SUMMARY OF BENEFITS SummaCare Medicare Sapphire (HMO-POS) (H3660_029) (H3660_048) SummaCare Medicare Emerald (HMO-POS) (H3660_028)

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1 SUMMARY OF BENEFITS Sapphire (HMO-POS) (H3660_029) (H3660_048) SummaCare Medicare Emerald (HMO-POS) (H3660_028) Plan Year January 1, 2017 through December 31, 2017 The SummaCare Sapphire (HMO-POS) Northeast plan is available to residents of the following counties: Ashland, Ashtabula, Carroll, Columbiana, Cuyahoga, Geauga, Holmes, Lake, Lorain, Mahoning, Medina, Portage, Stark, Summit, Trumbull, Tuscarawas and Wayne. The SummaCare Sapphire (HMO-POS) Northwest plan is available to residents of the following counties: Allen, Auglaize, Crawford, Defiance, Erie, Fulton, Hancock, Hardin, Henry, Huron, Lucas, Marion, Mercer, Morrow, Ottawa, Paulding, Putnam, Richland, Sandusky, Seneca, Van Wert, Williams, Wood and Wyandot. H3660_17_54 Accepted SUC EmeraldSapphireSOB_8.5x11.5.indd 1 The SummaCare Emerald (HMO-POS) plan is available to residents of the following counties: Ashtabula, Carroll, Columbiana, Cuyahoga, Geauga, Lake, Lorain, Mahoning, Medina, Portage, Stark, Summit, Trumbull, Tuscarawas and Wayne.

2 Sapphire (HMO-POS) Emerald (HMO-POS) 2 TABLE OF CONTENTS Ambulance Chiropractic Dental... 8, 15 Diabetes Programs & Supplies Diagnostic Tests... 7, 8 Doctor Visits... 5 Emergency Room... 7 Hearing Services... 8 Home Health Care Hospice Hospital Inpatient... 5 Hospital Outpatient Surgery Lab Services... 7, 8 Medical Equipment Mental Health Inpatient... 9 Mental Health Outpatient... 9 Podiatry Services Prescription Catastrophic Coverage Prescription Dollar Amount Limit... 5 Prescription Coverage Gap Amounts Prescription Part B Drugs Preventive Services Prosthetic Devices Radiology Services... 7, 8 Rehabilitation Inpatient... 9 Rehabilitation Outpatient... 9 Renal Dialysis Skilled Nursing Facility... 9 Substance Abuse Outpatient Transportation Urgent Care Vision Services... 8 X-Rays SUC EmeraldSapphireSOB_8.5x11.5.indd 2

3 Things to Know About Sapphire and Emerald What do we cover? Advantage Plans cover everything that Original Medicare covers and more. New for 2017! Preventive dental coverage Yearly prescription eyewear allowance 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 any restrictions on our website, medicare.summacare.com/member/drug_ benefits/findadrug.aspx. Or, call us and we will send you a copy of the formulary. No Referrals Needed Although we recommend that your Primary Care Physician (PCP) coordinate your medical care, you are not required to receive authorization before seeking care from most specialists. Pre-approval from SummaCare is needed before seeing a surgeon for back pain. Healthy You SummaCare is proud to offer Healthy You to members at no additional cost. Healthy You features health and wellness tools and programs designed to help you feel your best. Healthy You includes: SilverSneakers Fitness Program SummaCare 24-Hour Nurse Line Health Manager Powered by WebMD Preventive Health Reminders QuitCare Smoking Cessation Program Plus, many enhanced disease management programs How will I determine my drug costs? Our plan groups each medication into one of six tiers. You will need to use your formulary to locate what tier your drug is on to determine how much it will cost you. The amount you pay depends on the drug s tier and what stage of the benefit you have reached. Later in this document we discuss the benefit stages that occur: Initial Coverage, Coverage Gap and Catastrophic Coverage. Which doctors, hospitals and pharmacies can I use? Sapphire (HMO-POS) and Emerald (HMO-POS) has a network of doctors, hospitals, pharmacies, and other providers. For some services you can use providers that are not in our network but if you use providers that are not in our network your outof-pocket costs may be higher. You must generally use network pharmacies to fill your prescriptions for covered Part D drugs. You can see our plan s provider/pharmacy directory at our website, Or, call us and we will send you a copy of the provider/ pharmacy directories. Want to learn more? Call us at From October 1 through February 14, a representative is available to assist you from 8:00 a.m. through 8:00 p.m., seven days a week. From February 15 through September 30, a representative is available to assist you from 8:00 a.m. through 8:00 p.m., Monday through Friday. (TTY ) Visit and find more information about our plans. You can even enroll online at your convenience! 3 16SUC EmeraldSapphireSOB_8.5x11.5.indd 3

4 Sapphire and Emerald Phone Numbers and Website If you are a member of one of these plans, call toll-free If you are not a member of one of these plans, call toll-free Our website: SummaCare is an HMO and HMO-POS plan with a Medicare contract. Enrollment in SummaCare depends on contract renewal. The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or co-payments/co-insurance may change on January 1 of each year. 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 order a copy by calling MEDICARE ( ), 24 hours a day, 7 days a week. TTY users should call People with limited incomes may qualify for extra help to pay for their prescription drug costs and medical expenses. See if you qualify by calling: MEDICARE ( ), 24 hours per day/7 days a week. TTY/TDD users call The Social Security Administration at , Monday through Friday, 7 a.m. to 7 p.m. TTY/TDD users call Note: Some services may require preauthorization. This is a summary document. A complete list of services is found in the Evidence of Coverage (EOC). To request the EOC, please call one of the phone numbers at the top of this column. 4 16SUC EmeraldSapphireSOB_8.5x11.5.indd 4

5 Premiums and Benefits Sapphire (HMO-POS) Emerald (HMO-POS) What you should know Monthly Plan Premium In the Northeast plan, you pay $76 per month. In the Northwest plan, you pay $96 per month. You pay $180. You must continue to pay your Medicare Part B premium. Medical Deductible You pay nothing. You pay nothing. These plans do not have a deductible. Maximum Out-of- Pocket Responsibility (does not include prescription drugs) Your yearly limit(s) in this plan: $3,600 for in-network providers. Your yearly limit(s) in this plan: $3,400 for in-network providers. Our plan protects you by having a yearly limit on your out-of-pocket costs for medical and hospital costs. If you reach the limit on outof-pocket costs, you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year. Inpatient Hospital Coverage $295 copay per day for days 1 through 6 You pay nothing after day 6 $250 copay per day for days 1 through 7 You pay nothing after day 7 Our plan pays for an unlimited number of days for an inpatient hospital stay. 25% of the cost per day for days 1 through 90 20% of the cost per day for days 1 through 90 Doctor Visits Primary care physician visit: you pay nothing $20 copay Specialist visit: $40 copay Primary care physician visit: you pay nothing $20 copay Specialist visit: $25 copay You are not required to receive authorization before seeking care from most specialists. Pre-approval from SummaCare is needed before seeing a surgeon for back pain. $55 copay $40 copay 5 16SUC EmeraldSapphireSOB_8.5x11.5.indd 5

6 Premiums and Benefits Sapphire (HMO-POS) Emerald (HMO-POS) What you should know Preventive Care You pay nothing You pay nothing $20 copay $20 copay Our plan covers many preventive services, including: Our plan covers many preventive services, including: Abdominal aortic aneurysm screening Alcohol misuse counseling Bone mass measurement Breast cancer screening (mammogram) Cardiovascular disease (behavioral therapy) Cardiovascular screening Cervical and vaginal cancer screening Colorectal cancer screenings (Colonoscopy, Fecal occult blood test, Flexible sigmoidoscopy) Depression screening Diabetes screening HIV screening Medical nutrition therapy services Obesity screening and counseling Prostate cancer and counseling Sexually transmitted infections screening and counseling Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease) Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots Abdominal aortic aneurysm screening Alcohol misuse counseling Bone mass measurement Breast cancer screening (mammogram) Cardiovascular disease (behavioral therapy) Cardiovascular screening Cervical and vaginal cancer screening Colorectal cancer screenings (Colonoscopy, Fecal occult blood test, Flexible sigmoidoscopy) Depression screening Diabetes screening HIV screening Medical nutrition therapy services Obesity screening and counseling Prostate cancer and counseling Sexually transmitted infections screening and counseling Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease) Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots 6 16SUC EmeraldSapphireSOB_8.5x11.5.indd 6

7 Premiums and Benefits Sapphire (HMO-POS) Emerald (HMO-POS) What you should know Preventive Care (Continued) Welcome to Medicare preventive visit (one-time) Welcome to Medicare preventive visit (one-time) Yearly Wellness visit Yearly Wellness visit Emergency Care In-network and out-of-network: You pay $75 copay per visit. In-network and out-of-network: You pay $75 copay per visit. You are covered anywhere in the country for emergency and urgent care services, and up to $25,000 per year for emergency and urgent care services anywhere in the world. Urgently Needed Services In-network and out-of-network: You pay $40 copay per visit. In-network and out-of-network: You pay $40 copay per visit. You are covered anywhere in the country for emergency and urgent care services, and up to $25,000 per year for emergency and urgent care services anywhere in the world. Diagnostic Services/ Labs/Imaging Diagnostic radiology service (e.g., MRI): $ copay, depending on the location Diagnostic radiology service (e.g., MRI): $ copay, depending on the location The copay is based on where the procedure takes place. You pay a lower copay at a physician's office (office visit copay may apply). You pay a higher copay at all other locations. Diagnostic tests and procedures: $0-125 copay, depending on the location Diagnostic tests and procedures: $0-100 copay, depending on the location Lab services: $0-20 copay, depending on the location Lab services: $0-10 copay, depending on the location Outpatient X-rays: $0-150 copay, depending on the location Outpatient X-rays: $0-100 copay, depending on the location 7 16SUC EmeraldSapphireSOB_8.5x11.5.indd 7

8 Premiums and Benefits Sapphire (HMO-POS) Emerald (HMO-POS) What you should know Diagnostic Services/ Labs/Imaging (Continued) Therapeutic radiology services (such as radiation treatment for cancer): 20% of the cost Therapeutic radiology services (such as radiation treatment for cancer): 20% of the cost Hearing Services Exam to diagnose and treat hearing and balance issues: $40 copay Exam to diagnose and treat hearing and balance issues: $25 copay $55 copay $40 copay Routine hearing exam: $40 copay. You are covered for up to one every year. Routine hearing exam: $25 copay. You are covered for up to one every year. $55 copay $40 copay Preventive Dental Services $20 copay per visit $20 copay per visit Preventive dental covers one cleaning, one X-ray and one exam per year through the Delta Dental of Ohio Medicare Advantage PPO Network. Calendar year benefit maximum of $500. Vision Services Routine eye exam: $40 copay. $55 copay. You are covered for up to one exam every year. Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): $15 copay, depending on the service $55 copay Yearly prescription eyewear allowance: $150 allowance $75 allowance Routine eye exam: $25 copay. $40 copay. You are covered for up to one exam every year. Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): $10 copay, depending on the service $40 copay Yearly prescription eyewear allowance: $200 allowance $100 allowance Coverage for eyeglasses and/or contact lenses provided after cataract surgery limited to Medicare-allowed amount for Medicare-covered lenses and frames. In addition to an annual routine eye exam and Medicare-covered eye exams (for diagnosis and treatment for diseases and conditions of the eye). You will receive a calendar year allowance towards the purchase of prescription eyewear including frames, lenses or contact lenses, through the EyeMed Access Network. 8 16SUC EmeraldSapphireSOB_8.5x11.5.indd 8

9 Premiums and Benefits Sapphire (HMO-POS) Emerald (HMO-POS) What you should know Mental Health Services Inpatient visit: $295 copay per day for days 1 through 5. Inpatient visit: $250 copay per day for days 1 through 6. You pay nothing after day 5. You pay nothing after day 6. 25% of the cost per day for days 1 through % of the cost per day for days 1 through 90. Outpatient group therapy visit: $40 copay Outpatient group therapy visit: $25 copay $55 copay $40 copay Outpatient individual therapy visit: $40 copay Outpatient individual therapy visit: $25 copay $55 copay $40 copay Skilled Nursing Facility You pay nothing per day for days 1 through 20. $160 copay per day for days 21 through 100. You pay nothing per day for days 1 through 20. $100 copay per day for days 21 through 100. Our plan covers up to 100 days in a Skilled Nursing Facility. No prior hospital stay required. $160 copay per day for days 1 through 100. $100 copay per day for days 1 through 100. Rehabilitation Services Cardiac (heart) rehab services (for a maximum of 2-one hour sessions per day for up to 36 sessions up to 36 weeks): You pay nothing. Cardiac (heart) rehab services (for a maximum of 2-one hour sessions per day for up to 36 sessions up to 36 weeks): You pay nothing. $55 copay $40 copay Occupational therapy visit: $40 copay Occupational therapy visit: $25 copay $55 copay $40 copay Physical therapy and speech and language therapy visit: $40 copay Physical therapy and speech and language therapy visit: $25 copay $55 copay $40 copay 9 16SUC EmeraldSapphireSOB_8.5x11.5.indd 9

10 Premiums and Benefits Sapphire (HMO-POS) Emerald (HMO-POS) What you should know Ambulance $200 copay $200 copay $300 copay $200 copay Transportation Not covered Not covered Foot Care (podiatry services) $40 copay $55 copay $25 copay $40 copay Foot exams and treatment are covered if you have diabetes-related nerve damage and/or meet certain conditions. Medical Equipment/Supplies Durable medical equipment (e.g., wheelchairs, oxygen): 20% of the cost Durable medical equipment (e.g., wheelchairs, oxygen): 20% of the cost Prosthetic devices (e.g., braces, artificial limbs) 20% of the cost Prosthetic devices (e.g., braces, artificial limbs) 20% of the cost Diabetes monitoring supplies: 20% of the cost Diabetes monitoring supplies: 20% of the cost Diabetes self-management training: You pay nothing. Diabetes self-management training: You pay nothing. $20 copay $20 copay Therapeutic shoes or inserts: 20% of the cost Therapeutic shoes or inserts: 20% of the cost 10 16SUC EmeraldSapphireSOB_8.5x11.5.indd 10

11 Premiums and Benefits Sapphire (HMO-POS) Emerald (HMO-POS) What you should know Wellness Programs (e.g., fitness) SilverSneakers Fitness Program 24-Hour Nurse Line SilverSneakers Fitness Program 24-Hour Nurse Line Healthy You features health and wellness benefits and much more. One-on-one Health Coaching One-on-one Health Coaching Medicare Part B Drugs For Part B-covered chemotherapy drugs and other Part B-covered drugs: 20% of the cost For Part B-covered chemotherapy drugs and other Part B-covered drugs: 20% of the cost 11 16SUC EmeraldSapphireSOB_8.5x11.5.indd 11

12 PRESCRIPTION DRUG BENEFITS Prescription Drug Benefits Sapphire Emerald How much do I pay? For Part B-covered chemotherapy drugs and other Part B-covered drugs: 20% of the cost For Part B-covered chemotherapy drugs and other Part B-covered drugs: 20% of the cost Initial Coverage Tier 1 (Preferred Generic) Tier 2 (Generic) Tier 3 (Preferred Brand) Tier 4 (Non-Preferred Brand) Tier 5 (Specialty Tier) Tier 6 (Vaccines) Tier 1 (Preferred Generic) Tier 2 (Generic) Tier 3 (Preferred Brand) Tier 4 (Non-Preferred Brand) Tier 5 (Specialty Tier) Tier 6 (Vaccines) You pay the following until your total yearly drug costs reach $3,700. Total yearly drug costs are the total drug costs paid by both you and our Part D plan. You may get your drugs at network retail pharmacies and mail order pharmacies. Standard Retail Cost-Sharing One-month supply Three-month supply $0 $0 $15 copay $45 copay $47 copay $141 copay $100 copay $300 copay 33% of the cost 33% of the cost $0 $0 Standard Mail Order Cost-Sharing Three-month supply $0 $37.50 copay $ copay $300 copay N/A (limited to one-month supply) $0 If you reside in a long-term care facility, you pay the same as at a retail pharmacy. You may get drugs from an out-of-network pharmacy, but may pay more than you pay at an in-network pharmacy. You pay the following until your total yearly drug costs reach $3,700. Total yearly drug costs are the total drug costs paid by both you and our Part D plan. You may get your drugs at network retail pharmacies and mail order pharmacies. Standard Retail Cost-Sharing One-month supply Three-month supply $0 $0 $10 copay $30 copay $45 copay $135 copay $95 copay $285 copay 33% of the cost 33% of the cost $0 $0 Standard Mail Order Cost-Sharing Three-month supply $0 $25 copay $ copay $285 copay N/A (limited to one-month supply) $0 If you reside in a long-term care facility, you pay the same as at a retail pharmacy. You may get drugs from an out-of-network pharmacy, but may pay more than you pay at an in-network pharmacy SUC EmeraldSapphireSOB_8.5x11.5.indd 12

13 Prescription Drug Benefits continued Sapphire Emerald Coverage Gap Catastrophic Coverage Most Medicare drug plans have a coverage gap (also called the donut hole ). This means that there s a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $3,700. After you enter the coverage gap, you pay 40% of the plan s cost for covered brand name drugs and 51% of the plan s cost for covered generic drugs until your costs total $4,950, which is the end of the coverage gap. Not everyone will enter the coverage gap. Under this plan, you may pay even less for the brand and generic drugs on the formulary. Your cost varies by tier. You will need to use your formulary to locate your drug s tier. See the chart that follows to find out how much it will cost you. Standard Retail Cost-Sharing Tier 1 (Preferred Generic) Drugs Covered One-month supply Standard Mail Order Cost-Sharing Tier 1 (Preferred Generic) Three-month supply All $0 $0 Drugs Covered Three-month supply All $0 Tier 6 Vaccines are also covered at a $0 copay through the Coverage Gap. After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4,950, you pay the greater of 5% of the cost, or $3.30 copay for generic (including brand drugs treated as generic) and a $8.25 copayment for all other drugs. Most Medicare drug plans have a coverage gap (also called the donut hole ). This means that there s a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $3,700. After you enter the coverage gap, you pay 40% of the plan s cost for covered brand name drugs and 51% of the plan s cost for covered generic drugs until your costs total $4,950, which is the end of the coverage gap. Not everyone will enter the coverage gap. Under this plan, you may pay even less for the brand and generic drugs on the formulary. Your cost varies by tier. You will need to use your formulary to locate your drug s tier. See the chart that follows to find out how much it will cost you. Standard Retail Cost-Sharing Tier 1 (Preferred Generic) Drugs Covered One-month supply Standard Mail Order Cost-Sharing Tier 1 (Preferred Generic) Three-month supply All $0 $0 Drugs Covered Three-month supply All $0 Tier 6 Vaccines are also covered at a $0 copay through the Coverage Gap. After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4,950, you pay the greater of 5% of the cost, or $3.30 copay for generic (including brand drugs treated as generic) and a $8.25 copayment for all other drugs SUC EmeraldSapphireSOB_8.5x11.5.indd 13

14 Premiums and Benefits Sapphire (HMO-POS) Emerald (HMO-POS) What you should know Additional Benefits: Chiropractic Care Home Health Care Hospice Outpatient Substance Abuse Outpatient Surgery Over-the-Counter Items Renal Dialysis 14 $20 copay $55 copay You pay nothing. 20% of the cost You pay nothing for hospice care from a Medicarecertified hospice. You may have to pay part of the costs for drugs and respite care. Group therapy visit: $40 copay $55 copay Individual therapy visit: $40 copay $55 copay Ambulatory surgical center: $250 copay 20% of the cost Outpatient hospital: $250 copay 20% of the cost Select over-the-counter generic drugs are covered under this plan. Certain smoking cessation products are also covered under this plan. In-network and out-of-network: 20% of the cost $20 copay $40 copay You pay nothing. 20% of the cost You pay nothing for hospice care from a Medicarecertified hospice. You may have to pay part of the costs for drugs and respite care. Group therapy visit: $25 copay $40 copay Individual therapy visit: $25 copay $40 copay Ambulatory surgical center: $200 copay 20% of the cost Outpatient hospital: $200 copay 20% of the cost Select over-the-counter generic drugs are covered under this plan. Certain smoking cessation products are also covered under this plan. In-network and out-of-network: 20% of the cost 16SUC EmeraldSapphireSOB_8.5x11.5.indd 14

15 OPTIONAL SUPPLEMENTAL BENEFITS (you must pay an extra premium each month for this benefit) Optional Supplemental Dental Benefit Sapphire Emerald What you should know Monthly Plan Premium You pay $25 per month. You pay $25 per month. Coverage through the Delta Dental Medicare Advantage Premier network includes: Routine Exam: two per calendar year Routine Cleaning: two per calendar year Bitewing X-rays: one per calendar year Periapical X-rays: one per calendar year Minor restorative services: 50% covered Root canal to treat teeth with diseased or damaged nerves: 50% covered Relines and repairs to bridges and/or dentures: 50% covered Calendar Year Benefit Maximum: $1, SUC EmeraldSapphireSOB_8.5x11.5.indd 15

16 MULTI-LANGUAGE INSERT MULTI-LANGUAGE INTERPRETER SERVICES 16 16SUC EmeraldSapphireSOB_8.5x11.5.indd 16

17 NOTICE 17 16SUC EmeraldSapphireSOB_8.5x11.5.indd 17

18 NOTES 18 16SUC EmeraldSapphireSOB_8.5x11.5.indd 18

19 NOTES 19 16SUC EmeraldSapphireSOB_8.5x11.5.indd 19

20 20 SC17_11_01 16SUC EmeraldSapphireSOB_8.5x11.5.indd 20