2016 Summary of Benefits

Transcription

1 HMO and 2016 Summary of Benefits Western Pennsylvania H3957_15_0265 Accepted

2 SUMMARY OF BENEFITS January 1, December 31, 2016 This booklet gives you a summary of what we cover and what you pay. It doesn't list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, call us and ask for the "Evidence of Coverage." YOU HAVE CHOICES ABOUT HOW TO GET YOUR MEDICARE BENEFITS 1 One choice is to get your Medicare benefits through Original Medicare (fee-for-service Medicare). Original Medicare is run directly by the Federal government. 1 Another choice is to get your Medicare benefits by joining a Medicare health plan (such as Community Blue Medicare HMO Signature (HMO), HMO Prestige (HMO), Basic (HMO), ValueRx (HMO), Standard (HMO), and Security Blue HMO Deluxe (HMO)). TIPS FOR COMPARING YOUR MEDICARE CHOICES This Summary of Benefits booklet gives you a summary of what HMO Signature (HMO), HMO Prestige (HMO), Basic (HMO), Security Blue HMO ValueRx (HMO), Standard (HMO), and Deluxe (HMO) covers and what you pay. 1 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 1 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 1 Things to Know About HMO Signature (HMO), HMO Prestige (HMO), Basic (HMO), ValueRx (HMO), Security Blue HMO Standard (HMO), and Deluxe (HMO) 1 Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services 1 Covered Medical and Hospital Benefits 1 Prescription Drug Benefits This document is available in other formats such as Braille and large print. This document may be available in a non-english language. For additional information, call Community Blue Medicare HMO Signature (HMO) or HMO Prestige (HMO) at (TTY/TDD 711) or Basic (HMO), ValueRx (HMO), Security Blue HMO Standard (HMO), or Deluxe (HMO) at (TTY/TDD 711). 2

3 THINGS TO KNOW ABOUT COMMUNITY BLUE MEDICARE HMO SIGNATURE (HMO), COMMUNITY BLUE MEDICARE HMO PRESTIGE (HMO), SECURITY BLUE HMO BASIC (HMO), SECURITY BLUE HMO VALUERX (HMO), SECURITY BLUE HMO STANDARD (HMO), AND SECURITY BLUE HMO DELUXE (HMO) HOURS OF OPERATION You can call us 7 days a week from 8:00 a.m. to 8:00 p.m. Eastern time. COMMUNITY BLUE MEDICARE HMO SIGNATURE (HMO), COMMUNITY BLUE MEDICARE HMO PRESTIGE (HMO), SECURITY BLUE HMO BASIC (HMO), SECURITY BLUE HMO VALUERX (HMO), SECURITY BLUE HMO STANDARD (HMO), AND SECURITY BLUE HMO DELUXE (HMO) PHONE NUMBERS AND WEBSITE 1 If you are a member of HMO Signature (HMO) or HMO Prestige (HMO), call toll-free (TTY/TDD 711). 1 If you are a member of Basic (HMO), ValueRx (HMO), Security Blue HMO Standard (HMO), or Deluxe (HMO), call toll-free (TTY/ TDD 711). 1 If you are not a member of HMO Signature (HMO) or HMO Prestige (HMO), call toll-free (TTY/TDD ( ). 1 If you are not a member of Basic (HMO), ValueRx (HMO), Security Blue HMO Standard (HMO), or Deluxe (HMO), call toll-free (TTY/ TDD ). 1 Our website: WHO CAN JOIN? To join Basic (HMO), ValueRx (HMO), Standard (HMO) and Deluxe (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 Pennsylvania: Allegheny, Armstrong, Beaver, Butler, Cambria, Fayette, Greene, Indiana, Lawrence, Washington, and Westmoreland in Southwestern PA and Bedford, Blair, Cameron, Clarion, Clearfield, Crawford, Elk, Erie, Forest, Huntingdon, Jefferson, McKean, Mercer, Potter, Somerset, Venango, and Warren in West Central PA. To join HMO Signature (HMO) or HMO Prestige (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 Pennsylvania: Allegheny, Armstrong, Beaver, Bedford, Butler, Cambria, Cameron, Clarion, Clearfield, Crawford, Elk, Erie, Fayette, Forest, Greene, Huntingdon, Indiana, Jefferson, Lawrence, McKean, Mercer, Somerset, Venango, Warren, Washington and Westermoreland. WHICH DOCTORS, HOSPITALS, AND PHARMACIES CAN I USE? HMO Signature (HMO), HMO Prestige (HMO), Basic (HMO), ValueRx (HMO), Standard (HMO), and Deluxe (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 ( 3

4 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. 1 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. 1 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 for HMO Signature (HMO), HMO Prestige (HMO), ValueRx (HMO), Standard (HMO), and Deluxe (HMO). In addition, we cover Part B drugs such as chemotherapy and some drugs administered by your provider. 1 You can see the complete plan formulary (list of Part D prescription drugs) and any restrictions on our website, client.formularynavigator.com/clients/hm/default.html. 1 Or, call us and we will send you a copy of the formulary. Basic (HMO) covers Part B drugs including chemotherapy and some drugs administered by your provider. However, this plan does not cover Part D prescription drugs. HOW WILL I DETERMINE MY DRUG COSTS? HMO Signature (HMO), HMO Prestige (HMO), ValueRx (HMO), Standard (HMO), and Deluxe (HMO) 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. Highmark Choice Company is a HMO plan with a Medicare contract. Enrollment in Highmark Choice Company depends on contract renewal. 4

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6 SUMMARY OF BENEFITS January 1, December 31, 2016 BENEFIT CATEGORY HMO Signature (HMO) HMO Prestige (HMO) MONTHLY PREMIUM, DEDUCTIBLE, AND LIMITS ON HOW MUCH YOU PAY FOR COVERED SERVICES How much is the monthly premium? $0 per month. In addition, you must keep paying your Medicare Part B premium. Highmark Choice Company will reduce your Medicare Part B premium by up to $3. $ per month. In addition, you must keep paying your Medicare Part B premium. How much is the deductible? This plan does not have a deductible. This plan does not have a deductible. Is there any limit on how much I will pay for my covered services? 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: 1 $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. 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: 1 $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. 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 services that apply. Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply. 6

7 Basic (HMO) ValueRx (HMO) Standard (HMO) Deluxe (HMO) $ per month. In addition, you must keep paying your Medicare Part B premium. $ per month. In addition, you must keep paying your Medicare Part B premium. $ per month. In addition, you must keep paying your Medicare Part B premium. $ per month. In addition, you must keep paying your Medicare Part B premium. Please refer to the Premium Table to find out the premium in your area. Please refer to the Premium Table to find out the premium in your area. Please refer to the Premium Table to find out the premium in your area. Please refer to the Premium Table to find out the premium in your area. This plan does not have a deductible. This plan does not have a deductible. This plan does not have a deductible. This plan does not have a deductible. Yes. Like all Medicare health plans, our plan protects you by having Yes. Like all Medicare health plans, our plan protects you by having Yes. Like all Medicare health plans, our plan protects you by having Yes. Like all Medicare health plans, our plan protects you by having yearly limits on your yearly limits on your yearly limits on your yearly limits on your out-of-pocket costs for medical and hospital care. Your yearly limit(s) in this plan: out-of-pocket costs for medical and hospital care. Your yearly limit(s) in this plan: out-of-pocket costs for medical and hospital care. Your yearly limit(s) in this plan: out-of-pocket costs for medical and hospital care. Your yearly limit(s) in this plan: 1 $6,700 for services you 1 $6,700 for services you 1 $6,700 for services you 1 $6,700 for services you receive from in-network providers. receive from in-network providers. receive from in-network providers. receive from in-network providers. If you reach the limit on out-of-pocket costs, you keep getting covered If you reach the limit on out-of-pocket costs, you keep getting covered If you reach the limit on out-of-pocket costs, you keep getting covered 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. 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. 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. 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. Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply. Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply. Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply. 7

8 BENEFIT CATEGORY HMO Signature (HMO) COVERED MEDICAL AND HOSPITAL BENEFITS Note: 1 Services with a 1 may require prior authorization. OUTPATIENT CARE AND SERVICES Acupuncture For up to 5 visit(s) every year: $30 HMO Prestige (HMO) For up to 5 visit(s) every year: $30 Ambulance Chiropractic Care 1 $300 Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): $20 Routine chiropractic visit (for up to 6 every year): $20 $100 Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): $20 Routine chiropractic visit (for up to 8 every year): $20 Dental Services 1 Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): $45-350, depending on the service Preventive dental services: 1 Dental x-ray(s) (for up to 1): $25 Dental services: $30 for a single office visit that includes: 1 Cleaning (for up to 1 every year) 1 Oral exam (for up to 1 every year) Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): $10-50, depending on the service Preventive dental services: 1 Dental x-ray(s) (for up to 1): $20 Dental services: $20 for a single office visit that includes: 1 Cleaning (for up to 1 every six months) 1 Oral exam (for up to 1 every six months) Diabetes Supplies and Services 1 Diabetes monitoring supplies: 0-20% of the cost, depending on the supply Diabetes self-management training: Therapeutic shoes or inserts: 20% of the cost Diabetes monitoring supplies: 0-20% of the cost, depending on the supply Diabetes self-management training: Therapeutic shoes or inserts: 20% of the cost 8

9 Basic (HMO) ValueRx (HMO) Standard (HMO) Deluxe (HMO) Not covered Not covered Not covered Not covered $125 $200 $125 $100 Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): $20 Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): $20 Routine chiropractic visit (for up to 6 every year): $20 Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): $20 Routine chiropractic visit (for up to 8 every year): $20 Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): $20 Routine chiropractic visit (for up to 8 every year): $20 Routine chiropractic visit (for up to 6 every year): $20 Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): $30-200, depending on the service Preventive dental services: 1 Dental x-ray(s) (for up to 1): $25 Dental services: $30 for a single office visit that includes: 1 Cleaning (for up to 1 every year) 1 Oral exam (for up to 1 every year) Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): $35-250, depending on the service Preventive dental services: 1 Dental x-ray(s) (for up to 1): $25 Dental services: $30 for a single office visit that includes: 1 Cleaning (for up to 1 every year) 1 Oral exam (for up to 1 every year) Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): $30-225, depending on the service Preventive dental services: 1 Dental x-ray(s) (for up to 1): $25 Dental services: $30 for a single office visit that includes: 1 Cleaning (for up to 1 every year) 1 Oral exam (for up to 1 every year) Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): $25-150, depending on the service Preventive dental services: 1 Dental x-ray(s) (for up to 1): $20 Dental services: $20 for a single office visit that includes: 1 Cleaning (for up to 1 every year) 1 Oral exam (for up to 1 every year) Diabetes monitoring supplies: 0-20% of the cost, depending on the supply Diabetes self-management training: Therapeutic shoes or inserts: 20% of the cost Diabetes monitoring supplies: 0-20% of the cost, depending on the supply Diabetes self-management training: Therapeutic shoes or inserts: 20% of the cost Diabetes monitoring supplies: 0-20% of the cost, depending on the supply Diabetes self-management training: Therapeutic shoes or inserts: 20% of the cost Diabetes monitoring supplies: 0-20% of the cost, depending on the supply Diabetes self-management training: Therapeutic shoes or inserts: 20% of the cost 9

10 BENEFIT CATEGORY Diagnostic Tests, Lab and Radiology Services, and X-Rays (Costs for these services may vary based on place of service) 1 HMO Signature (HMO) Diagnostic radiology services (such as MRIs, CT scans): $200 Diagnostic tests and procedures: $5-20, depending on the service Lab services: $5-20, depending on the service Outpatient x-rays: $50 Therapeutic radiology services (such as radiation treatment for cancer): HMO Prestige (HMO) Diagnostic radiology services (such as MRIs, CT scans): $35 Diagnostic tests and procedures: Lab services: Outpatient x-rays: $10 Therapeutic radiology services (such as radiation treatment for cancer): Doctor's Office Visits Durable Medical Equipment (wheelchairs, oxygen, etc.) 1 Emergency Care Primary care physician visit: You pay nothing Specialist visit: $45 20% of the cost $75 If you are admitted to the hospital within 3 days, 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. Emergency Care is covered worldwide. Primary care physician visit: You pay nothing Specialist visit: $10 20% of the cost $75 If you are admitted to the hospital within 3 days, 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. Emergency Care is covered worldwide. Foot Care (podiatry services) Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: $45 Routine foot care (for up to 8 visit(s) every year): $45 Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: $10 Routine foot care (for up to 10 visit(s) every year): $10 10

11 Basic (HMO) ValueRx (HMO) Standard (HMO) Deluxe (HMO) Diagnostic radiology services (such as MRIs, CT scans): $100 Diagnostic radiology services (such as MRIs, CT scans): $125 Diagnostic radiology services (such as MRIs, CT scans): $75 Diagnostic radiology services (such as MRIs, CT scans): $50 Diagnostic tests and procedures: $0-10, depending on the service Diagnostic tests and procedures: $0-10, depending on the service Diagnostic tests and procedures: You pay nothing Diagnostic tests and procedures: You pay nothing Lab services: $0-10, depending on the service Lab services: $0-10, depending on the service Lab services: You pay nothing Lab services: You pay nothing Outpatient x-rays: $45 Outpatient x-rays: $30 Outpatient x-rays: $25 Outpatient x-rays: $20 Therapeutic radiology services (such as radiation treatment for cancer): You pay nothing Therapeutic radiology services (such as radiation treatment for cancer): You pay nothing Therapeutic radiology services (such as radiation treatment for cancer): You pay nothing Therapeutic radiology services (such as radiation treatment for cancer): You pay nothing Primary care physician visit: $5 Primary care physician visit: $10 Primary care physician visit: $10 Primary care physician visit: $5 Specialist visit: $30 Specialist visit: $35 Specialist visit: $30 Specialist visit: $25 20% of the cost 20% of the cost 20% of the cost 20% of the cost $75 $75 $75 $75 If you are admitted to the hospital within 3 days, 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 admitted to the hospital within 3 days, 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 admitted to the hospital within 3 days, 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 admitted to the hospital within 3 days, 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. Emergency Care is covered worldwide. Emergency Care is covered worldwide. Emergency Care is covered worldwide. Emergency Care is covered worldwide. Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: $30 Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: $35 Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: $30 Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: $25 Routine foot care (for up to 8 visit(s) every year): $30 Routine foot care (for up to 8 visit(s) every year): $35 Routine foot care (for up to 10 visit(s) every year): $30 Routine foot care (for up to 10 visit(s) every year): $25 11

12 BENEFIT CATEGORY Hearing Services HMO Signature (HMO) Exam to diagnose and treat hearing and balance issues: $45 Routine hearing exam (for up to 1 every year): $45 Hearing aid fitting/evaluation (for up to 1 every year): $45 Hearing aid: $ for each hearing aid, depending on the type Copayment for hearing aids applies only to TruHearing Chime products. TruHearing is the exclusive provider of the Chime 500 and Chime 900 hearing aids. Up to two Chime hearing aids once every calendar year. HMO Prestige (HMO) Exam to diagnose and treat hearing and balance issues: $10 Routine hearing exam (for up to 1 every year): $10 Hearing aid fitting/evaluation (for up to 1 every year): $10 Hearing aid: $ for each hearing aid, depending on the type Copayment for hearing aids applies only to TruHearing Chime products. TruHearing is the exclusive provider of the Chime 500 and Chime 900 hearing aids. Up to two Chime hearing aids once every calendar year. Home Health Care 1 Mental Health Care 1 Inpatient visit: Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The 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 inpatient hospital care limit does not apply to inpatient mental services apply to inpatient mental services provided in a general hospital. provided in a general hospital. Our plan covers 90 days for an Our plan covers 90 days for an inpatient hospital stay. inpatient hospital stay. Our plan also covers 60 "lifetime Our plan also covers 60 "lifetime reserve days." These are "extra" days reserve days." These are "extra" days that we cover. If your hospital stay that we cover. If your hospital stay is longer than 90 days, you can use is longer than 90 days, you can use these extra days. But once you have these extra days. But once you have used up these extra 60 days, your used up these extra 60 days, your inpatient hospital coverage will be inpatient hospital coverage will be limited to 90 days. limited to 90 days. 1 $275 per day for days 1 1 $100 per stay through 5 Outpatient group therapy visit: $10 12

13 Basic (HMO) ValueRx (HMO) Standard (HMO) Deluxe (HMO) Exam to diagnose and treat hearing and balance issues: $30 Routine hearing exam (for up to 1 every year): $30 Hearing aid fitting/ evaluation (for up to 1 every year): $30 Hearing aid: $ for each hearing aid, depending on the type Copayment for hearing aids applies only to TruHearing Chime products. TruHearing is the exclusive provider of the Chime 500 and Chime 900 hearing aids. Up to two Chime hearing aids once every calendar year. Exam to diagnose and treat hearing and balance issues: $35 Routine hearing exam (for up to 1 every year): $35 Hearing aid fitting/ evaluation (for up to 1 every year): $35 Hearing aid: $ for each hearing aid, depending on the type Copayment for hearing aids applies only to TruHearing Chime products. TruHearing is the exclusive provider of the Chime 500 and Chime 900 hearing aids. Up to two Chime hearing aids once every calendar year. Exam to diagnose and treat hearing and balance issues: $30 Routine hearing exam (for up to 1 every year): $30 Hearing aid fitting/ evaluation (for up to 1 every year): $30 Hearing aid: $ for each hearing aid, depending on the type Copayment for hearing aids applies only to TruHearing Chime products. TruHearing is the exclusive provider of the Chime 500 and Chime 900 hearing aids. Up to two Chime hearing aids once every calendar year. Exam to diagnose and treat hearing and balance issues: $25 Routine hearing exam (for up to 1 every year): $25 Hearing aid fitting/ evaluation (for up to 1 every year): $25 Hearing aid: $ for each hearing aid, depending on the type Copayment for hearing aids applies only to TruHearing Chime products. TruHearing is the exclusive provider of the Chime 500 and Chime 900 hearing aids. Up to two Chime hearing aids once every calendar year. 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 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 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 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." "lifetime reserve days." "lifetime reserve days." "lifetime reserve days." These are "extra" days that These are "extra" days that These are "extra" days that These are "extra" days that we cover. If your hospital we cover. If your hospital we cover. If your hospital we cover. If your hospital stay is longer than 90 days, stay is longer than 90 days, stay is longer than 90 days, stay is longer than 90 days, you can use these extra you can use these extra you can use these extra you can use these extra days. But once you have days. But once you have days. But once you have days. But once you have 13

14 BENEFIT CATEGORY Mental Health Care 1 (continued) HMO Signature (HMO) 1 per day for days 6 through 90 Outpatient group therapy visit: $40 Outpatient individual therapy visit: $40 HMO Prestige (HMO) Outpatient individual therapy visit: $10 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): Occupational therapy visit: $40 Physical therapy and speech and language therapy visit: $40 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: $10 Physical therapy and speech and language therapy visit: $10 Outpatient Substance Abuse 1 Group therapy visit: $40 Individual therapy visit: $40 Group therapy visit: $10 Individual therapy visit: $10 Outpatient Surgery 1 Ambulatory surgical center: $350 Outpatient hospital: $350 Ambulatory surgical center: $50 Outpatient hospital: $50 Over-the-Counter Items Prosthetic Devices (braces, artificial limbs, etc.) 1 Not Covered Prosthetic devices: 20% of the cost Related medical supplies: 20% of the cost Not Covered Prosthetic devices: 20% of the cost Related medical supplies: 20% of the cost Renal Dialysis 14

15 Basic (HMO) ValueRx (HMO) Standard (HMO) Deluxe (HMO) used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days. used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days. used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days. used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days. 1 $350 per stay Outpatient group therapy visit: $30 Outpatient individual therapy visit: $30 1 $200 per day for days 1 through 7 1 per day for days 8 through 90 Outpatient group therapy visit: $35 1 $325 per stay Outpatient group therapy visit: $30 Outpatient individual therapy visit: $30 1 $225 per stay Outpatient group therapy visit: $25 Outpatient individual therapy visit: $25 Outpatient individual therapy visit: $35 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 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 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 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: $30 Occupational therapy visit: $35 Occupational therapy visit: $30 Occupational therapy visit: $25 Physical therapy and speech and language therapy visit: $30 Physical therapy and speech and language therapy visit: $35 Physical therapy and speech and language therapy visit: $30 Physical therapy and speech and language therapy visit: $25 Group therapy visit: $30 Group therapy visit: $35 Group therapy visit: $30 Group therapy visit: $25 Individual therapy visit: $30 Individual therapy visit: $35 Individual therapy visit: $30 Individual therapy visit: $25 Ambulatory surgical center: $100 Ambulatory surgical center: $135 Ambulatory surgical center: $125 Ambulatory surgical center: $75 Outpatient hospital: $200 Outpatient hospital: $250 Outpatient hospital: $225 Outpatient hospital: $150 Not Covered Not Covered Not Covered Not Covered Prosthetic devices: 20% of the cost Prosthetic devices: 20% of the cost Prosthetic devices: 20% of the cost Prosthetic devices: 20% of the cost Related medical supplies: 20% of the cost Related medical supplies: 20% of the cost Related medical supplies: 20% of the cost Related medical supplies: 20% of the cost 15

16 BENEFIT CATEGORY HMO Signature (HMO) HMO Prestige (HMO) Transportation $40 $40 Urgently Needed Services Vision Services $50. Not waived if admitted. Urgently Needed Services are covered worldwide. Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): $0-45, depending on the service Routine eye exam (for up to 1 every year): $0 Contact lenses (for up to 1 every year): $0 1 Our plan pays up to $100 every year for contact lenses. Eyeglass frames (for up to 1 every year): $0 1 Our plan pays up to $100 every year for eyeglass frames. Eyeglass lenses (for up to 1 every year): $0 1 Our plan pays up to $100 every year for eyeglass lenses. Eyeglasses or contact lenses after cataract surgery: $0 1 A $200 benefit max applies to upgrades to post-cataract surgery eyewear that are not medically necessary. Available following cataract surgery once per operated eye. $50. Not waived if admitted. Urgently Needed Services are covered worldwide. Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): $0-10, depending on the service Routine eye exam (for up to 1 every year): $0 Contact lenses (for up to 1 every year): $0 1 Our plan pays up to $100 every year for contact lenses. Eyeglass frames (for up to 1 every year): $0 1 Our plan pays up to $100 every year for eyeglass frames. Eyeglass lenses (for up to 1 every year): $0 1 Our plan pays up to $100 every year for eyeglass lenses. Eyeglasses or contact lenses after cataract surgery: $0 1 A $200 benefit max applies to upgrades to post-cataract surgery eyewear that are not medically necessary. Available following cataract surgery once per operated eye. 16

17 Basic (HMO) ValueRx (HMO) Standard (HMO) Deluxe (HMO) $40 $40 $40 $40 $50. $50. $50. $50. Not waived if admitted. Not waived if admitted. Not waived if admitted. Not waived if admitted. Urgently Needed Services are covered worldwide. Urgently Needed Services are covered worldwide. Urgently Needed Services are covered worldwide. Urgently Needed Services are covered worldwide. Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): $0-30, depending on the service Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): $0-35, depending on the service Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): $0-30, depending on the service Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): $0-25, depending on the service Routine eye exam (for up to 1 every year): $0 Routine eye exam (for up to 1 every year): $0 Routine eye exam (for up to 1 every year): $0 Routine eye exam (for up to 1 every year): $0 Contact lenses (for up to 1 every year): $0 Contact lenses (for up to 1 every year): $0 Contact lenses (for up to 1 every year): $0 Contact lenses (for up to 1 every year): $0 1 Our plan pays up to $100 every year for contact lenses. 1 Our plan pays up to $100 every year for contact lenses. 1 Our plan pays up to $100 every year for contact lenses. 1 Our plan pays up to $100 every year for contact lenses. Eyeglass frames (for up to 1 every year): $0 Eyeglass frames (for up to 1 every year): $0 Eyeglass frames (for up to 1 every year): $0 Eyeglass frames (for up to 1 every year): $0 1 Our plan pays up to $100 every year for eyeglass frames. 1 Our plan pays up to $100 every year for eyeglass frames. 1 Our plan pays up to $100 every year for eyeglass frames. 1 Our plan pays up to $100 every year for eyeglass frames. Eyeglass lenses (for up to 1 every year): $0 Eyeglass lenses (for up to 1 every year): $0 Eyeglass lenses (for up to 1 every year): $0 Eyeglass lenses (for up to 1 every year): $0 1 Our plan pays up to $100 every year for eyeglass lenses. 1 Our plan pays up to $100 every year for eyeglass lenses. 1 Our plan pays up to $100 every year for eyeglass lenses. 1 Our plan pays up to $100 every year for eyeglass lenses. Eyeglasses or contact lenses after cataract surgery: $0 Eyeglasses or contact lenses after cataract surgery: $0 Eyeglasses or contact lenses after cataract surgery: $0 Eyeglasses or contact lenses after cataract surgery: $0 17

18 BENEFIT CATEGORY Vision Services (continued) HMO Signature (HMO) HMO Prestige (HMO) Preventive Care Our plan covers many preventive services, including: 1 Abdominal aortic aneurysm screening 1 Alcohol misuse counseling 1 Bone mass measurement 1 Breast cancer screening (mammogram) 1 Cardiovascular disease (behavioral therapy) 1 Cardiovascular screenings 1 Cervical and vaginal cancer screening 1 Colorectal cancer screenings (Colonoscopy, Fecal occult blood test, Flexible sigmoidoscopy) 1 Depression screening 1 Diabetes screenings 1 HIV screening 1 Medical nutrition therapy services 1 Obesity screening and counseling 1 Prostate cancer screenings (PSA) 1 Sexually transmitted infections screening and counseling 1 Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease) 1 Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots 1 "Welcome to Medicare" preventive visit (one-time) Our plan covers many preventive services, including: 1 Abdominal aortic aneurysm screening 1 Alcohol misuse counseling 1 Bone mass measurement 1 Breast cancer screening (mammogram) 1 Cardiovascular disease (behavioral therapy) 1 Cardiovascular screenings 1 Cervical and vaginal cancer screening 1 Colorectal cancer screenings (Colonoscopy, Fecal occult blood test, Flexible sigmoidoscopy) 1 Depression screening 1 Diabetes screenings 1 HIV screening 1 Medical nutrition therapy services 1 Obesity screening and counseling 1 Prostate cancer screenings (PSA) 1 Sexually transmitted infections screening and counseling 1 Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease) 1 Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots 1 "Welcome to Medicare" preventive visit (one-time) 18

19 Basic (HMO) ValueRx (HMO) Standard (HMO) 1 A $200 benefit max 1 A $200 benefit max 1 A $200 benefit max 1 applies to upgrades to post-cataract surgery eyewear that are not medically necessary. Available following cataract surgery once per operated eye. applies to upgrades to post-cataract surgery eyewear that are not medically necessary. Available following cataract surgery once per operated eye. applies to upgrades to post-cataract surgery eyewear that are not medically necessary. Available following cataract surgery once per operated eye. Deluxe (HMO) A $200 benefit max applies to upgrades to post-cataract surgery eyewear that are not medically necessary. Available following cataract surgery once per operated eye. Our plan covers many Our plan covers many Our plan covers many Our plan covers many preventive services, preventive services, preventive services, preventive services, including: including: including: including: 1 Abdominal aortic 1 Abdominal aortic 1 Abdominal aortic 1 Abdominal aortic aneurysm screening aneurysm screening aneurysm screening aneurysm screening 1 Alcohol misuse 1 Alcohol misuse 1 Alcohol misuse 1 Alcohol misuse counseling counseling counseling counseling 1 Bone mass 1 Bone mass 1 Bone mass 1 Bone mass measurement measurement measurement measurement 1 Breast cancer 1 Breast cancer 1 Breast cancer 1 Breast cancer screening screening screening screening (mammogram) (mammogram) (mammogram) (mammogram) 1 Cardiovascular disease 1 Cardiovascular disease 1 Cardiovascular disease 1 Cardiovascular disease (behavioral therapy) (behavioral therapy) (behavioral therapy) (behavioral therapy) 1 Cardiovascular 1 Cardiovascular 1 Cardiovascular 1 Cardiovascular screenings screenings screenings screenings 1 Cervical and vaginal 1 Cervical and vaginal 1 Cervical and vaginal 1 Cervical and vaginal cancer screening cancer screening cancer screening cancer screening 1 Colorectal cancer 1 Colorectal cancer 1 Colorectal cancer 1 Colorectal cancer screenings screenings screenings screenings (Colonoscopy, Fecal (Colonoscopy, Fecal (Colonoscopy, Fecal (Colonoscopy, Fecal occult blood test, occult blood test, occult blood test, occult blood test, Flexible Flexible Flexible Flexible sigmoidoscopy) sigmoidoscopy) sigmoidoscopy) sigmoidoscopy) 1 Depression screening 1 Depression screening 1 Depression screening 1 Depression screening 1 Diabetes screenings 1 Diabetes screenings 1 Diabetes screenings 1 Diabetes screenings 1 HIV screening 1 HIV screening 1 HIV screening 1 HIV screening 1 Medical nutrition 1 Medical nutrition 1 Medical nutrition 1 Medical nutrition therapy services therapy services therapy services therapy services 1 Obesity screening and 1 Obesity screening and 1 Obesity screening and 1 Obesity screening and counseling counseling counseling counseling 1 Prostate cancer 1 Prostate cancer 1 Prostate cancer 1 Prostate cancer screenings (PSA) screenings (PSA) screenings (PSA) screenings (PSA) 1 Sexually transmitted 1 Sexually transmitted 1 Sexually transmitted 1 Sexually transmitted infections screening infections screening infections screening infections screening and counseling and counseling and counseling and counseling 19

20 BENEFIT CATEGORY Preventive Care (continued) HMO Signature (HMO) 1 Yearly "Wellness" visit Any additional preventive services approved by Medicare during the contract year will be covered. HMO Prestige (HMO) 1 Yearly "Wellness" visit Any additional preventive services approved by Medicare during the contract year will be covered. Hospice for hospice care from a Medicare-certified hospice. You may have to pay part of the costs for drugs and respite care. Hospice is covered outside of our plan. Please contact us for more details. for hospice care from a Medicare-certified hospice. You may have to pay part of the costs for drugs and respite care. Hospice is covered outside of our plan. Please contact us for more details. INPATIENT CARE Inpatient Hospital Care 1 Our plan covers an unlimited number of days for an inpatient hospital stay. $275 per day for days 1 Our plan covers an unlimited number of days for an inpatient hospital stay. 1 1 $100 per stay through 5 1 per day for days 6 through 90 1 per day for days 91 and beyond 1 per day for days 91 and beyond Inpatient Mental Health Care For inpatient mental health care, see the "Mental Health Care" section of this booklet. For inpatient mental health care, see the "Mental Health Care" section of this booklet. 20

21 Basic (HMO) ValueRx (HMO) 1 Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease) 1 Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots 1 "Welcome to Medicare" preventive visit (one-time) 1 Yearly "Wellness" visit Any additional preventive services approved by Medicare during the contract year will be covered. Standard (HMO) 1 Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease) 1 Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots 1 "Welcome to Medicare" preventive visit (one-time) 1 Yearly "Wellness" visit Any additional preventive services approved by Medicare during the contract year will be covered. Deluxe (HMO) 1 Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease) 1 Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots 1 "Welcome to Medicare" preventive visit (one-time) 1 Yearly "Wellness" visit Any additional preventive services approved by Medicare during the contract year will be covered. 1 Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease) 1 Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots 1 "Welcome to Medicare" preventive visit (one-time) 1 Yearly "Wellness" visit Any additional preventive services approved by Medicare during the contract year will be covered. for hospice care from a Medicare-certified hospice. You may have to pay part of the costs for drugs and respite care. Hospice is covered outside of our plan. Please contact us for more details. for hospice care from a Medicare-certified hospice. You may have to pay part of the costs for drugs and respite care. Hospice is covered outside of our plan. Please contact us for more details. for hospice care from a Medicare-certified hospice. You may have to pay part of the costs for drugs and respite care. Hospice is covered outside of our plan. Please contact us for more details. for hospice care from a Medicare-certified hospice. You may have to pay part of the costs for drugs and respite care. Hospice is covered outside of our plan. Please contact us for more details. Our plan covers an unlimited number of days for an inpatient hospital stay. 1 $350 per stay 1 per day for days 91 and beyond Our plan covers an unlimited number of days for an inpatient hospital stay. 1 $200 per day for days 1 through 7 1 per day for days 8 through 90 1 per day for days 91 and beyond Our plan covers an unlimited number of days for an inpatient hospital stay. 1 $325 per stay 1 per day for days 91 and beyond Our plan covers an unlimited number of days for an inpatient hospital stay. 1 $225 per stay 1 per day for days 91 and beyond 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. For inpatient mental health care, see the "Mental Health Care" section of this booklet. 21

22 BENEFIT CATEGORY Skilled Nursing Facility (SNF) 1 HMO Signature (HMO) Our plan covers up to 100 days in a SNF. 1 per day for days 1 through 20 1 $160 per day for days 21 through 100 HMO Prestige (HMO) Our plan covers up to 100 days in a SNF. 1 per day for days 1 through 20 1 $160 per day for days 21 through 100 PRESCRIPTION DRUG BENEFITS How much do I pay? For Part B drugs such as chemotherapy drugs 1 : 0-20% of the cost depending on the drug Other Part B drugs 1 : 0-20% of the cost depending on the drug For Part B drugs such as chemotherapy drugs 1 : 0-20% of the cost depending on the drug Other Part B drugs 1 : 0-20% of the cost depending on the drug Initial Coverage You pay the following until your total yearly drug costs reach $3,310. 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 Threemonth One-month Tier supply supply Tier 1 (Preferred $0 $0 Generic) Tier 2 $20 $60 (Generic) Tier 3 (Preferred $47 $141 Tier 4 (Non- 45% of the 45% of the Preferred cost cost You pay the following until your total yearly drug costs reach $3,310. 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 Threemonth One-month Tier supply supply Tier 1 (Preferred $3 $9 Generic) Tier 2 (Generic) Tier 3 (Preferred Tier 4 (Non- Preferred $15 $42 $45 $126 45% of the 45% of the cost cost 22

23 Basic (HMO) ValueRx (HMO) Standard (HMO) Deluxe (HMO) 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. Our plan covers up to 100 days in a SNF. 1 per day for days 1 through 20 1 $160 per day for days 21 through per day for days 1 through 20 1 $160 per day for days 21 through per day for days 1 through 20 1 $160 per day for days 21 through per day for days 1 through 20 1 $160 per day for days 21 through 100 For Part B drugs such as chemotherapy drugs 1 : 0-20% of the cost depending on the drug For Part B drugs such as chemotherapy drugs 1 : 0-20% of the cost depending on the drug For Part B drugs such as chemotherapy drugs 1 : 0-20% of the cost depending on the drug For Part B drugs such as chemotherapy drugs 1 : 0-20% of the cost depending on the drug Other Part B drugs 1 : 0-20% of the cost depending on the drug Other Part B drugs 1 : 0-20% of the cost depending on the drug Other Part B drugs 1 : 0-20% of the cost depending on the drug Other Part B drugs 1 : 0-20% of the cost depending on the drug Our plan does not cover Part D prescription drug. You pay the following until your total yearly drug costs reach $3,310. Total yearly drug costs are the total drug costs paid by both you and our Part D plan. You pay the following until your total yearly drug costs reach $3,310. Total yearly drug costs are the total drug costs paid by both you and our Part D plan. You pay the following until your total yearly drug costs reach $3,310. 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. You may get your drugs at network retail pharmacies and mail order pharmacies. You may get your drugs at network retail pharmacies and mail order pharmacies. Standard Retail Cost-Sharing One- Threemonth month Tier supply supply Tier 1 $3 $9 (Preferred Generic) Tier 2 $15 $45 (Generic) Tier 3 $47 $141 (Preferred Tier 4 (Nonthe cost 45% of 45% of Preferredthe cost Standard Retail Cost-Sharing One- Threemonth month Tier supply supply Tier 1 $3 $9 (Preferred Generic) Tier 2 $15 $45 (Generic) Tier 3 $45 $135 (Preferred Tier 4 (Nonthe cost 45% of 45% of Preferredthe cost Standard Retail Cost-Sharing One- Threemonth month Tier supply supply Tier 1 $3 $9 (Preferred Generic) Tier 2 $15 $45 (Generic) Tier 3 $42 $126 (Preferred Tier 4 (Nonthe cost 45% of 45% of Preferredthe cost 23

24 BENEFIT CATEGORY Initial Coverage (continued) HMO Signature (HMO) Three- One-monthmonth Tier supply supply Tier 5 33% of the (Specialty Not Offered cost Tier) Standard Mail Order Cost-Sharing Tier Tier 1 (Preferred Generic) Tier 2 (Generic) Tier 3 (Preferred Tier 4 (Non- Preferred Tier 5 (Specialty Tier) Not Offered$0 Not Offered$50 $ Not Offered 45% of the Not Offered cost 33% of the cost Not Offered 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, but may pay more than you pay at an in-network pharmacy. HMO Prestige (HMO) Tier Tier 5 (Specialty Tier) Three- One-monthmonth supply supply Threemonth One-month supply supply 33% of the cost Not Offered Standard Mail Order Cost-Sharing Threemonth One-month Tier supply supply Tier 1 (Preferred Not Offered$7.50 Generic) Tier 2 $37.50 Not Offered (Generic) Tier 3 (Preferred Not Offered$105 Tier 4 (Non- 45% of the Not Offered Preferred cost Tier 5 33% of the (Specialty Not Offered cost Tier) If you reside in a long-term care facility, you pay the same as at a retail pharmacy. You may get drugs from an out-of-network pharmacy, but may pay more than you pay at an in-network 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 $3,310. After you enter the coverage gap, you pay 45% of the plan's cost for 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 $3,310. After you enter the coverage gap, you pay 45% of the plan's cost for 24

25 Basic (HMO) ValueRx (HMO) Standard (HMO) Deluxe (HMO) Onemonth Tier supply Tier 5 33% of (Specialty the cost Tier) Threemonth supply Not Offered Onemonth Tier supply Tier 5 33% of (Specialty the cost Tier) Threemonth supply Not Offered Onemonth Tier supply Tier 5 33% of (Specialty the cost Tier) Threemonth supply Not Offered Tier 1 Not (Preferred Offered Generic) Tier 2 Not (Generic) Offered Tier 3 Not (Preferred Offered Tier 4 (Non- Not Preferred Offered Tier 5 33% of (Specialty the cost Tier) Standard Mail Order Cost-Sharing Onemontmonth Three- Tier supply supply Tier 1 Not (Preferred Offered Generic) Tier 2 Not (Generic) Offered Tier 3 Not (Preferred Offered Tier 4 (Non- Not Preferred Offered Tier 5 33% of (Specialty the cost Tier) $7.50 $37.50 $ % of the cost Not Offered Standard Mail Order Cost-Sharing Onemontmonth Three- Tier supply supply $7.50 $37.50 $ % of the cost Not Offered Standard Mail Order Cost-Sharing Onemontmonth Three- Tier supply supply Tier 1 Not (Preferred Offered Generic) Tier 2 Not (Generic) Offered Tier 3 Not (Preferred Offered Tier 4 (Non- Not Preferred Offered Tier 5 33% of (Specialty the cost Tier) $7.50 $37.50 $105 45% of the cost Not Offered If you reside in a long-term care facility, you pay the same as at a retail pharmacy. If you reside in a long-term care facility, you pay the same as at a retail pharmacy. If you reside in a long-term care facility, you pay the same as at a retail pharmacy. You may get drugs from an out-of-network pharmacy, but may pay more than you pay at an in-network pharmacy. You may get drugs from an out-of-network pharmacy, but may pay more than you pay at an in-network pharmacy. You may get drugs from an out-of-network pharmacy, but may pay more than you pay at an in-network pharmacy. 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 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 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 our plan has paid and what our plan has paid and what you have paid) reaches you have paid) reaches you have paid) reaches $3,310. $3,310. $3,

26 BENEFIT CATEGORY Coverage Gap (continued) HMO Signature (HMO) covered brand name drugs and 58% of the plan's cost for covered generic drugs until your costs total $4,850, which is the end of the coverage gap. Not everyone will enter the coverage gap. HMO Prestige (HMO) covered brand name drugs and 58% of the plan's cost for covered generic drugs until your costs total $4,850, which is the end of the coverage gap. Not everyone will enter the coverage gap. Under this plan, you may pay even less for the brand and generic drugs on the formulary. Your cost varies by tier. You will need to use your formulary to locate your drug's tier. See the chart that follows to find out how much it will cost you. Standard Retail Cost-Sharing Onemontmonth Three- Drugs Tier Covered supply supply Tier 1 (Preferred All $3 $9 Generic) Tier 2 All (Generic) $15 Standard Mail Order Cost-Sharing Onemonth Drugs Tier Covered supply Tier 1 Not (Preferred All Offered Generic) Tier 2 Not All (Generic) Offered $45 Threemonth supply $7.50 $37.50 Catastrophic Coverage After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4,850, you pay the greater of: After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4,850, you pay the greater of: 26

27 Basic (HMO) ValueRx (HMO) After you enter the coverage gap, you pay 45% of the plan's cost for covered brand name drugs and 58% of the plan's cost for covered generic drugs until your costs total $4,850, which is the end of the coverage gap. Not everyone will enter the coverage gap. Standard (HMO) Deluxe (HMO) Tier 1 (Preferred All Generic) Tier 2 All (Generic) $3 $9 $15 $45 After you enter the After you enter the coverage gap, you pay coverage gap, you pay 45% of the plan's cost for 45% of the plan's cost for covered brand name drugs covered brand name drugs and 58% of the plan's cost and 58% of the plan's cost for covered generic drugs for covered generic drugs until your costs total until your costs total $4,850, which is the end of $4,850, which is the end of the coverage gap. Not the coverage gap. Not everyone will enter the everyone will enter the coverage gap. coverage gap. Under this plan, you may pay even less for the brand and generic drugs on the formulary. Your cost varies by tier. You will need to use your formulary to locate your drug's tier. See the chart that follows to find out how much it will cost you. Standard Retail Cost-Sharing Onemonth Three- Drugsmonth Tier Covered supply supply Standard Mail Order Cost-Sharing Onemonth Three- Drugsmonth Tier Covered supply supply Tier 1 Not $7.50 (Preferred All Offered Generic) Tier 2 Not $37.50 All (Generic) Offered After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through 27

28 BENEFIT CATEGORY Catastrophic Coverage (continued) HMO Signature (HMO) HMO Prestige (HMO) 1 5% of the cost, or 1 5% of the cost, or 1 $2.95 for generic 1 $2.95 for generic (including brand drugs treated as generic) and a $7.40 ment for all other drugs. (including brand drugs treated as generic) and a $7.40 ment for all other drugs. 28

29 Basic (HMO) ValueRx (HMO) Standard (HMO) Deluxe (HMO) mail order) reach $4,850, you pay the greater of: 1 5% of the cost, or 1 $2.95 for generic (including brand drugs treated as generic) and a $7.40 ment for all other drugs. mail order) reach $4,850, you pay the greater of: 1 5% of the cost, or 1 $2.95 for generic (including brand drugs treated as generic) and a $7.40 ment for all other drugs. mail order) reach $4,850, you pay the greater of: 1 5% of the cost, or 1 $2.95 for generic (including brand drugs treated as generic) and a $7.40 ment for all other drugs. 29

30 PREMIUM TABLE As a member of our plan, you pay a monthly plan premium. The table below shows the monthly plan premium amount for each region we serve. The service area for HMO Signature (HMO) and HMO Prestige (HMO) includes the following counties: Allegheny, Armstrong, Beaver, Bedford, Butler, Cambria, Cameron, Clarion, Clearfield, Crawford, Elk, Erie, Fayette, Forest, Greene, Huntingdon, Indiana, Jefferson, Lawrence, McKean, Mercer, Somerset, Venango, Warren, Washington and Westmoreland. Plan Name HMO Signature (HMO) HMO Prestige (HMO) Premium $0 $ The service area for Basic (HMO), ValueRx (HMO), Standard (HMO), and Deluxe (HMO) in Southwestern, PA includes the following counties: Allegheny, Armstrong, Beaver, Butler, Cambria, Fayette, Greene, Indiana, Lawrence, Washington and Westmoreland. The service area for Basic (HMO), ValueRx (HMO), Standard (HMO), and Deluxe (HMO) in West Central, PA includes the following counties: Bedford, Blair, Cameron, Clarion, Clearfield, Crawford, Elk, Erie, Forest, Huntingdon, Jefferson, McKean, Mercer, Potter, Somerset, Venango and Warren. Plan Name Southwestern, PA Premium Basic (HMO) $49.00 ValueRx (HMO) $59.50 Standard (HMO) $ Deluxe (HMO) $ West Central, PA Premium $44.00 $49.50 $ $

31 31

32 Highmark Choice Company and Highmark Blue Cross Blue Shield are independent licensees of the Blue Cross and Blue Shield Association. Blue Cross, Blue Shield and the Cross and Shield symbols are registered service marks of the Blue Cross and Blue Shield Association. Community Blue and Security Blue are service marks of the Blue Cross and Blue Shield Association. Highmark is a registered mark of Highmark Inc (R9/15)