical nutrition therapy services Colonoscopy Colorectal cancer screenings Depression screening Diabetes screenings Fecal occult blood test Flexible sigmoidoscopy HIV screening Medical nutrition therapy services Hospice Hospice You pay nothing for hospice care from a Medicare-certified hospice. You may have to pay part of the cost for drugs and respite care. You pay nothing for hospice care from a Medicare-certified hospice. You may have to pay part of the cost for drugs and respite care. Obesity screening and counseling Obesity screening and counseling Prostate cancer screenings (PSA) Prostate cancer screenings (PSA) 16 17

11 COVERED MEDICAL AND HOSPITAL S Inpatient Care COVERED MEDICAL AND HOSPITAL S Inpatient Care Inpatient Our plan covers an unlimited number of Our plan covers an unlimited number of Hospital Care 1,2 days for an inpatient hospital stay. days for an inpatient hospital stay. In-network: $150 per day for days 1 through 5 You pay nothing per day for days 6 through 90 You pay nothing per day for days 91 and beyond In-network: $125 per day for days 1 through 5 You pay nothing per day for days 6 through 90 You pay nothing per day for days 91 and beyond Skilled Nursing Our plan covers up to 100 days in a SNF. Our plan covers up to 100 days in a SNF. Facility (SNF) 1,2 In-network: In-network: Out-of-network: $100 per day for days 1 through 20 $145 per day for days 21 through 100 In-network: Out-of-network: $100 per day for days 1 through 20 $145 per day for days 21 through 100 In-network: Out-of-network: Out-of-network: $15 per day for days 1 through 20 $15 per day for days 1 through 20 $300 per day for days 1 through 5 You pay nothing per day for days 6 and beyond $250 per day for days 1 through 5 You pay nothing per day for days 6 and beyond $155 per day for days 21 through 100 $155 per day for days 21 through 100 Inpatient Mental Health Care For inpatient mental health care, see the Mental Health Care section of this booklet. For inpatient mental health care, see the Mental Health Care section of this booklet

12 PRESCRIPTION DRUG S Prescription Drug Benefits PRESCRIPTION DRUG S Prescription Drug Benefits Prescription Drug How much do I pay? Benefits For Part B drugs such as chemotherapy drugs: In-network: 0-20% of the cost depending on the drug Other Part B drugs: In-network: 0-20% of the cost depending on the drug How much do I pay? For Part B drugs such as chemotherapy drugs: In-network: 0-20% of the cost depending on the drug Other Part B drugs: In-network: 0-20% of the cost depending on the drug Initial Coverage You pay the following until your total yearly drug costs reach $2,960. Total yearly drug costs are the total drug costs paid by both you and our Part D plan. You may get your drugs at network retail pharmacies and mail order pharmacies. Standard Retail Cost-Sharing Tier One- Two- Threemonth month month supply supply supply Tier 1 $2 ( $4 $5 After you pay your yearly deductible, you pay the following until your total yearly drug costs reach $2,960. Total yearly drug costs are the total drug costs paid by both you and our Part D plan. You may get your drugs at network retail pharmacies and mail order pharmacies. Standard Retail Cost-Sharing Tier One- Two- Threemonth month month supply supply supply Tier 1 $4 $8 $10 ( Tier 2 $15 $30 $37.50 (Non- Tier 2 $10 $20 $25 (Non- Tier 3 $45 $90 $ ( Brand) Tier 3 $40 $80 $100 ( Brand) Tier 4 33% of the 33% of the 33% of (Non- cost cost the cost Brand) Tier 4 29% of 29% of 29% of (Non- the cost the cost the cost Brand) Tier 5 33% of the 33% of the 33% of (Specialty cost cost the cost Tier) Tier 5 29% of 29% of 29% of (Specialty the cost the cost the cost Tier) 20 21

13 PRESCRIPTION DRUG S Prescription Drug Benefits PRESCRIPTION DRUG S Prescription Drug Benefits Initial Coverage (cont d) Standard Mail Order Cost-Sharing Tier One- Two- Threemonth month month supply supply supply Tier 1 $2 ( $4 $5 Tier 2 $15 $30 $37.50 (Non- Tier 3 $45 $90 $ ( Brand) Standard Mail Order Cost-Sharing Tier One- Two- Threemonth month month supply supply supply Tier 1 $4 $8 $10 ( Tier 2 $10 $20 $25 (Non- Tier 3 $40 $80 $100 ( Brand) Coverage Gap Most Medicare drug plans have a coverage gap (also called the donut hole ). This means that there s a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $2,960. After you enter the coverage gap, you pay 45% of the plan s cost for covered brand name drugs and 65% of the plan s cost for covered generic drugs until your costs total $4,700, which is the end of the coverage gap. Not everyone will enter the coverage gap. Most Medicare drug plans have a coverage gap (also called the donut hole ). This means that there s a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $2,960. After you enter the coverage gap, you pay 45% of the plan s cost for covered brand name drugs and 65% of the plan s cost for covered generic drugs until your costs total $4,700, which is the end of the coverage gap. Not everyone will enter the coverage gap. Tier 4 33% of the 33% of the 33% of (Non- cost cost the cost Brand) Tier 5 33% of the 33% of the 33% of (Specialty cost cost the cost Tier) If you reside in a long-term care facility, you pay the same as at a retail pharmacy. You may get drugs from an out-of-network pharmacy, but may pay more than you pay at an in-network pharmacy. Tier 4 29% of 29% of 29% of (Non- the cost the cost the cost Brand) Tier 5 29% of 29% of 29% of (Specialty the cost the cost the cost Tier) If you reside in a long-term care facility, you pay the same as at a retail pharmacy. You may get drugs from an out-of-network pharmacy, but may pay more than you pay at an in-network pharmacy. Part D deductible applies to drugs in Tiers 3, 4 and 5. Under this plan, you may pay even less for the brand and generic drugs on the formulary. Your cost varies by tier. You will need to use your formulary to locate your drug s tier. See the chart that follows to find out how much it will cost you. Standard Retail Cost-Sharing Tier Tier 1 ( Tier 2 (Non- Drugs Covered All All Onemonth supply $4 $10 Twomonth supply $8 $20 Threemonth supply $10 $

14 PRESCRIPTION DRUG S Prescription Drug Benefits OPTIONAL S (you must pay an extra premium each month for these benefits) Coverage Gap (cont d) Standard Mail Order Cost-Sharing Tier Drugs One- Two- Three- Covered month month month supply supply supply Tier 1 All $4 $8 $10 ( Package 1: Delta Dental / QUESTIONS Package 1: Delta Dental Benefits include: Preventive Dental Comprehensive Dental Benefits include: Preventive Dental Comprehensive Dental Tier 2 All $10 $20 $25 (Non- How much is the monthly premium? Additional $23.40 per month. You must keep paying your Medicare Part B premium and your $126 monthly plan premium. Additional $23.40 per month. You must keep paying your Medicare Part B premium and your $210 monthly plan premium. Catastrophic Coverage After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4,700, you pay the greater of: 5% of the cost, or After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4,700, you pay the greater of: 5% of the cost, or How much is the deductible? Is there a limit on how much the plan will pay? There is no deductible. Our plan pays up to $800 every year. There is no deductible. Our plan pays up to $800 every year. $2.65 for generic (including brand drugs treated as generic) and a $6.60 ment for all other drugs. $2.65 for generic (including brand drugs treated as generic) and a $6.60 ment for all other drugs

15 OPTIONAL S (you must pay an extra premium each month for these benefits) About Alliance Medicare PPO Alliance Medicare PPO is offered by Alliance Health and Life Insurance Company (Alliance). Alliance is a wholly owned subsidiary of Health Alliance Plan (HAP), a non-profit Michigan-based company. Package 2: Delta Dental / QUESTIONS Freedom of choice As an Alliance Medicare PPO member, you choose: Any Medicare-participating doctor or hospital in the U.S., or Doctors and hospitals who participate in our approved network. Package 2: Delta Dental Benefits include: Preventive Dental Comprehensive Dental Benefits include: Preventive Dental Comprehensive Dental Alliance Medicare PPO covers your care whether it is in- or out-of-network. Your costs may be higher when using out-of-network providers. You have coverage anywhere in the world for emergency and urgent care at the amount. You can go to any network pharmacy with nationwide locations for your prescription drugs. How much is the monthly premium? Additional $44.90 per month. You must keep paying your Medicare Part B premium and your $126 monthly plan premium. Additional $44.90 per month. You must keep paying your Medicare Part B premium and your $210 monthly plan premium. Fitness benefit Use the Flexible Health Options benefit for the qualified program or activity you select: How much is the deductible? Is there a limit on how much the plan will pay? There is no deductible. Our plan pays up to $1,500 every year. There is no deductible. Our plan pays up to $1,500 every year. Membership at a gym, fitness facility or health club of your choice. Choose the type of exercise or program you like best fitness classes, aerobics, swimming, yoga, weight training and more Fitness memberships and classes that focus on weight management, such as Weight Watchers. covers up to $25 monthly (up to $300 annually); covers up to $40 monthly (up to $480 annually)

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