MINNESOTA 2019 MEDICARE PLANS. MEDICA ADVANTAGE SOLUTION (HMO-POS) ADVANTAGE SOLUTION (PPO) Coverage Details Y0088_5408_M

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1 MINNESOTA 2019 MEDICARE PLANS MEDICA ADVANTAGE SOLUTION (HMO-POS) ADVANTAGE SOLUTION (PPO) Coverage Details Y0088_5408_M

2 MORE PLANS. MORE VALUE. Medica Advantage Solution offers an affordable portfolio of new plan options with medical and Part D drug coverage PLUS the extra benefits you want. Advantage Solution is available in three areas of Minnesota: Twin Cities Metro, Greater Twin Cities Metro and Southeast Minnesota. 2 Talk with an expert consultant you can trust. Call (TTY: 711) to speak with a Medicare consultant who can help you evaluate your situation and make the best coverage choice for you and your budget. Attend a free Medicare Workshop. To find a workshop near you, visit medica.com/ MedicareWorkshops. You ll learn everything you need to know about Medicare and affordable plan options from Medica. Get the details online. Visit medica.com/medicare for valuable information and resources to help you make the best coverage decisions.

3 NEW PLAN OPTIONS FOR 2019 Get combined medical and Part D drug coverage you can afford. Advantage Solution pays costs Medicare doesn t cover and gives you additional benefits that Medicare alone doesn t provide, like Part D drug coverage and more. Affordability budget-friendly premiums and copays/coinsurance Options select from a range of coverage levels in most areas Choice networks include major health care providers Extras SilverSneakers, dental, prescription eyewear and more! Find your best match with Medica. When it s time to choose your coverage, Medica has the options you need to make sure you have the plan that fits you. We ve been serving fellow Minnesotans like you for over 40 years. Let our local Medicare consultants help you find your best match today!. All the plan features you want» Plan options with low to no copays» Broad provider networks with no referrals required» Out-of-network coverage for most services when you travel in the U.S.» Worldwide emergency care» $0 evisits through virtuwell» Extensive drug formulary with over 3,200 prescription drugs» No Part D deductible on Tier 1 and 2 drugs» Free fitness membership through SilverSneakers» Dental coverage through any licensed dentist» Over-the-counter (OTC) benefit allowance on health and wellness products» Routine eye & hearing exam coverage» Prescription eyewear coverage on most plans 3

4 MEDICA ADVANTAGE SOLUTION When can I enroll? Initial Enrollment Period (IEP) This is when you first become eligible for Medicare at around age 65. You have a sevenmonth window during which you can sign up for Medicare. Annual Election Period (AEP) Medicare open enrollment is October 15 December 7 each year for January 1 coverage. All enrollments options are available at this time. Special Enrollment Period (SEP) An SEP allows you to make changes to your coverage that normally you can only make during your IEP or AEP. There are many types of events that can trigger an SEP, such as when your current plan is no longer available. Advantage Solution is a Medicare Advantage plan, which is a type of private plan that administers your Part A and Part B benefits on behalf of Medicare. Some Medicare Advantage plans, like Advantage Solution, also include Part D prescription drug coverage and other additional benefits. There are several types of Medicare Advantage plans and Medica offers two of them: (1) Medicare Advantage HMO-POS plan and (2) Medicare Advantage PPO plan. Both types of plans have a network of doctors, hospitals, and other health care providers. You will pay your lowest cost-sharing when you use these network providers for covered services. Out-of-Network Coverage Emergency Services You pay the same copay for emergency services received out of network within the U.S. and its territories as you do in network. Outside the U.S. and its territories, you pay coinsurance for emergency care coverage worldwide. If the plan has an out-of-network deductible, it does not apply for emergency services. Non-Emergency Services When you visit an out-of-network provider for non-emergency care, you pay coinsurance for most covered services after your out-of-network deductible is met (if your plan has one). You may use any provider that accepts Medicare. Not all services are covered. See the plan Summary of Benefits for more information. Advantage Solution Eligibility You are eligible to enroll in Medica Advantage Solution if:» you have Medicare Part A and Part B» you do not have End-Stage Renal Disease (ESRD)» your permanent residence is in the Advantage Solution service area. 4

5 ADVANTAGE SOLUTION SERVICE AREAS AND PROVIDER NETWORKS Advantage Solution is available in three service areas in Minnesota. Different plan options are offered in each service area. Advantage Solution has broad provider networks that include major health care systems* and many other facilities and providers. Service Areas Twin Cities Metro Provider Networks Twin Cities Metro and Greater Twin Cities Metro» Allina Health» CentraCare Health There are three Advantage Solution plan options available in the Twin Cities Metro to permanent residents of Anoka, Carver, Dakota, Hennepin, Ramsey, Scott and Washington counties. Greater Twin Cities Metro» Fairview Health Services/HealthEast Care System» Hennepin Healthcare» North Memorial Health» And many more! There are two Advantage Solution plan options available in the Greater Twin Cities Metro to permanent residents of Chisago, Isanti, Stearns, Kandiyohi, Wright and Sherburne counties. Southeast Minnesota Southeast Minnesota» Mayo Clinic Health System» Allina Health» Fairview Health Services/HealthEast Care System There is one Advantage Solution plan option available in Southeastern Minnesota to permanent residents of Blue Earth, Brown, Dodge, Faribault, Fillmore, Freeborn, Houston, Martin, Mower, Nicollet, Olmsted, Steele, Wabasha, Waseca, Watonwan and Winona counties.» Mankato Clinic» Olmsted Medical Center» And many more! * These providers may also contract with other Medicare plans/part D sponsors. 5

6 TWIN CITIES METRO 2018 Original Medicare ADVANTAGE SOLUTION PLAN OPTIONS H (HMO-POS) H (PPO) H (PPO) IN-NETWORK OUT-OF-NETWORK IN-NETWORK OUT-OF-NETWORK IN-NETWORK OUT-OF-NETWORK Monthly Premium $26.40 $98.50 $ Annual Medical Deductible $0 $400 $0 $0 Annual Out-of-Pocket Maximum $6,700 n/a $3,000 $4,500 *** $3,000 $4,500 *** Medical Benefits YOU PAY YOU PAY YOU PAY YOU PAY Preventive Services $0 $0 40% $0 30% $0 20% Annual Physical Exam n/a $0 n/a $0 30% $0 20% Primary Care 20% $20 40% $0 30% $0 20% virtuwell evisits n/a $0 n/a $0 n/a $0 n/a Specialist Offce Visit 20% $45 40% $25 30% $10 20% Urgent Care 20% $45 $45* $0 - $25 $0 - $25 $0 - $10 $0 - $10 Chiropractic** 20% $20 n/a $20 30% $10 20% Eye Exam - Routine Annual 100% $25 n/a $0 30% $0 20% Hearing Exam - Routine Annual 100% $0 n/a $0 n/a $0 n/a X-Ray / Radiology 20% 20% 40% 15% 30% 10% 20% Diagnostic Tests 20% 20% 40% 15% 30% 10% 20% Lab Services $0 $0 40% $0 30% $0 20% Diabetes Supplies 20% 20% 40% 20% 30% 20% 20% Durable Medical Equipment 20% 20% n/a 20% 30% 20% 20% Part B Drugs 20% 20% 40% 20% 30% 20% 20% Outpatient Surgery 20% $250 40% $100 30% $50 20% Ambulance (Ground) 20% $250 $250* $175 $175 $80 $80 Emergency Care - U.S. 20% $90 $90* $100 $100 $50 $50 Emergency Care - Worldwide 20% 20% 20% 20% 20% 20% 20% Inpatient Hospital Skilled Nursing Facility For residents of Anoka, Carver, Dakota, Hennepin, Ramsey, Scott and Washington counties. Days 1-60: $1,340 total Days 61-90: $335/day Days 1-20: $0/day Days : $167.50/day Days 1-5: $320/day Days 6-90: $0 Days 1-20: $0 Days : $172/day 40% 40% Days 1-5: $200/day Days 6-90: $0 Days 1-20: $0 Days : $150/day 30% 30% Days 1-4: $100/day Days 5-90: $0 Days 1-20: $0 Days : $100/day Part D Prescription Drug Coverage Annual Part D Deductible n/a $270 $265 $135 Level One - Initial Coverage (Shared drug costs $0 -$3,820) 30-Day Retail Tier 1 - Commonly Prescribed Generic 100% Up to $2 Up to $2 Up to $2 Tier 2 - Low-Cost Generic 100% Up to $8 Up to $8 Up to $8 Tier 3 - More Expensive Generic & Brand 100% Up to $41 Up to $46 Up to $44 Tier 4 - Higher Priced Generic & Brand 100% 50% 50% 50% Tier 5 - Generic or Brand for Complex Conditions 100% 27% 28% 30% Level Two - Coverage Gap Donut Hole (Member-only drug costs up to $5,100) Generic at 37% and Covered Brand at 25% for all plan options Level Three - Catastrophic Coverage (Member-only drug costs $5,100 and up) Generic at $3.40 or 5%**** and Other Drugs at $8.50 or 5%**** for all plan options * Out-of-Network medical deductible does not apply / ** Medicare-covered visit for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part). / *** Combined in- and out-of-network. **** Whichever is greater / When using an EPIC provider. / Deductible does not apply to Tier 1 and 2 drugs % 20%

7 Original Medicare ADVANTAGE SOLUTION PLAN OPTIONS H (HMO-POS) H (PPO) IN-NETWORK OUT-OF-NETWORK IN-NETWORK OUT-OF-NETWORK Monthly Premium $68.70 $ Annual Medical Deductible $0 $400 $0 $0 Annual Out-of-Pocket Maximum $6,700 n/a $3,000 $4,500*** Medical Benefits YOU PAY YOU PAY YOU PAY Preventive Services $0 $0 40% $0 30% Annual Physical Exam n/a $0 n/a $0 30% Primary Care 20% $20 40% $0 30% virtuwell evisits n/a $0 n/a $0 n/a Specialist Offce Visit 20% $45 40% $25 30% Urgent Care 20% $45 $45* $0 - $25 $0 - $25 Chiropractic** 20% $20 n/a $20 30% Eye Exam - Routine Annual 100% $25 n/a $0 30% Hearing Exam - Routine Annual 100% $0 n/a $0 n/a X-Ray / Radiology 20% 20% 40% 15% 30% Diagnostic Tests 20% 20% 40% 15% 30% Lab Services $0 $0 40% $0 30% Diabetes Supplies 20% 20% 40% 20% 30% Durable Medical Equipment 20% 20% n/a 20% 30% Part B Drugs 20% 20% 40% 20% 30% Outpatient Surgery 20% $250 40% $100 30% Ambulance (Ground) 20% $250 $250* $175 $175 Emergency Care - U.S. 20% $90 $90* $100 $100 Emergency Care - Worldwide 20% 20% 20% 20% 20% Inpatient Hospital Skilled Nursing Facility GREATER TWIN CITIES METRO For residents of Chisago, Isanti, Stearns, Kandiyohi, Wright and Sherburne counties. Days 1-60: $1,340 total Days 61-90: $335/day Days 1-20: $0/day Days : $167.50/day Days 1-5: $320/day Days 6-90: $0 Days 1-20: $0 Days : $172/day 40% 40% Days 1-5: $200/day Days 6-90: $0 Days 1-20: $0 Days : $150/day Part D Prescription Drug Coverage Annual Part D Deductible n/a $275 $265 Level One - Initial Coverage (Shared drug costs $0 -$3,820) 30-Day Retail Tier 1 - Commonly Prescribed Generic 100% Up to $2 Up to $2 Tier 2 - Low-Cost Generic 100% Up to $8 Up to $8 Tier 3 - More Expensive Generic & Brand 100% Up to $44 Up to $46 Tier 4 - Higher Priced Generic & Brand 100% 50% 50% Tier 5 - Generic or Brand for Complex Conditions 100% 27% 28% Level Two - Coverage Gap Donut Hole (Member-only drug costs up to $5,100) Level Three - Catastrophic Coverage (Member-only drug costs $5,100 and up) Generic at 37% and Covered Brand at 25% for all plan options Generic at $3.40 or 5%**** and Other Drugs at $8.50 or 5%**** for all plan options * Out-of-Network medical deductible does not apply / ** Medicare-covered visit for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part). *** Combined in- and out-of-network / **** Whichever is greater / When using an EPIC provider. / Deductible does not apply to Tier 1 and 2 drugs 30% 30% Local Customer Service At Medica, you ll always receive the caring, personal service you deserve from our local Medicare experts, right here in Minnesota. Our health plan specialists can answer your questions and help you maximize your coverage. 9

8 10 SOUTHEAST MINNESOTA For residents of Blue Earth, Brown, Dodge, Faribault, Fillmore, Freeborn, Houston, Martin, Mower, Nicollet, Olmsted, Steele, Wabasha, Waseca, Watonwan and ADVANTAGE SOLUTION Winona counties. H (PPO) 2018 Original Medicare IN-NETWORK OUT-OF-NETWORK Monthly Premium $ Annual Medical Deductible $0 $0 Annual Out-of-Pocket Maximum $4,000 $6,700*** Medical Benefits YOU PAY YOU PAY Preventive Services $0 $0 30% Annual Physical Exam n/a $0 30% Primary Care 20% $0 30% virtuwell evisits n/a $0 n/a Specialist Offce Visit 20% $30 30% Urgent Care 20% $0 - $30 $0 - $30 Chiropractic** 20% $20 30% Eye Exam - Routine Annual 100% $0 30% Hearing Exam - Routine Annual 100% $0 n/a X-Ray / Radiology / Diagnostic Tests 20% 15% 30% Lab Services $0 $0 30% Diabetes Supplies / Durable Medical Equipment 20% 20% 30% Part B Drugs 20% 20% 30% Outpatient Surgery 20% $150 30% Ambulance (Ground) 20% $200 $200 Emergency Care - U.S. 20% $90 $90 Emergency Care - Worldwide 20% 20% 20% Inpatient Hospital Days 1-60: $1,340 total Days 1-5: $250/day 30% Skilled Nursing Facility Days 61-90: $335/day Days 1-20: $0/day Days : $167.50/day Days 6-90: $0 Days 1-20: $0 Days : $150/day Part D Prescription Drug Coverage Annual Part D Deductible n/a $265 Level One - Initial Coverage (Shared drug costs $0 -$3,820) 30-Day Retail Tier 1 - Commonly Prescribed Generic 100% Up to $2 Tier 2 - Low-Cost Generic 100% Up to $8 Tier 3 - More Expensive Generic & Brand 100% Up to $44 Tier 4 - Higher Priced Generic & Brand 100% 50% Tier 5 - Generic or Brand for Complex Conditions 100% 28% Level Two - Coverage Gap Donut Hole (Member-only drug costs up to $5,100) Generic at 37% and Covered Brand at 25% Level Three - Catastrophic Coverage (Member-only drug costs $5,100 and up) Generic at $3.40 or 5%**** and Other Drugs at $8.50 or 5%**** * Out-of-Network medical deductible does not apply / ** Medicare-covered visit for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part). / *** Combined in- and out-of-network **** Whichever is greater / When using an EPIC provider. / Deductible does not apply to Tier 1 and 2 drugs. 30%

9 THE EXTRA BENEFITS YOU VALUE Convenience and Drug Savings Through Mail Order Save on your prescription drugs when you use mail order. You can order your refills online anytime, anywhere it s fast and easy.» With our PPO (H8889) plans, there is no copay on Tier 1-2 drugs through mail order and you pay only two copays for a three-month supply of Tier 3 drugs.» With our HMO-POS (H6154) plans, you pay only two copays for a three-month supply of Tier 1-3 drugs. Eyewear Reimbursement Receive an annual reimbursement for prescription eyewear with our PPO (H8889) plans. Reimbursement amount varies by plan. Metro Twin Cities Annual Amount H (PPO) $75 H (PPO) $125 Greater Metro Twin Cities H (PPO) $75 Southeastern Minnesota H (PPO) $75 Dental Reimbursement Advantage Solution offers reimbursement for dental services provided by any licensed dentist. This covers both preventive and restorative care. Annual reimbursement amount varies by plan.» With our HMO-POS (H6154) plans, you are reimbursed up to $150 per year» With our PPO (H8889) plans, you are reimbursed up to $225 per year Over-the-Counter (OTC) Savings All plans have a benefit allowance that can be used toward the purchase of eligible over-thecounter (OTC) health and wellness products. Allowance amount varies by plan. Metro Twin Cities Quarterly Amount H (PPO) $25 H (PPO) $50 H (HMO-POS) $50 Greater Metro Twin Cities H (PPO) $25 H (HMO-POS) $50 Southeastern Minnesota H (PPO) $50 11

10 OUR EXTRAS MAKE A HEALTHY PLAN EVEN HEALTHIER. A great Medicare plan is only one piece of the puzzle when it comes to maintaining your health. So we provide you with the extra resources you need to stay healthy each and every day. Stay Active with SilverSneakers Advantage Solution includes a FREE SilverSneakers membership. This program helps people age 65 and over improve their well being through a variety of fitness options.» More than 14,000 participating fitness locations nationwide» Enroll at multiple locations any time» Access to classes, exercise equipment and other amenities» Track your fitness progress online and find useful health information. Visit SilverSneakers.com for a complete list of facilities and options. Personal Advocates and NurseLine HealthAdvocate SM has your back if you have questions about your Medica plan coverage, or need help navigating the medical system. Our trained Personal Health Advocates can help you tackle health-related questions from finding the right doctor to resolving claims questions. NurseLine is available 24/7 highly trained nurses can answer your questions about symptoms, medications and health conditions. Both services are available at no additional cost. $0 evisits through virtuwell With Advantage Solution you will have access to quick, convenient online care through virtuwell. Available anytime, anywhere from your computer or mobile device, virtuwell can treat over 50 common conditions.» Get a diagnosis, treatment plan and prescription (if needed), often in less than 30 minutes.» The service is available 24/7 with no appointment needed» $0 copay. 12

11 Savings on Hearing Aids & Exams When hearing services are received from an EPIC Hearing provider, you receive the following special benefits:» $0 copay for routine hearing exam» Special pricing on hearing aids pay just $599 for the Vista 610 hearing aid or $899 for the Vista 810 hearing aid. Both come in various styles and colors.» $0 copay for up to 3 provider visits within the first year of hearing aid purchase to help with fitting and adjustment of the hearing aid. Care Management When You Need it Medica provides extra support to members with complex health conditions who need community-based services.» Working alongside your doctor, Medica s team of nurse care managers and pharmacists partner with you to set goals and work toward improving your health.» Care Managers will help support you through transitions of care settings as your care needs change.» They can support you and your family in navigating the complexities of the health care system.» Enrollment in our care management program is offered at no extra cost for qualifying members. Member Information Online and in the Mail As a Medica member, you will have access to mymedica.com, a one-stop member resource that puts your health plan benefits and activity at your fingertips 365 days a year. Also, you will receive our Medica Magazine three times a year. It is full of practical information to help you maintain or improve your well being. Shortly after enrolling, you will receive a new member kit that includes a Quick Reference Guide to help you understand your coverage and get the most from it. 13

12 HOW TO ENROLL IN MEDICA ADVANTAGE SOLUTION What to expect after you enroll Once you have submitted your application, you can expect to receive the following communications from us: 1 2 Acknowledgement Within about a week, you will receive a letter letting you know that your application has been received. Member Packet Within two weeks, you will receive your member packet, which will contain your Evidence of Coverage, member guide and other important materials that you will want to read and keep for future reference. There are three ways to enroll in Advantage Solution. Choose the one that works best for you: Call (TTY: 711) for fast and easy enrollment over the phone. Go to medica.com/medicare to complete your enrollment online. Complete and sign a paper application and submit via mail, fax or web. You can request a paper application by calling (TTY: 711). Submit your completed paper forms via mail, fax or web. Mail to: Medica Medicare Solutions PO Box 6300 Eau Claire, WI Or fax to: Or upload securely at: medica.com/enrollmentupload ID Card Your ID card will arrive one to three weeks prior to your effective date. (NOTE: Your ID card is not included in your member packet it is sent separately.) Verification Communication Medicare requires that we contact you to verify that you are familiar with the terms of your new plan. Confirmation Letter This letter confirms Medicare s approval of your enrollment in Medica Advantage Solution. 14

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14 MEDICA. April THE FIRST WORD IN MEDICARE. Call toll free at (TTY: 711) Hours of operation: October 1 March 31 8 a.m. to 8 p.m. Central, seven days a week 1 September 30 8 a.m. to 8 p.m. Central, Monday - Friday Visit us online to learn more at medica.com/medicare Locate a Medicare Workshop near you at medica.com/medicareworkshops Find a broker in your community at medica.com/medicare Centers for Medicare & Social Security Follow Medica: Medicaid Services (CMS) Administration Toll free at MEDICARE Toll free at ( ) (TTY/TTD: ) (TTY/TTD: ) Hours of operation: Hours of operation: 7 a.m. to 7 p.m., 24 hours a day, seven days a week Monday-Friday medicare.gov ssa.gov This information is not a complete description of benefits. Call Medica at (TTY: 711) for more information. Out-of-network/non-contracted providers are under no obligation to treat Medica members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services. Medica is an HMO-POS and PPO plan with a Medicare contract. Enrollment in Medica depends on contract renewal. The SilverSneakers fitness program is provided by Tivity Health, an independent company. Tivity Health and SilverSneakers are registered trademarks or trademarks of Tivity Health, Inc., and/or its subsidiaries and/or affliates in the USA and/or other countries. HealthAdvocate SM is a service mark of Health Advocate, Inc. Virtuwell is a registered service mark of HealthPartners, Inc Medica. Medica and Medica Advantage Solution are registered service marks of Medica Health Plans. Medica refers to the family of health plan businesses that includes Medica Health Plans, Medica Health Plans of Wisconsin, Medica Insurance Company, Medica Self-Insured, Medica Health Management, LLC and MMSI, Inc. CHA A