SUMMARY OF BENEFITS \ TTY \ NetworkHealthMedicare.com. H5215_646_ Accepted <code>

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1 2016 SUMMARY OF BENEFITS H5215_646_ Accepted <code> \ TTY \ NetworkHealthMedicare.com

2 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 Someone who speaks English 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 Alguien que hable español le podrá ayudar. Este es un servicio gratuito. CHINESE MANDARIN: 我 们 提 供 免 们 的 翻 们 服 们, 们 助 们 解 答 们 于 健 康 或 们 物 保 们 的 任 何 疑 们 如 果 们 需 要 此 翻 们 服 们, 们 致 们 我 们 的 中 文 工 作 人 们 很 们 意 们 助 们 们 是 一 们 免 们 服 们 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 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 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 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 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 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 번으로 문의해 주십시오. 한국어를 하는 담당자가 도와 드릴 것입니다. 이 서비스는 무료로 운영됩니다. 1

3 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 Вам окажет помощь сотрудник, который говорит по-pусски. Данная услуга бесплатная. كيلع سيل يروف مجرتم ىلع لوصحلل.انيدل ةيودألا لودج وأ ةحصلاب قلعتت ةلئسأ يأ نع ةباجإلل ةيناجملا يروفلا مجرتملا تامدخ مدقن اننإ ARABIC:.ةيناجم ةمدخ هذه.كتدعاسمب ةيبرعلا ثدحتي ام صخش موقيس ىلع انب لاصتالا ىوس 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 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 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 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 Ta usługa jest bezpłatna. HINDI: 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 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 HMONG: Peb muaj neeg txhais lus dawb rau nej, yuav teb nej txhua lo lus nug txog kev noj qab haus huv los yog tshuaj raws li peb muaj. Yog xav tau tus txhais lus, hu rau peb ntaws tus xov tooj Yuav muaj tus neeg hais lus hmoob pab nej. Txoj kev pab no dawb xwb. H5215_MultiLangIns Accepted

4 SECTION 1 - INTRODUCTION TO SUMMARY OF BENEFITS 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 Advantage plan. TIPS FOR COMPARING YOUR MEDICARE CHOICES This Summary of Benefits booklet gives you a summary of what Medicare Advantage plans cover and what you pay. If you want to compare our plan 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 SECTIONS IN THIS BOOKLET Things to Know About Network Medicare Advantage plans Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services Covered Medical and Hospital Benefits 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 TTY/TDD users should call THINGS TO KNOW ABOUT NETWORK HEALTH MEDICARE ADVANTAGE PLANS HOURS OF OPERATION From October 1 to February 14, you can call us 7 days a week from 8:00 a.m. to 8:00 p.m. Central time. From February 15 to September 30, you can call us Monday through Friday from 8:00 a.m. to 8:00 p.m. Central time. NETWORK HEALTH MEDICARE ADVANTAGE PLANS PHONE NUMBERS AND WEBSITE If you are a member of this plan, call toll-free TTY/TDD users should call If you are not a member of this plan, call toll-free TTY/TDD users should call Our website: 3

5 WHO CAN JOIN? To join Network Health Medicare Advantage plans, 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 Wisconsin: Brown, Calumet, Dodge, Fond du Lac, Green Lake, Kewaunee, Manitowoc, Marquette, Oconto, Outagamie, Portage, Shawano, Sheboygan, Waupaca, and Winnebago. Network PlatinumPlus Pharmacy (PPO), Network PlatinumPremier (PPO) and Network PlatinumPremier Pharmacy (PPO) plans are also available in Waushara County. WHICH DOCTORS, HOSPITALS AND PHARMACIES CAN I USE? Network Medicare Advantage plans have a network of doctors, hospitals, 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. Some of our network pharmacies have preferred cost-sharing. You may pay less if you use these pharmacies. You can see our plan s provider directory at our website, Or, call us and we will send you a copy of the provider directory. 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 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. Some of the extra benefits are outlined in this booklet. Network PlatinumPlus Pharmacy (PPO), Network PlatinumPremier Pharmacy (PPO) and Network PlatinumSelect (PPO) plans 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. Network PlatinumPlus (PPO) and Network PlatinumPremier (PPO) plans cover Part B drugs including chemotherapy and some drugs administered by your provider. However, Network PlatinumPlus (PPO) and Network PlatinumPremier (PPO) plans do not cover Part D prescription drugs. 4

6 If you have any questions about this plan s benefits or costs, please contact Network Health Medicare Advantage Plans for details. 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. 5

7 SECTION II - SUMMARY OF BENEFITS If you have any questions about this plan s benefits or costs, please contact Network Health Medicare Advantage Plans for details. BENEFIT Network PlatinumSelect (PPO) Network PlatinumPlus (PPO) MONTHLY PREMIUM, DEDUCTIBLE, AND LIMITS ON HOW MUCH YOU PAY FOR COVERED SERVICES How much is the monthly premium? $0 per month. In addition, you must keep paying your Medicare Part B premium. $76 per month. In addition, you must keep paying your Medicare Part B premium. How much is the This plan has deductibles for some hospital and medical services, This plan does not have a deductible. deductible? and Part D prescription drugs. $150 per year for some in-network and out-of-network services. $200 per year for Part D prescription drugs except for drugs listed on Tier 1 and Tier 2 which are excluded from the deductible. Is there any limit on Yes. Like all Medicare health plans, our plan protects you by Yes. Like all Medicare health plans, our plan protects you by having yearly limits on how much I will pay for having yearly limits on your out-of-pocket costs your out-of-pocket costs for medical and hospital care. my covered services? for medical and hospital care. Your yearly limit(s) in this plan: Your yearly limit(s) in this plan: $3,400 for services you receive from in-network providers. $4,900 for services you receive from in-network providers. $4,900 for services you receive from any provider. Your limit for $3,400 for services you receive from any provider. Your limit for services received services received from in-network providers will count toward this from in-network providers will count toward this limit. 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. 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. Is there a limit on how much the plan will pay? Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply. Our plan has a coverage limit every year for certain benefits from any provider. Contact us for services that apply. COVERED MEDICAL AND HOSPITAL BENEFITS NOTE: SERVICES WITH A 1 MAY REQUIRE PRIOR AUTHORIZATION. 6

8 Network PlatinumPlus Pharmacy (PPO) Network PlatinumPremier (PPO) Network PlatinumPremier Pharmacy (PPO) $107 per month. In addition, you must keep paying your Medicare Part B premium. $200 per year for Part D prescription drugs except for drugs listed on Tier 1 and Tier 2 which are excluded from the deductible $194 per month. In addition, you must keep paying your Medicare Part B premium. This plan does not have a deductible. $275 per month. In addition, you must keep paying your Medicare Part B premium. This plan does not have a deductible. 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. Your yearly limit(s) in this plan: $3,400 for services you receive from in-network providers. $3,400 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. 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. Your yearly limit(s) in this plan: $1,900 for services you receive from in-network providers. $5,000 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. Our plan has a coverage limit every year for certain benefits from any provider. Contact us for services that apply. 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. Your yearly limit(s) in this plan: $1,900 for services you receive from in-network providers. $5,000 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. 7

9 OUTPATIENT CARE AND SERVICES BENEFIT Network PlatinumSelect (PPO) Network PlatinumPlus (PPO) Acupuncture Not covered Not covered Ambulance In-network: $250 copay In-network: $250 copay Out-of-network: $250 copay Out-of-network: $250 copay Chiropractic Care Dental Services 1 Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): In-network: $20 copay Out-of-network: $50 copay Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): In-network: $30 copay Out-of-network: $45 copay Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): In-network: $20 copay Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): In-network: $25 copay Diabetes Supplies and Services 1 Diabetes monitoring supplies: In-network: $10 copay Diabetes self-management training: Out-of-network: $20-50 copay, depending on the service Therapeutic shoes or inserts: In-network: $10 copay Copays for diabetes monitoring supplies apply up to a 90-day supply. Diabetes self-management training will always be a $20 copay out-of-network. Diabetes monitoring supplies: In-network: $10 copay Diabetes self-management training: Therapeutic shoes or inserts: In-network: $10 copay Copays for diabetes monitoring supplies apply up to a 90-day supply. 8

10 Network PlatinumPlus Pharmacy (PPO) Network PlatinumPremier (PPO) Network PlatinumPremier Pharmacy (PPO) Not covered Not covered Not covered In-network: $250 copay Out-of-network: $250 copay Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): In-network: $20 copay Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): In-network: $25 copay Diabetes monitoring supplies: In-network: $10 copay Diabetes self-management training: Therapeutic shoes or inserts: In-network: $10 copay Copays for diabetes monitoring supplies apply up to a 90-day supply. Out-of-network: You pay nothing Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): Diabetes monitoring supplies: Diabetes self-management training: Therapeutic shoes or inserts: Copays for diabetes monitoring supplies apply up to a 90-day supply. Out-of-network: You pay nothing Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): Diabetes monitoring supplies: Diabetes self-management training: Therapeutic shoes or inserts: Copays for diabetes monitoring supplies apply up to a 90-day supply. 9

11 BENEFIT Network PlatinumSelect (PPO) Network PlatinumPlus (PPO) Diagnostic Tests, Lab Diagnostic radiology services (such as MRIs, CT scans): Diagnostic radiology services (such as MRIs, CT scans): and Radiology Services, In-network: 20% of the cost In-network: $150 copay and XRays (Costs for Out-of-network: 30% of the cost these services may be Diagnostic tests and procedures: Diagnostic tests and procedures: different if received in an In-network: $13-35 copay, depending on the service In-network: $5-25 copay, depending on the service outpatient surgery setting) 1 Out-of-network: $20-50 copay, depending on the service Lab services: In-network: $13 copay Out-of-network: $20-50 copay, depending on the service Lab services: In-network: $5 copay Outpatient x-rays: In-network: $30 copay Out-of-network: $50 copay Therapeutic radiology services (such as radiation treatment for cancer): In-network: 20% of the cost Out-of-network: 30% of the cost Ultrasounds, EKGs, EEGs and stress tests: In-network: $35 Out-of-network: $50 Other diagnostic tests, procedures and lab services: In-network: $13 Out-of-network: $20 Outpatient x-rays: In-network: $25 copay Therapeutic radiology services (such as radiation treatment for cancer): In-network: $45 copay Ultrasounds, EKGs, EEGs and stress tests: In-network: $25 Other diagnostic tests, procedures and lab services: In-network: $5 Doctor s Office Visits Primary care physician visit: In-network: $16.25 copay Out-of-network: $30 copay Specialist visit: In-network: $50 copay Out-of-network: $55 copay Primary care physician visit: In-network: $15 copay Specialist visit: In-network: $40 copay 10

12 Network PlatinumPlus Pharmacy (PPO) Network PlatinumPremier (PPO) Network PlatinumPremier Pharmacy (PPO) Diagnostic radiology services (such as MRIs, CT scans): Diagnostic radiology services (such as MRIs, CT scans): Diagnostic radiology services (such as MRIs, CT scans): In-network: $150 copay Diagnostic tests and procedures: In-network: $5-25 copay, depending on the service Lab services: In-network: $5 copay Outpatient x-rays: In-network: $25 copay Therapeutic radiology services (such as radiation treatment for cancer): In-network: $45 copay Ultrasounds, EKGs, EEGs and stress tests: In-network: $25 Other diagnostic tests, procedures and lab services: In-network: $5 Primary care physician visit: In-network: $15 copay Specialist visit: In-network: $40 copay Diagnostic tests and procedures: Lab services: Outpatient x-rays: Therapeutic radiology services (such as radiation treatment for cancer): Ultrasounds, EKGs, EEGs and stress tests: Other diagnostic tests, procedures and lab services: Primary care physician visit: Specialist visit: Diagnostic tests and procedures: Lab services: Outpatient x-rays: Therapeutic radiology services (such as radiation treatment for cancer): Ultrasounds, EKGs, EEGs and stress tests: Other diagnostic tests, procedures and lab services: Primary care physician visit: Specialist visit: 11

13 BENEFIT Network PlatinumSelect (PPO) Network PlatinumPlus (PPO) Durable Medical Equipment (wheelchairs, oxygen, etc.) 1 In-network: 17% of the cost In-network: 23% of the cost Emergency Care $75 copay If you are admitted to the hospital within 24 hours, 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. When Emergency Care is received outside of the United States and its territories (worldwide coverage) you will be responsible for 25% of the cost. Network will pay the remaining 75% of the cost up to the maximum $100,000 every year. $75 copay If you are admitted to the hospital within 24 hours, 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. When Emergency Care is received outside of the United States and its territories (worldwide coverage) you will be responsible for 25% of the cost. Network will pay the remaining 75% of the cost up to the maximum $100,000 every year. Foot Care (podiatry services) Hearing Services Foot exams and treatment if you have diabetes-related nerve damage and/ or meet certain conditions: In-network: $50 copay Out-of-network: $55 copay Exam to diagnose and treat hearing and balance issues: In-network: $30 copay Out-of-network: $45 copay Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: In-network: $40 copay Exam to diagnose and treat hearing and balance issues: In-network: $25 copay Home Health Care 1 Out-of-network: 30% of the cost 12

14 Network PlatinumPlus Pharmacy (PPO) Network PlatinumPremier (PPO) Network PlatinumPremier Pharmacy (PPO) In-network: 23% of the cost $75 copay If you are admitted to the hospital within 24 hours, 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. When Emergency Care is received outside of the United States and its territories (worldwide coverage) you will be responsible for 25% of the cost. Network will pay the remaining 75% of the cost up to the maximum $100,000 every year. Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: In-network: $40 copay Exam to diagnose and treat hearing and balance issues: In-network: $25 copay $65 copay If you are admitted to the hospital within 24 hours, 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. When Emergency care is received outside of the United States and its territories (worldwide coverage) you will be responsible for 0% of the costs. Network will pay 100% of costs up to the maximum of $100,000 every year Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: Exam to diagnose and treat hearing and balance issues: Routine hearing exam (for up to 1 every year): Hearing aid: In-network: $0 copay Out-of-network: $0 copay Our plan pays up to $75 every year for hearing aids from any provider. $65 copay If you are admitted to the hospital within 24 hours, 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. When Emergency care is received outside of the United States and its territories (worldwide coverage) you will be responsible for 0% of the costs. Network will pay 100% of costs up to the maximum of $100,000 every year Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: Exam to diagnose and treat hearing and balance issues: Routine hearing exam (for up to 1 every year): Hearing aid: In-network: $0 copay Out-of-network: $0 copay Our plan pays up to $75 every year for hearing aids from any provider. 13

15 BENEFIT Network PlatinumSelect (PPO) Network PlatinumPlus (PPO) Mental Health Care 1 Inpatient visit: 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. Inpatient visit: 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. The copays for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you re admitted as an inpatient and ends when you haven t received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There s no limit to the number of benefit periods. Our plan covers 90 days for an inpatient hospital stay. Our plan also covers 60 lifetime reserve days. These are extra days that we cover. 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. In-network: $150 copay per day for days 1 through 10 You pay nothing per day for days 11 through 90 Out-of-network: $250 copay per day for days 1 through 10 You pay nothing per day for days 11 through 190 Outpatient group therapy visit: In-network: $40 copay Out-of-network: $45 copay Outpatient individual therapy visit: In-network: $40 copay Out-of-network: $45 copay The copays for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you re admitted as an inpatient and ends when you haven t received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There s no limit to the number of benefit periods. Our plan covers 90 days for an inpatient hospital stay. Our plan also covers 60 lifetime reserve days. These are extra days that we cover. 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. In-network: $150 copay per day for days 1 through 10 You pay nothing per day for days 11 through 90 Out-of-network: 50% of the cost per day for days 1 through 190 Outpatient group therapy visit: In-network: $35 copay Outpatient individual therapy visit: In-network: $35 copay 14

16 Network PlatinumPlus Pharmacy (PPO) Network PlatinumPremier (PPO) Network PlatinumPremier Pharmacy (PPO) Inpatient visit: 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. Inpatient visit: 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. Inpatient visit: 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. The copays for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you re admitted as an inpatient and ends when you haven t received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There s no limit to the number of benefit periods. Our plan covers 90 days for an inpatient hospital stay. Our plan also covers 60 lifetime reserve days. These are extra days that we cover. 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. In-network: $150 copay per day for days 1 through 10 You pay nothing per day for days 11 through 90 Out-of-network: 50% of the cost per day for days 1 through 190 Outpatient group therapy visit: In-network: $35 copay Outpatient individual therapy visit: In-network: $35 copay Our plan covers 90 days for an inpatient hospital stay. Our plan also covers 60 lifetime reserve days. These are extra days that we cover. 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. Out-of-network: 50% of the cost per day for days 1 through 190 Outpatient group therapy visit: Outpatient individual therapy visit: Our plan covers 90 days for an inpatient hospital stay. Our plan also covers 60 lifetime reserve days. These are extra days that we cover. 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. Out-of-network: 50% of the cost per day for days 1 through 190 Outpatient group therapy visit: Outpatient individual therapy visit: 15

17 BENEFIT Network PlatinumSelect (PPO) Network PlatinumPlus (PPO) Outpatient Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions Rehabilitation 1 day for up to 36 sessions up to 36 weeks): per day for up to 36 sessions up to 36 weeks): In-network: $20 copay. Additional visits are covered, but your cost may be more. In-network: $25 copay. Additional visits are covered, but your cost may be more. Out-of-network: Additional visits are covered, but your cost may be more. Out-of-network: Additional visits are covered, but your cost may be more. Out-of-network: $40 copay Occupational therapy visit: In-network: $40 copay Out-of-network: $45 copay Physical therapy and speech and language therapy visit: In-network: $40 copay Out-of-network: $45 copay Peripheral arterial disease (PAD) rehabilitation is available as an additional benefit, for members who have had a PAD diagnosis in which claudication was a major symptom (which limits exercise and mobility). Contact the plan for details. Peripheral Arterial Disease Rehabilitation Services In-Network $20 Out of Network $36 Occupational therapy visit: In-network: $35 copay Physical therapy and speech and language therapy visit: In-network: $35 copay Peripheral arterial disease (PAD) rehabilitation is available as an additional benefit, for members who have had a PAD diagnosis in which claudication was a major symptom (which limits exercise and mobility). Contact the plan for details. Peripheral Arterial Disease Rehabilitation Services In-Network $20 Out of Network $36 Outpatient Substance Group therapy visit: Group therapy visit: Abuse 1 In-network: $40 copay In-network: $20 copay Out-of-network: $45 copay Individual therapy visit: Individual therapy visit: In-network: $40 copay In-network: $20 copay Out-of-network: $45 copay Outpatient Surgery 1 Ambulatory surgical center: In-network: 15% of the cost Out-of-network: 45% of the cost Outpatient hospital: In-network: $395 copay Over-the-Counter Items Not Covered Not Covered Ambulatory surgical center: In-network: 15% of the cost Outpatient hospital: In-network: 20% of the cost 16

18 Network PlatinumPlus Pharmacy (PPO) Network PlatinumPremier (PPO) Network PlatinumPremier Pharmacy (PPO) Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): In-network: $25 copay. Additional visits are covered, but your cost may be more. Out-of-network: Additional visits are covered, but your cost may be more. Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks):. Additional visits are covered, but your cost may be more. Out-of-network: Additional visits are covered, but your cost may be more. Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks):. Additional visits are covered, but your cost may be more. Out-of-network: Additional visits are covered, but your cost may be more. Occupational therapy visit: In-network: $35 copay Physical therapy and speech and language therapy visit: In-network: $35 copay Peripheral arterial disease (PAD) rehabilitation is available as an additional benefit, for members who have had a PAD diagnosis in which claudication was a major symptom (which limits exercise and mobility). Contact the plan for details. Peripheral Arterial Disease Rehabilitation Services In-Network $20 Out of Network $36 Occupational therapy visit: Physical therapy and speech and language therapy visit: Peripheral arterial disease (PAD) rehabilitation is available as an additional benefit, for members who have had a PAD diagnosis in which claudication was a major symptom (which limits exercise and mobility). Contact the plan for details. Peripheral Arterial Disease Rehabilitation Services Occupational therapy visit: Physical therapy and speech and language therapy visit: Peripheral arterial disease (PAD) rehabilitation is available as an additional benefit, for members who have had a PAD diagnosis in which claudication was a major symptom (which limits exercise and mobility). Contact the plan for details. Peripheral Arterial Disease Rehabilitation Services In-Network $20 Out of Network $36 In-Network $20 Out of Network $36 Group therapy visit: Group therapy visit: Group therapy visit: In-network: $20 copay Individual therapy visit: Individual therapy visit: Individual therapy visit: In-network: $20 copay Ambulatory surgical center: Ambulatory surgical center: Ambulatory surgical center: In-network: 15% of the cost Outpatient hospital: Outpatient hospital: Outpatient hospital: In-network: 20% of the cost Not Covered Not Covered Not Covered 17

19 BENEFIT Network PlatinumSelect (PPO) Network PlatinumPlus (PPO) Prosthetic Devices Prosthetic devices: Prosthetic devices: (braces, artificial limbs, In-network: 17% of the cost In-network: 23% of the cost etc.) 1 Renal Dialysis 1 Related medical supplies: In-network: 17% of the cost In-network: 20% of the cost Out-of-network: 20% of the cost Transportation Not covered Not covered Related medical supplies: In-network: 23% of the cost In-network: $25 copay Urgently Needed Services $ copay, depending on the service In-network visit with a primary care physician will be $16.25 Out-of-network will be $50 $15 copay or 50% of the cost (up to $65), depending on the service In-network visit with a primary care physician will be $15 Out-of-network will be 50% of the cost (up to $65) Vision Services Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): In-network: $0-35 copay, depending on the service Out-of-network: $50 copay Eyeglasses or contact lenses after cataract surgery: In-network: $30 copay Out-of-network: $45 copay Medicare-covered eye exam: In-network: $35 Out-of-network: $50 copay CMS-defined preventive glaucoma screenings: In-network: $0 copay Out-of-network: $50 copay Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): In-network: $0-25 copay, depending on the service Eyeglasses or contact lenses after cataract surgery: In-network: $15 copay Medicare-covered eye exam: In-network: $25 CMS-defined preventive glaucoma screenings: In-network: $0 copay 18

20 Network PlatinumPlus Pharmacy (PPO) Network PlatinumPremier (PPO) Network PlatinumPremier Pharmacy (PPO) Prosthetic devices: Prosthetic devices: Prosthetic devices: In-network: 23% of the cost Related medical supplies: Related medical supplies: Related medical supplies: In-network: 23% of the cost In-network: $25 copay Not covered Not covered Not covered $15 copay or 50% of the cost (up to $65), depending on 0-50% of the cost (up to $65), depending on the service 0-50% of the cost (up to $65), depending on the the service In-network visit with a primary care physician will be 0% of service In-network visit with a primary care physician will be $15 the cost In-network visit with a primary care physician will be 0% Out-of-network will be 50% of the cost (up to $65) Out-of-network will be 50% of the cost (up to $65) of the cost Out-of-network will be 50% of the cost (up to $65) Exam to diagnose and treat diseases and conditions of the Exam to diagnose and treat diseases and conditions of the Exam to diagnose and treat diseases and conditions of eye (including yearly glaucoma screening): eye (including yearly glaucoma screening): the eye (including yearly glaucoma screening): In-network: $0-25 copay, depending on the service Eyeglasses or contact lenses after cataract surgery: Eyeglasses or contact lenses after cataract surgery: In-network: $15 copay Eyeglasses or contact lenses after cataract surgery: Medicare-covered eye exam: In-network: $25 Medicare-covered eye exam: Medicare-covered eye exam: CMS-defined preventive glaucoma screenings: In-network: $0 copay CMS-defined preventive glaucoma screenings: In-network: $0 copay CMS-defined preventive glaucoma screenings: In-network: $0 copay 19

21 BENEFIT Network PlatinumSelect (PPO) Network PlatinumPlus (PPO) PREVENTIVE CARE Out-of-network: $30 copay Our plan covers many preventive services, including: Abdominal aortic aneurysm screening Alcohol misuse counseling Bone mass measurement Breast cancer screening (mammogram) Cardiovascular disease (behavioral therapy) Cardiovascular screenings Cervical and vaginal cancer screening Colorectal cancer screenings (Colonoscopy, Fecal occult blood test, Flexible sigmoidoscopy) Depression screening Diabetes screenings HIV screening Medical nutrition therapy services Obesity screening and counseling Prostate cancer screenings (PSA) Sexually transmitted infections screening and counseling Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease) Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots Welcome to Medicare preventive visit (one-time) Yearly Wellness visit Any additional preventive services approved by Medicare during the contract year will be covered. Our plan covers many preventive services, including: Abdominal aortic aneurysm screening Alcohol misuse counseling Bone mass measurement Breast cancer screening (mammogram) Cardiovascular disease (behavioral therapy) Cardiovascular screenings Cervical and vaginal cancer screening Colorectal cancer screenings (Colonoscopy, Fecal occult blood test, Flexible sigmoidoscopy) Depression screening Diabetes screenings HIV screening Medical nutrition therapy services Obesity screening and counseling Prostate cancer screenings (PSA) Sexually transmitted infections screening and counseling Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease) Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots Welcome to Medicare preventive visit (one-time) Yearly Wellness visit Any additional preventive services approved by Medicare during the contract year will be covered. HOSPICE You pay nothing for hospice care from a Medicare-certified hospice. You may have to pay part of the costs for drugs and respite care. Hospice is covered outside of our plan. Please contact us for more details. You pay nothing for hospice care from a Medicare-certified hospice. You may have to pay part of the costs for drugs and respite care. Hospice is covered outside of our plan. Please contact us for more details. 20

22 Network PlatinumPlus Pharmacy (PPO) Network PlatinumPremier (PPO) Network PlatinumPremier Pharmacy (PPO) Our plan covers many preventive services, including: Abdominal aortic aneurysm screening Alcohol misuse counseling Bone mass measurement Breast cancer screening (mammogram) Cardiovascular disease (behavioral therapy) Cardiovascular screenings Cervical and vaginal cancer screening Colorectal cancer screenings (Colonoscopy, Fecal occult blood test, Flexible sigmoidoscopy) Depression screening Diabetes screenings HIV screening Medical nutrition therapy services Obesity screening and counseling Prostate cancer screenings (PSA) Sexually transmitted infections screening and counseling Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease) Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots Welcome to Medicare preventive visit (one-time) Yearly Wellness visit Any additional preventive services approved by Medicare during the contract year will be covered. Our plan covers many preventive services, including: Abdominal aortic aneurysm screening Alcohol misuse counseling Bone mass measurement Breast cancer screening (mammogram) Cardiovascular disease (behavioral therapy) Cardiovascular screenings Cervical and vaginal cancer screening Colorectal cancer screenings (Colonoscopy, Fecal occult blood test, Flexible sigmoidoscopy) Depression screening Diabetes screenings HIV screening Medical nutrition therapy services Obesity screening and counseling Prostate cancer screenings (PSA) Sexually transmitted infections screening and counseling Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease) Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots Welcome to Medicare preventive visit (one-time) Yearly Wellness visit Any additional preventive services approved by Medicare during the contract year will be covered. Our plan covers many preventive services, including: Abdominal aortic aneurysm screening Alcohol misuse counseling Bone mass measurement Breast cancer screening (mammogram) Cardiovascular disease (behavioral therapy) Cardiovascular screenings Cervical and vaginal cancer screening Colorectal cancer screenings (Colonoscopy, Fecal occult blood test, Flexible sigmoidoscopy) Depression screening Diabetes screenings HIV screening Medical nutrition therapy services Obesity screening and counseling Prostate cancer screenings (PSA) Sexually transmitted infections screening and counseling Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease) Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots Welcome to Medicare preventive visit (one-time) Yearly Wellness visit Any additional preventive services approved by Medicare during the contract year will be covered. You pay nothing for hospice care from a Medicare-certified hospice. You may have to pay part of the costs for drugs and respite care. Hospice is covered outside of our plan. Please contact us for more details. You pay nothing for hospice care from a Medicare-certified hospice. You may have to pay part of the costs for drugs and respite care. Hospice is covered outside of our plan. Please contact us for more details. You pay nothing for hospice care from a Medicarecertified hospice. You may have to pay part of the costs for drugs and respite care. Hospice is covered outside of our plan. Please contact us for more details. 21

23 INPATIENT CARE BENEFIT Network PlatinumSelect (PPO) Network PlatinumPlus (PPO) Inpatient Hospital Care 1 The copays for hospital and skilled nursing facility (SNF) benefits are based The copays for hospital and skilled nursing facility (SNF) benefits are on benefit periods. A benefit period begins the day you re admitted as an based on benefit periods. A benefit period begins the day you re admitted inpatient and ends when you haven t received any inpatient care (or skilled as an inpatient and ends when you haven t received any inpatient care (or care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after skilled care in a SNF) for 60 days in a row. If you go into a hospital or a one benefit period has ended, a new benefit period begins. You must pay SNF after one benefit period has ended, a new benefit period begins. You the inpatient hospital deductible for each benefit period. There s no limit to must pay the inpatient hospital deductible for each benefit period. There s the number of benefit periods. no limit to the number of benefit periods. Our plan covers an unlimited number of days for an inpatient hospital stay. In-network: $300 copay per day for days 1 through 5 $80 copay per day for days 6 through 20 You pay nothing per day for days 21 through 90 You pay nothing per day for days 91 and beyond Out-of-network: $340 copay per day for days 1 through 10 You pay nothing per day for days 11 and beyond For inpatient mental health care, see the Mental Health Care section of this booklet. Our plan covers an unlimited number of days for an inpatient hospital stay. In-network: $150 copay per day for days 1 through 20 You pay nothing per day for days 21 through 90 You pay nothing per day for days 91 and beyond Out-of-network: 50% of the cost per day for days 1 and beyond For inpatient mental health care, see the Mental Health Care section of this booklet. Inpatient Mental Health Care Skilled Nursing Facility Our plan covers up to 100 days in a SNF. Our plan covers up to 100 days in a SNF. (SNF) 1 In-network: You pay nothing per day for days 1 through 20 $160 copay per day for days 21 through 100 Out-of-network: $175 copay per day for days 1 through 100 We will cover skilled care only if you have an inpatient stay of three (3) consecutive days or more (a qualifying stay), counting the day of inpatient admission to the hospital (but not the day of discharge) before being admitted to the SNF. PRESCRIPTION DRUG BENEFITS How much do I pay? For Part B drugs such as chemotherapy drugs 1 : In-network: 20% of the cost Other Part B drugs 1 : In-network: 20% of the cost $200 deductible per year for Part D prescription drugs listed on Tier 3, 4 and 5. In-network: $40 copay per day for days 1 through 20 $75 copay per day for days 21 through 54 You pay nothing per day for days 55 through 100 Out-of-network: 50% of the cost per day for days 1 through 100 We will cover skilled care only if you have an inpatient stay of three (3) consecutive days or more (a qualifying stay), counting the day of inpatient admission to the hospital (but not the day of discharge) before being admitted to the SNF. For Part B drugs such as chemotherapy drugs 1 : In-network: 20% of the cost Other Part B drugs 1 : In-network: 20% of the cost Our plan does not cover Part D prescription drugs. 22

24 Network PlatinumPlus Pharmacy (PPO) Network PlatinumPremier (PPO) Network PlatinumPremier Pharmacy (PPO) The copays for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you re admitted as an inpatient and ends when you haven t received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There s no limit to the number of benefit periods. Our plan covers an unlimited number of days for an inpatient hospital stay. In-network: $150 copay per day for days 1 through 20 You pay nothing per day for days 21 through 90 You pay nothing per day for days 91 and beyond Out-of-network: 50% of the cost per day for days 1 and beyond For inpatient mental health care, see the Mental Health Care section of this booklet Our plan covers up to 100 days in a SNF. In-network: $40 copay per day for days 1 through 20 $75 copay per day for days 21 through 54 You pay nothing per day for days 55 through 100 Out-of-network: 50% of the cost per day for days 1 through 100 We will cover skilled care only if you have an inpatient stay of three (3) consecutive days or more (a qualifying stay), counting the day of inpatient admission to the hospital (but not the day of discharge) before being admitted to the SNF. Our plan covers an unlimited number of days for an inpatient hospital stay. Out-of-network: 50% of the cost per day for days 1 and beyond For inpatient mental health care, see the Mental Health Care section of this booklet. Our plan covers up to 100 days in a SNF. Out-of-network: 50% of the cost per day for days 1 through 100 We will cover skilled care only if you have an inpatient stay of three (3) consecutive days or more (a qualifying stay), counting the day of inpatient admission to the hospital (but not the day of discharge) before being admitted to the SNF. Our plan covers an unlimited number of days for an inpatient hospital stay. Out-of-network: 50% of the cost per day for days 1 and beyond For inpatient mental health care, see the Mental Health Care section of this booklet. Our plan covers up to 100 days in a SNF. Out-of-network: 50% of the cost per day for days 1 through 100 We will cover skilled care only if you have an inpatient stay of three (3) consecutive days or more (a qualifying stay), counting the day of inpatient admission to the hospital (but not the day of discharge) before being admitted to the SNF. For Part B drugs such as chemotherapy drugs 1 : For Part B drugs such as chemotherapy drugs 1 : For Part B drugs such as chemotherapy drugs 1 : In-network: 20% of the cost In-network: 20% of the cost In-network: 20% of the cost Other Part B drugs 1 : Other Part B drugs 1 : Other Part B drugs 1 : In-network: 20% of the cost In-network: 20% of the cost In-network: 20% of the cost $200 deductible per year for Part D prescription drugs Our plan does not cover Part D prescription drugs. No deductible for Part D prescriptions drugs. listed on Tier 3, 4 and 5. 23