2015 Summary of Benefits Mercy Care Advantage (HMO SNP)

2015 Summary of Benefits Mercy Care Advantage (HMO SNP) January 1, 2015 December 31, 2015 Maricopa, Pima and Santa Cruz County H5580 001, 004, 005 H5580_15_008 CMS Accepted

Section I Introduction to Summary of Benefits (a Medicare Advantage Health Maintenance Organization (HMO)) offered by SOUTHWEST CATHOLIC HEALTH NETWORK CORPORATION 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. 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 Mercy Care Advantage (HMO SNP)). Tips for comparing your Medicare choices This Summary of Benefits booklet gives you a summary of what 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 Mercy Care Advantage (HMO SNP) Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services Covered Medical and Hospital Benefits 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 us at 602 263 3000. This information is available for free in other languages. Please contact our number at 602 263 3000 or 1 800 624 3879 (TTY 711) for additional information. Hours of operation: 24 hours a day, 7 days a week. Esta información está disponible gratis en otros idiomas. Por favor comuníquese a nuestro número de Servicios al Miembro al 602 263 2000 o 1 800 634 3879 (TTY 711) para informacíon adicional. Horas de servicio: 24 horas al dia, 7 dias a la semana. Things to Know About Mercy Care Advantage (HMO SNP) Hours of Operation You can call us 24 hours a day Mountain time, 7 days a week. Phone Numbers and Website If you are a member of this plan, call toll free 602 263 3000 or 1 800 624 3879 (TTY 711). If you are not a member of this plan, call toll free 602 414 7630 or 1 866 571 5781 (TTY 711). Visit our website at www.mercycareadvantage.com. 1

Section I Introduction to Summary of Benefits Who can join? To join, you must be entitled to Medicare Part A, be enrolled in Medicare Part B and System (AHCCCS), and live in our service area. Our service area includes the following counties in Arizona: Maricopa, Santa Cruz and Pima. Which doctors, hospitals, and pharmacies can I use? 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 on our website at (www.mercycareadvantage.com/ members/mca/information). 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 www.mercycareadvantage.com/members/mca/ information. 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. 2

Section II Summary of Benefits BENEFIT 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? MONTHLY PREMIUM, DEDUCTIBLE, AND LIMITS ON HOW MUCH YOU PAY FOR COVERED SERVICES $0 per month. In addition, you must keep paying your Medicare Part B premium. This plan has deductibles for some hospital and medical services: $0 or $147 per year for in network services, depending on your level of Medicaid eligibility. This amount may change for 2015. This plan does not have a deductible 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. In this plan, you may pay nothing for Medicare covered services, depending on your level of System (AHCCCS) eligibility. Is there a limit on how much the plan will pay? Refer to the Medicare & You handbook for Medicare covered services. For Arizona Health Care System (AHCCCS) covered services, refer to the Medicaid Coverage section in this document. 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. No. There are no limits on how much our plan will pay. Medicare Care Advantage (HMO SNP) is a Coordinated care plan with a Medicare contract and a contract with the Arizona Medicaid Program. Enrollment in Mercy Care Advantage 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. BENEFIT Acupuncture and Other Alternative Therapies Ambulance OUTPATIENT CARE AND SERVICES Not covered 0% or 20% of the cost 3

Section II Summary of Benefits BENEFIT Chiropractic Care 1 OUTPATIENT CARE AND SERVICES Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): 0% or 20% of the cost Routine chiropractic visit (for up to 12 every year): You pay nothing. Dental Services 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 every year): You pay nothing. Fluoride treatment (for up to 1 every six months): You pay nothing. Oral exam (for up to 1 every six months): You pay nothing. Diabetes Supplies and Services Diagnostic Tests, Lab and Radiology Services, and X Rays 1,2 Additional Comprehensive benefits: $2,100 plan coverage limit (every year) for services like extractions, crowns, fillings, and root canals. No referral or prior authorization required. Full mouth Panorex x ray every 3 years. Diabetes monitoring supplies: 0% or 20% of the cost Diabetes self management training: 0% or 20% of the cost Therapeutic shoes or inserts: 0% or 20% of the cost Diagnostic radiology services (such as MRIs, CT scans): 0% or 20% of the cost Diagnostic tests and procedures: 0% or 20% of the cost, depending on the service Lab services: 0% or 20% of the cost, depending on the service Outpatient x rays: 0% or 20% of the cost Therapeutic radiology services (such as radiation treatment for cancer): 0% or 20% of the cost Services may require prior authorization or a referral from your doctor. The following radiology and lab services require prior authorization: PET Scans, MRI, MRA, 3 D Ultrasounds, 3 D Imaging, and Genetic testing. 4

Section II Summary of Benefits BENEFIT Doctor s Office Visits 1,2 OUTPATIENT CARE AND SERVICES Primary care physician visit: 0% or 20% of the cost Specialist visit: 0% or 20% of the cost Durable Medical Equipment (wheelchairs, oxygen, etc.) 1 Emergency Care Services from a specialist physician may require prior authorization or a referral from your doctor. 0% or 20% of the cost 0% or 20% of the cost 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. Foot Care (podiatry services) 1,2 Hearing Services Home Health Care 1 Coverage is limited to emergency care received in the U.S. and its territories. Foot exams and treatment if you have diabetes related nerve damage and/or meet certain conditions: 0% or 20% of the cost Routine foot care (for up to 1 visit every three months): You pay nothing. Services may require prior authorization or a referral from your doctor Exam to diagnose and treat hearing and balance issues: 0% or 20% of the cost Routine hearing exam (for up to 1 every year): You pay nothing. Hearing aid fitting/evaluation: You pay nothing. Hearing aid: You pay nothing. Our plan pays up to $1,200 every three years for hearing aids. You pay nothing. 5

Section II Summary of Benefits BENEFIT Mental Health Care 1,2 Inpatient visit: OUTPATIENT CARE AND SERVICES 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. The copays for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you re admitted as an inpatient and ends when you haven t received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There s no limit to the number of benefit periods. 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. In 2014 the amounts for each benefit period were $0 or: $1,216 deductible for days 1 through 60 $304 copay per day for days 61 through 90 $608 copay per day for 60 lifetime reserve days These amounts may change for 2015. Outpatient Rehabilitation 1,2 Services may require prior authorization or a referral from your doctor. Cardiac (heart) rehab services (for a maximum of 2 one hour sessions per day for up to 36 sessions up to 36 weeks): 0% or 20% of the cost Occupational therapy visit: 0% or 20% of the cost Physical therapy and speech and language therapy visit: 0% or 20% of the cost Services may require prior authorization or a referral from your doctor. Outpatient Substance Abuse 1,2 Pulmonary rehab services covered: 0% or 20% of the cost. Group therapy visit: 0% or 20% of the cost Individual therapy visit: 0% or 20% of the cost Services may require prior authorization or a referral from your doctor. 6

Section II Summary of Benefits BENEFIT Outpatient Surgery 1,2 Over the Counter Items Prosthetic Devices (braces, artificial limbs, etc.) 1 Renal Dialysis Transportation Urgent Care Vision Services OUTPATIENT CARE AND SERVICES Ambulatory surgical center: 0% or 20% of the cost Outpatient hospital: 0% or 20% of the cost Services may require prior authorization or a referral from your doctor. Please visit our website to see our list of covered over the counter items. $75 maximum every quarter for covered over the counter items. Prosthetic devices: 0% or 20% of the cost Related medical supplies: 0% or 20% of the cost 0% or 20% of the cost Kidney Disease Education covered: 0% or 20% of the cost Not covered 0% or 20% of the cost Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): 0% or 20% of the cost Routine eye exam (for up to 1 every year): You pay nothing. Contact lenses: You pay nothing. Eyeglasses (frames and lenses): You pay nothing. Eyeglasses or contact lenses after cataract surgery: You pay nothing. Our plan pays up to $200 every two years for contact lenses and eyeglasses (frames and lenses). 7

Section II Summary of Benefits BENEFIT Preventive Care OUTPATIENT CARE AND SERVICES 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. Hospice 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. 8

Section II Summary of Benefits BENEFIT Inpatient Hospital Care 1 Inpatient Care The copays for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you re admitted as an inpatient and ends when you haven t received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There s no limit to the number of benefit periods. 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. In 2014 the amounts for each benefit period were $0 or: $1,216 deductible for days 1 through 60 $304 copay per day for days 61 through 90 $608 copay per day for 60 lifetime reserve days These amounts may change for 2015. Inpatient Mental Health Care Skilled Nursing Facility (SNF) 1 For inpatient mental health care, see the Mental Health Care section of this booklet. Our plan covers up to 100 days in a SNF. In 2014 the amounts for each benefit period were $0 or: You pay nothing for days 1 through 20 $152 copay per day for days 21 through 100 These amounts may change for 2015. 9

Section II Summary of Benefits BENEFIT PRESCRIPTION DRUG BENEFITS How much do I pay? For Part B drugs such as chemotherapy drugs 1 : 0% or 20% of the cost Other Part B drugs 1 : 0% or 20% of the cost Initial Coverage Our plan does not have a deductible for Part D prescription drugs. Depending on your income and institutional status, you pay the following: 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 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 in network pharmacy. Retail Pharmacy You can get drugs the following way(s): one month (31 day) supply three month (90 day) supply Long Term Care Pharmacy one month (31 day) supply Mail Order three month (90 day) supply Out of Network Pharmacy one month (31 day) supply Some covered drugs may have additional requirements or limits on coverage. 10

Additional Information about Mercy Care Advantage is a Medicare Advantage HMO SNP. It s specially designed to serve the health care needs of people who are on Medicare and are also eligible for Medicaid benefits. When you join our plan, you get all of your Medicare hospital, health care services, and prescription drug coverage through our plan. And you will have access to your Medicaid services too all through a single plan. This is called coordination of benefits, meaning that all of your health insurance coverage works together to pay for the health care services you need. When you enroll in our plan, you ll choose a primary care provider (PCP) to be your healthcare partner. For most services, you will need referrals from your PCP before you see specialists. You re always covered for an emergency or urgently need care. Mercy Care Advantage offers extra benefits that Medicare and AHCCCS don t provide. We offer supplemental health education and wellness programs. Here are a few examples: After hours nursing hotline Activities that meet your unique physical needs, such as our VanGo Active Steps program, which provides classes that will help our members remain active and healthy at all stages of life. Smoking Cessation with a Quit Coach Diabetes prevention and education with a Diabetic Educator 11

Section III - Medicaid Benefits Medicare Advantage Special Needs Plan for the Dual Eligible/ System 2015 Benefits In order for you to better understand your health care options, the following chart notes your charge for certain services under the Cost Containment System (Medicaid) as an individual who has both Medicare and Medicaid. Your Medicare cost sharing responsibility is based on your level of Medicaid eligibility. Qualified Medicare Beneficiary (QMB) $0, your Medicare cost sharing will be paid by your Medicaid Health Plan unless otherwise noted below. Non QMB with Medicare Parts A and B your Medicare cost sharing will be paid by your Medicaid Health Plan only when the benefit is also covered by Medicaid. The benefits described below are covered by Medicaid. The benefits described in the Covered Medical and Hospital Benefits section of the Summary of Benefits are covered by Medicare. For each benefit listed below, you can see what AHCCCS covers and what our plan covers. What you pay for covered services may depend on your level of Medicaid eligibility. 12

Benefit System (AHCCCS) QMB Dual Eligible You Pay: System (AHCCCS) Non QMB Dual Eligible You Pay: ACUTE AND LONG TERM CARE MEDICAID Inpatient Hospital Visit $0 $0 The copays for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you re admitted as an inpatient and ends when you haven t received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There s no limit to the number of benefit periods. 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 one you have used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days. In 2014 the amounts for each benefit period were $0 or: $1,216 deductible for days 1 through 60 $304 copay per day for days 61 through 90 $608 copay per day for 60 lifetime reserve days These amounts may change for 2015. 13

Benefit Inpatient Mental Health Care System (AHCCCS) QMB Dual Eligible You Pay: System (AHCCCS) Non QMB Dual Eligible You Pay: ACUTE AND LONG TERM CARE MEDICAID $0 $0 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. The copays for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you re admitted as an inpatient and ends when you haven t received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There s no limit to the number of benefit periods. 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. In 2014 the amounts for each benefit period were $0 or: $1,216 deductible for days 1 through 60 $304 copay per day for days 61 through 90 $608 copay per day for 60 lifetime reserve days These amounts may change for 2015. Services may require prior authorization or a referral from your doctor. 14

Benefit Skilled Nursing Facility Services System (AHCCCS) QMB Dual Eligible You Pay: System (AHCCCS) Non QMB Dual Eligible You Pay: ACUTE AND LONG TERM CARE MEDICAID $0 $0 Our plan covers up to 100 days in a SNF. In 2014 the amounts for each benefit period were $0 or: You pay nothing for days 1 through 20 $152 copay per day for days 21 through 100 These amounts may change for 2015. Home Health Care Visits $0 $0 You pay nothing. Primary Care Physician Visit $0 $0 for well visits and $0 to $5 for other visits depending on eligibility for age 21 and over* $0 for age 20 and under. Specialist Visit $0 $0 for well visits and $0 to $5 for other visits depending on eligibility for age 21 and over $0 for age 20 and under. Medicare Covered Chiropractic Care Visit $0 $0 for age 20 and under. Not covered for people age 21 and over. 0% or 20% of the cost 0% or 20% of the cost Services from a specialist physician may require prior authorization or a referral from your doctor. Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): 0% or 20% of the cost. Routine chiropractic visit (for up to 12 every year): You pay nothing. 15

Benefit System (AHCCCS) QMB Dual Eligible You Pay: System (AHCCCS) Non QMB Dual Eligible You Pay: ACUTE AND LONG TERM CARE MEDICAID Podiatry Services Visit $0 $0 for age 20 and under. If furnished by a podiatrist (or other registered provider when included in an office visit) not covered for people age 21and over. Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: 0% or 20% of the cost Routine foot care (for up to 1 visit every three months): You pay nothing Services may require prior authorization or a referral from your doctor Outpatient Mental Health Care Visit Outpatient Substance Abuse Care Visit $0 $0 0% or 40% of the cost Services from a specialist physician may require prior authorization or a referral from your doctor. $0 $0 Group therapy visit: 0% or 20% of the cost Individual therapy visit: 0% or 20% of the cost Ambulatory Surgical Center or Outpatient Hospital Facility Visit $0 $0 to $3 depending on eligibility for age 21 and over $0 for age 20 and under. Services may require prior authorization or a referral from your doctor. Ambulatory surgical center: 0% or 20% of the cost Outpatient hospital: 0% or 20% of the cost Services may require prior authorization or a referral from your doctor. Ambulance Services $0 $0 0% or 20% of the cost Emergency Room Visit $0 $0 0% or 20% of the cost 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. Coverage is limited to emergency care received in the U.S. and its territories. 16

Benefit System (AHCCCS) QMB Dual Eligible You Pay: System (AHCCCS) Non QMB Dual Eligible You Pay: ACUTE AND LONG TERM CARE MEDICAID Urgently Needed Care Visit $0 $0 to $5 depending 0% or 20% of the cost on eligibility *for age 21 and over. $0 for age 20 and under. Outpatient Occupational/ Physical/Speech Therapy Visit $0 $0 to $3 depending on eligibility * for age 21 and over. $0 for age 20 and under. Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): 0% or 20% of the cost Occupational therapy visit: 0% or 20% of the cost. Physical therapy and speech and language therapy visit: 0% or 20% of the cost Services may require prior authorization or a referral from your doctor. Pulmonary rehab services covered: 0% or 20% of the cost. Durable Medical Equipment $0 $0 0% or 20% of the cost Prosthetic Devices $0 $0. Lower limb microprocessor controlled limb or joint not covered for people age 21 and over. Diabetes Self Monitoring Training & Supplies (Provided as part of a PCP visit) Prosthetic devices: 0% or 20% of the cost Related medical supplies: 0% or 20% of the cost $0 $0 Diabetes monitoring supplies: 0% or 20% of the cost Diabetes self-management training: 0% or 20% of the cost Therapeutic shoes or inserts: 0% or 20% of the cost 17

Benefit Diagnostic Tests, X rays and Lab Services System (AHCCCS) QMB Dual Eligible You Pay: System (AHCCCS) Non QMB Dual Eligible You Pay: ACUTE AND LONG TERM CARE MEDICAID $0 $0 Diagnostic radiology services (such as MRIs, CT scans): 0% or 20% of the cost Diagnostic tests and procedures: 0% or 20% of the cost, depending on the service Lab services: 0% or 20% of the cost, depending on the service Outpatient X-rays: 0% or 20% of the cost Therapeutic radiology services (such as radiation treatment for cancer): 0% or 20% of the cost Services may require prior authorization or a referral from your doctor. The following radiology and lab services require prior authorization: PET Scans, MRI, MRA, 3-D Ultrasounds, 3-D Imaging, and Genetic testing. Colorectal Screening $0 $0 You pay nothing. Flu & Pneumonia Vaccines $0 $0 You pay nothing. Screening Mammogram $0 $0 You pay nothing. Pap Smear & Pelvic Exam $0 $0 You pay nothing. Prostate Cancer Screening $0 $0 You pay nothing. Renal Dialysis or Nutritional Therapy for End Stage Renal Disease $0 $0 0% or 20% of the cost Kidney Disease Education covered: 0% or 20% of the cost 18

Benefit System (AHCCCS) QMB Dual Eligible You Pay: System (AHCCCS) Non QMB Dual Eligible You Pay: ACUTE AND LONG TERM CARE MEDICAID Prescription Drugs $0 $0 to $4 depending on eligibility * for age 21 and over. $0 for age 20 and under. For Part B drugs such as chemotherapy drugs: 0% or 20% of the cost Other Part B drugs: 0% or 20% of the cost Our plan does not have a deductible for Part D prescription drugs. Depending on your income and institutional status, you pay the following: 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 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 in-network pharmacy. Retail Pharmacy You can get drugs the following way(s): one-month (31-day) supply three-month (90-day) supply Long-Term Care Pharmacy one-month (31-day) supply Mail Order three-month (90-day) supply Out of Network Pharmacy one-month (31-day) supply Some covered drugs may have additional requirements or limits on coverage. 19

Benefit Hearing Exams, Routine Hearing Tests, Fitting Evaluations for a Hearing Aid & Hearing Aid Yearly Routine Eye Exam, Eyeglasses, Contact Lenses, Lenses and Frames System (AHCCCS) QMB Dual Eligible You Pay: Not covered for people age 21 and over. $0 for age 20 and under. System (AHCCCS) Non QMB Dual Eligible You Pay: ACUTE AND LONG TERM CARE MEDICAID $0 for age 20 and under. Not covered for people age 21 and over. Not covered for people over age 21 unless following cataracts surgery. $0 for age 20 and under. $0 for age 20 and under. Not covered for people age 21 and over. Exam to diagnose and treat hearing and balance issues: 0% or 20% of the cost Routine hearing exam (for up to 1 every year): You pay nothing Hearing aid fitting/evaluation: You pay nothing. Hearing aid: You pay nothing. Our plan pays up to $1,200 every three years for hearing aids. Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): 0% or 20% of the cost Routine eye exam (for up to 1 every year): You pay nothing. Contact lenses: You pay nothing. Eyeglasses (frames and lenses): You pay nothing. Eyeglasses or contact lenses after cataract surgery: You pay nothing. Transportation $0 $2 per trip for Taxi transportation depending on eligibility and county of residence * for age 21 and over. $0 for age 20 and under. Our plan pays up to $200 every two years for contact lenses and eyeglasses (frames and lenses). Not covered. 20

Benefit Nursing Facility System (AHCCCS) QMB Dual Eligible You Pay: System (AHCCCS) Non QMB Dual Eligible You Pay: LONG TERM ONLY Member Contribution Member Contribution determined by determined by Medicaid Agency Medicaid Agency Our plan covers up to 100 days in a SNF. In 2014 the amounts for each period were $0 or: You pay nothing for days 1 through 20 $152 copay per day for days 21 through 100 These amounts may change for 2015. Respite $0. Subject to a 600 hour limit per 1 year period beginning October 1st of each year. Home and Community Based Services Member Contribution determined by Medicaid Agency $0. Subject to a 600 hour limit per 1 year period beginning October 1st of each year. Member Contribution determined by Medicaid Agency Not covered. Not covered. *Refer to AHCCCS website for additional copay and benefit related information 21

Multi language Interpreter Services English: We have free interpreter services to answer any questions you may have about our health or drug plan. To get an interpreter, just call us at 1 800 624 3879. Someone who speaks English/Language can help you. This is a free service. Spanish: Tenemos servicios de intérprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos. Para hablar con un intérprete, por favor llame al 1 800 624 3879. Alguien que hable español le podrá ayudar. Este es un servicio gratuito. Chinese Mandarin: 我 们 提 供 免 费 的 翻 译 服 务, 帮 助 您 解 答 关 于 健 康 或 药 物 保 险 的 任 何 疑 问 如 果 您 需 要 此 翻 译 服 务, 请 致 电 1 800 624 3879 我 们 的 中 文 工 作 人 员 很 乐 意 帮 助 您 这 是 一 项 免 费 服 务 Chinese Cantonese: 您 對 我 們 的 健 康 或 藥 物 保 險 可 能 存 有 疑 問, 為 此 我 們 提 供 免 費 的 翻 譯 服 務 如 需 翻 譯 服 務, 請 致 電 1 800 624 3879 我 們 講 中 文 的 人 員 將 樂 意 為 您 提 供 幫 助 這 是 一 項 免 費 服 務 Tagalog: Mayroon kaming libreng serbisyo sa pagsasaling wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot. Upang makakuha ng tagasaling wika, tawagan lamang kami sa 1 800 624 3879. Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog. Ito ay libreng serbisyo. French: Nous proposons des services gratuits d interprétation pour répondre à toutes vos questions relatives à notre régime de santé ou d assurance médicaments. Pour accéder au service d interprétation, il vous suffit de nous appeler au 1 800 624 3879. Un interlocuteur parlant Français pourra vous aider. Ce service est gratuit. Vietnamese: Chúng tôi có dịch vụ thông dịch miễn phí để trả lời các câu hỏi về chương sức khỏe và chương trình thuốc men. Nếu quí vị cần thông dịch viên xin gọi 1 800 624 3879 sẽ có nhân viên nói tiếng Việt giúp đỡ quí vị. Đây là dịch vụ miễn phí. German: Unser kostenloser Dolmetscherservice beantwortet Ihren Fragen zu unserem Gesundheits und Arzneimittelplan. Unsere Dolmetscher erreichen Sie unter 1 800 624 3879. Man wird Ihnen dort auf Deutsch weiterhelfen. Dieser Service ist kostenlos. Korean: 당사는 의료 보험 또는 약품 보험에 관한 질문에 답해 드리고자 무료 통역 서비스를 제공하고 있습니다. 통역 서비스를 이용하려면 전화1 800 624 3879 번으로 문의해 주십시오. 한국어를 하는 담당자가 도와 드릴 것입니다. 이 서비스는 무료로 운영됩니다. Russian: Если у вас возникнут вопросы относительно страхового или медикаментного плана, вы можете воспользоваться нашими бесплатными услугами переводчиков. Чтобы воспользоваться услугами переводчика, позвоните нам по телефону 1 800 624 3879. Вам окажет помощь сотрудник, который говорит по pусски. Данная услуга бесплатная. H5580_15_007 CMS Accepted 22

Arabic: ةيودألا لودج وأ ةحصلاب قلعتت ةلئسأ يأ نع ةباجإلل ةيناجملا يروفلا مجرتملا تامدخ مدقن اننإ موقيس. 3879 624 800 1 ىلع انب لاصتالا ىوس كيلع سيل يروف مجرتم ىلع لوصحلل.انيدل.ةيناجم ةمدخ هذه.كتدعاسمب ةيبرعلا ثدحتي ام صخش Hindi: हम र स व स थ य य दव क य जन क ब र म आपक क स भ प रश न क जव ब द न क ल ए हम र प स म फ त द भ ष य स व ए उपलब ध ह. एक द भ ष य प र प त करन क ल ए, बस हम 1 800 624 3879 पर फ न कर. क ई व यक त ज ह न द ब लत ह आपक मदद कर सकत ह. यह एक म फ त स व ह. Italian: È disponibile un servizio di interpretariato gratuito per rispondere a eventuali domande sul nostro piano sanitario e farmaceutico. Per un interprete, contattare il numero 1 800 624 3879. Un nostro incaricato che parla Italianovi fornirà l assistenza necessaria. È un servizio gratuito. Portugués: Dispomos de serviços de interpretação gratuitos para responder a qualquer questão que tenha acerca do nosso plano de saúde ou de medicação. Para obter um intérprete, contacte nos através do número 1 800 624 3879. Irá encontrar alguém que fale o idioma Português para o ajudar. Este serviço é gratuito. French Creole: Nou genyen sèvis entèprèt gratis pou reponn tout kesyon ou ta genyen konsènan plan medikal oswa dwòg nou an. Pou jwenn yon entèprèt, jis rele nou nan 1 800 624 3879. Yon moun ki pale Kreyòl kapab ede w. Sa a se yon sèvis ki gratis. Polish: Umożliwiamy bezpłatne skorzystanie z usług tłumacza ustnego, który pomoże w uzyskaniu odpowiedzi na temat planu zdrowotnego lub dawkowania leków. Aby skorzystać z pomocy tłumacza znającego język polski, należy zadzwonić pod numer 1 800 624 3879. Ta usługa jest bezpłatna. Japanese: 当 社 の 健 康 健 康 保 険 と 薬 品 処 方 薬 プランに 関 するご 質 問 にお 答 えするため に 無 料 の 通 訳 サービス がありますございます 通 訳 をご 用 命 になるには 1 800 624 3879. にお 電 話 ください 日 本 語 を 話 す 人 者 が 支 援 いたします これは 無 料 のサー ビスです H5580_15_007 CMS Accepted 23