Summary of Benefits. January 1, 2015 - December 31, 2015

Summary of Benefits January 1, 2015 - December 31, 2015 Y0093_SOB_841 Y0093_SOB_1351_ACCEPTED_09152014

Keystone VIP Choice (HMO SNP) (a Medicare Advantage Health Maintenance Organization (HMO) offered by VISTA 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 (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 Keystone VIP Choice (HMO-SNP)). Tips for comparing your Medicare choices This Summary of Benefits booklet gives you a summary of what Keystone VIP Choice (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 Keystone VIP Choice (HMO-SNP) Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services Covered Medical and Hospital Benefits Prescription Drug Benefits Additional Information About Keystone VIP Choice(HMO SNP) Summary of Medicaid-Covered 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 1-855-241-3648. 1

Things to Know About Keystone VIP Choice (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. Eastern time. From February 15 to September 30, you can call us Monday through Friday from 8:00 a.m. to 8:00 p.m. Eastern time. Keystone VIP Choice (HMO-SNP) Phone Numbers and Website If you are a member of this plan, call toll-free 1-800-450-1166. If you are not a member of this plan, call toll-free 1-855-241-3648. Our website: http://www.keystonevipchoice.com Who can join? To join Keystone VIP Choice (HMO-SNP), you must be entitled to Medicare Part A, be enrolled in Medicare Part B and the Pennsylvania Medical Assistance Program, and live in our service area. Our service area includes the following counties in Pennsylvania: Bucks, Chester, Delaware, Montgomery, and Philadelphia. Which doctors, hospitals, and pharmacies can I use? Keystone VIP Choice (HMO-SNP) has a network of doctors, hospitals, pharmacies, and other providers. If you use the providers that are not in our network, the plan may not pay for these services. You must generally use network pharmacies to fill your prescriptions for covered Part D drugs. You can see our plan s Provider and Pharmacy Directory at our website (http://www.keystonevipchoice.com). Or, call us and we will send you a copy of the provider and pharmacy directories. 2

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.keystonevipchoice.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 five 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 January 1, 2015 - December 31, 2015 Monthly premium, deductible, and limits on how much you pay for covered services How much is the monthly premium? $0 per month. How much is the deductible? 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. Is there any limit on how much I will pay for my covered services? 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 Pennsylvania Medical Assistance eligibility. Refer to the Medicare & You handbook for Medicare-covered services. For Pennsylvania Medical Assistance-covered services, refer to the Medicaid Coverage section in this document. 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. Is there a limit on how much the plan will pay? Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply. Keystone VIP Choice is a HMO-SNP plan with a Medicare contract and a contract with the Pennsylvania Medical Assistance Program. Enrollment in Keystone VIP Choice depends on Medicare contract renewal. 4

Covered medical and hospital benefits Note: Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor. OUTPATIENT CARE AND SERVICES Acupuncture and Other Alternative Therapies Ambulance 1 Chiropractic Care 1 Dental Services Diabetes Supplies and Services 1 Diagnostic Tests, Lab and Radiology Services, and X-Rays 1 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 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 $500 plan coverage limit for supplemental comprehensive dental benefits every two years. This benefit includes coverage for minor restorations (such as fillings), simple extractions, dentures and denture repair. Diabetes monitoring supplies: You pay nothing Diabetes self-management training: You pay nothing Therapeutic shoes or inserts: You pay nothing 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 5

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 Doctor s Office Visits 2 Durable Medical Equipment (wheelchairs, oxygen, etc.) 1 Emergency Care Foot Care (podiatry services) 2 Hearing Services Home Health Care 1 Primary care physician visit: You pay nothing Specialist visit: You pay nothing 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 three years): You pay nothing Hearing aid: You pay nothing Our plan pays up to $800 every three years for hearing aids. You pay nothing 6

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 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 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 Outpatient Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 Rehabilitation 1 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 Outpatient Substance Abuse Outpatient Surgery 1 Group therapy visit: You pay nothing Individual therapy visit: You pay nothing Ambulatory surgical center: You pay nothing Outpatient hospital: You pay nothing 7

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 Over-the-Counter Items Prosthetic Devices (braces, artificial limbs, etc.) 1 Renal Dialysis Transportation 1 Urgent Care Vision Services Preventive Care Please visit our website to see our list of covered over-the-counter items. Up to $40 per quarter may be spent for OTC. Monies not spent in a quarter do not roll over into the next quarter. Prosthetic devices: You pay nothing Related medical supplies: You pay nothing You pay nothing You pay nothing $0 for up to 32 one way trip(s) to plan-approved locations every year. May consist of car, shuttle or van service depending on appropriateness for situation. Authorization and scheduling rules apply. 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 Eyeglasses (frames and lenses) (for up to 1 every two years): You pay nothing Eyeglasses or contact lenses after cataract surgery: You pay nothing Our plan pays up to $150 every two years for contact lenses and eyeglasses (frames and lenses). You pay nothing Our plan covers many preventive services, including: Abdominal aortic aneurysm screening Alcohol misuse counseling 8

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 Preventive Care Continued Hospice 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. 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. 9

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. INPATIENT CARE Inpatient Hospital Care 1 Inpatient Mental Health Care Skilled Nursing Facility (SNF) 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. 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 10

Prescription drug benefits How much do I pay? For Part B drugs such as chemotherapy drugs: You pay nothing Other Part B drugs: You pay nothing Initial Coverage 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. Standard Retail Cost-Sharing TIER Tier 1 (Preferred Generic) Tier 2 (Non-Preferred Generic) Tier 3 (Preferred Brand) Tier 4 (Non-Preferred Brand) Tier 5 (Specialty Tier) ONE-MONTH SUPPLY TWO-MONTH SUPPLY THREE-MONTH SUPPLY 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. 11

Standard Mail Order Cost-Sharing TIER Tier 1 (Preferred Generic) Tier 2 (Non-Preferred Generic) Tier 3 (Preferred Brand) Tier 4 (Non-Preferred Brand) Tier 5 (Specialty Tier) THREE-MONTH SUPPLY 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. 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. Catastrophic Coverage You pay nothing 12

Additional Information About Keystone VIP Choice (HMO SNP) Keystone VIP Choice also offers these additional benefits BENEFIT Membership in Health Club/Fitness classes Additional Smoking and Tobacco Use Cessation Nursing Hotline KEYSTONE VIP CHOICE (HMO-SNP) You pay nothing. The benefit will reimburse members to attend a health club or a fitness class at a plan approved location. The benefit is limited to reimbursement of the membership fee. The goals of the benefit are to encourage a healthy lifestyle, to improve health status and to help manage chronic conditions. You pay nothing. Four additional face-to-face PCP visits for smoking/tobacco cessation annually. You pay nothing. The Nursing Hotline is a service available to all members 24 hours a day; seven days a week. The service is designed to provide members with a resource to answer health-related questions and to recommend the appropriate level of care. 13

Summary of Medicaid-Covered Benefits With Keystone VIP Choice (HMO-SNP), you receive Medicare cost sharing assistance from the Pennsylvania Medical Assistance Program. You pay no cost-sharing for Medicare-covered services listed in Section II. When you receive medical services, the provider should only bill Keystone VIP Choice or the Medical Assistance Program for the cost of those services and cost sharing amounts. The provider should not charge you for medical services or cost-sharing. In order to be a member of Keystone VIP Choice (HMO SNP), you must qualify for Medical Assistance at one of the following categories of aid: Qualified Medicare Beneficiary (QMB only) Qualified Medicare Beneficiary Plus (QMB+) or Specified Low-lncome Medicare Beneficiary Plus (SLMB+) If you have questions about your eligibility, call Member Services at 1-855-241-3648. 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 Pennsylvania Medical Assistance Program covers and what our plan covers. What you pay for your covered services may depend on your level of Medicaid eligibility. Services Covered under Pennsylvania Medical Assistance On the following page is a list of Medicaid State Plan Benefits and Home Community-Based Services (HCBS) Waiver Services covered by Pennsylvania Medical Assistance as well as any applicable benefit limits. Home and community-based Waiver Services allow for long term care services in home and community based settings under the Medicaid Program. There is no copayment for any of the services listed. 14

BENEFITS COVERED UNDER MEDICAL ASSISTANCE BENEFIT LIMITS UNDER MEDICAL ASSISTANCE Inpatient Acute Hospital YES N/A Inpatient Rehab Hospital YES N/A Inpatient Psych YES 30 Days per Fiscal Year Inpatient Drug & Alcohol YES 30 Days per Fiscal Year Emergency Room YES N/A Outpatient Hospital Short Procedure Unit and Ambulatory Surgical Center YES N/A Outpatient Hospital Clinic YES 18 visits per Fiscal Year* Outpatient Psych Clinic YES 5 hrs psychotherapy per 30 days Psych Partial YES 540 hrs per Fiscal Year Outpatient Drug & Alcohol Clinic YES 8 hrs psychotherapy per 30 days 7 methadone visits per week 42 opiate detox visits per 365 days Independent Medical Clinic YES 18 visits per Fiscal Year * Federally Qualified Health Center/Rural Health Center YES 18 visits per Fiscal Year * Family Planning Clinic YES 18 visits per Fiscal Year * Maternity Physician, Certified Nurse Midwife, Birth Center YES N/A Physician Services YES 18 visits per Fiscal Year * 15

BENEFITS COVERED UNDER MEDICAL ASSISTANCE BENEFIT LIMITS UNDER MEDICAL ASSISTANCE Certified Registered Nurse Practitioner Services YES 18 visits per Fiscal Year * Optometrist Services YES 18 visits per Fiscal Year * Podiatrist Services YES 18 visits per Fiscal Year * Renal Dialysis YES N/A Hospice YES N/A Skilled Nursing Facility/Long Term Care YES N/A Intermediate Care Facility/Mental Retardation and Intermediate Care Facility/Other Related Conditions YES N/A Laboratory YES N/A Radiology (x-ray) YES N/A Home Health Agency YES N/A Medical Supplies YES Categorically Needy unlimited Medically Needy - only in conjunction w/home Health Agency services Durable Medical Equipment YES Categorically Needy unlimited Ambulance (emergency) YES N/A Medically Needy - only in conjunction w/home Health Agency services 16

BENEFITS COVERED UNDER MEDICAL ASSISTANCE BENEFIT LIMITS UNDER MEDICAL ASSISTANCE Non Emergency Medical Treatment YES N/A Pharmacy YES Categorically Needy Audiologist Services YES under age 21 only Medically Needy- Birth Control only. Long Term Care all legend RX Case Management (Targeted Case Management) YES Limited to target groups Chiropractor Services YES 18 visits per Fiscal Year * Dentist Services (office) YES Categorically Needy- N/A 2 Medically Needy- Not covered Eyeglasses YES under age 21 only Hearing Aids YES under age 21 only Personal Care YES under age 21 only Private Duty Nursing YES under age 21 only Psychologist Services (office) YES under age 21 only Residential Treatment Facility YES under age 21 only Social Worker Services YES under age 21 only Therapy (Speech, Language, Hearing) YES under age 21 only 17

BENEFITS COVERED UNDER MEDICAL ASSISTANCE BENEFIT LIMITS UNDER MEDICAL ASSISTANCE Home and Community-Based Services YES Personal Assistance Services Home Health Accessibility Adaptations, Equipment, Technology, and Medical Supplies Respite Therapeutic and Counseling Services Financial Management Services Community Transition Services Personal Emergency Response System (PERS) Adult Daily Living TeleCare Non-Medical Transportation Community Integration Supported Employment Education Services Service Coordination Home Delivered Meals Prevocational Services Participant-Directed Community Supports Participant-Directed Goods and Services Residential Habilitation Structured Day Habilitation 18

1 Combined total of specific evaluation, management and consultation procedures by physicians, podiatrists, optometrists, CRNPs, chiropractors, outpatient and independent clinics, RHCs and FQHCs. Limit applies to adults, excluding adults who are pregnant or live in a nursing facility, ICF/MR or ICF/ORC settings. A Benefit Limit Exceptions process is available. 2 New dental limits will apply to adults eft, 9/30/11: Dental exams and prophylaxis are limited to 1 per 180 days, per recipient; crowns, endodontic and periodontal services will not be covered; and dentures will be limited to one upper arch or partial and one lower arch or partial, or one full set of dentures per lifetime. A Benefit Limit Exception process will be available. These dental charges do not apply to adults who live in a nursing facility, ICF/MR or ICF/ORC settings 3 Fiscal Year. The Pennsylvania State fiscal year begins on July 1 and ends on June 30. SERVICES COVERED UNDER KEYSTONE VIP CHOICE A description of the benefits and cost-sharing covered under Keystone VIP Choice (HMO-SNP) Plan are listed in the section titled Covered Medical and Hospital Benefits. 19

you. This is a free service. Spanish: Tenemos servicios de intérprete sin costo alguno para responder cualquier pregunta que pueda tener Multi- language sobre nuestro plan Interpreter de salud o medicamentos. Services Para hablar con un intérprete, por favor llame al 1-800- 450-1166. Alguien que hable español le podrá ayudar. Este es un servicio gratuito. English: We have free interpreter services to answer any questions you may have about our health or drug plan. Chinese To Mandarin: get interpreter, 我 们 提 供 just 免 费 call 的 us 翻 at 译 1-800- 450-1166. 服 务, 帮 助 您 解 答 Someone 关 于 健 康 who 或 药 speaks 物 保 险 English/Language 的 任 何 疑 问 如 can 果 您 help 需 you. 要 此 翻 This 译 服 is a 务 free, 请 service. 致 电 1-800-450-1166 我 们 的 中 文 工 作 人 员 很 乐 意 帮 助 您 这 是 一 项 免 费 服 务 20 Spanish: Chinese Cantonese: Tenemos servicios 您 對 我 de 們 的 intérprete 健 康 或 藥 sin 物 costo 保 險 可 alguno 能 存 有 para 疑 問 responder, 為 此 我 cualquier 們 提 供 免 pregunta 費 的 翻 譯 que 服 務 pueda 如 需 tener 翻 sobre 譯 服 務 nuestro, 請 致 plan 電 1-800-450-1166 de salud o medicamentos. 我 們 講 中 文 Para 的 人 hablar 員 將 con 樂 意 un 為 intérprete, 您 提 供 幫 助 por 這 favor 是 一 llame 項 免 al 費 服 務 1-800- 450-1166. Alguien que hable español le podrá ayudar. Este es un servicio gratuito. Tagalog: Mayroon kaming libreng serbisyo sa pagsasaling- wika upang masagot ang anumang mga katanungan 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 ninyo hinggil sa aming planong pangkalusugan o panggamot. Upang makakuha ng tagasaling- wika, tawagan 要 lamang 此 翻 译 kami 服 务 sa, 1-800- 450-1166. 请 致 电 1-800-450-1166 Maaari kayong 我 们 的 tulungan 中 文 工 作 ng 人 isang 员 很 nakakapagsalita 乐 意 帮 助 您 这 ng 是 Tagalog. 一 项 免 费 Ito 服 ay 务 libreng serbisyo. 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 French: 服 務, Nous 請 致 proposons 電 1-800-450-1166 des services 我 gratuits 們 講 中 文 d'interprétation 的 人 員 將 樂 意 pour 為 您 répondre 提 供 幫 助 à toutes 這 是 一 vos 項 免 questions 費 服 務 relatives à notre régime de santé ou d'assurance- médicaments. Pour accéder au service d'interprétation, il vous suffit Tagalog: de nous appeler Mayroon au kaming 1-800- 450-1166. libreng serbisyo Un interlocuteur sa pagsasaling- wika parlant Français upang masagot pourra vous ang anumang aider. Ce service mga katanungan est ninyo gratuit. hinggil sa aming planong pangkalusugan o panggamot. Upang makakuha ng tagasaling- wika, tawagan lamang kami sa 1-800- 450-1166. Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog. Ito ay libreng serbisyo. 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- 450-1166 sẽ có nhân viên nói tiếng Việt giúp đỡ quí French: vị. Đây Nous là dịch proposons vụ miễn des phí 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 German: nous appeler Unser kostenloser au 1-800- 450-1166. Dolmetscherservice Un interlocuteur beantwortet parlant Ihren Français Fragen pourra zu unserem vous aider. Gesundheits- Ce service est und gratuit. Arzneimittelplan. Unsere Dolmetscher erreichen Sie unter 1-800- 450-1166. Man wird Ihnen dort auf Deutsch weiterhelfen. Dieser Service ist kostenlos. Vietnamese: Chúng tôi có dịch vụ thông dịch miễn phí để trả lời các câu hỏi về chương sức khỏe và chương Korean: trình thuốc 당사는 men. 의료 Nếu quí 보험 vị 또는 cần thông 약품 dịch 보험에 viên 관한 xin gọi 질문에 1-800- 450-1166 답해 드리고자 sẽ có 무료 nhân 통역 viên 서비스를 nói tiếng Việt 제공하고 giúp đỡ quí 있습니다. vị. Đây là 통역 dịch 서비스를 vụ miễn phí 이용하려면. 전화 1-800-450-1166번으로 문의해 주십시오. 한국어를 하는 담당자가 도와 드릴 것입니다. 이 서비스는 무료로 운영됩니다. German: Unser kostenloser Dolmetscherservice beantwortet Ihren Fragen zu unserem Gesundheits- und Keystone Arzneimittelplan. VIP Choice Unsere is an Dolmetscher HMO- SNP plan erreichen with a Medicare Sie unter contract 1-800- 450-1166. and a contract Man wird with Ihnen the Pennsylvania dort auf Deutsch weiterhelfen. Medicaid program. Dieser This Service plan ist available kostenlos. to anyone who has both Medical Assistance from the State and Medicare. Enrollment in Keystone VIP Choice depends on Medicare contract renewal. Korean: 당사는 의료 보험 또는 약품 보험에 관한 질문에 답해 드리고자 무료 통역 서비스를 제공하고 있습니다. 통역 서비스를 이용하려면 전화 1-800-450-1166번으로 문의해 주십시오. 한국어를 하는 담당자가 도와 드릴 것입니다. 이 서비스는 무료로 운영됩니다. Y0093_MLI_696_Accepted_09012013 Keystone VIP Choice is an HMO- SNP plan with a Medicare contract and a contract with the Pennsylvania KVIPCPA- 1322-04 Medicaid program. This plan is available to anyone who has both Medical Assistance from the State and

있습니다. you. This is 통역 a free 서비스를 service. 이용하려면 전화 1-800-450-1166번으로 문의해 주십시오. 한국어를 하는 담당자가 도와 드릴 것입니다. 이 서비스는 무료로 운영됩니다. Spanish: Tenemos servicios de intérprete sin costo alguno para responder cualquier pregunta que pueda tener Keystone sobre nuestro VIP Choice plan de is salud an HMO- SNP o medicamentos. plan with a Para Medicare hablar contract un intérprete, and a contract por favor with llame the Pennsylvania al Medicaid 1-800- 450-1166. program. Alguien This plan que is hable available español to anyone le podrá who ayudar. has both Este Medical es un servicio Assistance gratuito. from the State and Medicare. Enrollment in Keystone VIP Choice depends on Medicare contract renewal. 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 Russian: 要 此 翻 译 Если 服 务 у, вас 请 致 возникнут 电 1-800-450-1166 вопросы относительно 我 们 的 中 文 工 страхового 作 人 员 很 乐 или 意 медикаментного 帮 助 您 这 是 一 项 плана, 免 费 服 вы 务 можете воспользоваться нашими бесплатными услугами переводчиков. Чтобы воспользоваться услугами Y0093_MLI_696_Accepted_09012013 переводчика, Chinese Cantonese: позвоните 您 對 我 нам 們 的 по 健 телефону 康 或 藥 物 1-800- 450-1166. 保 險 可 能 存 有 疑 Вам 問, окажет 為 此 我 們 помощь 提 供 免 сотрудник, 費 的 翻 譯 服 который 務 如 需 翻 KVIPCPA- 1322-04 говорит 譯 服 務, по- pусски. 請 致 電 1-800-450-1166 Данная услуга бесплатная. 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 االمترجم االفورريي anumang ang االمجانيیة للا جابة masagot عن ا أيي upang ا أسي لة تتعلق بالصحة ا أوو pagsasaling- wika جدوولل sa االا ددوويیة serbisyo لديینا. libreng للحصولل على kaming مترجم فورريي Mayroon ليیس Tagalog: Arabic: mga ا إننا نقدمم خدماتت katanungan سيیقومم aming شخص sa ما hinggil يیتحدثث ninyo االعربيیة planong. 1161 بنا على 054 pangkalusugan 008 1 o.بمساعدتك. هھھھذهه خدمة makakuha مجانيیة Upang عليیك سوىى panggamot. االاتصالل ng tagasaling- wika, tawagan lamang kami sa 1-800- 450-1166. Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog. Ito ay libreng Italian: serbisyo. 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- 450-1166. Un nostro incaricato che French: parla Nous Italianovi proposons fornirà des l'assistenza services gratuits necessaria. d'interprétation È un servizio pour gratuito. répondre à toutes vos questions relatives à notre régime de santé ou d'assurance- médicaments. Pour accéder au service d'interprétation, il vous suffit Portugués: de nous appeler Dispomos au 1-800- 450-1166. de serviços de interpretação Un interlocuteur gratuitos parlant para Français responder pourra a qualquer vous aider. questão Ce service que est tenha acerca gratuit. do nosso plano de saúde ou de medicação. Para obter um intérprete, contacte- nos através do número 1-800- 450-1166. Irá encontrar alguém que fale o idioma Português para o ajudar. Este serviço é gratuito. Vietnamese: Chúng tôi có dịch vụ thông dịch miễn phí để trả lời các câu hỏi về chương sức khỏe và chương French trình thuốc Creole: men. Nou Nếu genyen quí vị sèvis cần thông entèprèt dịch gratis viên xin pou gọi reponn 1-800- 450-1166 tout kesyon sẽ ou có ta nhân genyen viên konsènan nói tiếng Việt plan giúp medikal đỡ oswa quí vị. dwòg Đây là nou dịch an. vụ Pou miễn jwenn phí. yon entèprèt, jis rele nou nan 1-800- 450-1166. Yon moun ki pale Kreyòl kapab ede w. Sa a se yon sèvis ki gratis. German: Unser kostenloser Dolmetscherservice beantwortet Ihren Fragen zu unserem Gesundheits- und Polish: Arzneimittelplan. Umożliwiamy Unsere bezpłatne Dolmetscher skorzystanie erreichen z usług Sie unter tłumacza 1-800- 450-1166. ustnego, który Man pomoże wird w Ihnen uzyskaniu dort auf odpowiedzi Deutsch na weiterhelfen. temat planu Dieser zdrowotnego Service ist lub kostenlos. dawkowania leków. Aby skorzystać z pomocy tłumacza znającego język polski, należy zadzwonić pod numer 1-800- 450-1166. Ta usługa jest bezpłatna. Korean: 당사는 의료 보험 또는 약품 보험에 관한 질문에 답해 드리고자 무료 통역 서비스를 제공하고 Hindi: 있습니다. 통역 서비스를 이용하려면 전화 1-800-450-1166번으로 문의해 주십시오. 한국어를 하는 담당자가 도와 드릴 것입니다. 이 서비스는 무료로 운영됩니다. Keystone VIP Choice is an HMO- SNP plan with a Medicare contract and a contract with the Pennsylvania Medicaid program. This plan is available to anyone who has both Medical Assistance from the State and 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 Medicare. Enrollment in Keystone VIP Choice depends on Medicare contract renewal. 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- 450-1166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 Y0093_MLI_696_Accepted_09012013 KVIPCPA- 1322-04 21

www.keystonevipchoice.com KVIPCPA-1422-30 22