Gateway Health Medicare Assured RubySM (HMO SNP) $6,700 out-of-pocket limit for Medicare-covered services. No No No No. Days 1-6: $0 or $225 copay per

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1 Assured RubySM (HMO Premium $0 monthly plan $0 - $33.90 monthly plan Assured GoldSM (HMO $ $46.30 monthly plan $ $77.80 monthly plan In Network Maximum Out-of-Pocket $3,400 out-of-pocket limit for Referral Required for Network Providers No No No No Inpatient Hospital Care Days 1-90: $0 copay per day Days 1-6: $0 or $225 copay per day Days 1-6: $225 copay per day Days 1-5: $200 copay per day Days 91 and beyond: 10% of the cost per day Days 7-90: $0 copay per day Days 7-90: $0 copay per day Days 6-90: $0 copay per day Inpatient Mental Health Care Days 1-150: $0 copay per day Days 1-6: $0 or $225 copay per day Days 1-6: $225 copay per day Days 1-5: $200 copay per day Days 7-90: $0 copay per day Days 7-90: $0 copay per day Days 6-90: $0 copay per day Skilled Nursing Facility Days 1-100: $0 copay per day Days 1-20: $0 copay per day Days 1-20: $0 copay per day Days 1-20: $0 copay per day Days : $0 or $ copay per day Days : $ copay per day Network Home Health Care $0 copay $0 copay $0 copay $0 copay Days : $ copay per day Network Doctor Office Visits $0 copay for primary care doctor visit $0 or $15 copay for primary care $20 copay for primary care $15 copay for primary care $0 copay for specialist visit $0 or $30 copay for specialist $40 copay for specialist visit $30 copay for specialist visit Network Chiropractic Visits $0 copay visit $0 or $20 copay $20 copay $20 copay Network Podiatry Visits $0 copay for podiatry visits $0 or $30 copay for podiatry visits $40 copay for podiatry visits $30 copay for podiatry visits Routine foot care 20% coinsurance $30 copay for routine foot care

2 Network Outpatient Individual or Group Mental Health Care Assured RubySM (HMO Assured GoldSM (HMO $0 copay per visit $0 or $30 copay per visit $40 copay per visit $30 copay per visit Network Outpatient Individual or Group Substance Abuse Care Network Outpatient Surgery Network Ambulance Services $0 copay per visit $0 or $30 copay per visit $40 copay per visit $30 copay per visit $0 copay for ambulatory surgical center or outpatient $0 or $175 copay for ambulatory $0 copay for ambulance $0 or $200 copay for ambulance $225 copay for ambulatory $200 copay for ambulance $200 copay for ambulatory $175 copay for ambulance Emergency Room (ER) Care $0 copay for Medicare- covered $0 or $65 copay for Medicarecovered $65 copay for Medicarecovered $65 copay for Medicarecovered Urgently Needed Care $0 copay per visit $0 or $30 copay per visit $40 copay per visit $30 copay per visit Outpatient Rehabilitation Services $0 copay for occupational, physical or speech therapy visits $0 or $30 copay for occupational, physical or speech therapy visits $40 copay for occupational, $30 copay for occupational, physical or speech therapy visits physical or speech therapy visits Network Durable Medical Equipment $0 copay $0 copay or 20% of the cost 20% of the cost 20% of the cost Network Prosthetic Devices $0 copay $0 copay or 20% of the cost 20% of the cost 20% of the cost Network Diabetes Programs and Supplies $0 copay for diabetes self- $0 copay for diabetes selfmanagement training, monitoring management training and 0% or supplies, therapeutic shoes or 20% of the cost for monitoring inserts supplies, therapeutic shoes or inserts $0 copay for diabetes selfmanagement training, monitoring supplies, therapeutic shoes or inserts $0 copay for diabetes selfmanagement training, monitoring supplies, therapeutic shoes or inserts Network Diagnostic Tests, X- Rays, Lab Services and Radiology Services Authorization rules may apply Authorization rules may apply Authorization rules may apply Authorization rules may apply $0 copay for lab services $0 copay for lab services $0 copay for lab services $0 copay for lab services

3 Network Diagnostic Tests, X- Benefit Rays, Lab Services and Radiology Services Network Cardiac and Pulmonary Rehabilitation Services Preventive Services, Wellness/Education and Supplemental Benefits Assured RubySM (HMO Assured GoldSM (HMO $0 copay for X-rays $0 or $30 copay for X-rays $40 copay for X-rays $30 copay for X-rays radiology services (not including $0 copay for therapeutic $0 or $140 copay for diagnostic (not including $0 or $60 copay for therapeutic $0 or $30 copay for Medicarecovered cardiac rehabilitation services $140 copay for diagnostic (not including $60 copay for therapeutic $150 copay for diagnostic (not including $60 copay for therapeutic Kidney Disease and Conditions - Network Renal Dialysis $0 copay $0 or 20% of the cost 20% of the cost 20% of the cost Drugs Covered Under Medicare Part B For such as chemotherapy drugs: You pay nothing Other : You pay nothing $0 or 20% of the cost for Part B 20% of the cost for Part B 20% of the cost for Part B Rx Initial Coverage $2,960 $2,960 $2,960 $2,960 Formulary: Retail Pharmacy For generic drugs (including brand drugs treated as generic), either: $0 copay or $1.20 copay or $2.65 copay For all other drugs, either: $0 copay or $3.60 copay or $6.60 copay For generic drugs (including brand drugs treated as generic), either: $0 copay or $1.20 copay or $2.65 copay For all other drugs, either: $0 copay or $3.60 copay or $6.60 copay Tier 1: $4/$8/$12 Tier 2: $10/$20/$30 Tier 3: $45/$90/$135 Tier 4: $95/$190/$285 Tier 5: 33% coinsurance/30 day only Tier 6: $10/$20/$30 Tier 1: $0/$0/$0 Tier 2: $10/$20/$30 Tier 3: $45/$90/$135 Tier 4: $95/$190/$285 Tier 5: 33% coinsurance/30 day only Tier 6: $10/$20/$30 Mail Order Rx n/a n/a Two times retail copay (90 day) Two times retail copay (90 day)

4 Assured RubySM (HMO Catastrophic Coverage $0 copay After yearly out-of-pocket drug pay $0 copay Assured GoldSM (HMO After yearly out-of-pocket drug pay the greater of: - 5% coinsurance or - $2.65 copay for generic (including brand drugs treated as generic) and a $6.60 copay for all other drugs After yearly out-of-pocket drug pay the greater of: - 5% coinsurance or - $2.65 copay for generic (including brand drugs treated as generic) and a $6.60 copay for all other drugs Dental Services Dentures Network Hearing Services $500 comprehensive dental every two years One set of dentures every five years hearing Comprehensive dental not covered Comprehensive dental not covered $500 comprehensive dental every two years Not covered Not covered One set of dentures every five years hearing hearing hearing $0 copay for supplemental $0 copay for supplemental Supplemental routine hearing exam not covered $40 copay for supplemental Hearing aids not covered Network Vision Services $0 copay for Medicarecovered diagnosis and treatment for diseases and conditions of $0 or $30 copay for Medicarecovered diagnosis and treatment for diseases and conditions of $40 copay for Medicarecovered diagnosis and treatment for diseases and conditions of $30 copay for Medicarecovered diagnosis and treatment for diseases and conditions of

5 $150 plan coverage limit a year for contact lenses or eyeglasses Assured RubySM (HMO $150 plan coverage limit a year for contact lenses or eyeglasses Assured GoldSM (HMO $150 plan coverage limit a year $150 plan coverage limit a year for contact lenses or eyeglasses for contact lenses or eyeglasses Over-the-Counter Items $10 per quarter $10 per quarter $25 per month $25 per month Network Transportation $0 copay for up to 24 one-way trips to plan-approved locations $0 copay for up to 24 one-way trips to plan-approved locations n/a n/a Take Charge of Your Health Rewards Program $0 copay $0 copay $0 copay $0 copay Bathroom Safety Products products/$200 per year products/$100 per year Not covered products/$100 per year Health Club Membership/ Fitness Classes Assured Diamond SM and Medicare Assured Ruby SM are HMO plans wilth a Medicare contract and a contract with Pennsylvania Medicaid. Medicare Assured Gold SM and Medicare Assured Platinum SM are HMO plans with a Medicare contract. Enrollment in these plans depends on contract renewal. Gateway Health SM Special Needs Plans are available to anyone with Medicare and Medicaid, Medicare and receive assistance from the State, or Medicare and diabetes or chronic heart failure or a cardiovascular disorder. The benefit information provided is a brief summary, not a complete description of. For more information, contact the plan. Limitations, copayments, and restrictions may apply. Benefits, formulary, pharmacy network, provider network, and/or copayments/coinsurance may change on January 1 of each year. Premiums and copays may vary based on the level of Extra Help you receive. Please contact the plan for further details. You must continue to pay your Medicare Part B. The State pays the Part B for full dual members. Y0097_467_PA Accepted

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