2016 Summary of Benefits

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1 2016 Summary of Benefits Plans 001, 002, 009 H6298_15_028 accepted

2 Summary of Benefits January 1, December 31, 2016 This booklet gives you a summary of what we cover and what you pay. It doesn t list every service that we cover 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,, or ). Tips for comparing your Medicare choices This Summary of Benefits booklet gives you a summary of what, Standard (HMO), and Enhanced (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 medicare.gov. If you want to know more about the coverage and s 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 HealthSpan Medicare, HealthSpan Medicare, and HealthSpan Medicare 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 Things to Know About HealthSpan Medicare, Standard (HMO) and 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. Eastern time. From February 15 to September 30, you can call us Monday through Friday from 8:00 a.m. to 8:00 p.m. Eastern time., Standard (HMO) and Phone Numbers and Website If you are a member of this plan, call toll-free (TTY 711). If you are not a member of this plan, call tollfree (TTY 711). Our website: Who can join? To join,, or, you must be entitled to Medicare Part A, be enrolled in Medicare Part B, and live in our service area. 2

3 Our service area includes the following counties in Ohio: Adams, Allen, Auglaize, Brown, Butler, Champaign, Clark, Clermont, Clinton, Cuyahoga, Fulton, Geauga, Hamilton, Henry, Highland, Lake, Lorain, Lucas, Mahoning, Medina, Mercer, Ottawa, Portage, Preble, Putnam, Shelby, Stark, Summit, Trumbull, Van Wert, and Wood. Which doctors and hospitals can I use?,, and have 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 (healthspan.org/medicare). You can see our plan s pharmacy directory at our website ( seniormedrx). Or, call us and we will send you a copy 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 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 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, healthspan.org/seniormedrx. Or, call us and will send you a copy formulary. How will I determine my drug s? Our plan groups each medication into one of six tiers. You will need to use your formulary to locate what tier your drug is on to determine how much it will you. The amount you pay depends on the drug s tier and what stage benefit you have reached. Later in this document we discuss the benefit stages that occur: Initial Coverage, Coverage Gap, and Catastrophic Coverage. 3

4 Summary of Benefits January 1, 2016 December 31, 2016 MONTHLY PREMIUM, DEDUCTIBLE, AND LIMITS ON HOW MUCH YOU PAY FOR COVERED SERVICES How much is the monthly premium? How much is the deductible? Is there any limit on how much I will pay for my covered services? 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 s for medical and hospital care. $49 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 s for medical and hospital care. $99 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 s for medical and hospital care. Your yearly limit(s) in this plan: $4,000 for services you receive from innetwork providers. If you reach the limit on out-of-pocket s, you keep getting covered hospital and medical services and we will pay the full for the rest year. Please note that you will still need to pay your monthly premiums and sharing for your Part D prescription drugs. Your yearly limit(s) in this plan: $3,700 for services you receive from innetwork providers. If you reach the limit on out-of-pocket s, you keep getting covered hospital and medical services and we will pay the full for the rest year. Please note that you will still need to pay your monthly premiums and sharing for your Part D prescription drugs. Your yearly limit(s) in this plan: $3,500 for services you receive from innetwork providers. If you reach the limit on out-of-pocket s, you keep getting covered hospital and medical services and we will pay the full for the rest year. Please note that you will still need to pay your monthly premiums and sharing for your Part D prescription drugs. 4

5 Is there a limit on how much the plan will pay? No. There are no limits on how much our plan will pay. Our plan has a coverage limit every year for certain innetwork benefits. Our plan has a coverage limit every year for certain innetwork benefits. Contact us for the services that apply. 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. Contact us for the services that apply. Acupuncture Not covered Not covered Not covered Ambulance 1 $275 $225 $150 Chiropractic Care Manipulation spine to correct a subluxation (when 1 or more bones of your spine move out of position): $20 Manipulation spine to correct a subluxation (when 1 or more bones of your spine move out of position): $10 Manipulation spine to correct a subluxation (when 1 or more bones of your spine move out of position): $10 5

6 Dental Services Limited dental services (this does not include services in connection with care, treatment, filling, removal or replacement of teeth): Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): Preventive dental services: Cleaning (for up to 2 every year): Dental x-ray(s) (for up to 1): Oral exam (for up to 2 every year): Preventive dental services: Cleaning (for up to 2 every year): Dental x-ray(s) (for up to 1): Oral exam (for up to 2 every year): Our plan pays up to $500 every year for most dental services. Our plan pays up to $750 every year for most dental services. Member is responsible for the full of dental services that exceed the plan maximum benefit of $500 each year. Member is responsible for the full of dental services that exceed the plan maximum benefit of $750 each year. Diabetes Supplies and Services 1 Diabetes monitoring supplies: Diabetes monitoring supplies: Diabetes monitoring supplies: Diabetes selfmanagement training: Diabetes selfmanagement training: Diabetes selfmanagement training: Therapeutic shoes or inserts: Therapeutic shoes or inserts: Therapeutic shoes or inserts: 6

7 Diagnostic Tests, Lab and Radiology Services, and X- Rays (Costs for these services may be different if received in an outpatient surgery setting) 1, 2 Diagnostic radiology services (such as MRIs, CT scans): $275 Diagnostic tests and procedures: You pay nothing Lab services: You pay nothing Diagnostic radiology services (such as MRIs, CT scans): $200 Diagnostic tests and procedures: You pay nothing Lab services: You pay nothing Diagnostic radiology services (such as MRIs, CT scans): $125 Diagnostic tests and procedures: You pay nothing Lab services: You pay nothing Outpatient x-rays: $100 Outpatient x-rays: $75 Outpatient x-rays: $50 Therapeutic radiology services (such as radiation treatment for cancer): 20% Therapeutic radiology services (such as radiation treatment for cancer): 20% Therapeutic radiology services (such as radiation treatment for cancer): 20% Doctor s Office Visits Primary care physician visit: Primary care physician visit: Primary care physician visit: Specialist visit: $40 Specialist visit: $30 Specialist visit: $20 Durable Medical Equipment (wheelchairs, oxygen, etc.) 1 If you go to a preferred vendor, your may be less. If you go to a preferred vendor, your may be less. If you go to a preferred vendor, your may be less. Contact us for a list of preferred vendors. Contact us for a list of preferred vendors. Contact us for a list of preferred vendors. Emergency Care $75 $75 $75 If you are admitted to the hospital within 24 hours, you do not have to pay your share for emergency care. If you are admitted to the hospital within 24 hours, you do not have to pay your share for emergency care. If you are admitted to the hospital within 24 hours, you do not have to pay your share for emergency care. See the Inpatient Hospital Care section of this booklet for other s. See the Inpatient Hospital Care section of this booklet for other s. See the Inpatient Hospital Care section of this booklet for other s. 7

8 Foot Care (podiatry services) Hearing Services 1,2 Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: $40 Exam to diagnose and treat hearing and balance issues: $40 Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: $30 Exam to diagnose and treat hearing and balance issues: $30 Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: $20 Exam to diagnose and treat hearing and balance issues: $20 Routine hearing exam: $30 Routine hearing exam: $20 Hearing aid fitting/ evaluation: $30 Hearing aid fitting/ evaluation: $20 Hearing aid: Hearing aid: Our plan pays up to $1,000 every three years for hearing aids. Our plan pays up to $1,500 every three years for hearing aids. Member is responsible for hearing aid s that exceed the plan maximum benefit of $1,000 every three years. Member is responsible for hearing aid s that exceed the plan maximum benefit of $1,500 every three years. Home Health Care 1 8

9 Mental Health Care 1 Inpatient visit: Inpatient visit: 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. 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 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 s 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. The s 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. 9

10 Our plan covers 90 days for an inpatient hospital stay. Our plan also covers 60 lifetime reserve days. Our plan covers 90 days for an inpatient hospital stay. Our plan also covers 60 lifetime reserve days. 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. 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. 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. $220 per day for days 1 through 7 per day for days 8 through 90 $185 per day for days 1 through 5 per day for days 6 through 90 Outpatient group therapy visit: $20 Outpatient group therapy visit: $15 Outpatient group therapy visit: $10 Outpatient individual therapy visit: $40 Outpatient individual therapy visit: $30 Outpatient individual therapy visit: $20 Outpatient Rehabilitation Cardiac (heart) rehab services (for a maximum of 2 onehour sessions per day for up to 36 sessions up to 36 weeks): $40 Cardiac (heart) rehab services (for a maximum of 2 onehour sessions per day for up to 36 sessions up to 36 weeks): $30 Cardiac (heart) rehab services (for a maximum of 2 onehour sessions per day for up to 36 sessions up to 36 weeks): $20 Occupational therapy visit: $40 Occupational therapy visit: $30 Occupational therapy visit: $20 Physical therapy and speech and language therapy visit: $40 Physical therapy and speech and language therapy visit: $30 Physical therapy and speech and language therapy visit: $20 10

11 Outpatient Substance Abuse Group therapy visit: $20 Group therapy visit: $15 Group therapy visit: $10 Individual therapy visit: $40 Individual therapy visit: $30 Individual therapy visit: $20 Outpatient Surgery 1,2 Ambulatory surgical center: $300 Ambulatory surgical center: $200 Ambulatory surgical center: $125 Over-the-Counter Items Prosthetic Devices (braces, artificial limbs, etc.) 1 Outpatient hospital: $300 or 20% of the, depending on the service Outpatient hospital: $200 or 20% of the, depending on the service Outpatient hospital: $125 or 20% of the, depending on the service Not Covered Not Covered Not Covered Prosthetic devices: Related medical supplies: Prosthetic devices: Related medical supplies: Prosthetic devices: Related medical supplies: Renal Dialysis 1,2 Transportation Not covered Not covered Not covered Urgently Needed Services $45 $45 $45 11

12 Vision Services Exam to diagnose and treat diseases and conditions eye (including yearly glaucoma screening): $40 Exam to diagnose and treat diseases and conditions eye (including yearly glaucoma screening): $30 Exam to diagnose and treat diseases and conditions eye (including yearly glaucoma screening): $20 Routine eye exam: $30-50, depending on the service Routine eye exam: $20 50, depending on the service Contact lenses: Contact lenses: Eyeglasses (frames and lenses): Eyeglasses (frames and lenses): Eyeglass frames: Eyeglass frames: Eyeglass lenses: Eyeglass lenses: Eyeglasses or contact lenses after cataract surgery: You pay nothing Eyeglasses or contact lenses after cataract surgery: You pay nothing Eyeglasses or contact lenses after cataract surgery: You pay nothing Our plan pays up to $100 every two years for eyewear. Our plan pays up to $150 every two years for eyewear. Member is responsible for eyewear s that exceed the plan maximum benefit of $100 every two years. Member is responsible for eyewear s that exceed the plan maximum benefit of $150 every two years. 12

13 Preventive Care Our plan covers many preventive services, including: Our plan covers many preventive services, including: 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) 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) 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) 13

14 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 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 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. 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 for hospice care from a Medicare-certified hospice. for hospice care from a Medicare-certified hospice. for hospice care from a Medicare-certified hospice. You may have to pay part for drugs and respite care. You may have to pay part for drugs and respite care. You may have to pay part for drugs and respite care. Hospice is covered outside of our plan. Please contact us for more details. Hospice is covered outside of our plan. Please contact us for more details. Hospice is covered outside of our plan. Please contact us for more details. 14

15 INPATIENT CARE Inpatient Hospital Care 1 The s 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. The s 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. 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. $270 per day for days 1 through 7 per day for days 8 through 90 per day for days 91 and beyond $185 per day for days 1 through 5 per day for days 6 through 90 per day for days 91 and beyond per day for days 91 and beyond 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. 15

16 Skilled Nursing Facility (SNF) 1 The s for skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you re admitted and ends when you haven t received any skilled care in a SNF for 60 days in a row. If you go into a SNF after one benefit period has ended, a new benefit period begins. The s for skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you re admitted and ends when you haven t received any skilled care in a SNF for 60 days in a row. If you go into a SNF after one benefit period has ended, a new benefit period begins. The s for skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you re admitted and ends when you haven t received any skilled care in a SNF for 60 days in a row. If you go into a SNF after one benefit period has ended, a new benefit period begins. Our plan covers up to 100 days in a SNF. per day for days 1 through 20 $125 per day for days 21 through 100 Our plan covers up to 100 days in a SNF. per day for days 1 through 20 $125 per day for days 21 through 100 Our plan covers up to 100 days in a SNF. per day for days 1 through 20 $125 per day for days 21 through 100 PRESCRIPTION DRUG BENEFITS How much do I pay? 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 : Other Part B drugs 1 : Other Part B drugs 1 : Other Part B drugs 1 : 16

17 Initial Coverage You pay the following until your total yearly drug s reach $3,310. Total yearly drug s are the total drug s paid by both you and our Part D plan. You may get your drugs at network retail pharmacies and mail order pharmacies. Value (HMO) Standard Retail Cost-Sharing Standard Retail Cost-Sharing Standard Retail Cost-Sharing Tier Onemonth Threemonth Tier Onemonth Threemonth Tier Onemonth Threemonth Tier 1 generic) Tier 1 generic) Tier 1 generic) Tier 2 (Generic) $14 $42 Tier 2 (Generic) $14 $42 Tier 2 (Generic) $14 $42 Tier 3 Brand) $45 $135 Tier 3 Brand) $45 $135 Tier 3 Brand) $45 $135 Tier 4 (Nonpreferred brand) $95 $285 Tier 4 (Nonpreferred brand) $95 $285 Tier 4 (Nonpreferred brand) $95 $285 Tier 5 (Specialty Tier) Tier 5 (Specialty Tier) Tier 5 (Specialty Tier) Tier 6 (Vaccines) Not Offered Tier 6 (Vaccines) Not Offered Tier 6 (Vaccines) Not Offered 17

18 Value (HMO) Standard Mail Order Cost- Sharing Standard Mail Order Cost- Sharing Standard Mail Order Cost- Sharing Tier Onemonth Threemonth Tier Onemonth Threemonth Tier Onemonth Threemonth Tier 1 generic) Tier 1 generic) Tier 1 generic) Tier 2 (Generic) $14 $28 Tier 2 (Generic) $14 $28 Tier 2 (Generic) $14 $28 Tier 3 Brand) $45 $90 Tier 3 Brand) $45 $90 Tier 3 Brand) $45 $90 Tier 4 (Nonpreferred brand) $95 $190 Tier 4 (Nonpreferred brand) $95 $190 Tier 4 (Nonpreferred brand) $95 $190 Tier 5 (Specialty Tier) Tier 5 (Specialty Tier) Tier 5 (Specialty 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 at the same as an innetwork 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 at the same as an innetwork 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 at the same as an innetwork pharmacy. 18

19 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 (including what our plan has paid and what you have paid) reaches $3,310. After you enter the coverage gap, you pay 45% plan s for covered brand name drugs and 58% plan s for covered generic drugs until your s total $4,850, which is the end coverage gap. Not everyone will enter the coverage gap. Under this plan, you may pay even less for the brand and generic drugs on the formulary. Your 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 you. Standard Retail Cost- Sharing Tier 1 Generic) Drugs Covered: All One-month : Three-month : Tier 6 (Vaccines) Drugs Covered: All One-month : Three-month : Not offered Under this plan, you may pay even less for the brand and generic drugs on the formulary. Your 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 you. Standard Retail Cost- Sharing Tier 1 Generic) Drugs Covered:All One-month : Three-month : Tier 6 (Vaccines) Drugs Covered: All One-month : Three-month : Not offered Under this plan, you may pay even less for the brand and generic drugs on the formulary. Your 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 you. Standard Retail Cost- Sharing Tier 1 Generic) Drugs Covered: All One-month : Three-month : Tier 2 (Generic) Drugs Covered: All One-month : $14 Three-month : $42 Tier 6 (Vaccines) Drugs Covered: All One-month : Three-month : Not offered 19

20 Standard Mail Order Cost-Sharing Tier 1 Generic) Drugs Covered: All One-month : Three-month : Standard Mail Order Cost-Sharing Tier 1 Generic) Drugs Covered: All One-month : Three-month : Standard Mail Order Cost-Sharing Tier 1 Generic) Drugs Covered: All One-month : Three-month : Tier 2 (Generic) Drugs Covered: All One-month : $14 Three-month : $28 Catastrophic Coverage After your yearly out-of-pocket drug s (including drugs purchased through your retail pharmacy and through mail order) reach $4,850, you pay the following: Value (HMO) Tier Your Tier Your Tier Your Tier 1 generic) $2.95 or 5% s more) Tier 1 generic) $2.95 or 5% s more) Tier 1 generic) $2.95 or 5% s more) Tier 2 (Generic) $2.95 or 5% s more) Tier 2 (Generic) $2.95 or 5% s more) Tier 2 (Generic) $2.95 or 5% s more) Tier 3 Brand) $7.40 or 5% s more) Tier 3 Brand) $7.40 or 5% s more) Tier 3 Brand) $7.40 or 5% s more) Tier 4 (Nonpreferred brand) $7.40 or 5% s more) Tier 4 (Nonpreferred brand) $7.40 or 5% s more) Tier 4 (Nonpreferred brand) $7.40 or 5% s more) Tier 5 (Specialty Tier) $7.40 or 5% s more) Tier 5 (Specialty Tier) $7.40 or 5% s more) Tier 5 (Specialty Tier) $7.40 or 5% s more) Tier 6 (Vaccines) Tier 6 (Vaccines) Tier 6 (Vaccines) 20

21 Additional Information About Advantage Plans General exclusions (services our plan does not cover) Please refer to your Evidence of Coverage for a complete list of benefits that are not covered under our Advantage plans. Some services and items are not covered by our plan unless they are covered by Original Medicare or they are described otherwise in the Evidence of Coverage. # HSPBRO (8/15) 21

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