Summary of Benefits 1

Transcription

1 Summary of Benefits

2 Summary of Benefits January, 207 to December 3, 207. This booklet gives you a summary of what we cover and what you pay. It doesn t list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, call us and ask for the Evidence of Coverage. You Have Choices About How To Get Your Medicare Benefits > > One choice is to get your Medicare benefits through Original Medicare (fee-forservice 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 SelectHealth Advantage (HMO). 2 H994_29769_ID Accepted

3 TIPS FOR COMPARING YOUR MEDICARE CHOICES This Summary of Benefits booklet gives you a summary of what SelectHealth Advantage covers and what you pay. > > If you want to compare our plan 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 -800-MEDICARE ( ), 24 hours a day, 7 days a week. TTY users should call SECTIONS IN THIS BOOKLET > > Things to Know About SelectHealth Advantage > > Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services > > Covered Medical and Hospital Benefits > > Prescription Drug Benefits > > Optional Benefits (you must pay an extra premium for these 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 puede estar disponible en un lenguaje que no sea inglés, Para información adicional, llamenos al SelectHealth is an HMO plan sponsor with a Medicare contract. Enrollment in SelectHealth Advantage depends on contract renewal. THINGS TO KNOW ABOUT SELECTHEALTH ADVANTAGE SelectHealth Advantage Phone Numbers and Website > > Call Member Services toll-free at (TTY: 7) or visit our website at selecthealthadvantage.org Hours of Operation > > From October to February 4, you can call us weekdays 7:00 a.m. to 8:00 p.m., Saturday and Sunday from 8:00 a.m. to 8:00 p.m. Mountain time. Outside of these hours of operation, please leave a message and your call will be returned within one business day. > > From February 5 to September 30, you can call us weekdays 7:00 a.m. to 8:00 p.m., Saturday from 9:00 a.m. to 2:00 p.m. Mountain time, closed Sunday. Outside of these hours of operation, please leave a message and your call will be returned within one business day. WHO CAN JOIN? To join SelectHealth Advantage, you must be entitled to Medicare Part A, be enrolled in Medicare Part B, and live in our service area. The service areas covered under this Summary of Benefits include the following: > > Treasure Valley service area, which includes: Ada, Adams, Boise, Canyon, Elmore, Gem, Owyhee, and Washington counties in Idaho. > > Magic Valley service area, which includes Blaine, Cassia, Jerome, Minidoka, and Twin Falls counties in Idaho. > > Eastern and Central Idaho service area, which includes: Bingham and Bonneville counties in Idaho. 3 SUMMARY OF BENEFITS

4 WHICH DOCTORS, HOSPITALS, AND PHARMACIES CAN I USE? SelectHealth Advantage (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. You must generally use network pharmacies to fill your prescriptions for covered Part D drugs. You can see our most up-to-date provider directory on our website selecthealthadvantage.org. You can see our most up-to-date pharmacy directory on our website selecthealthadvantage.org. Or, call us and we will send you a copy of the Provider and Pharmacy Directory. 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 plan 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, selecthealthadvantage.org. > > Or, call us and we will send you a copy of the formulary. HOW WILL I DETERMINE MY DRUG COSTS? Our plan groups each medication into one of five 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: Deductible, Initial Coverage, Coverage Gap, and Catastrophic Coverage. REFERRALS NOT REQUIRED Some specialists require what is known as a provider referral or gatekeeper before they will see you. When seeking a referral, your primary care physician must request or recommend further consultation by a specialist in order for the specialist to allow consultation or treatment. With SelectHealth, there is no gatekeeper of services and no referrals you can see any in-network provider, when you need to. PRIOR AUTHORIZATION Some services require prior approval from SelectHealth. This approval is called Prior Authorization. Participating providers will typically get it for you, but if you are seeing a Nonparticipating Provider, you may need to get it yourself. Once prior authorization is submitted to us, it may take up to 4 days for us to process the request. For any decision SelectHealth makes regarding the prior authorization, you and your provider will receive a notification in writing. 4

5 Notes SUMMARY OF BENEFITS 5

6 TREASURE VALLEY MONTHLY PREMIUM, DEDUCTIBLE, AND LIMITS ON HOW MUCH YOU PAY FOR COVERED SERVICES How much is the monthly premium? This table contains information on which premium applies in each of our service areas. Premiums vary by region based on the amounts the plan receives from the Centers for Medicare & Medicaid Services, regional healthcare costs, and other factors. In addition, you must keep paying your Medicare Part B premium. Premium Amount Service Area (Counties) SelectHealth Advantage Essential (PBP ) $0 Ada, Adams, Boise, Canyon, Elmore, Gem, Owyhee, and Washington Counties in Idaho SelectHealth Advantage Enhanced (PBP ) $3 Ada, Adams, Boise, Canyon, Elmore, Gem, Owyhee, and Washington Counties in Idaho SelectHealth Advantage Deductible SelectHealth Advantage Essential SelectHealth Advantage Enhanced Medical $0 $0 There is no medical deductible. Pharmacy $50 $0 There is a pharmacy deductible only on SelectHealth Advantage Essential. The pharmacy deductible only applies to tier 3, 4, and 5 medications (brand name and specialty). There is no deductible on tier and 2 (generic) medications. 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. See Member Out-of-Pocket Maximum. Member Out-of-Pocket Maximum (does not include prescription drugs or hearing aid copays) SelectHealth Advantage Essential $6,700 $5,900 SelectHealth Advantage Enhanced 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. Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs. 6

7 TREASURE VALLEY COVERED MEDICAL AND HOSPITAL BENEFITS Inpatient Hospital Coverage Doctor s Office Visits Primary care physician visit SelectHealth Advantage Essential $295 copay per day for days through 6 $0 copay for days 7 and beyond $0 copay $5 copay SelectHealth Advantage Enhanced $225 copay per day for days through 5 $0 copay for days 6 and beyond Specialist visit $50 copay $35 copay Preventive Care $0 copay $0 copay Emergency Care Urgently Needed Services Diagnostic Services, Lab, and Radiology Services, and X-Rays Diagnostic radiology services (such as MRIs, CT scans) Diagnostic tests and procedures $75 copay $75 copay $50 copay $45 copay $300 copay $200 copay $0 copay or 20% coinsurance, depending on the service Lab services $0 copay $0 copay Outpatient x-rays $20 copay $0 copay Therapeutic radiology services (such as radiation treatment for cancer) $0 copay or 20% coinsurance, depending on the service 20% coinsurance 20% coinsurance Our plan covers an unlimited number of days for an inpatient hospital stay. These copays start over each time you are admitted to an inpatient hospital facility. SelectHealth does not require referrals. If a prior authorization is required your in network provider, not you, will request the authorization. All Medicare $0 preventive services are also $0 in our plan. In addition, we cover an annual physical/comprehensive wellness visit at $0. If you are admitted to the hospital within 24 hours, your emergency care copay is waived. You have worldwide emergency coverage. There will be no extra charge for labs and/ or x-rays. You have national coverage for urgently needed care. The Urgent Care copay is waived if you are referred to the Emergency Department or admitted inpatient to the hospital within 24 hours for the same condition, you will instead pay the applicable Emergency Services or Inpatient Hospital copay. Costs for these services may vary based on place of service. Only one lab or diagnostic test copayment is collected when multiple lab tests are performed during the same visit. Services are in addition to any applicable primary care or specialist copay. SUMMARY OF BENEFITS Treasure Valley Service may require prior authorization. 7

8 TREASURE VALLEY COVERED MEDICAL AND HOSPITAL BENEFITS (continued) Hearing Services Exam to diagnose and treat hearing and balance issues Hearing Aids Copay for each hearing aid SelectHealth Advantage Essential $50 copay Tier Essential: $699 Tier 2 Standard: $999 Tier 3 Advanced: $,399 Tier 4 Premium: $,899 SelectHealth Advantage Enhanced $35 copay Dental Services $50 copay $35 copay Vision Services Exam to diagnose and treat diseases and conditions of the eye Eyeglasses or contact lenses after cataract surgery Medicare-covered non-routine eye exams Inpatient Mental Health Services $50 copay $35 copay $0 copay $0 copay $50 copay $35 copay $260 copay per day for days through 6 $0 copay for days 7 through 90 $0 copay for lifetime reserve days Tier Essential: $699 Tier 2 Standard: $999 Tier 3 Advanced: $,399 Tier 4 Premium: $,899 $225 copay per day for days through 5 $0 copay for days 6 through 90 $0 copay for lifetime reserve days Selected hearing aids purchased through participating audiology providers are covered under one of four benefit tiers. The copay includes the device, three fitting and adjustment appointments, and a one-year supply of batteries. Limited dental services related to a medical condition. Our plan covers 90 days for an inpatient hospital stay each time you are admitted. Our plan also covers 60 lifetime reserve days. These are extra days that we cover. If your hospital stay is longer than 90 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 90 days. Our plan covers up to 90 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital. 8 Service may require prior authorization.

9 TREASURE VALLEY SelectHealth Advantage Essential SelectHealth Advantage Enhanced Outpatient Mental Health Services Outpatient group therapy visit $40 copay $40 copay Outpatient individual therapy visit $40 copay $40 copay Partial Hospitalization for Mental Health Skilled Nursing Facility (SNF) Outpatient 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) $55 copay $55 copay Our plan covers up to 00 days in a SNF. > $0 copay per day for days through 20 > $60 copay per day for days 2 through 00 $40 copay $30 copay Occupational therapy visit $40 copay $30 copay Physical therapy and speech and language therapy visit $40 copay $30 copay Pulmonary rehab services $30 copay $30 copay Our plan covers up to 00 days in a SNF. > $0 copay per day for days through 20 Ambulance $225 copay $200 copay > $25 copay per day for days 2 through 00 Transportation Not Covered Not Covered Foot Care (podiatry services) $50 copay $35 copay No prior hospital stay required. There is no limitation on the number of visits on occupational, speech, and physical therapy. Covered ambulance services include fixed wing, rotary wing, and ground ambulance services, to the nearest appropriate facility. This would include services such as getting a ride to or from your doctor. Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions. SUMMARY OF BENEFITS Treasure Valley Service may require prior authorization. 9

10 TREASURE VALLEY COVERED MEDICAL AND HOSPITAL BENEFITS (continued) Medical Equipment / Supplies SelectHealth Advantage Essential SelectHealth Advantage Enhanced Durable Medical Equipment (wheelchairs, oxygen, etc.) 20% coinsurance 20% coinsurance Prosthetic Devices and supplies (braces, artificial limbs, etc.) 20% coinsurance 20% coinsurance Diabetes monitoring supplies $0 copay $0 copay Diabetes self-management training $0 copay $0 copay Therapeutic Shoe Inserts 20% coinsurance 20% coinsurance Wellness Programs SelectHealth will reimburse you for participating in healthy behaviors. Eligible expenses include Gym or Fitness Center Memberships, Fitness Classes, Health Education, Weight Loss or Weight Management Programs. Medicare Part B Drugs Up to $240 Up to $240 Includes chemotherapy drugs 20% coinsurance 20% coinsurance and other Part B drugs Chiropractic Care $20 copay $20 copay Home Health Care $0 copay $0 copay Outpatient Substance Abuse Individual or group therapy in a provider s office Individual or group therapy in an outpatient facility setting $40 copay per visit. $40 copay per visit. $50 copay per visit. $50 copay per visit. Coverage for glucose monitors and test strips is limited to Freestyle and Precision brands produced by Abbott Labs. If you or your physician feel that it is medically necessary for you to use a different monitor or test strips call Member Services. You receive reimbursement for up to a combined total of $240 per year for approved services. Your benefit is the total of $20 times the number of months you will be covered during the year. For example, if you renew in January your benefit is $240, if you enroll in July your total benefit is $20 for the year. Manipulation of the spine to correct a subluxation (when or more of the bones of your spine move out of position). 0 Service may require prior authorization.

11 TREASURE VALLEY Outpatient Services SelectHealth Advantage Essential SelectHealth Advantage Enhanced Outpatient Surgery $300 copay $225 copay Ambulatory surgical center $300 copay $225 copay Diagnostic Colonoscopy $300 copay $225 copay IV Infusion Therapy 20% coinsurance 20% coinsurance Non-Nuclear Cardiac Stress Tests 20% coinsurance 20% coinsurance Sleep Studies 20% coinsurance 20% coinsurance Other Covered Services 20% coinsurance 20% coinsurance Over-the-Counter Items Not Covered Not Covered Renal Dialysis 20% coinsurance 20% coinsurance Hospice You pay nothing for hospice care from a Medicare-certified hospice. TeleHealth Services $50 copay $35 copay You pay nothing for hospice care from a Medicare-certified hospice. You may have to pay part of the costs for drugs and respite care. Hospice is covered outside of our plan. Please contact us for more details. In addition to TeleHealth services covered by Medicare you are also covered for genetic counseling services. SUMMARY OF BENEFITS Treasure Valley Service may require prior authorization.

12 TREASURE VALLEY PRESCRIPTION DRUG BENEFITS SelectHealth Advantage Essential SelectHealth Advantage Enhanced DEDUCTIBLE You begin in this payment stage when you fill your first prescription of the year. During this stage, you pay the full cost of your brand name and specialty drugs until you have reached the annual deductible. Annual deductible does not apply to generic drugs. Pharmacy Deductible Tiers and 2 $0 $0 Tiers 3, 4, and 5 $50 $0 INITIAL COVERAGE During this stage, the plan pays its share of the cost of your drugs and you pay your share of the cost. You stay in this stage until the amount of your year-to-date total drug costs reaches $3,700. Then you move to the COVERAGE GAP. Retail Cost-Sharing One-Month Two-Month Three-Month One-Month Two-Month Three-Month Tier (Preferred Generic) $3 $6 $9 $0 $0 $0 Tier 2 (Generic) $5 $30 $45 $0 $20 $30 Tier 3 (Preferred Brand) $45 $90 $35 $45 $90 $35 Tier 4 (Non-Preferred Brand) $95 $90 $285 $95 $90 $285 Tier 5 (Specialty Tier) 30% coinsurance Not Offered Not Offered 33% coinsurance Not Offered Not Offered Mail Order Cost-Sharing One-Month Two-Month Three-Month One-Month Two-Month Three-Month Tier (Preferred Generic) $3 $6 $6 $0 $0 $0 Tier 2 (Generic) $5 $30 $30 $0 $20 $20 Tier 3 (Preferred Brand) $45 $90 $35 $45 $90 $35 Tier 4 (Non-Preferred Brand) $95 $90 $285 $95 $90 $285 Tier 5 (Specialty Tier) 30% coinsurance Not Offered Not Offered 33% coinsurance Not Offered Not Offered 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. 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. 2

13 COVERAGE GAP (DONUT HOLE) You stay in this stage until the amount of your year-to-date out-of-pocket costs reaches $4,950. Coverage Gap (Donut Hole) Up to $4,950 out-of-pocket costs 40% cost-sharing on applicable brand name drugs 5% cost-sharing on applicable generic / non-applicable drug cost. 40% cost-sharing on applicable brand name drugs 5% cost-sharing on applicable generic / non-applicable drug cost. CATASTROPHIC COVERAGE During this payment stage, the plan pays most of the cost for your covered drugs. You stay in this stage for the rest of the calendar year through December 3, 207. Catastrophic Coverage Through the end of the year Dec. 3, 207 $3.30 for generic drugs and $8.25 for all other drugs; or 5% coinsurance, whichever is greater. $3.30 for generic drugs and $8.25 for all other drugs; or 5% coinsurance, whichever is greater. OPTIONAL BENEFITS (you must pay an extra premium each month for these benefits) PACKAGE : Delta Dental Idaho Comprehensive Benefit How much is the monthly premium? How much is the deductible? Is there a limit on how much the plan will pay? PACKAGE 2: Delta Dental Idaho Comprehensive Plus Eyewear How much is the monthly premium? How much is the deductible? Is there a limit on how much the plan will pay? Benefits include: Preventive dental care, and Comprehensive dental care Additional $45.00 per month. You must keep paying your Medicare Part B premium and your monthly plan premium if applicable. This package does not have a deductible. Our plan pays up to $,000 every year. Our plan has additional coverage limits for certain benefits. $0 copay for preventive dental services including: two exams/cleanings with x-rays per year. You pay 50% for all other covered dental services, such as fillings, extractions, root canal, crowns, dentures (rebasing & relining), bridges, and implants. Benefits include: Preventive dental care, Comprehensive dental care, and Eyewear Additional $50.00 per month. You must keep paying your Medicare Part B premium and your monthly plan premium if applicable. This package does not have a deductible. This optional supplemental benefit package offers the same coverage for dental preventive and corrective services as Package #. You also have a $200 retail value allowance for glasses or contacts at participating locations. See the Evidence of Coverage for more information on these benefits. SUMMARY OF BENEFITS Treasure Valley 3

14 MAGIC VALLEY EASTERN AND CENTRAL IDAHO MONTHLY PREMIUM, DEDUCTIBLE, AND LIMITS ON HOW MUCH YOU PAY FOR COVERED SERVICES How much is the monthly premium? Please refer to the Premium/Cost-Sharing Table to find out the premium/cost-sharing in your area. This table contains information on which premium applies in each of our service areas. Premiums vary by region based on the amounts the plan receives from the Centers for Medicare & Medicaid Services, regional healthcare costs, and other factors. In addition, you must keep paying your Medicare Part B premium. Premium Amount Service Area (Counties) Magic Valley (PBP ) $47 Blaine, Cassia, Jerome, Minidoka, and Twin Falls Counties in Idaho Eastern and Central Idaho (PBP ) $87 Bingham, and Bonneville Counties in Idaho SelectHealth Advantage Deductible Magic Valley (PBP ) Eastern and Central Idaho (PBP ) Medical $0 $0 There is no medical deductible. Pharmacy $50 $200 The pharmacy deductible only applies to tier 3, 4, and 5 medications (brand name and specialty). There is no deductible on tier and 2 (generic) medications. 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. See Member Out-of-Pocket Maximum. Member Out-of-Pocket Maximum (does not include prescription drugs or hearing aid copays) Magic Valley (PBP ) $6,700 $6,700 Eastern and Central Idaho (PBP ) 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. Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs. 4

15 MAGIC VALLEY EASTERN AND CENTRAL IDAHO COVERED MEDICAL AND HOSPITAL BENEFITS Inpatient Hospital Coverage Doctor s Office Visits Primary care physician visit Magic Valley (PBP ) $295 copay per day for days through 6 $0 copay for days 7 and beyond Eastern and Central Idaho (PBP ) $295 copay per day for days through 6 $0 copay for days 7 and beyond $0 copay $0 copay Specialist visit $50 copay $50 copay Preventive Care $0 copay $0 copay Emergency Care Urgently Needed Services Diagnostic Services, Lab, and Radiology Services, and X-Rays Diagnostic radiology services (such as MRIs, CT scans) Diagnostic tests and procedures $75 copay $75 copay $50 copay $50 copay $300 copay $300 copay $0 copay or 20% coinsurance, depending on the service Lab services $0 copay $0 copay Outpatient x-rays $20 copay $20 copay Therapeutic radiology services (such as radiation treatment for cancer) $0 copay or 20% coinsurance, depending on the service 20% coinsurance 20% coinsurance Our plan covers an unlimited number of days for an inpatient hospital stay. These copays start over each time you are admitted to an inpatient hospital facility. SelectHealth does not require referrals. If a prior authorization is required your in network provider, not you, will request the authorization. All Medicare $0 preventive services are also $0 in our plan. In addition, we cover an annual physical/comprehensive wellness visit at $0. If you are admitted to the hospital within 24 hours, your emergency care copay is waived. You have worldwide emergency coverage. There will be no extra charge for labs and/ or x-rays. You have national coverage for urgently needed care. The Urgent Care copay is waived if you are referred to the Emergency Department or admitted inpatient to the hospital within 24 hours for the same condition, you will instead pay the applicable Emergency Services or Inpatient Hospital copay. Costs for these services may vary based on place of service. Only one lab or diagnostic test copayment is collected when multiple lab tests are performed during the same visit. Services are in addition to any applicable primary care or specialist copay. SUMMARY OF BENEFITS Magic Valley Eastern and Central Idaho Service may require prior authorization. 5

16 MAGIC VALLEY EASTERN AND CENTRAL IDAHO COVERED MEDICAL AND HOSPITAL BENEFITS (continued) Hearing Services Exam to diagnose and treat hearing and balance issues Hearing Aids Copay for each hearing aid Magic Valley (PBP ) $50 copay Tier Essential: $699 Tier 2 Standard: $999 Tier 3 Advanced: $,399 Tier 4 Premium: $,899 Eastern and Central Idaho (PBP ) $50 copay Dental Services $50 copay $50 copay Vision Services Exam to diagnose and treat diseases and conditions of the eye Eyeglasses or contact lenses after cataract surgery Medicare-covered non-routine eye exams Inpatient Mental Health Services $50 copay $50 copay $0 copay $0 copay $50 copay $50 copay $260 copay per day for days through 6 $0 copay for days 7 through 90 $0 copay for lifetime reserve days Hearing aids: Not covered $260 copay per day for days through 6 $0 copay for days 7 through 90 $0 copay for lifetime reserve days Selected hearing aids purchased through participating audiology providers are covered under one of four benefit tiers. The copay includes the device, three fitting and adjustment appointments, and a one-year supply of batteries. Limited dental services related to a medical condition. Our plan covers 90 days for an inpatient hospital stay each time you are admitted. Our plan also covers 60 lifetime reserve days. These are extra days that we cover. If your hospital stay is longer than 90 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 90 days. Our plan covers up to 90 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital. 6 Service may require prior authorization.

17 MAGIC VALLEY EASTERN AND CENTRAL IDAHO Outpatient Mental Health Services Magic Valley (PBP ) Outpatient group therapy visit $40 copay $40 copay Outpatient individual therapy visit $40 copay $40 copay Partial Hospitalization for Mental Health Skilled Nursing Facility (SNF) Outpatient 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) $55 copay $55 copay Our plan covers up to 00 days in a SNF. > $0 copay per day for days through 20 > $60 copay per day for days 2 through 00 $40 copay $40 copay Occupational therapy visit $40 copay $40 copay Physical therapy and speech and language therapy visit $40 copay $40 copay Pulmonary rehab services $30 copay $30 copay Eastern and Central Idaho (PBP ) Our plan covers up to 00 days in a SNF. > $0 copay per day for days through 20 Ambulance $225 copay $225 copay > $60 copay per day for days 2 through 00 Transportation Not Covered Not Covered Foot Care (podiatry services) $50 copay $50 copay No prior hospital stay required. There is no limitation on the number of visits on occupational, speech, and physical therapy. Covered ambulance services include fixed wing, rotary wing, and ground ambulance services, to the nearest appropriate facility. This would include services such as getting a ride to or from your doctor. Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions. SUMMARY OF BENEFITS Magic Valley Eastern and Central Idaho Service may require prior authorization. 7

18 MAGIC VALLEY EASTERN AND CENTRAL IDAHO COVERED MEDICAL AND HOSPITAL BENEFITS (continued) Medical Equipment / Supplies Magic Valley (PBP ) Eastern and Central Idaho (PBP ) Durable Medical Equipment (wheelchairs, oxygen, etc.) 20% coinsurance 20% coinsurance Prosthetic Devices and supplies (braces, artificial limbs, etc.) 20% coinsurance 20% coinsurance Diabetes monitoring supplies $0 copay $0 copay Diabetes self-management training $0 copay $0 copay Therapeutic Shoe Inserts 20% coinsurance 20% coinsurance Wellness Programs SelectHealth will reimburse you for participating in healthy behaviors. Eligible expenses include Gym or Fitness Center Memberships, Fitness Classes, Health Education, Weight Loss or Weight Management Programs. Medicare Part B Drugs Up to $240 Up to $240 Includes chemotherapy drugs 20% coinsurance 20% coinsurance and other Part B drugs Chiropractic Care $20 copay $20 copay Home Health Care $0 copay $0 copay Outpatient Substance Abuse Individual or group therapy in a provider s office Individual or group therapy in an outpatient facility setting $40 copay per visit. $40 copay per visit. $50 copay per visit. $50 copay per visit. Coverage for glucose monitors and test strips is limited to Freestyle and Precision brands produced by Abbott Labs. If you or your physician feel that it is medically necessary for you to use a different monitor or test strips call Member Services. You receive reimbursement for up to a combined total of $240 per year for approved services. Your benefit is the total of $20 times the number of months you will be covered during the year. For example, if you renew in January your benefit is $240, if you enroll in July your total benefit is $20 for the year. Manipulation of the spine to correct a subluxation (when or more of the bones of your spine move out of position). 8 Service may require prior authorization.

19 MAGIC VALLEY EASTERN AND CENTRAL IDAHO Outpatient Services Magic Valley (PBP ) Outpatient Surgery $300 copay $300 copay Ambulatory surgical center $300 copay $300 copay Diagnostic Colonoscopy $300 copay $300 copay Eastern and Central Idaho (PBP ) IV Infusion Therapy 20% coinsurance 20% coinsurance Non-Nuclear Cardiac Stress Tests 20% coinsurance 20% coinsurance Sleep Studies 20% coinsurance 20% coinsurance Other Covered Services 20% coinsurance 20% coinsurance Over-the-Counter Items Not Covered Not Covered Renal Dialysis 20% coinsurance 20% coinsurance Hospice You pay nothing for hospice care from a Medicare-certified hospice. TeleHealth Services $50 copay $50 copay You pay nothing for hospice care from a Medicare-certified hospice. You may have to pay part of the costs for drugs and respite care. Hospice is covered outside of our plan. Please contact us for more details. In addition to TeleHealth services covered by Medicare you are also covered for genetic counseling services. SUMMARY OF BENEFITS Magic Valley Eastern and Central Idaho Service may require prior authorization. 9

20 MAGIC VALLEY EASTERN AND CENTRAL IDAHO PRESCRIPTION DRUG BENEFITS DEDUCTIBLE Magic Valley (PBP ) Eastern and Central Idaho (PBP ) You begin in this payment stage when you fill your first prescription of the year. During this stage, you pay the full cost of your brand name and specialty drugs until you have reached the annual deductible. Annual deductible does not apply to generic drugs. Pharmacy Deductible Tiers and 2 $0 $0 Tiers 3, 4, and 5 $50 $200 INITIAL COVERAGE During this stage, the plan pays its share of the cost of your drugs and you pay your share of the cost. You stay in this stage until the amount of your year-to-date total drug costs reaches $3,700. Then you move to the COVERAGE GAP. Retail Cost-Sharing 20 One-Month Two-Month Three-Month One-Month Two-Month Three-Month Tier (Preferred Generic) $3 $6 $9 $3 $6 $9 Tier 2 (Generic) $5 $30 $45 $5 $30 $45 Tier 3 (Preferred Brand) $45 $90 $35 $45 $90 $35 Tier 4 (Non-Preferred Brand) $95 $90 $285 $95 $90 $285 Tier 5 (Specialty Tier) 30% coinsurance Not Offered Not Offered 29% coinsurance Not Offered Not Offered Mail Order Cost-Sharing One-Month Two-Month Three-Month One-Month Two-Month Three-Month Tier (Preferred Generic) $3 $6 $6 $3 $6 $6 Tier 2 (Generic) $5 $30 $30 $5 $30 $30 Tier 3 (Preferred Brand) $45 $90 $35 $45 $90 $35 Tier 4 (Non-Preferred Brand) $95 $90 $285 $95 $90 $285 Tier 5 (Specialty Tier) 30% coinsurance Not Offered Not Offered 29% coinsurance Not Offered Not Offered 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. 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.

21 COVERAGE GAP (DONUT HOLE) You stay in this stage until the amount of your year-to-date out-of-pocket costs reaches $4,950. Coverage Gap (Donut Hole) Up to $4,950 out-of-pocket costs CATASTROPHIC COVERAGE OPTIONAL BENEFITS (you must pay an extra premium each month for these benefits) PACKAGE : Delta Dental Idaho Comprehensive Benefit How much is the monthly premium? How much is the deductible? Is there a limit on how much the plan will pay? PACKAGE 2: Delta Dental Idaho Comprehensive Plus Eyewear How much is the monthly premium? How much is the deductible? Is there a limit on how much the plan will pay? 40% cost-sharing on applicable brand name drugs 5% cost-sharing on applicable generic / non-applicable drug cost. During this payment stage, the plan pays most of the cost for your covered drugs. You stay in this stage for the rest of the calendar year through December 3, 207. Catastrophic Coverage Through the end of the year Dec. 3, 207 $3.30 for generic drugs and $8.25 for all other drugs; or 5% coinsurance, whichever is greater. Benefits include: Preventive dental care, and Comprehensive dental care Additional $45.00 per month. You must keep paying your Medicare Part B premium and your monthly plan premium if applicable. This package does not have a deductible. Our plan pays up to $,000 every year. Our plan has additional coverage limits for certain benefits. $0 copay for preventive dental services including: two exams/cleanings with x-rays per year. You pay 50% for all other covered dental services, such as fillings, extractions, root canal, crowns, dentures (rebasing & relining), bridges, and implants. Benefits include: Preventive dental care, Comprehensive dental care, and Eyewear Additional $50.00 per month. You must keep paying your Medicare Part B premium and your monthly plan premium if applicable. This package does not have a deductible. 40% cost-sharing on applicable brand name drugs 5% cost-sharing on applicable generic / non-applicable drug cost. $3.30 for generic drugs and $8.25 for all other drugs; or 5% coinsurance, whichever is greater. This optional supplemental benefit package offers the same coverage for dental preventive and corrective services as Package #. You also have a $200 retail value allowance for glasses or contacts at participating locations. See the Evidence of Coverage for more information on these benefits. SUMMARY OF BENEFITS Magic Valley Eastern and Central Idaho 206 SelectHealth. All rights reserved /6 2