Summary Of Benefits. January 1, December 31, Blue Shield Promise TotalDual Plan (HMO SNP)

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1 Summary Of Benefits Blue Shield of California Promise Health Plan is an independent licensee of the Blue Shield Association Care1st is an independent licensee of the Blue Shield Association January 1, December 31, 2019 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 Blue Shield Promise TotalDual Plan (HMO SNP) California: Los Angeles County On January 1, 2019, Care1st Health Plan is changing its name to Blue Shield of California Promise Health Plan Until 12/31/18 H5928_19_280_MK_M Accepted Effective 1/1/2019

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3 2019 Summary Of Benefits Blue Shield Promise TotalDual Plan (HMO SNP) Los Angeles County, Plan 001 This is a summary of drug and health services covered by Blue Shield Promise TotalDual Plan (HMO SNP) January 1, December 31, Blue Shield Promise TotalDual Plan (HMO SNP) is a Medicare Advantage HMO plan with a Medicare contract. Enrollment in the Plan depends on contract renewal. The benefit information provided does not list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, please request the Evidence of Coverage. To join Blue Shield Promise TotalDual Plan (HMO SNP), you must be entitled to Medicare Part A, be enrolled in Medicare Part B, and live in our service area. Our service area includes the following counties in California: Los Angeles. If you use the providers that are not in our network, we may not pay for these services. For coverage and costs of Original Medicare, look in your current Medicare & You handbook. View it online at or get a copy by calling MEDICARE ( ). TTY users should call This document is available in other formats such as Braille, large print or audio. For more information, please call us at (TTY users should call 711), 8:00 a.m. 8:00 p.m. 7 days a week, from October 1 to March 31 and 8:00 a.m. 8:00 p.m. weekdays, from April 1 to September 30 or visit us at 3

4 Premiums and Benefits Blue Shield Promise TotalDual Plan (HMO SNP) Monthly Plan Premium Deductible No deductible Maximum Out-of-Pocket Responsibility (does not include prescription drugs) Inpatient Hospital Outpatient Hospital Doctor Visits Primary Specialists Preventive Care (Mammography & influenza vaccines. No referral needed.) Emergency Care Urgently Needed Services Diagnostic Services/Labs/Imaging Procedures/Tests Lab services Therapeutic radiology services (such as radiation treatment for cancer) Hearing Services Routine hearing exam Hearing aid Dental Services Unlimited oral exams every year Cleaning, one every 6 months Fluoride treatment, one every six months X-rays, one full set every two years Vision Services Routine exam (every year) Eyewear coverage limit Refraction test (one every 2 years) You pay $34.80 You must continue to pay your Medicare Part B premium. You pay no more than $6,700 annually. Includes copays and other costs for medical services for the year. Medicare-defined cost shares 2018 Medicare-defined cost shares For 2018: $1,316 deductible days 1-60 $329 copay days $670 copy days per lifetime reserve day (up to 60 days over your lifetime) Other preventive services are available. There are some covered services that have a cost. Medicare-covered benefits; for routine exams (1 every year); for fitting/evaluation for hearing aid for 2 hearing aids every year $1,500 limit every year You pay $5 $300 limit for glasses and contacts every year 4

5 Premiums and Benefits Mental Health Services Outpatient group therapy/individual therapy visit Skilled Nursing Facility Physical Therapy Ambulance Services Transportation Services Medicare Part B Drugs Blue Shield Promise TotalDual Plan (HMO SNP) Medicare-defined cost shares 2018 Medicare-defined cost shares For 2018: $0 copay days 1-20 $ copay for days % of cost for Medicare covered transportation services 48 one-way trips to plan approved locations. Transportation must be arranged 24 hours in advance. for chemotherapy drugs for other Part B drugs Outpatient Prescription Drugs Deductible You pay $415 Initial Coverage Phase (After you pay your deductible, if applicable, up to the initial coverage limit of $3,820) Tier 1: Preferred Generic Tier 2: Non-Preferred Generic Tier 3: Preferred Brand Tier 4: Non-Preferred Brand Tier 5: Specialty Tier Coverage Gap Phase (After the total drug costs paid by you and the plan reach $3,820, up to the out-of-pocket threshold of $5,100) Catastrophic Coverage (When your annual out-of-pocket costs exceed $5,100) Standard Retail Rx 30-day supply $0 - $3.40 or 15% or 25% $0 - $3.40 or 15% or 25% 5 Mail-Order 90-day supply $0 - $3.40 or 15% or 25% $0 - $3.40 or 15% or 25% Tier 1: Preferred Generic Drugs For all other tiers, you pay 25% of the negotiated price for brand name drugs (plus a portion of the dispensing fee) and 37% of the price for generic drugs. Extra Help (LIS): GAP doesn t apply Generic drugs: Greater of 5% or $3.40 copay Brand-name drugs: Greater of 5% or $8.50 copay

6 Optional Supplemental Plan Health Club/Fitness Nurse Advice Line Worldwide Emergency/Urgent Care Routine Chiropractic Acupuncture Over-the-Counter Worldwide Emergency/Urgent Coverage up to $25,000 per year (Not Waived if admitted) $0 copay /15 visits per year $0 copay /15 visits per year $170/Quarterly IMPORTANT NOTE: To view important information on non-discrimination requirements, you can go to our website at Blue Shield of California Promise Health Plan is an HMO and an HMO SNP plan with a Medicare contract and a contract with the California State Medicaid Program. Enrollment in Blue Shield of California Promise Health Plan depends on contract renewal. Blue Shield of California Promise Health Plan complies with applicable State and Federal civil rights laws and does not discriminate on the basis of race, color, national origin, ancestry, religion, sex, marital status, gender, gender identity, sexual orientation, age or disability. This information is not a complete description of benefits. Call (TTY:711) for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or co-payments/co-insurance may change on January 1 of ATTENTION: Language assistance services, free of charge, are available to you. Call (TTY: 711). ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: 711). 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY:711) Care1st Health Plan is an independent licensee of the Blue Shield of California Association. On January 1, 2019, Care1st Health Plan is changing its name to Blue Shield of California Promise Health Plan. Blue Shield of California Promise Health Plan is an independent licensee of the Blue Shield Association. H5928_19_280_MK_M Accepted Effective 1/1/2019 6

7 Pre-Enrollment Checklist Before making an enrollment decision, it is important that you fully understand our benefits and rules. If you have any questions, you can call and speak to a customer service representative at (TTY/TDD users call 711). Understanding the Benefits Review the full list of benefits found in the Evidence of Coverage (EOC), especially for those services that you routinely see a doctor. Visit or call (TTY/TDD users call 711) to view a copy of the EOC. Review the provider directory (or ask your doctor) to make sure the doctors you see now are in the network. If they are not listed, it means you will likely have to select a new doctor. Review the pharmacy directory to make sure the pharmacy you use for any prescription medicines is in the network. If the pharmacy is not listed, you will likely have to select a new pharmacy for your prescriptions. Understanding Important Rules In addition to your monthly plan premium, you must continue to pay your Medicare Part B premium. This premium is normally taken out of your Social Security check each month. Benefits, premiums and/or copayments/ may change on January 1, Except in emergency or urgent situations, we do not cover services by out-of-network providers (doctors who are not listed in the provider directory). This plan is a dual eligible special needs plan (D-SNP). Your ability to enroll will be based on verification that you are entitled to both Medicare and medical assistance from a state plan under Medicaid. On January 1, 2019, Care1st Health Plan is changing its name to Blue Shield of California Promise Health Plan Blue Shield of California Promise Health Plan is an independent licensee of the Blue Shield Association H5928_19_280_MK_M Accepted Effective 1/1/2019 7

8 For enrollment inquiries please call (TTY users should call 711) Member Services representatives will be available to answer your call 8:00 a.m. 8:00 p.m. 7 days a week, from October 1 to March 31 and 8:00 a.m. 8:00 p.m. weekdays, from April 1 to September 30. On January 1, 2019, Care1st Health Plan is changing its name to Blue Shield of California Promise Health Plan 601 Potrero Grande Dr., Monterey Park, CA