January 1, 2015 December 31, 2015

ALOHACARE ADVANTAGE PLUS PLAN 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. H5969_106101_1 CMS Accepted 09242014

Section I Introduction to Summary of Benefits You have choices about how to get your Medicare benefits One choice is to get your Medicare benefits through Original Medicare (fee-for-service Medicare). Original Medicare is run directly by the Federal government. Another choice is to get your Medicare benefits by joining a Medicare health plan (such as ). Tips for comparing your Medicare choices This Summary of Benefits booklet gives you a summary of what (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/TDD users should call 1-877-486-2048. Sections in this booklet Things to Know About Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services Covered Medical and Hospital Benefits Prescription Drug Benefits This document is available in other formats such as Braille and large print. This document may be available in a non-english language. For additional information, call us at 973-6395 or toll free at 1-866-973-6395. TTY/TDD users should call at 1-877-447-5990. Page 1

Things to know About 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. Hawaii time. From February 15 to September 30, you can call us Monday through Friday from 8:00 a.m. to 8:00 p.m. Hawaii time. Phone Numbers and Website If you are a member of this plan, call toll-free 1-866-973-6395. If you are not a member of this plan, call toll-free 1-866-973-6395. Our website: AlohaCare.org Who can join? To join (HMO SNP), you must be entitled to Medicare Part A, be enrolled in Medicare Part B and QUEST Integration Program (), and live in our service area. Our service area includes the following counties in Hawaii: Hawaii, Honolulu, Kalawao, Kauai, and Maui. Which doctors, hospitals, and pharmacies can I use? has a network of doctors, hospitals, pharmacies, and other providers. If you use the providers that are not in our network, the plan may not pay for these You must generally use network pharmacies to fill your prescriptions for covered Part D drugs. You can see our plan s provider directory at our website (www.alohacare.org) You can see our plan s pharmacy directory at our website (www.alohacare.org/ providersearch). 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, AlohaCare.org. Or, call us and we will send you a copy of the formulary. How will I determine my drug costs? The amount you pay for drugs depends on the drug you are taking and what stage of the benefit you have reached. Later in this document we discuss the benefit stages that occur after you meet your deductible: Initial Coverage, Coverage Gap, and Catastrophic Coverage. Page 2

Section II Summary of Benefits January 1, 2015 December 31, 2015 SUMMARY OF BENEFITS Monthly Premium, Deductible, and Limits on how much you pay for Covered Services How much is the $0 per month monthly premium? How much is the This plan does not have a deductible. deductible? This plan does not have a deductible for chemotherapy and other drugs administered in your doctor s office (Part B drugs). Is there any limit on how much I will pay for my covered services? This plan does not have a deductible for Part D prescription drugs. Yes. Like all Medicare health plans, our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care. In this plan, you may pay nothing for Medicare-covered services, depending on your level of QUEST Integration eligibility. Refer to the Medicare & You handbook for Medicare-covered For QUEST Integration-covered services, refer to the Coverage section in this document. Your yearly limit(s) in this plan: $6,700 for services you receive from in-network providers. If you reach the limit on out-of-pocket costs, you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year. Is there a limit on how much the plan will pay? Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs. Our plan has a coverage limit every year for certain in-network benefits. Contact us for services that apply. is an HMO plan with a Medicare contract and a contract with the Hawaii program. Enrollment in depends on contract renewal. The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Limitations, copayments, and restrictions may apply. Benefits, formulary, pharmacy network, provider network, premium and/or copayments/coinsurance may change on January 1 of each year. The Part B premium is covered for full-dual enrollees who are eligible for. This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, copayments, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details. Page 3

NOTE: Covered Medical and Hospital Benefits Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor. Acupuncture and Other Alternative Therapies 1 Ambulance 1 Chiropractic Care 1 Dental Services Diabetes Supplies and Services 1 Diagnostic Tests, Lab and Radiology Services, and X-Rays 1 Outpatient Care and Services For up to 15 visit(s) every year; there is a limit to how much our plan will pay: $1000 plan coverage limit for acupuncture and other alternative therapies every year. Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): Preventive dental services: Cleaning (for up to 2 every year): Dental x-ray(s) (for up to 2 every year): Oral exam (for up to 2 every year): Diabetes monitoring supplies: Diabetes self-management training: Therapeutic shoes or inserts: Diagnostic radiology services (such as MRIs, CT scans): Diagnostic tests and procedures: Lab services: Outpatient x-rays: Therapeutic radiology services (such as radiation treatment for cancer): You pay nothing. You pay nothing. You pay nothing. You pay nothing. You pay nothing. You pay nothing. Doctor s Office Primary care physician visit: You pay nothing. Visits 2 Specialist visit: Durable Medical Equipment (wheelchairs, oxygen, etc.) 1 You pay nothing. Page 4

Emergency Care Foot Care (podiatry services) 1, 2 Hearing Services 1, 2 Home Health Care 1 Mental Health Care 1 World-wide benefit Outside the U.S., plan annual maximum covered benefit limit of $1000. You pay a $0 copay and any amounts over $1000. You will have to pay the facility or provider for Receipts must be in English with billed charges in U.S. dollars. will reimburse you up to your benefit limit. Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: Routine food care (for up to 8 visit(s) every year): Exam to diagnose and treat hearing and balance issues: 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. Outpatient group therapy visit: Outpatient Individual therapy visit: SUMMARY OF BENEFITS You pay nothing. You pay nothing. You pay nothing. You pay nothing. You pay nothing. Page 5

Outpatient Rehabilitation 1 Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): Occupational therapy visit: Physical therapy and speech and language therapy visit: You pay nothing. Outpatient Group therapy visit: You pay nothing. Substance Individual therapy visit: Abuse 1 Outpatient Ambulatory surgical center: You pay nothing. Surgery 1 Outpatient hospital: Over-the-Counter Items Please visit our website to see our list of covered over-the-counter items. Prosthetic Prosthetic devices: You pay nothing. Devices (braces, Related medical supplies: artificial limbs, etc.) 1 Renal Dialysis 1, 2 You pay nothing. Transportation Not covered. Urgent Care You pay nothing. Vision Services Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): You pay nothing. Eyeglasses or contact lenses after cataract surgery: Page 6

Preventive Care Our plan covers many preventive services, including: Abdominal aortic aneurysm screening Alcohol misuse counseling Bone mass measurement Breast cancer screening (mammogram) Cardiovascular disease (behavioral therapy) Cardiovascular screenings Cervical and vaginal cancer screening Colonoscopy Colorectal cancer screenings Depression screenings 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 You pay nothing. Any additional preventive services approved by Medicare during the contract year will be covered. Annual physical exam Hospice 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. Page 7

Inpatient Care Inpatient Hospital The copays for hospital and skilled nursing You pay nothing. Care 1 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. Inpatient Mental For inpatient mental health care, see the Mental Health Care section of this Health Care booklet. Skilled Nursing Our plan covers up to 100 days in a SNF. You pay nothing. Facility (SNF) 1 Page 8

How much do I pay? Initial Coverage Prescription Drug Benefits For Part B drugs such as chemotherapy drugs 1 : You pay nothing. Other Part B drugs 1 : Our plan does not have a deductible for Part D prescription drugs. Depending on your income and institutional status, you pay the following: For generic drugs (including brand drugs $0 copay; or treated as generic), either: $1.20 copay; or $2.65 copay For all other drugs, either: $0 copay; or $3.60 copay; or Catastrophic Coverage You may get your drugs at network retail pharmacies. If you reside in a long-term care facility, you pay the same as at a retail pharmacy. You may get drugs from an out-of-network pharmacy at the same cost as an in-network pharmacy. $6.60 copay You pay nothing. Page 9

Summary of -Covered Benefits, H5969, Plan 002 The following section will describe benefits that you are entitled to as a recipient of benefits, in the State of Hawaii. Medicare members, who also qualify for, are eligible for additional benefits, including assistance with paying for their Medicare premiums, deductibles and cost sharing, such as copays and coinsurance. The benefits available to you are managed under the QUEST Integration Program. This document does not describe all of the details of your benefits. Please contact your QUEST Integration plan for a complete listing. As a QUEST Integration beneficiary, you can access these benefits through one of five health plans handbooks; AlohaCare, HMSA, Kaiser Foundation Health Plan, Ohana Health Plan, or United Healthcare Community Plan. You can also get more information from Med-QUEST: Med-QUEST Enrollment Services Section Oahu: 524-3370 Neighbor Islands: 1-800-316-8005 The benefits described below are covered by. 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 QUEST Integration covers and what our plan covers. What you pay for covered services may depend on your level of eligibility. Benefit Category Premium and Other Important Information IMPORTANT INFORMATION There are no copays and General no coinsurance for this plan $0 monthly plan premium.* In-Network $0 annual deductible.* $6,700 out-of-pocket limit for Medicarecovered However, in this plan you will have no cost sharing responsibility for Medicare-covered services, based on your level of eligibility. * Depending on your level of eligibility, you may not have any cost-sharing responsiblity for Original Medicare Page 10

Benefit Category Doctor and Hospital Choice (For more information, see Emergency Care and Urgently Needed Care.) SUMMARY OF BENEFITS In-Network You must go to network doctors, specialists, and hospitals. Referral required for network specialists (for certain benefits). Inpatient Hospital Care (Includes Substance Abuse and Rehabilitation Services) SUMMARY OF BENEFITS INPATIENT CARE No limit on number of days of service. Includes the cost of room and board for Inpatient stays for: Nursing care Medical supplies Equipment In-Network Plan covers 90 days each benefit period. You will not be charged additional cost sharing for professional $0 annual service category deductible.* $0 copay.* Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital. Drugs Diagnostic services Physical and occupational therapy Audiology Speech-language pathology services * Depending on your level of eligibility, you may not have any cost-sharing responsiblity for Original Medicare Page 11

Benefit Category Inpatient Mental Health Care No limit on number of days of service. Covered services include all medically necessary behavioral health These services include: Ambulatory services, including 24-hours-aday, 7-days-a-week crisis services 24-hour-a-day care for acute psychiatric illnesses, including: - Room and board - Nursing care - Medical supplies and equipment - Diagnostic services - Physician services - Other practitioner services, as needed - Other medically necessary services In-Network You get up to 190 days of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital. $0 annual service category deductible. $0 copay.* Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital. * Depending on your level of eligibility, you may not have any cost-sharing responsiblity for Original Medicare Page 12

Benefit Category Skilled Nursing Facility (SNF) (In a Medicare-certified skilled nursing facility) No limit on number of days of service. Covered for members who need 24-hour-a-day help with activities of daily living (ADLs) and instrumental activities of daily living (IADLs.) These members need regular, longterm care from licensed nurses and para-medical personnel. The care that is provided in a nursing facility includes: Independent and group activities Meals and snacks Housekeeping and laundry services Nursing and social work services Nutritional monitoring and counseling Pharmaceutical services and rehabilitative services SUMMARY OF BENEFITS General Authorization rules may apply. In-Network Plan covers up to 100 days each benefit period. No prior hospital stay is required. $0 annual service category deductible.* $0 copay for SNF * You will not be charged additional cost sharing for professional * Depending on your level of eligibility, you may not have any cost-sharing responsiblity for Original Medicare Page 13

Benefit Category Home Health Care (Includes medically necessary intermittent skilled nursing care, home health aide services, and rehabilitation services, etc.) Some home health services included are: Skilled nursing Home health aides Medical supplies Physical and occupational Therapy Audiology and speechlanguage pathology General Authorization rules may apply. In-Network $0 copay for Medicare-covered home health visits.* Hospice Provides care to terminally ill patients who have 6 months or less to live. General You must get care from a Medicare-certified hospice. You must consult with your plan before you select hospice. Doctor Office Visits OUTPATIENT CARE Services include: Initial and interval histories Comprehensive physical examinations (including developmental services) Immunizations Diagnostic and screening laboratory X-ray services (including screening for tuberculosis) In-Network $0 copay for each Medicare-covered primary care doctor visit.* $0 copay for each Medicare-covered specialist visit.* * Depending on your level of eligibility, you may not have any cost-sharing responsiblity for Original Medicare Page 14

Benefit Category Cornea Transplants and Bone Graft Services Cornea transplants (keraplasty) and Bone graft. SUMMARY OF BENEFITS Chiropractic Services Not Covered. General Authorization rules may apply. In-Network $0 copay for Medicare-covered chiropractic visits.* Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part). Podiatry Services Medically necessary foot care. General Authorization rules may apply. In-Network $0 copay for Medicare-covered podiatry visits.* You pay nothing for up to 8 supplemental routine podiatry visit(s) every year. Medicare-covered podiatry visits are for medically necessary foot care. * Depending on your level of eligibility, you may not have any cost-sharing responsiblity for Original Medicare Page 15

Benefit Category Outpatient Mental Health Care Covered services include all medically necessary behavioral health These services include: Ambulatory services, including 24-hours-aday, 7-days-a-week crisis services Acute day hospital/ partial hospitalization, including: Medication management psychiatrist* Prescribed drugs Medical supplies Diagnostic tests Therapeutic services, including individual, and group therapy and aftercare Other medically necessary services In-Network $0 copay for: each Medicare-covered individual therapy visit.* each Medicare-covered group therapy visit.* $0 copay for: each Medicare-covered individual therapy visit with a psychiatrist.* each Medicare-covered group therapy visit with a psychiatrist.* $0 copay for Medicare-covered partial hospitalization program * * Depending on your level of eligibility, you may not have any cost-sharing responsiblity for Original Medicare Page 16

Benefit Category Outpatient Substance Abuse Care Covered services include all medically necessary behavioral health These services include: Methadone treatment services, which include the provision of methadone or a suitable alternative (e.g. LAAM), as well as outpatient counseling services Prescribed drugs including medication management and patient counseling Diagnostic/laboratory services, including: - Psychological testing - Screening for drug and alcohol problems - Other medically necessary diagnostic services Psychiatric or psychological evaluation Physician services Rehabilitation services Occupational therapy Other medically necessary therapeutic services SUMMARY OF BENEFITS General Authorization rules may apply. In-Network $0 copay for: each Medicare-covered individual substance abuse outpatient treatment visit.* each Medicare-covered group substance abuse outpatient treatment. * Depending on your level of eligibility, you may not have any cost-sharing responsiblity for Original Medicare Page 17

Benefit Category Outpatient Services $0 copay per visit for -covered This service includes 24-hour-a-day, 7-days-perweek care for: Emergency services Ambulatory center services Urgent care services Medical supplies Equipment and drugs Diagnostic services Therapeutic services (including chemotherapy and radiation therapy) General Authorization rules may apply. In-Network $0 copay for each Medicare-covered ambulatory surgical center visit.* $0 copay for each Medicare-covered outpatient hospital facility visit.* Ambulance Services (medically necessary ambulance services) Emergency Care (You may go to any emergency room if you reasonably believe you need emergency care.) $0 copay per trip for -covered $0 copay per visit for -covered Covered for medically necessary No prior authorization is required. General Authorization rules may apply. In-Network $0 copay for Medicare-covered ambulance benefits.* General $0 annual service category deductible.* $0 copay for Medicare-covered emergency room visits.* $1,000 plan coverage limit for supplemental emergency services outside the U.S. and its territories every year. If you are admitted to the hospital within 3-day(s) for the same condition, you pay $0 for the emergency room visit. * Depending on your level of eligibility, you may not have any cost-sharing responsiblity for Original Medicare Page 18

Benefit Category Urgently Needed Care Outpatient Rehabilitation Services (Occupational Therapy, Physical Therapy, Speech and Language Therapy, Audiology) Durable Medical Equipment (Includes wheelchairs, oxygen, etc.) Covered as medically necessary. No prior authorization is required. Covered services include: Physical and occupational therapy Audiology and speechlanguage pathology Covered services include but are not limited to the following: Oxygen tanks and concentrators Ventilators Wheelchairs Crutches and canes Eyeglasses Orthotic devices Prosthetic devices Hearing aids Pacemakers Medical supplies such as surgical dressings and ostomy supplies SUMMARY OF BENEFITS General $0 copay for Medicare-covered urgentlyneeded-care visits.* General Authorization rules may apply. Medically necessary physical therapy, occupational therapy, and speech and language pathology services are covered. In-Network $0 copay for Medicare-covered Occupational Therapy visits.* $0 copay for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits.* General $0 annual service category deductible.* Authorization rules may apply. In-Network $0 copay for Medicare-covered durable medical equipment.* * Depending on your level of eligibility, you may not have any cost-sharing responsiblity for Original Medicare Page 19

Benefit Category Prosthetic Devices (Includes braces, artificial limbs and eyes, etc.) Diabetes Programs and Supplies Diagnostic Tests, X-Rays, Lab Services, and Radiology Services Covered as medically necessary. Covered services include: Coverage for glucose monitors Test strips Lancets Screening tests Management Training $0 copay per visit for -covered Covered services include: Diagnostic Therapeutic radiology and imaging Screening and diagnostic laboratory tests Laboratory and diagnostic exclusions: Experimental Investigational or generally unproven Chromosomal evaluations IgG4 testing General Authorization rules may apply. $0 copay for Medicare-covered: prosthetic devices* medical supplies related to prosthetics, splints, and other device* General Authorization rules may apply. In-Network $0 copay for Medicare-covered Diabetes self-management training.* $0 copay for Medicare-covered: Diabetes monitoring supplies.* Therapeutic shoes or inserts.* General Authorization rules may apply. In-Network $0 copay for Medicare-covered: lab services* diagnostic procedures and tests* X-rays* diagnostic radiology services (not including X-rays)* therapeutic radiology services* * Depending on your level of eligibility, you may not have any cost-sharing responsiblity for Original Medicare Page 20

Benefit Category Cardiac Pulmonary Rehabilitation Services Covered as medically necessary. SUMMARY OF BENEFITS General Authorization rules may apply. In-Network $0 copay for: Medicare-covered Cardiac Rehabilitation Services* Medicare-covered Intensive Cardiac Rehabilitation Services* Preventive Services PREVENTIVE SERVICES Health Education and Counseling Substance use (including Alcohol) Diet and exercise Injury prevention Sexual behavior Medicare-covered Pulmonary Rehabilitation Services* General $0 copay for all preventive services covered under Original Medicare at zero cost sharing. Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare. Plan covers a physical exam annually. Bone Mass Measurement (for people with Medicare who are at risk) Colorectal Screening Exams (for people with Medicare age 50 and older) Annually One sigmoidoscopy or annual fecal occult blood test Every 10 years after initial screening Initial screening completed at age 50 You pay nothing. You pay nothing. * Depending on your level of eligibility, you may not have any cost-sharing responsiblity for Original Medicare Page 21

Benefit Category Immunizations (Flu vaccine, Hepatitis B vaccine - for people with Medicare who are at risk, Pneumonia vaccine) Mammograms (Annual Screening) (for women with Medicare age 40 and older) Pap Smears and Pelvic Exams (for women with Medicare) Prostate Cancer Screening Exams (for men with Medicare age 50 and older) Kidney Disease and Conditions $0 copay for Medicarecovered Tetanus-diphtheria (td) booster, Rubella, Hepatitis B in high risk - household and contacts of HBsAg positive person Mammography and clinical breast exam every year. A woman of any age with a history of breast cancer, or whose mother or sister has a history of breast cancer, is eligible for a screening mammography when authorized by a physician. Annually One Pap Test and pelvic exam $0 copay per visit for -covered Dialysis Services and Epogen Injections. Acute hospital admissions solely to provide chronic dialysis are not covered. Authorization rules may apply. In-Network $0 copay for Medicare-covered renal dialysis.* $0 copay for Medicare-covered kidney disease education * * Depending on your level of eligibility, you may not have any cost-sharing responsiblity for Original Medicare Page 22

Benefit Category Outpatient Prescription Drugs PRESCRIPTION DRUG BENEFITS Covers drugs listed on the Drugs covered under Medicare Part B Plan s Preferred Drug List (PDL). Drugs covered under Medicare Part B General $0 yearly deductible for Medicare Part B drugs.* This list will also have drugs that may have limits such as prior authorization, quantity limits, step therapy, age limits or gender limits. Alternate Drugs may be covered with prior authorization. OTC drugs may be covered by the Plan when physician prescribed and medically necessary at $0 copay. $0 copay for Part B chemotherapy drugs and other Part-B drugs.* Drugs covered under Medicare Part D General This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at http://alohacare.org on the web. Different out-of-pocket costs may apply for people who: - have limited incomes, - live in long term care facilities, or - have access to Indian/Tribal/Urban (Indian Health Service) providers. Your in-network prescription coverage may be limited to the plan s service area. This means that if you travel outside the service area, you may have to pay the full cost of your prescription. In certain emergencies, your drugs will be covered if you get them at an out-of-network-pharmacy, although you may have to pay additional charges. Contact the plan for details. Total yearly drug costs are the total drug costs paid by you, the plan, and Medicare. The plan may require you to first try one drug to treat your condition before it will cover another drug for that condition. Some drugs have quantity limits. * Depending on your level of eligibility, you may not have any cost-sharing responsiblity for Original Medicare Page 23

Benefit Category Outpatient Prescription Drugs (continued) Your provider must get prior authorization from (HMO SNP) for certain drugs. The plan will pay for certain over-thecounter drugs as part of its utilization management program. Some over-thecounter drugs are less expensive than prescription drugs and work just as well. Contact the plan for details. You must go to certain pharmacies for a very limited number of drugs, due to special handling, provider coordination, or patient education requirements that cannot be met by most pharmacies in your network. These drugs are listed on the plan s website, formulary, printed materials, as well as on the Medicare Prescription Drug Plan Finder on Medicare.gov. If the actual cost of a drug is less than the normal cost-sharing amount for that drug, you will pay the actual cost, not the higher cost-sharing amount. In-Network You pay a $0 annual deductible. Initial Coverage Depending on your income and institutional status, you pay the following: For generic drugs (including brand drugs treated as generic), either: - A $0 copay; or - A $1.20 copay; or - A $2.65 copay * Depending on your level of eligibility, you may not have any cost-sharing responsiblity for Original Medicare Page 24

Benefit Category Outpatient Prescription Drugs (continued) SUMMARY OF BENEFITS For all other drugs, either: - A $0 copay; or - A $3.60 copay; or - A $6.60 copay. Retail Pharmacy Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed. You can get drugs the following way(s): - one-month (30-day) supply - three-month (90-day) supply Long Term Care Pharmacy Long term care pharmacies must dispense brand name drugs in amounts less than a 14 days supply at a time. They may also dispense less than a month s supply of generic drugs at a time. Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed. You can get drugs the following way(s): - one-month (31-day) supply of drugs Mail Order Contact your plan if you have questions about cost-sharing or billing when less than a one-month `supply is dispensed. You can get drugs the following way(s): - one-month (30-day) supply - three-month (90-day) supply Catastrophic Coverage You pay a $0 copay. * Depending on your level of eligibility, you may not have any cost-sharing responsiblity for Original Medicare Page 25

Benefit Category Outpatient Prescription Drugs (continued) Out-of-Network Plan drugs may be covered in special circumstances, for instance, illness while traveling outside of the plan s service area where there is no network pharmacy. You may have to pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy. In addition, you will likely have to pay the pharmacy s full charge for the drug and submit documentation to receive reimbursement from (HMO SNP). You can get out-of-network drugs the following way: - one-month (30-day) supply Out-of-Network Initial Coverage Depending on your income and institutional status, you will be reimbursed by up to the plan s cost of the drug minus the following: For generic drugs purchased out-ofnetwork (including brand drugs treated as generic), either: - A $0 copay; or - A $1.20 copay; or - A $2.65 copay For all other drugs purchased out-ofnetwork, either: - A $0 copay; or - A $3.60 copay; or - A $6.60 copay. Out-of-Network Catastrophic Coverage You will be reimbursed in full for drugs purchased out-of-network. * Depending on your level of eligibility, you may not have any cost-sharing responsiblity for Original Medicare Page 26

Benefit Category Dental Services OUTPATIENT MEDICAL SERVICES AND SUPPLIES $0 copay for medically related -covered In-Network $0 annual service category deductible for Medicare- covered dental benefits.* For adults, emergency-only dental services are also covered under the FFS dental Plan. Dental services are coordinated through Community Case Management Corporation (CCMC). CCMC will help members: Find a dentist $0 copay for Medicare-covered dental benefits.* $0 copay for the following preventive dental benefits: up to 2 oral exam(s) every year up to 2 cleaning(s) every year up to 2 dental x-ray(s) every year Make an appointment Coordinate transportation and translation Call from Oahu 1-808-792-1070 or toll-free 1-888-792-1070. * Depending on your level of eligibility, you may not have any cost-sharing responsiblity for Original Medicare Page 27

Benefit Category Hearing Services Hearing/Audiology Services - $0 copay per visit for -covered Hearing Evaluation - 1 Per year (Hearing Aid Suppliers will not be paid for a hearing evaluation) Hearing Services - Ear Plugs (Custommade earplugs can be prescribed only by ENT specialists for individuals with recurrent middle ear infections) Hearing Aids - $0 per item prescribed by an ENT specialist Hearing aid examination and selection, monaural - 1 per 3 yrs Hearing aid examination and selection, binaural - 1 per 3 yrs Fitting/orientation/ checking of hearing aid (to follow initial hearing aid exam and selection) - 1 per 3 yrs General Authorization rules may apply. In-Network $0 annual service category deductible for Medicare covered diagnostic hearing exams.* In general, supplemental routine hearing exams and hearing aids not covered. $0 copay for: Medicare-covered diagnostic hearing exams.* * Depending on your level of eligibility, you may not have any cost-sharing responsiblity for Original Medicare Page 28

Benefit Category Vision Services The Plan provides eye and vision services: once every 2 years More visits may be allowed, depending on the symptoms or medical condition. Covered services include: Vision examinations Prescription lenses Cataract removal Prosthetic eyes Ophthalmologic exam with refraction Visual aids (eyeglasses) Contact lenses and miscellaneous vision supplies (if medically necessary). SUMMARY OF BENEFITS In-Network This plan offers only Medicare-covered eye care and eyewear. $0 copay for: Medicare-covered diagnosis and treatment for diseases and conditions of the eye, including an annual glaucoma screening for people at risk.* $0 copay for one pair of Medicare-covered eyeglasses (lenses and frames) or contact lenses after cataract surgery. * Wellness/Education and Other Supplemental Benefits & Services This includes the costs for the lens, frames, or other parts of the glasses. Fittings and adjustments are also covered. In-Network The plan covers the following supplemental education/wellness programs: Health Club Membership/Fitness Classes $0 copay for Weight Loss Program. Contact plan for details. * Depending on your level of eligibility, you may not have any cost-sharing responsiblity for Original Medicare Page 29

Benefit Category Over-the-Counter Items Not Covered. General The plan provides $125 credit every three months. Please visit our website to see our list of covered over-the-counter items. Transportation (Routine) The Plan provides both emergency and nonemergency ground and air services to and from medically necessary medical appointments for members who: Have no means of transportation Reside in areas not served by public transportation Cannot access public transportation due to their medical condition In-Network This plan does not cover supplemental routine transportation. Acupuncture and Other Alternative Therapies Not covered Authorization rules may apply. In-Network $0 copay for up to 15 visit(s) for acupuncture and other alternative therapies every year. * Depending on your level of eligibility, you may not have any cost-sharing responsiblity for Original Medicare Page 30

Benefit Category Methadone maintenance Treatment Program (MMTP) Long-Term Care Services (Institutional) - Nursing Facility services Medication management, prescribed drugs, medical supplies, diagnostic tests, therapeutic services, (individual, family, group and after care), and other medically necessary Includes the provision of methadone or a suitable alternatives as well as outpatient counseling Cost sharing amounts from members who have cost sharing requirements may apply. SUMMARY OF BENEFITS This service is covered under your QUEST Integration health plan. Please contact your QUEST Integration health plan for details on this benefit. This service is covered under your QUEST Integration health plan. Please contact your QUEST Integration health plan for details on this benefit. * Depending on your level of eligibility, you may not have any cost-sharing responsiblity for Original Medicare Page 31

Benefit Category At-Risk Services At-risk services are certain Home and Community-based Services (HCBS) which are listed below and that are provided to you if your assessment indicates that you are at-risk for worsening and going into a nursing home or other type of care outside of your home. Adult Day Care Services include: Observation and supervision by center staff Coordination of behavioral, medical and social plans and implementation of the instructions as listed in the participant s care plan Therapeutic, social, educational, recreational activities Adult day care staff may not perform healthcare related services such as medication administration This service is covered under your QUEST Integration health plan. Please contact your QUEST Integration health plan for details on this benefit. * Depending on your level of eligibility, you may not have any cost-sharing responsiblity for Original Medicare Page 32

Benefit Category Adult Day Health Home-Delivered Meals Adult day health services are organized day programs for therapeutic, social and health services for individuals that requires nursing oversight or care). This also includes: Emergency care Dietetic services Occupational therapy Physical therapy Physician services Pharmaceutical services Psychiatric or psychological services Recreational and social activities Social services Speech-language pathology Transportation services Includes nutritious meals delivered to a location where an individual resides (excluding residential or institutional settings). The meals will not replace or substitute for a full day s nutrition (i.e., no more than 2 meals per day). SUMMARY OF BENEFITS This service is covered under your QUEST Integration health plan. Please contact your QUEST Integration health plan for details on this benefit. This service is covered under your QUEST Integration health plan. Please contact your QUEST Integration health plan for details on this benefit. * Depending on your level of eligibility, you may not have any cost-sharing responsiblity for Original Medicare Page 33

Benefit Category Personal Assistance Services Level 1 Services may include: Routine housekeeping Meal preparation Laundry Shopping Errands This service is covered under your QUEST Integration health plan. Please contact your QUEST Integration health plan for details on this benefit. * Depending on your level of eligibility, you may not have any cost-sharing responsiblity for Original Medicare Page 34

Benefit Category Personal Assistance Services Level 2 Covered for those that require assistance with their activities of daily living (ADL). This level of service is to be provided by a Home Health Aide (HHA), Personal Care Aide (PCA), Certified Nurse Aide (CNA) or Nurse Aide (NA) with applicable skills. Some activities include: Personal hygiene and grooming, including bathing, skin care, oral hygiene, hair care and dressing Help with bowel and bladder care Help with mobility Help with transfers Help with medications Help with routine or maintenance health care services by a personal care provider Help with feeding, nutrition, meal preparation and other dietary activities Help with exercise, positioning and range of motion Taking and recording vital signs, including blood pressure SUMMARY OF BENEFITS This service is covered under your QUEST Integration health plan. Please contact your QUEST Integration health plan for details on this benefit. * Depending on your level of eligibility, you may not have any cost-sharing responsiblity for Original Medicare Page 35

Benefit Category Personal Emergency Response Services (PERS) PERS services are limited to those individuals: Who live alone Who are alone for significant parts of the day Who have no regular caregiver for extended periods Who would otherwise need extensive routine supervision This service is covered under your QUEST Integration health plan. Please contact your QUEST Integration health plan for details on this benefit. Skilled Nursing Services PERS services will only be offered to a member living in a non-licensed setting Covered for those who need on-going nursing care. The service is provided by licensed nurses within the scope of state law. This service is covered under your QUEST Integration health plan. Please contact your QUEST Integration health plan for details on this benefit. * Depending on your level of eligibility, you may not have any cost-sharing responsiblity for Original Medicare Page 36

Benefit Category SUMMARY OF BENEFITS Home and Community-Based Services You must meet certain level of care requirements and have an assessment performed with your QUEST Integration Service Coordinator. Your Service Coordinator will determine what services you need based on your assessment. Please contact your QUEST Integration health plan for details on this benefit. Adult Day Care Services include: Observation and supervision by center staff Coordination of behavioral, medical and social plans and implementation of the instructions as listed in the participant s care plan Therapeutic, social, educational, recreational activities Adult day care staff may not perform healthcare related services such as medication administration This service is covered under your QUEST Integration health plan. Please contact your QUEST Integration health plan for details on this benefit. * Depending on your level of eligibility, you may not have any cost-sharing responsiblity for Original Medicare Page 37

Benefit Category Adult Day Health Adult day health services are organized day programs for therapeutic, social and health services for individuals that requires nursing oversight or care). This also includes: Emergency care Dietetic services Occupational therapy Physical therapy Physician services Pharmaceutical services Psychiatric or psychological services Recreational and social activities Social services Speech-language pathology Transportation services This service is covered under your QUEST Integration health plan. Please contact your QUEST Integration health plan for details on this benefit. * Depending on your level of eligibility, you may not have any cost-sharing responsiblity for Original Medicare Page 38

Benefit Category Assisted Living Services Assisted living services include: Personal care Supportive care services (homemaker, chore, attendant services and meal preparation) SUMMARY OF BENEFITS This service is covered under your QUEST Integration health plan. Please contact your QUEST Integration health plan for details on this benefit. Community Care Management Agency (CCMA) The QUEST Integration health plan is not responsible for payment for room and board. Covered for members living in Community Care Foster Family Homes and other community settings, as required. This service is covered under your QUEST Integration health plan. Please contact your QUEST Integration health plan for details on this benefit. * Depending on your level of eligibility, you may not have any cost-sharing responsiblity for Original Medicare Page 39

Benefit Category Community Care Foster Family Home (CCFFH) Services Covered services include: Personal care Supportive services Homemaker services Attendant care Companion services Local transportation Day programming Medication oversight (to the extent permitted under state law) All services must be provided in a certified private home by a principal care provider who lives in the home. The QUEST Integration health plan is not responsible for payment for room and board. This service is covered under your QUEST Integration health plan. Please contact your QUEST Integration health plan for details on this benefit. Counseling and Training Counseling and training activities include the following: Member care training for members, family and caregivers regarding the nature of the disease and the disease process This service is covered under your QUEST Integration health plan. Please contact your QUEST Integration health plan for details on this benefit. * Depending on your level of eligibility, you may not have any cost-sharing responsiblity for Original Medicare Page 40

Benefit Category Counseling and Training (continued) Methods of transmission and infection control measures Biological, psychological care and special treatment needs/ regimens Use of equipment specified in the service plan employer Skills updates as necessary to safely maintain the individual at home Crisis intervention Supportive counseling Family therapy Suicide risk assessments and intervention Death and dying counseling Substance abuse counseling Nutritional assessment and counseling SUMMARY OF BENEFITS Counseling and training is a service provided to: Members Families/caregivers on behalf of the member Professional and paraprofessional caregivers on behalf of the member * Depending on your level of eligibility, you may not have any cost-sharing responsiblity for Original Medicare Page 41

Benefit Category Environmental Accessibility Adaptations Covered services include: The installation of ramps and grab-bars Widening of doorways Modification of bathroom facilities Installation of specialized electric and plumbing systems (must be necessary to accommodate the medical equipment and supplies that are necessary for the welfare of the individual) This service is covered under your QUEST Integration health plan. Please contact your QUEST Integration health plan for details on this benefit. Home-Delivered Meals All services shall comply with state or local building codes. Includes nutritious meals delivered to a location where an individual resides (excluding residential or institutional settings). The meals will not replace or substitute for a full day s nutrition (i.e., no more than 2 meals per day). This service is covered under your QUEST Integration health plan. Please contact your QUEST Integration health plan for details on this benefit. * Depending on your level of eligibility, you may not have any cost-sharing responsiblity for Original Medicare Page 42

Benefit Category Home Maintenance Home maintenance services are those services not included as a part of personal assistance and include: Heavy-duty cleaning to bring a home up to acceptable standards of cleanliness at the start of service to a member Minor repairs to essential appliances, limited to stoves, refrigerators and water heaters Fumigation or extermination services SUMMARY OF BENEFITS This service is covered under your QUEST Integration health plan. Please contact your QUEST Integration health plan for details on this benefit. This benefit is provided to individuals who cannot perform these services without assistance and are determined, through assessment, to require the service to prevent institutionalization. * Depending on your level of eligibility, you may not have any cost-sharing responsiblity for Original Medicare Page 43

Benefit Category Moving Assistance This benefit is provided in the rare instances when it is determined, through assessment that an individual needs to move to a new home. This benefit is not utilized when the individual has family members, a landlord, and other community members who can provide this service. This includes: Unsafe home due to deterioration The individual is wheelchair bound, living in a building with no elevator, multistory building with no elevator or where the client lives above the first floor Member is evicted from his or her current home Member can no longer afford the home due to a rent increase This service is covered under your QUEST Integration health plan. Please contact your QUEST Integration health plan for details on this benefit. Moving expenses include packing and moving of belongings. * Depending on your level of eligibility, you may not have any cost-sharing responsiblity for Original Medicare Page 44

Benefit Category Non-Medical Transportation Personal Assistance Services Level 1 This service helps members travel as specified by the member care plan. It helps members get to community services, activities and resources. Whenever possible, those who can offer this service without cost will be used. They include family, neighbors, friends or community agencies. Exclusion: Members living in a residential care setting or a CCFFH are not eligible for this service. Services may include: Routine housekeeping Meal preparation Laundry Shopping Errands SUMMARY OF BENEFITS This service is covered under your QUEST Integration health plan. Please contact your QUEST Integration health plan for details on this benefit. This service is covered under your QUEST Integration health plan. Please contact your QUEST Integration health plan for details on this benefit. * Depending on your level of eligibility, you may not have any cost-sharing responsiblity for Original Medicare Page 45

Benefit Category Personal Assistance Services Level 2 Covered for those that require assistance with their activities of daily living (ADL). This level of service is to be provided by a Home Health Aide (HHA), Personal Care Aide (PCA), Certified Nurse Aide (CNA) or Nurse Aide (NA) with applicable skills. Some activities include: Personal hygiene and grooming, including bathing, skin care, oral hygiene, hair care and dressing Help with bowel and bladder care Help with mobility Help with transfers Help with medications Help with routine or maintenance health care services by a personal care provider Help with feeding, nutrition, meal preparation and other dietary activities Help with exercise, positioning and range of motion Taking and recording vital signs, including blood pressure This service is covered under your QUEST Integration health plan. Please contact your QUEST Integration health plan for details on this benefit. * Depending on your level of eligibility, you may not have any cost-sharing responsiblity for Original Medicare Page 46

Benefit Category Personal Emergency Response Services (PERS) PERS services are limited to those individuals: Who live alone Who are alone for significant parts of the day Who have no regular caregiver for extended periods Who would otherwise need extensive routine supervision SUMMARY OF BENEFITS This service is covered under your QUEST Integration health plan. Please contact your QUEST Integration health plan for details on this benefit. PERS services will only be offered to a member living in a non-licensed setting Skilled or Private-Duty Nursing Covered for those who need on-going nursing care. The service is provided by licensed nurses within the scope of state law. This service is covered under your QUEST Integration health plan. Please contact your QUEST Integration health plan for details on this benefit. * Depending on your level of eligibility, you may not have any cost-sharing responsiblity for Original Medicare Page 47

Benefit Category Licensed Residential Care Residential care is provided in a licensed private home by a principle care provider who lives in the home. He or she gives the following services to members: Personal care services Homemaker, chore, attendant care and companion services Medication oversight (to the extent allowed by law) Transportation to medical appointments This service is covered under your QUEST Integration health plan. Please contact your QUEST Integration health plan for details on this benefit. The QUEST Integration health plan is not responsible for payment for room and board. * Depending on your level of eligibility, you may not have any cost-sharing responsiblity for Original Medicare Page 48

Benefit Category Respite Care Respite care is short-term basis for individuals who are unable to care for themselves. It provides relief to caregivers. It may be provided hourly, daily and overnight. Respite care may be provided in the following locations: Member s home or place of residence Foster home or expanded-care adult residential care home -certified nursing facility Licensed respite day care facility Other community care residential facility approved by the Plan Respite care services are authorized by the member s PCP as part of the member s care plan. SUMMARY OF BENEFITS This service is covered under your QUEST Integration health plan. Please contact your QUEST Integration health plan for details on this benefit. * Depending on your level of eligibility, you may not have any cost-sharing responsiblity for Original Medicare Page 49

Benefit Category Specialized Medical Equipment Warranty and Supplies Refers to the purchase, rental, lease, costs, installation, repairs and removal of devices, controls or appliances specified in the care plan. This also includes: Items necessary for life support Supplies and equipment needed for the proper functioning of such items Durable and nondurable medical equipment not available under the state plan This service is covered under your QUEST Integration health plan. Please contact your QUEST Integration health plan for details on this benefit. Examples include: Shower seat Portable humidifiers Electric bills specific to electrical life support devices (ventilator, oxygen concentrator) Medical supplies * Depending on your level of eligibility, you may not have any cost-sharing responsiblity for Original Medicare Page 50

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