I want a local insurer that understands our needs.

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1 2019 I want a lcal insurer that understands ur needs. Summary f Benefits Stride SM Medicare Advantage Plan New Hampshire Belknap, Carrll, Cheshire, Cs, Graftn, Hillsbrugh, Merrimack, Rckingham, Straffrd and Sullivan cunties Y0098_19015_M Accepted

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3 , and Plus Summary f Benefits January 1, 2019 December 31, 2019 This is a summary f drug and health services cvered by, and Plus fr January 1, December 31, Harvard Pilgrim is an HMO plan with a Medicare cntract. Enrllment in Stride SM depends n cntract renewal. The benefit infrmatin prvided is a summary f what we cver and what yu pay. It des nt list every service that we cver r list every limitatin r exclusin. The cmplete list f services is fund in the Evidence f Cverage (EOC) which is available nline at T rder a cpy f the Evidence f Cverage, please call ur Member Services department (phne number listed n the back cver). T jin, r Plus, yu must be entitled t Medicare Part A, be enrlled in Medicare Part B, and live in ur service area. Our service area fr includes the fllwing cunties in New Hampshire: Belknap, Carrll, Cheshire, Cs, Graftn, Hillsbrugh, Merrimack, Rckingham, Straffrd, and Sullivan., and Plus have a netwrk f dctrs, hspitals, pharmacies, and ther prviders. Except in emergency situatins, if yu use the prviders that are nt in ur netwrk, the plan may nt pay fr these services. NOTE: Services with a 1 may require authrizatin frm the plan. Services with a 2 may require referral frm yur dctr. An individual service will rarely require bth authrizatin and referral, althugh bth may be indicated in this bklet. Fr mre infrmatin abut whether a particular item r service requires a referral r an authrizatin, please call the phne number listed n the back cver. Y0098_19015_M Accepted 1

4 Cvered Services Plus Mnthly Plan Premium Yu pay $0. Yu pay $39. Yu pay $113. Yu must cntinue t pay yur Medicare Part B premium. Deductible Medical Deductible: Yu pay $0. Medical Deductible: Yu pay $0. Medical Deductible: Yu pay $0. Prescriptin Drug Deductible: Yu pay a $415 deductible per year fr Part D prescriptin drugs except fr drugs listed n Tier 1 and Tier 2 which are excluded frm the deductible. Prescriptin Drug Deductible: Yu pay a $270 deductible per year fr Part D prescriptin drugs except fr drugs listed n Tier 1 and Tier 2 which are excluded frm the deductible. Prescriptin Drug Deductible: Yu pay a $200 deductible per year fr Part D prescriptin drugs except fr drugs listed n Tier 1 and Tier 2 which are excluded frm the deductible. Maximum Out-f- Pcket (This amunt des nt include yur mnthly premiums r any prescriptin drug csts.) $6,700 annually. $5,600 annually. $5,000 annually. Our plan prtects yu by having yearly limits n yur ut-f-pcket csts fr medical and hspital care frm innetwrk prviders. If yu reach the limit n ut-f-pcket csts, yu keep getting Medicare- cvered hspital and medical services frm innetwrk prviders, and we will pay the full cst fr the rest f the year. Please nte that yu will still need t pay yur mnthly premiums, as well as yur cst-shares fr Part D prescriptin drugs. 2

5 Cvered Services Plus Inpatient Hspital Cverage 1 Our plan cvers an unlimited number f days fr an inpatient hspital stay. Yu pay a $370 cpayment per day fr Days 1-5, then $0 cpayment after Day 5. Yu pay a $310 cpayment per day fr Days 1-6, then $0 cpayment after Day 6. Yu pay a $265 cpayment per day fr Days 1-6, then $0 cpayment after Day 6. Outpatient Hspital Cverage 1 Yu pay a $60 t $350 cpayment Yu pay a $60 t $290 cpayment Yu pay a $60 t $250 cpayment Dctr Visits Primary Care Yu pay a $20 cpayment Specialists 2 Yu pay a $40 cpayment Yu pay a $35 cpayment Yu pay a $30 cpayment Chirpractic Care 2 Yu pay a $20 cpayment Yu pay a $20 cpayment Yu pay a $20 cpayment Medicare-Cvered Preventive Care (e.g. flu vaccine, diabetic screenings) Any additinal preventive services apprved by Medicare during the cntract year will be cvered. Yu pay nthing fr mst preventive services. Yur cst fr sme preventive services will be greater than a $0 Yu pay nthing fr mst preventive services. Yur cst fr sme preventive services will be greater than a $0 Yu pay nthing fr mst preventive services. Yur cst fr sme preventive services will be greater than a $0 Annual Rutine Physical Exam Yu pay nthing. Yu pay nthing. Yu pay nthing. Emergency Care If yu are admitted t the hspital within 24 hurs fr the same cnditin, yu pay $0 cpayment fr the emergency rm visit. Yu pay a $90 cpayment Yu pay a $90 cpayment Yu pay a $90 cpayment If yu are held fr bservatin, the emergency cpayment still applies. 3

6 Cvered Services Plus Urgently Needed Services Yu pay a $65 cpayment Yu pay a $65 cpayment Yu pay a $65 cpayment If yu are admitted t the hspital within 24 hurs fr the same cnditin, yu pay $0 cpayment fr the urgent care visit. If yu are held fr bservatin, the urgent care cpayment still applies. Outpatient Diagnstic Services/Labs/ Imaging 1,2 Diagnstic radilgy service such as ultrasunds, MRIs, and CT scans Yu pay a $20 t $300 Yu pay a $15 t $200 Yu pay a $10 t $100 Lab services Yu pay a $20 Yu pay a $10. Diagnstic tests and prcedures Yu pay a $20 t $60 Yu pay a $10 t $60 Yu pay a $0 t $60 Outpatient X-rays Yu pay a $20 Yu pay a $15 Yu pay a $10 Therapeutic radilgy services (such as radiatin treatment fr cancer) Yu pay a $60 Yu pay a $60 Yu pay a $60 4

7 Cvered Services Plus Hearing Services diagnstic hearing exam 2 Annual rutine hearing exam Yu pay a $40 Yu pay a $35 Yu pay a $30 Yu pay a $40 Yu pay a $35 Yu pay a $30 Hearing aids Up t tw hearing aids every year. Benefit is limited t the TruHearing Advanced and TruHearing Premium hearing aids, which cme in varius styles and clrs. Yu pay a $699 r $999 cpayment fr each hearing aid. Yu pay a $699 r $999 cpayment fr each hearing aid. Yu pay a $699 r $999 cpayment fr each hearing aid. Dental Services Dental services are administered by Dental Benefit Prviders, Inc. Yu can see any licensed dentist t receive cvered dental services. Yu may visit ur website at g/medicare fr a listing f participating dentists. If yu chse t use a prvider wh des nt participate in ur rutine dental prvider netwrk, yu will be subject t: (1) 20% cinsurance fr cvered services and (2) the difference between the dentist s billed charges and the amunt paid by Harvard Pilgrim. Yu pay a $40 cpayment fr dental services. Preventive dental services nt cvered. Yu pay a $35 cpayment fr dental services. After the $35 deductible, yu pay a $0 cpayment fr the fllwing dental services: Peridic ral exams tw per year Cleanings (adult prphylaxis) tw per year Bitewing X-rays nce per year Cmplete series r panramic X-rays nce every three years There is a $500 benefit limit n cvered preventive dental services each year. Yu pay a $30 cpayment fr dental services. After the $35 deductible, yu pay a $0 cpayment fr the fllwing dental services: Peridic ral exams tw per year Cleanings (adult prphylaxis) tw per year Bitewing X-rays nce per year Cmplete series r panramic X-rays nce every three years There is a $500 benefit limit n cvered preventive dental services each year. 5

8 Cvered Services Plus Visin Services visin exam 2 (Refractins are cvered when medically necessary t diagnse r treat cnditins f the eye.) fr Diabetic Retinpathy screening. Yu pay a $40 cpayment fr all ther exams t diagnse and treat diseases and cnditins f the eye. fr Diabetic Retinpathy screening. Yu pay a $35 cpayment fr all ther exams t diagnse and treat diseases and cnditins f the eye. fr Diabetic Retinpathy screening. Yu pay a $30 cpayment fr all ther exams t diagnse and treat diseases and cnditins f the eye. eyewear pst cataract surgery... Annual rutine visin exam (Refractin is cvered t prescribe crrective eyewear r t screen fr cnditins f the eye.)... Supplemental eyewear after reimbursement fr ne pair f prescriptin cntact lenses, eyeglasses (lenses and frames), lenses nly, frames nly, r upgrades every year. Please refer t the plan's Wallet Benefit fr mre infrmatin. after reimbursement fr ne pair f prescriptin cntact lenses, eyeglasses (lenses and frames), lenses nly, frames nly, r upgrades every year. Please refer t the plan's Wallet Benefit fr mre infrmatin. after reimbursement fr ne pair f prescriptin cntact lenses, eyeglasses (lenses and frames), lenses nly, frames nly, r upgrades every year. Please refer t the plan's Wallet Benefit fr mre infrmatin. 6

9 Cvered Services Plus Behaviral Health Services Inpatient visit 1 Our plan cvers an unlimited number f days fr an inpatient hspital stay Yu pay a $370 cpayment per day fr Days 1-4, then $0 cpayment after Day 4. Yu pay a $310 cpayment per day fr Days 1-5, then $0 cpayment after Day 5. Yu pay a $265 cpayment per day fr Days 1-6, then $0 cpayment after Day 6. Outpatient visit with a psychiatrist r licensed prvider Yu pay a $40 cpayment per individual r grup therapy visit. Yu pay a $35 cpayment per individual r grup therapy visit. Yu pay a $30 cpayment per individual r grup therapy visit. Skilled Nursing Facility (SNF) 1 Our plan cvers up t 100 days per admissin in a SNF. A hspital stay prir t SNF admissin is nt required. Rehabilitatin Services 1,2 Occupatinal therapy visit per day fr Days 1-20, then $172 cpayment per day fr Days per day fr Days 1-20, then $165 cpayment per day fr Days per day fr Days 1-20, then $155 cpayment per day fr Days Yu pay a $30 Yu pay a $25 Yu pay a $25 Physical therapy and speech language therapy visit Cardiac rehabilitatin Yu pay a $30 Yu pay a $25 Yu pay a $25 Yu pay a $30 Yu pay a $25 Yu pay a $25 Ambulance 1 Yu pay a $250 cpayment fr ne-way ambulance transprt. Yu pay a $250 cpayment fr ne-way ambulance transprt. Yu pay a $250 cpayment fr ne-way ambulance transprt. 7

10 Cvered Services Plus Transprtatin 1 By way f wheelchair van. Cvered when medically necessary, instead f ambulance. Yu pay a $60 cpayment per ne-way trip t planapprved lcatins. Yu pay a $60 cpayment per ne-way trip t planapprved lcatins. Yu pay a $60 cpayment per ne-way trip t planapprved lcatins. Medicare Part B Drugs 1 Yu pay 20% f the ttal cst fr chemtherapy drugs. Yu pay 20% f the ttal cst fr chemtherapy drugs. Yu pay 20% f the ttal cst fr chemtherapy drugs. Yu pay 20% f the ttal cst fr ther Part B drugs. Yu pay 20% f the ttal cst fr ther Part B drugs. Yu pay 20% f the ttal cst fr ther Part B drugs. Ft Care (pdiatry services) 2 Ft exams and treatment Yu pay a $40 Yu pay a $35 Yu pay a $30 Rutine ft care (May be cvered if yu have diabetesrelated nerve damage and/r meet certain cnditins.) Yu pay a $40 Yu pay a $35 Yu pay a $30 Durable Medical Equipment (DME) and Related Supplies 1 Durable Medical Equipment (e.g. wheelchairs, xygen) Yu pay 20% f the ttal cst. Yu pay 20% f the ttal cst. Yu pay 20% f the ttal cst. Prsthetics (e.g. braces, artificial limbs) Diabetes supplies (Preferred brand is Abbtt Diabetes Care.) Yu pay 20% f the ttal cst. Yu pay 20% f the ttal cst. Yu pay 20% f the ttal cst.... 8

11 Cvered Services Plus Wellness Prgrams Acupuncture Visits Alternative Therapies Fitness Membership Massage Therapy Practitiners must be licensed, if applicable, in the state where they prvide services. Over-The-Cunter Benefit Please cntact the plan r visit ur website fr specific instructins n using this benefit and fr ur list f cvered Over-the-Cunter items. after reimbursement. Please refer t the plan s Wallet Benefit fr mre infrmatin. Alternative Therapies are hlistic medicine, bdywrk, and mind/bdy therapies. Limitatins/exclusins apply. Our plan prvides a $150 annual ver-the-cunter allwance, which may nt exceed $50 per mnth. after reimbursement. Please refer t the plan s Wallet Benefit fr mre infrmatin. Alternative Therapies are hlistic medicine, bdywrk, and mind/bdy therapies. Limitatins/exclusins apply. Our plan prvides a $200 annual ver-the-cunter allwance, which may nt exceed $50 per mnth. after reimbursement. Please refer t the plan s Wallet Benefit fr mre infrmatin. Alternative Therapies are hlistic medicine, bdywrk, and mind/bdy therapies. Limitatins/exclusins apply. Our plan prvides a $250 annual ver-the-cunter allwance, which may nt exceed $50 per mnth. Outpatient Substance Abuse Yu pay a $40 Yu pay a $35 Yu pay a $30 Partial Hspitalizatin 1 Yu pay a $55 cpayment per day. Yu pay a $55 cpayment per day. Yu pay a $55 cpayment per day. Wallet Benefit Cvers the cst f any f the fllwing items r services: Plan includes a $250 annual reimbursement amunt. Plan includes a $325 annual reimbursement amunt. Plan includes a $400 annual reimbursement amunt. Acupuncture Visits Alternative Therapies (Limitatins / exclusins apply) Massage Therapy Supplemental Eyewear 9

12 PRESCRIPTION DRUG BENEFITS Part D Prescriptin Drug Stage Deductible During this stage, yu pay the full cst f yur Tier 3, 4 and 5 drugs. During this stage, yu pay the full cst f yur Tier 3, 4 and 5 drugs. Plus During this stage, yu pay the full cst f yur Tier 3, 4 and 5 drugs. Yu stay in this stage until yu have paid $415 fr yur Tier 3, 4 and 5 drugs Yu stay in this stage until yu have paid $270 fr yur Tier 3, 4 and 5 drugs Yu stay in this stage until yu have paid $200 fr yur Tier 3, 4 and 5 drugs Cst-sharing may change depending n the pharmacy yu chse and when yu enter a new phase f the Part D benefit. Initial Cverage Cverage Gap After yu pay yur yearly deductible, yu pay the cpayments r cinsurance until yur ttal yearly drug csts reach $3,820. Ttal yearly drug csts are the ttal drug csts paid by bth yu and Harvard Pilgrim. Yu may get yur drugs at pharmacies in ur netwrk, including retail and mail rder pharmacies. Mst Medicare drug plans have a cverage gap. The cverage gap begins after the ttal yearly drug cst (what ur plan has paid and what yu have paid) reaches $3,820. Mst Medicare drug plans have a cverage gap. The cverage gap begins after the ttal yearly drug cst (what ur plan has paid and what yu have paid) reaches $3,820. Mst Medicare drug plans have a cverage gap. The cverage gap begins after the ttal yearly drug cst (what ur plan has paid and what yu have paid) reaches $3,820. Catastrphic Cverage During this stage, yu pay 25% f the price fr brandname drugs (plus a prtin f the dispensing fee) and 37% f the price fr generic drugs until yur csts ttal $5,100 and the cverage gap ends. Nt everyne will enter the cverage gap. During this stage, yu pay 25% f the price fr brandname drugs (plus a prtin f the dispensing fee) and 37% f the price fr generic drugs until yur csts ttal $5,100 and the cverage gap ends. Nt everyne will enter the cverage gap. Under this plan nly, yu will cntinue t pay a $0 cpayment fr Tier 1 drugs frm retail r mail-rder netwrk pharmacies during the cverage gap. Otherwise, yu pay 25% f the price fr brand-name drugs (plus a prtin f the dispensing fee) and 37% f the price fr generic drugs until yur csts ttal $5,100 and the cverage gap ends. Nt everyne will enter the cverage gap. After yur ut-f-pcket drug csts (including drugs purchased thrugh yur retail pharmacy and thrugh mail rder) reach $5,100 yu pay the greater f either: cinsurance that is 5% f the cst f the drug, r $3.40 fr a generic drug r a drug that is treated like a generic and $8.50 fr all ther drugs. Our plan pays the rest f the cst. 10

13 Initial Cverage Retail Cst-Shares (30-day supply) Tier Plus Tier 1: Preferred Generic Tier 2: Yu pay a $15 cpayment Yu pay a $10 cpayment Yu pay a $10 cpayment Generic Tier 3: Yu pay a $47 cpayment Yu pay a $47 cpayment Yu pay a $47 cpayment Preferred Brand-Name Tier 4: Nn- Yu pay a $100 cpayment Yu pay a $100 cpayment Yu pay a $100 cpayment Preferred Brand-Name Tier 5: Specialty Yu pay 25% f the ttal cst Yu pay 27% f the ttal cst Yu pay 29% f the ttal cst Initial Cverage Mail Order Cst-Shares (90-day supply) Tier Plus Tier 1: Preferred Generic Tier 2: Yu pay a $30 cpayment Yu pay a $20 cpayment Yu pay a $20 cpayment Generic Tier 3: Yu pay a $94 cpayment Yu pay a $94 cpayment Yu pay a $94 cpayment Preferred Brand-Name Tier 4: Nn- Yu pay a $250 cpayment Yu pay a $250 cpayment Yu pay a $250 cpayment Preferred Brand-Name Tier 5: Specialty Yu pay 25% f the ttal cst Yu pay 27% f the ttal cst Yu pay 29% f the ttal cst If yu reside in a lng-term care facility, yu pay the same as at a retail pharmacy. Yu may get a 30-day supply f drugs frm an ut-f-netwrk pharmacy at the same cst as an innetwrk pharmacy. 11

14 Mre infrmatin T learn mre abut Stride r t view plan dcuments, please visit ur website r call us. Our cntact infrmatin is belw. Stride Current members: (TTY: 711) Prspective members: (TTY: 711) Website: harvardpilgrim.rg/medicare Prvider and Pharmacy Directry Frmulary (List f Cvered Drugs) Original Medicare Mre infrmatin abut cverage and csts f Original Medicare Hurs f peratin: harvardpilgrim.rg/medicare harvardpilgrim.rg/medicare Octber 1 March 31, we re available 8 a.m.- 8 p.m., seven days a week. April 1 September 30, we re available Mnday Friday, 8 a.m.- 8 p.m. We cver Part D drugs. In additin, we cver Part B drugs such as chemtherapy and sme drugs administered by yur prvider. Medicare & Yu handbk View nline at Get a cpy by calling MEDICARE ( ) 24 hurs a day, 7 days a week TTY users shuld call This dcument is available in ther frmats such as Braille, large print r audi. This infrmatin is nt a cmplete descriptin f benefits. Call Member Services at (TTY: 711) fr mre infrmatin. 12

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16 Fr mre infrmatin abut Stride SM, call: Prspective Members: Fr TTY service, call 711 Current Members: Fr TTY service, call 711 Hurs f peratin: Octber 1 - March 31, 8 a.m. - 8 p.m. 7 days a week, April 1 - September 30, 8 a.m. - 8 p.m. Mnday - Friday. Or visit us nline: hpfrlife.rg Harvard Pilgrim is an HMO plan with a Medicare cntract. Enrllment in Stride SM depends n cntract renewal. 93 Wrcester Street, Suite 100 Wellesley, MA /18