2016 Summary of Benefits

Transcription

1 Freedom Blue PPO 2016 Summary of Benefits Western Pennsylvania H3916_15_0266 Accepted

2 SUMMARY OF BENEFITS January 1, December 31, 2016 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 1 One choice is to get your Medicare benefits through Original Medicare (fee-for-service Medicare). Original Medicare is run directly by the Federal government. 1 Another choice is to get your Medicare benefits by joining a Medicare health plan (such as, Freedom Blue PPO Select and ). TIPS FOR COMPARING YOUR MEDICARE CHOICES This Summary of Benefits booklet gives you a summary of what, and Freedom Blue PPO Classic cover and what you pay. 1 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 1 If you want to know more about the coverage and s 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 1 Things to Know About, and 1 Monthly Premiums, Deductibles, and Limits on How Much You Pay for Covered Services 1 Covered Medical and Hospital Benefits 1 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 (TTY/TDD 711). 2

3 THINGS TO KNOW ABOUT FREEDOM BLUE PPO VALUERX, FREEDOM BLUE PPO SELECT AND FREEDOM BLUE PPO CLASSIC HOURS OF OPERATION You can call us 7 days a week from 8:00 a.m. to 8:00 p.m. Eastern time. FREEDOM BLUE PPO VALUERX, FREEDOM BLUE PPO SELECT AND FREEDOM BLUE PPO CLASSIC PHONE NUMBERS AND WEBSITE 1 If you are a member of this plan, call toll-free (TTY/TDD 711). 1 If you are not a member of this plan, call toll-free (TTY/TDD ). 1 Our website: WHO CAN JOIN? To join, or, you must be entitled to Medicare Part A, be enrolled in Medicare Part B, and live in our service area. Our service area includes the following counties in Pennsylvania: Allegheny, Armstrong, Beaver, Butler, Cambria, Fayette, Greene, Indiana, Lawrence, Washington, and Westmoreland in Southwestern PA and Bedford, Blair, Cameron, Clarion, Clearfield, Crawford, Elk, Erie, Forest, Huntingdon, Jefferson, McKean, Mercer, Potter, Somerset, Venango, and Warren in West Central PA. WHICH DOCTORS, HOSPITALS, AND PHARMACIES CAN I USE?, and have a network of doctors, hospitals, pharmacies, and other providers. If you use the providers in our network, you may pay less for your covered services. But if you want to, you can also use providers that are not in our network. You must generally use network pharmacies to fill your prescriptions for covered Part D drugs. 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. WHAT DO WE COVER? Like all Medicare health plans, we cover everything that Original Medicare covers - and more. 1 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. 1 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. 3

4 1 You can see the complete plan formulary (list of Part D prescription drugs) and any restrictions on our website, client.formularynavigator.com/clients/ hm/default.html. 1 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 five "tiers." You will need to use your formulary to locate what tier your drug is on to determine how much it will 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. Highmark Senior Health Company is a PPO plan with a Medicare contract. Enrollment in Highmark Senior Health Company depends on contract renewal. 4

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6 SUMMARY OF BENEFITS January 1, December 31, 2016 BENEFIT CATEGORY 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. Please refer to the Premium Table after this section to find out the premium in your area. $ per month. In addition, you must keep paying your Medicare Part B premium. Please refer to the Premium Table after this section to find out the premium in your area. $ per month. In addition, you must keep paying your Medicare Part B premium. Please refer to the Premium Table after this section to find out the premium in your area. 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 s for medical and hospital care. Your yearly limit(s) in this plan: 1 $6,700 for services you receive from in-network providers. 1 $10,000 for services you receive from any provider. Your limit for services received from in-network providers will count toward this limit. If you reach the limit on out-of-pocket s, you keep getting covered hospital and medical services and we will pay the full for the rest of the year. Please note that you will still need to pay your monthly premiums and Yes. Like all Medicare health plans, our plan protects you by having yearly limits on your out-of-pocket s for medical and hospital care. Your yearly limit(s) in this plan: 1 $6,700 for services you receive from in-network providers. 1 $10,000 for services you receive from any provider. Your limit for services received from in-network providers will count toward this limit. If you reach the limit on out-of-pocket s, you keep getting covered hospital and medical services and we will pay the full for the rest of the year. Please note that you will still need to pay your monthly premiums and Yes. Like all Medicare health plans, our plan protects you by having yearly limits on your out-of-pocket s for medical and hospital care. Your yearly limit(s) in this plan: 1 $6,700 for services you receive from in-network providers. 1 $10,000 for services you receive from any provider. Your limit for services received from in-network providers will count toward this limit. If you reach the limit on out-of-pocket s, you keep getting covered hospital and medical services and we will pay the full for the rest of the year. Please note that you will still need to pay your monthly premiums and 6

7 Is there any limit on how much I will pay for my covered services? (continued) -sharing for your Part D prescription drugs. -sharing for your Part D prescription drugs. -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. COVERED MEDICAL AND HOSPITAL BENEFITS Note: 1 Services with a 1 may require prior authorization. OUTPATIENT CARE AND SERVICES Acupuncture Not covered Not covered Not covered Ambulance Chiropractic Care 1 1 In-network: $200 1 In-network: $150 1 In-network: $100 1 Out-of-network: $200 or 1 Out-of-network: $150 or 1 Out-of-network: $100 or 30% of the, depending on the service 30% of the, depending on the service 30% of the, depending on the service Manipulation of the spine to correct Manipulation of the spine to correct Manipulation of the spine to correct a subluxation (when 1 or more of the a subluxation (when 1 or more of the a subluxation (when 1 or more of the bones of your spine move out of bones of your spine move out of bones of your spine move out of position): position): position): 1 In-network: $20 1 In-network: $20 1 In-network: $20 Routine chiropractic visit (for up to Routine chiropractic visit (for up to Routine chiropractic visit (for up to 8 every year): 8 every year): 8 every year): 1 In-network: $20 1 In-network: $20 1 In-network: $20 7

8 Dental Services 1 Diabetes Supplies and Services 1 Limited dental services (this does Limited dental services (this does not include services in connection not include services in connection with care, treatment, filling, removal, with care, treatment, filling, or replacement of teeth): removal, or replacement of teeth): 1 In-network: $40-300, 1 In-network: $30-250, depending on the service depending on the service Preventive dental services: Preventive dental services: 1 Dental x-ray(s) (for up to 1): 1 Dental x-ray(s) (for up to 1): 4 In-network: $25 4 In-network: $25 4 Out-of-network: 50% of the 4 Out-of-network: 50% of the A single office visit that includes: A single office visit that includes: 1 Cleaning (for up to 1 every year) 1 Cleaning (for up to 1 every year) 1 Oral exam (for up to 1 every 1 Oral exam (for up to 1 every year) year) 4 In-network: $30 4 In-network: $30 4 Out-of-network: 50% of the 4 Out-of-network: 50% of the Diabetes monitoring supplies: Diabetes monitoring supplies: 1 In-network: 0-20% of the, 1 In-network: 0-20% of the, depending on the supply depending on the supply Diabetes self-management training: Diabetes self-management training: 1 In-network: You pay nothing 1 In-network: You pay nothing 1 Out-of-network: You pay 1 Out-of-network: You pay nothing nothing Therapeutic shoes or inserts: Therapeutic shoes or inserts: 1 In-network: 20% of the 1 In-network: 20% of the Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): 1 In-network: $25-250, depending on the service Preventive dental services: 1 Dental x-ray(s) (for up to 1): 4 In-network: $20 4 Out-of-network: 50% of the A single office visit that includes: 1 Cleaning (for up to 1 every year) 1 Oral exam (for up to 1 every year) 4 In-network: $20 4 Out-of-network: 50% of the Diabetes monitoring supplies: 1 In-network: 0-20% of the, depending on the supply Diabetes self-management training: 1 In-network: You pay nothing 1 Out-of-network: You pay nothing Therapeutic shoes or inserts: 1 In-network: 20% of the 8

9 BENEFIT CATEGORY Diagnostic Tests, Lab and Diagnostic radiology services (such Diagnostic radiology services (such Diagnostic radiology services (such Radiology Services, and X-Rays as MRIs, CT scans): as MRIs, CT scans): as MRIs, CT scans): (Costs for these services may vary based on place of service) 1 1 In-network: $200 1 In-network: $150 1 In-network: $100 Diagnostic tests and procedures: Diagnostic tests and procedures: Diagnostic tests and procedures: 1 In-network: $5-15, 1 In-network: $0-10, 1 In-network: You pay nothing depending on the service depending on the service Lab services: Lab services: Lab services: 1 In-network: You pay nothing 1 In-network: $5-15, 1 In-network: $0-10, depending on the service depending on the service Outpatient x-rays: 1 In-network: $20 Outpatient x-rays: Outpatient x-rays: 1 In-network: $50 1 In-network: $40 Therapeutic radiology services (such as radiation treatment for cancer): Therapeutic radiology services (such as radiation treatment for cancer): Therapeutic radiology services (such as radiation treatment for cancer): 1 In-network: You pay nothing 1 In-network: You pay nothing Doctor's Office Visits Primary care physician visit: Primary care physician visit: Primary care physician visit: 1 In-network: $15 1 In-network: $10 1 In-network: $5 1 Out-of-network: $20 1 Out-of-network: $20 1 Out-of-network: $10 Specialist visit: Specialist visit: Specialist visit: 1 In-network: You pay nothing 1 In-network: $40 1 In-network: $30 1 In-network: $25 1 Out-of-network: $45 1 Out-of-network: $45 1 Out-of-network: $40 Durable Medical Equipment 1 In-network: 20% of the 1 In-network: 20% of the 1 In-network: 20% of the (wheelchairs, oxygen, etc.) 1 9

10 Emergency Care $75 $75 $75 If you are admitted to the hospital within 3 days, you do not have to pay your share of the for emergency care. See the "Inpatient Hospital Care" section of this booklet for other s. If you are admitted to the hospital within 3 days, you do not have to pay your share of the for emergency care. See the "Inpatient Hospital Care" section of this booklet for other s. If you are admitted to the hospital within 3 days, you do not have to pay your share of the for emergency care. See the "Inpatient Hospital Care" section of this booklet for other s. Emergency Care is covered worldwide. Emergency Care is covered worldwide. Emergency Care is covered worldwide. Foot Care (podiatry services) Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: 1 In-network: $40 1 In-network: $30 1 In-network: $25 Routine foot care (for up to 10 visit(s) every year): Routine foot care (for up to 10 visit(s) every year): Routine foot care (for up to 10 visit(s) every year): 1 In-network: $40 1 In-network: $30 1 In-network: $25 Hearing Services Exam to diagnose and treat hearing and balance issues: Exam to diagnose and treat hearing and balance issues: Exam to diagnose and treat hearing and balance issues: 1 In-network: $40 1 In-network: $30 1 In-network: $25 Routine hearing exam (for up to 1 every year): Routine hearing exam (for up to 1 every year): Routine hearing exam (for up to 1 every year): 1 In-network: $40 1 In-network: $30 1 In-network: $25 Hearing aid fitting/evaluation (for up to 1 every year): Hearing aid fitting/evaluation (for up to 1 every year): Hearing aid fitting/evaluation (for up to 1 every year): 1 In-network: $40 1 In-network: $30 1 In-network: $25 10

11 Hearing Services (continued) Hearing aid: 1 In-network: $ for each hearing aid, depending on the type 1 Out-of-network: $ for each hearing aid, depending on the type Copayment for hearing aids applies only to TruHearing Chime products. TruHearing is the exclusive provider of the Chime 500 and Chime 900 hearing aids. Up to two Chime hearing aids once every calendar year. Hearing aid: 1 In-network: $ for each hearing aid, depending on the type 1 Out-of-network: $ for each hearing aid, depending on the type Copayment for hearing aids applies only to TruHearing Chime products. TruHearing is the exclusive provider of the Chime 500 and Chime 900 hearing aids. Up to two Chime hearing aids once every calendar year. Hearing aid: 1 In-network: $ for each hearing aid, depending on the type 1 Out-of-network: $ for each hearing aid, depending on the type Copayment for hearing aids applies only to TruHearing Chime products. TruHearing is the exclusive provider of the Chime 500 and Chime 900 hearing aids. Up to two Chime hearing aids once every calendar year. Home Health Care 1 1 In-network: You pay nothing 1 In-network: You pay nothing 1 In-network: You pay nothing Mental Health Care 1 Inpatient visit: Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The Inpatient visit: Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not inpatient hospital care limit does not apply to inpatient mental services apply to inpatient mental services provided in a general hospital. provided in a general hospital. Our plan covers 90 days for an Our plan covers 90 days for an inpatient hospital stay. inpatient hospital stay. Our plan also covers 60 "lifetime Our plan also covers 60 "lifetime reserve days." These are "extra" days reserve days." These are "extra" days that we cover. If your hospital stay that we cover. If your hospital stay is longer than 90 days, you can use is longer than 90 days, you can use these extra days. But once you have these extra days. But once you have Inpatient visit: Our plan covers up to 190 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. Our plan covers 90 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 90 days, you can use these extra days. But once you have 11

12 Mental Health Care 1 (continued) used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days. used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days. used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days. 1 In-network: 4 $250 per day for days 1 through 5 4 You pay nothing per day for days 6 through 90 1 In-network: 4 $200 per day for days 1 through 5 4 You pay nothing per day for days 6 through 90 1 In-network: 4 $125 per day for days 1 through 5 4 You pay nothing per day for days 6 through 90 1 Out-of-network: 4 10% of the per stay 1 Out-of-network: 4 30% of the per stay 1 Out-of-network: 4 30% of the per stay Outpatient group therapy visit: Outpatient group therapy visit: Outpatient group therapy visit: 1 In-network: $40 1 In-network: $30 1 In-network: $25 Outpatient individual therapy visit: Outpatient individual therapy visit: Outpatient individual therapy visit: 1 In-network: $40 1 In-network: $30 1 In-network: $25 Outpatient Rehabilitation 1 Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): 1 In-network: You pay nothing 1 In-network: You pay nothing 1 In-network: You pay nothing Occupational therapy visit: Occupational therapy visit: Occupational therapy visit: 1 In-network: $40 1 In-network: $30 1 In-network: $25 Physical therapy and speech and language therapy visit: Physical therapy and speech and language therapy visit: Physical therapy and speech and language therapy visit: 1 In-network: $40 1 In-network: $30 1 In-network: $25 12

13 Outpatient Substance Abuse 1 Outpatient Surgery 1 Group therapy visit: Group therapy visit: Group therapy visit: 1 In-network: $40 1 In-network: $30 1 In-network: $25 Individual therapy visit: Individual therapy visit: Individual therapy visit: 1 In-network: $40 1 In-network: $30 1 In-network: $25 Ambulatory surgical center: Ambulatory surgical center: Ambulatory surgical center: 1 In-network: $200 1 In-network: $150 1 In-network: $150 Outpatient hospital: Outpatient hospital: Outpatient hospital: 1 In-network: $300 1 In-network: $250 1 In-network: $250 Over-the-Counter Items Not Covered Not Covered Not Covered Prosthetic Devices (braces, Prosthetic devices: Prosthetic devices: Prosthetic devices: artificial limbs, etc.) 1 1 In-network: 20% of the 1 In-network: 20% of the 1 In-network: 20% of the Related medical supplies: Related medical supplies: Related medical supplies: 1 In-network: 20% of the 1 In-network: 20% of the 1 In-network: 20% of the Renal Dialysis Transportation 1 In-network: You pay nothing 1 In-network: You pay nothing 1 In-network: You pay nothing 1 Out-of-network: 0-30% of the 1 Out-of-network: 0-30% of the 1 Out-of-network: 0-30% of the, depending on the service, depending on the service, depending on the service 1 In-network: $40 1 In-network: $40 1 In-network: $40 1 Out-of-network: 50% of the 1 Out-of-network: 50% of the 1 Out-of-network: 50% of the Urgently Needed Services $50. $50. $50. 13

14 Urgently Needed Services (continued) Not waived if admitted. Urgently Needed Services are covered worldwide. Not waived if admitted. Urgently Needed Services are covered worldwide. Not waived if admitted. Urgently Needed Services are covered worldwide. Vision Services Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): 1 In-network: $0-40, depending on the service 1 Out-of-network: $45 1 In-network: $0-30, depending on the service 1 Out-of-network: $45 1 In-network: $0-25, depending on the service 1 Out-of-network: $40 Routine eye exam (for up to 1 every year): Routine eye exam (for up to 1 every year): Routine eye exam (for up to 1 every year): 1 Out-of-network: $40 1 Out-of-network: $40 1 Out-of-network: $40 Contact lenses (for up to 1 every year): Contact lenses (for up to 1 every year): Contact lenses (for up to 1 every year): 1 Out-of-network: $0 1 Out-of-network: $0 1 Out-of-network: $0 Our plan pays up to $100 every year for contact lenses from any provider. Our plan pays up to $100 every year for contact lenses from any provider. Our plan pays up to $100 every year for contact lenses from any provider. Eyeglass frames (for up to 1 every year): Eyeglass frames (for up to 1 every year): Eyeglass frames (for up to 1 every year): 1 Out-of-network: $0 1 Out-of-network: $0 1 Out-of-network: $0 Our plan pays up to $100 every year for eyeglass frames from any provider. Our plan pays up to $100 every year for eyeglass frames from any provider. Our plan pays up to $100 every year for eyeglass frames from any provider. Eyeglass lenses (for up to 1 every year): Eyeglass lenses (for up to 1 every year): Eyeglass lenses (for up to 1 every year): 1 Out-of-network: $0 1 Out-of-network: $0 1 Out-of-network: $0 14

15 Vision Services (continued) Our plan pays up to $100 every year for eyeglass lenses from any provider. Eyeglasses or contact lenses after cataract surgery: 1 Out-of-network: $0 A $200 benefit max applies to upgrades to post-cataract surgery eyewear that are not medically necessary. Available following cataract surgery once per operated eye. Our plan pays up to $100 every year for eyeglass lenses from any provider. Eyeglasses or contact lenses after cataract surgery: 1 Out-of-network: $0 A $200 benefit max applies to upgrades to post-cataract surgery eyewear that are not medically necessary. Available following cataract surgery once per operated eye. Our plan pays up to $100 every year for eyeglass lenses from any provider. Eyeglasses or contact lenses after cataract surgery: 1 Out-of-network: $0 A $200 benefit max applies to upgrades to post-cataract surgery eyewear that are not medically necessary. Available following cataract surgery once per operated eye. Preventive Care 1 In-network: You pay nothing 1 Out-of-network: You pay nothing Our plan covers many preventive services, including: 1 Abdominal aortic aneurysm screening 1 Alcohol misuse counseling 1 Bone mass measurement 1 Breast cancer screening (mammogram) 1 Cardiovascular disease (behavioral therapy) 1 Cardiovascular screenings 1 Cervical and vaginal cancer screening 1 Colorectal cancer screenings (Colonoscopy, Fecal occult blood test, Flexible sigmoidoscopy) 1 In-network: You pay nothing 1 Out-of-network: You pay nothing Our plan covers many preventive services, including: 1 Abdominal aortic aneurysm screening 1 Alcohol misuse counseling 1 Bone mass measurement 1 Breast cancer screening (mammogram) 1 Cardiovascular disease (behavioral therapy) 1 Cardiovascular screenings 1 Cervical and vaginal cancer screening 1 Colorectal cancer screenings (Colonoscopy, Fecal occult blood test, Flexible sigmoidoscopy) 1 In-network: You pay nothing 1 Out-of-network: You pay nothing Our plan covers many preventive services, including: 1 Abdominal aortic aneurysm screening 1 Alcohol misuse counseling 1 Bone mass measurement 1 Breast cancer screening (mammogram) 1 Cardiovascular disease (behavioral therapy) 1 Cardiovascular screenings 1 Cervical and vaginal cancer screening 1 Colorectal cancer screenings (Colonoscopy, Fecal occult blood test, Flexible sigmoidoscopy) 15

16 Preventive Care (continued) 1 Depression screening 1 Depression screening 1 Depression screening 1 Diabetes screenings 1 Diabetes screenings 1 Diabetes screenings 1 HIV screening 1 HIV screening 1 HIV screening 1 Medical nutrition therapy 1 Medical nutrition therapy 1 Medical nutrition therapy services services services 1 Obesity screening and 1 Obesity screening and 1 Obesity screening and counseling counseling counseling 1 Prostate cancer screenings (PSA) 1 Prostate cancer screenings (PSA) 1 Prostate cancer screenings (PSA) 1 Sexually transmitted infections 1 Sexually transmitted infections 1 Sexually transmitted infections screening and counseling 1 Tobacco use cessation screening and counseling 1 Tobacco use cessation screening and counseling 1 Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease) counseling (counseling for people with no sign of tobacco-related disease) counseling (counseling for people with no sign of tobacco-related disease) 1 Vaccines, including Flu shots, 1 Vaccines, including Flu shots, 1 Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots 1 "Welcome to Medicare" 1 Hepatitis B shots, Pneumococcal shots "Welcome to Medicare" 1 Hepatitis B shots, Pneumococcal shots "Welcome to Medicare" preventive visit (one-time) preventive visit (one-time) preventive visit (one-time) 1 Yearly "Wellness" visit 1 Yearly "Wellness" visit 1 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. Hospice You pay nothing for hospice care You pay nothing for hospice care You pay nothing for hospice care from a Medicare-certified hospice. from a Medicare-certified hospice. from a Medicare-certified hospice. You may have to pay part of the You may have to pay part of the You may have to pay part of the s for drugs and respite care. s for drugs and respite care. s for drugs and respite care. Hospice is covered outside of our Hospice is covered outside of our Hospice is covered outside of our plan. Please contact us for more plan. Please contact us for more plan. Please contact us for more details. details. details. 16

17 INPATIENT CARE Inpatient Hospital Care 1 Our plan covers an unlimited number of days for an inpatient hospital stay. 1 In-network: 4 $250 per day for days 1 through 5 4 You pay nothing per day for days 6 through 90 4 You pay nothing per day for days 91 and beyond 1 Out-of-network: 4 10% of the per stay Our plan covers an unlimited number of days for an inpatient hospital stay. 1 In-network: 4 $200 per day for days 1 through 5 4 You pay nothing per day for days 6 through 90 4 You pay nothing per day for days 91 and beyond 1 Out-of-network: 4 30% of the per stay Our plan covers an unlimited number of days for an inpatient hospital stay. 1 In-network: 4 $125 per day for days 1 through 5 4 You pay nothing per day for days 6 through 90 4 You pay nothing per day for days 91 and beyond 1 Out-of-network: 4 30% of the 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) 1 Our plan covers up to 100 days in a SNF. 1 In-network: 4 You pay nothing per day for days 1 through 20 4 $160 per day for days 21 through Out-of-network: 4 30% of the per stay Our plan covers up to 100 days in a SNF. 1 In-network: 4 You pay nothing per day for days 1 through 20 4 $160 per day for days 21 through Out-of-network: 4 30% of the per stay Our plan covers up to 100 days in a SNF. 1 In-network: 4 You pay nothing per day for days 1 through 20 4 $160 per day for days 21 through Out-of-network: 4 30% of the per stay PRESCRIPTION DRUG BENEFITS How much do I pay? For Part B drugs such as chemotherapy drugs 1 : For Part B drugs such as chemotherapy drugs 1 : For Part B drugs such as chemotherapy drugs 1 : 17

18 How much do I pay? (continued) 1 In-network: 0-20% of the depending on the drug 1 Out-of-network: 0-30% of the, depending on the drug Other Part B drugs 1 : 1 In-network: 0-20% of the depending on the drug 1 Out-of-network: 0-30% of the, depending on the drug Other Part B drugs 1 : 1 In-network: 0-20% of the depending on the drug 1 Out-of-network: 0-30% of the, depending on the drug Other Part B drugs 1 : 1 In-network: 0-20% of the depending on the drug 1 Out-of-network: 0-30% of the, depending on the drug 1 In-network: 0-20% of the depending on the drug 1 Out-of-network: 0-30% of the, depending on the drug 1 In-network: 0-20% of the depending on the drug 1 Out-of-network: 0-30% of the, depending on the drug Initial Coverage You pay the following until your total yearly drug s reach $3,310. Total yearly drug s are the total drug s 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 Three- One-monthmonth Tier supply supply Tier 1 (Preferred $3 $9 Generic) Tier 2 $15 $45 (Generic) Tier 3 (Preferred $47 $141 Brand) Tier 4 (Non 45% of the 45% of the Preferred Brand) You pay the following until your total yearly drug s reach $3,310. Total yearly drug s are the total drug s paid by both you and our Part D plan. You may get your drugs at network retail pharmacies and mail order pharmacies. 45% of the 45% of the Standard Retail Cost-Sharing Three- One-monthmonth Tier supply supply Tier 1 (Preferred $3 $9 Generic) Tier 2 $15 $45 (Generic) Tier 3 (Preferred $47 $141 Brand) Tier 4 (Non- Preferred Brand) You pay the following until your total yearly drug s reach $3,310. Total yearly drug s are the total drug s 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 Tier Tier 1 (Preferred Generic) Tier 2 (Generic) Tier 3 (Preferred Brand) Tier 4 (Non- Preferred Brand) Threemonth One-month supply supply $3 $15 $47 $9 $45 $141 45% of the 45% of the 18

19 Initial Coverage (continued) Tier Tier 5 (Specialty Tier) Threemonth One-month supply supply 33% of the Tier Tier 5 (Specialty Tier) Threemonth One-month supply supply 33% of the Tier Tier 5 (Specialty Tier) Threemonth One-month supply supply 33% of the Standard Mail Order Cost-Sharing Tier Tier 1 (Preferred Generic) Tier 2 (Generic) Tier 3 (Preferred Brand) Tier 4 (Non- Preferred Brand) Tier 5 (Specialty Tier) Tier Tier 1 (Preferred Generic) Tier 2 (Generic) Tier 3 (Preferred Brand) Tier 4 (Non- Preferred Brand) Tier 5 (Specialty Tier) Threemonth One-month supply supply $7.50 $37.50 $ % of the 33% of the Standard Mail Order Cost-Sharing Tier Tier 1 (Preferred Generic) Tier 2 (Generic) Tier 3 (Preferred Brand) Tier 4 (Non- Preferred Brand) Tier 5 (Specialty Tier) Threemonth One-month supply supply $7.50 $37.50 $ % of the 33% of the Standard Mail Order Cost-Sharing Threemonth One-month supply supply $7.50 $37.50 $ % of the 33% of the 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. 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. 19

20 Coverage Gap Most Medicare drug plans have a Most Medicare drug plans have a coverage gap (also called the "donut coverage gap (also called the "donut hole"). This means that there's a hole"). This means that there's a temporary change in what you will temporary change in what you will pay for your drugs. The coverage pay for your drugs. The coverage gap begins after the total yearly drug gap begins after the total yearly drug (including what our plan has (including what our plan has paid and what you have paid) paid and what you have paid) reaches $3,310. reaches $3,310. After you enter the coverage gap, After you enter the coverage gap, you pay 45% of the plan's for you pay 45% of the plan's for covered brand name drugs and 58% covered brand name drugs and 58% of the plan's for covered generic of the plan's for covered generic drugs until your s total $4,850, drugs until your s total $4,850, which is the end of the coverage gap. which is the end of the coverage gap. Not everyone will enter the coverage Not everyone will enter the coverage gap. 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 (including what our plan has paid and what you have paid) reaches $3,310. After you enter the coverage gap, you pay 45% of the plan's for covered brand name drugs and 58% of the plan's for covered generic drugs until your s total $4,850, 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 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 you. Standard Retail Cost-Sharing Drugs Onemonth Threemonth Tier Covered supply supply Tier 1 (Preferred All Generic) Tier 2 All (Generic) $3 $15 $9 $45 20

21 Coverage Gap (continued) Standard Mail Order Cost-Sharing Onemonth Drugs Tier Covered supply Tier 1 Not (Preferred All Offered Generic) Tier 2 Not All (Generic) Offered Threemonth supply $7.50 $37.50 Catastrophic Coverage After your yearly out-of-pocket drug s (including drugs purchased through your retail pharmacy and through mail order) reach $4,850, you pay the greater of: After your yearly out-of-pocket drug s (including drugs purchased through your retail pharmacy and through mail order) reach $4,850, you pay the greater of: After your yearly out-of-pocket drug s (including drugs purchased through your retail pharmacy and through mail order) reach $4,850, you pay the greater of: 1 5% of the, or 1 $2.95 for generic (including brand drugs treated as generic) and a $7.40 ment for all other drugs. 1 5% of the, or 1 $2.95 for generic (including brand drugs treated as generic) and a $7.40 ment for all other drugs. 1 5% of the, or 1 $2.95 for generic (including brand drugs treated as generic) and a $7.40 ment for all other drugs. 21

22 PREMIUM TABLE As a member of our plan, you pay a monthly plan premium. The table below shows the monthly plan premium amount for each region we serve. The service area for Southwestern PA includes the following counties in Pennsylvania: Allegheny, Armstrong, Beaver, Butler, Cambria, Fayette, Greene, Indiana, Lawrence, Washington, and Westmoreland and West Central PA includes the following counties in Pennsylvania: Bedford, Blair, Cameron, Clarion, Clearfield, Crawford, Elk, Erie, Forest, Huntingdon, Jefferson, McKean, Mercer, Potter, Somerset, Venango, and Warren. Plan Name Southwestern PA $79.50 $ $ West Central PA $69.50 $ $

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24 Highmark Senior Health Company and Highmark Blue Cross Blue Shield are independent licensees of the Blue Cross and Blue Shield Association. Blue Cross, Blue Shield and the Cross and Shield symbols are registered service marks of the Blue Cross and Blue Shield Association. Freedom Blue is a service mark of the Blue Cross and Blue Shield Association. Highmark is a registered mark of Highmark Inc (R9/15)