SCAN Health Plan. 2015 Summary of Benefits

SCAN Health Plan 2015 Summary of Benefits Y0057_SCAN_8712_2014F File & Use Accepted 09032014

( a Medicare Advantage Health Maintenance Organization (HMO) offered by SCAN Health Plan with a Medicare contract) SUMMARY OF BENEFITS JANUARY 1, 2015 DECEMBER 31, 2015 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. 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 SCAN Healthy at Home (HMO SNP)). Tips for comparing your Medicare choices This Summary of Benefits booklet gives you a summary of what SCAN Healthy at Home (HMO SNP) 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 http://www.medicare.gov. 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 http://www.medicare.gov or get a copy by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. Sections in this booklet Things to Know About SCAN Healthy at Home (HMO SNP) Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services Covered Medical and Hospital Benefits Prescription Drug Benefits Optional Benefits (you must pay an extra premium for these benefits) This document is available in other formats such as Braille and large print. This document may be available in a non-english language. For additional information, call us at 1-800-559-3500. Summary of Benefits SCAN Healthy at Home (HMO SNP) 1

Este documento se encuentra disponible en otros formatos, tales como Braille y en letra grande. Este documento puede estar disponible en un idioma que no sea el inglés. Llámenos al 1-800-559-3500 para obtener información adicional. THINGS TO KNOW ABOUT SCAN HEALTHY AT HOME (HMO SNP) Hours of Operation You can call us 7 days a week from 8 a.m. to 8 p.m. Pacific time. SCAN Healthy at Home (HMO SNP) Phone Numbers and Website If you are a member of this plan, call toll-free 1-800-559-3500. If you are not a member of this plan, call toll-free 1-800-915-7226. Our website: http://www.scanhealthplan.com Who can join? To join SCAN Healthy at Home (HMO SNP), you must be entitled to Medicare Part A, be enrolled in Medicare Part B, and live in our service area, but require the same level of care as those who live in a nursing home. Our service area includes the following counties in California: Los Angeles*, Orange*, Riverside*, and San Bernardino*. * denotes partial county Los Angeles County, these zip codes only 90001 90002 90003 90004 90005 90006 90007 90008 90010 90011 90012 90013 90014 90015 90016 90017 90018 90019 90020 90021 90022 90023 90024 90025 90026 90027 90028 90029 90031 90032 90033 90034 90035 90036 90037 90038 90039 90040 90041 90042 90043 90044 90045 90046 90047 90048 90049 90056 90057 90058 90059 90061 90062 90063 90064 90065 90066 90067 90068 90069 90071 90073 90077 90089 90094 90095 90201 90210 90211 90212 90220 90221 90222 90223 90224 90230 90231 90232 90233 90240 90241 90242 90245 90247 90248 90249 90250 90254 90255 90260 90261 90262 90265 90266 90270 90272 90274 90275 90277 90278 90280 90291 90292 90293 90301 90302 90303 90304 90305 90306 90307 90308 90309 90310 90401 90402 90403 90404 90405 90501 90502 90503 90504 90505 90506 90507 90508 90509 90510 90601 90602 90603 90604 90605 90606 90607 90608 90637 90638 90639 90640 90650 90660 90670 90701 90703 90706 90710 90712 90713 90714 90715 90716 90717 90723 90731 90732 90733 90744 90745 90746 90747 90755 90801 90802 90803 90804 90805 90806 90807 90808 90809 90810 90813 90814 90815 90822 91001 91006 91007 91008 91010 91011 91016 91020 91024 91030 91040 91042 91046 91101 91103 91104 91105 91106 91107 91108 91109 91201 91202 91203 91204 91205 91206 91207 91208 91214 91303 91304 91306 91307 91311 91316 91324 91325 91326 91330 91331 91334 91335 91340 91342 91343 91344 91345 91352 91356 91364 91367 91371 91394 91401 91402 91403 91405 91406 91411 91423 91436 91501 91502 91503 91504 91505 91506 91523 91601 91602 91604 91605 91606 91607 91702 91706 91711 91722 91723 91724 91731 91732 91733 91740 91741 91744 91745 91746 91747 91748 91749 91750 91754 91755 91765 91766 91767 91768 91770 91773 91775 91776 91780 91789 91790 91791 91792 91793 91801 91803 93534 93535 93536 93543 93550 93551 93552 93591 2 Summary of Benefits SCAN Healthy at Home (HMO SNP)

Orange County, these zip codes only 90620 90621 90622 90623 90630 90631 90632 90633 90680 90720 90740 90742 90743 92602 92603 92604 92606 92610 92612 92614 92617 92618 92620 92624 92626 92627 92628 92629 92630 92637 92646 92647 92648 92649 92651 92652 92653 92654 92655 92656 92672 92673 92675 92676 92677 92678 92679 92683 92688 92691 92692 92694 92697 92701 92702 92703 92704 92705 92706 92707 92708 92709 92711 92728 92780 92781 92782 92799 92801 92802 92803 92804 92805 92806 92807 92808 92809 92821 92822 92823 92831 92832 92833 92834 92835 92836 92837 92838 92840 92841 92842 92843 92844 92845 92846 92856 92857 92859 92861 92862 92864 92865 92866 92867 92868 92869 92870 92871 92885 92886 92887 Riverside County, these zip codes only 91752 92201 92202 92203 92210 92211 92220 92223 92230 92234 92236 92240 92241 92253 92254 92255 92258 92260 92261 92262 92263 92264 92270 92274 92276 92282 92320 92501 92502 92503 92504 92505 92506 92507 92508 92509 92513 92514 92515 92516 92517 92518 92519 92521 92522 92530 92532 92536 92539 92543 92544 92545 92548 92549 92551 92552 92553 92554 92555 92556 92557 92561 92562 92563 92567 92570 92571 92582 92583 92584 92585 92586 92587 92590 92591 92592 92595 92596 92860 92877 92878 92879 92880 92881 92882 92883 San Bernardino County, these zip codes only 91701 91708 91709 91710 91729 91730 91737 91739 91743 91761 91762 91763 91764 91784 91786 92252 92256 92268 92277 92278 92284 92285 92301 92305 92307 92308 92311 92312 92313 92314 92315 92316 92317 92318 92321 92322 92324 92325 92326 92327 92334 92335 92336 92337 92338 92339 92340 92341 92342 92344 92345 92346 92347 92352 92354 92356 92359 92368 92371 92372 92373 92374 92375 92376 92377 92382 92385 92386 92391 92392 92393 92394 92395 92397 92399 92401 92402 92403 92404 92405 92406 92407 92408 92410 92411 92412 92413 92414 92415 92418 92423 92424 92427 Which doctors, hospitals, and pharmacies can I use? SCAN Healthy at Home (HMO SNP) has 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 (http://www.scanhealthplan.com). 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. 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, http://www.scanhealthplan.com. Summary of Benefits SCAN Healthy at Home (HMO SNP) 3

Or, call us and we will send you a copy of the formulary. How will I determine my drug costs? Our plan groups each medication into one of six 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. 4 Summary of Benefits SCAN Healthy at Home (HMO SNP)

SUMMARY OF BENEFITS JANUARY 1, 2015 DECEMBER 31, 2015 MONTHLY PREMIUM, DEDUCTIBLE, AND LIMITS ON HOW MUCH YOU PAY FOR COVERED SERVICES SCAN Healthy at Home (HMO SNP) 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? $0 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. 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. SCAN Healthy at Home (HMO SNP) is an HMO plan with a Medicare contract. Enrollment in SCAN Health Plan depends on contract renewal. COVERED MEDICAL AND HOSPITAL BENEFITS NOTE: Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor. OUTPATIENT CARE AND SERVICES Acupuncture and Other Alternative Therapies Ambulance 1 Chiropractic Care 1,2 Not covered $110 copay Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): $20 copay Summary of Benefits SCAN Healthy at Home (HMO SNP) 5

Dental Services 1,2 Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): $20 copay This plan covers Optional Supplemental dental benefits for an extra cost. See Basic and Enhanced Dental plans on page 14. Diabetes Supplies and Services 1,2 Diabetes monitoring supplies: You pay nothing Diabetes self-management training: You pay nothing Therapeutic shoes or inserts: You pay nothing This benefit covers a select manufacturer for glucose monitors, test strips, lancets, and control solution. Therapeutic shoes and inserts are available for people with diabetes who have severe diabetic foot disease as defined by Medicare. Diagnostic Tests, Lab and Radiology Services, and X-Rays 1,2 Diagnostic radiology services (such as MRIs, CT scans): 20% of the cost 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 Doctor s Office Visits 1,2 Primary care physician visit: $10 copay Specialist visit: $20 copay Durable Medical Equipment (wheelchairs, oxygen, etc.) 1 Emergency Care 20% of the cost $65 copay If you are immediately admitted to the hospital, 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. You are covered for emergency services only in the U.S. and its territories. Foot Care (podiatry services) 1,2 Hearing Services 1,2 Home Health Care 1,2 Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: $20 copay Exam to diagnose and treat hearing and balance issues: $20 copay You pay nothing 6 Summary of Benefits SCAN Healthy at Home (HMO SNP)

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. $150 copay per day for days 1 through 10 You pay nothing per day for days 11 through 90 Outpatient group therapy visit: $35 copay Outpatient individual therapy visit: $35 copay Outpatient Rehabilitation 1,2 Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): $20 copay Occupational therapy visit: $20 copay Physical therapy and speech and language therapy visit: $20 copay Outpatient Substance Abuse 1,2 Group therapy visit: $35 copay Individual therapy visit: $35 copay Outpatient Surgery 1,2 Ambulatory surgical center: $20 100 copay, depending on the service Outpatient hospital: $20 100 copay or 20% of the cost, depending on the service You pay $20 for non-surgical services, $100 for surgical services, and 20% of the total cost for diagnostic and therapeutic radiological services. Over-the-Counter Items Prosthetic Devices (braces, artificial limbs, etc.) 1 Renal Dialysis 1,2 Transportation Not Covered Prosthetic devices: 20% of the cost Related medical supplies: 20% of the cost You pay nothing Not covered Summary of Benefits SCAN Healthy at Home (HMO SNP) 7

Urgent Care $35 copay You are covered for urgently needed care only in the U.S. and its territories. Vision Services 1,2 Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): $0 20 copay, depending on the service Routine eye exam (for up to 1 every year): You pay nothing Contact lenses (for up to 1 every two year): You pay nothing Our plan pays up to $175 every two years for contact lenses. Eyeglasses (frames and lenses)(for up to 1 every two year): You pay nothing Eyeglass frames (for up to 1 every two years): You pay nothing Our plan pays up to $175 every two years for eyeglass frames. Eyeglass lenses (for up to 1 every two years): You pay nothing Eyeglasses or contact lenses after cataract surgery: $10 copay 8 Summary of Benefits SCAN Healthy at Home (HMO SNP)

Preventive Care 1,2 You pay nothing Our plan covers many preventive services, including: Abdominal aortic aneurysm screening Alcohol misuse counseling Bone mass measurement Breast cancer screening (mammogram) Cardiovascular disease (behavioral therapy) Cardiovascular screenings Cervical and vaginal cancer screening Colonoscopy Colorectal cancer screenings Depression screening Diabetes screenings Fecal occult blood test Flexible sigmoidoscopy HIV screening Medical nutrition therapy services Obesity screening and counseling Prostate cancer screenings (PSA) Sexually transmitted infections screening and counseling Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease) Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots Welcome to Medicare preventive visit (one-time) Yearly Wellness visit Any additional preventive services approved by Medicare during the contract year will be covered. In addition, you are also covered for an annual physical exam: You pay nothing Hospice 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. Summary of Benefits SCAN Healthy at Home (HMO SNP) 9

INPATIENT CARE Inpatient Hospital Care 1,2 Our plan covers an unlimited number of days for an inpatient hospital stay. $150 copay per day for days 1 through 10 You pay nothing per day for days 11 through 90 You pay nothing per day for days 91 and beyond Inpatient Mental Health Care Skilled Nursing Facility (SNF) 1,2 For inpatient mental health care, see the Mental Health Care section of this booklet. Our plan covers up to 100 days in a SNF. You pay nothing per day for days 1 through 20 $100 copay per day for days 21 through 100 No prior hospital stay is required. PRESCRIPTION DRUG BENEFITS How much do I pay? For Part B drugs such as chemotherapy drugs 1 : 20% of the cost Other Part B drugs 1 : 20% of the cost 10 Summary of Benefits SCAN Healthy at Home (HMO SNP)

Initial Coverage You pay the following 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. Standard Retail Cost-Sharing TIER ONE-MONTH TWO-MONTH THREE- MONTH Tier 1 (Preferred Generic) Tier 2 (Non- Preferred Generic) Tier 3 (Preferred Brand) Tier 4 (Non- Preferred Brand) $3 copay $6 copay $9 copay $10 copay $20 copay $30 copay $45 copay $90 copay $135 copay $95 copay $190 copay $285 copay Tier 5 (Specialty Tier) 33% of the cost Not Offered Not Offered Tier 6 (Select Care Drugs) $10 copay $20 copay $30 copay Summary of Benefits SCAN Healthy at Home (HMO SNP) 11

Standard Mail Order Cost-Sharing TIER ONE-MONTH TWO-MONTH THREE- MONTH Tier 1 (Preferred Generic) Tier 2 (Non- Preferred Generic) Tier 3 (Preferred Brand) Tier 4 (Non- Preferred Brand) $3 copay $6 copay $6 copay $10 copay $20 copay $20 copay $45 copay $90 copay $125 copay $95 copay $190 copay $275 copay Tier 5 (Specialty Tier) 33% of the cost Not Offered Not Offered Tier 6 (Select Care Drugs) $10 copay $20 copay $20 copay 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. 12 Summary of Benefits SCAN Healthy at Home (HMO SNP)

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. 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 TIER DRUGS COVERED ONE- MONTH TWO- MONTH THREE- MONTH Tier 1 (Preferred Generic) Tier 2 (Non- Preferred Generic) All $3 copay $6 copay $9 copay All $10 copay $20 copay $30 copay Standard Mail Order Cost-Sharing TIER DRUGS COVERED ONE- MONTH TWO- MONTH THREE- MONTH Tier 1 (Preferred Generic) Tier 2 (Non- Preferred Generic) All $3 copay $6 copay $6 copay All $10 copay $20 copay $20 copay Summary of Benefits SCAN Healthy at Home (HMO SNP) 13

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. OPTIONAL BENEFITS (YOU MUST PAY AN EXTRA PREMIUM EACH MONTH FOR THESE BENEFITS) Package 1: Basic Dental Benefits include: Preventive Dental Comprehensive Dental How much is the monthly premium? How much is the deductible? Additional $8.00 per month. You must keep paying your Medicare Part B premium and your $0 monthly plan premium. This package does not have a deductible. You pay $0 for oral exams, $0 for 1 x-ray every 6 months, and $5 per visit for up to 2 cleanings every year. For additional dental benefits and copay information, please refer to SCAN s dental fee schedule. Is there a limit on how much the plan will pay? No. There is no limit to how much our plan will pay for benefits in this package. OPTIONAL BENEFITS (YOU MUST PAY AN EXTRA PREMIUM EACH MONTH FOR THESE BENEFITS) Package 2: Enhanced Dental Benefits include: Preventive Dental Comprehensive Dental How much is the monthly premium? How much is the deductible? Additional $16 per month. You must keep paying your Medicare Part B premium and your $0 monthly plan premium. This package does not have a deductible. You pay $0 for oral exams, $0 for 1 x-ray every 6 months, and $5 per visit for up to 2 cleanings every year. For additional dental benefits and copay information, please refer to SCAN s dental fee schedule. Is there a limit on how much the plan will pay? No. There is no limit to how much our plan will pay for benefits in this package. 14 Summary of Benefits SCAN Healthy at Home (HMO SNP)