Summary of Benefits for CareMore Connect (HMO SNP)

Summary of Benefits for CareMore Connect (HMO SNP) Available in Los Angeles County (partial) SBLACNT15 Y0017_15_081477A CHP CMS Accepted (09082014)

Section I: Introduction to Summary of Benefits 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 CareMore Connect (HMO SNP)). Tips for comparing your Medicare choices This Summary of Benefits booklet gives you a summary of what CareMore Connect (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 CareMore Connect (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 1-800-589-3146. Este documento podría estar disponible en otros formatos como Braille o texto con letras grandes. Este documento podría estar disponible en idiomas distintos del inglés. Para obtener más información, llámenos al 1-800-589-3146. Things to Know About CareMore Connect (HMO SNP) Hours of Operation From October 1 to February 14, you can call us 7 days a week from 8:00 a.m. to 8:00 p.m. Pacific time. From February 15 to September 30, you can call us Monday through Friday from 8:00 a.m. to 8:00 p.m. Pacific time. CareMore Connect (HMO SNP) Phone Numbers and Website If you are a member of this plan, call toll-free 1-800-589-3146 (TTY/TDD: 711). If you are not a member of this plan, call toll-free 1-866-622-2820 (TTY/TDD: 711). Our website: http://www.caremore.com Who can join? To join CareMore Connect (HMO SNP), you must be entitled to Medicare Part A, be enrolled in Medicare Part B and Medi-Cal, and live in our service area. Our service area includes the following counties in California: Los Angeles*. Los Angeles County: 90001; 90002; 90003; 90004; 90005; 90006; 90007; 90008; 90009; 90010; 90011; 90012; 90013; 90014; 90015; 90016; 90017; 90018; 90019; 90020; 90021; 90022; 90023; 90026; 90027; 90028; 90029; 90030; 90031; 90032; 90033; 90034; 90036; 90037; 90038; 90039; 90040; 90041; 90042; 90043; 90044; 90045; 90046; 90047; 90048; 90050; 90051; 90052; 90053; 90054; 90055; 90056; 90057; 90058; 90059; 90060; 90061; 90062; 90063; 90065; Page 2 - CareMore Connect (HMO SNP)

90066; 90068; 90070; 90071; 90072; 90074; 90075; 90076; 90078; 90079; 90080; 90081; 90082; 90083; 90084; 90086; 90087; 90088; 90089; 90091; 90093; 90094; 90096; 90097; 90099; 90101; 90102; 90103; 90174; 90185; 90189; 90201; 90202; 90220; 90221; 90222; 90223; 90224; 90230; 90231; 90232; 90233; 90239; 90240; 90241; 90242; 90245; 90247; 90248; 90249; 90250; 90251; 90254; 90255; 90260; 90261; 90262; 90266; 90267; 90270; 90274; 90275; 90277; 90278; 90280; 90301; 90302; 90303; 90304; 90305; 90306; 90307; 90308; 90309; 90310; 90311; 90312; 90313; 90397; 90398; 90501; 90502; 90503; 90504; 90505; 90506; 90507; 90508; 90509; 90510; 90601; 90602; 90603; 90604; 90605; 90606; 90607; 90608; 90609; 90610; 90612; 90637; 90638; 90639; 90640; 90650; 90651; 90652; 90659; 90660; 90661; 90662; 90665; 90670; 90671; 90701; 90702; 90703; 90706; 90707; 90710; 90711; 90712; 90713; 90714; 90715; 90716; 90717; 90723; 90731; 90732; 90733; 90734; 90744; 90745; 90746; 90747; 90748; 90749; 90755; 90801; 90802; 90803; 90804; 90805; 90806; 90807; 90808; 90809; 90810; 90813; 90814; 90815; 90822; 90831; 90832; 90833; 90834; 90835; 90840; 90842; 90844; 90845; 90846; 90847; 90848; 90853; 90888; 90895; 90899; 91006; 91007; 91009; 91010; 91016; 91017; 91020; 91021; 91030; 91031; 91046; 91050; 91051; 91066; 91077; 91101; 91102; 91103; 91104; 91105; 91106; 91107; 91108; 91109; 91110; 91114; 91115; 91116; 91117; 91118; 91121; 91123; 91124; 91125; 91126; 91129; 91131; 91175; 91182; 91184; 91185; 91186; 91187; 91188; 91189; 91191; 91199; 91201; 91202; 91203; 91204; 91205; 91206; 91207; 91208; 91209; 91210; 91214; 91221; 91222; 91224; 91225; 91226; 91329; 91501; 91502; 91503; 91504; 91505; 91506; 91507; 91508; 91510; 91521; 91522; 91523; 91526; 91611; 91612; 91702; 91706; 91711; 91714; 91715; 91716; 91722; 91723; 91724; 91731; 91732; 91733; 91734; 91735; 91740; 91741; 91744; 91745; 91746; 91747; 91748; 91749; 91750; 91754; 91755; 91756; 91765; 91766; 91767; 91768; 91769; 91770; 91771; 91772; 91773; 91775; 91776; 91778; 91780; 91788; 91789; 91790; 91791; 91792; 91793; 91795; 91797; 91799; 91801; 91802; 91803; 91804; 91841; 91896; 91899 * denotes partial county Which doctors, hospitals, and pharmacies can I use? CareMore Connect (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 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.caremore.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.caremore.com. 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 after you meet your deductible: Initial Coverage, Coverage Gap, and Catastrophic Coverage. Page 3 - CareMore Connect (HMO SNP)

If you have any questions about this plan's benefits or costs, please contact CareMore Health Plan for details. Section II: Summary of Benefits CareMore Connect (HMO SNP) 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. How much is the deductible? Is there any limit on how much I will pay for my covered services? Is there a limit on how much the plan will pay? 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. In this plan, you will pay nothing for Medicare-covered services from in-network providers. Refer to the "Medicare & You" handbook for Medicare-covered For -covered services, refer to the Medicaid Coverage section in this document. 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. CareMore Health Plan is an HMO/HMO SNP plan with a Medicare contract and a contract with the Medi-Cal program. Enrollment in CareMore 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 Not covered Ambulance You pay nothing Page 4 - CareMore Connect (HMO SNP)

Chiropractic Care Dental Services Diabetes Supplies and Services Diagnostic Tests, Lab and Radiology Services, and X-Rays Doctor's Office Visits Durable Medical Equipment (wheelchairs, oxygen, etc.) Emergency Care CareMore Connect (HMO SNP) Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): You pay nothing 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 2 every year): $35 copay Dental x-ray(s) (for up to 1 every three years): $0-$10 copay, depending on the service Fluoride treatment (for up to 2 every year): $5 copay Oral exam: $5-$15 copay, depending on the service Diabetes monitoring supplies: You pay nothing Diabetes self-management training: You pay nothing Therapeutic shoes or inserts: You pay nothing Diabetic Supplies and Services are limited to specific manufacturers, products and/or brands. Contact the plan for a list of covered supplies. Diagnostic radiology services (such as MRIs, CT scans): You pay nothing 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): You pay nothing Primary care physician visit: You pay nothing Specialist visit: You pay nothing You pay nothing You pay nothing If you are admitted to the hospital within 24 hours, you do not have to pay your share of the cost for emergency care. See the "Inpatient Hospital Care" section of this booklet for other costs. $10,000 plan coverage limit for supplemental emergency services outside the U.S. and its territories every year. If you are admitted to the hospital within 24-hour(s) for the same condition, you pay $0 for the emergency room visit. Page 5 - CareMore Connect (HMO SNP)

Foot Care (podiatry services) Hearing Services Home Health Care Mental Health Care Outpatient Rehabilitation Outpatient Substance Abuse Outpatient Surgery Over-the-Counter Items Prosthetic Devices (braces, artificial limbs, etc.) Renal Dialysis Transportation CareMore Connect (HMO SNP) Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: You pay nothing Routine foot care (for up to 12 visit(s) every year): You pay nothing Exam to diagnose and treat hearing and balance issues: You pay nothing Routine hearing exam (for up to 1 every year): You pay nothing Hearing aid fitting/evaluation (for up to 1 every year): You pay nothing Hearing aid: You pay nothing Our plan pays up to $1,500 every two years for hearing aids. You pay nothing Inpatient visit: Our plan covers an unlimited number of days for an inpatient hospital stay. You pay nothing per stay Outpatient group therapy visit: You pay nothing Outpatient individual therapy visit: 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: You pay nothing Physical therapy and speech and language therapy visit: You pay nothing Group therapy visit: You pay nothing Individual therapy visit: You pay nothing Ambulatory surgical center: You pay nothing Outpatient hospital: You pay nothing Not Covered Prosthetic devices: You pay nothing Related medical supplies: You pay nothing You pay nothing You pay nothing General Page 6 - CareMore Connect (HMO SNP)

Transportation (continued) Urgent Care Vision Services Preventive Care CareMore Connect (HMO SNP) Authorization rules may apply. In-Network $0 copay for up to 50 one-way trip(s) to plan approved location every year. You pay nothing Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): You pay nothing Routine eye exam (for up to 1 every year): You pay nothing Contact lenses (for up to 1 every two years): You pay nothing Our plan pays up to $100 every two years for contact lenses. Eyeglasses frames (for up to 1 every two years): You pay nothing Our plan pays up to $100 every two years for eyeglass frames. Eyeglasses lenses (for up to 1 every two years): $20 copay Eyeglasses or contact lenses after cataract surgery: You pay nothing 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) Page 7 - CareMore Connect (HMO SNP)

CareMore Connect (HMO SNP) Preventive Care (continued) Hospice INPATIENT CARE Inpatient Hospital Care Inpatient Mental Health Care Skilled Nursing Facility (SNF) Yearly "Wellness" visit Any additional preventive services approved by Medicare during the contract year will be covered. Annual physical exam: You pay nothing You pay nothing for hospice care from a Medicare-certified hospice. You may have to pay part of the cost for drugs and respite care. Our plan covers 325 days for an inpatient hospital stay. You pay nothing per stay 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 stay No prior hospital stay required. PRESCRIPTION DRUG BENEFITS How much do I pay? For Part B drugs such as chemotherapy drugs 1 : You pay nothing Other Part B drugs 1 : You pay nothing Initial Coverage Our plan does not have a deductible for Part D prescription drugs. You may get your drugs at network retail pharmacies and mail order pharmacies. Depending on your income and institutional status, you pay the following: Page 8 - CareMore Connect (HMO SNP)

Initial Coverage (continued) CareMore Connect (HMO SNP) Standard Retail Cost-Sharing Tier One-month supply Three-month supply Tier 1 (Preferred Generic) and Tier 2 (Non-Preferred Generic) $0 $0 Tier 3 (Preferred Brand) and Tier 4 (Non-Preferrede Generic) For generic drugs (including brand drugs treated as generic), either: For generic drugs (including brand drugs treated as generic), either: $0 copay; or $0 copay; or $1.20 copay; or $1.20 copay; or $2.65 copay $2.65 copay For all other drugs, either: For all other drugs, either: $0 copay; or $0 copay; or $3.60 copay; or $3.60 copay; or $6.60 copay. $6.60 copay. Tier 5 (Specialty Tier) Tier 6 (Select Care Drugs) 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. $0 Not Offered $0 Page 9 - CareMore Connect (HMO SNP)

Initial Coverage (continued) CareMore Connect (HMO SNP) Standard Mail Order Cost-Sharing Tier One-month supply Three-month supply Tier 1 (Preferred Generic) and Tier 2 (Non-Preferred Generic) Tier 3 (Preferred Brand) and Tier 4 (Non-Preferred Brand) Tier 5 (Specialty Tier) Tier 6 (Select Care Drugs) Not Offered Not Offered 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. Not Offered $0 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. Not Offered $0 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. Long-Term Care Pharmacy Long term care pharmacies must dispense brand name drugs in amounts less than a 14 days supply at a time. They may also dispense less than a month's supply of drugs at a time. Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed. Page 10 - CareMore Connect (HMO SNP)

Initial Coverage (continued) Catastrophic Coverage CareMore Connect (HMO SNP) Standard Mail Order Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed. After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4,700, you pay nothing for all drugs. You qualify for the catastrophic coverage stage when your out-of-pocket costs have reached the $4,700 limit for the calendar year. Once you are in the Catastrophic Coverage Stage, you will stay in this payment stage until the end of the calendar year. Out-of-Network Catastrophic Coverage After your yearly out-of-pocket drug costs reach $4,700, you will be reimbursed for drugs purchased out-of-network up to the plan's cost of the drug minus your cost share noted above. You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount. Once you are in the Catastrophic Coverage Stage, you will stay in this payment stage until the end of the calendar year. Page 11 - CareMore Connect (HMO SNP)

Section III: CareMore Care Centers CareMore Care Centers offer easy access to health care and coordination of care. Programs offered* at your local CareMore Care Center are: Healthy Start - Health exam performed by specially trained nurse practitioner. Recommendations for future care offered. Healthy Journey - Annual head-to-toe exam for Special Needs Plan members. Fall Prevention Program - Assessment for people who have fallen or are at risk. Diabetes Management Program - Education and treatment to control blood sugars. Nutrition counseling with dietician. Toll-free helpline provided. Hypertension Program - Treatment for blood pressures that are difficult to get under control. Blood pressure monitoring, classes & follow up exams. Foot Center - Foot exams / routine toenail trimming. Wound Care Program - Individualized wound care & supplies. Anticoagulation Therapy Program - For members on anticoagulation medication. Education & monitoring on side effects & interactions. Congestive Heart Failure (CHF) Program - For members with CHF. Helps prevent exacerbations, improve patient education & optimize health. Chronic Obstructive Pulmonary Disease (COPD) Program - For members with COPD. Helps prevent exacerbations; promotes well-being that decreases hospitalization. Ideal Life Program - Electronic home monitoring devices for members who qualify with CHF or hypertension. *Not all programs available at each center. Page 12 - CareMore Connect (HMO SNP)

Section IV: Summary of Benefits STATE OF CALIFORNIA MEDICAID (MEDI-CAL) PROGRAM COVERED BENEFITS FOR DUAL ELIGIBLE (MEDICARE AND MEDICAID) BENEFICIARIES Benefit 1 Inpatient Hospital Services 2 Outpatient Hospital Services 3 Rural Health Clinic Services 4 Federally Qualified Health Center Services 5 Laboratory Services 6 X-ray 7 Skilled Nursing Facility Care for over 21 years of age Subacute Care 4 8 Pediatric Nursing Facility Care for under 21 years of age Subacute services (Early & periodic screening, diagnosis, and treatment supplemental services) 9 Physician Services 10 Medical & Surgical Dental Services Medicaid (Medi-Cal) CareMore Connect (HMO SNP) Benefits No limit to the number of days covered by the plan each benefit period. No prior hospital stay required. Page 13 - CareMore Connect (HMO SNP)

Benefit 11 Podiatry Services 1 12 Optometry 1, 3 13 Chiropractic Services 1 14 Psychology Services 1, 2 15 Nurse Anesthetist Services 16 Medical Supplies (does not include incontinence creams and washes) 17 Dialysis Medicaid (Medi-Cal) $0 copay for Medi-Cal-covered services CareMore Connect (HMO SNP) Benefits $0 copay for up to 12 visits for Routine podiatry. $0 copay for one pair of Medicare-covered eyeglasses or contact lenses after cataract surgery. exams to diagnose and treat diseases and conditions of the eye. $0 copay for up to 1 supplemental routine eye exam(s) every year. $0 copay for up to 1 pair(s) of contacts every two years. $20 copay for up to 1 pair(s) of lenses every two years. $0 copay for up to 1 frame(s) every two years. $100 plan coverage limit for contact lenses every two years $100 plan coverage limit for eye glass frames every two years. $0 copay for Medicare covered services Page 14 - CareMore Connect (HMO SNP)

Benefit 18 Durable Medical Equipment 19 Hearing Aids 20 Acupuncture Services 1 21 Home Health Services through a home health agency (including home health nursing and aide services, physical and occupational therapy, speech pathology and audiology services, intermittent nursing, home health aid care, medical supplies equipment and appliances) 22 Physical Therapy and Related Services 1, 2 23 Rehabilitation Facilities 4 24 Private Duty Nursing (Waiver only) 25 Clinic (Organized outpatient clinic, Indian Health Services, alternate birthing centers, ambulatory surgical centers) 26 Dental Services Medicaid (Medi-Cal) CareMore Connect (HMO SNP) Benefits $0 copay for hearing aids. $1,500 plan coverage limit for hearing aids every two years. Not covered by CareMore Connect HMO SNP. Not covered by CareMore Connect HMO SNP. $5 to $15 copay for oral exams. $35 copay for up to 2 cleaning(s) every year. $5 copay for up to 2 fluoride treatment(s) every year. Page 15 - CareMore Connect (HMO SNP)

Benefit 26 Dental Services (continued) 27 Occupational Therapy 1, 2 28 Speech Pathology / Speech Therapy 1, 2 29 Audiology Services 30 Pharmaceutical Services and Prescribed Drugs Medicaid (Medi-Cal) $0 copay for drugs excluded from Medicare Part D coverage. CareMore Connect (HMO SNP) Benefits $0 to $10 copay for up to 1 dental X-ray(s) every three years. Plan offers additional comprehensive dental benefits. $0 copay for: up to 1 supplemental routine hearing exam(s) every year. up to 1 fitting-evaluation(s) for a hearing aid every year. For generic drugs (including brand drugs treated as generic), either: A $0 copay; or A $1.20 copay; or A $2.65 copay. 31 Prosthetic Appliances (Orthotic appliances) prosthetic eyes For all other generics, either: A $0 copay; or A $3.60 copay; or A $6.60 copay. After your yearly out-of-pocket drug costs reach $4,700, you pay a $0 copay. Page 16 - CareMore Connect (HMO SNP)

Benefit 32 Eyeglasses, other eye appliances 33 Comprehensive Perinatal Services Program (Preventive Services) 34 Rehabilitation Services (ADHC, chronic dialysis, outpatient heroin detoxification, rehabilitative mental health, drug Medi-Cal, independent rehabilitation centers) 35 Intermediate Care Facility 36 Hospice 37 TB-Related Services 38 Respiratory Care for ventilator-dependent patients 39 Family nurse practitioner Medicaid (Medi-Cal) CareMore Connect (HMO SNP) Benefits $0 copay for one pair of Medicare-covered eyeglasses or contact lenses after cataract surgery. $0 copay for up to 1 supplemental routine eye exam(s) every year. $0 copay for up to 1 pair(s) of contacts every two years. $20 copay for up to 1 pair(s) of lenses every two years. $0 copay for up to 1 frame(s) every two years. $100 plan coverage limit for contact lenses every two years. $100 plan coverage limit for eye glass frames every two years. Generally, $0 copay for Medicare-covered Not covered by CareMore Connect HMO SNP. When you enroll in a Medicare-certified Hospice program, your hospice services are paid for by the Original Medicare plan. Page 17 - CareMore Connect (HMO SNP)

Benefit 40 Rural Primary Care Hospital 41 Nonmedical health Facilities 42 Emergency Hospital Services 43 Transportation (State provides emergency and non-emergency medical transportation. Meets federal requirement for assurance of transportation to medically necessary services) 44 Licensed Clinical Social Worker Services (Early & periodic screening, diagnosis, and treatment services & waiver only) 45 Case Management (Early & periodic screening, diagnosis, and treatment services & waiver only) 46 Private Duty Nursing Agency Services (Early & periodic screening, diagnosis, and treatment services & waiver only) Medicaid (Medi-Cal) CareMore Connect (HMO SNP) Benefits Generally, $0 copay for Medicare-covered $10,000 plan coverage limit for supplemental emergency services outside the U.S. and its territories every year. Emergency Transportation: $0 copay for Medicare-covered Routine Transportation: $0 copay for up to 50 one-way trip(s) to plan approved locations every year. 1 Optional benefits coverage is limited to only beneficiaries in "Exempt Groups": 1) beneficiaries under 21 years of age for services rendered pursuant to EPSDT program; 2) beneficiaries residing in a skilled nursing facility (Nursing Facilities Level A and Level B, including subacute care facilities; 3) beneficiaries who are pregnant (pregnancy-related benefits and services; other benefits and services to treat conditions that, if left untreated, might cause difficulties for the pregnancy); 4) California Children s Services beneficiaries; and 5) beneficiaries enrolled in the Program of All-Inclusive Care for the Elderly. Services include: Chiropractic Services, Psychologist, Acupuncturist, Audiologist and Audiology Services, Optician and Optical Fabricating Lab, Dental*, Speech Pathology, Dentures, Eye glasses. 2 Services provided by psychiatrists; psychologists; licensed clinical social workers; marriage, family, and child counselors; or other specialty mental health provider are not covered. 3 Fabrication of optical lenses not covered 4 Only covered for the month of admission and the following month Page 18 - CareMore Connect (HMO SNP)