Harvard Pilgrim Health Care 1600 Crown Colony Drive Quincy, MA hpforlife.org. Mr. Stuart M Holbrook 8 JACKSON ST Milton, MA 02186

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1 Harvard Pilgrim Health Care 1600 Crown Colony Drive Quincy, MA hpforlife.org Mr. Stuart M Holbrook 8 JACKSON ST Milton, MA Quote Number: Quote Date: September 1, 2016 Dear Mr. Stuart M Holbrook, Thank you for your interest in Harvard Pilgrim. We are pleased to provide you a quote for health insurance coverage. This quote is based on the information outlined below, which was provided by you when you submitted your request. You ll also want to review the helpful plan documents and important information about the plan. If you have any questions about the coverage or need assistance enrolling in a plan, you can reach us at , for TTY service dial 711. or visit us online at hpforlife.org. Covered Person Date of Birth Zip Code Mr. Stuart M Holbrook May 31, The following premiums are based on the above information you provided. The premium may be adjusted if any of the information is altered. Product Name Stride (HMO) Value Rx Plus $73.00 Monthly Premium

2 SM Harvard Pilgrim is an HMO plan with a Medicare contract. Enrollment in Stride (HMO) depends on contract renewal. This information is not a complete description of benefits. Contact the plan for more information. Call and TTY: 711 Product Compare New Hampshire Stride (HMO) Value Rx Plus Benefits You Pay Medical Benefits Annual Medical Deductible $0 Primary Care Provider (PCP) Office Visit $0 copay per visit Annual Physical Exam $0 copay, 1 visit per year Specialist Office Visit $40 copay per visit Diagnostic Tests, X-Rays, Lab Services $10 copay for X-Rays $0 copay for lab services $100 copay for MRI/CT scans Outpatient Surgery $200 copay Inpatient Hospital Care (includes Substance Abuse and Rehabilitation Services) Days 1-5, $265 copay each day Skilled Nursing Facility (in a Medicare Certified Skilled Nursing Facility) Days 1-20, $0 copay per day Days , $100 copay per day

3 Durable Medical Equipment 20% coinsurance Home Health Care $0 copay Worldwide Emergency Coverage $75 copay (waived if admitted within 3 days) Urgent Care $40 copay Ambulance $125 copay per trip Routine Eye Exam $0 copay, 1 visit per year Eyewear Benefit $150 annual allowance for eyewear Routine Hearing Exam $15 copay, 1 visit per year Fitness Reinbursement Up to $200 annual Fitness club reimbursement Over-the-Counter Allowance $150 annual allowance towards over-the-counter health care related supplies Out-of-Pocket Limit $5,000 yearly out-of-pocket limit Prescription Drug Benefit Annual Prescription Drug Deductible $0

4 Initial Coverage Limit $3,310 Drug Tiers 30 day Retail/90 Day Mail Order Tier 1 Preferred Generic $0/$0 Tier 2 Non Preferred Generic $10/$20 Tier 3 Preferred Brand $47/$94 Tier 4 Non Preferred Brand $100/$200 Tier 5 Specialty 33% coinsurance Coverage Gap You pay the following until you have paid a total of $4,850* for covered Part D drugs Drug Tiers 30 day Retail/90 Day Mail Order Tier 1 Preferred Generic $0/$0 Tier 2 Non Preferred Generic $10/$20 Tier 3 Preferred Brand, Tier 4 Non Preferred Brand and Tier 5 Specialty You pay 45% of the negotiated price plus a portion of the dispensing fee Catastrophic Coverage You pay the following for the remainder of the calendar year

5 Generic Drugs (including Brand Drugs treated as Generic) Greater of 5% coinsurance or $2.95 copay All other Drugs Greater of 5% coinsurance or $7.40 copay SM *Please note: Drugs covered by Stride (HMO) that are not covered by Medicare Part D do not count toward this amount. Different out-of-pocket costs may apply for people who may have limited incomes, live in long term care facilities or have access to Indian/Tribal/Urban (Indian Health Service Providers). Want help in choosing a plan type? Call (TTY: 711). Hours of operation are: 8 a.m. to 8 p.m. 7 days a week October 1 - March 31 and from April 1 - September 30, from 8 a.m. to 8 p.m. Monday through Friday.