2018 SUMMARY OF BENEFITS

2018 SUMMARY OF BENEFITS Citrus, Hernando and H2962_2018SB_ACCEPTED

Turn to page 3 to learn how to keep $1,260.00 per year in your pocket in 2018! How to use this booklet network of local doctors and hospitals conveniently located throughout Citrus, Hernando and Pasco extra services not covered by Original Medicare. Browse through this booklet to get more details 3-14 15-17 18 19 20 21 22 23 how to enroll

important things to know Who can join? To join, or, you must. ies i Which doctors, hospitals and pharmacies can I use? We have a network of doctors, hospitals, pharmacies, and other providers. Except in an emergency, you must use network providers and pharmacies. If you use providers that are not in our network, the plan may not pay for these services. You can see our plan s provider and pharmacy directory at We cover everything that Original Medicare covers - and more! (like doctor visits, hospital stays and medical equipment) as well as extra e r co s ever rvice Toll-free: 1-855-858-7526 / TTY: 711 / Monday Sunday: 8am-8pm

and n You pay $0 your monthly Medicare Part B premium by up to $105.00. Y You pay $0 Y f- k R $3,400 annually $3,400 annually (Primary and Specialist ) $90 copay per day for days 1 Y per day for days 6 Primary: Y Specialist: $20 copay Y Primary: Y Specialist: Y Y Y You pay $60 copay per visit You pay $50 copay per visit U n You pay $20 copay per visit You pay $10 copay per visit

What you should know Use this space to compare your current plan or write down notes This amount is the most you ll pay for copays, coinsurance and other costs for medical services for the year. stay. A referral is required for specialist visits. be covered. pay your share of the cost for emergency care. We also cover supplemental Emergency are worldwide (See Worldwide Emergency Care further down in this table) pay your share of the cost for urgently needed services. Toll-free: 1-855-858-7526 / TTY: 711 / Monday Sunday: 8am-8pm 4

and te Elite (HMO) vices Lab services ests and procedures -rays Lab services: You pay nothing You pay nothing 20% of the cost for Ultrasound, Echocardiography, Colonoscopy, Endoscopy and for Stress, Ner for CT, CTA, MRI, MRA, PET, SPECT copay f copay for Sleep Study, Psychological Tests Hearing Services Exam to diagnose and treat hearing and balance issues xam Hearing aids Exam to diagnose and treat hearing and balance issues: You pay nothing You pay nothing $10 copay Hearing aids: $10 copay for each hearing aid Our plan pays up to $750 every two years for hearing aids. 5

y n o Lab services: Y Outpa Y Ther 20% of the cost $0 for Ultrasound, Echocardiography, Colonoscopy, Endoscopy and $25 $50 for CT, CTA, MRI, MRA, PET, SPECT ests $0 copay f $50 copay for Sleep Study, Psychological Tests Exam to diagnose and treat hearing and balance issues: Y R Y $5 copay Hearing aids: $5 copay for each hearing aid Our plan pays up to $750 every two years for hearing aids. Toll-free: 1-855-858-7526 / TTY: 711 / Monday Sunday: 8am-8pm 6

n es Cleaning X-rays Fluoride Oral exam Contact lenses Eyeglass frames Eyeglass lenses Eye exam to diagnose and treat eye lenses (1 every year) and Y f 1 months 1 comprehensive oral exam every 3 years 1 cleaning every 6 months 1 months 1 dental x-ray every year dental services Y Contact lenses: Y Eyeglass frames (1 every year): Y Eyeglass lenses (1 pair every year): Y Upgrade to progressive lenses for $50 copay. s (1 every year). You pay a $40 copay. cataract surgery: Y Exam to diagnose and treat eye (including yearly glaucoma screening): $0-20 copay* *$0 with optometrist, $20 with ophthalmologist. Y f 1 months 1 comprehensive oral exam every 3 years 1 cleaning every 6 months 1 months 1 dental x-ray every year dental services Y Contact lenses: Y Eyeglass frames (1 every year): Y Eyeglass lenses (1 pair every year): Y Upgrade to progressive lenses for $50 copay. s (1 every year). You pay a $40 copay. cataract surgery: Y Exam to diagnose and treat eye (including yearly glaucoma screening): Y 7

What you should know Use this space to compare your current plan or write down notes oral exam every 3 years. necessary prior to another Medicare-covered medical procedure. Our plan pays up to $150 per-year for eyewear. Contact lenses OR One pair of standard CR-39 single-vision, bifocal (FT 28) or trifocal (7X28) lenses AND/OR one eyeglass frame $150 may be applied to lenses only, frame only or to both. Toll-free: 1-855-858-7526 / TTY: 711 / Monday Sunday: 8am-8pm 8

and n ay visit $90 copay per day for days 1 through 5 Y per day for days 6 through 90 Outpa $20 copay Y t group therapy visit: Y $20 copay apy visit: t individual therapy visit: Y F Y per day for days 1 through 20 $100 copay per day for days 21 through 54 Y per day for days 55 through 100 Y per day for days 1 through 30 $75 copay per day for days 31 through 76 Y per day for days 77 through 100 9

What you should know Use this space to compare your current plan or write down notes 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 Except in an emergency, your doctor must tell the plan that you are is required for some services. Please contact the plan for more periods. Our plan covers up to 100 days in a SNF. Toll-free: 1-855-858-7526 / TTY: 711 / Monday Sunday: 8am-8pm

and Physical therapy visit visit $20 copay $ 0 copay $100 copay each way $100 copay each way Not covered Not covered Medic e F Foot exams and treatment $20 copay Y

What you should know Use this space to compare your current plan or write down notes copayment for the ambulance services. Except in an emergency, this Our plan covers Toll-free: 1-855-858-7526 / TTY: 711 / Monday Sunday: 8am-8pm

and e Elite (HMO) Medic E n Durable Medical Equipment (e.g., wheelchairs, oxygen) limbs) Diabetes supplies and services Durable edical quipment: You pay 20% of the cost You pay 20% of the cost Diabetes monitoring supplies, self-management training and Y y nothing Durable edical quipment: You pay 20% of the cost You pay 20% of the cost Diabetes monitoring supplies, self-management training and Y y nothing W og SilverSneakers Fitness Program Y y nothing Y y nothing 24/7 Nurse Hotline $20 copay $20 copay Ove nt t OTC) Y y nothing Y y nothing Ambulatory surgical center: $25 Ambulatory surgical center: $25 $150 al: $75 al: W g e You pay the applicable copay listed in the

What you should know Use this space to compare your current plan or write down notes $100 every three months $400. does not We pa to $50,000 for covered emergency services received Toll-free: 1-855-858-7526 / TTY: 711 / Monday Sunday: 8am-8pm

How Much Do I ay in Each Stage? and Coverage Gap RETAIL PHARMACY Your cost for a one-month supply Tier 1: Preferred Generic You pay: $0 Tier 2: Generic You pay: $12 Tier 3: Preferred Brand You pay: $35 Tier 4: Non-Preferred Drug You pay: $60 Tier 5: Specialty Tier You pay: 33% of the cost RETAIL PHARMACY Your cost for a one-month supply Tier 1: Preferred Generic You pay: $0 Tier 2: Generic You pay: $12 MAIL ORDER PHARMACY at a network mail order pharmacy: Tier 1: Preferred Generic You pay: $0 Tier 2: Generic You pay: $24 Tier 3: Preferred Brand You pay: $70 Tier 4: Non-Preferred Drug You pay: $120 Tier 5: Specialty Tier You pay: 33% of the cost MAIL ORDER PHARMACY at a network mail order pharmacy: Tier 1: Preferred Generic You pay: $0 Tier 2: Generic You pay: $24 What you should know What you pay for a drug depends on which drug payment stage you are in when you get the drug. total yearly drug cost (including what our plan has paid and what you have paid) reaches $3,750. Not everyone will enter the coverage gap. Most Medicare drug plans have a coverage gap (also called the donut hole ). This means that there s a temporary change in what you will pay to cover drugs in Tier 1 Preferred Generic and Tier 2 Generic. For drugs in Tiers 1 and 2 you pay the copay amounts shown above or 44% of the plan s cost, whichever is less.

y n o RETAIL PHARMACY at a network retail pharmacy: Tier 1: Preferred Generic You pay: $0 Tier 2: Generic You pay: $8 Tier 3: Preferred Brand You pay: $25 Tier 4: Non-Preferred Drug You pay: $50 Tier 5: Specialty Tier You pay: 33% of the cost RETAIL PHARMACY Your cost for a one-month supply Tier 1: Preferred Generic You pay: $0 Tier 2: Generic You pay: $8 MAIL ORDER PHARMACY network mail order pharmacy: Tier 1: Preferred Generic You pay: $0 Tier 2: Generic You pay: $16 Tier 3: Preferred Brand You pay: $50 Tier 4: Non-Preferred Drug You pay: $100 Tier 5: Specialty Tier You pay: 33% of the cost MAIL ORDER PHARMACY at a network mail order pharmacy: Tier 1: Preferred Generic You pay: $0 Tier 2: Generic You pay: $16 For covered brand name drugs you pay 35% of the in the coverage gap. You stay in the coverage gap 5,000, which is the end of the coverage gap and the beginning of the catastrophic coverage stage, during which the plan pays most of the cost for your drugs. Cost-Sharing may change depending on the pharmacy you choose (i.e. network, out of network, Toll-free: 1-855-858-7526 / TTY: 711 / Monday Sunday: 8am-8pm

Determining your drug costs You will need to use our plan s drug list (also called the how much it will cost you. The amount you pay depends drugs we cover, you can see our complete drug list and www.. Or, call us and we will send you a copy of the drug list. The Formulary may change at any Tier 1: Preferred Generic Tier 2: Generic Tier 3: Preferred Brand Tier 4: Non-Preferred Drug Tier 5: Specialty Save even more with mail order You can save even more by Mail Order Pharmacy Service! You ll receive a three month straight to your door and pay the same copay that you would normally pay for a two month supply at your local pharmacy. We group the drugs on our drug list into categories depending on the type of medical are listed under the category, Cardiovascular Agents. If you know what your drug is used for, look for the category name in the drug list. Then look under the category name for your drug. If you are not sure what category to look under, you should look for your drug in the Index included at the back of the drug list. The Index included in this document. Both brand name drugs and generic drugs are listed in the Index. drug, you will see the page number where you

Original Medicare does not cover Over-the-Counter (OTC) medicines. But we do! allows $ every three months 400 amount does not roll over from quarter to quarter. You pay $0 copay for each quarter. Our plan even covers the cost of mailing the items to you! such as a dec stan n First Aid peroxide, thermomet tapes tamins cement, such as phyt terone or DHEA Topic nt st r, to test f y, HIV, fec c Bathroom sc co f to monit contains a list of all plan-covered OTC items and the price of each item. We mail you the catalog, and you may also access and mail your order or, to place an order by phone, simply are available to take your order Monday through Friday from 8:00 am to 8:00 pm EST. Toll-free: 1-855-858-7526 / TTY: 711 / Monday Sunday: 8am-8pm

Vision Original Medicare covers exams to diagnose We cover those eye exams and much more!. In eyeglasses or contact lenses for $0 copay. You ll get up to $150 to spend on eyewear. Contact lenses or One pair of standard single-vision, bifocal or trifocal lenses and/or One eyeglass frame xible! You can use the $150 Hearing hearing exam for $0 copay and hearing aids and $5 or $10 depending on the plan you choose). Our plan pays up to $750 for hearing aids every t o years. available to our members are top of the line. help you manage your hearing aid. Scheduling an appointment is eas zed concierge customer service that guides you you: for lenses only rame only or for both. You can even upgrade your standard lenses to progressives for just $50 copay can get a pair of sunglasses for a $40 copay. Dental $0 copay. Cleaning Dental x-rays Fluoride treatment am

Plan members enjoy the SilverSneakers Fitness program SilverSneakers Fitness is a health and access to a specially trained Senior Advisor. or call 1-888-423-4632 (TTY: 711), Monday through Friday, 8 am to 8 pm EST. Toll-free: 1-855-858-7526 / TTY: 711 / Monday Sunday: 8am-8pm

(counseling to stop smoking and tobacco use) beyond what is covered to-face visits. disease processes, treatments and drug therapies, signs and symptoms Our 24/7 Nurse Hotline Members can call the hotline to talk with a nurse 24 hours a day, 7 days Hotline by calling 1-855-238-4687. Calls to this line are free. TTY users should dial 711. Worldwide Emergency Care Coverage Our members get covered emergency medical care and ambulance services whenever they need it, anywhere in the world! We ll pay up to $50,000 for emergency services received outside the U.S. and its territories.

preventive services 8 You pay $ 0 for: Annual Wellness and Welcome to Medicare Bone Mass Measurement Cardiovascular Disease Tes Colorectal Cancer Screening Diabetes Screening and Diabe Self-Management Training Glaucoma Screening Screening Mammograms Pap Smears and Pelvic Exams Prostate Cancer Screening (PSA test) Counseling to Stop Smoking and Tobacco Use W not listed here. See our Evidence of Coverage for the complete list and Toll-free: 1-855-858-7526 / TTY: 711 / Monday Sunday: 8am-8pm

enrolling in an Ultimate Medicare Advantage Plan When can you enroll? Each fall, from, Medicare allows you to enroll in or change your Medicare health and drug coverage during the Annual Enrollment Period (AEP). 201 Monday Tuesday Wednesday Thursday Friday Saturday Sunday make sure it will meet your needs for the coming year. with Medicaid, those who get Extra Help paying for their drugs, those who have or are leaving employer coverage, and those who move out of the service area are allowed to are eligible for a Special Enrollment Period, please contact our plan, call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week (TTY 1-877-486-2048), or visit the Medicare website at www.medicare.gov. 201 Monday Tuesday Wednesday Thursday Friday Saturday Sunday 201 Monday Tuesday Wednesday Thursday Friday Saturday Sunday 3 Choosing the right plan e sure the plan you re considering is right for you - see pages 3-16 Make sure the doctors and other providers you want to use are in our network - see page 2 Make sure the drugs you take are on our drug list - see page 17

enrolling in an Ultimate Medicare Advantage Plan Complete an enrollment form there are several ways to enroll: You can enroll online on the Medicare website by going to the below link, entering your zip code and typing the word in the box labeled Plan Name. To enroll online, visit: Enroll at one of our free mee You ll receive your ID card and welcome kit, including CALL US TODAY 1-855-858-7526 (TTY 711) or to schedule a near you users dial 711), Monday - Sunday 8 am-8 pm. A sales person will be presen Toll-free: 1-855-858-7526 / TTY: 711 / Monday Sunday: 8am-8pm

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Hernando/Citrus Pasco