SUPERIOR HEALTHPLAN ADVANTAGE 2015 Summary of Benefits

SUPERIOR HEALTHPLAN ADVANTAGE 2015 Summary of Benefits Superior HealthPlan Advantage is an HMO SNP plan with a Medicare contract and a contract with the Texas Medicaid program. Enrollment in Superior HealthPlan Advantage depends on contract renewal. H5294-001_SummaryOfBenefits15_Accepted_09132014 TEXAS

SUPERIOR HEALTHPLAN ADVANTAGE (HMO SNP) (a Medicare Advantage Heath Maintenance Organization (HMO) offered by SUPERIOR HEALTH PLAN, INC. 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 (feefor-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 Superior HealthPlan Advantage (HMO SNP)). Tips for comparing your Medicare choices This Summary of Benefits booklet gives you a summary of what Superior HealthPlan Advantage (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 Superior HealthPlan Advantage (HMO SNP) Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services H5294-001_SummaryOfBenefits15_Accepted_09132014 1

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 1-877-935-8023. (TTY users should call 711.) Este documento puede estar disponible en un idioma que no sea inglés. Para obtener información adicional, llámenos al 1-877-935-8023. (Usuarios de TTY deben llamar al 711.) Things to Know About Superior HealthPlan Advantage (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 p.m. Central time. From February 15 to September 30, you can call us Monday through Friday from 8:00 a.m. to 8:00 p.m. Central time. Superior HealthPlan Advantage (HMO SNP) Phone Numbers and Website If you are a member of this plan, call toll-free 1-877-935-8023. (TTY users should call 711.) If you are not a member of this plan, call toll-free 1-877-935-8023. (TTY users should call 711.) Our website: http://advantage.superiorhealthplan.com Who can join? To join Superior HealthPlan Advantage (HMO SNP), you must be entitled to Medicare Part A, be enrolled in Medicare Part B and Texas Medicaid, and live in our service area. Our service area includes the following counties in Texas: Bexar, Collin, Dallas, Nueces, and Rockwall. 2

Which doctors, hospitals, and pharmacies can I use? Superior HealthPlan Advantage (HMO SNP) has a network of doctors, hospitals, pharmacies, and other providers. If you use 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://advantage.superiorhealthplan.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://advantage.superiorhealthplan.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 four 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. 3

Summary of Benefits Report For Contract H5294, Plan 001 Superior HealthPlan Advantage (HMO SNP) MONTHLY PREMIUM, DEDUCTIBLE, AND LIMITS ON HOW MUCH YOU PAY FOR COVERED SERVICES 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? $27.30 per month. This plan does not have a deductible. This plan does not have a deductible for chemotherapy and other drugs administered in your doctor's office (Part B drugs). 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 some services, depending on your level of the Texas Medicaid eligibility. Your yearly limit(s) in this plan: $3,400 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. 4

Summary of Benefits Report For Contract H5294, Plan 001 Superior HealthPlan Advantage (HMO SNP) Is there a limit on how much the plan will pay? Our plan has a coverage limit every year for certain innetwork benefits. Contact us for the services that apply. Superior HealthPlan Advantage (HMO SNP) is an HMO SNP plan with a Medicare contract and a contract with the Texas Medicaid program. Enrollment in Superior HealthPlan Advantage (HMO SNP) 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 Dental Services Not covered You pay nothing 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): You pay nothing Dental x-ray(s) (for up to 1 every year): You pay nothing Fluoride treatment (for up to 2 every year): You 5

Summary of Benefits Report For Contract H5294, Plan 001 Superior HealthPlan Advantage (HMO SNP) Dental Services continued pay nothing Oral exam (for up to 2 every year): You pay nothing This plan offers additional supplemental comprehensive dental benefits. Diabetes Supplies and Services $350 plan coverage limit for comprehensive dental benefits every year. Diabetes monitoring supplies: You pay nothing Diabetes self-management training: You pay nothing Therapeutic shoes or inserts: You pay nothing Diagnostic Tests, Lab and Radiology Services, and X-rays 1 If you receive a service that is different from diabetes self-management training, then a separate coinsurance will apply. Diagnostic radiology services (such as MRIs, CT scans): You pay nothing Diagnostic tests and procedures: You pay nothing Doctor's Office Visits 2 Lab services: You pay nothing Outpatient x-rays: You pay nothing Therapeutic radiology services (such as radiation treatment for cancer): You pay nothing If you receive a service that is different from the covered diagnostic procedure/test, lab, and/or radiology service(s), then a separate coinsurance will apply. Primary care physician visit: You pay nothing Specialist visit: You pay nothing 6

Summary of Benefits Report For Contract H5294, Plan 001 Superior HealthPlan Advantage (HMO SNP) Durable Medical Equipment (wheelchairs, oxygen, etc.) 1 Emergency Care Foot care (podiatry services) Hearing Services You pay nothing You pay nothing Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: 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 Home Health Care 1 Our plan pays up to $500 every year for hearing aids. You pay nothing Mental Health Care 1 Inpatient visit: Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient 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 7

Summary of Benefits Report For Contract H5294, Plan 001 Superior HealthPlan Advantage (HMO SNP) Mental Health Care 1 continued 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. You pay nothing Outpatient group therapy visit: You pay nothing Outpatient individual therapy visit: You pay nothing Authorization must be obtained from the designated behavioral health organization. Outpatient Cardiac (heart) rehab services (for a maximum of 2 one Rehabilitation 1 hour sessions per day for up to 36 sessions up to 36 weeks): You pay nothing Occupational therapy visit: You pay nothing Outpatient Substance Abuse 1 Physical therapy and speech and language therapy visit: You pay nothing Group therapy visit: You pay nothing Individual therapy visit: You pay nothing 8

Summary of Benefits Report For Contract H5294, Plan 001 Superior HealthPlan Advantage (HMO SNP) Outpatient Substance Abuse 1 continued Outpatient Surgery 1 Over-the-Counter Items Prosthetic Devices (braces, artificial limbs, etc.) 1 Renal Dialysis Transportation 1 Urgent Care Vision Services Authorization must be obtained from the designated behavioral health organization. Ambulatory surgical center: You pay nothing Outpatient hospital: You pay nothing Please visit our website to see our list of covered overthe-counter items. Prosthetic devices: You pay nothing Related medical supplies: You pay nothing You pay nothing You pay nothing You are covered for up to 30 one-way trips to planapproved locations every year. You must: use this plan's contracted transportation providers schedule trips 48 hours in advance Contact us for details. 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: You pay nothing Eyeglasses (frames and lenses): You pay nothing 9

Summary of Benefits Report For Contract H5294, Plan 001 Superior HealthPlan Advantage (HMO SNP) Vision Services Continued Eyeglasses or contact lenses after cataract surgery: You pay nothing Our plan pays up to $200 every year for contact lenses and eyeglasses (frames and lenses). Preventive Care Please contact us for a list of network providers in your service area. 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 screenings 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) 10

Summary of Benefits Report For Contract H5294, Plan 001 Superior HealthPlan Advantage (HMO SNP) Preventive Care continued Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots "Welcome to Medicare" preventive visit (onetime) 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 Medicarecertified hospice. You may have to pay part of the cost for drugs and respite care. INPATIENT CARE Inpatient Hospital Care 1 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. 11

Summary of Benefits Report For Contract H5294, Plan 001 Superior HealthPlan Advantage (HMO SNP) Inpatient Hospital Care 1 continued Inpatient Mental Health Care Skilled Nursing Facility (SNF) 1 You pay nothing 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 PRESCRIPTION DRUG BENEFITS How much do I pay? Initial Coverage For Part B drugs such as chemotherapy drugs 1 : You pay nothing Other Part B drugs 1 : You pay nothing Our plan does not have a deductible for Part D prescription drugs. Standard Retail Cost-Sharing You pay the following: You may get your drugs at network retail pharmacies and mail order pharmacies. Tier One-month supply Three-month supply Tier 1 (Generic) $0 $0 Tier 2 (Preferred Brand) For generic drugs (including brand drugs treated as generic), either: $1.20 copay; or $2.65 copay For generic drugs (including brand drugs treated as generic), either: $1.20 copay; or $2.65 copay For all other drugs, either: 12

Summary of Benefits Report For Contract H5294, Plan 001 Superior HealthPlan Advantage (HMO SNP) Tier 2 (Preferred Brand) continued $3.60 copay; or $6.60 copay. For all other drugs, either: $3.60 copay; or $6.60 copay. Tier 3 (Non-Preferred Brand) Tier 4 (Injectable Drugs) For generic drugs (including brand drugs treated as generic), either: $1.20 copay; or $2.65 copay For all other drugs, either: $3.60 copay; or $6.60 copay. For generic drugs (including brand drugs treated as generic), either: $1.20 copay; or $2.65 copay For all other drugs, either: $3.60 copay; or $6.60 copay. For generic drugs (including For generic drugs brand drugs treated as generic), either: $1.20 copay; or $2.65 copay For all other drugs, either: $3.60 copay; or $6.60 copay. (including brand drugs treated as generic), either: $1.20 copay; or $2.65 copay For all other drugs, either: $3.60 copay; or $6.60 copay. 13

Summary of Benefits Report For Contract H5294, Plan 001 Superior HealthPlan Advantage (HMO SNP) Standard Mail Order Cost-Sharing Tier Three-month supply Tier 1 (Generic) $0 Tier 2 (Preferred Brand) For generic drugs (including brand drugs treated as generic), either: $1.20 copay; or $2.65 copay For all other drugs, either: $3.60 copay; or $6.60 copay. Tier 3 (Non-Preferred Brand) Tier 4 (Injectable Drugs) For generic drugs (including brand drugs treated as generic), either: $1.20 copay; or $2.65 copay For all other drugs, either: $3.60 copay; or $6.60 copay. For generic drugs (including brand drugs treated as generic), either: $1.20 copay; or 14

Summary of Benefits Report For Contract H5294, Plan 001 Superior HealthPlan Advantage (HMO SNP) Tier 4 (Injectable Drugs) continued $2.65 copay For all other drugs, either: $3.60 copay; or $6.60 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 at the same cost as an innetwork pharmacy. Catastrophic Coverage You pay nothing 15

Summary of Benefits Report For Contract H5294, Plan 001 Superior HealthPlan Advantage (HMO SNP) ADDITIONAL INFORMATION ABOUT SUPERIOR HEALTHPLAN ADVANTAGE (HMO SNP) Superior HealthPlan Advantage (HMO SNP) provides access to personal, local care and promotes health and independence. As a member, you will receive all medically-necessary services covered by Medicare. In addition to the extra benefits listed in the Covered Medical and Hospital Benefits section, you will also get these extra services we offer: SilverSneakers - You can participate in the SilverSneakers Fitness program at specified gyms at no cost to you. Nursewise - Nursewise is a free health information line that is available 24 hours a day, 7 days a week. The line is staffed with registered nurses and other health professionals who are available to answer your health questions. 16

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 1-877-935-8023. 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 1-877-935-8023. Alguien que hable español le podrá ayudar. Este es un servicio gratuito. Chinese Mandarin: ᡃԜᥦ౪ච 䍩 h 䈁 㸪 ᑞᛘゎ ޣனᗣᡈ 㦟 ಖ 䲙 h ఱ 䰞 ዴᯝᛘࠋ 㟂 せṈ 䈁 㸪 䈧 ᡃԜh ᕤస ઈᚇҀពᑞࠋ1-877-935-8023 ࠋ 䘉 亩 ච 䍩 ࠋᛘ Chinese Cantonese: ᛘሽᡁفⲴڕᓧᡆ 㰕 䳚 ਟ 㜭 ݽᨀفᆈᴹˈ ᡁ 䋫 Ⲵ 㘫 ѝ᮷ⲵӫሷ ᛘᨀ 䅋 ف 1-877-935-8023DŽᡁ 䆟 ᴽउDŽ 䴰 㘫 䆟 ᴽउˈ 䃻 㠤 䴫 ᒛDŽ 䙉 ᱟа 丵 ݽ 䋫 ᴽउDŽ 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 1-877-935 8023. 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 1-877-935-8023. 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 1-877-935-8023 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 1-877-935 8023. Man wird Ihnen dort auf Deutsch weiterhelfen. Dieser Service ist kostenlos. Korean: 㢌 䜌 㚱 䖼 䜌 㜄 Ḵ 䚐 㫼 ⱬ 㜄 䚨 Ḕ 㣄 ⱨ 䋩 㜡 PTE p.m. 㥐 ḩ 䚌 Ḕ 㢼. 䋩 㜡 PTE p.m. 㢨 㟝 䚌 㤸 䞈 1-877-935-8023ⶼ 㡰 ⱬ 㢌 䚨 㨰 㐡 㐐 㝘. 䚐 ạ 㛨 䚌 㣄 ᴴ ⓸ 㝴 ᶷ 㢹. 㢨 PTE p.m. ⱨ 㟨 㜵. Y0020_MultiLangInsert15_2_Accepted_09022014 17

f f 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 1-877-935 8023. Вам окажет помощь сотрудник, который говорит по-pусски. Данная услуга бесплатная. ا ننا نقدم خدمات المترجم الفوري المجانية للا جابة عن ا ي ا سي لة تتعلق بالصحة ا و جدول الا دوية لدينا. للحصول Arabic: بمساعدتك. على مترجم فوري ليس عليك سوى الاتصال بنا على 3208-539-778-1. سيقوم شخص ما يتحدث العربية.هذه خدمة مجانية Hindi: हम र व य य दव क य जन क ब र म आपक कस भ > न क जव ब दन क लए हम र प स म त दभ षय सव ए उपल ध ह. 6 एक दभ षय > त करन क लए, बस हम 1-877-935-8023 पर फ न कर. f क ई cय iत ज ह द ब लत ह आपक मदद कर सकत ह. यह एक म त सव 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 1-877-935-8023. 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 1-877-935-8023. 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 1-877 935-8023. 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 1-877-935-8023. Ta usługa jest bezpłatna. ࡓࡍ ၥࡈࡍ 㛵 ฎ᪉ ရ ᙜ ᗣ ᗣಖ 㝤 Japanese: 1 ࠊ ࡈ ヂࠋࡍ ࡊࡈࡍ ࡀࢫ ࢧ ヂ ࠊ ࡇࠋࡍࡋࡓ ᨭࡀ ࡍヰ ᮏㄒࠋ ࡉࡔࡃヰ 㟁 877-935-8023 ࠋࡍ ࢫ ࢧ 18

SUMMARY OF MEDICAID-COVERED BENEFITS 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 Texas Medicaid covers and what our plan covers. What you pay for covered services may depend on your level of Medicaid eligibility. Coverage of the benefits described below depends upon your level of Medicaid eligibility. No matter what your level of Medicaid eligibility is, Superior HealthPlan Advantage (HMO SNP) will cover the benefits described in the Covered Medical and Hospital Benefits section of the Summary of Benefits. If you have questions about your Medicaid eligibility and what benefits you are entitled to call: 1-800 335-8957 (TTY users should call 711.) The Medicaid services described below are only a summary of benefits. Those who meet Qualified Medicare Beneficiary (QMB) requirements and also meet the financial criteria for full Medicaid coverage may be eligible to receive all Medicaid services not covered by Medicare, including Medicaid waiver services. Waiver services are limited to individuals who meet additional Medicaid waiver eligibility criteria. For more information, please contact Texas Medicaid for more information. NOTE (Superior HealthPlan Advantage (HMO SNP): Services covered with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor. Summary of Medicaid-Covered Benefits for Contract H5294 Plan 001 Benefit Texas Medicaid Superior HealthPlan Advantage (HMO SNP) OUTPATIENT CARE AND SERVICES Ambulance 1 Medicaid pays for this service if it $0 copay is not covered by Medicare or when the Medicare benefit is exhausted. $0 copay for Medicaid-covered services. 19

Benefit Texas Medicaid Superior HealthPlan Advantage (HMO SNP) Medicaid pays for this service if it Diagnostic radiology is not covered by Medicare or services (such as MRIs, when the Medicare benefit is CT scans): $0 copay exhausted. $0 copay for Medicaid-covered services. Diagnostic Tests, Lab and Radiology Services, and X-rays 1 Diagnostic tests and procedures: $0 copay Lab services: $0 copay Outpatient x-rays: $0 copay Therapeutic radiology services (such as radiation treatment for cancer): $0 copay Doctor 2 and Hospital Choice 1 Members should follow Medicare guidelines related to hospital and doctor choice. If you receive a service that is different from the covered diagnostic procedure/test, lab, and/or radiology service(s), then a separate coinsurance will apply. Primary care physician visit: $0 copay Specialist visit: $0 copay Inpatient hospital care and inpatient mental health care: The copays for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A 20

Benefit Texas Medicaid Superior HealthPlan Advantage (HMO SNP) Doctor 2 and Hospital Choice 1 continued 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. $0 copay 21

Benefit Texas Medicaid Superior HealthPlan Advantage (HMO SNP) Doctor Office Visits 2 Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted. $0 copay for Primary care physician visit: $0 copay Specialist visit: $0 copay Medicaid-covered services. Durable Medical Equipment (wheelchairs, oxygen, etc.) 1 Emergency Care (Any emergency room visit if the member reasonably believes he or she needs emergency care) Foot care (podiatry services) Home Health Care 1 Orthotic and Prosthetic Devices 1 (includes braces, artificial limbs, etc.) Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted. $0 copay for Medicaid-covered services. Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted. $0 copay for Medicaid-covered services. Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted. $0 copay for Medicaid-covered services. Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted. $0 copay for Medicaid-covered services. For members birth through 20 (CCP), Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted. Medicaid pays for breast $0 copay $0 copay Foot exams and treatment if you have diabetes related nerve damage and/or meet certain conditions: $0 copay $0 copay Prosthetic devices: $0 copay Related medical supplies: $0 copay 22

Benefit Texas Medicaid Superior HealthPlan Advantage (HMO SNP) Orthotic and Prosthetic Devices 1 (includes braces, artificial limbs, etc.) continued prostheses for members of all ages if not covered by Medicare or when the Medicare benefit is exhausted. $0 copay for Medicaid-covered Outpatient Mental Health Care 1 services. Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted. $0 copay for Medicaid-covered services. Outpatient group therapy visit: $0 copay Outpatient individual therapy visit: $0 copay Outpatient For members birth through 20, Rehabilitation Services 1 Medicaid pays for the service if it is not covered by Medicare or when the Medicare benefit is exhausted. $0 copay for Medicaid-covered services. Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): $0 copay Outpatient Services/Surgery 1 Urgently Needed Care Medicaid pays for certain surgical services if it is not covered by Medicare or when the Medicare benefit is exhausted. $0 copay for Medicaid-covered services. Medicaid pays for this service if it not covered by Medicare or when the Medicare benefit is exhausted. Members of a Medicaid managed care organization should check with Occupational Therapy visits: $0 copay Physical therapy and speech and language therapy visit: $0 copay Ambulatory surgical center: $0 copay Outpatient hospital: $0 copay $0 copay 23

Benefit Texas Medicaid Superior HealthPlan Advantage (HMO SNP) Urgently Needed Care continued their health plan to ensure coverage is available through a network provider. $0 copay for Medicaid-covered services. Preventive Care Colorectal screening exams (for people aged 50 and older): Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted. $0 copay for Medicaid-covered services. Immunizations: Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted. $0 copay for Medicaid-covered services. Mammograms (annual screenings): Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted. $0 copay for Medicaid-covered services. Pap smears and pelvic exams: Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted. $0 copay for Medicaid covered services. $0 copay 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 screenings Colonoscopy Colorectal cancer screenings 24

Benefit Texas Medicaid Superior HealthPlan Advantage (HMO SNP) Preventive Care Prostate cancer screening exams: Depression continued Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted. $0 copay for Medicaid covered services. 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 tobaccorelated disease) Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots "Welcome to Medicare" preventive visit 25

Benefit Texas Medicaid Superior HealthPlan Advantage (HMO SNP) Preventive Care continued (one-time) Yearly "Wellness" visit Any additional preventive services approved by Medicare during the contract year will be covered. INPATIENT CARE Inpatient Hospital Care 1 Inpatient hospital stays are a covered benefit. Medicaid pays coinsurance, co-payments, and deductibles for Medicare covered services. Members should follow Medicare guidelines related to hospital choice. $0 co-pay for Medicaid-covered services. $0 copay: Annual physical exam $0 copay 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. 26

Benefit Texas Medicaid Superior HealthPlan Advantage (HMO SNP) Inpatient Hospital Care 1 continued 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. Inpatient Mental Inpatient psychiatric hospital For inpatient mental Health Care 1 stays are a covered benefit for children. Inpatient hospital stays for acute psychiatric treatment are a covered benefit for adults. Medicaid pays coinsurance, copayments, and deductibles for Medicare covered services. Members should follow Medicare guidelines related to hospital choice. $0 co-pay for Medicaid-covered services. health care, see the Mental Health Care section of this booklet. Skilled Nursing Facility (SNF) 1 Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted. $0 co-pay for Medicaid-covered services. Our plan covers up to 100 days in a SNF. $0 copay 27

Benefit Texas Medicaid Superior HealthPlan Advantage (HMO SNP) PRESCRIPTION DRUG BENEFITS Standard Retail Cost-Sharing Prescription Drugs $0 copay for Medicaid-covered prescription drugs not covered by Medicare Part D. $0 Copay: For part B drugs such as chemotherapy drugs 1. Initial Coverage Tier 1 Generic Tier 2 Preferred Brand Note: Medicaid will not cover any Medicare Part D drug. $0 copay for Medicaid-covered prescription drugs not covered by Medicare Part D. Note: Medicaid will not cover any Medicare Part D drug. $0 copay for Medicaid-covered prescription drugs not covered by Medicare Part D. Note: Medicaid will not cover any Medicare Part D drug. $0 copay for Medicaid-covered prescription drugs not covered by Medicare Part D. Note: Medicaid will not cover any Medicare Part D drug. $0 copay: Other part B drugs 1 Our plan does not have a deductible for Part D prescription drugs. You pay the following: You may get your drugs at network retail pharmacies and mail order pharmacies. $0 copay For generic drugs (including brand drugs treated as generic), either: $1.20 copay; or $2.65 copay For all other drugs, either: 28

Benefit Texas Medicaid Superior HealthPlan Advantage (HMO SNP) Tier 2 Preferred Brand continued $3.60 copay; or $6.60 copay. Tier 3 Non-Preferred $0 copay for Medicaid-covered For generic drugs Brand prescription drugs not covered by Medicare Part D. Note: Medicaid will not cover any Medicare Part D drug. (including brand drugs treated as generic), either: $1.20 copay; or $2.65 copay Tier 4 Injectable Drugs $0 copay for Medicaid-covered prescription drugs not covered by Medicare Part D. Note: Medicaid will not cover any Medicare Part D drug. For all other drugs, either: $3.60 copay; or $6.60 copay. For generic drugs (including brand drugs treated as generic), either: $1.20 copay; or $2.65 copay For all other drugs, either: $3.60 copay; or $6.60 copay. If you reside in a longterm care facility, you pay the same as at a retail pharmacy. You may get drugs from an out-of-network pharmacy at the same 29

Benefit Texas Medicaid Superior HealthPlan Advantage (HMO SNP) Tier 4 Injectable Drugs continued cost as an in-network pharmacy. Catastrophic Coverage $0 copay for Medicaid-covered prescription drugs not covered by Medicare Part D. Note: Medicaid will not cover any Medicare Part D drug. $0 copay 30

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