Summary of Benefits. for CareMore Breathe (HMO SNP), CareMore Heart (HMO SNP) and CareMore Reliance (HMO SNP)

Transcription

1 Summary of Benefits for CareMore Breathe (HMO, CareMore Heart (HMO and Available in Los Angeles and Orange Counties (partial) SBLAOCBRTHRTREL15 Y0017_15_081478A CHP CMS Accepted ( )

2 Section I: Introduction to Summary of Benefits You have choices about how to get your Medicare benefits One choice is to get your Medicare benefits through Original Medicare (fee-for-service Medicare). Original Medicare is run directly by the Federal government. Another choice is to get your Medicare benefits by joining a Medicare health plan (such as CareMore Breathe (HMO, CareMore Heart (HMO and ). Tips for comparing your Medicare choices This Summary of Benefits booklet gives you a summary of what CareMore Breathe (HMO, CareMore Heart (HMO and cover and what you pay. If you want to compare our plans with other Medicare health plans, ask the other plans for their Summary of Benefits booklets. Or, use the Medicare Plan Finder on 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 Sections in this booklet Things to Know About CareMore Breathe (HMO, CareMore Heart (HMO and Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services Covered Medical and Hospital Benefits Prescription Drug Benefits This document is available in other formats such as Braille and large print. This document may be available in a non-english language. For additional information, call us at Este documento podría estar disponible en otros formatos como Braille o texto con letras grandes. Este documento podría estar disponible en idiomas distintos del inglés. Para obtener más información, llámenos al Things to Know About CareMore Breathe (HMO, CareMore Heart (HMO and CareMore Reliance (HMO Hours of Operation From October 1 to February 14, you can call us 7 days a week from 8:00 a.m. to 8:00 p.m. Pacific time. From February 15 to September 30, you can call us Monday through Friday from 8:00 a.m. to 8:00 p.m. Pacific time. CareMore Breathe (HMO, CareMore Heart (HMO and Phone Numbers and Website If you are a member of these plans, call toll-free (TTY/TTD: 711). If you are not a member of these plans, call toll-free (TTY/TDD: 711). Our website: Who can join? To join CareMore Breathe (HMO, CareMore Heart (HMO and, you must be entitled to Medicare Part A, be enrolled in Medicare Part B, be diagnosed with Cardiovascular Disorders, Chronic Heart Failure, and/ or Diabetes, and live in our service area. Page 2 - CareMore Breathe (HMO, CareMore Heart (HMO and

3 Our service area includes the following counties in California: Los Angeles* and Orange*. Los Angeles County: 90001; 90002; 90003; 90004; 90005; 90006; 90007; 90008; 90009; 90010; 90011; 90012; 90013; 90014; 90015; 90016; 90017; 90018; 90019; 90020; 90021; 90022; 90023; 90026; 90027; 90028; 90029; 90030; 90031; 90032; 90033; 90034; 90036; 90037; 90038; 90039; 90040; 90041; 90042; 90043; 90044; 90045; 90046; 90047; 90048; 90050; 90051; 90052; 90053; 90054; 90055; 90056; 90057; 90058; 90059; 90060; 90061; 90062; 90063; 90065; 90066; 90068; 90070; 90071; 90072; 90074; 90075; 90076; 90078; 90079; 90080; 90081; 90082; 90083; 90084; 90086; 90087; 90088; 90089; 90091; 90093; 90094; 90096; 90097; 90099; 90101; 90102; 90103; 90174; 90185; 90189; 90201; 90202; 90220; 90221; 90222; 90223; 90224; 90230; 90231; 90232; 90233; 90239; 90240; 90241; 90242; 90245; 90247; 90248; 90249; 90250; 90251; 90254; 90255; 90260; 90261; 90262; 90266; 90267; 90270; 90274; 90275; 90277; 90278; 90280; 90301; 90302; 90303; 90304; 90305; 90306; 90307; 90308; 90309; 90310; 90311; 90312; 90313; 90397; 90398; 90501; 90502; 90503; 90504; 90505; 90506; 90507; 90508; 90509; 90510; 90601; 90602; 90603; 90604; 90605; 90606; 90607; 90608; 90609; 90610; 90612; 90637; 90638; 90639; 90640; 90650; 90651; 90652; 90659; 90660; 90661; 90662; 90665; 90670; 90671; 90701; 90702; 90703; 90706; 90707; 90710; 90711; 90712; 90713; 90714; 90715; 90716; 90717; 90723; 90731; 90732; 90733; 90734; 90744; 90745; 90746; 90747; 90748; 90749; 90755; 90801; 90802; 90803; 90804; 90805; 90806; 90807; 90808; 90809; 90810; 90813; 90814; 90815; 90822; 90831; 90832; 90833; 90834; 90835; 90840; 90842; 90844; 90845; 90846; 90847; 90848; 90853; 90888; 90895; 90899; 91006; 91007; 91009; 91010; 91016; 91017; 91020; 91021; 91030; 91031; 91046; 91050; 91051; 91066; 91077; 91101; 91102; 91103; 91104; 91105; 91106; 91107; 91108; 91109; 91110; 91114; 91115; 91116; 91117; 91118; 91121; 91123; 91124; 91125; 91126; 91129; 91131; 91175; 91182; 91184; 91185; 91186; 91187; 91188; 91189; 91191; 91199; 91201; 91202; 91203; 91204; 91205; 91206; 91207; 91208; 91209; 91210; 91214; 91221; 91222; 91224; 91225; 91226; 91329; 91501; 91502; 91503; 91504; 91505; 91506; 91507; 91508; 91510; 91521; 91522; 91523; 91526; 91611; 91612; 91702; 91706; 91711; 91714; 91715; 91716; 91722; 91723; 91724; 91731; 91732; 91733; 91734; 91735; 91740; 91741; 91744; 91745; 91746; 91747; 91748; 91749; 91750; 91754; 91755; 91756; 91765; 91766; 91767; 91768; 91769; 91770; 91771; 91772; 91773; 91775; 91776; 91778; 91780; 91788; 91789; 91790; 91791; 91792; 91793; 91795; 91797; 91799; 91801; 91802; 91803; 91804; 91841; 91896; Orange County: 90620; 90621; 90622; 90623; 90624; 90630; 90631; 90632; 90633; 90680; 90720; 90721; 90740; 90742; 90743; 92605; 92615; 92626; 92627; 92628; 92646; 92647; 92648; 92649; 92655; 92683; 92684; 92685; 92701; 92702; 92703; 92704; 92705; 92706; 92707; 92708; 92710; 92711; 92712; 92725; 92728; 92735; 92780; 92781; 92782; 92799; 92801; 92802; 92803; 92804; 92805; 92806; 92807; 92808; 92809; 92811; 92812; 92814; 92815; 92816; 92817; 92821; 92822; 92823; 92825; 92831; 92832; 92833; 92834; 92835; 92836; 92837; 92838; 92840; 92841; 92842; 92843; 92844; 92845; 92846; 92850; 92856; 92857; 92859; 92861; 92862; 92863; 92864; 92865; 92866; 92867; 92868; 92869; 92870; 92871; 92885; 92886; 92887; * denotes partial county Which doctors, hospitals, and pharmacies can I use? CareMore Breathe (HMO, CareMore Heart (HMO and have 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. You must generally use network pharmacies to fill your prescriptions for covered Part D drugs. Some of our network pharmacies have preferred cost-sharing. You may pay less if you use these pharmacies. You can see our plan's provider and pharmacy directory at our website ( Or, call us and we will send you a copy of the provider and pharmacy directories. Page 3 - CareMore Breathe (HMO, CareMore Heart (HMO and

4 What do we cover? Like all Medicare health plans, we cover everything that Original Medicare covers - and more. Our plan members get all of the benefits covered by Original Medicare. For some of these benefits, you may pay more in our plans than you would in Original Medicare. For others, you may pay less. Our plan members also get more than what is covered by Original Medicare. Some of the extra benefits are outlined in this booklet. 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 any restrictions on our website, Or, call us and we will send you a copy of the formulary. How will I determine my drug costs? Our plans group 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. Page 4 - CareMore Breathe (HMO, CareMore Heart (HMO and

5 If you have any questions about these plans' benefits or costs, please contact CareMore Health Plan for details. Section II: Summary of Benefits CareMore Breathe (HMO CareMore Heart (HMO MONTHLY PREMIUM, DEDUCTIBLE, AND LIMITS ON HOW MUCH YOU PAY FOR COVERED SERVICES How much is the monthly premium? per month. In addition, you must keep paying your Medicare Part B premium. per month. In addition, you must keep paying your Medicare Part B premium. per month. In addition, you must keep paying your Medicare Part B premium. How much is the deductible? This plan does not have a deductible. This plan does not have a deductible. This plan does not have a deductible. Is there any limit on how much I will pay for my covered services? Yes. Like all Medicare health plans, our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care. Yes. Like all Medicare health plans, our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care. Yes. Like all Medicare health plans, our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care. Your yearly limit(s) in this plan: Your yearly limit(s) in this plan: Your yearly limit(s) in this plan: $3,000 for services you receive from in-network providers. $3,000 for services you receive from in-network providers. $3,000 for services you receive from in-network providers. If you reach the limit on out-of-pocket costs, you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year. If you reach the limit on out-of-pocket costs, you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year. If you reach the limit on out-of-pocket costs, you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year. Page 5 - CareMore Breathe (HMO, CareMore Heart (HMO and

6 CareMore Heart (HMO Is there any limit on how much I will pay for my covered services? (continued) Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs. Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs. Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs. Is there a limit on how much the plan will pay? Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply. Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply. Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply. CareMore Health Plan is an HMO/HMO SNP plan with a Medicare contract. Enrollment in CareMore Health Plan depends on contract renewal. COVERED MEDICAL AND HOSPITAL BENEFITS NOTE: Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor. OUTPATIENT CARE AND SERVICES Acupuncture and Other Alternative Therapies Ambulance Not covered $100 Not covered $100 Not covered $100 Chiropractic Care Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): You pay Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): You pay Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): You pay Page 6 - CareMore Breathe (HMO, CareMore Heart (HMO and

7 CareMore Heart (HMO Dental Services Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): You pay Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): You pay Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): You pay Preventive dental services: Preventive dental services: Preventive dental services: Cleaning (for up to 2 every year): $35 Dental x-ray(s) (for up to 1 every three years): -$10, depending on the service Fluoride treatment (for up to 2 every year): $5 Oral exam: $5-$15, depending on the service Cleaning (for up to 2 every year): $35 Dental x-ray(s) (for up to 1 every three years): -$10, depending on the service Fluoride treatment (for up to 2 every year): $5 Oral exam: $5-$15, depending on the service Cleaning (for up to 2 every year): $35 Dental x-ray(s) (for up to 1 every three years): -$10, depending on the service Fluoride treatment (for up to 2 every year): $5 Oral exam: $5-$15, depending on the service Diabetes Supplies and Services Diabetes monitoring supplies: You pay Diabetes monitoring supplies: You pay Diabetes monitoring supplies: You pay Diabetes self-management training: You pay Diabetes self-management training: You pay Diabetes self-management training: You pay Therapeutic shoes or inserts: You pay Therapeutic shoes or inserts: You pay Therapeutic shoes or inserts: You pay Diabetic Supplies and Services are limited to specific manufacturers, products and/or brands. Contact the plan for a list of covered supplies. Diabetic Supplies and Services are limited to specific manufacturers, products and/or brands. Contact the plan for a list of covered supplies. Diabetic Supplies and Services are limited to specific manufacturers, products and/or brands. Contact the plan for a list of covered supplies. Page 7 - CareMore Breathe (HMO, CareMore Heart (HMO and

8 CareMore Heart (HMO Diagnostic Tests, Lab and Radiology Services, and X-Rays Diagnostic radiology services (such as MRIs, CT scans): -$75, depending on the service Diagnostic radiology services (such as MRIs, CT scans): -$75, depending on the service Diagnostic radiology services (such as MRIs, CT scans): -$75, depending on the service Diagnostic tests and procedures: You pay Diagnostic tests and procedures: You pay Diagnostic tests and procedures: You pay Lab services: You pay Lab services: You pay Lab services: You pay Outpatient x-rays: You pay Outpatient x-rays: You pay Outpatient x-rays: You pay Therapeutic radiology services (such as radiation treatment for cancer): $60 Therapeutic radiology services (such as radiation treatment for cancer): $60 Therapeutic radiology services (such as radiation treatment for cancer): $60 Doctor's Office Visits Primary care physician visit: You pay Primary care physician visit: You pay Primary care physician visit: You pay Specialist visit: You pay Specialist visit: You pay Specialist visit: You pay Durable Medical Equipment (wheelchairs, oxygen, etc.) 0%-20% of the cost, depending on the equipment You pay 0% of the total cost when the purchase or rental price of the Medicare-covered durable medical equipment and related supplies is -$499 per item. 0%-20% of the cost, depending on the equipment You pay 0% of the total cost when the purchase or rental price of the Medicare-covered durable medical equipment and related supplies is -$499 per item. 0%-20% of the cost, depending on the equipment You pay 0% of the total cost when the purchase or rental price of the Medicare-covered durable medical equipment and related supplies is -$499 per item. You pay 20% of the total cost when the purchase or rental price of the Medicare-covered durable medical equipment and related supplies is $500 or greater per item. You pay 20% of the total cost when the purchase or rental price of the Medicare-covered durable medical equipment and related supplies is $500 or greater per item. You pay 20% of the total cost when the purchase or rental price of the Medicare-covered durable medical equipment and related supplies is $500 or greater per item. Page 8 - CareMore Breathe (HMO, CareMore Heart (HMO and

9 CareMore Heart (HMO Emergency Care $65 $65 $65 If you are admitted to the hospital within 24 hours, you do not have to pay your share of the cost for emergency care. See the "Inpatient Hospital Care" section of this booklet for other costs. If you are admitted to the hospital within 24 hours, you do not have to pay your share of the cost for emergency care. See the "Inpatient Hospital Care" section of this booklet for other costs. If you are admitted to the hospital within 24 hours, you do not have to pay your share of the cost for emergency care. See the "Inpatient Hospital Care" section of this booklet for other costs. $10,000 plan coverage limit for supplemental emergency services outside the U.S. and its territories every year. $10,000 plan coverage limit for supplemental emergency services outside the U.S. and its territories every year. $10,000 plan coverage limit for supplemental emergency services outside the U.S. and its territories every year. If you are admitted to the hospital within 24-hour(s) for the same condition, you pay for the emergency room visit. If you are admitted to the hospital within 24-hour(s) for the same condition, you pay for the emergency room visit. If you are admitted to the hospital within 24-hour(s) for the same condition, you pay for the emergency room visit. Foot Care (podiatry services) Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: You pay Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: You pay Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: You pay Routine foot care (for up to 12 visit(s) every year): You pay Routine foot care (for up to 12 visit(s) every year): You pay Routine foot care (for up to 12 visit(s) every year): You pay Hearing Services Exam to diagnose and treat hearing and balance issues: You pay Exam to diagnose and treat hearing and balance issues: You pay Exam to diagnose and treat hearing and balance issues: You pay Routine hearing exam (for up to 1 every year): You pay Routine hearing exam (for up to 1 every year): You pay Routine hearing exam (for up to 1 every year): You pay Hearing aid fitting/evaluation (for up to 1 every year): You pay Hearing aid fitting/evaluation (for up to 1 every year): You pay Hearing aid fitting/evaluation (for up to 1 every year): You pay Hearing aid: You pay Hearing aid: You pay Hearing aid: You pay Page 9 - CareMore Breathe (HMO, CareMore Heart (HMO and

10 CareMore Heart (HMO Hearing Services (continued) Our plan pays up to $250 every year for hearing aids. Our plan pays up to $250 every year for hearing aids. Our plan pays up to $250 every year for hearing aids. Home Health Care You pay You pay You pay Mental Health Care Inpatient visit: Inpatient visit: Inpatient visit: Our plan covers 150 days for an inpatient hospital stay. Our plan covers 150 days for an inpatient hospital stay. Our plan covers 150 days for an inpatient hospital stay. Our plan also covers 60 "lifetime reserve days." These are "extra" days that we cover. If your hospital stay is longer than 150 days, you can use these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 150 days. Our plan also covers 60 "lifetime reserve days." These are "extra" days that we cover. If your hospital stay is longer than 150 days, you can use these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 150 days. Our plan also covers 60 "lifetime reserve days." These are "extra" days that we cover. If your hospital stay is longer than 150 days, you can use these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 150 days. You pay per stay You pay per stay You pay per stay Outpatient group therapy visit: You pay Outpatient group therapy visit: You pay Outpatient group therapy visit: You pay Outpatient individual therapy visit: You pay Outpatient individual therapy visit: You pay Outpatient individual therapy visit: You pay Outpatient Rehabilitation 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 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 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 Occupational therapy visit: You pay Occupational therapy visit: You pay Occupational therapy visit: You pay Page 10 - CareMore Breathe (HMO, CareMore Heart (HMO and

11 CareMore Heart (HMO Outpatient Rehabilitation (continued) Physical therapy and speech and language therapy visit: You pay Physical therapy and speech and language therapy visit: You pay Physical therapy and speech and language therapy visit: You pay Outpatient Substance Abuse Group therapy visit: $15 Individual therapy visit: $15 Group therapy visit: $15 Individual therapy visit: $15 Group therapy visit: $15 Individual therapy visit: $15 Outpatient Surgery Ambulatory surgical center: You pay Ambulatory surgical center: You pay Ambulatory surgical center: You pay Outpatient hospital: You pay Outpatient hospital: You pay Outpatient hospital: You pay Over-the-Counter Items Not Covered Not Covered Not Covered Prosthetic Devices (braces, artificial limbs, etc.) Prosthetic devices: You pay Related medical supplies: You pay Prosthetic devices: You pay Related medical supplies: You pay Prosthetic devices: You pay Related medical supplies: You pay Renal Dialysis You pay You pay You pay Transportation You pay You pay You pay General General General Authorization rules may apply. Authorization rules may apply. Authorization rules may apply. In-Network In-Network In-Network for 44 trips to plan-approved locations; unlimited trips to CareMore Care Centers. for 44 trips to plan-approved locations; unlimited trips to CareMore Care Centers. for 44 trips to plan-approved locations; unlimited trips to CareMore Care Centers. Urgent Care You pay You pay You pay Page 11 - CareMore Breathe (HMO, CareMore Heart (HMO and

12 CareMore Heart (HMO Vision Services Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): You pay Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): You pay Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): You pay Routine eye exam (for up to 1 every year): You pay Routine eye exam (for up to 1 every year): You pay Routine eye exam (for up to 1 every year): You pay Contact lenses (for up to 1 every two years): You pay Contact lenses (for up to 1 every two years): You pay Contact lenses (for up to 1 every two years): You pay Our plan pays up to $100 every two years for contact lenses. Our plan pays up to $100 every two years for contact lenses. Our plan pays up to $100 every two years for contact lenses. Eyeglasses frames (for up to 1 every two years): You pay Eyeglasses frames (for up to 1 every two years): You pay Eyeglasses frames (for up to 1 every two years): You pay Our plan pays up to $100 every two years for eyeglass frames. Our plan pays up to $100 every two years for eyeglass frames. Our plan pays up to $100 every two years for eyeglass frames. Eyeglasses lenses (for up to 1 every two years): $20 Eyeglasses lenses (for up to 1 every two years): $20 Eyeglasses lenses (for up to 1 every two years): $20 Eyeglasses or contact lenses after cataract surgery: You pay Eyeglasses or contact lenses after cataract surgery: You pay Eyeglasses or contact lenses after cataract surgery: You pay Preventive Care You pay You pay You pay Our plan covers many preventive services, including: 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) Abdominal aortic aneurysm screening Alcohol misuse counseling Bone mass measurement Breast cancer screening (mammogram) Abdominal aortic aneurysm screening Alcohol misuse counseling Bone mass measurement Breast cancer screening (mammogram) Page 12 - CareMore Breathe (HMO, CareMore Heart (HMO and

13 CareMore Heart (HMO Preventive Care (continued) Cardiovascular disease (behavioral therapy) Cardiovascular screenings Cervical and vaginal cancer screening Colonoscopy Colorectal cancer screenings Depression screening Diabetes screenings Fecal occult blood test Flexible sigmoidoscopy HIV screening Medical nutrition therapy services Obesity screening and counseling Prostate cancer screenings (PSA) 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 "Welcome to Medicare" preventive visit (one-time) Yearly "Wellness" visit Cardiovascular disease (behavioral therapy) Cardiovascular screenings Cervical and vaginal cancer screening Colonoscopy Colorectal cancer screenings Depression screening Diabetes screenings Fecal occult blood test Flexible sigmoidoscopy HIV screening Medical nutrition therapy services Obesity screening and counseling Prostate cancer screenings (PSA) 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 "Welcome to Medicare" preventive visit (one-time) Yearly "Wellness" visit Cardiovascular disease (behavioral therapy) Cardiovascular screenings Cervical and vaginal cancer screening Colonoscopy Colorectal cancer screenings Depression screening Diabetes screenings Fecal occult blood test Flexible sigmoidoscopy HIV screening Medical nutrition therapy services Obesity screening and counseling Prostate cancer screenings (PSA) 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 "Welcome to Medicare" preventive visit (one-time) Yearly "Wellness" visit Any additional preventive services approved by Medicare during the contract year will be covered. Any additional preventive services approved by Medicare during the contract year will be covered. Any additional preventive services approved by Medicare during the contract year will be covered. Page 13 - CareMore Breathe (HMO, CareMore Heart (HMO and

14 CareMore Heart (HMO Hospice You pay for hospice care from a Medicare-certified hospice. You may have to pay part of the cost for drugs and respite care. You pay for hospice care from a Medicare-certified hospice. You may have to pay part of the cost for drugs and respite care. You pay for hospice care from a Medicare-certified hospice. You may have to pay part of the cost for drugs and respite care. INPATIENT CARE Inpatient Hospital Care Our plan covers 250 days for an inpatient hospital stay. Our plan covers 250 days for an inpatient hospital stay. Our plan covers 250 days for an inpatient hospital stay. Our plan also covers 60 "lifetime reserve days." These are "extra" days that we cover. If your hospital stay is longer than 250 days, you can use these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 250 days. Our plan also covers 60 "lifetime reserve days." These are "extra" days that we cover. If your hospital stay is longer than 250 days, you can use these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 250 days. Our plan also covers 60 "lifetime reserve days." These are "extra" days that we cover. If your hospital stay is longer than 250 days, you can use these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 250 days. You pay per stay You pay per stay You pay per stay Inpatient Mental Health Care For inpatient mental health care, see the "Mental Health Care" section of this booklet. For inpatient mental health care, see the "Mental Health Care" section of this booklet. For inpatient mental health care, see the "Mental Health Care" section of this booklet. Skilled Nursing Facility (SNF) Our plan covers up to 100 days in a SNF. You pay per day for days 1 through 31 $25 per day for days 32 through 100 Our plan covers up to 100 days in a SNF. You pay per day for days 1 through 31 $25 per day for days 32 through 100 Our plan covers up to 100 days in a SNF. You pay per day for days 1 through 31 $25 per day for days 32 through 100 No prior hospital stay required. No prior hospital stay required. No prior hospital stay required. Page 14 - CareMore Breathe (HMO, CareMore Heart (HMO and

15 PRESCRIPTION DRUG BENEFITS How much do I pay? For Part B drugs such as chemotherapy drugs 1 : 20% of the cost Other Part B drugs 1 : 20% of the cost CareMore Heart (HMO For Part B drugs such as chemotherapy drugs 1 : 20% of the cost Other Part B drugs 1 : 20% of the cost For Part B drugs such as chemotherapy drugs 1 : 20% of the cost Other Part B drugs 1 : 20% of the cost Initial Coverage You pay the following until your total yearly drug costs reach $2,960. Total yearly drug costs are the total drug costs paid by both you and our Part D plan. You pay the following until your total yearly drug costs reach $2,960. Total yearly drug costs are the total drug costs paid by both you and our Part D plan. You pay the following until your total yearly drug costs reach $2,960. 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. You may get your drugs at network retail pharmacies and mail order pharmacies. You may get your drugs at network retail pharmacies and mail order pharmacies. Page 15 - CareMore Breathe (HMO, CareMore Heart (HMO and

16 CareMore Heart (HMO Initial Coverage (continued) Standard Retail Cost-Sharing One-month Threemonth Standard Retail Cost-Sharing One-month Threemonth Standard Retail Cost-Sharing One-month Threemonth $7.50 $ $7.50 $ $7.50 $ $37.50 $ $37.50 $ $37.50 $ $85 $255 4 $85 $255 4 $85 $255 5 (Specialty ) 33% of the cost 5 (Specialty ) 33% of the cost 5 (Specialty ) 33% of the cost 6 (Select Care 6 (Select Care 6 (Select Care Page 16 - CareMore Breathe (HMO, CareMore Heart (HMO and

17 CareMore Heart (HMO Initial Coverage (continued) Standard Mail Order Cost-Sharing One-month Threemonth Standard Mail Order Cost-Sharing One-month Threemonth Standard Mail Order Cost-Sharing One-month Threemonth $ $ $ $ $ $ $ $ $ (Specialty ) 33% of the cost 5 (Specialty ) 33% of the cost 5 (Specialty ) 33% of the cost 6 (Select Care 6 (Select Care 6 (Select Care If you reside in a long-term care facility, you pay the same as at a retail pharmacy. If you reside in a long-term care facility, you pay the same as at a retail pharmacy. If you reside in a long-term care facility, you pay the same as at a retail pharmacy. Page 17 - CareMore Breathe (HMO, CareMore Heart (HMO and

18 CareMore Heart (HMO Initial Coverage (continued) You may get drugs from an out-of-network pharmacy, but may pay more than you pay at an in-network pharmacy. You may get drugs from an out-of-network pharmacy, but may pay more than you pay at an in-network pharmacy. You may get drugs from an out-of-network pharmacy, but may pay more than you pay at an in-network pharmacy. Long-Term Care Pharmacy Long-Term Care Pharmacy Long-Term Care Pharmacy Long term care pharmacies must dispense brand name drugs in amounts less than a 14 days at a time. They may also dispense less than a month's of drugs at a time. Contact your plan if you have questions about cost-sharing or billing when less than a one-month is dispensed. Long term care pharmacies must dispense brand name drugs in amounts less than a 14 days at a time. They may also dispense less than a month's of drugs at a time. Contact your plan if you have questions about cost-sharing or billing when less than a one-month is dispensed. Long term care pharmacies must dispense brand name drugs in amounts less than a 14 days at a time. They may also dispense less than a month's of drugs at a time. Contact your plan if you have questions about cost-sharing or billing when less than a one-month is dispensed. Standard Mail Order Standard Mail Order Standard Mail Order Contact your plan if you have questions about cost-sharing or billing when less than a one-month is dispensed. Contact your plan if you have questions about cost-sharing or billing when less than a one-month is dispensed. Contact your plan if you have questions about cost-sharing or billing when less than a one-month is dispensed. Coverage Gap 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 $2,960. 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 $2,960. 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 $2,960. After you enter the coverage gap, you pay 45% of the plan's cost for covered brand name drugs and 65% of the plan's cost After you enter the coverage gap, you pay 45% of the plan's cost for covered brand name drugs and 65% of the plan's cost After you enter the coverage gap, you pay 45% of the plan's cost for covered brand name drugs and 65% of the plan's cost Page 18 - CareMore Breathe (HMO, CareMore Heart (HMO and

19 CareMore Heart (HMO Coverage Gap (continued) for covered generic drugs until your costs total $4,700, which is the end of the coverage gap. Not everyone will enter the coverage gap. for covered generic drugs until your costs total $4,700, which is the end of the coverage gap. Not everyone will enter the coverage gap. for covered generic drugs until your costs total $4,700, 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. 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. 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. Additional Coverage in the Gap Additional Coverage in the Gap Additional Coverage in the Gap After your total yearly drug costs reach $2,960, you also receive limited coverage by the plan on certain drugs. After your total yearly drug costs reach $2,960, you also receive limited coverage by the plan on certain drugs. After your total yearly drug costs reach $2,960, you also receive limited coverage by the plan on certain drugs. Page 19 - CareMore Breathe (HMO, CareMore Heart (HMO and

20 CareMore Heart (HMO Coverage Gap (continued) Standard Retail Cost-Sharing Drugs Covered Onemonth Threemonth Standard Retail Cost-Sharing Drugs Covered Onemonth Threemonth Standard Retail Cost-Sharing Drugs Covered Onemonth Threemonth $7.50 $ $7.50 $ $7.50 $ (Select Care 6 (Select Care 6 (Select Care Page 20 - CareMore Breathe (HMO, CareMore Heart (HMO and

21 CareMore Heart (HMO Coverage Gap (continued) Standard Mail Order Cost-Sharing Drugs Covered Onemonth Threemonth Standard Mail Order Cost-Sharing Drugs Covered Onemonth Threemonth Standard Mail Order Cost-Sharing Drugs Covered Onemonth Threemonth 1 Not Offered 1 Not Offered 1 Not Offered 2 Not Offered $ Not Offered $ Not Offered $ (Select Care Not Offered 6 (Select Care Not Offered 6 (Select Care Not Offered Catastrophic Coverage After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4,700, you pay the following: After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4,700, you pay the following: After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4,700, you pay the following: Page 21 - CareMore Breathe (HMO, CareMore Heart (HMO and

22 CareMore Heart (HMO Catastrophic Coverage (continued) 1 Your cost 1 Your cost 1 Your cost 2 $2.65 or 5% of the cost (whichever costs more) 2 $2.65 or 5% of the cost (whichever costs more) 2 $2.65 or 5% of the cost (whichever costs more) 3 $6.60 or 5% of the cost (whichever costs more) 3 $6.60 or 5% of the cost (whichever costs more) 3 $6.60 or 5% of the cost (whichever costs more) 4 $6.60 or 5% of the cost (whichever costs more) 4 $6.60 or 5% of the cost (whichever costs more) 4 $6.60 or 5% of the cost (whichever costs more) 5 (Specialty ) $6.60 or 5% of the cost (whichever costs more) 5 (Specialty ) $6.60 or 5% of the cost (whichever costs more) 5 (Specialty ) $6.60 or 5% of the cost (whichever costs more) 6 (Select Care or 0% of the cost (whichever costs more) 6 (Select Care or 0% of the cost (whichever costs more) 6 (Select Care or 0% of the cost (whichever costs more) You qualify for the catastrophic coverage stage when your out-of-pocket costs have reached the $4,700 limit for the calendar year. Once you are in the Catastrophic Coverage Stage, you will stay in this You qualify for the catastrophic coverage stage when your out-of-pocket costs have reached the $4,700 limit for the calendar year. Once you are in the Catastrophic Coverage Stage, you will stay in this You qualify for the catastrophic coverage stage when your out-of-pocket costs have reached the $4,700 limit for the calendar year. Once you are in the Catastrophic Coverage Stage, you will stay in this Page 22 - CareMore Breathe (HMO, CareMore Heart (HMO and

23 CareMore Heart (HMO Catastrophic Coverage (continued) payment stage until the end of the calendar year. payment stage until the end of the calendar year. payment stage until the end of the calendar year. Out-of-Network Catastrophic Coverage Out-of-Network Catastrophic Coverage Out-of-Network Catastrophic Coverage After your yearly out-of-pocket drug costs reach $4,700, you will be reimbursed for drugs purchased out-of-network up to the plan's cost of the drug minus your cost share noted in the table above. After your yearly out-of-pocket drug costs reach $4,700, you will be reimbursed for drugs purchased out-of-network up to the plan's cost of the drug minus your cost share noted in the table above. After your yearly out-of-pocket drug costs reach $4,700, you will be reimbursed for drugs purchased out-of-network up to the plan's cost of the drug minus your cost share noted in the table above. You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount. You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount. You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount. Once you are in the Catastrophic Coverage Stage, you will stay in this payment stage until the end of the calendar year. Once you are in the Catastrophic Coverage Stage, you will stay in this payment stage until the end of the calendar year. Once you are in the Catastrophic Coverage Stage, you will stay in this payment stage until the end of the calendar year. Optional Benefits (you must pay an extra premium each month for these benefits) PACKAGE 1: Optional Dental Benefits include: Preventive Dental Comprehensive Dental Benefits include: Preventive Dental Comprehensive Dental Benefits include: Preventive Dental Comprehensive Dental How much is the monthly premium? Additional $9.00 per month. You must keep paying your Medicare Part B premium and your monthly plan premium. Additional $9.00 per month. You must keep paying your Medicare Part B premium and your monthly plan premium. Additional $9.00 per month. You must keep paying your Medicare Part B premium and your monthly plan premium. Page 23 - CareMore Breathe (HMO, CareMore Heart (HMO and

24 CareMore Heart (HMO How much is the deductible? This package does not have a deductible. This package does not have a deductible. This package does not have a deductible. Is there a limit on how much the plan will pay? No. There is no limit to how much our plan will pay for benefits in this package. No. There is no limit to how much our plan will pay for benefits in this package. No. There is no limit to how much our plan will pay for benefits in this package. Page 24 - CareMore Breathe (HMO, CareMore Heart (HMO and

25 Section III: CareMore Care Centers CareMore Care Centers offer easy access to health care and coordination of care. Programs offered* at your local CareMore Care Center are: Healthy Start - Health exam performed by specially trained nurse practitioner. Recommendations for future care offered. Healthy Journey - Annual head-to-toe exam for Special Needs Plan members. Fall Prevention Program - Assessment for people who have fallen or are at risk. Diabetes Management Program - Education and treatment to control blood sugars. Nutrition counseling with dietician. Toll-free helpline provided. Hypertension Program - Treatment for blood pressures that are difficult to get under control. Blood pressure monitoring, classes & follow up exams. Foot Center - Foot exams / routine toenail trimming. Wound Care Program - Individualized wound care & supplies. Anticoagulation Therapy Program - For members on anticoagulation medication. Education & monitoring on side effects & interactions. Congestive Heart Failure (CHF) Program - For members with CHF. Helps prevent exacerbations, improve patient education & optimize health. Chronic Obstructive Pulmonary Disease (COPD) Program - For members with COPD. Helps prevent exacerbations; promotes well-being that decreases hospitalization. Ideal Life Program - Electronic home monitoring devices for members who qualify with CHF or hypertension. *Not all programs available at each center. Page 25 - CareMore Breathe (HMO, CareMore Heart (HMO and