VIP HMO MEDICARE PLAN 2014 Summary of Benefits For Medicare-Eligible Retirees Residing in Manhattan, Brooklyn, Bronx, Staten Island & Queens

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1 214 Summary of Benefits PROFESSIONAL SERVICES PCP office visits Specialist office visits Annual physical exam/preventive care Physical, Speech & Occupational Therapy Flu & Pneumonia Vaccinations Diagnostic Services including X-ray, Lab Tests, EKG's Routine Foot Care (Up to 4 visits per year) Chiropractic Care INPATIENT HOSPITAL SERVICES Surgeon & physician fees 214 Medicare Plan $1 copay per visit $1 copay per visit $1 copay per visit $1 copay per visit 214 Medicare Plan Semi-private room and board Anesthesia Nursing care (hospital provided) X-ray & Lab tests (inpatient) Prescribed drugs Operating & recovery room fees Intensive Care Unit Therapy (physical, speech and occupational therapy) OUTPATIENT FACILITY SERVICES Ambulatory surgery Emergency room fees Ambulance service to the hospital Renal dialysis X-ray & Lab tests (outpatient) Diagnostic Services including MRI's, MRA s, PET, and CAT Scans Outpatient Hospital Facility Services Radiation Therapy 214 Medicare Plan $5 copay per visit $5 copay per visit (waived if admitted) $5 copay per service 5 $5 copay per visit (waived if 5

2 214 Summary of Benefits MENTAL HEALTH AND ALCOHOL AND SUBSTANCE ABUSE CARE Mental Health Care Inpatient: no limit in a general hospital; 19- day lifetime limit in a psychiatric facility Outpatient therapy Alcohol and Substance Abuse Care Inpatient: based on medical necessity, up to Medicare limits Inpatient Detoxification Outpatient therapy PRESCRIPTION DRUGS When prescribed by a Participating Provider and filled by a participating pharmacy. **Low income subsidy 214 Medicare Plan 214 Medicare Plan Deductible: $ Initial Coverage Limit (ICL): $2,85 Retail: Preferred Generic: $1 copay per 3-day supply Preferred Brand: $15 copay per 3-day supply Non-Formulary: 5% coinsurance per 3-day supply Generic: Generic:

3 214 Summary of Benefits PRESCRIPTION DRUGS (CONT'D) When prescribed by a Participating Provider and filled by a participating pharmacy mail order vendor. 214 Medicare Plan Mail Order: Preferred Generic: $5 copay per 3-day supply Preferred Brand: $7.5 copay per 3-day supply Non-Formulary: 5% coinsurance per 3-day supply Catastrophic Coverage: When a member reaches $4,55 of true out-ofpocket (TrOOP) costs for the calendar year, the member will pay the greater of $2.55 copay for generic, $6.35 copay for brand, or 5% coinsurance. Mail Order: Preferred Generic: $5 copay per 3-day supply Preferred Brand: $7.5 copay per 3-day supply Non- Formulary: 5% coinsuranc e per 3- day supply Catastrophi c Coverage: When a member reaches $4,55 of true out-ofpocket (TrOOP) costs for the calendar year, the member will pay the greater of PART B DRUGS in

4 $ 5 fo r o n e ex amin atio n (co mp reh en siv e o r p erio d ic) ev ery 6 mo n th s. $ 1 p er v isit fo r o n e p ro p h y lax is (clean in g ) ev ery 6 mo n th s. Ad d itio n al serv ices, in clu d in g b u t n o t limited to X-ray s, fillin g s, cro wn s o r d en tu res will b e p ro v id ed at a d isco u n ted rate su b ject to a fee sch ed u le. VIP HMO MEDICARE PLAN 214 Summary of Benefits OTHER BENEFITS Skilled Nursing Facility Care Up to 1 days per benefit period 214 Medicare Plan $ copay per day (days 1-2) $ copay per day (days 1-2) Home Health Care (non-custodial) Hospice Care Provided by Medicare-certified hospice. for 18 days plus unlimited 6-day extension if Medicare guidelines are met. Urgent Care Routine Vision Care One eye exam per calendar year by a Participating provider. Corrective lenses after cataract surgery One pair of eyeglasses every 12 months when chosen from a select group of frames at a participating optical provider. Hearing Exam and Aid One routine hearing exam per calendar year by a participating provider. Hearing Aid Preventive Dental Care HIP Participating Dentist must be used Private Duty Nursing Durable Medical Equipment* Transportation (Non-emergent transportation) $25 copay per day (days 21-1) by Medicare $1 copay $15 copay per visit $4 copay $4 copay $1 copay per visit One hearing aid or a $5 credit toward the purchase of a hearing aid every 36 months $25 copay per day (days 21- One hearing aid or a $ $5 for one examination (comprehensive or periodic) every 6 months. $1 per visit for one prophylaxis (cleaning) every 6 months. Additional services, including but not limited to X-rays, fillings, crowns or dentures will be provided at a discounted rate subject to a fee schedule. in in covered covered 4 1

5 214 Summary of Benefits ADDITIONAL BENEFITS Transitional Health Care Services (Members will receive home health aide services and personal care services (ADL S) performed by a home health aide for up to 3 days after their discharge from a hospital.) Over the Counter Medication (OTCS) Cough and Cold PPI (Proton Pump Inhibitors) Axid, Prilosec etc. Analgesics (includes aspirins) Anti Acid (Mylanta, Bismuth) FOOTNOTES 214 Medicare Plan *Durable Medical Equipment must be Medically Necessary, in accordance with Medicare guidelines and prescribed by a HIP Participating Medical Provider, to be covered. Please note prior approval for customized Durable Medical Equipment must be obtained through the CMP program. Maximum Out of Pocket Costs - $3,4 annual out of pocket maximum. Once met, medical and hospital services have no cost sharing. The out of pocket maximum does not apply to supplemental benefits not covered by Medicare such as hearing aids and preventive dental care. **Member is eligible for the applicable low income copay and premium subsidy. For further information please contact If you have a hearing or speech impairment and use a TDD, call 711. Your benefit will be made up of two plans Your benefit consists of a primary Medicare Advantage plan and a secondary supplemental plan for the Coverage Gap Stage only. Your pharmacy will only need to submit your prescription once to the Emblem Health Premier (HMO) Medicare Plan. During the Coverage Gap Stage, if your prescription is identified as an applicable drug typically brand-name drugs the prescription will automatically process under the secondary supplemental coverage. This ensures the correct copayment is applied to your prescription in all stages of the benefit. All of the information needed to process your prescription is included on your member ID card. To ensure your coverage is applied correctly, present your ID card each time you fill a prescription. For more information on the Medicare Coverage Gap Discount Program refer to the benefits description above. This benefit design does not apply if you are receiving Extra Help from Medicare. HIP Health Plan of New York is an EmblemHealth Company, an HMO operating with Medicare Advantage contract. Enrolled members must use HIP Participating Providers for all medical and hospital services except for emergency care or urgently needed care. If you receive medical or hospital care that is not provided or authorized by HIP (other than emergency care or urgently needed care as defined in your contract) neither HIP nor Medicare will pay for that service and you will be responsible for the payment for the care you received. This benefit package is subject to change annually at the plan's contracted renewal time with the Centers for Medicare & Medicaid Services. (CMS) (Effective through ) The information contained in the Summary is intended to provide a general overview of the benefits available in the VIP HMO Medicare Plan. For an actual description of your benefits including exclusions, limitations or specific conditions that may modify the benefits described in this Summary see your 214 Medicare EOC. In the event of a discrepancy between the information contained in this Summary and the provisions of your 214 Medicare EOC, the specific provisions of the EOC shall prevail over the overview provided in this Summary.

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