2017 Summary. Choice (HMO) Value Preferred Choice (HMO) H0545, Plan 014

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1 It s Personal Summary Desert Preferred of Benefits Choice (HMO) Value Preferred Choice (HMO) H0545, Plan 014 This is a summary of drug and health services covered by Value Preferred Choice (HMO) January 1, 2017 December 31, Value Preferred Choice (HMO) is a Medicare Advantage HMO plan with a Medicare contract. Enrollment in the Plan depends on contract renewal. The benefit information provided is a summary of what we cover and what you pay. It 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 Value Preferred Choice (HMO), 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, Orange and San Bernardino. Value Preferred Choice (HMO) has a network of doctors, hospitals, pharmacies, and other providers. If you use the providers that are not in our network, the plan may not pay for these services. Member: Celeste Palmer H0545_FUY2017_022 Accepted

2 & BENEFITS CHOICE (HMO) MEDICARE & FULL MEDI-CAL ELIGIBILITY MONTHLY PLAN PREMIUM DEDUCTIBLE MAXIMUM OUT-OF-POCKET RESPONSIBILITY (Does not include prescription drugs) INPATIENT HOSPITAL COVERAGE DOCTOR VISITS: Primary Specialists PREVENTIVE CARE EMERGENCY CARE (Within the U.S. and its territories) URGENTLY NEEDED SERVICES DIAGNOSTIC SERVICES/ LABS/IMAGING Diagnostic radiology service (e.g., MRI) Lab services Diagnostic tests & procedures Outpatient x-rays You pay $36.20 Medicare fee-for-service deductible $5,900 annually The most you pay for copays, coinsurance and other costs for Medicare covered services for the year. You pay: $1,288 deductible each benefit period. Days 1 60 $0 Days $322 per day (These amounts may change in 2017) Any additional preventive services approved by Medicare during the contract year are covered. You pay $75 copay per visit You do not have a deductible. Costs for this plan may be greatly reduced or even eliminated based upon eligibility for Medi-Cal and the Part D extra help program. Prior authorization is required for specialists visits. You must receive urgent care services from an in-network provider when available. Prior authorization is required for some services by your doctor or other network provider. Please contact the Plan for more information.

3 & BENEFITS CHOICE (HMO) MEDICARE & FULL MEDI-CAL ELIGIBILITY HEARING SERVICES Hearing exam Coverage for hearing aids DENTAL SERVICES Oral exam Cleaning Dental x-rays $1500 (every 2 years) for hearing exam Our plan offers an allowance of $1500 towards the purchase of hearing aids every 2 years. Additional dental services available. Copays based upon the procedures performed by a general dentist. VISION SERVICES Routine eye exam Coverage for Eyeglasses (frames and lenses) $175 (every 2 years) Our plan covers up to $175 towards eye glasses every 2 years. Routine vision services provided by Vision Service Plan (VSP). MENTAL HEALTH SERVICES Inpatient visit Outpatient group/individual therapy visit You pay: $1,288 deductible each benefit period. $0 coinsurance for days 1 60: $322 per day for days 61 90, (These amounts may change in 2017) Our plan covers up to 190-lifetime limit in a psychiatric hospital. SKILLED NURSING FACILITY You pay: $0 for days 1-20 each benefit period $161 each day for days (These amounts may change in 2017) Our plan covers up to 100 days in a skilled nursing facility REHABILITATION SERVICES Occupational therapy visit Physical therapy/speech and language therapy visit AMBULANCE

4 & BENEFITS CHOICE (HMO) MEDICARE & FULL MEDI-CAL ELIGIBILITY TRANSPORTATION FOOT CARE (podiatry services) Foot exams and treatment Routine foot care Offers up to 60 one-way trips each year Our plan covers up to 60 oneway trips each year. You must use plan contracted providers for transportation services. Our plan covers up to 4 routine foot care visits each year. MEDICAL EQUIPMENT & SUPPLIES Durable Medical Equipment (DME) (e.g., wheelchairs, oxygen) Prosthetics (e.g., braces, artificial limbs) Diabetes supplies WELLNESS PROGRAMS (e.g., fitness) Gym/health club benefits provided by Silver & Fit ACUPUNCTURE & CHIROPRACTIC SERVICES (Routine) 20 visits per year combined Services provided by American Specialty Health OVER-THE-COUNTER ITEMS Coverage up to $35 every month towards over-the-counter items. Contact the Plan for a list of available items and detailed instructions on ordering items. PERSONAL EMERGENCY RESPONSE SYTEM Prior authorization is required. Criteria and limitations apply. HOME-DELIVERED MEALS Prior authorization is required. Criteria and limitations (postdischarge from inpatient stay) apply.

5 & BENEFITS CHOICE (HMO) with Medicare & BENEFITS CHOICE (HMO) MEDICARE & FULL MEDI-CAL & Full Medi-Cal ELIGIBILITY eligibility. Medicare Part B Drugs PRESCRIPTION DRUGS Phase 1: INITIAL COVERAGE (After you pay your deductible, if applicable) Generic drugs All other drugs 30-day supply retail You pay 25% You pay 25% Depending on your income & institutional status; you pay: $0 or $1.20 or $3.30 $0 or $3.70 or $8.25 Cost sharing may change depending on the pharmacy you choose and when you enter another phase of the Part D benefit. For more information on cost sharing and the phases of the benefit, please call us or access our Evidence of Coverage online. If you want to know more about the coverage and costs of Original Medicare, look in your current Medicare & You handbook. View it online at or get a copy by calling MEDICARE ( ), 24 hours a day, 7 days a week. TTY users should call This document is available in other formats such as Spanish or large print. It s Personal.

6 For more information please call the number below or visit us at Toll free , TTY users should call 711. You can call us 7 days a week from 7:30 am to 8 pm. You can see our plan s provider/pharmacy directory on our website at We cover Part D drugs. In addition, we cover Part B drugs such as chemotherapy and some drugs administered by your provider. You can see the complete plan formulary (list of Part D prescription drugs) and restrictions on our website at It s Personal or TTY 711 7:30 am to 8 pm, 7 days a week. 300 S. Park Avenue P.O. Box 6002, Pomona, CA MED300VPC 9/16

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