Summary of Benefits Effective January 1, 2015 Wisconsin and Iowa

Transcription

1 Summary of Benefits Effective January 1, 2015 Wisconsin and Iowa ELITE ELITE - D VALUE VALUE - D seniorpreferred.org H5262_14 02 CMS Accepted

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3 Other Pharmacies/Physicians/Providers are available in our network. Other plans may be available in the service area. Marketing Comparison Revision Date: 10/1/2014 H5262_

4 You have choices about how to get your Medicare benefits: SECTION I INTRODUCTION TO SUMMARY OF BENEFITS Once 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 Gundersen Senior Preferred (HMO)). Tips for comparing your Medicare choices: This Summary of Benefits booklet gives you a summary of what Gundersen Senior Preferred (HMO) covers 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 and You handbook. View it online at medicare.gov 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 Gundersen Senior Preferred (HMO) 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 (800) Marketing Comparison Revision Date: 10/1/2014 H5262_

5 Things to know about Gundersen Senior Preferred (HMO): Hours of Operation From October 1 to February 14, you can call us 7 days a week from 8:00 am to 8:00 pm Central time. From February 15 to September 30, you can call us Monday through Friday from 8:00 am to 8:00 pm Central time. Gundersen Senior Preferred (HMO) Phone Numbers and Website If you are a member of this plan, call toll-free (800) If you are not a member of this plan, call toll-free (800) Our website: Who Can Join? To join Gundersen Senior Preferred, 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: Iowa: Allamakee, Clayton, Fayette, Howard and Winneshiek Wisconsin: Buffalo*, Crawford, Grant*, Jackson, Juneau*, La Crosse, Monroe, Richland*, Sauk*, Trempealeau and Vernon. *denotes partial county Partial Counties by zip code: Grant County: 53801, 53804, 53817, 53821, 53816, 53827, 53826, and Richland County: 53805, 54631, 54655, 54652, 54664, 54639, 54634, 53924, and Sauk County: 53924, 53968, and Juneau County: 53962, 53968, 54634, 53929, 54638, 54660, 54618, 54641, and Buffalo County: 54629, 54612, 54625, 54661, and Marketing Comparison Revision Date: 10/1/2014 H5262_

6 Which doctors, hospitals, and pharmacies can I use? Gundersen Senior Preferred (HMO) has a network of doctors, hospitals, pharmacies, and other providers. If you use the providers that are not in our network, the plan may not pay for these services. 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 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. 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. Marketing Comparison Revision Date: 10/1/2014 H5262_

7 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 after you meet your deductible: Initial Coverage, Coverage Gap, and Catastrophic Coverage. If you have any questions about this plan s benefits or costs, please contact Minnesota for details. Marketing Comparison Revision Date: 10/1/2014 H5262_

8 If you have any questions about this plan's benefits or costs, please contact, Inc. for details. SECTION II - SUMMARY OF BENEFITS Benefit Senior Preferred Elite Senior Preferred EliteD Senior Preferred Value Senior Preferred ValueD MONTHLY PREMIUM, DEDUCTIBLE, AND LIMITS ON HOW MUCH YOU PAY FOR COVERED SERVICES How much is $ per month. $ per month. $20.00 per month. $64.20 per month. the monthly premium? In addition, you must keep paying your Medicare Part B premium. In addition, you must keep paying your Medicare Part B premium. In addition, you must keep paying your Medicare Part B premium. In addition, you must keep paying your Medicare Part B premium. How much is the deductible? This plan does not have a deductible. $100 per year for Part D prescription drugs. This plan does not have a deductible. $195 per year for Part D prescription drugs. Is there a Yes. Like all Medicare health Yes. Like all Medicare health Yes. Like all Medicare health Yes. Like all Medicare health limit on how plans, our plan protects you by plans, our plan protects you by plans, our plan protects you by plans, our plan protects you by much I will having yearly limits on your having yearly limits on your having yearly limits on your having yearly limits on your pay for my out-of-pocket costs for medical out-of-pocket costs for medical out-of-pocket costs for medical out-of-pocket costs for medical covered and hospital care. and hospital care. and hospital care. and hospital care. services? Your yearly limit(s) in this plan: Your yearly limit(s) in this plan: Your yearly limit(s) in this plan: Your yearly limit(s) in this plan: $3,400 for services you receive from in-network providers. $3,400 for services you receive from in-network providers. $3,400 for services you receive from in-network providers. $3,400 for services you receive from in-network providers. If you reach the limit on out-ofpocket costs, you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year. If you reach the limit on out-ofpocket costs, you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year. If you reach the limit on out-ofpocket costs, you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year. If you reach the limit on out-ofpocket costs, you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year. 6

9 Benefit Senior Preferred Elite Senior Preferred EliteD Senior Preferred Value Senior Preferred ValueD Is there a Please note that you will still Please note that you will still Please note that you will still Please note that you will still limit on how need to pay your monthly need to pay your monthly need to pay your monthly need to pay your monthly much the premiums and cost-sharing for premiums and cost-sharing for premiums and cost-sharing for premiums and cost-sharing for plan will your Part D prescription drugs. your Part D prescription drugs. your Part D prescription drugs. your Part D prescription drugs. pay? Our plan has a coverage limit Our plan has a coverage limit Our plan has a coverage limit Our plan has a coverage limit every year for certain in- every year for certain in- every year for certain in- every year for certain innetwork benefits. Contact us network benefits. Contact us network benefits. Contact us network benefits. Contact us for the services that apply. for the services that apply. for the services that apply. for the services that apply. Senior Preferred is an HMO Senior Preferred is an HMO Senior Preferred is an HMO Senior Preferred is an HMO plan with a Medicare Contract. plan with a Medicare Contract. plan with a Medicare Contract. plan with a Medicare Contract. Enrollment in Senior Preferred Enrollment in Senior Preferred Enrollment in Senior Preferred Enrollment in Senior Preferred depends on contract renewal. depends on contract renewal. depends on contract renewal. depends on contract renewal. COVERED MEDICAL AND HOSPITAL BENEFITS NOTE: SERVICES WITH A 1 MAY REQUIRE PRIOR AUTHORIZATION. SERVICES WITH A 2 MAY REQUIRE A REFERRAL FROM YOUR DOCTOR. OUTPATIENT CARE AND SERVICES Acupuncture and other Alternative Not covered. Not covered. Not covered. Not covered. Therapies Ambulance Chiropractic Care Manipulation of the spine to correct subluxation (when 1 or more of the bones of your spine move out of position): Manipulation of the spine to correct subluxation (when 1 or more of the bones of your spine move out of position): Manipulation of the spine to correct subluxation (when 1 or more of the bones of your spine move out of position): Manipulation of the spine to correct subluxation (when 1 or more of the bones of your spine move out of position): $15.00 co-pay $15.00 co-pay $15.00 co-pay $15.00 co-pay Routine Chiropractic visit: $15.00 co-pay Routine Chiropractic visit: $15.00 co-pay Routine Chiropractic visit: $15.00 co-pay Routine Chiropractic visit: $15.00 co-pay 7

10 Benefit Senior Preferred Elite Senior Preferred EliteD Senior Preferred Value Senior Preferred ValueD Dental Limited dental services (this Limited dental services (this Limited dental services (this Limited dental services (this Services does not include services in connection with care, treatment filling, removal or replacement of teeth): does not include services in connection with care, treatment filling, removal or replacement of teeth): does not include services in connection with care, treatment filling, removal or replacement of teeth): does not include services in connection with care, treatment filling, removal or replacement of teeth): Diabetic Diabetes monitoring supplies: Diabetes monitoring supplies: Diabetes monitoring supplies: Diabetes monitoring supplies: Supplies and Services 5-25% of the cost, depending on the supply. 5-25% of the cost, depending on the supply. 5-25% of the cost, depending on the supply. 5-25% of the cost, depending on the supply. Diabetes self-management training: Diabetes self-management training: Diabetes self-management training: Diabetes self-management training: Therapeutic shoes or inserts: 10% of the cost Therapeutic shoes or inserts: 10% of the cost Therapeutic shoes or inserts: 20% of the cost Therapeutic shoes or inserts: 20% of the cost Diagnostic Diagnostic radiology services Diagnostic radiology services Diagnostic radiology services Diagnostic radiology services Tests, Lab (such as MRIs, CT scans): (such as MRIs, CT scans): (such as MRIs, CT scans): (such as MRIs, CT scans): and 10% of the cost 10% of the cost Radiology Services, and Diagnostic tests and procedures: Diagnostic tests and procedures: Diagnostic tests and procedures: Diagnostic tests and procedures: X-rays 0-10% of the cost, depending on the service 0-10% of the cost, depending on the service Lab Services: You pay Lab Services: You pay Lab Services: 0-10% of the cost, depending on the service Lab Services: 0-10% of the cost, depending on the service Outpatient X-rays: Outpatient X-rays: Outpatient X-rays: 10% of the cost Outpatient X-rays: 10% of the cost Therapeutic radiology services (such as radiation treatment for cancer): Therapeutic radiology services (such as radiation treatment for cancer): Therapeutic radiology services (such as radiation treatment for cancer): 10% of the cost Therapeutic radiology services (such as radiation treatment for cancer): 10% of the cost 8

11 Benefit Senior Preferred Elite Senior Preferred EliteD Senior Preferred Value Senior Preferred ValueD Doctor s Primary care physician visit: Primary care physician visit: Primary care physician visit: Primary care physician visit: Office Visits Specialist visit: Specialist visit: Specialist visit: Specialist visit: Durable 10% of the cost 10% of the cost 20% of the cost 20% of the cost Medical Equipment (wheelchairs, oxygen, etc.) 1 Emergency Care $0-$50.00 co-pay, depending on the service $0-$50.00 co-pay, depending on the service $0-$50.00 co-pay, depending on the service $0-$50.00 co-pay, depending on the service If you admitted to the hospital within 3 days, 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. If you admitted to the hospital within 3 days, 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. If you admitted to the hospital within 3 days, 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. If you admitted to the hospital within 3 days, 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. Foot Care Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: Hearing Exam to diagnose and treat Exam to diagnose and treat Exam to diagnose and treat Exam to diagnose and treat Services hearing and balance issues: hearing and balance issues: hearing and balance issues: hearing and balance issues: Routine hearing exam (for up to 1 every year): Routine hearing exam (for up to 1 every year): Routine hearing exam (for up to 1 every year): Routine hearing exam (for up to 1 every year): 9

12 Benefit Senior Preferred Elite Senior Preferred EliteD Senior Preferred Value Senior Preferred ValueD Home Health Care 1 Mental Inpatient visit: Inpatient visit: Inpatient visit: Inpatient visit: Health Care Our plan covers an unlimited number of days for an inpatient hospital stay. In Network: Our plan covers an unlimited number of days for an inpatient hospital stay. In Network: Our plan covers an unlimited number of days for an inpatient hospital stay. In Network: Our plan covers an unlimited number of days for an inpatient hospital stay. In Network: $ per stay $ per stay $ per stay $ per stay You pay nothing for days 91 and beyond. You pay nothing for days 91 and beyond. You pay nothing for days 91 and beyond. You pay nothing for days 91 and beyond. Outpatient group therapy visit: Outpatient group therapy visit: Outpatient group therapy visit: Outpatient group therapy visit: Outpatient individual therapy visit: Outpatient individual therapy visit: Outpatient individual therapy visit: Outpatient individual therapy visit: Outpatient Cardiac (heart) rehab services Cardiac (heart) rehab services Cardiac (heart) rehab services Cardiac (heart) rehab services Rehabilita- (for a maximum of 2 one-hour (for a maximum of 2 one-hour (for a maximum of 2 one-hour (for a maximum of 2 one-hour tion 1 sessions per day for up to 36 sessions up to 36 weeks): $10.00 co-pay sessions per day for up to 36 sessions up to 36 weeks): $10.00 co-pay sessions per day for up to 36 sessions up to 36 weeks): $15.00 co-pay sessions per day for up to 36 sessions up to 36 weeks): $15.00 co-pay Additional visits are covered, but your cost may be more. Additional visits are covered, but your cost may be more. Additional visits are covered, but your cost may be more. Additional visits are covered, but your cost may be more. Occupational therapy visit: Occupational therapy visit: Occupational therapy visit: Occupational therapy visit: Physical therapy and speech and language therapy visit: Physical therapy and speech and language therapy visit: Physical therapy and speech and language therapy visit: Physical therapy and speech and language therapy visit: 10

13 Benefit Senior Preferred Elite Senior Preferred EliteD Senior Preferred Value Senior Preferred ValueD Outpatient Substance Abuse Group therapy visit: Individual therapy visit: Group therapy visit: Individual therapy visit: Group therapy visit: Individual therapy visit: Group therapy visit: Individual therapy visit: Outpatient Surgery 1 Ambulatory surgical center: Ambulatory surgical center: Ambulatory surgical center: $0-75 co-pay or 0-10% of the cost, depending on the service Ambulatory surgical center: $0-75 co-pay or 0-10% of the cost, depending on the service Outpatient hospital: Outpatient hospital: Outpatient hospital: $0-75 copay or 0-10% of the cost, depending on the service Outpatient hospital: $0-75 copay or 0-10% of the cost, depending on the service Over-the- Counter Items Not Covered. Not Covered. Not Covered. Not Covered. Prosthetic Devices (braces, artificial limbs, etc.) 1 Prosthetic Devices: 10% of the cost Related medical supplies: 10% of the cost Prosthetic Devices: 10% of the cost Related medical supplies: 10% of the cost Prosthetic Devices: 20% of the cost Related medical supplies: 20% of the cost Prosthetic Devices: 20% of the cost Related medical supplies: 20% of the cost Renal Dialysis 20% of the cost 20% of the cost 20% of the cost 20% of the cost Transportation Not covered. Not covered. Not covered. Not covered. Urgent Care 11

14 Benefit Senior Preferred Elite Senior Preferred EliteD Senior Preferred Value Senior Preferred ValueD Vision Exam to diagnose and treat Exam to diagnose and treat Exam to diagnose and treat Exam to diagnose and treat Services diseases and conditions of the eye (including yearly glaucoma screening): $0-, depending on the service. diseases and conditions of the eye (including yearly glaucoma screening): $0-, depending on the service. diseases and conditions of the eye (including yearly glaucoma screening): $0-, depending on the service. diseases and conditions of the eye (including yearly glaucoma screening): $0-, depending on the service. Routine eye exam: $0-$20.00 copay, depending on the service. Routine eye exam: $0-$20.00 copay, depending on the service. Routine eye exam: $0-$35.00 copay, depending on the service. Routine eye exam: $0-$35.00 copay, depending on the service. Eyeglasses (frames and lenses): Eyeglasses (frames and lenses): Eyeglasses (frames and lenses): Eyeglasses (frames and lenses): -Eyeglass frames: You pay -Eyeglass lenses: You pay -Eyeglass frames: You pay -Eyeglass lenses: You pay -Eyeglass frames: You pay -Eyeglass lenses: You pay -Eyeglass frames: You pay -Eyeglass lenses: You pay Eyeglasses or contact lenses after cataract surgery: You pay Eyeglasses or contact lenses after cataract surgery: You pay Eyeglasses or contact lenses after cataract surgery: You pay Eyeglasses or contact lenses after cataract surgery: You pay Our plan pays up to $300 every year for eyeglasses (frames and lenses), eyeglass lenses, and eyeglass frames. Our plan pays up to $300 every year for eyeglasses (frames and lenses), eyeglass lenses, and eyeglass frames. Our plan pays up to $100 every year for eyeglasses (frames and lenses), eyeglass lenses, and eyeglass frames. Our plan pays up to $100 every year for eyeglasses (frames and lenses), eyeglass lenses, and eyeglass frames. 12

15 Benefit Preventive Care Senior Preferred Elite 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 Colonoscopy Colorectal cancer screenings Depression screening Diabetes screening Fecal occult blood test Flexible sigmoidoscopy HIV screening Medical nutrition therapy services Obesity screening and counseling Prostate cancer screenings (PSA) Sexually transmitted infections screening and counseling Senior Preferred EliteD 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 Colonoscopy Colorectal cancer screenings Depression screening Diabetes screening Fecal occult blood test Flexible sigmoidoscopy HIV screening Medical nutrition therapy services Obesity screening and counseling Prostate cancer screenings (PSA) Sexually transmitted infections screening and counseling Senior Preferred Value 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 Colonoscopy Colorectal cancer screenings Depression screening Diabetes screening Fecal occult blood test Flexible sigmoidoscopy HIV screening Medical nutrition therapy services Obesity screening and counseling Prostate cancer screenings (PSA) Sexually transmitted infections screening and counseling Senior Preferred ValueD 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 Colonoscopy Colorectal cancer screenings Depression screening Diabetes screening Fecal occult blood test Flexible sigmoidoscopy HIV screening Medical nutrition therapy services Obesity screening and counseling Prostate cancer screenings (PSA) Sexually transmitted infections screening and counseling 13

16 Benefit Senior Preferred Elite Senior Preferred EliteD Senior Preferred Value Senior Preferred ValueD Preventive Tobacco use cessation Tobacco use cessation Tobacco use cessation Tobacco use cessation Services counseling (counseling counseling (counseling counseling (counseling counseling (counseling continued for people with no sign of tobacco-related diseases) for people with no sign of tobacco-related diseases) for people with no sign of tobacco-related diseases) for people with no sign of tobacco-related diseases) Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots Welcome to Medicare preventive visit (onetime) Welcome to Medicare preventive visit (onetime) Welcome to Medicare preventive visit (onetime) Welcome to Medicare preventive visit (onetime) Yearly Wellness visit Yearly Wellness visit Yearly Wellness visit Yearly Wellness visit 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. 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. Hospice You pay nothing for hospice care from a Medicare-certified hospice. You may have to pay part of the cost or drugs and respite care. You pay nothing for hospice care from a Medicare-certified hospice. You may have to pay part of the cost or drugs and respite care. You pay nothing for hospice care from a Medicare-certified hospice. You may have to pay part of the cost or drugs and respite care. You pay nothing for hospice care from a Medicare-certified hospice. You may have to pay part of the cost or drugs and respite care. INPATIENT CARE Inpatient Hospital Care Our plan covers an unlimited number of days for an inpatient hospital stay. Our plan covers an unlimited number of days for an inpatient hospital stay. Our plan covers an unlimited number of days for an inpatient hospital stay. Our plan covers an unlimited number of days for an inpatient hospital stay. In Network: $500 co-pay per stay In Network: $500 co-pay per stay In Network: $200 co-pay per day for days In Network: $200 co-pay per day for days You pay nothing per day for days You pay nothing per day for days You pay nothing per day for days 91 and beyond. You pay nothing per day for days 91 and beyond. You pay nothing per day for days 91 and beyond. You pay nothing per day for days 91 and beyond. 14

17 Benefit Senior Preferred Elite Senior Preferred EliteD Senior Preferred Value Senior Preferred ValueD 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. 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. Skilled Our plan covers up to 100 days Our plan covers up to 100 days Our plan covers up to 100 days Our plan covers up to 100 days Nursing in SNF. in SNF. in SNF. in SNF. Facility (SNF) 1 You pay nothing per day for days 1 through 20. You pay nothing per day for days 1 through 20. You pay nothing per day for days 1 through 20. You pay nothing per day for days 1 through 20. $125 co-pay per day for days 21 through 100. $125 co-pay per day for days 21 through 100. $125 co-pay per day for days 21 through 100. $125 co-pay per day for days 21 through 100. PRESCRIPTION DRUG BENEFITS How much For Part B drugs such as For Part B drugs such as For Part B drugs such as For Part B drugs such as do I pay? chemotherapy drugs: chemotherapy drugs: chemotherapy drugs: chemotherapy drugs: Other Part B drugs: Other Part B drugs: Other Part B drugs: Other Part B drugs: Our plan does not cover Part D prescription drugs. Our plan does not cover Part D prescription drugs. 15

18 Benefit How much do I pay? Initial Coverage: Senior Preferred EliteD 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. Standard Retail Cost-Sharing Initial Coverage: Senior Preferred ValueD 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. Standard Retail Cost-Sharing Tier Tier 1 (Preferred Generic) Tier 2 (Non-Preferred Generic) Tier 3 (Preferred Brand) Tier 4 (Non-Preferred Brand Name) Tier 5 (Specialty Tier) Onemonth supply Twomonth supply Threemonth supply $9 $18 $27 $30 $60 $90 $45 $90 $135 $95 $190 $285 30% of the cost Not Offered Not Offered Tier Tier 1 (Preferred Generic) Tier 2 (Non-Preferred Generic) Tier 3 (Preferred Brand) Tier 4 (Non-Preferred Brand Name) Tier 5 (Specialty Tier) Onemonth supply Twomonth supply Threemonth supply $9 $18 $27 $30 $60 $90 $45 $90 $135 $95 $190 $285 28% of the cost Not Offered Not Offered 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 that you pay at an in-network pharmacy. 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 that you pay at an in-network pharmacy. 16

19 Benefit Senior Preferred EliteD Senior Preferred ValueD Coverage Most Medicare drug plans have a coverage gap (also called the Most Medicare drug plans have a coverage gap (also called the Gap donut hole ). This means 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. donut hole ). This means 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. 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. 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 $2.65 co-pay for generic (including brand drugs treated as generic) and a $6.60 co-payment for all other drugs. 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 $2.65 co-pay for generic (including brand drugs treated as generic) and a $6.60 co-payment for all other drugs. 17

20 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/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 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 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 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: 私 たちは 私 たちの 健 康 や 薬 物 計 画 について 持 つかもしれないあらゆる 質 問 に 答 えるための 無 料 通 訳 サービスがあります 通 訳 を 取 得 す るには ちょうど 私 たち で 呼 び 出 します 誰 かは 英 語 の 言 語 を 話 すことができます これは 無 料 のサービスです 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. ااتتصصلل ففققطط ششففوويي ممتتررججمم ععللىى للللححصصوولل االلممخخددررااتت ا أوو االلصصححييةة خخططتتنناا ععنن للددييككمم تتككوونن ققدد ا أسسي ئللةة ا أييةة ععللىى للللا إججااببةة ممججاانناا ششففوويي ررججممممتت خخددممااتت للدديينناا Arabic:.ممججااننييةة خخددممةة ووههذذاا تتسسااععددكك ا أنن ييممككنن/االلا إننككللييززييةة االلللغغةة ييتتححددثث ششخخصص ففيي ببنناا 18

21 Hindi: हम क स भ प रश न आप ह सकत ह हम र स व स थ य य दव क य जन क ब र म जव ब द न क ल ए न : श ल क द भ ष य स व ह एक द भ ष य प न क ल ए, बस हम पर फ न क ई ह ज अ ग र ज /भ ष ब लत ह आप मदद कर सकत ह यह एक म फ त स व ह 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 językpolski, należy zadzwonić pod numer 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 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 Protecting Your Privacy (GHP) is committed to protecting the privacy and confidentiality of your protected personal and health information. We comply with all state and federal privacy laws, including the Gramm-Leach-Bliley Act (GLBA), the Health Insurance Portability and Accountability Act (HIPAA) and the Health Information Technology for Economic and Clinical Health Act (HITECH). These laws require that we provide our members with a Privacy Notice that explains our privacy practices. We must also provide you with access to your records, allow you to request corrections to your information and allow you to request that access to your information be limited. In order to provide you with insurance products and services, we must collect healthcare and personal information about you. Access to your information is restricted to those persons who need to know in order to provide service or administer GHP insurance products and services. We maintain physical, electronic, and procedural safeguards that comply with state and federal laws to protect your information. GHP does not use, disclose, sell, or make available any protected personal or health information about you to affiliates or non-affiliated third parties, unless required or permitted by law. Furthermore, if any of this information is disclosed without your authorization, we will notify you as required by law. The Notice of Privacy Practices is located at or call Customer Service to request a copy. 19

22 20 Notes

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24 Wisconsin and Iowa (608) or (800) TTY 711 seniorpreferred.org