2015 Summary of Benefits

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1 2015 Summary of Benefits Value (HMO-POS) Value Plus (HMO-POS) Essentials Rx (HMO-POS) Classic (HMO-POS) (H2459) January 1, December 31, 2015 Minnesota H2459_082914_4 CMS Accepted ( )

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3 SECTION I INTRODUCTION TO SUMMARY OF BENEFITS Value (HMO-POS), Value Plus (HMO-POS), UCare for Seniors Essentials Rx (HMO-POS), and Classic (HMO-POS) 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 UCare for Seniors Value (HMO-POS), Value Plus (HMO-POS), Essentials Rx (HMO-POS), or Classic (HMO-POS) ). Tips for comparing your Medicare choices This Summary of Benefits booklet gives you a summary of what Value (HMO-POS), UCare for Seniors Value Plus (HMO-POS), Essentials Rx (HMO-POS), and Classic (HMO-POS) cover 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 Sections in this booklet Things to Know About Value (HMO-POS), Value Plus (HMO-POS), Essentials Rx (HMO-POS), and Classic (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 Braille and large print. This document may be available in a non-english language. For additional information, call us locally at (TTY/TDD ), or toll free at (TTY/TDD ). Summary of Benefits

4 Things to Know About Value (HMO-POS), UCare for Seniors Value Plus (HMO-POS), Essentials Rx (HMO- POS), and Classic (HMO-POS) Hours of Operation You can call us 24 Hours a day Central time, 7 days a week. Value (HMO-POS), UCare for Seniors Value Plus (HMO-POS), UCare for Seniors Essentials Rx (HMO-POS), and Classic (HMO-POS) Phone Numbers and Website If you are a member of this plan, call locally (TTY/TDD ), or toll free at (TTY/TDD ). If you are not a member of this plan, call locally (TTY/TDD ), or toll free at (TTY/TDD ). Our website: Who can join? To join Value (HMO-POS), or UCare for Seniors Essentials Rx (HMO-POS), 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 Minnesota: Aitkin, Anoka, Becker, Beltrami, Benton, Big Stone, Blue Earth, Brown, Carlton, Carver, Cass, Chippewa, Chisago, Clay, Clearwater, Cook, Cottonwood, Crow Wing, Dakota, Dodge, Douglas, Faribault, Fillmore, Freeborn, Goodhue, Grant, Hennepin, Houston, Hubbard, Isanti, Itasca, Jackson, Kanabec, Kandiyohi, Kittson, Koochiching, Lac qui Parle, Lake, Lake of the Woods, Le Sueur, Lincoln, Lyon, Mahnomen, Marshall, Martin, McLeod, Meeker, Mille Lacs, Morrison, Mower, Murray, Nicollet, Nobles, Norman, Olmsted, Otter Tail, Pennington, Pine, Pipestone, Polk, Pope, Ramsey, Red Lake, Redwood, Renville, Rice, Rock, Roseau, Scott, Sherburne, Sibley, St. Louis, Stearns, Steele, Stevens, Swift, Todd, Traverse, Wabasha, Wadena, Waseca, Washington, Watonwan, Wilkin, Winona, Wright, and Yellow Medicine. To join Value Plus (HMO-POS), or Classic (HMO-POS), 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 Minnesota: Aitkin, Anoka, Becker, Benton, Blue Earth, Carlton, Carver, Cass, Chisago, Clay, Cook, Crow Wing, Dakota, Dodge, Faribault, Fillmore, Freeborn, Goodhue, Hennepin, Houston, Hubbard, Isanti, Kanabec, Lake, Le Sueur, Mille Lacs, Morrison, Mower, Nicollet, Olmsted, Pine, Ramsey, Rice, Scott, Sherburne, St. Louis, Stearns, Steele, Wabasha, Waseca, Washington, Watonwan, Winona, and Wright. Which doctors, hospitals, and pharmacies can I use? Value (HMO-POS) has a network of doctors, hospitals, and other providers. For some services you can use providers that are not in our network. Value Plus (HMO-POS), UCare for Seniors Essentials Rx (HMO-POS), and UCare for Seniors Classic (HMO-POS) have a network of doctors, hospitals, pharmacies, and other providers. For some services 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. NOTE: Value (HMO-POS) does NOT cover Medicare Part D prescription drugs. You can see our plan s provider and pharmacy directory at our website (http://www.ucare.org). Or, call us and we will send you a copy of the provider and pharmacy directory. 2 Value, Value Plus, Essentials Rx, Classic

5 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. Value (HMO-POS) covers Part B drugs including chemotherapy and some drugs administered by your provider. However, this plan does not cover Part D prescription drugs. Value Plus (HMO-POS), UCare for Seniors Essentials Rx (HMO-POS), and UCare for Seniors Classic (HMO-POS) cover Part D drugs. In addition, these plans cover Part B drugs such as chemotherapy and some drugs administered by your provider. You can see the complete plan formulary (list of Part D prescription drugs) and any restrictions on our website, Or, call us and we will send you a copy of the formulary. How will I determine my drug costs under Value Plus (HMO-POS), Essentials Rx (HMO- POS), and Classic (HMO- POS)? Value Plus (HMO-POS), UCare for Seniors Essentials Rx (HMO-POS), and UCare for Seniors Classic (HMO-POS) 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 that occur: Initial Coverage, Coverage Gap, and Catastrophic Coverage. If you have any questions about these plans benefits or costs, please contact UCare for details. Summary of Benefits

6 SECTION II - SUMMARY OF BENEFITS For Contract H2459, Plan 001, 013, 019, 002 MONTHLY PREMIUM, DEDUCTIBLE, AND LIMITS ON HOW MUCH YOU PAY FOR COVERED SERVICES QUESTION 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? VALUE (HMO-POS) $44 per month. In addition, you must keep paying your Medicare Part B premium. This plan does not have a deductible. Yes. Like all Medicare health plans, our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care. Your yearly limit(s) in this plan: $3,400 for services you receive from innetwork providers. $20,000 for services you receive from out-of-network providers. If you reach the limit on out-of-pocket costs, you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year. VALUE PLUS (HMO-POS) $115 per month. In addition, you must keep paying your Medicare Part B premium. This plan does not have a deductible. Yes. Like all Medicare health plans, our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care. Your yearly limit(s) in this plan: $3,400 for services you receive from innetwork providers. $20,000 for services you receive from out-of-network providers. If you reach the limit on out-of-pocket costs, you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year. Is there a limit on how much the plan will pay? Please note that you will still need to pay your monthly premiums. No. There are no limits on how much our plan will pay. Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs. No. There are no limits on how much our plan will pay. UCare Minnesota is a Medicare Advantage plan with a Medicare contract. Enrollment in UCare Minnesota depends on contract renewal. 4 Value, Value Plus, Essentials Rx, Classic

7 ESSENTIALS Rx (HMO-POS) CLASSIC (HMO-POS) $48 per month. In addition, you must keep paying your Medicare Part B premium. $168 per month. In addition, you must keep paying your Medicare Part B premium. $75 per year for Part D prescription drugs. This plan does not have a deductible. Yes. Like all Medicare health plans, our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care. Your yearly limit(s) in this plan: $3,400 for services you receive from innetwork providers. $20,000 for services you receive from out-of-network providers. If you reach the limit on out-of-pocket costs, you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year. Yes. Like all Medicare health plans, our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care. Your yearly limit(s) in this plan: $3,400 for services you receive from innetwork providers. $20,000 for services you receive from out-of-network providers. If you reach the limit on out-of-pocket costs, you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year. Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs. No. There are no limits on how much our plan will pay. Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs. Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply. Summary of Benefits

8 VALUE (HMO-POS) COVERED MEDICAL AND HOSPITAL BENEFITS NOTE: SERVICES WITH A 1 MAY REQUIRE PRIOR AUTHORIZATION. VALUE PLUS (HMO-POS) SERVICES WITH A 2 MAY REQUIRE A REFERRAL FROM YOUR DOCTOR. OUTPATIENT CARE AND SERVICES Acupuncture and Other Alternative Therapies Ambulance Chiropractic Care Not covered. In-network: $100 copay. Out-of-network: $100 copay. Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): Not covered. In-network: $100 copay. Out-of-network: $100 copay. Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): 6 Value, Value Plus, Essentials Rx, Classic

9 ESSENTIALS Rx (HMO-POS) CLASSIC (HMO-POS) Not covered. Not covered. In-network: $200 copay. Out-of-network: $200 copay. Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): In-network: $15 copay. In-network: $100 copay. Out-of-network: $100 copay. Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): Summary of Benefits

10 Dental Services VALUE (HMO-POS) Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): VALUE PLUS (HMO-POS) Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): Diabetes Supplies and Services Diabetes monitoring supplies: Diabetes self-management training: Therapeutic shoes or inserts: Diabetes monitoring supplies: Diabetes self-management training: Therapeutic shoes or inserts: 8 Value, Value Plus, Essentials Rx, Classic

11 ESSENTIALS Rx (HMO-POS) Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): Preventive dental services: Cleaning: - In-network: You pay nothing. You are covered for up to 1 every year. - Out-of-network: You pay nothing. There may be a limit to how often these services are covered. Dental x-ray(s): - In-network: You pay nothing. You are covered for up to 1 every year. - Out-of-network: You pay nothing. There may be a limit to how often these services are covered. Oral exam: - In-network: You pay nothing. You are covered for up to 1 every year. - Out-of-network: You pay nothing. There may be a limit to how often these services are covered. Diabetes monitoring supplies: In-network: 20% of the cost. Diabetes self-management training: Therapeutic shoes or inserts: CLASSIC (HMO-POS) Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): Preventive dental services: Cleaning: - In-network: You pay nothing. You are covered for up to 3 every year. - Out-of-network: You pay nothing. There may be a limit to how often these services are covered. Dental x-ray(s): - In-network: You pay nothing. You are covered for up to 1. - Out-of-network: You pay nothing. There may be a limit to how often these services are covered. Fluoride treatment: - In-network: You pay nothing. - Out-of-network: You pay nothing. Oral exam: - In-network: You pay nothing. You are covered for up to 2 every year. - Out-of-network: You pay nothing. There may be a limit to how often these services are covered. Diabetes monitoring supplies: Diabetes self-management training: Therapeutic shoes or inserts: Summary of Benefits

12 Diagnostic Tests, Lab and Radiology Services, and X-Rays Doctor s Office Visits Durable Medical Equipment (wheelchairs, oxygen, etc.) Emergency Care VALUE (HMO-POS) Diagnostic radiology services (such as MRIs, CT scans): In-network: 10% of the cost. Diagnostic tests and procedures: In-network: 10% of the cost. Lab services: Out-of-network: You pay nothing. Outpatient x-rays: In-network: 10% of the cost. Therapeutic radiology services (such as radiation treatment for cancer): In-network: 10% of the cost. In-network coinsurance not to exceed $50 each day. Primary care physician visit: Specialist visit: In-network: 20% of the cost. $65 copay. If you are admitted to the hospital within 24 hours, you do not have to pay your share of the cost for emergency care. See the Inpatient Hospital Care section of this booklet for other costs. VALUE PLUS (HMO-POS) Diagnostic radiology services (such as MRIs, CT scans): In-network: 10% of the cost. Diagnostic tests and procedures: In-network: 10% of the cost. Lab services: Out-of-network: You pay nothing. Outpatient x-rays: In-network: 10% of the cost. Therapeutic radiology services (such as radiation treatment for cancer): In-network: 10% of the cost. In-network coinsurance not to exceed $50 each day. Primary care physician visit: Specialist visit: In-network: 20% of the cost. $65 copay. If you are admitted to the hospital within 24 hours, you do not have to pay your share of the cost for emergency care. See the Inpatient Hospital Care section of this booklet for other costs. 10 Value, Value Plus, Essentials Rx, Classic

13 ESSENTIALS Rx (HMO-POS) Diagnostic radiology services (such as MRIs, CT scans): In-network: 10% of the cost. Diagnostic tests and procedures: In-network: 10% of the cost. Lab services: Out-of-network: You pay nothing. Outpatient x-rays: In-network: 10% of the cost. Therapeutic radiology services (such as radiation treatment for cancer): In-network: 10% of the cost. CLASSIC (HMO-POS) Diagnostic radiology services (such as MRIs, CT scans): Diagnostic tests and procedures: Lab services: Out-of-network: You pay nothing. Outpatient x-rays: Therapeutic radiology services (such as radiation treatment for cancer): In-network coinsurance not to exceed $75 each day. Primary care physician visit: In-network: $15 copay. Specialist visit: In-network: $40 copay. In-network: 20% of the cost. Primary care physician visit: Specialist visit: In-network: $20 copay. In-network: 20% of the cost. $65 copay. If you are admitted to the hospital within 24 hours, you do not have to pay your share of the cost for emergency care. See the Inpatient Hospital Care section of this booklet for other costs. $65 copay. If you are admitted to the hospital within 24 hours, you do not have to pay your share of the cost for emergency care. See the Inpatient Hospital Care section of this booklet for other costs. Summary of Benefits

14 Foot Care (podiatry services) Hearing Services VALUE (HMO-POS) Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: Exam to diagnose and treat hearing and balance issues: Routine hearing exam: You are covered for up to 1 every year. VALUE PLUS (HMO-POS) Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: Exam to diagnose and treat hearing and balance issues: Routine hearing exam: You are covered for up to 1 every year. Home Health Care 12 Value, Value Plus, Essentials Rx, Classic

15 ESSENTIALS Rx (HMO-POS) Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: In-network: $40 copay. Exam to diagnose and treat hearing and balance issues: In-network: $40 copay. Routine hearing exam: You are covered for up to 1 every year. CLASSIC (HMO-POS) Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: In-network: $20 copay. Exam to diagnose and treat hearing and balance issues: In-network: $20 copay. Routine hearing exam: You are covered for up to 1 every year. Hearing aid fitting/evaluation: Hearing aid: Our plan pays up to $500 every three years for hearing aids from an in-network provider. Summary of Benefits

16 Mental Health Care VALUE (HMO-POS) 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 90 days for an inpatient hospital stay. Our plan also covers 60 lifetime reserve days. These are extra days that we cover. If your hospital stay is longer than 90 days, you can use these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days. In-network: - $400 copay per stay. Out-of-network: - 20% of the cost per stay. Outpatient group therapy visit: Outpatient individual therapy visit: VALUE PLUS (HMO-POS) 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 90 days for an inpatient hospital stay. Our plan also covers 60 lifetime reserve days. These are extra days that we cover. If your hospital stay is longer than 90 days, you can use these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days. In-network: - $400 copay per stay. Out-of-network: - 20% of the cost per stay. Outpatient group therapy visit: Outpatient individual therapy visit: 14 Value, Value Plus, Essentials Rx, Classic

17 ESSENTIALS Rx (HMO-POS) 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 90 days for an inpatient hospital stay. Our plan also covers 60 lifetime reserve days. These are extra days that we cover. If your hospital stay is longer than 90 days, you can use these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days. In-network: - $300 copay per day for days 1 through 5. - You pay nothing per day for days 6 through 90. Out-of-network: - 20% of the cost per stay. Outpatient group therapy visit: In-network: $40 copay. Outpatient individual therapy visit: In-network: $40 copay. CLASSIC (HMO-POS) 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 90 days for an inpatient hospital stay. Our plan also covers 60 lifetime reserve days. These are extra days that we cover. If your hospital stay is longer than 90 days, you can use these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days. In-network: - $200 copay per stay. Out-of-network: - 20% of the cost per stay. Outpatient group therapy visit: In-network: $20 copay. Outpatient individual therapy visit: In-network: $20 copay. Summary of Benefits

18 Outpatient Rehabilitation Outpatient Substance Abuse Outpatient Surgery Over-the-Counter Items VALUE (HMO-POS) Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): Occupational therapy visit: Physical therapy and speech and language therapy visit: Group therapy visit: Individual therapy visit: Ambulatory surgical center: In-network: $200 copay. Outpatient hospital: In-network: $200 copay or 10% of the cost, depending on the service. Outpatient surgery services provided at an in-network Ambulatory surgical center or an in-network Outpatient hospital have a $200 copayment. All other in-network outpatient hospital services have a 10% coinsurance, not to exceed $50 each day. Not covered. VALUE PLUS (HMO-POS) Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): Occupational therapy visit: Physical therapy and speech and language therapy visit: Group therapy visit: Individual therapy visit: Ambulatory surgical center: In-network: $200 copay. Outpatient hospital: In-network: $200 copay or 10% of the cost, depending on the service. Outpatient surgery services provided at an in-network Ambulatory surgical center or an in-network Outpatient hospital have a $200 copayment. All other in-network outpatient hospital services have a 10% coinsurance, not to exceed $50 each day. Not covered. 16 Value, Value Plus, Essentials Rx, Classic

19 ESSENTIALS Rx (HMO-POS) Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): In-network: $40 copay. Occupational therapy visit: In-network: $40 copay. Physical therapy and speech and language therapy visit: In-network: $40 copay. Group therapy visit: In-network: $40 copay. Individual therapy visit: In-network: $40 copay. Ambulatory surgical center: In-network: $250 copay. Outpatient hospital: In-network: $250 copay or 10% of the cost, depending on the service. Outpatient surgery services provided at either an in-network Ambulatory surgical center or Outpatient hospital have a $250 copayment. All other in-network outpatient hospital services have a 10% coinsurance, not to exceed $75 each day. Not covered. CLASSIC (HMO-POS) Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): In-network: $20 copay. Occupational therapy visit: In-network: $20 copay. Physical therapy and speech and language therapy visit: In-network: $20 copay. Group therapy visit: In-network: $20 copay. Individual therapy visit: In-network: $20 copay. Ambulatory surgical center: In-network: $100 copay. Outpatient hospital: In-network: $0-100 copay, depending on the service. Outpatient surgery services provided at either an in-network Ambulatory surgical center or Outpatient hospital have a $100 copayment. All other in-network outpatient hospital services have $0 copayment. Not covered. Summary of Benefits

20 Prosthetic Devices (braces, artificial limbs, etc.) VALUE (HMO-POS) Prosthetic devices: In-network: 20% of the cost. VALUE PLUS (HMO-POS) Prosthetic devices: In-network: 20% of the cost. Renal Dialysis Related medical supplies: In-network: 20% of the cost. Out-of-network: You pay nothing. Related medical supplies: Transportation Not covered. Not covered. Urgent Care $25 copay. $25 copay. Vision Services Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): In-network: $0-30 copay, depending on the service. In-network: 20% of the cost. Out-of-network: You pay nothing. Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): In-network: $0-30 copay, depending on the service. Routine eye exam: You are covered for up to 1 every year. Eyeglasses or contact lenses after cataract surgery: Routine eye exam: You are covered for up to 1 every year. Eyeglasses or contact lenses after cataract surgery: 18 Value, Value Plus, Essentials Rx, Classic

21 ESSENTIALS Rx (HMO-POS) Prosthetic devices: In-network: 20% of the cost. CLASSIC (HMO-POS) Prosthetic devices: In-network: 10% of the cost. Related medical supplies: In-network: 20% of the cost. Out-of-network: You pay nothing. Not covered. Related medical supplies: In-network: 10% of the cost. Out-of-network: You pay nothing. Not covered. $25 copay. $25 copay. Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): In-network: $0-40 copay, depending on the service. Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): In-network: $0-20 copay, depending on the service. Routine eye exam: You are covered for up to 1 every year. Eyeglasses or contact lenses after cataract surgery: Routine eye exam: You are covered for up to 1 every year. Contact lenses: Out-of-network: You pay nothing. Eyeglasses frames: Out-of-network: You pay nothing. Eyeglasses lenses: Out-of-network: You pay nothing. Eyeglasses or contact lenses after cataract surgery: Our plan pays up to $75 every year for contact lenses, eyeglass lenses, and eyeglass frames from an in-network provider. Summary of Benefits

22 Preventive Care VALUE (HMO-POS) Out-of-network: You pay nothing. 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 screenings. 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. 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. VALUE PLUS (HMO-POS) Out-of-network: You pay nothing. 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 screenings. 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. 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. 20 Value, Value Plus, Essentials Rx, Classic

23 ESSENTIALS Rx (HMO-POS) Out-of-network: You pay nothing. 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 screenings. 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. 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. CLASSIC (HMO-POS) Out-of-network: You pay nothing. 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 screenings. 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. 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. Summary of Benefits

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