HMO-POS. HAP Senior Plus- Expanded Network (hmo-pos) H2312. hap.org/medicare. Individual Plan 012 Individual Plan 007 Individual Plan 010

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1 hap.org/medicare HMO-POS 2015 Summary of Benefits 2850 W. Grand Boulevard Detroit, MI hap.org/medicare HAP Senior Plus- Expanded Network (hmo-pos) H2312 Individual Plan 012 Individual Plan 007 Individual Plan 010 Genesee Lapeer Livingston Macomb Monroe Oakland St. Clair Washtenaw Wayne Counties January 1, December 31, Health Alliance Plan of Michigan. A Nonprofit Company. Y0076_HMO POS SB15 CMS Accepted 9/22/2014

2 HAP Senior Plus - Expanded Network (hmo-pos) (a Medicare Advantage Health Maintenance Organization with Point of Service Option (hmo-pos) offered by HEALTH ALLIANCE PLAN OF MICHIGAN with a Medicare contract). Summary of Benefits January 1, December 31, 2015 There is more than one plan listed in this Summary of Benefits booklet. The booklet gives you a summary of what each plan covers and what you pay. It doesn t list every that we cover or list every limitation or exclusion. To get a complete list of s 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- 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 HAP Senior Plus - Expanded Network (hmo-pos)). Tips for comparing your Medicare choices This Summary of Benefits booklet gives you a summary of what HAP Senior Plus - Expanded Network (hmo-pos) covers and what you pay. If you want to compare our plans with other Medicare health plans, ask the other plans for their Summary of Benefits booklets. Or, use the Medicare Plan Finder on If you want to know more about the coverage and costs of Original Medicare, look in your current Medicare & You handbook. View it online at or get a copy by calling MEDICARE ( ), 24 hours a day, 7 days a week. TTY users should call (Introduction continued on next page) 1

3 Sections in this booklet Things to Know About HAP Senior Plus - Expanded Network (hmo-pos) Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services Covered Medical and Hospital Benefits Prescription Drug Benefits Optional Benefits (you must pay an extra premium for these benefits) This document is available in other formats such as large print. This document may be available in a non-english language. For additional information, call us at (800) Things to Know About HAP Senior Plus - Expanded Network (hmo-pos) 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 March 31, you can call us Saturday from 8:00 a.m. to 12:00 p.m. Eastern time, Monday from 8:00 a.m. to 8:00 p.m. Eastern time, Tuesday from 8:00 a.m. to 8:00 p.m. Eastern time, Wednesday from 8:00 a.m. to 8:00 p.m. Eastern time, Thursday from 8:00 a.m. to 8:00 p.m. Eastern time, Friday from 8:00 a.m. to 8:00 p.m. Eastern time. From April 1 to September 30, you can call us Monday through Friday from 8:00 a.m. to 8:00 p.m. Eastern time. Which doctors, hospitals, and pharmacies can I use? HAP Senior Plus - Expanded Network (hmo-pos) has a network of doctors, hospitals, pharmacies, and other providers. For some s you can use providers that are not in our network. You must generally use network pharmacies to fill your prescriptions for covered Part D drugs. You can see our plan s provider directory at our website ( You can see our plan s pharmacy directory at our website ( Or, call us and we will send you a copy of the provider and pharmacy directories. What do we cover? Like all Medicare health plans, we cover everything that Original Medicare covers - and more. Our plan members get all of the benefits covered by Original Medicare. For some of these benefits, you may pay more in our plans than you would in Original Medicare. For others, you may pay less. Our plan members also get more than what is covered by Original Medicare. Some of the extra benefits are outlined in this booklet. We cover Part D drugs. In addition, we cover Part B drugs such as chemotherapy and some drugs administered by your provider. You can see the complete plan formulary (list of Part D prescription drugs) and any restrictions on our website, HAP Senior Plus - Expanded Network (hmo-pos) 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 HAP Senior Plus - Expanded Network (hmo-pos), you must be entitled to Medicare Part A, be enrolled in Medicare Part B, and live in our area. Our area includes the following counties in Michigan: Genesee, Lapeer, Livingston, Macomb, Monroe, Oakland, St. Clair, Washtenaw, and Wayne. Or, call us and we will send you a copy of the formulary. How will I determine my drug costs? Our plans group 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: Initial Coverage, Coverage Gap, and Catastrophic Coverage. These benefit stages occur after you meet your deductible with Plan 007 () and Plan 010 (). 2 3

4 Mul -language Interpreter Services English: We have free interpreter s to answer any ques ns you may have about our health or drug plan. To get an interpreter, just call us at (800) (TTY: 711). Someone who speaks English/Language can help you. This is a free. Spanish: Tenemos servicios de intérprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos. Para hablar con un intérprete, por favor llame al (800) (TTY: 711). Alguien que hable español le podrá ayudar. Este es un servicio gratuito. Chinese Mandarin: 我 们 提 供 免 费 的 翻 译 服 务, 帮 助 您 解 答 关 于 健 康 或 药 物 保 险 的 任 何 疑 问 如 果 您 需 要 此 翻 译 服 务, 请 致 电 (800) (TTY: 711) 我 们 的 中 文 工 作 人 员 很 乐 意 帮 助 您 这 是 一 项 免 费 服 务 Chinese Cantonese: 您 對 我 們 的 健 康 或 藥 物 保 險 可 能 存 有 疑 問, 為 此 我 們 提 供 免 費 的 翻 譯 服 務 如 需 翻 譯 服 務, 請 致 電 (800) (TTY: 711). 我 們 講 中 文 的 人 員 將 樂 意 為 您 提 供 幫 助 這 是 一 項 免 費 服 務 Tagalog: Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot. Upang makakuha ng tagasaling-wika, tawagan lamang kami sa (800) (TTY: 711). Maaari kayong t ulungan ng isang nakakapagsalita ng Tagalog. Ito ay libreng serbisyo. French: Nous proposons des s gratuits d'interpréta on pour répondre à toutes vos ques ns rela à notre régime de santé ou d'assurance-médicaments. Pour accéder au d'interpréta on, il vous suffit de nous appeler au (800) (TTY: 711). Un interlocuteur parlant Français pourra vous aider. Ce est gratuit. Vietnamese: Chúng tôi có dịch vụ thông dịch miễn phí để trả lời các câu hỏi về chương sức khỏe và chương trình thuốc men. Nếu quí vị cần thông dịch viên xin gọi (800) (TTY: 711). sẽ có nhân viên nói ếng Việt giúp đỡ quí vị. Đây là dịch vụ miễn phí. German: Unser kostenloser Dolmetscher beantwortet Ihren Fragen zu unserem Gesundheits- und Arzneimi elplan. Unsere Dolmetscher erreichen Sie unter (800) (TTY: 711). Man wird Ihnen dort auf Deutsch weiterhelfen. Dieser Service ist kostenlos. Korean: 당사는 의료 보험 또는 약품 보험에 관한 질문에 답해 드리고자 무료 통역 서비스를 제공하고 있습니다. 통역 서비스를 이용하려면 전화 (800) (TTY: 711). 번으로 문의해 주십시오. 한국어를 하는 담당자가 도와 드릴 것입니다. 이 서비스는 무료로 운영됩니다. Russian: Если у вас Russian: возникнут Если вопросы у вас возникнут относительно вопросы страхового относительно или медикаментного страхового или медикаментного плана, вы можете воспользоваться плана, вы можете нашими воспользоваться бесплатными нашими услугами бесплатными переводчиков. услугами Чтобы переводчиков. Чтобы воспользоваться услугами воспользоваться переводчика, услугами позвоните переводчика, нам по телефону позвоните (800) нам по телефону or (800) (TTY: 711). Вам окажет (TTY: помощь 711). Вам сотрудник, окажет помощь который сотрудник, говорит по-pусски. к оторый говорит по-pусски. Данная услуга бесплатная. Данная услуга бесплатная. إننا نقدم خدمات المترجم إننا الفوري نقدم المجانیة خدمات للا جابة المترجمعن أي الفوريأسي لة المجانیة تتعلق للا جابة بالصحة عنأو أيجدول أسي لة الا دویة تتعلق لدینا. بالصحة أو للحصول جدول علىالا دویة Arabic: لدینا. للحصول على Arabic:. سیقوم شخص ما..(711 سیقوم : TTY )شخص ما (711 (800) (TTY: or مترجم فوري لیس علیك (800) سوى مترجم الاتصال فوري بنا لیسعلى علیك سوى الاتصال بنا على. بمساعدتك. ھذه خدمة. مجانیة بمساعدتك یتحدث. ھذه العربیةخدمة مجانیة یتحدث العربیة Italian: È disponibile Italian: un servizio È disponibile interpretariato un servizio gratuito di interpretariato per rispondere gratuito a eventuali per rispondere domande a eventuali domande sul nostro piano sanitario sul nostro e farmaceu piano sanitario co. Per e un farmaceu interprete, co. conta Per un are interprete, il numero conta are il numero ( 800) (800) or (TTY: 711). Un Un nostro incaricato che che parla Italianovi fornirà l'assistenza necessaria. l'assistenza necessaria. È un È servizio un servizio gratuito. gratuito. Portugués: Dispomos Portugués: de serviços Dispomos de interpretação de serviços gratuitos de interpretação para responder gratuitos a qualquer para responder a qualquer questão que tenha acerca questão do que nosso tenha plano acerca de saúde do nosso ou de plano medicação. de saúde Para ou de obter medicação. um intérprete, Para obter um intérprete, contacte-nos através contacte-nos do número (800) através do número or (TTY: (800) 711) Irá encontrar (TTY: 711). Irá encontrar alguém que alguém que fale o idioma fale o Português idioma Português para o ajudar. para o Este ajudar. serviço Este é serviço gratuito. é gratuito. French Creole: Nou French genyen Creole: sèvis entèprèt Nou genyen gra sèvis pou reponn entèprèt tout gra kesyon pou reponn ou ta genyen tout kesyon ou ta genyen konsènan plan medikal konsènan oswa dwòg plan medikal nou an. oswa Pou jwenn dwòg yon nou entèprèt, an. Pou jwenn jis rele yon nou entèprèt, nan jis rele nou nan (800) or (TYY: (800) 711) Yon moun (TTY: ki 711). pale Kreyòl Yon moun kapab ki pale ede w. Kreyòl Sa a kapab se yon ede sèvis w. ki Sa gra a se yon sèvis ki gra Polish: Umożliwiamy Polish: bezpłatne Umożliwiamy skorzystanie bezpłatne z usług skorzystanie tłumacza ustnego, z usług który tłumacza pomoże ustnego, w który pomoże w uzyskaniu odpowiedzi uzyskaniu na temat odpowiedzi planu zdrowotnego na temat planu lub dawkowania zdrowotnego leków. lub dawkowania Aby skorzystać leków. z Aby skorzystać z pomocy tłumacza znającego pomocy tłumacza język polski, znającego należy zadzwonić język polski, pod należy numer zadzwonić (800) pod numer or (800) (TTY: 711). Ta usługa (TTY: jest 711). bezpłatna. Ta usługa jest bezpłatna. Hindi: हम र Hindi: य दव हम र य जन क य ब र दव आपक य जन क ब र भ आपक जव ब द न क भ क जव ब द न क हम र प स म त द भ हम र षय प स स व एम उपल त दभ षय. एक सव ए द भ उपल षय. एक करन दभ क षय, बस करन क, बस (800) or (TTY: (800) 711) पर फ न (TTY: 711).. क ई पर फ न ज. क ई ब लत ह ज ब लत ह मदद कर सकत ह. मदद यह एक कर म सकत त स ह. व यह ह. एक म त सव ह. Japanese: 当 社 の 健 Japanese: 康 健 康 保 当 険 社 と の 薬 健 品 康 処 健 方 康 薬 保 プランに 険 と 薬 品 関 するご 処 方 薬 質 プランに 問 にお 答 関 えするため するご 質 問 にお 答 えするため に 無 料 の 通 訳 サービスがありますございます に 無 料 の 通 訳 サービスがありますございます 通 訳 をご 用 命 になるには 通 訳 をご 用 命 になるには (TTY: 711). にお 電 話 ください にお 日 本 電 語 話 を ください 話 す 人 者 日 本 語 を 話 す 人 者 が 支 援 いたします これは が 支 援 いたします これは 無 料 のサービスです 無 料 のサービスです Y0076_HMO 676 HMO Y0076_HMO POS ML INS 676 HMO POS CMS ML ACCEPTED INS 09/04/2012 CMS ACCEPTED 09/04/

5 Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services QUESTIONS How much is the monthly premium? $55 per month. In addition, you must keep paying your Medicare Part B premium. $106 per month. In addition, you must keep paying your Medicare Part B premium. $192 per month. In addition, you must keep paying your Medicare Part B premium. How much is the deductible? This package has additional deductibles for some s. This package has additional deductibles for some s. This package has additional deductibles for some s. $380 per year for in-network s. $100 per year for in-network s. $75 per year for in-network s. This plan does not have a deductible for Part D prescription drugs. $100 per year for Part D prescription drugs. $50 per year for Part D prescription drugs. Is there any limit on how much I will pay for my covered s? Yes. Like all Medicare health plans, our plan protects you by having yearly limits on your outof-pocket costs for medical and hospital care. Yes. Like all Medicare health plans, our plan protects you by having yearly limits on your outof-pocket costs for medical and hospital care. Yes. Like all Medicare health plans, our plan protects you by having yearly limits on your outof-pocket costs for medical and hospital care. Your yearly limit(s) in this plan: $3,400 for s you receive from in-network providers. $3,400 for s you receive from any provider. Your yearly limit(s) in this plan: $3,400 for s you receive from in-network providers. $3,400 for s you receive from any provider. Your yearly limit(s) in this plan: $3,400 for s you receive from in-network providers. $3,400 for s you receive from any provider. Your limit for s received from in-network providers will count toward this limit. Your limit for s received from in-network providers will count toward this limit. Your limit for s 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 s and we will pay the full cost for the rest of the year. If you reach the limit on out-of-pocket costs, you keep getting covered hospital and medical s and we will pay the full cost for the rest of the year. If you reach the limit on out-of-pocket costs, you keep getting covered hospital and medical s 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 Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs 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 s that apply. Our plan has a coverage limit every year for certain in-network benefits. Contact us for the s that apply. Our plan has a coverage limit every year for certain in-network benefits. Contact us for the s that apply. HAP Senior Plus (hmo-pos)-expanded Network is a plan with a Medicare contract. Enrollment in the plan depends on contract renewal. 6 7

6 COVERED MEDICAL AND HOSPITAL S 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 Therapies Not covered Not covered Not covered Ambulance 1 In-network: $75 copay In-network: $75 copay In-network: $75 copay. There is a limit to Chiropractic Care 1 Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): 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 In-network: $20 copay In-network: $20 copay. There is a limit to Dental Services 1,2 Limited dental s (this does not include s in connection with care, treatment, filling, removal, or replacement of teeth): Limited dental s (this does not include s in connection with care, treatment, filling, removal, or replacement of teeth): Limited dental s (this does not include s in connection with care, treatment, filling, removal, or replacement of teeth): In-network: $20-40 copay, depending on the. In-network: $15-35 copay, depending on the In-network: $15-30 copay, depending on the. There is a limit to Diabetes Supplies and Services 1 Diabetes monitoring supplies: Diabetes monitoring supplies: Diabetes monitoring supplies:. There is a limit to.. 8 9

7 COVERED MEDICAL AND HOSPITAL S Note: Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor. Outpatient Care and Services Diabetes Supplies and Services 1 (cont d) Diabetes self-management training: Diabetes self-management training: Diabetes self-management training:. There is a limit to Therapeutic shoes or inserts:. There is a limit to Therapeutic shoes or inserts:. Therapeutic shoes or inserts: Diagnostic Tests, Lab and Radiology Services, and X-Rays 1,2 Diagnostic radiology s (such as MRIs, CT scans): Diagnostic radiology s (such as MRIs, CT scans): Diagnostic radiology s (such as MRIs, CT scans): In-network: $0-100 copay, depending on the. There is a limit to In-network: $0-100 copay, depending on the In-network: $0-75 copay, depending on the Diagnostic tests and procedures: Diagnostic tests and procedures: Diagnostic tests and procedures: In-network: $0-100 copay, depending on the. There is a limit to In-network: $0-100 copay, depending on the In-network: $0-75 copay, depending on the Lab s: Lab s: Lab s:. There is a limit to 10 11

8 COVERED MEDICAL AND HOSPITAL S Note: Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor. Outpatient Care and Services Diagnostic Tests, Lab and Radiology Services, and X-Rays 1,2 (cont d) Outpatient X-Rays: In-network: $0-100 copay, depending on the. There is a limit to Outpatient X-Rays: In-network: $0-100 copay, depending on the Outpatient X-Rays: In-network: $0-75 copay, depending on the Therapeutic radiology s (such as radiation treatment for cancer): Therapeutic radiology s (such as radiation treatment for cancer): Therapeutic radiology s (such as radiation treatment for cancer): In-network: $25 copay In-network: $25 copay In-network: $25 copay. There is a limit to Doctor s Office Visits 1 Primary care physician visit: Primary care physician visit: Primary care physician visit: In-network: $0-20 copay, depending on the. There is a limit to In-network: $0-15 copay, depending on the In-network: $0-15 copay, depending on the Specialist visit: Specialist visit: Specialist visit: In-network: $0-40 copay, depending on the. There is a limit to In-network: $0-35 copay, depending on the In-network: $0-30 copay, depending on the Durable Medical Equipment (wheelchairs, oxygen, etc.) 1 In-network: 20% of the cost. There is a limit to In-network: 20% of the cost In-network: 20% of the cost 12 13

9 COVERED MEDICAL AND HOSPITAL S Note: Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor. Outpatient Care and Services Emergency Care $65 copay $65 copay $65 copay If you are immediately admitted to the hospital, you do not have to pay your share of the cost for emergency care. See the Inpatient Hospital Care section of this booklet for other costs. If you are immediately admitted to the hospital, you do not have to pay your share of the cost for emergency care. See the Inpatient Hospital Care section of this booklet for other costs. If you are immediately admitted to the hospital, you do not have to pay your share of the cost for emergency care. See the Inpatient Hospital Care section of this booklet for other costs. Worldwide coverage. Worldwide coverage. Worldwide coverage. Foot Care (podiatry s) 1 Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: In-network: $40 copay. There is a limit to Foot exams and treatment if you have diabetesrelated nerve damage and/or meet certain conditions: In-network: $35 copay Foot exams and treatment if you have diabetesrelated nerve damage and/or meet certain conditions: In-network: $30 copay Hearing Services Exam to diagnose and treat hearing and balance issues: Exam to diagnose and treat hearing and balance issues: Exam to diagnose and treat hearing and balance issues:. There is a limit to Routine hearing exam: Routine hearing exam: Routine hearing exam: 14 15

10 COVERED MEDICAL AND HOSPITAL S Note: Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor. Outpatient Care and Services Home Health Care In-network: 20% of the cost In-network: 20% of the cost In-network: 20% of the cost. There is a limit to Mental Health Care 1,2 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 s 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 s 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 s provided in a general hospital. Our plan covers 90 days for an inpatient hospital stay. Our plan covers 90 days for an inpatient hospital stay. 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. 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. 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: In-network: In-network: $150 copay per day for days 1 through 5 $125 copay per day for days 1 through 5 $75 copay per day for days 1 through 5 You pay nothing per day for days 6 through 90 You pay nothing per day for days 6 through 90 You pay nothing per day for days 6 through 90 Out-of-network: Out-of-network: Out-of-network: 20% of the cost per stay 20% of the cost per stay 20% of the cost per stay 16 17

11 COVERED MEDICAL AND HOSPITAL S Note: Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor. Outpatient Care and Services Mental Health Care 1,2 (cont d) Outpatient group therapy visit: Outpatient group therapy visit: Outpatient group therapy visit: In-network: $40 copay In-network: $35 copay In-network: $30 copay. There is a limit to Outpatient individual therapy visit: In-network: $40 copay. There is a limit to Outpatient individual therapy visit: In-network: $35 copay Outpatient individual therapy visit: In-network: $30 copay Outpatient Rehabilitation 1 Cardiac (heart) rehab s (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): In-network: $15 copay. There is a limit to Occupational therapy visit: In-network: $15 copay. There is a limit to Cardiac (heart) rehab s (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): In-network: $15 copay Occupational therapy visit: In-network: $15 copay Cardiac (heart) rehab s (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): In-network: $15 copay Occupational therapy visit: In-network: $15 copay 18 19

12 COVERED MEDICAL AND HOSPITAL S Note: Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor. Outpatient Care and Services Outpatient Rehabilitation 1 (cont d) Physical therapy and speech and language therapy visit: Physical therapy and speech and language therapy visit: Physical therapy and speech and language therapy visit: In-network: $15 copay In-network: $15 copay In-network: $15 copay. There is a limit to. The Point of Service benefit limit is $1,000. The Point of Service benefit limit is $1,000 Outpatient Substance Abuse Group therapy visit: Group therapy visit: Group therapy visit: In-network: $40 copay In-network: $35 copay In-network: $30 copay. There is a limit to Individual therapy visit: In-network: $40 copay. There is a limit to Individual therapy visit: In-network: $35 copay Individual therapy visit: In-network: $30 copay Outpatient Surgery 1,2 Ambulatory surgical center: Ambulatory surgical center: Ambulatory surgical center: In-network: $0-100 copay, depending on the. There is a limit to In-network: $0-100 copay, depending on the In-network: $0-75 copay, depending on the 20 21

13 COVERED MEDICAL AND HOSPITAL S Note: Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor. Outpatient Care and Services Outpatient Surgery 1,2 (cont d) Outpatient hospital: Outpatient hospital: Outpatient hospital: In-network: $0-100 copay, depending on the. There is a limit to In-network: $0-100 copay, depending on the In-network: $0-75 copay, depending on the Over-the-Counter Items Not Covered Not Covered Not Covered Prosthetic Devices (braces, artificial limbs, etc.) 1 Prosthetic devices: Prosthetic devices: Prosthetic devices: In-network: 20% of the cost In-network: 20% of the cost In-network: 20% of the cost. There is a limit to Related medical supplies: In-network: 20% of the cost. There is a limit to Related medical supplies: In-network: 20% of the cost Related medical supplies: In-network: 20% of the cost Renal Dialysis 1 In-network: $0-25 copay, depending on the. There is a limit to In-network: $0-25 copay, depending on the In-network: $0-25 copay, depending on the Transportation Not covered Not covered Not covered 22 23

14 COVERED MEDICAL AND HOSPITAL S Note: Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor. Outpatient Care and Services Urgent Care $35 copay $35 copay $35 copay If you are immediately admitted to the hospital, you do not have to pay your share of the cost for urgent care. See the Inpatient Hospital Care section of this booklet for other costs. If you are immediately admitted to the hospital, you do not have to pay your share of the cost for urgent care. See the Inpatient Hospital Care section of this booklet for other costs. If you are immediately admitted to the hospital, you do not have to pay your share of the cost for urgent care. See the Inpatient Hospital Care section of this booklet for other costs. Worldwide coverage. Worldwide coverage. Worldwide coverage. Vision Services Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening):. There is a limit to Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): Routine eye exam: Routine eye exam: Routine eye exam: There is a limit to how much our plan will pay from an out-of-network provider. Eyeglasses or contact lenses after cataract surgery: Contact lenses:. You are covered for up to 1 every two years. Eyeglasses or contact lenses after cataract surgery:. There may be a limit to how often these s are covered. Our plan pays up to $80 every two years for contact lenses from an in-network provider

15 COVERED MEDICAL AND HOSPITAL S Note: Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor. Outpatient Care and Services Vision Services (cont d) Eyeglass frames:. You are covered for up to 1 every two years.. There may be a limit to how often these s are covered. Our plan pays up to $80 every two years for eyeglass frames from an in-network provider. Eyeglass lenses:. You are covered for up to 1 every two years.. There may be a limit to how often these s are covered. Eyeglasses or contact lenses after cataract surgery: 26 27

16 COVERED MEDICAL AND HOSPITAL S Note: Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor. Preventive Care Preventive Care 2. There is a limit to Our plan covers many preventive s, including: Our plan covers many preventive s, including: Our plan covers many preventive s, including: Abdominal aortic aneurysm screening Abdominal aortic aneurysm screening Abdominal aortic aneurysm screening Alcohol misuse counseling Alcohol misuse counseling Alcohol misuse counseling Bone mass measurement Bone mass measurement Bone mass measurement Breast cancer screening (mammogram) Breast cancer screening (mammogram) Breast cancer screening (mammogram) Cardiovascular disease (behavioral therapy) Cardiovascular disease (behavioral therapy) Cardiovascular disease (behavioral therapy) Cardiovascular screenings Cardiovascular screenings Cardiovascular screenings Cervical and vaginal cancer screening Cervical and vaginal cancer screening Cervical and vaginal cancer screening Colonoscopy Colonoscopy Colonoscopy Colorectal cancer screenings Colorectal cancer screenings Colorectal cancer screenings Depression screening Depression screening Depression screening Diabetes screenings Diabetes screenings Diabetes screenings Fecal occult blood test Fecal occult blood test Fecal occult blood test Flexible sigmoidoscopy Flexible sigmoidoscopy Flexible sigmoidoscopy HIV screening HIV screening HIV screening Medical nutrition therapy s Medical nutrition therapy s Medical nutrition therapy s Obesity screening and counseling Obesity screening and counseling Obesity screening and counseling 28 29

17 COVERED MEDICAL AND HOSPITAL S Note: Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor. Preventive Care Preventive Care 2 (cont d) Prostate cancer screenings (PSA) Prostate cancer screenings (PSA) Prostate cancer screenings (PSA) Sexually transmitted infections screening and counseling Sexually transmitted infections screening and counseling Sexually transmitted infections screening and counseling Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease) Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease) Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease) 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 (one-time) Welcome to Medicare preventive visit (one-time) Welcome to Medicare preventive visit (one-time) Yearly Wellness visit Yearly Wellness visit Yearly Wellness visit Any additional preventive s approved by Medicare during the contract year will be covered. Any additional preventive s approved by Medicare during the contract year will be covered. Any additional preventive s approved by Medicare during the contract year will be covered. Hospice Hospice You pay nothing for hospice care from a Medicarecertified hospice. You may have to pay part of the cost for drugs and respite care. You pay nothing for hospice care from a Medicarecertified hospice. You may have to pay part of the cost for drugs and respite care. You pay nothing for hospice care from a Medicarecertified hospice. You may have to pay part of the cost for drugs and respite care

18 COVERED MEDICAL AND HOSPITAL S Note: Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor. Inpatient Care Inpatient Hospital Care 1,2 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: In-network: In-network: $150 copay per day for days 1 through 5 $125 copay per day for days 1 through 5 $75 copay per day for days 1 through 5 You pay nothing per day for days 6 through 90 You pay nothing per day for days 91 and beyond You pay nothing per day for days 6 through 90 You pay nothing per day for days 91 and beyond You pay nothing per day for days 6 through 90 You pay nothing per day for days 91 and beyond Out-of-network: Out-of-network: Out-of-network: 20% of the cost per stay 20% of the cost per stay 20% of the cost per stay 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. Skilled Nursing Facility (SNF) 1,2 Our plan covers up to 100 days in a SNF. Our plan covers up to 100 days in a SNF. Our plan covers up to 100 days in a SNF. In-network: In-network: In-network: Medicare-covered SNF stay: Medicare-covered SNF stay: Medicare-covered SNF stay: Out-of-network: Out-of-network: Out-of-network: Medicare-covered SNF stay: Medicare-covered SNF stay: Medicare-covered SNF stay: 20% of the cost per stay 20% of the cost per stay 20% of the cost per stay For in-network stay you pay: For in-network stay you pay: For in-network stay you pay: $15 per day for days 1-20 $15 per day for days 1-20 $15 per day for days 1-20 $155 per day for days $155 per day for days $155 per day for days

19 PRESCRIPTION DRUG S Prescription Drug Benefits How much do I pay? For Part B drugs such as chemotherapy drugs: For Part B drugs such as chemotherapy drugs: For Part B drugs such as chemotherapy drugs: In-network: 0-20% of the cost depending on the drug In-network: 0-20% of the cost depending on the drug In-network: 0-20% of the cost depending on the drug. There is a limit to Other Part B drugs: In-network: 0-20% of the cost depending on the drug. There is a limit to Other Part B drugs: In-network: 0-20% of the cost depending on the drug Other Part B drugs: In-network: 0-20% of the cost depending on the drug Initial Coverage You pay the following until your total yearly drug costs reach $2,960. Total yearly drug costs are the total drug costs paid by both you and our Part D plan. You may get your drugs at network retail pharmacies and mail order pharmacies. After you pay your yearly deductible, you pay the following until your total yearly drug costs reach $2,960. Total yearly drug costs are the total drug costs paid by both you and our Part D plan. You may get your drugs at network retail pharmacies and mail order pharmacies. After you pay your yearly deductible, you pay the following until your total yearly drug costs reach $2,960. Total yearly drug costs are the total drug costs paid by both you and our Part D plan. You may get your drugs at network retail pharmacies and mail order pharmacies

20 PRESCRIPTION DRUG S Prescription Drug Benefits Initial Coverage (cont d) Standard Retail Cost-Sharing Standard Retail Cost-Sharing Standard Retail Cost-Sharing Tier One- Two- Threemonth month month supply supply supply Tier 1 ( $6 copay $12 copay $15 copay Tier 2 (Non- $10 copay $20 copay $25 copay Tier 3 $45 copay $90 copay $ ( copay Brand) Tier 4 33% of the 33% of the 33% of the (Non- cost cost cost Brand) Tier 5 33% of the 33% of the 33% of the (Specialty cost cost cost Tier) Tier One- Two- Threemonth month month supply supply supply Tier 1 ( $2 copay $4 copay $5 copay Tier 2 $15 copay $30 copay $37.50 (Non- copay Tier 3 $45 copay $90 copay $ ( copay Brand) Tier 4 30% of the 30% of the 30% of the (Non- cost cost cost Brand) Tier 5 30% of the 30% of the 30% of the (Specialty cost cost cost Tier) Tier One- Two- Threemonth month month supply supply supply Tier 1 ( $4 copay $8 copay $10 copay Tier 2 (Non- $10 copay $20 copay $25 copay Tier 3 $45 copay $90 copay $ ( copay Brand) Tier 4 31% of the 31% of the 31% of the (Non- cost cost cost Brand) Tier 5 31% of the 31% of the 31% of the (Specialty cost cost cost Tier) 36 37