AETNA BETTER HEALTH SM PREMIER PLAN Summary of Benefits

AETNA BETTER HEALTH SM PREMIER PLAN Summary of Benefits Aetna Better Health SM Premier Plan (Medicare-Medicaid Plan) is a health plan that contracts with both Medicare and Illinois Medicaid to provide benefits of both programs to enrollees. www.aetnabetterhealth.com/illinois

Helpful information Aetna Better Health Premier Plan Member Services 1-866-600-2139 (toll free) Representatives available 24 hours a day, 7 days a week Address Aetna Better Health Premier Plan One South Wacker Drive Suite 1200, Mail Stop F646 Chicago, IL 60606 Services for the Hearing Impaired Illinois Relay 7-1-1 Enrollment and Application Services Illinois Client Enrollment Broker (ICEB) 1-877-912-8880 (toll free) TTY: 1-866-565-8576 Transportation Services Medical Transportation Management, Inc. Non-Emergency Transportation 1-888-513-1612 (toll free) Dental Services DentaQuest 1-800-416-9185 (toll free) Behavioral Health Services 1-866-600-2139 (toll free) Vision Services March Vision 1-888-493-4070 (toll free) Pharmacy Services Aetna Better Health Premier Plan Call Member Services 1-866-600-2139 (toll free) Prescriptions by Mail CVS Caremark PO Box 2110 Pittsburgh, PA 15230-2110 TTY: 1-800-899-2114 Monday through Friday 8 a.m. to 5 p.m. Language Interpretation Services Including Sign Language Interpretation and CART Reporting Call Aetna Better Health Premier Plan Member Services 1-866-600-2139 (toll free) Representatives available 24 hours a day, 7 days a week Appeals and Grievances Aetna Better Health Premier Plan Attn: Appeals and Grievances Manager One South Wacker Drive Mail Stop F646 Chicago, IL 60606 1-866-600-2139 Illinois Relay 7-1-1 (hearing impaired) To make a request for a fair hearing: Illinois Department of Healthcare and Family Services Bureau of Assistance Hearings 401 South Clinton, Sixth Floor Chicago, IL 60607 1-800-435-0774 (toll free) TTY: 1-877-734-7429 Fraud and Abuse Hotline 1-877-436-8154 (toll free) www.aetnabetterhealth.com/illinois

AETNA BETTER HEALTH PREMIER PLAN: Summary of Benefits This is a summary of health services covered by Aetna Better Health Premier Plan for 2014. This is only a summary. Please read the Member Handbook for the full list of benefits. Aetna Better Health Premier Plan is a health plan that contracts with both Medicare and Illinois Medicaid to provide benefits of both programs to enrollees. It is for people with both Medicare and Medicaid. The Aetna Better Health Premier Plan will be available to individuals who meet all of the following criteria: o Age 21 and older at the time of enrollment; o Entitled to benefits under Medicare Part A and enrolled under Medicare Parts B and D, and receiving full Medicaid benefits; and o Enrolled in the Medicaid Aid to the Aged, Blind, and Disabled (ABD) category of assistance. o Eligible populations include: Beneficiaries who meet all other Demonstration criteria and are in the following Medicaid 1915(c) waivers: Persons who are Elderly; Persons with Disabilities; Persons with HIV/AIDS; Persons with Brain Injury; and Persons residing in Supportive Living Facilities. o Individuals with End Stage Renal Disease (ESRD) at the time of enrollment. Under Aetna Better Health Premier Plan you can get your Medicare and Medicaid services in one health plan. An Aetna Better Health Premier Plan care management team, led by a care manager will help manage your health care needs. www.aetnabetterhealth.com/illinois. 1 CMS ACCEPTED

This is not a complete list. The benefit information is a brief summary, not a complete description of benefits. For more information contact the plan or read the Member Handbook. Limitations and restrictions may apply. For more information, call Member Services or read the Aetna Better Health Premier Plan Member Handbook. Benefits, List of Covered Drugs, and pharmacy and provider networks may change from time to time throughout the year and on January 1 of each year. We will notify you, by mail and on our website, www.aetnabetterhealth.com/illinois, of any changes. You can ask for this information in other formats, such as Braille or large print. Call 1-866-600-2139, TTY/TDD IL Relay 7-1- 1 24 hours a day, 7 days a week. The call is free. You can get this document in Spanish, or speak with someone about this information in other languages for free. Call 1-866-600-2139, TTY/TDD IL Relay 7-1-1 24 hours a day, 7 days a week. The call is free. Usted puede obtener este documento en español, o hablar gratuitamente con una persona en otros idiomas sobre esta información. Llame a Servicios al Miembro al 1-866-600-2139 y TTY/TDD al 7-1-1, 24 horas al día, siete días de la semana. La llamada es gratis. Aetna Better Health Premier Plan is a health plan that contracts with both Medicare and Illinois Medicaid to provide benefits of both programs to enrollees. www.aetnabetterhealth.com/illinois. 2

The following chart lists frequently asked questions. Frequently Asked Questions (FAQ) What is a Medicare-Medicaid Plan What is an Aetna Better Health Premier Plan care manager What are long-term services and supports Will you get the same Medicare and Medicaid benefits in Aetna Better Health Premier Plan that you get now Answers A Medicare-Medicaid Plan is an organization made up of doctors, hospitals, pharmacies, providers of long-term services, and other providers. It also has care coordinators to help you manage all your providers and services. They all work together to provide the care you need. An Aetna Better Health Premier Plan care manager is one main person for you to contact. This person helps manage all your providers and services and makes sure you get what you need. Long-term services and supports are services provided through a Long Term Care Facility or through a Home and Community Based Waiver. Enrollees have the option to receive long-term services and supports (LTSS) in the least restrictive setting when appropriate, with a preference for the home and the community, and in accordance with the Enrollee s wishes and Care Plan. You will get your covered Medicare and Medicaid benefits directly from Aetna Better Health Premier Plan. You will work with a team of providers who will help determine what services will best meet your needs. This means that some of the services you get now may change. When you enroll in Aetna Better Health Premier Plan, you and your care team will work together to develop an Individualized Care Plan to address your health and support needs. During this time, you can keep seeing your doctors and getting your current services for 180 days, or until your care plan is complete. When you join our plan, if you are taking any Medicare Part D prescription drugs that Aetna Better Health Premier Plan does not normally cover, you can get a temporary supply. We will help you get another drug or get an exception for Aetna Better Health Premier Plan to cover your drug, if medically necessary. www.aetnabetterhealth.com/illinois. 3

Frequently Asked Questions (FAQ) Can you go to the same doctors you see now What happens if you need a service but no one in Aetna Better Health Premier Plan s network can provide it Where is Aetna Better Health Premier Plan available Answers Often that is the case. If your providers (including doctors, therapists, and pharmacies) work with Aetna Better Health Premier Plan and have a contract with us, you can keep going to them. Providers with an agreement with us are in-network. You must use the providers in Aetna Better Health Premier Plan s network. If you need urgent or emergency care or out-of-area dialysis services, you can use providers outside of Aetna Better Health Premier Plan's network. If Aetna Better Health Premier Plan is unable to provide necessary medical/surgical services covered under your benefits, Aetna Better Health Premier Plan will cover these services out of network for you, for as long as Aetna Better Health Premier Plan is unable to provide the services in network. To find out if your doctors are in the plan s network, call Member Services at 1-866-600-2139, TTY/TDD IL Relay 7-1-1, 24 hours a day, 7 days a week or read Aetna Better Health Premier Plan s Provider and Pharmacy Directory on our website at www.aetnabetterhealth.com/illinois. If Aetna Better Health Premier Plan is new for you, you can continue seeing the doctors you go to now for the next 180 days or until you and your care manager decide who is best to care for you and your health needs. Most services will be provided by our network providers. If you need a service that cannot be provided within our network, Aetna Better Health Premier Plan will pay for the cost of an out-of-network provider. The service area for this plan includes: Cook County, DuPage County, Kane County, Kankakee County and Will County in Illinois. You must live in one of these areas to join the plan. www.aetnabetterhealth.com/illinois. 4

Frequently Asked Questions (FAQ) Do you pay a monthly amount (also called a premium) under Aetna Better Health Premier Plan What is prior authorization What is a referral Answers You will not pay any monthly premiums to Aetna Better Health Premier Plan for your health coverage. Prior authorization means that you must get approval from Aetna Better Health Premier Plan before you can get a specific service or drug or see an out-of-network provider. Aetna Better Health Premier Plan may not cover the service or drug if you don t get approval. If you need urgent or emergency care or out-of-area dialysis services, you don't need to get approval first. A referral means that your primary care provider must give you approval to see someone that is not your primary care provider. If you don t get approval, Aetna Better Health Premier Plan may not cover the services. There are certain specialists in which you do not need a referral, such as women health specialists. For more information on when a referral is necessary, see the Member Handbook. www.aetnabetterhealth.com/illinois. 5

Frequently Asked Questions (FAQ) Who should you contact if you have questions or need help Answers If you have general questions or questions about our plan, services, billing, or member cards, please call Aetna Better Health Premier Plan Member Services: CALL 1-866-600-2139 TTY/TDD IL Relay 7-1-1, 24 hours a day, 7 days a week. The call is free. Member Services also has free language interpreter services available for people who do not speak English. TTY TTY/TDD Relay 7-1-1. This number is for people who have hearing or speaking problems. You must have special telephone equipment to call it. For more information call Member Services and we can answer any questions you have. Call 1-866-600-2139, TTY/TDD IL Relay 7-1-1, 24 hours a day, 7 days a week. The call is free. www.aetnabetterhealth.com/illinois. 6

Frequently Asked Questions (FAQ) Who should you contact if you have questions or need help (continued) Answers If you have questions about your health, please call the Nurse Advice Call line: CALL Call 1-866-600-2139, TTY/TDD IL Relay 7-1-1, 24 hours a day, 7 days a week. The call is free. Follow the prompts for the Nurse Advice Line. Member Services also has free language interpreter services available for people who do not speak English. TTY TTY/TDD IL Relay 7-1-1, 24 hours a day, 7 days a week. The call is free. Member Services also has free language interpreter services available for people who do not speak English. If you need immediate behavioral health crises services, please call 911 or the Behavioral Health Crisis Line: CALL TTY Call 1-866-600-2139, TTY/TDD IL Relay 7-1-1, 24 hours a day, 7 days a week. The call is free. Press 9 for the Nurse Advice Line. Member Services also has free language interpreter services available for people who do not speak English. TTY/TDD IL Relay 7-1-1, 24 hours a day, 7 days a week. Member Services also has free language interpreter services available for people who do not speak English. www.aetnabetterhealth.com/illinois. 7

The following chart is a quick overview of what services you may need, your costs and rules about the benefits. Health need or problem You want to see a doctor Services you may need Your costs for in-network providers Limitations, exceptions, & benefit information (rules about benefits) Visits to treat an injury or illness $0 100% - no limitations/no authorizations Wellness visits, such as a physical $0 100% - no limitations/no authorizations Transportation to a doctor s office $0 100% - prior authorization required Specialist care: Prof - Behavioral Health Non-Medical Prof - Cardiac Rehabilitation Prof - Chiropractic Prof - Intensive Cardiac Rehabilitation Prof - Orthopedic Shoes Prof - Preventative Services Prof - Lab Tests and services Prof - Pulmonary Rehabilitation Prof - Routine Foot Care $0 In some cases an authorization maybe required None 36 visit limit 12 per year 36 visit limit 5 per year with Diabetic diagnosis None None 36 visit limit Routine Foot Care Diagnosis Restriction - 1 visit every 3 months www.aetnabetterhealth.com/illinois. 8

Health need or problem Services you may need Care to keep you from getting sick, such as flu shots Welcome to Medicare preventive visit (one time only) Your costs for in-network providers Limitations, exceptions, & benefit information (rules about benefits) $0 100% - no limitations/no authorizations $0 100% - no limitations/no authorizations You need medical tests Lab tests, such as blood work $0 100% - prior authorization may be required for certain tests X-rays or other pictures, such as CAT scans Screening tests, such as tests to check for cancer $0 100% - some radiology requests require authorizations $0 100% - no authorizations required if seeing a network provider www.aetnabetterhealth.com/illinois. 9

Health need or problem Services you may need Your costs for in-network providers Limitations, exceptions, & benefit information (rules about benefits) You need drugs to treat your illness or condition There may be limitations on the types of drugs covered. Please see Aetna Better Health Premier Plan s List of Covered Drugs (Drug List) for more information. Generic drugs (no brand name) $0 for a 30-day supply. Extended day supplies of covered drugs are available at network, retail and mail order pharmacies. These drugs are usually considered maintenance drugs. Your copay for the extended day supply is the same as the 30-day supply. Some drugs have coverage rules or have limits on the amount you can get. For example: For some drugs, you or your doctor must get approval from the plan before you fill your prescription. Sometimes the plan limits the amount of a drug you can get. Step therapy: Sometimes the plan requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor thinks the first drug doesn t work for you, then we will cover the second. www.aetnabetterhealth.com/illinois. 10

Health need or problem Services you may need Your costs for in-network providers Limitations, exceptions, & benefit information (rules about benefits) Brand name drugs $0 for a 30-day supply. Extended day supplies of covered drugs are available at network retail and mail order pharmacies. These drugs are usually considered maintenance drugs. Your copay for the extended day supply is the same as the 30 day supply. Some drugs have coverage rules or have limits on the amount you can get. For example: For some drugs, you or your doctor must get approval from the plan before you fill your prescription. Sometimes the plan limits the amount of a drug you can get. Step therapy: Sometimes the plan requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor thinks the first drug doesn t work for you, then we will cover the second. www.aetnabetterhealth.com/illinois. 11

Health need or problem You need therapy after a stroke or accident You need emergency care Services you may need Your costs for in-network providers Limitations, exceptions, & benefit information (rules about benefits) Over-the-counter drugs $0 100% (in accordance with Medicaid covered benefits) Medicare Part B prescription drugs covered by Aetna Better Health Premier Plan. Part B drugs include drugs given by your doctor in his or her office, some oral cancer drugs, and some drugs used with certain medical equipment. Read the Member Handbook for more information on these drugs. Occupational, physical, or speech therapy $0 $0 100% Emergency room services $0 Emergency room services can be provided by in network and out of network providers and do not require prior authorization Ambulance services $0 Emergency ambulance services do not require a prior authorization www.aetnabetterhealth.com/illinois. 12

Health need or problem Services you may need Your costs for in-network providers Limitations, exceptions, & benefit information (rules about benefits) Urgent care $0 Urgent Care services can be provided by in network and out of network providers and do not require prior authorization You need hospital care Hospital stay $0 Emergency admissions, hospitals are required to notify the health plan. Elective admissions require prior authorization. Doctor or surgeon care $0 100% - no limitations/no authorizations You need help getting better or have special health needs Rehabilitation services $0 Rehabilitation = limit of 36 visits - in network provider (cardiac, pulmonary) Chiropractic = limit of 12 visits - in network provider Medical equipment for home care $0 100 % - with prior authorization requirements Skilled nursing care $0 100% - SNF Co-pay - Days 21-100 = Medicare and Medicaid = 0 co-pay You need eye care Eye exams $0 1 exam every 12 months Glasses or contact lenses $0 1 pair of glasses or contacts every 24 months www.aetnabetterhealth.com/illinois. 13

Health need or problem Services you may need Your costs for in-network providers Limitations, exceptions, & benefit information (rules about benefits) You need dental care Dental check-ups $0 Preventive (exams, cleaning, x-rays) 2/year You need hearing/auditory services You have a chronic condition, such as diabetes or heart disease Hearing screenings $0 100% - no limitations/no authorizations Hearing aids Services to help manage your disease $0 $0 100% - prior authorization required (in accordance with Medicaid covered benefits) 100% - no limitations/no authorizations Diabetes supplies and services $0 100% - no limitations/no authorizations You have a mental health condition You have a substance abuse problem You need long-term mental health services You need durable medical equipment (DME) Mental or behavioral health services $0 100% - no limitations/no authorizations Substance abuse services $0 100% - no limitations/no authorizations Inpatient care for people who need mental health care $0 100% - no limitations/no authorizations required Wheelchairs $0 100% - prior authorization required Canes $0 100% - no limitations/no authorizations www.aetnabetterhealth.com/illinois. 14

Health need or problem Services you may need Your costs for in-network providers Limitations, exceptions, & benefit information (rules about benefits) Crutches $0 100% - no limitations/no authorizations Walkers $0 100% - no limitations/no authorizations Oxygen $0 100% - no limitations/no authorizations www.aetnabetterhealth.com/illinois. 15

Health need or problem Services you may need Your costs for in-network providers Limitations, exceptions, & benefit information (rules about benefits) You need help living at home Meals brought to your home 0 These services are only available if you are enrolled on a waiver program in Illinois, prior authorization is required Home services, such as cleaning or housekeeping Changes to your home, such as ramps and wheelchair access Personal care assistant (You may be able to employ your own assistant. Call Member Services for more information.) Training to help you get paid or unpaid jobs 0 These services are only available if you are enrolled on a waiver program in Illinois, prior authorization is required 0 These services are only available if you are enrolled on a waiver program in Illinois, prior authorization is required 0 These services are only available if you are enrolled on a waiver program in Illinois, prior authorization is required 0 These services are only available if you are enrolled on a waiver program in Illinois, prior authorization is required Home health care services 0 These services are only available if you are enrolled on a waiver program in Illinois, prior authorization is required Services to help you live on your own 0 These services are only available if you are enrolled on a waiver program in Illinois, prior authorization is required www.aetnabetterhealth.com/illinois. 16

Health need or problem Services you may need Your costs for in-network providers Limitations, exceptions, & benefit information (rules about benefits) You need a place to live with people available to help you Your caregiver needs some time off Adult day services or other support services 0 These services are only available if you are enrolled on a waiver program in Illinois, prior authorization is required Assisted living or other housing services 0 These services are only available if you are enrolled on a waiver program in Illinois, prior authorization is required Nursing home care 0 These services are only available if you are enrolled on a waiver program in Illinois, prior authorization is required Respite care 0 These services are only available if you are enrolled on a waiver program in Illinois, prior authorization is required www.aetnabetterhealth.com/illinois. 17

Other services that Aetna Better Health Premier Plan covers: Other services Aetna Better Health Premier Plan covers (This is not a complete list. Call Member Services or read the Member Handbook to find out about other covered services.) Podiatry - expanded benefit Over The Counter Products Health Education Smoking and Tobacco Use Cessation Health and Wellness Nursing Hotline Nutritional Education 1 annual visit for routine foot care $20 per month through mail-order catalog service Wide array of health and education tools and programs that is available to members at no additional cost Medically necessary cessation counseling sessions (up to 50 per year), nicotine patches, gum, and lozenges, as well as certain pharmacy medications without needing prior authorization Access to the Silver & Fit program at no cost at participating locations Access to a registered nurse 24 hours a day, 7 days a week, 365 days a year Health and nutrition tools and programs that is available to members at no additional cost www.aetnabetterhealth.com/illinois. 18

Services that Aetna Better Health Premier Plan does not cover: Services Aetna Better Health Premier Plan does not cover (This is not a complete list. Call Member Services to find out about other excluded services.) Hospice Services Covered under Medicare fee for service Your rights as a member of the plan As a member of Aetna Better Health Premier Plan you have certain rights. You can exercise these rights without being punished. You can also use these rights without losing your health care services. We will tell you about your rights at least once a year. For more information on your rights, please read the Member Handbook. Your rights include, but are not limited to, the following: You have a right to respect, fairness and dignity. This includes: o The right to get covered services without concern about race, ethnicity, national origin, religion, gender, age, mental or physical disability, sexual orientation, genetic information, ability to pay, or ability to speak English o The right to request information in other formats (e.g., audio CD ROM, large print, cassette, Braille) o The right to be free from any form of restraint or seclusion o The right not to be billed by providers You have the right to get information about your health care. This includes information on treatment and your treatment options. This information should be in a format you can understand. These rights include getting information on: o Description of the services we cover o How to get services o How much services will cost you o Names of health care providers and care managers www.aetnabetterhealth.com/illinois. 19

You have the right to make decisions about your care, including refusing treatment. This includes the right: o To choose a Primary Care Provider (PCP) and you can change your PCP at any time o To see a women s health care provider without a referral o To get your covered services and drugs quickly o To know about all treatment options, no matter what they cost or whether they are covered o To refuse treatment, even if your doctor advises against it o To stop taking medicine o To ask for a second opinion. Aetna Better Health Premier Plan will pay for the cost of your second opinion visit. You have the right to timely access to care that does not have any communication or physical access barriers. This includes the right to: o Get medical care timely o Get in and out of a health care provider s office. This means barrier free access for people with disabilities, in accordance with the Americans with Disabilities Act o Have interpreters to help with communication with your doctors and your health plan. You have the right to seek emergency and urgent care when you need it. This means: o You have the right to get emergency services without prior approval in an emergency o You have the right to see an out of network urgent or emergency care provider, when necessary You have a right to confidentiality and privacy. This includes: o The right to ask for and get a copy of your medical records in a way that you can understand and to ask for your records to be changed or corrected. o The right to have your personal health information kept private. You have the right to make complaints about your covered services or care. This includes the right to: o File a complaint or grievance against us or our providers o Ask for a state fair hearing o Get a detailed reason for why services were denied www.aetnabetterhealth.com/illinois. 20

For more information about your rights, you can read the Aetna Better Health Premier Plan Member Handbook. If you have questions, you can also call Aetna Better Health Premier Plan Member Services. If you have a complaint or think we should cover something we denied If you have a complaint or think Aetna Better Health Premier Plan should cover something we denied, call Aetna Better Health Premier Plan Member Services toll-free number at 1-866-600-2139. For questions about your rights, you can read the Aetna Better Health Premier Plan Member Handbook. You can also call Aetna Better Health Premier Plan Member Services. For information and questions on for complaints, grievances, and appeals. You can call Aetna Better Health Premier Plan Member Services If you suspect fraud Most health care professionals and organizations that provide services are honest. Unfortunately, there may be some who are dishonest. If you think a doctor, hospital or other pharmacy is doing something wrong, please contact us. Call us at<plan name> Member Services. Phone numbers are on the cover of this summary. Or, call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You can call these numbers for free, 24 hours a day, 7 days a week. Or, call the office of Auditor General s Office at 1-855-217-1895 or contact them by email at OAG.Hotline@Illinois.gov www.aetnabetterhealth.com/illinois. 21