2015 Summary of Benefits Platinum and Gold Plans (HMO) Queens, Manhattan, and the Bronx. January 1, December 31, 2015

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1 2015 Summary of Benefits Platinum and Gold Plans (HMO) Queens, Manhattan, and the Bronx January 1, December 31, 2015 H4866_AM4004 Accepted

2 Proposed Effective Date: Primary Care Provider: Name: Address: Phone Number: Benefit Consultant Name: Phone Number: able of Contents Important Phone Numbers: Access Medicare Member Services TTY/TDD , 8am-8pm, 7 days a week Medicare Medicare ( ) TTY/TDD hours a day, 7 days a week Social Security Administration TTY/TDD MedImpact (Pharmacy Help Desk) Block Vision (Vision Services) Scion Dental (Dental Services) Elegante Services (Transportation Services) New York State Medicaid or Elderly Pharmacutical Insurance Coverage (EPIC) TTY/TDD Monday-Friday, 8:30am-5pm PAGE 1

3 TABLE OF CONTENTS SECTION I Introduction to Summary of Benefits... 4 SECTION II Summary of Benefits... 7 SECTION III Understanding the Benefits for Access Medicare PAGE 3

4 SECTION I Introduction to the Summary of Benefits Report PLATINUM (HMO) GOLD (HMO) January 1, December 31, 2015 (a Medicare Advantage Health Maintenance Organization (HMO) offered by CUATRO LLC with a Medicare contract) 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 Access Medicare Platinum (HMO) or Access Medicare Gold (HMO)). TIPS FOR COMPARING YOUR MEDICARE CHOICES This Summary of Benefits booklet gives you a summary of what Access Medicare Platinum (HMO) and Access Medicare Gold (HMO) covers and what you pay. If you want to compare our plan with other Medicare health plans, ask the other plans for their Summary of Benefits booklets. Or, use the Medicare Plan Finder on If you want to know more about the coverage and costs of Original Medicare, look in your current Medicare & 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 Access Medicare Platinum (HMO) and Access Medicare Gold (HMO) Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services Covered Medical and Hospital Benefits Prescription Drug Benefits PAGE 4

5 SECTION I Introduction to the Summary of Benefits Report 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 La información se encuentra disponible en español o en diferentes formatos como braille, letra grande o otros formatos alternativos. Llame a servicio para miembros al (los usuarios de TTY/TDD deben llamar al ) desde 8 am a 8 pm lunes a viernes. Servicio para miembros tambien tiene servicios de intérprete disponibles para los que no hablan ingles. THINGS TO KNOW ABOUT PLATINUM (HMO) AND ACCESS MEDICARE GOLD (HMO) HOURS OF OPERATION You can call us 7 days a week from 8:00 a.m. to 8:00 p.m. Eastern time. PLATINUM (HMO) AND GOLD (HMO) PHONE NUMBERS AND WEBSITE If you are a member of this plan, call toll-free If you are not a member of this plan, call toll-free Our website: WHO CAN JOIN? To join Access Medicare Platinum (HMO) or Access Medicare Gold (HMO), 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 New York: Bronx, New York, and Queens. WHICH DOCTORS, HOSPITALS, AND PHARMACIES CAN I USE? Access Medicare Platinum (HMO) and Access Medicare Gold (HMO) 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 and pharmacy directory at our website ( Or, call us and we will send you a copy of the provider and pharmacy directories. PAGE 5

6 SECTION I Introduction to the Summary of Benefits Report WHAT DO WE COVER? Like all Medicare health plans, we cover everything that Original Medicare covers and more. Our plan members get all of the benefits covered by Original Medicare. For some of these benefits, you may pay more in our plan than you would in Original Medicare. For others, you may pay less. Our plan members also get more than what is covered by Original Medicare. Some of the extra benefits are outlined in this booklet. We cover Part D drugs. In addition, we cover Part B drugs such as chemotherapy and some drugs administered by your provider. You can see the complete plan formulary (list of Part D prescription drugs) and any restrictions on our website, Or, call us and we will send you a copy of the formulary HOW WILL I DETERMINE MY DRUG COSTS? The amount you pay for drugs depends on the drug you are taking and what stage of the benefit you have reached. Later in this document we discuss the benefit stages that occur after you meet your deductible: Initial Coverage, Coverage Gap, and Catastrophic Coverage. PAGE 6

7 SECTION II - Summary of Benefits MONTHLY PREMIUM, DEDUCTIBLE, AND LIMITS ON HOW MUCH YOU PAY FOR COVERED SERVICES BENEFIT CATEGORY 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? Is there a limit on how much the plan will pay? PLATINUM (HMO) $36.90 per month. In addition, you must keep paying your Medicare Part B premium. $320 per year for Part D prescription drugs. 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: $6,700 for services you receive from in-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. Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply. GOLD (HMO) $12 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: $6,700 for services you receive from in-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. Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply. Access Medicare is an HMO with a Medicare contract. Enrollment in Access Medicare depends on contract renewal. PAGE 7

8 SECTION II - Summary of Benefits BENEFIT CATEGORY PLATINUM (HMO) COVERED MEDICAL AND HOSPITAL BENEFITS OUTPATIENT CARE AND SERVICES Acupuncture and Other Alternative Therapies Not covered Not covered GOLD (HMO) Ambulance 1 Chiropractic Care 2 Dental Services 1 $125 copay If you are admitted to the hospital, you do not have to pay for the ambulance services. Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): $15 copay Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): You pay nothing Preventive dental services: Cleaning (for up to 1 every six months): You pay nothing Dental x-ray(s) (for up to 1): You pay nothing Oral exam (for up to 1 every six months): You pay Nothing Plan offers additional comprehensive dental benefits. Enhanced benefits include: Non-routine Services Diagnostic Services Restorative Services Endodontics/ Periodontics/Extractions Prosthodontics, Other Oral/ Maxillofacial Surgery, Other Services $500 of coverage per year $125 copay If you are admitted to the hospital, you do not have to pay for the ambulance services. Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): $15 copay Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): You pay nothing Preventive dental services: Cleaning (for up to 1 every six months): You pay nothing Dental x-ray(s) (for up to 1): You pay nothing Oral exam (for up to 1 every six months): You pay Nothing Plan offers additional comprehensive dental benefits. Enhanced benefits include: Non-routine Services Diagnostic Services Restorative Services Endodontics/ Periodontics/Extractions Prosthodontics, Other Oral/ Maxillofacial Surgery, Other Services $500 of coverage per year PAGE 8

9 SECTION II - Summary of Benefits BENEFIT CATEGORY PLATINUM (HMO) OUTPATIENT CARE AND SERVICES Diabetes Supplies and Services 1 Diabetes monitoring supplies: You pay nothing Diabetes self-management training: You pay nothing Therapeutic shoes or inserts: You pay nothing GOLD (HMO) Diabetes monitoring supplies: You pay nothing Diabetes self-management training: You pay nothing Therapeutic shoes or inserts: You pay nothing Diagnostic Tests, Lab and Radiology Services, and X-Rays 1,2 Doctor's Office Visits 2 Diagnostic radiology services (such as MRIs, CT scans): $50 copay Diagnostic tests and procedures: You pay nothing Lab services: You pay nothing Outpatient x-rays: You pay nothing Therapeutic radiology services (such as radiation treatment for cancer): 20% of the cost Primary care physician visit: You pay nothing Specialist visit: $15 copay Diagnostic radiology services (such as MRIs, CT scans): $50 copay Diagnostic tests and procedures: You pay nothing Lab services: You pay nothing Outpatient x-rays: You pay nothing Therapeutic radiology services (such as radiation treatment for cancer): 20% of the cost Primary care physician visit: You pay nothing Specialist visit: $15 copay Durable Medical Equipment (wheelchairs, oxygen, etc.) 1 20% of the cost 20% of the cost Emergency Care $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. PAGE 9

10 SECTION II - Summary of Benefits BENEFIT CATEGORY PLATINUM (HMO) OUTPATIENT CARE AND SERVICES Foot Care (podiatry services) 2 Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: You pay nothing Routine foot care (for up to 1 visit(s) every three months): $15 copay GOLD (HMO) Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: $15 copay Routine foot care (for up to 1 visit(s) every three months): $15 copay Hearing Services Exam to diagnose and treat hearing and balance issues: $15 copay Hearing aid: You pay nothing Our plan pays up to $500 every three years for hearing aids. Any amount exceeding $500 is the member s responsibility. Exam to diagnose and treat hearing and balance issues: $15 copay Hearing aid: You pay nothing Our plan pays up to $500 every three years for hearing aids. Any amount exceeding $500 is the member s responsibility. Home Health Care 1 You pay nothing You pay nothing PAGE 10

11 SECTION II - Summary of Benefits BENEFIT CATEGORY PLATINUM (HMO) OUTPATIENT CARE AND SERVICES Mental Health Care 1,2 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. $210 copay per day for days 1 through 7 You pay nothing per day for days 8 through 90 Outpatient group therapy visit: 20% of the cost Outpatient individual therapy visit: 20% of the cost Inpatient visit: GOLD (HMO) 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. $230 copay per day for days 1 through 5 You pay nothing per day for days 6 through 90 Outpatient group therapy visit: 20% of the cost Outpatient individual therapy visit: 20% of the cost PAGE 11

12 SECTION II - Summary of Benefits BENEFIT CATEGORY PLATINUM (HMO) OUTPATIENT CARE AND SERVICES Outpatient Rehabilitation 1 Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): You pay nothing Occupational therapy visit: $15 copay Physical therapy and speech and language therapy visit: $15 copay Medicare coverage limits may apply. GOLD (HMO) Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): You pay nothing Occupational therapy visit: $15 copay Physical therapy and speech and language therapy visit: $15 copay Medicare coverage limits may apply. Outpatient Substance Abuse 2 Outpatient Surgery 1,2 Over-the-Counter Items Prosthetic Devices (braces, artificial limbs, etc.) 1 Group therapy visit: 20% of the cost Individual therapy visit: 20% of the cost Ambulatory surgical center: $50 copay Outpatient hospital: 20% of the cost Please visit our website to see our list of covered over-the-counter items. Access Medicare Platinum provides you with $40 credit each month towards the purchase of OTC items Unused monies cannot be rolled over towards the next month. Prosthetic devices: 20% of the cost Related medical supplies: 20% of the cost Group therapy visit: 20% of the cost Individual therapy visit: 20% of the cost Ambulatory surgical center: $50 copay Outpatient hospital: 20% of the cost Not Covered Prosthetic devices: 20% of the cost Related medical supplies: 20% of the cost Renal Dialysis 1,2 20% of the cost 20% of the cost PAGE 12

13 SECTION II - Summary of Benefits BENEFIT CATEGORY PLATINUM (HMO) OUTPATIENT CARE AND SERVICES Transportation 1 You pay nothing 16 one-way trips to plan-approved locations per year. Transportation for routine health related services only. Minimum 24 hours advance scheduling required. Prior authorization may be required for certain trips. Not covered GOLD (HMO) Urgent Care Vision Services $25 copay Copayment at urgent care facility is not waived if admitted within 24 hours. Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): $15 copay Routine eye exam (for up to 1 every year): $15 copay Contact lenses (for up to 1 every year): You pay nothing Eyeglasses (frames and lenses) (for up to 1 every year): You pay nothing Eyeglasses or contact lenses after cataract surgery: You pay nothing Our plan pays up to $150 every year for contact lenses and eyeglasses (frames and lenses). 20% discount for eyewear exceeding the $150 retail allowance. Certain provider restrictions apply. Any amount exceeding $150 is the member s responsibility. $25 copay Copayment at urgent care facility is not waived if admitted within 24 hours. Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): $15 copay Routine eye exam (for up to 1 every year): $15 copay Contact lenses (for up to 1 every year): You pay nothing Eyeglasses (frames and lenses) (for up to 1 every year): You pay nothing Eyeglasses or contact lenses after cataract surgery: You pay nothing Our plan pays up to $150 every year for contact lenses and eyeglasses (frames and lenses). 20% discount for eyewear exceeding the $150 retail allowance. Certain provider restrictions apply. Any amount exceeding $150 is the member s responsibility. PAGE 13

14 SECTION II - Summary of Benefits BENEFIT CATEGORY PREVENTIVE CARE Preventive Care PLATINUM (HMO) 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) GOLD (HMO) 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) PAGE 14

15 SECTION II - Summary of Benefits BENEFIT CATEGORY PREVENTIVE CARE Preventive Care (continued) HOSPICE Hospice INPATIENT CARE Inpatient Hospital Care 1,2 PLATINUM (HMO) Our plan covers many preventive services, including: 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. Annual physical exam: You pay nothing You pay nothing for hospice care from a Medicare-certified hospice. You may have to pay part of the cost for drugs and respite care. Our plan covers an unlimited number of days for an inpatient hospital stay. In-network: $210 copay per day for days 1 through 7 $0 copay per day for days 8 through 90 You pay nothing per day for days 91 and beyond GOLD (HMO) Our plan covers many preventive services, including: 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. Annual physical exam: You pay nothing You pay nothing for hospice care from a Medicare-certified hospice. You may have to pay part of the cost for drugs and respite care. Our plan covers an unlimited number of days for an inpatient hospital stay. In-network: $230 copay per day for days 1 through 5 $0 copay per day for days 6 through 90 You pay nothing per day for days 91 and beyond PAGE 15

16 SECTION II - Summary of Benefits BENEFIT CATEGORY INPATIENT CARE Inpatient Mental Health Care PLATINUM (HMO) For inpatient mental health care, see the Mental Health Care section of this booklet. GOLD (HMO) For inpatient mental health care, see the Mental Health Care section of this booklet. Skilled Nursing Facility (SNF) 1,2 PRESCRIPTION DRUG BENEFITS How much do I pay? Our plan covers up to 100 days in a SNF. You pay nothing per day for days 1 through 20 $ copay per day for days 21 through 100 A three day prior inpatient stay is required For Part B drugs such as chemotherapy drugs1: 20% of the cost Other Part B drugs 1 : 20% of the cost Our plan covers up to 100 days in a SNF. You pay nothing per day for days 1 through 20 $156 copay per day for days 21 through 100 A three day prior inpatient stay is required For Part B drugs such as chemotherapy drugs1: 20% of the cost Other Part B drugs 1 : 20% of the cost PAGE 16

17 SECTION II - Summary of Benefits BENEFIT CATEGORY PLATINUM (HMO) PRESCRIPTION DRUG BENEFITS Initial Coverage After you pay your yearly deductible, you pay 25% of the cost for all drugs covered by this plan 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. 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 cost as an innetwork pharmacy. GOLD (HMO) You pay the following until your total yearly drug costs reach $2,500. 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. Standard Retail Cost-Sharing Tier Tier 1 (Preferred Generic) Tier 2 (nonpreferred Generic) Tier 3 (Preferred Brand) Tier 4 (Nonpreferred Brand) Tier 5 (Specialty Drugs) One-Month Supply Three- Month Supply $4 copay $12 copay $8 copay $24 copay $35 copay $105 copay $75 copay $225 copay 33% of the cost 33% of the cost PAGE 17

18 SECTION II - Summary of Benefits BENEFIT CATEGORY PLATINUM (HMO) PRESCRIPTION DRUG BENEFITS Initial Coverage (continued) GOLD (HMO) Standard Mail Order Cost-Sharing Tier Tier 1 (Preferred Generic) Tier 2 (non-preferred Generic) Tier 3 (Preferred Brand) Tier 4 (Non-preferred Brand) Tier 5 (Specialty Drugs) Three-Month Supply $6 copay $12 copay $52.50 copay $ copay 33% of the cost 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 cost as an innetwork pharmacy. 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 cost (including what our plan has paid and what you have paid) reaches $2,960. After you enter the coverage gap, you pay 45% of the plan s cost for covered brand name drugs and 65% of the plan s cost for covered generic drugs until your costs total $4,700, which is the end of the coverage gap. Not everyone will enter the coverage gap. 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 cost (including what our plan has paid and what you have paid) reaches $2,500. After you enter the coverage gap, you pay 45% of the plan s cost for covered brand name drugs and 65% of the plan s cost for covered generic drugs until your costs total $4,700, which is the end of the coverage gap. Not everyone will enter the coverage gap. PAGE 18

19 SECTION II - Summary of Benefits BENEFIT CATEGORY PLATINUM (HMO) PRESCRIPTION DRUG BENEFITS Catastrophic Coverage After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4,700, you pay the greater of: 5% of the cost, or $2.65 copay for generic (including brand drugs treated as generic) and a $6.60 copayment for all other drugs. GOLD (HMO) After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4,700, you pay the greater of: 5% of the cost, or $2.65 copay for generic (including brand drugs treated as generic) and a $6.60 copayment for all other drugs. PAGE 19

20 SECTION III Understanding the Benefits for Access Medicare At Access Medicare, members are our top priority. Our mission is to assure members receive the highest level of specialized care by providing them with access to many of the top doctors and hospitals in their neighborhood. As a Medicare beneficiary, you must continue to pay your Medicare Part B premiums no matter which plan you choose. If you also receive Medicaid benefits or other LOW INCOME SUBSIDIES (LIS), you may have reduced out-of-pocket costs based on the program you are enrolled in and as long as your benefits remains active. There are many options available to you. Please speak to your Access Medicare Benefit Consultant to make sure you choose the plan that s best for you. The Access Medicare Platinum (HMO) and Access Medicare Gold (HMO) plans offer Medicare beneficiaries specialized benefits not fully covered by Original Medicare. Some of the plans feature comprehensive dental benefits, a free transportation benefit, eyeglasses and contacts through a vision benefit, and a unique OTC (overthe-counter) drug benefit. In addition, depending on the plan you choose, benefits can include $4 for preferred generic drugs and low copays for brand name prescription drugs. Following is a brief summary of the benefits listed in Section II. PREVENTIVE CARE Access Medicare plans offer $0 copays for numerous preventive services including: Annual Wellness PCP visits Diabetes Screening and Medical Nutrition Services Bone mass measurement Colorectal screening Flu Vaccines Pneumonia Vaccines Screening Mammograms Pap Smears and Pelvic Exams Prostate Cancer Screenings HEARING Up to $500 for one hearing aid every 3 years VISION: 1 routine visit every year 1 pair of eyeglasses and 1 pair of contacts each every year; or $150 retail allowance toward the purchase of one set of prescription eyeglasses per year 20% discount for eyewear exceeding the $150 retail allowance. Certain provider restrictions apply. PAGE 20

21 SECTION III Understanding the Benefits for Access Medicare DENTAL SERVICES Keep smiling with our enhanced dental benefits. Preventive benefits include: $0 copay for 1 oral exam every 6 months $0 copay for 1 cleaning every 6 months $0 copay for x-rays every year You are also entitled to up to $500 of comprehensive dental benefits each year. Additional benefits include diagnostic and preventive services, restorative services, oral surgery, root canal surgery, periodontics (prosthetics/crowns), and denture adjustments and repairs. Certain individual services may require prior authorization from Scion, the Access Medicare Plan contracted dental provider. Please see your Evidence of Coverage for further information. Restorative (silver or tooth colored fillings) 1 filling per tooth every 24 months Endodontics (root canals) 1 root canal per tooth per lifetime Periodontics (gum treatments) 1 scaling and root planning per quadrant every 24 months 1 full mouth debridement every 36 months 1 periodontal maintenance every 6 months Prosthodontics (full dentures) 1 full denture (upper or lower) every 60 months 1 full denture adjustment (upper or lower) every 12 months 2 full denture repairs every 12 months 1 full denture reline or rebase (upper or lower) every 24 months Prosthodontics (partial dentures) 1 partial denture (upper or lower) every 60 months 1 partial denture adjustment every 12 months 2 partial denture repairs every 12 months 1 partial denture reline or rebase (upper or lower) every 24 months Oral and Maxillofacial Surgery (simple, surgical, impaction or residual tooth extractions) 1 extraction per tooth per lifetime Crowns 1 Resin-Based Composite Crown, Anterior every 24 months PAGE 21

22 SECTION III Understanding the Benefits for Access Medicare OVER-THE-COUNTER (OTC) NON-PRESCRIPTION DRUG BENEFIT: Access Medicare offers an over-the counter benefit so you can purchase non-prescription and health-related items such as tooth paste, band-aids, aspirin, etc, at retail pharmacies including Rite Aid, Duane Reade, CVS, Dollar Stores, Walgreens and at many local participating pharmacies within our service area (select plans only). Plan Platinum Gold Benefit Amount up to $480 a year, $40 per month Not covered Any unused balances at the end of the month may not be carried over to the next month. For a comprehensive listing of Access Medicare approved non-prescription, over-the-counter drugs and healthrelated items, please see contact Member Services or visit our plan website to see our list of covered Over-the- Counter items TRANSPORTATION BENEFIT: Need a ride to your doctor? Access Medicare provides you with free car service to and from plan-approved locations (select plans only). Plan Platinum Gold Benefit 16 one-way trips per year Not covered Please call Elegante Services at (TTY ) at least 1 business day in advance to schedule your pick up but no more than 2 weeks before your appointment date. If you have any problems setting up your pick up with Elegante Services, please call Access Medicare Member Services at (TTY ) to schedule your appointment PAGE 22

23 SECTION III Understanding the Benefits for Access Medicare Understanding your Access Medicare Prescription Drug Plan Benefits Plan: Platinum Gold Premium $36.90* $12 Deductible $320 $0 First Level of Coverage Coverage Gap Amount Catastrophic Coverage After the deductible, you will pay a coinsurance of 25% until you reach $2,960 of the total drug cost From $2,960 total drug cost until you reach $4,700 out-of-pocket drug, you will receive a discount on brand name drugs and pay 65% for generic drugs. After your yearly out-of-pocket costs reach $4,700 you will pay greater of: -5% coinsurance, or -$2.65 copay for generic and $6.60 copay for all other drugs From $0 to $2,500 total drug costs you will pay the following copays: Tier 1: Preferred Generics - $4 copay for 30-day - $12 copay for 90-day Tier 2: Non-Preferred Generics - $8 copay for 30-day - $24 copay for 90-day Tier 3: Preferred Brand - $35 copay for 30-day - $105 copay for 90-day Tier 4:Non-Preferred Brand - $75 copay for 30-day - $225 copay for 90-day Tier 5: Specialty Tier - 33% coinsurance for 30-day and 90-day From $2,500 total drug costs until you reach $4,550 out-of-pocket drug costs, you will receive a discount on brand name drugs and pay 65% for all generics After your yearly out-of-pocket costs reach $4,700 you will pay greater of: -5% coinsurance, or -$2.65 copay for generic and $6.60 copay for all other drugs * If you are eligible for Medicaid or other forms of help (LIS), you may pay ZERO or only a portion of the amounts listed. PAGE 23

24 SECTION III Understanding the Benefits for Access Medicare There may be different out-of-pocket costs for people who have limited income, live in long term care facilities, and who have access to Indian/Tribe/Urban (Indian Health Services) providers. For complete formation on Access Medicare Part D plans, you should see Section II of this Summary of Benefits. For a listing of the covered drugs, please see the Access Medicare Formulary. PAGE 24

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