Evidence of Coverage

Transcription

1 Evidence of Coverage (EOC) Medicare Advantage Pans New York Bronx, Kings, New York, Queens, Richmond WeCare of New York, Inc. H /01/15 12/31/15 WeCare Rx (HMO) 130 H3361_NY026799_WCM_CMB_ENG CMS Accepted Form CMS ANOC/EOC OMB Approva (Approved 03/2014) WeCare 2014 NY5130EOC60719E_0614

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3 January 1 - December 31, 2015 Evidence of Coverage: Your Medicare Heath Benefits and Services and Prescription Drug Coverage as a Member of WeCare Rx (HMO) This booket gives you the detais about your Medicare heath care and prescription drug coverage from January 1 December 31, It expains how to get coverage for the heath care services and prescription drugs you need. This is an important ega document. Pease keep it in a safe pace. This pan, WeCare Rx (HMO), is offered by WeCare of New York, Inc. (When this Evidence of Coverage says we, us, or our, it means WeCare of New York, Inc. When it says pan or our pan," it means WeCare Rx (HMO).) WeCare (HMO) is a Medicare Advantage organization with a Medicare contract. Enroment in WeCare (HMO) depends on contract renewa. This information is avaiabe for free in other anguages. Pease contact our Customer Service number at for additiona information. (TTY users shoud ca ). Hours are Monday Friday, 8 a.m. to 8 p.m. Between October 1 and February 14, representatives are avaiabe Monday Sunday, 8 a.m. to 8 p.m. Customer service aso has free anguage interpreter services avaiabe for non-engish speakers. Esta información se encuentra disponibe en otros idiomas gratis. Por favor comuníquese con nuestro Servicio a Ciente amando a , para información adiciona. (Los usuarios de TTY deben amar a ). E horario es de unes a viernes de 8 a.m. a 8 p.m. Entre e 1 de Octubre y e 14 de Febrero, os representantes están disponibes de unes a domingo de 8 a.m. a 8 p.m. Servicio a ciente también tiene servicios disponibes de interpretación a otros idiomas gratis para personas que no haban ingés. H3361_NY026799_WCM_CMB_ENG CMS Accepted Form CMS ANOC/EOC OMB Approva (Approved 03/2014) WeCare 2014 NY5130EOC60719E_0614

4 This booket is aso avaiabe in different formats, incuding audio compact disc (CD) and Braie. Pease ca Customer Service if you need pan information in another format (phone numbers are printed on the back cover of this booket). Benefits, formuary, pharmacy network, premium, deductibe and/or co-payments/coinsurance may change on January 1, H3361_NY026799_WCM_CMB_ENG CMS Accepted Form CMS ANOC/EOC OMB Approva (Approved 03/2014) WeCare 2014 NY5130EOC60719E_0614

5 2015 Evidence of Coverage for WeCare Rx (HMO) Muti-anguage Interpreter Services Engish: We have free interpreter services to answer any questions you may have about our heath or drug pan. To get an interpreter, just ca us at Someone who speaks Engish/Language can hep you. This is a free service. Spanish: Tenemos servicios de intérprete sin costo aguno para responder cuaquier pregunta que pueda tener sobre nuestro pan de saud o medicamentos. Para habar con un intérprete, por favor ame a Aguien que habe españo e podrá ayudar. Este es un servicio gratuito. Chinese Mandarin: 我们提供免费的翻译服务, 帮助您解答关于健康或药物保险的任何疑问 如果您需 要此翻译服务, 请致电 我们的中文工作人员很乐意帮助您 这是一项免费服务 Chinese Cantonese: 您對我們的健康或藥物保險可能存有疑問, 為此我們提供免費的翻譯服務 如需 翻譯服務, 請致電 我們講中文的人員將樂意為您提供幫助 這是一項免費服務 Tagaog: Mayroon kaming ibreng serbisyo sa pagsasaing-wika upang masagot ang anumang mga katanungan ninyo hinggi sa aming panong pangkausugan o panggamot. Upang makakuha ng tagasaing-wika, tawagan amang kami sa Maaari kayong tuungan ng isang nakakapagsaita ng Tagaog. Ito ay ibreng serbisyo. French: Nous proposons des services gratuits d'interprétation pour répondre à toutes vos questions reatives à notre régime de santé ou d'assurance-médicaments. Pour accéder au service d'interprétation, i vous suffit de nous appeer au Un interocuteur parant Français pourra vous aider. Ce service est gratuit. Vietnamese: Chúng tôi có dịch vụ thông dịch miễn phí để trả ời các câu hỏi về chưong sức khỏe và chưong trình thuốc men. Nếu quí vị cần thông dịch viên xin gọi sẽ có nhân viên nói tiếng Việt giúp đỡ quí vị. Đây à dịch vụ miễn phí ế German: Unser kostenoser Dometscherservice beantwortet Ihren Fragen zu unserem Gesundheits- und Arzneimittepan. Unsere Dometscher erreichen Sie unter Man wird Ihnen dort auf Deutsch weiterhefen. Dieser Service ist kostenos. Korean: 당사는의료보험또는약품보험에관한질문에답해드리고자무료통역서비스를제공하고있습니다. 통역서비스를이용하려면전화 번으로문의해주십시오. 한국어를하는담당자가도와드릴것입니다. 이서비스는무료로운영됩니다. Y0070_NA023373_W CM _INS_M LT CMS Accepted

6 2015 Evidence of Coverage for WeCare Rx (HMO) Russian: Если у вас возникнут вопросы относительно страхового или медикаментного плана, вы можете воспользоваться нашими бесплатными услугами переводчиков. Чтобы воспользоваться услугами переводчика, позвоните нам по телефону Вам окажет помощь сотрудник, который говорит порусски. Данная услуга бесплатная. Itaian: È disponibie un servizio di interpretariato gratuito per rispondere a eventuai domande su nostro piano sanitario e farmaceutico. Per un interprete, contattare i numero Un nostro incaricato che para Itaianovi fornirà 'assistenza necessaria. È un servizio gratuito. Portugués: Dispomos de serviços de interpretação gratuitos para responder a quaquer questão que tenha acerca do nosso pano de saúde ou de medicação. Para obter um intérprete, contacte-nos através do número Irá encontrar aguém que fae o idioma Português para o ajudar. Este serviço é gratuito. French Creoe: Nou genyen sévis entèprèt gratis pou reponn tout kesyon ou ta genyen konsènan pan medika oswa dwôg nou an. Pou jwenn yon entèprèt, jis ree nou nan Yon moun ki pae Kreyô kapab ede w. Sa a se yon sévis ki gratis. Poish: Umożiwiamy bezpłatne skorzystanie z usług tłumacza ustnego, który pomoże w uzyskaniu odpowiedzi na temat panu zdrowotnego ub dawkowania eków. Aby skorzystać z pomocy tłumacza znającego język poski, naeży zadzwonić pod numer Ta usługa jest bezpłatna. Japanese: 当社の健康睫康保険と薬品処方薬プランに関するご質問にお答えするために 無料の通訳サービスがありますございます 通訳をご用命になるには にお電話ください 日本語を話す人者が支援いたします これは無料のサービスです Y0070_NA023373_W CM _INS_M LT CMS Accepted

7 2015 Evidence of Coverage for WeCare Rx (HMO) Tabe of Contents 2015 Evidence of Coverage Tabe of Contents This ist of chapters and page numbers is your starting point. For more hep in finding information you need, go to the first page of a chapter. You wi find a detaied ist of topics at the beginning of each chapter. Chapter 1. Chapter 2. Chapter 3. Getting started as a member... 8 Expains what it means to be in a Medicare heath pan and how to use this booket. Tes about materias we wi send you, your pan premium, your pan membership card, and keeping your membership record up to date. Important phone numbers and resources...24 Tes you how to get in touch with our pan (WeCare Rx (HMO)) and with other organizations incuding Medicare, the State Heath Insurance Assistance Program (SHIP), the Quaity Improvement Organization, Socia Security, Medicaid (the state heath insurance program for peope with ow incomes), programs that hep peope pay for their prescription drugs, and the Rairoad Retirement Board. Using the pan s coverage for your medica services Expains important things you need to know about getting your medica care as a member of our pan. Topics incude using the providers in the pan s network and how to get care when you have an emergency. Chapter 4. Medica Benefits Chart (what is covered and what you pay). 62 Chapter 5. Gives the detais about which types of medica care are covered and not covered for you as a member of our pan. Expains how much you wi pay as your share of the cost for your covered medica care. Using the pan s coverage for your Part D prescription drugs Expains rues you need to foow when you get your Part D drugs. Tes how to use the pan s List of Covered Drugs (Formuary) to find out which drugs are covered. Tes which

8 2015 Evidence of Coverage for WeCare Rx (HMO) Tabe of Contents Chapter 6. Chapter 7. Chapter 8. Chapter 9. kinds of drugs are not covered. Expains severa kinds of restrictions that appy to coverage for certain drugs. Expains where to get your prescriptions fied. Tes about the pan s programs for drug safety and managing medications. What you pay for your Part D prescription drugs Tes about the three stages of drug coverage (Initia Coverage Stage, Coverage Gap Stage, Catastrophic Coverage Stage) and how these stages affect what you pay for your drugs. Expains the five cost-sharing tiers for your Part D drugs and tes what you must pay for a drug in each cost-sharing tier.tes about the ate enroment penaty. Asking us to pay our share of a bi you have received for covered medica services or drugs Expains when and how to send a bi to us when you want to ask us to pay you back for our share of the cost for your covered services or drugs. Your rights and responsib iities Expains the rights and responsibiities you have as a member of our pan. Tes what you can do if you think your rights are not being respected. What to do if you have a probem or compaint (coverage decisions, appeas, compaints) Tes you step-by-step what to do if you are having probems or concerns as a member of our pan. Expains how to ask for coverage decisions and make appeas if you are having troube getting the medica care or prescription drugs you think are covered by our pan. This incudes asking us to make exceptions to the rues or extra restrictions on your coverage for prescription drugs, and asking us to keep covering hospita care and certain types of medica services if you think your coverage is ending too soon. Expains how to make compaints about quaity of care, waiting times, customer service, and other concerns. Chapter 10. Ending your membership in the pan

9 2015 Evidence of Coverage for WeCare Rx (HMO) Tabe of Contents Expains when and how you can end your membership in the pan. Expains situations in which our pan is required to end your membership. Chapter 11. Lega notices Incudes notices about governing aw and about non-discrimination. Chapter 12. Definitions of important words Expains key terms used in this booket.

10 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 1: Getting started as a member 8 Chapter 1. Getting started as a member SECTION 1 Introduction Section 1.1 You are enroed in WeCare Rx (HMO), which is a Medicare HMO Section 1.2 What is the Evidence of Coverage booket about? Section 1.3 What does this Chapter te you? Section 1.4 What if you are new to WeCare Rx (HMO)? Section 1.5 Lega information about the Evidence of Coverage SECTION 2 What makes you eigibe to be a pan member? Section 2.1 Your eigibiity requirements Section 2.2 What are Medicare Part A and Medicare Part B? Section 2.3 Here is the pan service area for WeCare Rx (HMO) SECTION 3 What other materias wi you get from us? Section 3.1 Your pan membership card - Use it to get a covered care and prescription drugs Section 3.2 The Provider & Pharmacy Directory: Your guide to a providers in the pan s network Section 3.3 The Provider & Pharmacy Directory: Your guide to pharmacies in our network Section3.4 Thepan s List of Covered Drugs (Formuary) Section 3.5 The Part D Expanation of Benefits (the "Part D EOB"): Reports with a summary of payments made for your Part D prescription drugs SECTION 4 Your monthy premium for WeCare Rx (HMO) Section 4.1 How much is your pan premium? Section 4.2 There are severa ways you can pay your pan premium... 18

11 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 1: Getting started as a member 9 Section 4.3 Can we change your monthy pan premium during the year? SECTION 5 Pease keep your pan membership record up to date Section 5.1 How to hep make sure that we have accurate information about you SECTION 6 We protect the privacy of your persona heath information Section 6.1 We make sure that your heath information is protected SECTION 7 How other insurance works with our pan Section 7.1 Which pan pays first when you have other insurance?... 22

12 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 1: Getting started as a member 10 SECTION 1 Section 1.1 Introduction You are enroed in WeCare Rx (HMO), which is a Medicare HMO You are covered by Medicare, and you have chosen to get your Medicare heath care and your prescription drug coverage through our pan, WeCare Rx (HMO). There are different types of Medicare heath pans. WeCare Rx (HMO) is a Medicare Advantage HMO Pan (HMO stands for Heath Maintenance Organization). Like a Medicare heath pans, this Medicare HMO is approved by Medicare and run by a private company. Section 1.2 What is the Evidence of Coverage booket about? This Evidence of Coverage booket tes you how to get your Medicare medica care and prescription drugs covered through our pan. This booket expains your rights and responsibiities, what is covered, and what you pay as a member of the pan. This pan, WeCare Rx (HMO), is offered by WeCare of New York, Inc.. (When this Evidence of Coverage says we, us, or our, it means WeCare of New York, Inc.. When it says pan or our pan, it means WeCare Rx (HMO).) The word coverage and covered services refers to the medica care and services and the prescription drugs avaiabe to you as a member of WeCare Rx (HMO). Section 1.3 What does this Chapter te you? Look through Chapter 1 of this Evidence of Coverage to earn: What makes you eigibe to be a pan member? What is your pan s service area? What materias wi you get from us? What is your pan premium and how can you pay it? How do you keep the information in your membership record up to date? Section 1.4 What if you are new to WeCare Rx (HMO)?

13 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 1: Getting started as a member 11 If you are a new member, then it s important for you to earn what the pan's rues are and what services are avaiabe to you. We encourage you to set aside some time to ook through this Evidence of Coverage booket. If you are confused or concerned or just have a question, pease contact our pan s Customer Service (phone numbers are printed on the back cover of this booket). Section 1.5 Lega information about the Evidence of Coverage It s part of our contract with you This Evidence of Coverage is part of our contract with you about how our pan covers your care. Other parts of this contract incude your enroment form, the List of Covered Drugs (Formuary), and any notices you receive from us about changes to your coverage or conditions that affect your coverage. These notices are sometimes caed riders or amendments. The contract is in effect for months in which you are enroed in WeCare Rx (HMO) between January 1, 2015 and December 31, Each caendar year, Medicare aows us to make changes to the pans that we offer. This means we can change the costs and benefits of WeCare Rx (HMO) after December 31, We can aso choose to stop offering the pan, or to offer it in a different service area, after December 31, Medicare must approve our pan each year Medicare (the Centers for Medicare & Medicaid Services) must approve our pan each year. You can continue to get Medicare coverage as a member of our pan as ong as we choose to continue to offer the pan and Medicare renews its approva of the pan. SECTION 2 Section 2.1 What makes you eigibe to be a pan member? Your eigibiity requirements You are eigibe for membership in our pan as ong as: You ive in our geographic service area (Section 2.3 beow describes our service area)

14 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 1: Getting started as a member and -- you have both Medicare Part A and Medicare Part B -- and -- you do not have End-Stage Rena Disease (ESRD), with imited exceptions, such as if you deveop ESRD when you are aready a member of a pan that we offer, or you were a member of a different pan that was terminated. Section 2.2 What are Medicare Part A and Medicare Part B? When you first signed up for Medicare, you received information about what services are covered under Medicare Part A and Medicare Part B. Remember: Medicare Part A generay heps cover services provided by hospitas (for inpatient services, skied nursing faciities or home heath agencies). Medicare Part B is for most other medica services (such as physician s services and other outpatient services) and certain items (such as durabe medica equipment and suppies). Section 2.3 Here is the pan service area for WeCare Rx (HMO) Athough Medicare is a Federa program, WeCare Rx (HMO) is avaiabe ony to individuas who ive in our pan service area. To remain a member of our pan, you must continue to reside in the pan service area. The service area is described beow. Our service area incudes these counties in New York: Bronx, Kings, New York, Queens, Richmond. If you pan to move out of the service area, pease contact Customer Service (phone numbers are printed on the back cover of this booket). When you move, you wi have a Specia Enroment Period that wi aow you to switch to Origina Medicare or enro in a Medicare heath or drug pan that is avaiabe in your new ocation. It is aso important that you ca Socia Security if you move or change your maiing address. You can find phone numbers and contact information for Socia Security in Chapter 2, Section 5. SECTION 3 Section 3.1 What other materias wi you get from us? Your pan membership card - Use it to get a covered care and prescription drugs

15 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 1: Getting started as a member 13 Whie you are a member of our pan, you must use your membership card for our pan whenever you get any services covered by this pan and for prescription drugs you get at network pharmacies. Here s a sampe membership card to show you what yours wi ook ike: As ong as you are a member of our pan you must not use your red, white, and bue Medicare card to get covered medica services (with the exception of routine cinica research studies and hospice services). Keep your red, white, and bue Medicare card in a safe pace in case you need it ater. Here s why this is so important: If you get covered services using your red, white, and bue Medicare card instead of using your WeCare Rx (HMO) membership card whie you are a pan member, you may have to pay the fu cost yoursef. If your pan membership card is damaged, ost, or stoen, ca Customer Service right away and we wi send you a new card. (Phone numbers for Customer Service are printed on the back cover of this booket.) Section 3.2 The Provider & Pharmacy Directory: Your guide to a providers in the pan s network The Provider & Pharmacy Directory ists our network providers. What are network providers? Network providers are the doctors and other heath care professionas, medica groups, hospitas, and other heath care faciities that have an agreement with us to accept our payment and any pan cost-sharing as payment in fu. We have arranged for these providers to deiver covered services to members in our pan.

16 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 1: Getting started as a member 14 Why do you need to know which providers are part of our network? It is important to know which providers are part of our network because, with imited exceptions, whie you are a member of our pan you must use network providers to get your medica care and services. The ony exceptions are emergencies, urgenty needed care when the network is not avaiabe (generay, when you are out of the area), out-of-area diaysis services, and cases in which our pan authorizes use of out-of-network providers. See Chapter 3 (Using the pan s coverage for your medica services) for more specific information about emergency, out-of-network, and out-of-area coverage. If you don t have your copy of the Provider & Pharmacy Directory, you can request a copy from Customer Service (phone numbers are printed on the back cover of this booket). You may ask Customer Service for more information about our network providers, incuding their quaifications. You can aso see the Provider & Pharmacy Directory at or downoad it from this website. Both Customer Service and the website can give you the most up-to-date information about changes in our network providers. Section 3.3 The Provider & Pharmacy Directory: Your guide to pharmacies in our network What are network pharmacies? Our Provider & Pharmacy Directory gives you a compete ist of our network pharmacies that means a of the pharmacies that have agreed to fi covered prescriptions for our pan members. Why do you need to know about network pharmacies? You can use the Provider & Pharmacy Directory to find the network pharmacy you want to use. The Provider & Pharmacy Directory incudes Retai, Chain, Mai Service, Long-Term Care, Home Infusion, Indian Heath Service and Speciaty pharmacies. This is important because, with few exceptions, you must get your prescriptions fied at one of our network pharmacies if you want our pan to cover (hep you pay for) them. The Provider & Pharmacy Directory wi aso te you which of the pharmacies in our network have preferred cost-sharing, which may be ower than the standard cost-sharing offered by other network pharmacies.

17 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 1: Getting started as a member 15 If you don t have the Provider & Pharmacy Directory, you can get a copy from Customer Service (phone numbers are printed on the back cover of this booket). At any time, you can ca Customer Service to get up-to-date information about changes in the pharmacy network. You can aso find this information on our website at Section 3.4 The pan s List of Covered Drugs (Formuary) The pan has a List of Covered Drugs (Formuary). We ca it the Drug List for short. It tes which Part D prescription drugs are covered by our pan. The drugs on this ist are seected by the pan with the hep of a team of doctors and pharmacists. The ist must meet requirements set by Medicare. Medicare has approved the WeCare Rx (HMO) Drug List. The Drug List aso tes you if there are any rues that restrict coverage for your drugs. We wi send you a copy of the Drug List. The Drug List we send to you incudes information for the covered drugs that are most commony used by our members. However, we cover additiona drugs that are not incuded in the printed Drug List. If one of your drugs is not isted in the Drug List, you shoud visit our website or contact Customer Service to find out if we cover it. To get the most compete and current information about which drugs are covered, you can visit the pan s website ( or ca Customer Service (phone numbers are printed on the back cover of this booket). Section 3.5 The Part D Expanation of Benefits (the "Part D EOB"): Reports with a summary of payments made for your Part D prescription drugs When you use your Part D prescription drug benefits, we wi send you a summary report to hep you understand and keep track of payments for your Part D prescription drugs. This summary report is caed the Part D Expanation of Benefits (or the "Part D EOB"). The Part D Expanation of Benefits tes you the tota amount you, or others on your behaf, have spent on your Part D prescription drugs and the tota amount we have paid for each of your Part D prescription drugs during the month. Chapter 6 (What you pay for your Part D prescription drugs) gives more information about the Part D Expanation of Benefits and how it can hep you keep track of your drug coverage.

18 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 1: Getting started as a member 16 A Part D Expanation of Benefits summary is aso avaiabe upon request. To get a copy, pease contact Customer Service (phone numbers are printed on the back cover of this booket). SECTION 4 Section 4.1 Your monthy premium for WeCare Rx (HMO) How much is your pan premium? As a member of our pan, you pay a monthy pan premium. For 2015, the monthy premium for WeCare Rx (HMO) is $ In addition, you must continue to pay your Medicare Part B premium (uness your Part B premium is paid for you by Medicaid or another third party). In some situations, your pan premium coud be ess There are programs to hep peope with imited resources pay for their drugs. These incude Extra Hep and State Pharmaceutica Assistance Programs. Chapter 2, Section 7 tes more about these programs. If you quaify, enroing in these programs might ower your monthy pan premium. If you are aready enroed and getting hep from one of these programs, the information about premiums in this Evidence of Coverage may not appy to you. We have incuded a separate insert, caed the Evidence of Coverage Rider for Peope Who Get Extra Hep Paying for Prescription Drugs (aso known as the Low Income Subsidy Rider or the LIS Rider ), which tes you about your drug coverage. If you don t have this insert, pease ca Customer Service and ask for the LIS Rider. (Phone numbers for Customer Service are printed on the back cover of this booket.) In some situations, your pan premium coud be more In some situations, your pan premium coud be more than the amount isted above in Section 4.1. These situations are described beow. Some members are required to pay a ate enroment penaty because they did not join a Medicare drug pan when they first became eigibe or because they had a continuous period of 63 days or more when they didn t have creditabe prescription drug coverage. ( Creditabe means the drug coverage is expected to pay, on average, at east as much as Medicare s standard prescription drug coverage.) For these members, the ate enroment penaty is added to the pan s monthy premium. Their premium amount wi be the monthy pan premium pus the amount of their ate enroment penaty.

19 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 1: Getting started as a member 17 If you are required to pay the ate enroment penaty, the amount of your penaty depends on how ong you waited before you enroed in drug coverage or how many months you were without drug coverage after you became eigibe. Chapter 6, Section 9 expains the ate enroment penaty. If you have a ate enroment penaty and do not pay it, you coud be disenroed from the pan. Many members are required to pay other Medicare premiums In addition to paying the monthy pan premium, many members are required to pay other Medicare premiums. As expained in Section 2 above, in order to be eigibe for our pan, you must be entited to Medicare Part A and enroed in Medicare Part B. For that reason, some pan members (those who aren't eigibe for premium-free Part A) pay a premium for Medicare Part A. And most pan members pay a premium for Medicare Part B. You must continue paying your Medicare premiums to remain a member of the pan. Some peope pay an extra amount for Part D because of their yeary income. This is known as Income Reated Monthy Adjustment Amounts, aso known as IRMAA. If your income is $85,000 or above for an individua (or married individuas fiing separatey) or $170,000 or above for married coupes, you must pay an extra amount directy to the government (not the Medicare pan) for your Medicare Part D coverage. If you are required to pay the extra amount and you do not pay it, you wi be disenroed from the pan and ose prescription drug coverage. If you have to pay an extra amount, Socia Security, not your Medicare pan, wi send you a etter teing you what that extra amount wi be. For more information about Part D premiums based on income, go to Chapter 6, Section 10 of this booket. You can aso visit on the web or ca MEDICARE ( ), 24 hours a day, 7 days a week. TTY users shoud ca Or you may ca Socia Security at TTY users shoud ca Your copy of Medicare & You 2015 gives information about the Medicare premiums in the section caed 2015 Medicare Costs. This expains how the Medicare Part B and Part D premiums differ for peope with different incomes. Everyone with Medicare receives a copy of Medicare & You each year in the fa. Those new to Medicare

20 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 1: Getting started as a member 18 receive it within a month after first signing up. You can aso downoad a copy of Medicare & You 2015 from the Medicare website ( Or, you can order a printed copy by phone at MEDICARE ( ), 24 hours a day, 7 days a week. TTY users, ca Section 4.2 There are severa ways you can pay your pan premium There are five ways you can pay your pan premium. The premium payment options were isted on the enroment appication, and you chose a method of payment when you enroed. You may change the premium payment option you chose during the year by caing Customer Service and submitting the required form. If you decide to change the way you pay your premium, it can take up to three months for your new payment method to take effect. Whie we are processing your request for a new payment method, you are responsibe for making sure that your pan premium is paid on time. Option 1: You can pay by check You may decide to pay your monthy pan premium directy to our Pan with a check or money order. Premium coupons wi be maied after confirmation of enroment. You may request repacement coupons by caing Customer Service. Payments are due by the 28th of each month for coverage of the current month. Checks must be made payabe to WeCare. Be sure to incude your biing payment coupon with your check to ensure the appropriate credit is appied to your account and send to the foowing address, which is aso isted in our payment coupons: WeCare, P.O. Box 78230, Phoenix, AZ Any checks made payabe to another entity (e.g., U.S. Department of Heath and Human Services (HHS) or the Centers for Medicare & Medicaid Services (CMS)) wi be returned to you. The pan reserves the right to charge a $30 administrative fee associated with checks returned for non-sufficient funds (NSF). This fee does not incude any additiona fees that may be appied by your bank. Option 2: You can pay onine by using our website with a credit card or your checking or savings bank information Instead of maiing a check each month, you can have your monthy pan premium deducted from your checking or savings account or even charged directy to your credit card. These payments can be a one-time ony payment or set up as a repeating monthy deduction. To make your payment onine: 1. Visit our website at

21 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 1: Getting started as a member Seect Member Login and enter your user id and password. If you don t have a user id or password, cick on Register to create one. 3. Once on the member porta, foow the instructions to set up your payment onine. Option 3: You can have Automatic Withdrawas or Eectronic Funds Transfer (EFT) Instead of paying by check, you may have your monthy pan premium automaticay withdrawn from your checking or savings account. Automatic withdrawas occur monthy and wi be deducted between the 24th and 28th of each month for the current month. You may access the form on our website at or ca our Customer Service department at the number printed on the back cover of this booket to request an EFT form. If you woud ike to have your monthy pan premiums deducted from your bank account instead of receiving a bi each month, pease foow the instructions on the form and compete and return the form to us. Once we receive your paperwork, the process may take up to two months to take effect. You shoud keep paying your monthy bi unti notified by mai of the actua month that EFT withdrawas wi start. There wi be a $30 administrative fee associated with EFT withdrawas returned for non-sufficient funds (NSF). This fee does not incude any additiona fees that may be appied by your bank. Option 4: You can have the monthy pan premium taken out of your monthy Rairoad Retirement Board check You can have the monthy pan premium taken out of your monthy Rairoad Retirement Board check. Contact Customer Service for more information on how to pay your monthy pan premium this way. We wi be happy to set this up. (Phone numbers for Customer Service are printed on the back cover of this booket.) Option 5: You can have the monthy pan premium taken out of your monthy Socia Security check You can have the monthy pan premium taken out of your monthy Socia Security check. Contact Customer Service for more information on how to pay your monthy pan premium this way. We wi be happy to hep you set this up. (Phone numbers for Customer Service are printed on the back cover of this booket.) What to do if you are having troube paying your monthy pan premium Your monthy pan premium must be received in our office by the 28 th day.

22 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 1: Getting started as a member 20 If you are having troube paying your monthy pan premium on time, pease contact Customer Service to see if we can direct you to programs that wi hep with your monthy pan premium. (Phone numbers for Customer Service are printed on the back cover of this booket.) Section 4.3 Can we change your monthy pan premium during the year? No. We are not aowed to change the amount we charge for the pan s monthy pan premium during the year. If the monthy pan premium changes for next year we wi te you in September and the change wi take effect on January 1. However, in some cases the part of the premium that you have to pay can change during the year. This happens if you become eigibe for the Extra Hep program or if you ose your eigibiity for the Extra Hep program during the year. If a member quaifies for Extra Hep with their prescription drug costs, the Extra Hep program wi pay part of the member s monthy pan premium. So a member who becomes eigibe for Extra Hep during the year woud begin to pay ess toward their monthy premium. And a member who oses their eigibiity during the year wi need to start paying their fu monthy premium. You can find out more about the Extra Hep program in Chapter 2, Section 7. SECTION 5 Section 5.1 Pease keep your pan membership record up to date How to hep make sure that we have accurate information about you Your membership record has information from your enroment form, incuding your address and teephone number. It shows your specific pan coverage incuding your Primary Care Provider or IPA. The doctors, hospitas, pharmacists, and other providers in the pan s network need to have correct information about you. These network providers use your membership record to know what services and drugs are covered and the cost-sharing amounts for you. Because of this, it is very important that you hep us keep your information up to date. Let us know about these changes: Changes to your name, your address, or your phone number Changes in any other heath insurance coverage you have (such as from your empoyer, your spouse s empoyer, workers compensation, or Medicaid) If you have any iabiity caims, such as caims from an automobie accident

23 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 1: Getting started as a member 21 If you have been admitted to a nursing home If you receive care in an out-of-area or out-of-network hospita or emergency room If your designated responsibe party (such as a caregiver) changes If you are participating in a cinica research study If any of this information changes, pease et us know by caing Customer Service (phone numbers are printed on the back cover of this booket). It is aso important to contact Socia Security if you move or change your maiing address. You can find phone numbers and contact information for Socia Security in Chapter 2, Section 5. Read over the information we send you about any other insurance coverage you have Medicare requires that we coect information from you about any other medica or drug insurance coverage that you have. That s because we must coordinate any other coverage you have with your benefits under our pan. (For more information about how our coverage works when you have other insurance, see Section 7 in this chapter.) Once each year, we wi send you a etter that ists any other medica or drug insurance coverage that we know about. Pease read over this information carefuy. If it is correct, you don t need to do anything. If the information is incorrect, or if you have other coverage that is not isted, pease ca Customer Service (phone numbers are printed on the back cover of this booket). In some cases, we may need to ca you to verify the information we have on fie. SECTION 6 Section 6.1 We protect the privacy of your persona heath information We make sure that your heath information is protected Federa and state aws protect the privacy of your medica records and persona heath information. We protect your persona heath information as required by these aws. For more information about how we protect your persona heath information, pease go to Chapter 8, Section 1.4 of this booket. SECTION 7 How other insurance works with our pan

24 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 1: Getting started as a member 22 Section 7.1 Which pan pays first when you have other insurance? When you have other insurance (ike empoyer group heath coverage), there are rues set by Medicare that decide whether our pan or your other insurance pays first. The insurance that pays first is caed the primary payer and pays up to the imits of its coverage. The one that pays second, caed the secondary payer, ony pays if there are costs eft uncovered by the primary coverage. The secondary payer may not pay a of the uncovered costs. These rues appy for empoyer or union group heath pan coverage: If you have retiree coverage, Medicare pays first. If your group heath pan coverage is based on your or a famiy member s current empoyment, who pays first depends on your age, the number of peope empoyed by your empoyer, and whether you have Medicare based on age, disabiity, or End-Stage Rena Disease (ESRD): If you re under 65 and disabed and you or your famiy member is sti working, your pan pays first if the empoyer has 100 or more empoyees or at east one empoyer in a mutipe empoyer pan has more than 100 empoyees. If you re over 65 and you or your spouse is sti working, the pan pays first if the empoyer has 20 or more empoyees or at east one empoyer in a mutipe empoyer pan has more than 20 empoyees. If you have Medicare because of ESRD, your group heath pan wi pay first for the first 30 months after you become eigibe for Medicare. These types of coverage usuay pay first for services reated to each type: No-faut insurance (incuding automobie insurance) Liabiity (incuding automobie insurance) Back ung benefits Workers compensation Medicaid and TRICARE never pay first for Medicare-covered services. They ony pay after Medicare, empoyer group heath pans, and/or Medigap have paid. If you have other insurance, te your doctor, hospita, and pharmacy. If you have questions about who pays first, or you need to update your other insurance information, ca Customer Service (phone numbers are printed on the back cover of

25 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 1: Getting started as a member 23 this booket.) You may need to give your pan member ID number to your other insurers (once you have confirmed their identity) so your bis are paid correcty and on time.

26 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 2: Important phone numbers and resources 24 Chapter 2. Important phone numbers and resources SECTION 1 WeCare Rx (HMO) contacts (how to contact us, incuding how to reach Customer Service at the pan) SECTION 2 Medicare (how to get hep and information directy from the Federa Medicare program) SECTION 3 State Heath Insurance Assistance Program (free hep, information, and answers to your questions about Medicare) SECTION 4 Quaity Improvement Organization (paid by Medicare to check on the quaity of care for peope with Medicare) SECTION 5 Socia Security SECTION 6 Medicaid (a joint Federa and state program that heps with medica costs for some peope with imited income and resources) SECTION 7 Information about programs to hep peope pay for their prescription drugs SECTION 8 How to contact the Rairoad Retirement Board SECTION 9 Do you have group insurance or other heath insurance from an empoyer?... 45

27 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 2: Important phone numbers and resources 25 SECTION 1 WeCare Rx (HMO) contacts (how to contact us, incuding how to reach Customer Service at the pan) How to contact our pan s Customer Service For assistance with caims, biing or member card questions, pease ca or write to WeCare Rx (HMO) Customer Service. We wi be happy to hep you. Method Customer Service - Contact Information CALL Cas to this number are free. Monday Friday, 8 a.m. to 8 p.m. Between October 1 and February 14, representatives are avaiabe Monday Sunday, 8 a.m. to 8 p.m. Customer Service aso has free anguage interpreter services avaiabe for non-engish speakers. TTY This number requires specia teephone equipment and is ony for peope who have difficuties with hearing or speaking. Cas to this number are free. Monday Friday, 8 a.m. to 8 p.m. Between October 1 and February 14, representatives are avaiabe Monday Sunday, 8 a.m. to 8 p.m. FAX WRITE Customer Service, P.O. Box Tampa, FL WEBSITE

28 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 2: Important phone numbers and resources 26 How to contact us when you are asking for a coverage decision about your medica care A coverage decision is a decision we make about your benefits and coverage or about the amount we wi pay for your medica services. For more information on asking for coverage decisions about your medica care, see Chapter 9 (What to do if you have a probem or compaint (coverage decisions, appeas, compaints)). You may ca us if you have questions about our coverage decision process. Method Coverage Decisions for Medica Care - Contact Information CALL Cas to this number are free. Monday Friday, 8 a.m. to 8 p.m. Between October 1 and February 14, representatives are avaiabe Monday Sunday, 8 a.m. to 8 p.m. TTY This number requires specia teephone equipment and is ony for peope who have difficuties with hearing or speaking. Cas to this number are free. Monday Friday, 8 a.m. to 8 p.m. Between October 1 and February 14, representatives are avaiabe Monday Sunday, 8 a.m. to 8 p.m. FAX WRITE WeCare Heath Pans Coverage Determinations Department - Medica P.O. Box Tampa, FL 33631

29 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 2: Important phone numbers and resources 27 How to contact us when you are making an appea about your medica care An appea is a forma way of asking us to review and change a coverage decision we have made. For more information on making an appea about your medica care, see Chapter 9 (What to do if you have a probem or compaint (coverage decisions, appeas, compaints)). Method Appeas for Medica Care - Contact Information CALL Cas to this number are free. Monday Friday, 8 a.m. to 8 p.m. Between October 1 and February 14, representatives are avaiabe Monday Sunday, 8 a.m. to 8 p.m. TTY This number requires specia teephone equipment and is ony for peope who have difficuties with hearing or speaking. Cas to this number are free. Monday Friday, 8 a.m. to 8 p.m. Between October 1 and February 14, representatives are avaiabe Monday Sunday, 8 a.m. to 8 p.m. FAX WRITE WeCare Heath Pans Appeas Department - Medica P.O. Box Tampa, FL

30 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 2: Important phone numbers and resources 28 How to contact us when you are making a compaint about your medica care You can make a compaint about us or one of our network providers, incuding a compaint about the quaity of your care. This type of compaint does not invove coverage or payment disputes. (If your probem is about the pan s coverage or payment, you shoud ook at the section above about making an appea.) For more information on making a compaint about your medica care, see Chapter 9 (What to do if you have a probem or compaint (coverage decisions, appeas, compaints)). Method Compaints about Medica Care - Contact Information CALL Cas to this number are free. Monday Friday, 8 a.m. to 8 p.m. Between October 1 and February 14, representatives are avaiabe Monday Sunday, 8 a.m. to 8 p.m. TTY This number requires specia teephone equipment and is ony for peope who have difficuties with hearing or speaking. Cas to this number are free. Monday Friday, 8 a.m. to 8 p.m. Between October 1 and February 14, representatives are avaiabe Monday Sunday, 8 a.m. to 8 p.m. FAX WRITE MEDICARE WEBSITE WeCare Heath Pans Grievance Department P.O. Box Tampa, FL You can submit a compaint about our pan directy to Medicare. To submit an onine compaint to Medicare, go to

31 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 2: Important phone numbers and resources 29 How to contact us when you are asking for a coverage decision about your Part D prescription drugs A coverage decision is a decision we make about your benefits and coverage or about the amount we wi pay for your Part D prescription drugs. For more information on asking for coverage decisions about your Part D prescription drugs, see Chapter 9 (What to do if you have a probem or compaint (coverage decisions, appeas, compaints)). Method Coverage Decisions for Part D Prescription Drugs - Contact Information CALL Cas to this number are free. Monday Friday, 8 a.m. to 8 p.m. Between October 1 and February 14, representatives are avaiabe Monday Sunday, 8 a.m. to 8 p.m. TTY This number requires specia teephone equipment and is ony for peope who have difficuties with hearing or speaking. Cas to this number are free. Monday Friday, 8 a.m. to 8 p.m. Between October 1 and February 14, representatives are avaiabe Monday Sunday, 8 a.m. to 8 p.m. FAX WRITE WeCare Heath Pans Pharmacy - Coverage Determinations P.O. Box Tampa, FL WEBSITE Overnight address: WeCare Heath Pans Pharmacy - Coverage Determinations 8735 Henderson Road, Ren 4 Tampa, FL

32 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 2: Important phone numbers and resources 30 How to contact us when you are making an appea about your Part D prescription drugs An appea is a forma way of asking us to review and change a coverage decision we have made. For more information on making an appea about your Part D prescription drugs, see Chapter 9 (What to do if you have a probem or compaint (coverage decisions, appeas, compaints)). Method Appeas for Part D Prescription Drugs - Contact Information CALL Cas to this number are free. Monday Friday, 8 a.m. to 8 p.m. Between October 1 and February 14, representatives are avaiabe Monday Sunday, 8 a.m. to 8 p.m. TTY This number requires specia teephone equipment and is ony for peope who have difficuties with hearing or speaking. Cas to this number are free. Monday Friday, 8 a.m. to 8 p.m. Between October 1 and February 14, representatives are avaiabe Monday Sunday, 8 a.m. to 8 p.m. FAX WRITE WeCare Prescription Insurance, Inc. Attn: Part D Appeas P.O. Box Tampa, FL WEBSITE Overnight address: WeCare Prescription Insurance, Inc. Attn: Part D Appeas 8735 Henderson Road, Ren 4 Tampa, FL

33 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 2: Important phone numbers and resources 31 How to contact us when you are making a compaint about your Part D prescription drugs You can make a compaint about us or one of our network pharmacies, incuding a compaint about the quaity of your care. This type of compaint does not invove coverage or payment disputes. (If your probem is about the pan s coverage or payment, you shoud ook at the section above about making an appea.) For more information on making a compaint about your Part D prescription drugs, see Chapter 9 (What to do if you have a probem or compaint (coverage decisions, appeas, compaints)). Method Compaints about Part D Prescription Drugs - Contact Information CALL Cas to this number are free. Monday Friday, 8 a.m. to 8 p.m. Between October 1 and February 14, representatives are avaiabe Monday Sunday, 8 a.m. to 8 p.m. TTY This number requires specia teephone equipment and is ony for peope who have difficuties with hearing or speaking. Cas to this number are free. Monday Friday, 8 a.m. to 8 p.m. Between October 1 and February 14, representatives are avaiabe Monday Sunday, 8 a.m. to 8 p.m. FAX WRITE MEDICARE WEBSITE WeCare Heath Pans Grievance Department P.O. Box Tampa, FL You can submit a compaint about our pan directy to Medicare. To submit an onine compaint to Medicare, go to

34 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 2: Important phone numbers and resources 32 Where to send a request asking us to pay for our share of the cost for medica care or a drug you have received For more information on situations in which you may need to ask us for reimbursement or to pay a bi you have received from a provider, see Chapter 7 (Asking us to pay our share of a bi you have received for covered medica services or drugs). Pease note: If you send us a payment request and we deny any part of your request, you can appea our decision. See Chapter 9 (What to do if you have a probem or compaint (coverage decisions, appeas, compaints) for more information. Method Payment Requests - Contact Information CALL Monday Friday, 8 a.m. to 8 p.m. Between October 1 and February 14, representatives are avaiabe Monday Sunday, 8 a.m. to 8 p.m. Cas to this number are free. TTY This number requires specia teephone equipment and is ony for peope who have difficuties with hearing or speaking. Cas to this number are free. WRITE WEBSITE Monday Friday, 8 a.m. to 8 p.m. Between October 1 and February 14, representatives are avaiabe Monday Sunday, 8 a.m. to 8 p.m. WeCare Heath Pans Pharmacy - Prescription Reimbursement Department P.O. Box Tampa, FL, WeCare Heath Pans Medica Reimbursement Department P.O. Box Tampa, FL

35 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 2: Important phone numbers and resources 33 SECTION 2 Medicare (how to get hep and information directy from the federa Medicare program) Medicare is the federa heath insurance program for peope 65 years of age or oder, some peope under age 65 with disabiities, and peope with End-Stage Rena Disease (permanent kidney faiure requiring diaysis or a kidney transpant). The federa agency in charge of Medicare is the Centers for Medicare & Medicaid Services (sometimes caed CMS ). This agency contracts with Medicare Advantage organizations incuding us. Method Medicare - Contact Information CALL MEDICARE, or Cas to this number are free. 24 hours a day, 7 days a week. TTY This number requires specia teephone equipment and is ony for peope who have difficuties with hearing or speaking. Cas to this number are free.

36 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 2: Important phone numbers and resources 34 WEBSITE This is the officia government website for Medicare. It gives you up-to-date information about Medicare and current Medicare issues. It aso has information about hospitas, nursing homes, physicians, home heath agencies, and diaysis faciities. It incudes bookets you can print directy from your computer. You can aso find Medicare contacts in your state. The Medicare website aso has detaied information about your Medicare eigibiity and enroment options with the foowing toos: Medicare Eigibiity Too: Provides Medicare eigibiity status information. Medicare Pan Finder: Provides personaized information about avaiabe Medicare prescription drug pans, Medicare heath pans, and Medigap (Medicare Suppement Insurance) poicies in your area. These toos provide an estimate of what your out-of-pocket costs might be in different Medicare pans. You can aso use the website to te Medicare about any compaints you have about our pan: Te Medicare about your compaint: You can submit a compaint about our pan directy to Medicare. To submit a compaint to Medicare, go to Medicare takes your compaints seriousy and wi use this information to hep improve the quaity of the Medicare program. If you don t have a computer, your oca ibrary or senior center may be abe to hep you visit this website using its computer. Or, you can ca Medicare and te them what information you are ooking for. They wi find the information on the website, print it out, and send it to you. (You can ca Medicare at MEDICARE ( ), 24 hours a day, 7 days a week. TTY users shoud ca )

37 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 2: Important phone numbers and resources 35 SECTION 3 State Heath Insurance Assistance Program (free hep, information, and answers to your questions about Medicare) The State Heath Insurance Assistance Program (SHIP) is a government program with trained counseors in every state. In New York, the SHIP is caed Heath Insurance Information Counseing and Assistance Program (HIICAP). Heath Insurance Information Counseing and Assistance Program (HIICAP) is independent (not connected with any insurance company or heath pan). It is a state program that gets money from the federa government to give free oca heath insurance counseing to peope with Medicare. Heath Insurance Information Counseing and Assistance Program (HIICAP) counseors can hep you with your Medicare questions or probems. They can hep you understand your Medicare rights, hep you make compaints about your medica care or treatment, and hep you straighten out probems with your Medicare bis. Heath Insurance Information Counseing and Assistance Program (HIICAP) counseors can aso hep you understand your Medicare pan choices and answer questions about switching pans. Method Heath Insurance Information Counseing and Assistance Program (HIICAP) (New York SHIP) - Contact Information CALL TTY 711 WRITE WEBSITE This number requires specia teephone equipment and is ony for peope who have difficuties with hearing or speaking. 2 Empire State Paza, Agency Bdg. #2, 4th Foor Abany, NY

38 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 2: Important phone numbers and resources 36 SECTION 4 Quaity Improvement Organization (paid by Medicare to check on the quaity of care for peope with Medicare) There is a Quaity Improvement Organization for each state. For New York, the Quaity Improvement Organization is caed Livanta. Livanta has a group of doctors and other heath care professionas who are paid by the Federa government. This organization is paid by Medicare to check on and hep improve the quaity of care for peope with Medicare. Livanta is an independent organization. It is not connected with our pan. You shoud contact Livanta in any of these situations: You have a compaint about the quaity of care you have received. You think coverage for your hospita stay is ending too soon. You think coverage for your home heath care, skied nursing faciity care, or Comprehensive Outpatient Rehabiitation Faciity (CORF) services are ending too soon. Method Livanta (New York's Quaity Improvement Organization) Contact Information CALL TTY This number requires specia teephone equipment and is ony for peope who have difficuties with hearing or speaking. WRITE BFCC-QIO Program 9090 Junction Drive, Suite 10 Annapois Junction, MD WEBSITE

39 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 2: Important phone numbers and resources 37 SECTION 5 Socia Security Socia Security is responsibe for determining eigibiity and handing enroment for Medicare. U.S. citizens who are 65 or oder, or who have a disabiity or End-Stage Rena Disease and meet certain conditions, are eigibe for Medicare. If you are aready getting Socia Security checks, enroment into Medicare is automatic. If you are not getting Socia Security checks, you have to enro in Medicare. Socia Security handes the enroment process for Medicare. To appy for Medicare, you can ca Socia Security or visit your oca Socia Security office. Socia Security is aso responsibe for determining who has to pay an extra amount for their Part D drug coverage because they have a higher income. If you got a etter from Socia Security teing you that you have to pay the extra amount and have questions about the amount or if your income went down because of a ife-changing event, you can ca Socia Security to ask for a reconsideration. If you move or change your maiing address, it is important that you contact Socia Security to et them know. Method Socia Security - Contact Information CALL Cas to this number are free. Avaiabe 7:00am to 7:00pm, Monday through Friday. You can use Socia Security's automated teephone services to get recorded information and conduct some business 24 hours a day. TTY This number requires specia teephone equipment and is ony for peope who have difficuties with hearing or speaking. Cas to this number are free. WEBSITE Avaiabe 7:00am to 7:00pm, Monday through Friday.

40 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 2: Important phone numbers and resources 38 SECTION 6 Medicaid (a joint federa and state program that heps with medica costs for some peope with imited income and resources) Medicaid is a joint federa and state government program that heps with medica costs for certain peope with imited incomes and resources. Some peope with Medicare are aso eigibe for Medicaid. In addition, there are programs offered through Medicaid that hep peope with Medicare pay their Medicare costs, such as their Medicare premiums. These "Medicare Savings Programs" hep peope with imited income and resources save money each year: Quaified Medicare Beneficiary (QMB): Heps pay Medicare Part A and Part B premiums, and other cost-sharing (ike deductibes, coinsurance, and co-payments). (Some peope with QMB are aso eigibe for fu Medicaid benefits (QMB+).) Specified Low-Income Medicare Beneficiary (SLMB): Heps pay Part B premiums. (Some peope with SLMB are aso eigibe for fu Medicaid benefits (SLMB+).) Quaified Individua (QI): Heps pay Part B premiums. Quaified Disabed & Working Individuas (QDWI): Heps pay Part A premiums. To find out more about Medicaid and its programs, contact New York State Department of Heath. Method New York State Department of Heath - Contact Information CALL TTY WRITE WEBSITE This number requires specia teephone equipment and is ony for peope who have difficuties with hearing or speaking. New York State Department of Heath, Corning Tower, Empire State Paza Abany, NY

41 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 2: Important phone numbers and resources 39 SECTION 7 Information about programs to hep peope pay for their prescription drugs Medicare s Extra Hep Program Medicare provides Extra Hep to pay prescription drug costs for peope who have imited income and resources. Resources incude your savings and stocks, but not your home or car. If you quaify, you get hep paying for any Medicare drug pan s monthy premium and prescription co-payments. This Extra Hep aso counts toward your out-of-pocket costs. Peope with imited income and resources may quaify for Extra Hep. Some peope automaticay quaify for "Extra Hep" and don t need to appy. Medicare mais a etter to peope who automaticay quaify for "Extra Hep". You may be abe to get Extra Hep to pay for your prescription drug premiums and costs. To see if you quaify for getting "Extra Hep", ca: MEDICARE ( ). TTY users shoud ca , 24 hours a day, 7 days a week; The Socia Security Office at , between 7 am to 7 pm, Monday through Friday. TTY users shoud ca ; or Your State Medicaid Office (appications). (See Section 6 of this chapter for contact information) If you beieve you have quaified for Extra Hep and you beieve that you are paying an incorrect cost-sharing amount when you get your prescription at a pharmacy, our pan has estabished a process that aows you to either request assistance in obtaining evidence of your proper co-payment eve, or, if you aready have the evidence, to provide this evidence to us. Your Best Avaiabe Evidence (BAE) is a document that shows you quaify for Extra Hep with your prescription drug costs. Documents you can use as Best Avaiabe Evidence are isted beow. Pease fax or mai a copy of one or more of these documents to WeCare. Medicaid card that incudes name and eigibiity date during a month after June of the previous caendar year Copy of a state document that confirms active Medicaid status during a month after June of the previous caendar year Socia Security Administration (SSA) award etter to determine eigibiity for fu or partia subsidy

42 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 2: Important phone numbers and resources 40 A print out from the State eectronic enroment fie showing Medicaid status during a month after June of the previous caendar year Screen print from your state s Medicaid systems showing Medicaid status during a month after June of the previous caendar year Other documentation provided by your state showing Medicaid status during a month after June of the previous caendar year State document that confirms Medicaid payment on behaf of the individua to the faciity for a fu caendar month after June of the previous caendar year Screen print from the State s Medicaid systems showing that individua s institutiona status based on at east a fu caendar month stay for Medicaid payment purposes during a month after June of the previous caendar year. A remittance from the faciity showing Medicaid payment for a fu caendar month during a month after June of the previous caendar year A etter from Socia Security showing that you receive SSI An appication fied by deemed eigibe confirming "...automaticay eigibe for Extra Hep..." A State-issued Notice of Action, Notice of Determination, or Notice of Enroment that incudes the beneficiary s name and HCBS (Home and Community Based Services) eigibiity date during a month after June of the previous caendar year A State-approved HCBS Service Pan that incudes the beneficiary s name and effective date beginning during a month after June of the previous caendar year A State-issued prior authorization approva etter for HCBS that incudes the beneficiary s name and effective date beginning during a month after June of the previous caendar year Other documentation provided by the State showing HCBS eigibiity status during a month after June of the previous caendar year; or, A state-issued document, such as a remittance advice, confirming payment for HCBS, incuding the beneficiary s name and the dates of HCBS. Urgent BAE Fax to: (Attn: BAE) OR (CCP) Mai to: WeCare Heath Pans Attn: LISOVR P.O. Box 31392

43 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 2: Important phone numbers and resources 41 Tampa, FL Non Urgent BAE Fax to: OR (CCP) Mai to: WeCare Heath Pans Attn: LISOVR P.O. Box Tampa, FL You can aso get more information about how to submit this evidence on our website at If you have difficuty obtaining any document isted above, contact Customer Service. When we receive the evidence showing your co-payment eve, we wi update our system so that you can pay the correct co-payment when you get your next prescription at the pharmacy. If you overpay your co-payment, we wi reimburse you. Either we wi forward a check to you in the amount of your overpayment or we wi offset future co-payments. If the pharmacy hasn t coected a co-payment from you and is carrying your co-payment as a debt owed by you, we may make the payment directy to the pharmacy. If a state paid on your behaf, we may make payment directy to the state. Pease contact Customer Service if you have questions (phone numbers are printed on the back cover of this booket). Medicare Coverage Gap Discount Program The Medicare Coverage Gap Discount Program provides manufacturer discounts on brand name drugs to Part D enroees who have reached the coverage gap and are not aready receiving Extra Hep. A 50% discount on the negotiated price (excuding the dispensing fee and vaccine administration fee, if any) is avaiabe for those brand name drugs from manufacturers that have agreed to pay the discount. The pan pays an additiona 5% and you pay the remaining 45% for your brand drugs. If you reach the coverage gap, we wi automaticay appy the discount when your pharmacy bis you for your prescription and your Part D Expanation of Benefits (Part D EOB) wi show any discount provided. Both the amount you pay and the amount discounted by the manufacturer count toward your out-of-pocket costs as if you had paid them and moves you through the coverage gap. The amount paid by the pan (5%) does not count toward your out-of-pocket costs. You aso receive some coverage for generic drugs. If you reach the coverage gap, the pan pays 35% of the price for generic drugs and you pay the remaining 65% of the price. For generic drugs, the amount paid by the pan (35%) does not count toward

44 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 2: Important phone numbers and resources 42 your out-of-pocket costs. Ony the amount you pay counts and moves you through the coverage gap. Aso, the dispensing fee is incuded as part of the cost of the drug. If you have any questions about the avaiabiity of discounts for the drugs you are taking or about the Medicare Coverage Gap Discount Program in genera, pease contact Customer Service (phone numbers are printed on the back cover of this booket). What if you have coverage from a State Pharmaceutica Assistance Program (SPAP) If you are enroed in a State Pharmaceutica Assistance Program (SPAP), or any other program that provides coverage for Part D drugs (other than Extra Hep), you sti get the 50% discount on covered brand name drugs. Aso, the pan pays 5% of the cost of brand drugs in the coverage gap. The 50% discount and the 5% paid by the pan is appied to the price of the drug before any SPAP or other coverage. What if you have coverage from an AIDS Drug Assistance Program (ADAP)? What is the AIDS Drug Assistance Program (ADAP)? The AIDS Drug Assistance Program (ADAP) heps ADAP-eigibe individuas iving with HIV/AIDS have access to ife-saving HIV medications. Medicare Part D prescription drugs that are aso covered by ADAP quaify for prescription cost-sharing assistance. Note: To be eigibe for the ADAP operating in your State, individuas must meet certain criteria, incuding proof of State residence and HIV status, ow income as defined by the State, and uninsured/under-insured status. If you are currenty enroed in an ADAP, it can continue to provide you with Medicare Part D prescription cost-sharing assistance for drugs on the ADAP formuary. In order to be sure you continue receiving this assistance, pease notify your oca ADAP enroment worker of any changes in your Medicare Part D pan name or poicy number. New York HIV Uninsured Care Programs, Empire Station at (TTY users shoud ca ) For information on eigibiity criteria, covered drugs, or how to enro in the program, pease ca New York HIV Uninsured Care Programs, Empire Station at (TTY users shoud ca ) What if you get "Extra Hep" from Medicare to hep pay your prescription drug costs? Can you get the discounts? No. If you get "Extra Hep", you aready get coverage for your prescription drug costs during the coverage gap.

45 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 2: Important phone numbers and resources 43 What if you don t get a discount, and you think you shoud have? If you think that you have reached the coverage gap and did not get a discount when you paid for your brand name drug, you shoud review your next Part D Expanation of Benefits (Part D EOB) notice. If the discount doesn t appear on your Part D Expanation of Benefits, you shoud contact us to make sure that your prescription records are correct and up-to-date. If we don t agree that you are owed a discount, you can appea. You can get hep fiing an appea from your State Heath Insurance Assistance Program (SHIP) (teephone numbers are in Section 3 of this Chapter) or by caing MEDICARE ( ), 24 hours a day, 7 days a week. TTY users shoud ca State Pharmaceutica Assistance Programs Many states have State Pharmaceutica Assistance Programs that hep some peope pay for prescription drugs based on financia need, age or medica condition. Each state has different rues to provide drug coverage to its members. These programs provide imited income and medicay needy seniors and individuas with disabiities financia hep for prescription drugs. In New York, the State Pharmaceutica Assistance Program is New York Edery Pharmaceutica Insurance Coverage Program (EPIC). Method New York Edery Pharmaceutica Insurance Coverage Program (EPIC) - Contact Information CALL TTY This number requires specia teephone equipment and is ony for peope who have difficuties with hearing or speaking. WRITE P.O. Box Abany, NY WEBSITE

46 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 2: Important phone numbers and resources 44 SECTION 8 How to contact the Rairoad Retirement Board The Rairoad Retirement Board is an independent federa agency that administers comprehensive benefit programs for the nation s rairoad workers and their famiies. If you have questions regarding your benefits from the Rairoad Retirement Board, contact the agency. If you receive your Medicare through the Rairoad Retirement Board, it is important that you et them know if you move or change your maiing address. Method Rairoad Retirement Board - Contact Information CALL Cas to this number are free. Avaiabe 9:00am to 3:30pm, Monday through Friday. If you have a touch-tone teephone, recorded information and automated services are avaiabe 24 hours a day, incuding weekends and hoidays. TTY This number requires specia teephone equipment and is ony for peope who have difficuties with hearing or speaking. WEBSITE Cas to this number are not free.

47 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 2: Important phone numbers and resources 45 SECTION 9 Do you have "group insurance" or other heath insurance from an empoyer? If you (or your spouse) get benefits from your (or your spouse s) empoyer or retiree group as part of this pan, you may ca the empoyer/union benefits administrator or Customer Service if you have any questions. You can ask about your (or your spouse s) empoyer or retiree heath benefits, premiums, or the enroment period. (Phone numbers for Customer Service are printed on the back cover of this booket.) You may aso ca MEDICARE ( ; TTY: ) with questions reated to your Medicare coverage under this pan. If you have other prescription drug coverage through your (or your spouse s) empoyer or retiree group, pease contact that group s benefits administrator. The benefits administrator can hep you determine how your current prescription drug coverage wi work with our pan.

48 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 3: Using the pan's coverage for your medica services 46 Chapter 3. Using the pan s coverage for your medica services SECTION 1 Things to know about getting your medica care covered as a member of our pan Section 1.1 What are network providers and covered services? Section 1.2 Basic rues for getting your medica care covered by the pan SECTION 2 Use providers in the pan s network to get your medica care Section 2.1 You must choose a Primary Care Provider (PCP) to provide and oversee your medica care Section 2.2 What kinds of medica care can you get without getting approva in advance from your PCP? Section 2.3 How to get care from speciaists and other network providers Section 2.4 How to get care from out-of-network providers SECTION 3 How to get covered services when you have an emergency or urgent need for care Section 3.1 Getting care if you have a medica emergency Section 3.2 Getting care when you have an urgent need for care SECTION 4 What if you are bied directy for the fu cost of your covered services? Section 4.1 You can ask us to pay our share of the cost covered services Section 4.2 If services are not covered by our pan, you must pay the fu cost SECTION 5 How are your medica services covered when you are in a cinica research study? Section 5.1 What is a cinica research study? Section 5.2 When you participate in a cinica research study, who pays for what? SECTION 6 Rues for getting care covered in a reigious non-medica heath care institution... 59

49 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 3: Using the pan's coverage for your medica services 47 Section 6.1 What is a reigious non-medica heath care institution? Section 6.2 What care from a reigious non-medica heath care institution is covered by our pan? SECTION 7 Rues for ownership of durabe medica equipment Section 7.1 Wi you own your durabe medica equipment after making a certain number of payments under our pan?... 60

50 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 3: Using the pan's coverage for your medica services 48 SECTION 1 Things to know about getting your medica care covered as a member of our pan This chapter expains what you need to know about using the pan to get your medica care covered. It gives definitions of terms and expains the rues you wi need to foow to get the medica treatments, services, and other medica care that are covered by the pan. For the detais on what medica care is covered by our pan and how much you pay when you get this care, use the benefits chart in the next chapter, Chapter 4 (Medica Benefits Chart, what is covered and what you pay). Section 1.1 What are network providers and covered services? Here are some definitions that can hep you understand how you get the care and services that are covered for you as a member of our pan: Providers are doctors and other heath care professionas icensed by the state to provide medica services and care. The term providers aso incudes hospitas and other heath care faciities. Network providers are the doctors and other heath care professionas, medica groups, hospitas, and other heath care faciities that have an agreement with us to accept our payment and your cost-sharing amount as payment in fu. We have arranged for these providers to deiver covered services to members in our pan. The providers in our network generay bi us directy for care they give you. When you see a network provider, you usuay pay ony your share of the cost for their services. Covered services incude a the medica care, heath care services, suppies, and equipment that are covered by our pan. Your covered services for medica care are isted in the benefits chart in Chapter 4. Section 1.2 Basic rues for getting your medica care covered by the pan As a Medicare heath pan, our pan must cover a services covered by Origina Medicare and must foow Origina Medicare s coverage rues. Our pan wi generay cover your medica care as ong as: The care you receive is incuded in the pan s Medica Benefits Chart (this chart is in Chapter 4 of this booket).

51 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 3: Using the pan's coverage for your medica services 49 The care you receive is considered medicay necessary. Medicay necessary means that the services, suppies, or drugs are needed for the prevention, diagnosis, or treatment of your medica condition and meet accepted standards of medica practice. You have a network primary care provider (a PCP) who is providing and overseeing your care. As a member of our pan, you must choose a network PCP (for more information about this, see Section 2.1 in this chapter). In most situations, your network PCP must give you approva in advance before you can use other providers in the pan s network, such as speciaists, hospitas, skied nursing faciities, or home heath care agencies. This is caed giving you a referra. For more information about this, see Section 2.3 of this chapter. Referras from your PCP are not required for emergency care or urgenty needed care. There are aso some other kinds of care you can get without having approva in advance from your PCP (for more information about this, see Section 2.2 of this chapter). You must receive your care from a network provider (for more information about this, see Section 2 in this chapter). In most cases, care you receive from an out-of-network provider (a provider who is not part of our pan s network) wi not be covered. Here are three exceptions: The pan covers emergency care or urgenty needed care that you get from an out-of-network provider. For more information about this, and to see what emergency or urgenty needed care means, see Section 3 in this chapter. If you need medica care that Medicare requires our pan to cover and the providers in our network cannot provide this care, you can get this care from an out-of-network provider. Pease ca us to find out about the authorization rues that you may need to foow prior to seeking care. In this situation, you wi pay the same as you woud pay if you got the care from a network provider. For information about getting approva to see an out-of-network doctor, see Section 2.4 in this chapter. Kidney diaysis services that you get at a Medicare-certified diaysis faciity when you are temporariy outside the pan s service area. SECTION 2 Section 2.1 Use providers in the pan s network to get your medica care You must choose a Primary Care Provider (PCP) to provide and oversee your medica care

52 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 3: Using the pan's coverage for your medica services 50 What is a PCP and what does the PCP do for you? When you become a member of our pan, you must choose a pan provider to be your primary care provider (PCP). Your PCP is a heath care professiona who meets state requirements and is trained to give you basic medica care. The PCPs in our network incude famiy practitioners, internists, and genera practitioners. You wi usuay see your PCP first for most of your routine heath care needs. There are ony a few types of covered services you can get on your own without contacting your PCP first. Exampe: femae members may see their gynecoogist at any time without a referra from the PCP (for more information see Section 2.2 of this chapter). Your PCP wi provide most of your care and wi hep you arrange or coordinate the covered services you get as a member of our pan, incuding: X-rays Laboratory tests Physica, Occupationa and/or Speech Therapies Care from doctors who are speciaists Hospita admissions Menta or Behaviora Heath Services Foow-up care Coordinating your services incudes checking or consuting with other pan providers about your care and how it is going. If you need certain types of covered services or suppies, you must get approva in advance from your PCP (such as giving you a referra). In some cases, your PCP wi need to get prior authorization (prior approva) from us. Since your PCP wi provide and coordinate your medica care, you shoud have a of your past medica records sent to your PCP s office. How do you choose your PCP? As a member of our pan, you wi need to choose a PCP upon enroment. You can aso choose a PCP by caing Customer Service (See Chapter 2, Section 1 on how to contact Customer Service). If you do not see your current PCP in the directory, you may want to ca your current PCP to see if he/she woud recommend a PCP isted in the Provider & Pharmacy Directory suppied to you. Changing your PCP You may change your PCP for any reason, at any time. Aso, it s possibe that your PCP might eave our pan s network of providers and you woud have to find a new PCP.

53 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 3: Using the pan's coverage for your medica services 51 The effective date of your PCP change may vary, depending on the date you request the change (see exampe beow). Simpy ca Customer Service and we wi check to make sure the new doctor is accepting new patients. You shoud aso ask whether the new PCP has a referra reationship with any speciaists or other pan providers you see who are providing covered services that need a PCP s approva (such as home heath services and durabe medica equipment). Customer Service wi hep make sure that you can continue with the speciaty care and other services you have been getting when you change to a new PCP. Customer Service wi change your membership record to show the name of your new PCP and te you when the change to your new PCP wi take effect. They wi aso send you a new membership card that shows the name and phone number of your new PCP. Exampe: If your PCP request is made on or before January 10, 2015, the change can be made effective January 1, If your request is made on or after January 11, 2015, then the change wi become effective on February 1, The Case Management department, aong with the Customer Service department, wi assist a members with PCP changes. Section 2.2 What kinds of medica care can you get without getting approva in advance from your PCP? You can get services such as those isted beow without getting approva in advance from your PCP. Routine women s heath care, which incudes breast exams, screening mammograms (X-rays of the breast), Pap tests, and pevic exams, as ong as you get them from a network provider. Fu shots, Hepatitis B vaccinations and pneumonia vaccinations, as ong as you get them from a network provider. Emergency services from network providers or from out-of-network providers. Urgenty needed care from in-network providers or from out-of-network providers when network providers are temporariy unavaiabe or inaccessibe, e.g., when you are temporariy outside of the pan s service area. Kidney diaysis services that you get at a Medicare-certified diaysis faciity when you are temporariy outside the pan s service area. (If possibe, pease ca Customer Service before you eave the service area so we can hep arrange for you to have maintenance diaysis whie you are away. Phone numbers for Customer Service are printed on the back cover of this booket.)

54 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 3: Using the pan's coverage for your medica services 52 Medicare-covered preventive services. You wi see an appe next to these services in the benefits chart in Chapter 4 Section 2.1. Section 2.3 How to get care from speciaists and other network providers A speciaist is a doctor who provides heath care services for a specific disease or part of the body. There are many kinds of speciaists. Here are a few exampes: Oncoogists care for patients with cancer. Cardioogists care for patients with heart conditions. Orthopedists care for patients with certain bone, joint, or musce conditions. When your PCP thinks that you need speciaized treatment, he or she may give you a referra to see a pan speciaist. Once you have been referred to a specific pan speciaist, you do not need a new referra from your PCP to see the same pan speciaist again. For some types of services, your PCP or pan speciaist may need to get approva in advance from the pan (prior authorization). Prior authorization may be granted for a certain number of visits. When this happens, your PCP or speciaist may need to request approva from the pan again for more visits. See the benefits chart in Chapter 4 Section 2.1 to earn which services may need prior authorization. Each pan PCP may have certain pan providers which he/she refers patients. (This is caed a referra reationship.) If there is a specific pan provider you want to see (incuding a speciaist), find out whether your PCP refers patients to this provider. The name and office teephone number of your PCP is printed on your membership card. Keep in mind, if you want to see a pan provider that your PCP does not currenty refer to, te your PCP the name of the pan provider you want to see. You have the right to request referra to a different pan provider than the one seected by your PCP. What if a speciaist or another network provider eaves our pan? We may make changes to the hospitas, doctors, and speciaists (providers) that are part of your pan during the year. There are a number of reasons why your provider might eave your pan but if your doctor or speciaist does eave your pan you have certain rights and protections that are summarized beow: Even though our network of providers may change during the year, Medicare requires that we furnish you with uninterrupted access to quaified doctors and speciaists. When possibe we wi provide you with at east 30 days notice that your provider is eaving our pan so that you have time to seect a new provider.

55 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 3: Using the pan's coverage for your medica services 53 We wi assist you in seecting a new quaified provider to continue managing your heath care needs. If you are undergoing medica treatment you have the right to request, and we wi work with you to ensure, that the medicay necessary treatment you are receiving is not interrupted. If you beieve we have not furnished you with a quaified provider to repace your previous provider or that your care is not being appropriatey managed you have the right to fie an appea of our decision. If you find out your doctor or speciaist is eaving your pan pease contact us so we can assist you in finding a new provider and managing your care. You can ca Customer Service (phone numbers are printed on the back cover of this booket). Section 2.4 How to get care from out-of-network providers If you need medica care that Medicare requires our pan to cover and the providers in our network cannot provide this care, you can get this care from an out-of-network provider. In this situation, you wi pay the same as you woud pay if you got the care from a network provider. Before seeking care from an out-of-network provider, tak to your primary care provider (PCP). He or she wi notify us by requesting approva from the pan ("prior authorization"). If you get non-emergency care from out-of-network providers without prior authorization, you must pay the entire cost yoursef. Limited cases such as emergency care, urgenty needed care when our network is not avaiabe, or diaysis out of the service area, do not require prior authorization and are aways covered at the in-network benefit eve, even when you get them from out-of-network providers. SECTION 3 Section 3.1 How to get covered services when you have an emergency or urgent need for care Getting care if you have a medica emergency What is a medica emergency and what shoud you do if you have one? A medica emergency is when you, or any other prudent ayperson with an average knowedge of heath and medicine, beieve that you have medica symptoms that require immediate medica attention to prevent oss of ife, oss of a imb, or oss

56 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 3: Using the pan's coverage for your medica services 54 of function of a imb. The medica symptoms may be an iness, injury, severe pain, or a medica condition that is quicky getting worse. If you have a medica emergency: Get hep as quicky as possibe. Ca 911 for hep or go to the nearest emergency room or hospita. Ca for an ambuance if you need it. You do not need to get approva or a referra first from your PCP. As soon as possibe, make sure that our pan has been tod about your emergency. We need to foow up on your emergency care. You or someone ese shoud ca to te us about your emergency care, usuay within 48 hours. You can ca the number in the back of this booket or the number ocated on the back the of your membership card. What is covered if you have a medica emergency? You may get covered emergency medica care whenever you need it, anywhere in the United States or its territories. Our pan covers ambuance services in situations where getting to the emergency room in any other way coud endanger your heath. For more information, see the Medica Benefits Chart in Chapter 4 of this booket. In addition, our pan offers coverage for emergency medica care wordwide whenever you need it. For more information about this benefit, see Chapter 4. Medica Benefits Chart (what is covered and what you pay). If you have an emergency, we wi tak with the doctors who are giving you emergency care to hep manage and foow up on your care. The doctors who are giving you emergency care wi decide when your condition is stabe and the medica emergency is over. After the emergency is over you are entited to foow-up care to be sure your condition continues to be stabe. Your foow-up care wi be covered by our pan. If your emergency care is provided by out-of-network providers, we wi try to arrange for network providers to take over your care as soon as your medica condition and the circumstances aow. If we are unabe to arrange your care with a network provider, we wi cover your care unti your medica condition and circumstances aow transfer to a network provider or discharge. What if it wasn t a medica emergency? Sometimes it can be hard to know if you have a medica emergency. For exampe, you might go in for emergency care thinking that your heath is in serious danger and the doctor may say that it wasn t a medica emergency after a. If it turns out that it was not an emergency, as ong as you reasonaby thought your heath was in serious danger, we wi cover your care.

57 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 3: Using the pan's coverage for your medica services 55 However, after the doctor has said that it was not an emergency, we wi cover additiona care ony if you get the additiona care in one of these two ways: You go to a network provider to get the additiona care. - or - the additiona care you get is considered urgenty needed care and you foow the rues for getting this urgent care (for more information about this, see Section 3.2 beow). Section 3.2 Getting care when you have an urgent need for care What is urgenty needed care? Urgenty needed care is a non-emergency, unforeseen medica iness, injury, or condition, that requires immediate medica care. Urgenty needed care may be furnished by in-network providers or by out-of-network providers when network providers are temporariy unavaiabe or inaccessibe. The unforeseen condition coud, for exampe, be an unforeseen fare-up of a known condition that you have. What if you are in the pan s service area when you have an urgent need for care? In most situations, if you are in the pan s service area, we wi cover urgenty needed care ony if you get this care from a network provider and foow the other rues described earier in this chapter. However, if the circumstances are unusua or extraordinary, and network providers are temporariy unavaiabe or inaccessibe, we wi cover urgenty needed care that you get from an out-of-network provider. Pease contact your PCP s office 24 hours a day if you need urgent care. You may be directed to obtain urgent care at a pan urgent care center. A ist of pan urgent care centers can be found in the Provider & Pharmacy Directory or on our website at If urgent care services are received in your doctor s office, you wi pay the office visit co-payment; however, if urgent care services are received at a pan urgent care center, you wi pay the urgent care center co-payment, which may be different. See Chapter 4. Medica Benefits Chart (what is covered and what you pay) for the co-payment that appies to services provided in a doctor s office or pan urgent care center. What if you are outside the pan s service area when you have an urgent need for care? When you are outside the service area and cannot get care from a network provider, our pan wi cover urgenty needed care that you get from any provider.

58 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 3: Using the pan's coverage for your medica services 56 In addition, our pan offers coverage for urgenty needed care wordwide whenever you need it. For more information about this benefit, see Chapter 4. Benefits Chart (what is covered and what you pay). SECTION 4 Section 4.1 What if you are bied directy for the fu cost of your covered services? You can ask us to pay our share of the cost of covered services If you have paid more than your share for covered services, or if you have received a bi for the fu cost of covered medica services, go to Chapter 7 (Asking us to pay our share of a bi you have received for covered medica services or drugs) for information about what to do. Section 4.2 If services are not covered by our pan, you must pay the fu cost Our pan covers a medica services that are medicay necessary, are isted in the pan s Medica Benefits Chart (this chart is in Chapter 4 of this booket), and are obtained consistent with pan rues. You are responsibe for paying the fu cost of services that aren t covered by our pan, either because they are not pan covered services, or they were obtained out-of-network and were not authorized. If you have any questions about whether we wi pay for any medica service or care that you are considering, you have the right to ask us whether we wi cover it before you get it. If we say we wi not cover your services, you have the right to appea our decision not to cover your care. Chapter 9 (What to do if you have a probem or compaint (coverage decisions, appeas, compaints)) has more information about what to do if you want a coverage decision from us or want to appea a decision we have aready made. You may aso ca Customer Service to get more information about how to do this (phone numbers are printed on the back cover of this booket). For covered services that have a benefit imitation, you pay the fu cost of any services you get after you have used up your benefit for that type of covered service. Costs paid once a benefit imit has been reached wi not count toward your out-of-pocket maximum. This is because services provided after a benefit imit has been reached are not covered by the pan. For more information, see Chapter 4,

59 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 3: Using the pan's coverage for your medica services 57 Section 1.2. You can ca Customer Service when you want to know how much of your benefit imit you have aready used. SECTION 5 Section 5.1 How are your medica services covered when you are in a cinica research study? What is a cinica research study? A cinica research study (aso caed a "cinica tria") is a way that doctors and scientists test new types of medica care, ike how we a new cancer drug works. They test new medica care procedures or drugs by asking for vounteers to hep with the study. This kind of study is one of the fina stages of a research process that heps doctors and scientists see if a new approach works and if it is safe. Not a cinica research studies are open to members of our pan. Medicare first needs to approve the research study. If you participate in a study that Medicare has not approved, you wi be responsibe for paying a costs for your participation in the study. Once Medicare approves the study, someone who works on the study wi contact you to expain more about the study and see if you meet the requirements set by the scientists who are running the study. You can participate in the study as ong as you meet the requirements for the study and you have a fu understanding and acceptance of what is invoved if you participate in the study. If you participate in a Medicare-approved study, Origina Medicare pays most of the costs for the covered services you receive as part of the study. When you are in a cinica research study, you may stay enroed in our pan and continue to get the rest of your care (the care that is not reated to the study) through our pan. If you want to participate in a Medicare-approved cinica research study, you do not need to get approva from us or your PCP. The providers that deiver your care as part of the cinica research study do not need to be part of our pan s network of providers. Athough you do not need to get our pan s permission to be in a cinica research study, you do need to te us before you start participating in a cinica research study. Here is why you need to te us: 1. We can et you know whether the cinica research study is Medicare-approved.

60 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 3: Using the pan's coverage for your medica services We can te you what services you wi get from cinica research study providers instead of from our pan. If you pan on participating in a cinica research study, contact Customer Service (phone numbers are printed on the back cover of this booket). Section 5.2 When you participate in a cinica research study, who pays for what? Once you join a Medicare-approved cinica research study, you are covered for routine items and services you receive as part of the study, incuding: Room and board for a hospita stay that Medicare woud pay for even if you weren t in a study. An operation or other medica procedure if it is part of the research study. Treatment of side effects and compications of the new care. Origina Medicare pays most of the cost of the covered services you receive as part of the study. After Medicare has paid its share of the cost for these services, our pan wi aso pay for part of the costs. We wi pay the difference between the cost-sharing in Origina Medicare and your cost-sharing as a member of our pan. This means you wi pay the same amount for the services you receive as part of the study as you woud if you received these services from our pan. Here s an exampe of how the cost-sharing works: Let s say that you have a ab test that costs $100 as part of the research study. Let s aso say that your share of the costs for this test is $20 under Origina Medicare, but the test woud be $10 under our pan s benefits. In this case, Origina Medicare woud pay $80 for the test and we woud pay another $10. This means that you woud pay $10, which is the same amount you woud pay under our pan s benefits. In order for us to pay for our share of the costs, you wi need to submit a request for payment. With your request, you wi need to send us a copy of your Medicare Summary Notices or other documentation that shows what services you received as part of the study and how much you owe. Pease see Chapter 7 for more information about submitting requests for payment. When you are part of a cinica research study, neither Medicare nor our pan wi pay for any of the foowing:

61 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 3: Using the pan's coverage for your medica services 59 Generay, Medicare wi not pay for the new item or service that the study is testing uness Medicare woud cover the item or service even if you were not in a study. Items and services the study gives you or any participant for free. Items or services provided ony to coect data, and not used in your direct heath care. For exampe, Medicare woud not pay for monthy CT scans done as part of the study if your medica condition woud normay require ony one CT scan. Do you want to know more? You can get more information about joining a cinica research study by reading the pubication Medicare and Cinica Research Studies on the Medicare website ( You can aso ca MEDICARE ( ), 24 hours a day, 7 days a week. TTY users shoud ca SECTION 6 Section 6.1 Rues for getting care covered in a reigious non-medica heath care institution What is a reigious non-medica heath care institution? A reigious non-medica heath care institution is a faciity that provides care for a condition that woud ordinariy be treated in a hospita or skied nursing faciity. If getting care in a hospita or a skied nursing faciity is against a member s reigious beiefs, we wi instead provide coverage for care in a reigious non-medica heath care institution. You may choose to pursue medica care at any time for any reason. This benefit is provided ony for Part A inpatient services (non-medica heath care services). Medicare wi ony pay for non-medica heath care services provided by reigious non-medica heath care institutions. Section 6.2 What care from a reigious non-medica heath care institution is covered by our pan? To get care from a reigious non-medica heath care institution, you must sign a ega document that says you are conscientiousy opposed to getting medica treatment that is non-excepted. Non-excepted medica care or treatment is any medica care or treatment that is vountary and not required by any federa, state, or oca aw.

62 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 3: Using the pan's coverage for your medica services 60 Excepted medica treatment is medica care or treatment that you get that is not vountary or is required under federa, state, or oca aw. To be covered by our pan, the care you get from a reigious non-medica heath care institution must meet the foowing conditions: The faciity providing the care must be certified by Medicare. Our pan s coverage of services you receive is imited to non-reigious aspects of care. If you get services from this institution that are provided to you in your home, our pan wi cover these services ony if your condition woud ordinariy meet the conditions for coverage of services given by home heath agencies that are not reigious non-medica heath care institutions. If you get services from this institution that are provided to you in a faciity, the foowing conditions appy: You must have a medica condition that woud aow you to receive covered services for inpatient hospita care or skied nursing faciity care. - and - you must get approva in advance from our pan before you are admitted to the faciity or your stay wi not be covered. Your stay in a reigious non-medica heath care institution is not covered by our pan uness you obtain authorization (approva) in advance from our pan. Pease refer to the benefits chart in Chapter 4 for inpatient hospita coverage rues and additiona information on cost-sharing and imitations for inpatient hospita coverage. SECTION 7 Section 7.1 Rues for ownership of durabe medica equipment Wi you own your durabe medica equipment after making a certain number of payments under our pan? Durabe medica equipment incudes items such as oxygen equipment and suppies, wheechairs, wakers, and hospita beds ordered by a provider for use in the home. Certain items, such as prosthetics, are aways owned by the member. In this section, we discuss other types of durabe medica equipment that must be rented. In Origina Medicare, peope who rent certain types of durabe medica equipment own the equipment after paying co-payments for the item for 13 months. As a member of the pan, however, you usuay wi not acquire ownership of rented durabe medica equipment items no matter how many co-payments you make for the

63 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 3: Using the pan's coverage for your medica services 61 item whie a member of our pan. Under certain imited circumstances we wi transfer ownership of the durabe medica equipment item. Ca Customer Service (phone numbers are printed on the back cover of this booket) to find out about the requirements you must meet and the documentation you need to provide. What happens to payments you have made for durabe medica equipment if you switch to Origina Medicare? If you switch to Origina Medicare after being a member of our pan: If you did not acquire ownership of the durabe medica equipment item whie in our pan, you wi have to make 13 new consecutive payments for the item whie in Origina Medicare in order to acquire ownership of the item. Your previous payments whie in our pan do not count toward these new 13 consecutive payments. If you made payments for the durabe medica equipment item under Origina Medicare before you joined our pan, these previous Origina Medicare payments aso do not count toward the 13 consecutive payments. You wi have to make 13 consecutive payments for the item under Origina Medicare in order to acquire ownership. There are no exceptions to this case when you return to Origina Medicare.

64 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 4: Medica Benefits Chart (what is covered and what you pay) 62 Chapter 4. Medica Benefits Chart (what is covered and what you pay) SECTION 1 Understanding your out-of-pocket costs for covered services Section 1.1 Types of out-of-pocket costs you may pay for your covered services Section 1.2 What is the most you wi pay for Medicare Part A and Part B covered medica services? Section 1.3 Our pan does not aow providers to baance bi you SECTION 2 Use the Medica Benefits Chart to find out what is covered for you and how much you wi pay Section 2.1 Your medica benefits and costs as a member of the pan SECTION 3 What benefits are not covered by the pan? Section 3.1 Benefits we do not cover (excusions)

65 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 4: Medica Benefits Chart (what is covered and what you pay) 63 SECTION 1 Understanding your out-of-pocket costs for covered services This chapter focuses on your covered services and what you pay for your medica benefits. It incudes a Medica Benefits Chart that ists your covered services and shows how much you wi pay for each covered service as a member of our pan. Later in this chapter, you can find information about medica services that are not covered. It aso expains imits on certain services. Section 1.1 Types of out-of-pocket costs you may pay for your covered services To understand the payment information we give you in this chapter, you need to know about the types of out-of-pocket costs you may pay for your covered services. A co-payment is the fixed amount you pay each time you receive certain medica services. You pay a co-payment at the time you get the medica service. (The Medica Benefits Chart in Section 2 tes you more about your co-payments.) Coinsurance is the percentage you pay of the tota cost of certain medica services. You pay a coinsurance at the time you get the medica service. (The Medica Benefits Chart in Section 2 tes you more about your coinsurance.) Some peope quaify for State Medicaid programs to hep them pay their out-of-pocket costs for Medicare. (These Medicare Savings Programs incude the Quaified Medicare Beneficiary (QMB), Specified Low-Income Medicare Beneficiary (SLMB), Quaifying Individua (QI), and Quaified Disabed & Working Individuas (QDWI) programs.) If you are enroed in one of these programs, you may sti have to pay a co-payment for the service, depending on the rues in your state. Section 1.2 What is the most you wi pay for Medicare Part A and Part B covered medica services? Because you are enroed in a Medicare Advantage Pan, there is a imit to how much you have to pay out-of-pocket each year for in-network medica services that are covered under Medicare Part A and Part B (see the Medica Benefits Chart in Section 2, beow). This imit is caed the maximum out-of-pocket amount for medica services. As a member of our pan, the most you wi have to pay out-of-pocket for in-network covered Part A and Part B services in 2015 is $6,700. The amounts you pay for co-payments and coinsurance for in-network covered services count toward this maximum out-of-pocket amount. (The amounts you pay for your pan premium and for your Part D prescription drugs do not count toward your maximum out-of-pocket

66 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 4: Medica Benefits Chart (what is covered and what you pay) 64 amount. In addition, amounts you pay for some services do not count toward your maximum out-of-pocket amount. These services are marked with an asterisk (*) in the Medica Benefits Chart.) If you reach the maximum out-of-pocket amount of $6,700, you wi not have to pay any out-of-pocket costs for the rest of the year for in-network covered Part A and Part B services. However, you must continue to pay your pan premium and the Medicare Part B premium (uness your Part B premium is paid for you by Medicaid or another third party). Section 1.3 Our pan does not aow providers to "baance bi" you As a member of our pan, an important protection for you is that you ony have to pay your cost-sharing amount when you get services covered by our pan. We do not aow providers to add additiona separate charges, caed baance biing. This protection (that you never pay more than your cost-sharing amount) appies even if we pay the provider ess than the provider charges for a service and even if there is a dispute and we don t pay certain provider charges. Here is how this protection works. If your cost-sharing is a co-payment (a set amount of doars, for exampe, $15.00), then you pay ony that amount for any covered services from a network provider. If your cost-sharing is a coinsurance (a percentage of the tota charges), then you never pay more than that percentage. However, your cost depends on which type of provider you see: If you receive the covered services from a network provider, you pay the coinsurance percentage mutipied by the pan s reimbursement rate (as determined in the contract between the provider and the pan). If you receive the covered services from an out-of-network provider who participates with Medicare, you pay the coinsurance percentage mutipied by the Medicare payment rate for participating providers. (Remember, the pan covers services from out-of-network providers ony in certain situations, such as when you get a referra.) If you receive the covered services from an out-of-network provider who does not participate with Medicare, then you pay the coinsurance percentage mutipied by the Medicare payment rate for non-participating providers. (Remember, the pan covers services from out-of-network providers ony in certain situations, such as when you get a referra.) SECTION 2 Use the Medica Benefits Chart to find out what is covered for you and how much you wi pay

67 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 4: Medica Benefits Chart (what is covered and what you pay) 65 Section 2.1 Your medica benefits and costs as a member of the pan The Medica Benefits Chart on the foowing pages ists the services our pan covers and what you pay out-of-pocket for each service. The services isted in the Medica Benefits Chart are covered ony when the foowing coverage requirements are met: Your Medicare covered services must be provided according to the coverage guideines estabished by Medicare. Your services (incuding medica care, services, suppies, and equipment) must be medicay necessary. "Medicay necessary" means that the services, suppies, or drugs are needed for the prevention, diagnosis, or treatment of your medica condition and meet accepted standards of medica practice. You receive your care from a network provider. In most cases, care you receive from an out-of-network provider wi not be covered. Chapter 3 provides more information about requirements for using network providers and the situations when we wi cover services from an out-of-network provider. You have a primary care provider (a PCP) who is providing and overseeing your care. In most situations, your PCP must give you approva in advance before you can see other providers in the pan s network. This is caed giving you a referra. Chapter 3 provides more information about getting a referra and the situations when you do not need a referra. Some of the services isted in the Medica Benefits Chart are covered ony if your doctor or other network provider gets approva in advance (sometimes caed prior authorization ) from us. Covered services that need approva in advance are marked in the Medica Benefits Chart in bod. Other important things to know about our coverage: Like a Medicare heath pans, we cover everything that Origina Medicare covers. For some of these benefits, you pay more in our pan than you woud in Origina Medicare. For others, you pay ess. (If you want to know more about the coverage and costs of Origina Medicare, ook in your Medicare & You 2015 Handbook. View it onine at or ask for a copy by caing MEDICARE ( ), 24 hours a day, 7 days a week. TTY users shoud ca ) For a preventive services that are covered at no cost under Origina Medicare, we aso cover the services at no cost to you. However, if you aso are treated or monitored for an existing medica condition during the visit when you receive the preventive service, a co-payment wi appy for the care received for the existing medica condition.

68 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 4: Medica Benefits Chart (what is covered and what you pay) 66 Sometimes, Medicare adds coverage under Origina Medicare for new services during the year. If Medicare adds coverage for any services during 2015, either Medicare or our pan wi cover those services.

69 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 4: Medica Benefits Chart (what is covered and what you pay) 67 You wi see this appe next to the preventive services in the benefits chart. Medica Benefits Chart Services that are covered for you Abdomina aortic aneurysm screening A one-time screening utrasound for peope at risk. The pan ony covers this screening if you get a referra for it as a resut of your Wecome to Medicare preventive visit. What you must pay when you get these services In-Network: There is no coinsurance, co-payment, or deductibe for beneficiaries eigibe for this preventive screening. $50 co-payment for each additiona screening. Acupuncture AUTHORIZATION RULES MAY APPLY Acupuncture is the procedure of inserting and manipuating needes into various points on the body to reieve pain or for therapeutic purposes. Limited by medica necessity. Ambuance services AUTHORIZATION RULES MAY APPLY Covered ambuance services incude fixed wing, rotary wing, and ground ambuance services, to the nearest appropriate faciity that can provide care if they are furnished to a member whose medica condition is such that other means of transportation are contraindicated (coud endanger the person s heath) or if authorized by the pan. In-Network: $0 co-payment each acupuncture visit for 20 visits every year* In-Network: $100 co-payment for Medicare-covered ambuance trips. Co-payment appies to each one-way trip.

70 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 4: Medica Benefits Chart (what is covered and what you pay) Services that are covered for you Non-emergency transportation by ambuance is appropriate if it is documented that the member s condition is such that other means of transportation are contraindicated (coud endanger the person s heath) and that transportation by ambuance is medicay required. What you must pay when you get these services 68 Annua weness visit If you ve had Part B for onger than 12 months, you can get an annua weness visit to deveop or update a personaized prevention pan based on your current heath and risk factors. This is covered once every 12 months. In-Network: There is no coinsurance, co-payment, or deductibe for the annua weness visit. Note: Your first annua weness visit can t take pace within 12 months of your Wecome to Medicare preventive visit. However, you don t need to have had a Wecome to Medicare visit to be covered for annua weness visits after you ve had Part B for 12 months. Bone mass measurement For quaified individuas (generay, this means peope at risk of osing bone mass or at risk of osteoporosis), the foowing services are covered every 24 months or more frequenty if medicay necessary: Procedures to identify bone mass, detect bone oss, or determine bone quaity, incuding a physician s interpretation of the resuts. In-Network: There is no coinsurance, co-payment, or deductibe for the Medicare-covered bone mass measurement.

71 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 4: Medica Benefits Chart (what is covered and what you pay) 69 Services that are covered for you Breast cancer screening (mammograms) Covered services incude: One baseine mammogram between the ages of 35 and 39 One screening mammogram every 12 months for women age 40 and oder Cinica breast exams once every 24 months Cardiac rehabiitation services AUTHORIZATION RULES MAY APPLY Comprehensive programs of cardiac rehabiitation services that incude exercise, education, and counseing are covered for members who meet certain conditions with a doctor s order. The pan aso covers intensive cardiac rehabiitation programs that are typicay more rigorous or more intense than cardiac rehabiitation programs. What you must pay when you get these services In-Network: There is no coinsurance, co-payment, or deductibe for the covered screening mammograms. In-Network: $20 co-payment for Medicare-covered cardiac rehabiitation services in a physician s office. $50 co-payment for Medicare-covered cardiac rehabiitation services in an outpatient hospita faciity. Cardiovascuar disease risk reduction visit (therapy for cardiovascuar disease) We cover 1 visit per year with your primary care doctor to hep ower your risk for cardiovascuar disease. During this visit, your doctor may discuss aspirin use (if appropriate), check your bood pressure, and give you tips to make sure you re eating we. In-Network: There is no coinsurance, co-payment, or deductibe for the intensive behaviora therapy cardiovascuar disease preventive benefit.

72 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 4: Medica Benefits Chart (what is covered and what you pay) 70 Services that are covered for you Cardiovascuar disease testing Bood tests for the detection of cardiovascuar disease (or abnormaities associated with an eevated risk of cardiovascuar disease) once every 5 years (60 months). What you must pay when you get these services In-Network: There is no coinsurance, co-payment, or deductibe for cardiovascuar disease testing that is covered once every 5 years. Cervica and vagina cancer screening Covered services incude: For a women: Pap tests and pevic exams are covered once every 24 months If you are at high risk of cervica cancer or have had an abnorma Pap test and are of chidbearing age: one Pap test every 12 months Chiropractic services AUTHORIZATION RULES MAY APPLY Covered services incude: We cover ony manua manipuation of the spine to correct subuxation. The pan covers routine visits to support the back, neck, or joints of the arms and egs. Routine care imited by medica necessity. Coorecta cancer screening For peope 50 and oder, the foowing are covered: Fexibe sigmoidoscopy (or screening barium enema as an aternative) every 48 months Feca occut bood test, every 12 months In-Network: There is no coinsurance, co-payment, or deductibe for the Medicare-covered preventive Pap and pevic exams. In-Network: $0 co-payment for each Medicare-covered chiropractor visit. $0 co-payment for each routine chiropractor visit for up to Unimited visits every year.* In-Network: There is no coinsurance, co-payment, or deductibe for the Medicare-covered coorecta cancer screening exam.

73 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 4: Medica Benefits Chart (what is covered and what you pay) Services that are covered for you For peope at high risk of coorecta cancer, we cover: Screening coonoscopy (or screening barium enema as an aternative) every 24 months What you must pay when you get these services 71 For peope not at high risk of coorecta cancer, we cover: Screening coonoscopy every 10 years (120 months), but not within 48 months of a screening sigmoidoscopy Denta services AUTHORIZATION RULES MAY APPLY In genera, preventive denta services (such as ceaning, routine denta exams, and denta x-rays) are not covered by Origina Medicare. We cover: In-Network: $20 co-payment for Medicare-covered denta services. Medicare-covered denta services which may incude: Services that are an integra part either of a covered procedure (e.g., reconstruction of the jaw foowing accidenta injury). Extractions done in preparation for radiation treatment for neopastic diseases invoving the jaw. Ora examinations, but not treatment, preceding kidney transpantation or heart vave repacement, under certain circumstances. Our pan aso covers the foowing suppementa (i.e., routine) denta services: Preventive services Ora Exam: 1 every 6 months Ceaning: 1 every 6 months $0 co-payment for each suppementa (i.e., routine) denta service covered by the pan.* There is a maximum pan benefit coverage amount

74 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 4: Medica Benefits Chart (what is covered and what you pay) 72 Services that are covered for you Denta X-ray: 1, 2 or 4 per procedure; 1, 2 or 4 every 1 or 3 years depending on the type of X-ray (bitewing, periapica, occusa, panoramic, compete series, extraora, posterior-anterior/atera sku and facia bone survey, siaography, temporomandibuar, tomographic, cephaometric, ora/facia or cone beam) Fuoride Treatment: 1 every year Emergency Treatment: 1 every year. In genera, any denta probem that requires immediate treatment in order to save a tooth, stop ongoing tissue beeding or aeviate severe pain is considered a denta emergency. A severe infection or abscess in the mouth can be ife-threatening and shoud be deat with immediatey. If your dentist can't be reached, seek hospita emergency room care. Periodontic: 1 deep ceaning every 2 years per quadrant, with 1 deep ceaning maintenance every 6 months. 1 treatment of disease processes affecting the gums and bone that support the teeth, per tooth, quadrant, arch, or procedure every 6 months or 1, 2 or 3 years, or per ifetime depending on the service provided; 1 fu mouth debridement every 3 years What you must pay when you get these services of $1000 per year, which appies to a suppementa (i.e., routine) denta services - both preventive and additiona comprehensive- covered by the pan. Member is responsibe for any cost above the $1000 maximum.* Additiona comprehensive denta services Diagnostic: 1 every year, per test. For exampe, pup vitaity test. Restorative: 1 amagam, resin, or composite fiing per tooth, every 3 years. 1 inay or onay per tooth, every 5 years

75 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 4: Medica Benefits Chart (what is covered and what you pay) Services that are covered for you Endodontic: 1 per tooth, per ifetime. For exampe, root cana. Extraction: 1 remova of erupted or exposed roots per tooth, per ifetime Prosthodontic: For exampe, 1 compete or partia denture every 5 years. Denture adjustments and repairs every 1, 2, or 5 years, depending on the type of service (add, repace, rebase, or reine). 1 crown per tooth, every 5 years. 1 repacement crown every year, per tooth. Other Ora Maxiofacia Surgery: For exampe, 1 surgica remova per tooth, per ifetime; 1 cosure of an oroantra fistua (an abnorma passageway between your sinus and the roof of your mouth) every 5 years, per procedure What you must pay when you get these services 73 The foowing is a compete ist of covered denta codes for which benefits are payabe under this Pan. Non isted procedures are not covered. This Pan does not aow aternate benefits. Covered denta codes for suppementa (i.e., routine) denta services are 0120, 0140, 0150, 0160, 0170, 0180, 0210, 0220, 0230, 0240, 0250, 0260, 0270, 0272, 0273, 0274, 0277, 0290, 0310, 0320, 0321, 0322, 0330, 0340, 0350, 0360, 0362, 0363, 0415, 0416, 0421, 0425, 0431, 0460, 0470, 0472, 0473, 0474, 0475, 0476, 0477, 0478, 0479, 0480, 0481, 0482, 0483, 0484, 0485, 0486, 0502, 0999, 1110, 1208, 2140, 2150, 2160, 2161, 2330, 2331, 2332, 2335, 2390, 2391, 2392, 2393, 2394, 2510, 2520, 2530, 2542, 2543, 2544, 2610, 2620, 2630, 2642, 2643, 2644, 2650, 2651, 2652, 2662, 2663, 2664, 2710, 2712, 2721, 2722, 2740, 2751, 2752, 2781, 2782, 2783, 2791, 2792, 2910, 2915, 2920, 2931, 2932, 2933, 2934, 2940, 2950, 2951, 2952, 2953, 2954, 2955, 2957, 2970, 2971, 2975, 2980, 2999, 3110, 3120,

76 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 4: Medica Benefits Chart (what is covered and what you pay) Services that are covered for you 3220, 3221, 3230, 3240, 3310, 3320, 3330, 3331, 3332, 3333, 3346, 3347, 3348, 3351, 3352, 3353, 3410, 3421, 3425, 3426, 3430, 3450, 3460, 3470, 3910, 3920, 3950, 3999, 4210, 4211, 4230, 4231, 4240, 4241, 4245, 4249, 4260, 4261, 4263, 4264, 4265, 4266, 4267, 4268, 4270, 4271, 4273, 4274, 4275, 4276, 4320, 4321, 4341, 4342, 4355, 4381, 4910, 4920, 4999, 5110, 5120, 5130, 5140, 5211, 5212, 5213, 5214, 5225, 5226, 5281, 5410, 5411, 5421, 5422, 5510, 5520, 5610, 5620, 5630, 5640, 5650, 5660, 5670, 5671, 5710, 5711, 5720, 5721, 5730, 5731, 5740, 5741, 5750, 5751, 5760, 5761, 5810, 5811, 5820, 5821, 5850, 5851, 5860, 5861, 5862, 5867, 5875, 5899, 6205, 6210, 6211, 6212, 6241, 6242, 6245, 6251, 6252, 6253, 6545, 6548, 6600, 6601, 6602, 6603, 6604, 6605, 6606, 6607, 6608, 6609, 6612, 6613, 6614, 6615, 6710, 6721, 6722, 6740, 6751, 6752, 6781, 6782, 6783, 6791, 6792, 6793, 6920, 6930, 6940, 6950, 6970, 6972, 6973, 6975, 6976, 6977, 6980, 6999, 7140, 7210, 7220, 7230, 7240, 7241, 7250, 7260, 7261, 7270, 7272, 7280, 7282, 7283, 7285, 7286, 7287, 7288, 7290, 7291, 7292, 7293, 7294, 7310, 7311, 7320, 7321, 7340, 7350, 7410, 7411, 7412, 7413, 7414, 7415, 7440, 7441, 7450, 7451, 7460, 7461, 7465, 7471, 7472, 7473, 7485, 7490, 7510, 7511, 7520, 7521, 7530, 7540, 7960, 7963, 7970, 7971, 7972, 7997, 7999, 9110, 9120, 9210, 9211, 9212, 9215, 9220, 9221, 9230, 9241, 9242, 9248, 9310, 9911, 9410, 9420, 9430, 9440, 9450, 9610, 9612, 9630, 9910, 9920, 9930, 9940, 9942, 9950, 9951 and What you must pay when you get these services 74 Limitations and excusions appy. Before obtaining services, members are advised to discuss their treatment options with a routine denta services participating provider. Treatment must be started and competed whie covered by

77 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 4: Medica Benefits Chart (what is covered and what you pay) Services that are covered for you the pan during the pan year. The cost of denta services not covered by the pan is the responsibiity of the member. What you must pay when you get these services 75 Suppementa (i.e., routine) denta services must be received from a participating provider in order to be covered by the pan. Depression screening We cover 1 screening for depression per year. The screening must be done in a primary care setting that can provide foow-up treatment and referras. Diabetes screening We cover this screening (incudes fasting gucose tests) if you have any of the foowing risk factors: high bood pressure (hypertension), history of abnorma choestero and trigyceride eves (dysipidemia), obesity, or a history of high bood sugar (gucose). Tests may aso be covered if you meet other requirements, ike being overweight and having a famiy history of diabetes. In-Network: There is no coinsurance, co-payment, or deductibe for an annua depression screening visit. In-Network: There is no coinsurance, co-payment, or deductibe for the Medicare-covered diabetes screening tests. Based on the resuts of these tests, you may be eigibe for up to two diabetes screenings every 12 months.

78 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 4: Medica Benefits Chart (what is covered and what you pay) 76 Services that are covered for you Diabetes sef-management training, diabetic services and suppies AUTHORIZATION RULES MAY APPLY For a peope who have diabetes (insuin and non-insuin users). Covered services incude: Suppies to monitor your bood gucose: Bood gucose monitor, bood gucose test strips, ancet devices and ancets, and gucose-contro soutions for checking the accuracy of test strips and monitors. For peope with diabetes who have severe diabetic foot disease: One pair per caendar year of therapeutic custom-moded shoes (incuding inserts provided with such shoes) and two additiona pairs of inserts, or one pair of depth shoes and three pairs of inserts (not incuding the non-customized removabe inserts provided with such shoes). Coverage incudes fitting. Diabetes sef-management training is covered under certain conditions. Our pan has preferred diabetic suppies. To get more information about the items that are on the pan s preferred diabetic suppies ist, pease contact Customer Service at the number isted in Chapter 2 of this Evidence of Coverage. If you use suppies that are not preferred by the pan, you shoud speak with your doctor to get a new prescription or to request prior authorization for a non-preferred bood gucose monitor and test strips. What you must pay when you get these services In-Network: $0 co-payment for Diabetes Sef-Management Education & Training. $0 co-payment for Medicare covered diabetes monitoring suppies. 20% of the cost for Medicare covered therapeutic shoes and inserts. See Diabetes screening section for diabetes screening test.

79 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 4: Medica Benefits Chart (what is covered and what you pay) 77 Services that are covered for you Durabe medica equipment and reated suppies AUTHORIZATION RULES MAY APPLY (For a definition of durabe medica equipment, see Chapter 12 of this booket.) Covered items incude, but are not imited to: wheechairs, crutches, hospita bed, IV infusion pump, oxygen equipment, nebuizer, and waker. What you must pay when you get these services In-Network: 20% of the cost for Medicare-covered durabe medica equipment. 20% of the cost for reated suppies. We cover a medicay necessary durabe medica equipment covered by Origina Medicare. If our suppier in your area does not carry a particuar brand or manufacturer, you may ask them if they can specia order it for you. Emergency care Emergency care refers to services that are: Furnished by a provider quaified to furnish emergency services, and Needed to evauate or stabiize an emergency medica condition. A medica emergency is when you, or any other prudent ayperson with an average knowedge of heath and medicine, beieve that you have medica symptoms that require immediate medica attention to prevent oss of ife, oss of a imb, or oss of function of a imb. The medica symptoms may be an iness, injury, severe pain, or a medica condition that is quicky getting worse. Emergency Room visits outside the United States are covered. In-Network: $65 co-payment for Medicare-covered emergency room visits. If you are admitted to the hospita within 24 hours for the same condition, you pay $0 for the emergency room visit. $65 co-payment for emergency room visits outside the United States. You are covered for up to $25,000 every year for emergency or urgent care services outside the United States.*

80 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 4: Medica Benefits Chart (what is covered and what you pay) Services that are covered for you What you must pay when you get these services 78 Heath and weness education programs Heath Cub Membership Annua membership at a participating fitness center. For more information regarding the heath cub membership, pease ca Customer Service (phone numbers are printed on the back cover of this booket). Nurse advice ine Members may ca when they have questions about symptoms they fee, whether they shoud see a doctor or go to a hospita or other heath-reated issues. A nursing professiona is standing by with answers 24 hours a day, seven days a week. For more information regarding the Nurse advice ine, pease ca Customer Service (phone numbers are printed on the back cover of this booket). If you receive emergency care at an out-of-network hospita and need inpatient care after your emergency condition is stabiized, you must have your inpatient care at the out-of-network hospita authorized by the pan and your cost is the cost sharing you woud pay at a network hospita. In-Network: $0 co-payment for a heath cub membership.* $0 co-payment for the nurse advice ine.

81 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 4: Medica Benefits Chart (what is covered and what you pay) 79 Services that are covered for you Hearing services AUTHORIZATION RULES MAY APPLY Diagnostic hearing and baance evauations performed by your provider to determine if you need medica treatment are covered as outpatient care when furnished by a physician, audioogist, or other quaified provider. Our pan aso covers the foowing suppementa (i.e., routine) hearing services: 1 routine hearing exam every year. A maximum of $350 towards the cost of 1 non-impantabe hearing aid every year. Benefit incudes a 1-year standard warranty and 1 package of batteries. 1 hearing aid fitting and evauation every year. What you must pay when you get these services In-Network: $20 co-payment for Medicare-covered diagnostic hearing exams. $0 co-payment for 1 routine hearing exam every year.* $0 co-payment for 1 hearing aid every year.* $0 co-payment for 1 hearing aid fitting and evauation every year.* Note: Any cost above $350 for 1 hearing aid is the member s responsibiity. A second hearing aid is not covered by the pan.* Note: Suppementa (i.e., routine) hearing services must be received from a participating provider in order to be covered by the pan.

82 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 4: Medica Benefits Chart (what is covered and what you pay) 80 Services that are covered for you HIV screening For peope who ask for an HIV screening test or who are at increased risk for HIV infection, we cover: One screening exam every 12 months For women who are pregnant, we cover: Up to three screening exams during a pregnancy Home heath agency care AUTHORIZATION RULES MAY APPLY Prior to receiving home heath services, a doctor must certify that you need home heath services and wi order home heath services to be provided by a home heath agency. You must be homebound, which means eaving home is a major effort. Covered services incude, but are not imited to: Part-time or intermittent skied nursing and home heath aide services (To be covered under the home heath care benefit, your skied nursing and home heath aide services combined must tota fewer than 8 hours per day and 35 hours per week) Physica therapy, occupationa therapy, and speech therapy Medica and socia services Medica equipment and suppies What you must pay when you get these services In-Network: There is no coinsurance, co-payment, or deductibe for beneficiaries eigibe for Medicare-covered preventive HIV screening. In-Network: $0 co-payment for Medicare-covered skied nursing and home heath aide services. $0 co-payment for Medicare-covered occupationa therapy, physica therapy, or speech-anguage therapy. 20% of the cost for Medicare-covered medica equipment and 20% of the cost for reated suppies.

83 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 4: Medica Benefits Chart (what is covered and what you pay) 81 Services that are covered for you Hospice care You may receive care from any Medicare-certified hospice program. Your hospice doctor can be a network provider or an out-of-network provider. Covered services incude: Drugs for symptom contro and pain reief Short-term respite care Home care For Hospice services and for services that are covered by Medicare Part A or B and are reated to your termina condition: Origina Medicare (rather than our pan) wi pay for your hospice services and any Part A and Part B services reated to your termina condition. Whie you are in the hospice program, your hospice provider wi bi Origina Medicare for the services that Origina Medicare pays for. What you must pay when you get these services In-Network: When you enro in a Medicare-certified hospice program, your hospice services and your Part A and Part B services reated to your termina condition are paid for by Origina Medicare, not our pan. See Physician services, incuding doctor s office visits section for cost-sharing amounts for hospice consutation services. For services that are covered by Medicare Part A or B and are not reated to your termina condition: If you need non-emergency, non-urgenty needed services that are covered under Medicare Part A or B and that are not reated to your termina condition, your cost for these services depends on whether you use a provider in our pan s network: If you obtain the covered services from a network provider, you ony pay the pan cost-sharing amount for in-network services

84 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 4: Medica Benefits Chart (what is covered and what you pay) Services that are covered for you If you obtain the covered services from an out-of-network provider, you pay the cost-sharing under Fee-for-Service Medicare (Origina Medicare) What you must pay when you get these services 82 For services that are covered by our pan but are not covered by Medicare Part A or B: our pan wi continue to cover pan-covered services that are not covered under Part A or B whether or not they are reated to your termina condition. You pay your pan cost-sharing amount for these services. For drugs that may be covered by the pan s Part D benefit: Drugs are never covered by both hospice and our pan at the same time. For more information, pease see Chapter 5, Section 9.4 (What if you re in Medicare-certified hospice). Note: If you need non-hospice care (care that is not reated to your termina condition), you shoud contact us to arrange the services. Getting your non-hospice care through our network providers wi ower your share of the costs for the services. Our pan covers hospice consutation services (one time ony) for a terminay i person who hasn t eected the hospice benefit. Immunizations Covered Medicare Part B services incude: Pneumonia vaccine Fu shots, once a year in the fa or winter In-Network: There is no coinsurance, co-payment, or deductibe for the pneumonia, infuenza, and Hepatitis B vaccines.

85 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 4: Medica Benefits Chart (what is covered and what you pay) Services that are covered for you What you must pay when you get these services 83 We offer most fu vaccines to our members at no cost. You can receive your fu vaccine from your doctor, at many oca pharmacies and cinics, or you can ca the Customer Service number on the back of your member ID card to find a fu shot provider near you. 20% of the cost for other Medicare-covered vaccines. Hepatitis B vaccine if you are at high or intermediate risk of getting Hepatitis B Other vaccines if you are at risk and they meet Medicare Part B coverage rues We aso cover some vaccines under our Part D prescription drug benefit. Inpatient hospita care AUTHORIZATION RULES MAY APPLY Incudes inpatient acute, inpatient rehabiitation, and other types of inpatient hospita services. Inpatient hospita care starts the day you are formay admitted to the hospita with a doctor s order. The day before you are discharged is your ast inpatient day. Covered services incude but are not imited to: Semi-private room (or a private room if medicay necessary) Meas incuding specia diets Reguar nursing services Costs of specia care units (such as intensive care or coronary care units) Drugs and medications Lab tests X-rays and other radioogy services In-Network: For Medicare-covered hospita stays: $100 co-pay per day for days 1-8 $0 co-pay per day for days 9-90 $0 co-pay for additiona hospita days. No imit to the number of days covered by the pan. Benefit periods do not appy. Co-payments appy per admission. Except in an emergency, your doctor must te the pan in advance that you are going to be admitted

86 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 4: Medica Benefits Chart (what is covered and what you pay) 84 Services that are covered for you Necessary surgica and medica suppies Use of appiances, such as wheechairs Operating and recovery room costs Physica, occupationa, and speech anguage therapy Inpatient substance abuse services Under certain conditions, the foowing types of transpants are covered: Cornea, kidney, kidney-pancreatic, heart, iver, ung, heart/ung, bone marrow, stem ce, and intestina/mutiviscera. If you need a transpant, we wi arrange to have your case reviewed by a Medicare-approved transpant center that wi decide whether you are a candidate for a transpant. Transpant providers may be oca or outside of the service area. If oca transpant providers are wiing to accept the Origina Medicare rate, then you can choose to obtain your transpant services ocay or at a distant ocation offered by the pan. If our pan provides transpant services at a distant ocation (outside of the service area) and you chose to obtain transpants at this distant ocation, we wi arrange or pay for appropriate odging and transportation costs for you and a companion. Bood - incuding storage and administration. Coverage of whoe bood and packed red ces begins ony with the fourth pint of bood that you need - you must either pay the cost for the first 3 pints of bood you get in a caendar year or have the bood donated by you or someone ese. A other components of bood are covered beginning with the first pint used. Physician services What you must pay when you get these services to the hospita. If you get authorized inpatient care at an out-of-network hospita after your emergency condition is stabiized, your cost is the cost sharing you woud pay at a network hospita.

87 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 4: Medica Benefits Chart (what is covered and what you pay) Services that are covered for you What you must pay when you get these services 85 Note: To be an inpatient, your provider must write an order to admit you formay as an inpatient of the hospita. Even if you stay in the hospita overnight, you might sti be considered an outpatient. If you are not sure if you are an inpatient or an outpatient, you shoud ask the hospita staff. You can aso find more information in a Medicare fact sheet caed Are You a Hospita Inpatient or Outpatient? If You Have Medicare - Ask! This fact sheet is avaiabe on the web at df or by caing MEDICARE ( ). TTY users ca You can ca these numbers for free, 24 hours a day, 7 days a week. Inpatient menta heath care In-Network: AUTHORIZATION RULES MAY APPLY Covered services incude menta heath care services that require a hospita stay. There is a 190-day ifetime imit for inpatient services in a psychiatric hospita. The 190-day imit does not appy to Menta Heath services provided in a psychiatric unit of a genera hospita. Note: Except in an emergency, your doctor must te the pan in advance that you are going to be admitted to the hospita. Note: If you get authorized inpatient care at an out-of-network hospita after your emergency condition is stabiized, your cost is the cost-sharing you woud pay at a network hospita. For Medicare-covered hospita stays: $100 co-pay per day for days 1-8 $0 co-pay per day for days 9-90 Benefit periods do not appy. Co-payments appy per admission. Lifetime Reserve Days: $0 co-payment per day Lifetime Reserve Days are additiona days that the pan wi pay for when members are in a hospita for more than the number

88 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 4: Medica Benefits Chart (what is covered and what you pay) 86 Services that are covered for you Inpatient services covered during a non-covered inpatient stay AUTHORIZATION RULES MAY APPLY If you have exhausted your inpatient benefits or if the inpatient stay is not reasonabe and necessary, we wi not cover your inpatient stay. However, in some cases, we wi cover certain services you receive whie you are in the hospita or the skied nursing faciity (SNF). Covered services incude, but are not imited to: Physician services Diagnostic tests (ike ab tests) X-ray, radium, and isotope therapy incuding technician materias and services Surgica dressings Spints, casts and other devices used to reduce fractures and disocations Prosthetics and orthotics devices (other than denta) that repace a or part of an interna body organ (incuding contiguous tissue), or a or part of the function of a permanenty inoperative or mafunctioning interna body organ, incuding repacement or repairs of such devices Leg, arm, back, and neck braces; trusses, and artificia egs, arms, and eyes incuding adjustments, repairs, and repacements required because of breakage, wear, oss, or a change in the patient s physica condition What you must pay when you get these services of days covered by the pan. Members have a tota of 60 reserve days that can be used during their ifetime. In-Network: Our pan wi cover a Medicare-covered services and post-stabiization care as ong as you remain an eigibe person. Co-payments and/or coinsurance may appy for these services. Pease review the benefits in this chart for information on these covered services. For exampe, see Prosthetic devices and reated suppies section for eg, arm, back and neck braces.

89 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 4: Medica Benefits Chart (what is covered and what you pay) Services that are covered for you What you must pay when you get these services 87 Physica therapy, speech therapy, and occupationa therapy Medica nutrition therapy This benefit is for peope with diabetes, rena (kidney) disease (but not on diaysis), or after a kidney transpant when referred by your doctor. We cover 3 hours of one-on-one counseing services during your first year that you receive medica nutrition therapy services under Medicare (this incudes our pan, any other Medicare Advantage pan, or Origina Medicare), and 2 hours each year after that. If your condition, treatment, or diagnosis changes, you may be abe to receive more hours of treatment with a physician s order. A physician must prescribe these services and renew their order yeary if your treatment is needed into the next caendar year. Medicare Part B prescription drugs AUTHORIZATION RULES MAY APPLY These drugs are covered under Part B of Origina Medicare. Members of our pan receive coverage for these drugs through our pan. Covered drugs incude: Drugs that usuay aren t sef-administered by the patient and are injected or infused whie you are getting physician, hospita outpatient, or ambuatory surgica center services Drugs you take using durabe medica equipment (such as nebuizers) that were authorized by the pan In-Network: There is no coinsurance, co-payment, or deductibe for beneficiaries eigibe for Medicare-covered medica nutrition therapy services. In-Network: 20% of the cost for Medicare Part B-covered chemotherapy drugs. 20% of the cost for the other Medicare Part B covered drugs.

90 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 4: Medica Benefits Chart (what is covered and what you pay) Services that are covered for you What you must pay when you get these services 88 Cotting factors you give yoursef by injection if you have hemophiia Immunosuppressive Drugs, if you were enroed in Medicare Part A at the time of the organ transpant Injectabe osteoporosis drugs, if you are homebound, have a bone fracture that a doctor certifies was reated to post-menopausa osteoporosis, and cannot sef-administer the drug Antigens Certain ora anti-cancer drugs and anti-nausea drugs Certain drugs for home diaysis, incuding heparin, the antidote for heparin when medicay necessary, topica anesthetics, and erythropoiesis-stimuating agents (such as Procrit ) Intravenous Immune Gobuin for the home treatment of primary immune deficiency diseases Chapter 5 expains the Part D prescription drug benefit, incuding rues you must foow to have prescriptions covered. What you pay for your Part D prescription drugs through our pan is expained in Chapter 6.

91 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 4: Medica Benefits Chart (what is covered and what you pay) 89 Services that are covered for you Non - emergency medica transportation AUTHORIZATION RULES MAY APPLY Non - emergency ground transportation within the pan's service area in order to obtain medicay necessary care and services under the pan's benefits. Trips are imited to 50 mies, one-way, uness approved by the pan based on medica necessity. Ca at east 72 hours in advance to schedue routine trips. Ca anytime for urgent trips. Certain ocations may be excuded. For more information about pan-approved ocations, pease ca Customer Service (phone numbers are printed on the back cover of this booket). What you must pay when you get these services In-Network: $0 co-payment per trip for 40 one-way trips every year to pan approved ocations.* Medicay necessary transportation services must be received from an in-network provider in order to be covered by the pan. Obesity screening and therapy to promote sustained weight oss If you have a body mass index of 30 or more, we cover intensive counseing to hep you ose weight. This counseing is covered if you get it in a primary care setting, where it can be coordinated with your comprehensive prevention pan. Tak to your primary care doctor or practitioner to find out more. Outpatient diagnostic tests and therapeutic services and suppies AUTHORIZATION RULES MAY APPLY Covered services incude, but are not imited to: X-rays In-Network: There is no coinsurance, co-payment, or deductibe for preventive obesity screening and therapy. In-Network: $20 co-payment for Medicare-covered therapeutic radioogy services. $0 co-payment after the first 3 pints of unrepaced

92 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 4: Medica Benefits Chart (what is covered and what you pay) 90 Services that are covered for you Radiation (radium and isotope) therapy incuding technician materias and suppies Surgica suppies, such as dressings Spints, casts and other devices used to reduce fractures and disocations Laboratory tests Bood. Coverage begins with the fourth pint of bood that you need - you must either pay for the cost of the first 3 pints of bood you get in a caendar year or have the bood donated by you or someone ese. Coverage of storage and administration begins with the first pint of bood that you need. Other outpatient diagnostic tests Spirometry for COPD. Spirometry is a common office test used to check how we your ungs are working once you re being treated for chronic obstructive pumonary disease (COPD). What you must pay when you get these services whoe bood and/or packed red ces. $20 co-payment for Medicare-covered basic diagnostic tests and procedures (i.e., aergy test or EKG) $50 co-payment for Medicare-covered advanced diagnostic tests and procedures (i.e., cardiac stress test) $0 co-payment for Medicare-covered basic diagnostic radioogy services (i.e., fat-fim X-ray) $50 co-payment for Medicare-covered advanced diagnostic radioogy services (i.e., MRI) $0 co-payment for Medicare-covered ab services (i.e., urinaysis) $0 co-payment for Spirometry for COPD If the benefit for one service is a co-payment (fixed doar amount) and the benefit for another service is a coinsurance (percentage of the aowed cost), you may be asked

93 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 4: Medica Benefits Chart (what is covered and what you pay) 91 Services that are covered for you Outpatient hospita services AUTHORIZATION RULES MAY APPLY We cover medicay-necessary services you get in the outpatient department of a hospita for diagnosis or treatment of an iness or injury. Covered services incude, but are not imited to: Services in an emergency department or outpatient cinic, such as observation services or outpatient surgery Laboratory and diagnostic tests bied by the hospita Menta heath care, incuding care in a partia-hospitaization program, if a doctor certifies that inpatient treatment woud be required without it X-rays and other radioogy services bied by the hospita Medica suppies such as spints and casts Certain screenings and preventive services Certain drugs and bioogicas that you can t give yoursef What you must pay when you get these services to pay both the co-payment and the coinsurance. This may ony happen when mutipe covered services are administered on the same day by the same provider. In-Network: $50 co-payment for each Medicare-covered non-surgica visit to an outpatient hospita faciity and $50 co-payment for each Medicare-covered surgery visit to an outpatient hospita faciity, with two exceptions: $0 co-payment for primary care physician services at a hospita-owned cinic. $20 co-payment for speciaist physician services at a hospita-owned cinic. If the benefit for one service is a co-payment (fixed doar amount) and the benefit for another service is a coinsurance (percentage of the aowed cost), you may be asked to pay both the co-payment and the

94 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 4: Medica Benefits Chart (what is covered and what you pay) 92 Services that are covered for you Note: Uness the provider has written an order to admit you as an inpatient to the hospita, you are an outpatient and pay the cost-sharing amounts for outpatient hospita services. Even if you stay in the hospita overnight, you might sti be considered an outpatient. If you are not sure if you are an outpatient, you shoud ask the hospita staff. You can aso find more information in a Medicare fact sheet caed Are You a Hospita Inpatient or Outpatient? If You Have Medicare - Ask! This fact sheet is avaiabe on the web at df or by caing MEDICARE ( ). TTY users ca You can ca these numbers for free, 24 hours a day, 7 days a week. Outpatient menta heath care AUTHORIZATION RULES MAY APPLY Covered services incude: Menta heath services provided by a state-icensed psychiatrist or doctor, cinica psychoogist, cinica socia worker, cinica nurse speciaist, nurse practitioner, physician assistant, or other Medicare-quaified menta heath care professiona as aowed under appicabe state aws. What you must pay when you get these services coinsurance. This may ony happen when mutipe covered services are administered on the same day by the same provider. In-Network: Outpatient menta heath care incudes psychiatric services. $20 co-payment for each Medicare-covered individua therapy visit. $10 co-payment for each Medicare-covered group therapy visit.

95 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 4: Medica Benefits Chart (what is covered and what you pay) 93 Services that are covered for you Outpatient rehabiitation services AUTHORIZATION RULES MAY APPLY Covered services incude: physica therapy, occupationa therapy, and speech anguage therapy. Outpatient rehabiitation services are provided in various outpatient settings, such as hospita outpatient departments, independent therapist offices, and Comprehensive Outpatient Rehabiitation Faciities (CORFs). Outpatient substance abuse services AUTHORIZATION RULES MAY APPLY Outpatient menta heath care for the diagnosis and/or treatment of substance-abuse reated disorders. Outpatient surgery, incuding services provided at hospita outpatient faciities and ambuatory surgica centers AUTHORIZATION RULES MAY APPLY Note: If you are having surgery in a hospita faciity, you shoud check with your provider about whether you wi be an inpatient or outpatient. Uness the provider writes an order to admit you as an inpatient to the hospita, you are an outpatient and pay the cost-sharing amounts for outpatient surgery. Even if you stay in the hospita overnight, you might sti be considered an outpatient. Over-the-Counter Items What you must pay when you get these services In-Network: $20 co-payment for Medicare-covered occupationa therapy visits. $20 co-payment for Medicare-covered physica and/or speech-anguage therapy visits. In-Network: $20 co-payment for each Medicare-covered individua visit. $10 co-payment for each Medicare-covered group visit. In-Network: $25 co-payment for each Medicare-covered ambuatory surgica center visit. $50 co-payment for each Medicare-covered surgica visit to an outpatient hospita faciity. In-Network:

96 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 4: Medica Benefits Chart (what is covered and what you pay) 94 Services that are covered for you AUTHORIZATION RULES MAY APPLY You receive a fixed doar amount each month to spend on eigibe over-the-counter (OTC) medicines and products that you use for medica purposes. Ony you can use your benefit, and the OTC medicines and products are intended for your use ony. There are two easy ways to get your item: Use your OTC card to purchase eigibe items from participating stores. To request a ist of eigibe items and find retaiers where you can use your OTC card, pease contact Customer Service at the number isted in Chapter 2 of this Evidence of Coverage. Purchase eigibe items from any retai ocation and we wi reimburse you. Reimbursement is based on the retai vaue charged by the merchant (incuding saes tax). You must submit a caim form for reimbursement, aong with the itemized receipt from the retai ocation. Caims must be submitted within 90 days of the date of purchase on your receipt. To request a caim form pease contact Customer Service (phone numbers are printed on the back cover of this booket). What you must pay when you get these services $40 every month for eigibe over-the-counter items. Any unused amount does not carry over to the next month.* Note: Under certain circumstances diagnostic equipment (such as equipment diagnosing bood pressure, choestero, diabetes, coorecta screenings, and HIV) and smoking-cessation aids are covered under the pan's medica benefits. You shoud access these items and/or services the same way you woud any other Medicare-covered benefit, rather than using your OTC benefit.

97 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 4: Medica Benefits Chart (what is covered and what you pay) 95 Services that are covered for you Partia hospitaization services AUTHORIZATION RULES MAY APPLY Partia hospitaization is a structured program of active psychiatric treatment provided in a hospita outpatient setting or by a community menta heath center, that is more intense than the care received in your doctor s or therapist s office and is an aternative to inpatient hospitaization. Physician/Practitioner services, incuding doctor s office visits AUTHORIZATION RULES MAY APPLY Covered services incude: Medicay-necessary medica care or surgica services furnished in a physician s office, certified ambuatory surgica center, hospita outpatient department, or any other ocation Consutation, diagnosis, and treatment by a speciaist Basic hearing and baance exams performed by your speciaist, if your doctor orders it to see if you need medica treatment Second opinion by another network provider prior to surgery Non-routine denta care (covered services are imited to surgery of the jaw or reated structures, setting fractures of the jaw or facia bones, extraction of teeth to prepare the jaw for radiation treatments of neopastic cancer disease, or What you must pay when you get these services In-Network: $55 co-payment per day for Medicare-covered partia hospitaization services. In-Network: $0 co-payment for each primary care visit for Medicare-covered services. $20 co-payment for each speciaist visit for Medicare-covered services. $20 co-payment for each visit to other heath care professionas (i.e., cinica nurse speciaists, nurse practitioners, or physician assistants) for Medicare-covered services.

98 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 4: Medica Benefits Chart (what is covered and what you pay) Services that are covered for you services that woud be covered when provided by a physician) What you must pay when you get these services 96 Podiatry services AUTHORIZATION RULES MAY APPLY Covered services incude: Diagnosis and the medica or surgica treatment of injuries and diseases of the feet (such as hammer toe or hee spurs). Routine foot care for members with certain medica conditions affecting the ower imbs. Prostate cancer screening exams For men age 50 and oder, covered services incude the foowing - once every 12 months: Digita recta exam Prostate Specific Antigen (PSA) test In-Network: $20 co-payment for each Medicare-covered podiatry visit. In-Network: There is no coinsurance, co-payment, or deductibe for an annua PSA test.

99 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 4: Medica Benefits Chart (what is covered and what you pay) 97 Services that are covered for you Prosthetic devices and reated suppies AUTHORIZATION RULES MAY APPLY Devices (other than denta) that repace a or part of a body part or function. These incude, but are not imited to: coostomy bags and suppies directy reated to coostomy care, pacemakers, braces, prosthetic shoes, artificia imbs, and breast prostheses (incuding a surgica brassiere after a mastectomy). Incudes certain suppies reated to prosthetic devices, and repair and/or repacement of prosthetic devices. Aso incudes some coverage foowing cataract remova or cataract surgery - see Vision Care ater in this section for more detai. Pumonary rehabiitation services AUTHORIZATION RULES MAY APPLY Comprehensive programs of pumonary rehabiitation are covered for members who have moderate to very severe chronic obstructive pumonary disease (COPD) and an order for pumonary rehabiitation from the doctor treating the chronic respiratory disease. What you must pay when you get these services In-Network: 20% of the cost for Medicare-covered prosthetics and orthotics. 20% of the cost for the reated suppies. In-Network: $20 co-payment for Medicare-covered pumonary rehabiitation services in a physician s office. $50 co-payment for Medicare-covered pumonary rehabiitation services in an outpatient hospita faciity.

100 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 4: Medica Benefits Chart (what is covered and what you pay) 98 Services that are covered for you Screening and counseing to reduce acoho misuse We cover one acoho misuse screening for aduts with Medicare (incuding pregnant women) who misuse acoho, but aren t acoho dependent. If you screen positive for acoho misuse, you can get up to 4 brief face-to-face counseing sessions per year (if you re competent and aert during counseing) provided by a quaified primary care doctor or practitioner in a primary care setting. What you must pay when you get these services In-Network: There is no coinsurance, co-payment, or deductibe for the Medicare-covered screening and counseing to reduce acoho misuse preventive benefit. Screening for sexuay transmitted infections (STIs) and counseing to prevent STIs We cover sexuay transmitted infection (STI) screenings for chamydia, gonorrhea, syphiis, and Hepatitis B. These screenings are covered for pregnant women and for certain peope who are at increased risk for an STI when the tests are ordered by a primary care provider. We cover these tests once every 12 months or at certain times during pregnancy. We aso cover up to 2 individua 20 to 30 minute, face-to-face high-intensity behaviora counseing sessions each year for sexuay active aduts at increased risk for STIs. We wi ony cover these counseing sessions as a preventive service if they are provided by a primary care provider and take pace in a primary care setting, such as a doctor s office. In-Network: There is no coinsurance, co-payment, or deductibe for the Medicare-covered screening for STIs and counseing to prevent STIs preventive benefit. Services to treat kidney disease and conditions AUTHORIZATION RULES MAY APPLY Covered services incude: In Network: 20% of the cost for Medicare-covered kidney

101 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 4: Medica Benefits Chart (what is covered and what you pay) 99 Services that are covered for you Kidney disease education services to teach kidney care and hep members make informed decisions about their care. For members with stage IV chronic kidney disease when referred by their doctor, we cover up to six sessions of kidney disease education services per ifetime. Outpatient diaysis treatments (incuding diaysis treatments when temporariy out of the service area, as expained in Chapter 3) Inpatient diaysis treatments (if you are admitted as an inpatient to a hospita for specia care) Sef-diaysis training (incudes training for you and anyone heping you with your home diaysis treatments) Home diaysis equipment and suppies Certain home support services (such as, when necessary, visits by trained diaysis workers to check on your home diaysis, to hep in emergencies, and check your diaysis equipment and water suppy) What you must pay when you get these services disease education services. 20% of the cost for the Medicare-covered outpatient diaysis treatments, sef-diaysis training, and home support services. 20% of the cost for Medicare-covered home diaysis equipment. 20% of the cost for Medicare-covered home diaysis suppies. See Inpatient hospita care section for inpatient diaysis treatments. Certain drugs for diaysis are covered under your Medicare Part B drug benefit. For information about coverage for Part B Drugs, pease go to the section caed Medicare Part B prescription drugs. Skied nursing faciity (SNF) care AUTHORIZATION RULES MAY APPLY (For a definition of skied nursing faciity care, see Chapter 12 of this booket. Skied nursing faciities are sometimes caed SNFs. ) In-Network: $0 co-pay per day for days 1-20 $ co-pay per day for days No prior hospita stay is required.

102 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 4: Medica Benefits Chart (what is covered and what you pay) 100 Services that are covered for you Covered services incude, but are not imited to: Semiprivate room (or a private room if medicay necessary) Meas, incuding specia diets Skied nursing services Physica therapy, occupationa therapy, and speech therapy Drugs administered to you as part of your pan of care (This incudes substances that are naturay present in the body, such as bood cotting factors.) Bood - incuding storage and administration. Coverage of whoe bood and packed red ces begins ony with the fourth pint of bood that you need - you must either pay the cost for the first 3 pints of bood you get in a caendar year or have the bood donated by you or someone ese. A other components of bood are covered beginning with the first pint used. Medica and surgica suppies ordinariy provided by SNFs Laboratory tests ordinariy provided by SNFs X-rays and other radioogy services ordinariy provided by SNFs Use of appiances such as wheechairs ordinariy provided by SNFs Physician/Practioner services What you must pay when you get these services Our pan covers up to 100 days each benefit period. A benefit period begins the day you go into a skied nursing faciity. The benefit period ends when you haven t received any skied care in a SNF for 60 days in a row. If you go into a skied nursing faciity after one benefit period has ended, a new benefit period begins. There is no imit to the number of benefit periods.

103 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 4: Medica Benefits Chart (what is covered and what you pay) Services that are covered for you Generay, you wi get your SNF care from network faciities. However, under certain conditions isted beow, you may be abe to pay in-network cost-sharing for a faciity that isn t a network provider, if the faciity accepts our pan s amounts for payment. A nursing home or continuing care retirement community where you were iving right before you went to the hospita (as ong as it provides skied nursing faciity care). A SNF where your spouse is iving at the time you eave the hospita. What you must pay when you get these services 101 Smoking and tobacco use cessation (counseing to stop smoking or tobacco use) If you use tobacco, but do not have signs or symptoms of tobacco-reated disease: We cover two counseing quit attempts within a 12-month period as a preventive service with no cost to you. Each counseing attempt incudes up to four face-to-face visits. In-Network: There is no coinsurance, co-payment, or deductibe for Medicare-covered smoking and tobacco use cessation preventive benefits. If you use tobacco and have been diagnosed with a tobacco-reated disease or are taking medicine that may be affected by tobacco: We cover cessation counseing services. We cover two counseing quit attempts within a 12-month period, however, you wi pay the appicabe cost-sharing. Each counseing attempt incudes up to four face-to-face visits.

104 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 4: Medica Benefits Chart (what is covered and what you pay) 102 Services that are covered for you Urgenty needed care Urgenty needed care is care provided to treat a non-emergency, unforeseen medica iness, injury, or condition, that requires immediate medica care. Urgenty needed care may be furnished by in-network providers or by out-of-network providers when network providers are temporariy unavaiabe or inaccessibe. Urgent care visits outside the United States are covered. Vision care AUTHORIZATION RULES MAY APPLY Covered services incude: Outpatient physician services for the diagnosis and treatment of diseases and injuries of the eye, incuding treatment for age-reated macuar degeneration. Origina Medicare doesn t cover routine eye exams (eye refractions) for eyegasses/contacts. For peope who are at high risk of gaucoma, such as peope with a famiy history of gaucoma, peope with diabetes, and African-Americans who are age 50 and oder: gaucoma screening once per year. What you must pay when you get these services In Network: $35 co-payment for Medicare-covered urgent care visits. If you are admitted to the hospita within 24 hours for the same condition, you pay $0 for the urgent care visit. $65 co-payment for urgent care visits outside the United States.* You are covered for up to $25,000 every year for emergency or urgent care services outside the United States. In-Network: $0 co-payment for Medicare-covered retina exam for diabetic members. $0 co-payment for Medicare-covered gaucoma screening. $20 co-payment for a other eye exams to diagnose and treat diseases and conditions of the eye.

105 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 4: Medica Benefits Chart (what is covered and what you pay) 103 Services that are covered for you One pair of eyegasses or contact enses after each cataract surgery that incudes insertion of an intraocuar ens. (If you have two separate cataract operations, you cannot reserve the benefit after the first surgery and purchase two eyegasses after the second surgery.) Corrective enses/frames (and repacements) needed after a cataract remova without a ens impant. Our pan covers: t Eye refractions when provided for the purpose of prescribing Medicare-covered eyewear. t The contact ens fitting fee for Medicare-covered contact enses. What you must pay when you get these services 20% of the cost for prosthetic ens inserted during cataract surgery. $0 co-payment for Medicare-covered eyewear, which, for our pan members, incudes: Eye refractions for the purpose of prescribing Medicare-covered eyewear.* Contact ens fitting for Medicare-covered contact enses.* In addition, our pan covers the foowing suppementa (i.e., routine) vision services: 1 routine eye exam every year. The routine eye exam incudes a gaucoma test for peope who are at risk for gaucoma and a retina exam for diabetics. 1 pair of prescription eyewear every year. A maximum benefit of $100 every year for member s choice of the foowing: Eyegasses (frame and enses) or Eyegass enses ony or Eyegass frames ony or Contact enses instead of eyegasses Note: Contact enses fitting fee is covered by the pan Maximum pan benefit coverage amount of $100 every year appies to the retai cost of frames and/or enses (incuding any ens options such as tints and coatings). The maximum benefit amount must be Suppementa (i.e., routine) vision services: $0 co-payment for 1 routine eye exam every year.* $0 co-payment for 1 pair of routine eyewear every year.*

106 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 4: Medica Benefits Chart (what is covered and what you pay) Services that are covered for you used in a singe visit. Medicare-covered eyewear is not incuded in the suppementa (i.e., routine) benefit maximum. Note: Member is responsibe for any costs above the $100 maximum for suppementa (i.e., routine) eyewear.* What you must pay when you get these services 104 Note: Suppementa (i.e., routine) vision services must be received from a participating provider in order to be covered by the pan. Wecome to Medicare preventive visit The pan covers the one-time Wecome to Medicare preventive visit. The visit incudes a review of your heath, as we as education and counseing about the preventive services you need (incuding certain screenings and shots), and referras for other care if needed. In-Network: There is no coinsurance, co-payment, or deductibe for the "Wecome to Medicare" preventive visit. Important: We cover the "Wecome to Medicare" preventive visit ony within the first 12 months you have Medicare Part B. When you make your appointment, et your doctor s office know you woud ike to schedue your Wecome to Medicare preventive visit. SECTION 3 Section 3.1 What benefits are not covered by the pan? Benefits we do not cover (excusions) This section tes you what kinds of benefits are excuded. Excuded means that the pan doesn t cover these benefits. The ist beow describes some services and items that aren t covered under any conditions and some that are excuded ony under specific conditions.

107 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 4: Medica Benefits Chart (what is covered and what you pay) 105 If you get benefits that are excuded, you must pay for them yoursef. We won t pay for the excuded medica benefits isted in this section (or esewhere in this booket), and neither wi Origina Medicare. The ony exception: If a benefit on the excusion ist is found upon appea to be a medica benefit that we shoud have paid for or covered because of your specific situation. (For information about appeaing a decision we have made to not cover a medica service, go to Chapter 9, Section 5.3 in this booket.) In addition to any excusions or imitations described in the Benefits Chart, or anywhere ese in this Evidence of Coverage, the foowing items and services aren t covered under Origina Medicare or by our pan: Services considered not reasonabe and necessary, according to the standards of Origina Medicare, uness these services are isted by our pan as covered services. Experimenta medica and surgica procedures, equipment and medications, uness covered by Origina Medicare or under a Medicare-approved cinica research study or by our pan. (See Chapter 3, Section 5 for more information on cinica research studies.) Experimenta procedures and items are those items and procedures determined by our pan and Origina Medicare to not be generay accepted by the medica community. Surgica treatment for morbid obesity, except when it is considered medicay necessary and covered under Origina Medicare. Private room in a hospita, except when it is considered medicay necessary. Private duty nurses. Persona items in your room at a hospita or a skied nursing faciity, such as a teephone or a teevision. Fu-time nursing care in your home. Custodia care is care provided in a nursing home, hospice, or other faciity setting when you do not require skied medica care or skied nursing care. Custodia care is persona care that does not require the continuing attention of trained medica or paramedica personne, such as care that heps you with activities of daiy iving, such as bathing or dressing. Homemaker services incude basic househod assistance, incuding ight housekeeping or ight mea preparation. Fees charged by your immediate reatives or members of your househod. Meas deivered to your home.

108 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 4: Medica Benefits Chart (what is covered and what you pay) 106 Eective or vountary enhancement procedures or services (incuding weight oss, hair growth, sexua performance, athetic performance, cosmetic purposes, anti-aging and menta performance), except when medicay necessary. Cosmetic surgery or procedures, uness because of an accidenta injury or to improve a maformed part of the body. However, a stages of reconstruction are covered for a breast after a mastectomy, as we as for the unaffected breast to produce a symmetrica appearance. Routine foot care, except for the imited coverage provided according to Medicare guideines. Orthopedic shoes, uness the shoes are part of a eg brace and are incuded in the cost of the brace or the shoes are for a person with diabetic foot disease. Supportive devices for the feet, except for orthopedic or therapeutic shoes for peope with diabetic foot disease. Radia keratotomy, LASIK surgery, vision therapy and other ow vision aids. Reversa of steriization procedures, sex change operations, and non-prescription contraceptive suppies. Naturopath services (uses natura or aternative treatments). Services provided to veterans in Veterans Affairs (VA) faciities. However, when emergency services are received at VA hospita and the VA cost-sharing is more than the cost-sharing under our pan, we wi reimburse veterans for the difference. Members are sti responsibe for our cost-sharing amounts. The pan wi not cover the excuded services isted above. Even if you receive the services at an emergency faciity, the excuded services are sti not covered.

109 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 5: Using the pan's coverage for your Part D prescription drugs 107 Chapter 5. Using the pan s coverage for your Part D prescription drugs SECTION 1 Introduction Section 1.1 This chapter describes your coverage for Part D drugs Section 1.2 Basic rues for the pan s Part D drug coverage SECTION 2 Fi your prescription at a network pharmacy or through the pan s mai service Section 2.1 To have your prescription covered, use a network pharmacy Section 2.2 Finding network pharmacies Section 2.3 Using the pan s mai service Section 2.4 How can you get a ong-term suppy of drugs? Section 2.5 When can you use a pharmacy that is not in the pan s network? SECTION 3 Your drugs need to be on the pan s Drug List Section 3.1 The Drug List tes which Part D drugs are covered Section 3.2 There are five cost-sharing tiers for drugs on the Drug List Section 3.3 How can you find out if a specific drug is on the Drug List? SECTION 4 There are restrictions on coverage for some drugs Section 4.1 Why do some drugs have restrictions? Section 4.2 What kinds of restrictions? Section 4.3 Do any of these restrictions appy to your drugs? SECTION 5 What if one of your drugs is not covered in the way you d ike it to be covered? Section 5.1 There are things you can do if your drug is not covered in the way you d ike it to be covered Section 5.2 What can you do if your drug is not on the Drug List or if the drug is restricted in some way?

110 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 5: Using the pan's coverage for your Part D prescription drugs 108 Section 5.3 What can you do if your drug is in a cost-sharing tier you think is too high? SECTION 6 What if your coverage changes for one of your drugs? Section 6.1 The Drug List can change during the year Section 6.2 What happens if coverage changes for a drug you are taking? SECTION 7 What types of drugs are not covered by the pan? Section 7.1 Types of drugs we do not cover SECTION 8 Show your pan membership card when you fi a prescription Section 8.1 Show your membership card Section 8.2 What if you don t have your membership card with you? SECTION 9 Part D drug coverage in specia situations Section 9.1 What if you re in a hospita or a skied nursing faciity for a stay that is covered by the pan? Section 9.2 What if you re a resident in a ong-term care (LTC) faciity? Section 9.3 What if you re aso getting drug coverage from an empoyer or retiree group pan? Section 9.4 What if you re in Medicare-certified hospice? SECTION 10 Programs on drug safety and managing medications Section 10.1 Programs to hep members use drugs safey Section 10.2 Medication Therapy Management (MTM) program to hep members manage their medications

111 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 5: Using the pan's coverage for your Part D prescription drugs 109 Did you know there are programs to hep peope pay for their drugs?? There are programs to hep peope with imited resources pay for their drugs. These incude Extra Hep and State Pharmaceutica Assistance Programs. For more information, see Chapter 2, Section 7. Are you currenty getting hep to pay for your drugs? If you are in a program that heps pay for your drugs, some information in this Evidence of Coverage about the costs for Part D prescription drugs may not appy to you. We have incuded a separate insert, caed the Evidence of Coverage Rider for Peope Who Get Extra Hep Paying for Prescription Drugs (aso known as the "Low Income Subsidy Rider" or the "LIS Rider"), which tes you about your drug coverage. If you don t have this insert, pease ca Customer Service and ask for the LIS Rider. (Phone numbers for Customer Service are printed on the back cover of this booket.) SECTION 1 Section 1.1 Introduction This chapter describes your coverage for Part D drugs This chapter expains rues for using your coverage for Part D drugs. The next chapter tes what you pay for Part D drugs (Chapter 6, What you pay for your Part D prescription drugs). In addition to your coverage for Part D drugs, our pan aso covers some drugs under the pan s medica benefits: The pan covers drugs you are given during covered stays in the hospita or in a skied nursing faciity. Chapter 4 (Medica Benefits Chart, what is covered and what you pay) tes about the benefits and costs for drugs during a covered hospita or skied nursing faciity stay. Medicare Part B aso provides benefits for some drugs. Part B drugs incude certain chemotherapy drugs, certain drug injections you are given during an office visit, and drugs you are given at a diaysis faciity. Chapter 4 (Medica Benefits Chart, what is covered and what you pay) tes about the benefits and costs for Part B drugs. In addition to the pan s Part D and medica benefits coverage, your drugs may be covered by Origina Medicare if you are in Medicare hospice. For more information, pease see Section 9.4 (What if you re in Medicare-certified hospice).

112 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 5: Using the pan's coverage for your Part D prescription drugs 110 Section 1.2 Basic rues for the pan s Part D drug coverage The pan wi generay cover your drugs as ong as you foow these basic rues: You must have a provider (a doctor or other prescriber) write your prescription. Effective June 1, 2015, your prescriber must either accept Medicare or fie documentation with CMS showing that he or she is quaified to write prescriptions. You shoud ask your prescribers the next time you ca or visit if they meet this condition. You generay must use a network pharmacy to fi your prescription. (See Section 2, Fi your prescriptions at a network pharmacy or through the pan s mai service.) Your drug must be on the pan s List of Covered Drugs (Formuary) (we ca it the Drug List for short). (See Section 3, Your drugs need to be on the pan s Drug List. ) Your drug must be used for a medicay accepted indication. A medicay accepted indication is a use of the drug that is either approved by the Food and Drug Administration or supported by certain reference books. (See Section 3 for more information about a medicay accepted indication.) SECTION 2 Section 2.1 Fi your prescription at a network pharmacy or through the pan s mai service To have your prescription covered, use a network pharmacy In most cases, your prescriptions are covered ony if they are fied at the pan s network pharmacies. (See Section 2.5 for information about when we woud cover prescriptions fied at out-of-network pharmacies.) A network pharmacy is a pharmacy that has a contract with the pan to provide your covered prescription drugs. The term covered drugs means a of the Part D prescription drugs that are covered on the pan's Drug List. Our network incudes pharmacies that offer standard cost-sharing and pharmacies that offer preferred cost-sharing. You may go to either type of network pharmacy to receive your covered prescription drugs. Your cost-sharing may be ess at pharmacies with preferred cost-sharing. Section 2.2 Finding network pharmacies

113 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 5: Using the pan's coverage for your Part D prescription drugs 111 How do you find a network pharmacy in your area? To find a network pharmacy, you can ook in your Provider & Pharmacy Directory, visit our website ( or ca Customer Service (phone numbers are printed on the back cover of this booket). Choose whatever is easiest for you. You may go to any of our network pharmacies. However, your costs may be even ess for your covered drugs if you use a network pharmacy that offers preferred cost-sharing rather than a network pharmacy that offers standard cost-sharing. The Provider & Pharmacy Directory wi te you which of the network pharmacies offer preferred cost-sharing. If you switch from one network pharmacy to another, and you need a refi of a drug you have been taking, you can ask either to have a new prescription written by a provider or to have your prescription transferred to your new network pharmacy. What if the pharmacy you have been using eaves the network? If the pharmacy you have been using eaves the pan s network, you wi have to find a new pharmacy that is in the network. Or if the pharmacy you have been using stays within the network but is no onger offering preferred cost-sharing, you may want to switch to a different pharmacy. To find another network pharmacy in your area, you can get hep from Customer Service (phone numbers are printed on the back cover of this booket) or use the Provider & Pharmacy Directory. You can aso find information on our website at ( What if you need a speciaized pharmacy? Sometimes prescriptions must be fied at a speciaized pharmacy. Speciaized pharmacies incude: Pharmacies that suppy drugs for home infusion therapy. Pharmacies that suppy drugs for residents of a ong-term care (LTC) faciity. Usuay, a ong-term care faciity (such as a nursing home) has its own pharmacy. Residents may get prescription drugs through the faciity s pharmacy as ong as it is part of our network. If your ong-term care pharmacy is not in our network, pease contact Customer Service. Pharmacies that serve the Indian Heath Service / Triba / Urban Indian Heath Program (not avaiabe in Puerto Rico). Except in emergencies, ony Native Americans or Aaska Natives have access to these pharmacies in our network. Pharmacies that dispense drugs that are restricted by the FDA to certain ocations or that require specia handing, provider coordination, or education on their use. (Note: This scenario shoud happen rarey.)

114 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 5: Using the pan's coverage for your Part D prescription drugs 112 To ocate a speciaized pharmacy, ook in your Provider & Pharmacy Directory or ca Customer Service (phone numbers are printed on the back cover of this booket). Section 2.3 Using the pan s mai service For certain kinds of drugs, you can use the pan s network mai services. Generay, the drugs provided through mai service are drugs that you take on a reguar basis, for a chronic or ong-term medica condition. The drugs avaiabe through our pan s mai service are marked as "mai service" drugs in our Drug List. Our pan s mai service aows you to order up to a 90-day suppy. To get order forms and information about fiing your prescriptions by mai: 1. Ca our Mai Service Customer Service at (TTY ) 24 hours a day, 7 days a week. Or, og on to 2. Compete the Mai Service Enroment Form. 3. New prescriptions must be maied with the enroment form. Providers may fax new prescriptions to Mai Service at Most orders are shipped by the U.S. Posta Service. Controed substances may require an adut signature upon receipt. Packaging does not show any indication that medications are encosed. If you prefer different shipping arrangements for privacy or other reasons, pease contact our mai service Customer Service at the phone number isted above. 5. Pease aow up to caendar days for deivery. The caendar days begins when we receive your prescription and order form. 6. Incude payment or payment information, if appicabe, to avoid any deays. 7. We accept checks, credit cards and debit cards. Pease do not send cash. 8. A non member initiated prescriptions wi require the pharmacy to contact you for consent. If you use a mai service pharmacy not in the pan s network, your prescription wi not be covered. Usuay a mai service pharmacy order wi get to you in no more than caendar days. However, sometimes your mai service prescription may be deayed. For ong-term medications that you need right away, ask your doctor for two prescriptions: one for a 30 day suppy to fi at a participating retai pharmacy, and one for a ong-term suppy

115 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 5: Using the pan's coverage for your Part D prescription drugs 113 to fi through the mai. If you have any probem with getting your 30 day suppy fied at a participating retai pharmacy when your mai service prescription is deayed, pease have your retai pharmacy ca our Provider Service Center at (TTY ), 24 hours a day, 7 days a week for assistance. Members can ca mai service Customer Service at (TTY ), 24 hours a day, 7 days a week. Or, og on to New prescriptions the pharmacy receives directy from your doctor s office After the pharmacy receives a prescription from a heath care provider, it wi contact you to see if you want the medication fied immediatey or at a ater time. This wi give you an opportunity to make sure the pharmacy is deivering the correct drug (incuding strength, amount, and form) and, if needed, aow you to stop or deay the order before you are bied and it is shipped. It is important that you respond each time you are contacted by the pharmacy, to et them know what to do with the new prescription and to prevent any deays in shipping. Refis on mai service prescriptions For refis of your drugs, you have the option to sign up for an automatic refi program. Under this program we wi start to process your next refi automaticay when our records show you shoud be cose to running out of your drug. The pharmacy wi contact you prior to shipping each refi to make sure you need more medication, and you can cance schedued refis if you have enough of your medication or if your medication has changed. If you choose not to use our auto refi program, pease contact your pharmacy at east 10 days before you think the drugs you have on hand wi run out to make sure your next order is shipped to you in time. To opt out of our program that automaticay prepares mai service refis, pease contact us by caing our mai service Customer Service at (TTY ). So the pharmacy can reach you to confirm your order before shipping, pease make sure to et the pharmacy know the best ways to contact you. Contact our mai service Customer Service at (TTY ). Section 2.4 How can you get a ong-term suppy of drugs? When you get a ong-term suppy of drugs, your cost sharing may be ower. The pan offers two ways to get a ong-term suppy of maintenance" drugs on our pan s Drug List. (Maintenance drugs are drugs that you take on a reguar basis, for a chronic or ong-term medica condition.) 1. Some retai pharmacies in our network aow you to get a ong-term suppy of maintenance drugs. Your Provider & Pharmacy Directory tes you which

116 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 5: Using the pan's coverage for your Part D prescription drugs 114 pharmacies in our network can give you a ong-term suppy of maintenance drugs. You can aso ca Customer Service for more information (phone numbers are printed on the back cover of this booket). 2. For certain kinds of drugs, you can use the pan s network mai services. The drugs avaiabe through our pan's mai service are marked as "mai service" drugs in our pan s Drug List. Our pan s mai service aows you to order up to a 90-day suppy. See Section 2.3 for more information about using our mai services. Section 2.5 When can you use a pharmacy that is not in the pan s network? Your prescription may be covered in certain situations We have network pharmacies outside of our service area where you can get your prescriptions fied as a member of our pan. Generay, we cover drugs fied at an out-of-network pharmacy ony when you are not abe to use a network pharmacy. Here are the circumstances when we woud cover prescriptions fied at an out-of-network pharmacy: Trave: Getting coverage when you trave or are away from the pan s service area If you take a prescription drug on a reguar basis and you are going on a trip, be sure to check your suppy of the drug before you eave. When possibe, take aong a the medication you wi need. You may be abe to order your prescription drugs ahead of time through our mai pharmacy service. If you are traveing within the United States and territories and become i, ose, or run out of your prescription drugs, we wi cover prescriptions that are fied at an out-of-network pharmacy. In this situation, you wi have to pay the fu cost (rather than paying just your co-payment or coinsurance) when you fi your prescription. You can ask us to reimburse you for our share of the cost by submitting a reimbursement form. If you go to an out-of-network pharmacy, you may be responsibe for paying the difference between what we woud pay for a prescription fied at an in-network pharmacy and what the out-of-network pharmacy charged for your prescription. To earn how to submit a reimbursement caim, pease refer to the How and where to send us your request for payment section in Chapter 7, Section 2.1. You can aso ca Customer Service to find out if there is a network pharmacy in the area where you are traveing.

117 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 5: Using the pan's coverage for your Part D prescription drugs 115 We cannot pay for any prescriptions that are fied by pharmacies outside of the United States and territories, even for a medica emergency. Medica Emergency: What if I need a prescription because of a medica emergency or because I needed urgent care? We wi cover prescriptions that are fied at an out-of-network pharmacy if the prescriptions are reated to care for a medica emergency or urgent care. In this situation, you wi have to pay the fu cost (rather than paying just your co-payment or coinsurance) when you fi your prescription. You can ask us to reimburse you for our share of the cost by submitting a reimbursement form. If you go to an out-of-network pharmacy, you may be responsibe for paying the difference between what we woud pay for a prescription fied at an in-network pharmacy and what the out-of-network pharmacy charged for your prescription. To earn how to submit a reimbursement caim, pease refer to the How and where to send us your request for payment section in Chapter 7, Section 2.1. Additiona Situations: Other times you can get your prescription covered if you go to an out-of-network pharmacy We wi cover your prescription at an out-of-network pharmacy if at east one of the foowing appies: If you are unabe to obtain a covered drug in a timey manner within our service area because there is no network pharmacy, within a reasonabe driving distance, that provides 24-hour service. If you are trying to fi a prescription drug that is not reguary stocked at an accessibe network retai or mai service pharmacy (incuding high cost and unique drugs). If you are getting a vaccine that is medicay necessary but not covered by Medicare Part B and some covered drugs that are administered in your doctor s office. For a of the above isted situations, you may receive up to a 30-day suppy of prescription drugs. In addition, you wi ikey have to pay the out-of-network pharmacy s charge for the drug and submit documentation to receive reimbursement from the pan. Pease be sure to incude an expanation of the situation concerning why you used a pharmacy outside of our network. This wi hep with the processing of your reimbursement request. In these situations, pease check first with Customer Service to see if there is a network pharmacy nearby. (Phone numbers for Customer Service are printed on the back cover of this booket.)

118 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 5: Using the pan's coverage for your Part D prescription drugs 116 How do you ask for reimbursement from the pan? If you must use an out-of-network pharmacy, you wi generay have to pay the fu cost (rather than your norma share of the cost) at the time you fi your prescription. You can ask us to reimburse you for our share of the cost. (Chapter 7, Section 2.1 expains how to ask the pan to pay you back.) SECTION 3 Section 3.1 Your drugs need to be on the pan s Drug List The Drug List tes which Part D drugs are covered The pan has a List of Covered Drugs (Formuary). In this Evidence of Coverage, we ca it the Drug List for short. The drugs on this ist are seected by the pan with the hep of a team of doctors and pharmacists. The ist must meet requirements set by Medicare. Medicare has approved the pan s Drug List. The drugs on the Drug List are ony those covered under Medicare Part D (earier in this chapter, Section 1.1 expains about Part D drugs). We wi generay cover a drug on the pan s Drug List as ong as you foow the other coverage rues expained in this chapter and the use of the drug is a medicay accepted indication. A medicay accepted indication is a use of the drug that is either: approved by the Food and Drug Administration. (That is, the Food and Drug Administration has approved the drug for the diagnosis or condition for which it is being prescribed.) -- or -- supported by certain reference books. (These reference books are the American Hospita Formuary Service Drug Information, the DRUGDEX Information System, and the USPDI or its successor.) The Drug List incudes both brand name and generic drugs A generic drug is a prescription drug that has the same active ingredients as the brand name drug. Generay, it works just as we as the brand name drug and usuay costs ess. There are generic drug substitutes avaiabe for many brand name drugs. Our pan aso covers certain over-the-counter drugs. Some over-the-counter drugs are ess expensive than prescription drugs and work just as we. For more information, ca Customer Service (phone numbers are printed on the back of this booket). What is not on the Drug List?

119 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 5: Using the pan's coverage for your Part D prescription drugs 117 The pan does not cover a prescription drugs. In some cases, the aw does not aow any Medicare pan to cover certain types of drugs (for more information about this, see Section 7.1 in this chapter). In other cases, we have decided not to incude a particuar drug on the Drug List. Section 3.2 There are five cost-sharing tiers for drugs on the Drug List Every drug on the pan s Drug List is in one of five cost-sharing tiers. In genera, the higher the cost-sharing tier, the higher your cost for the drug: Cost-Sharing Tier 1 (Preferred Generic Drugs) incudes preferred generic drugs. This is the owest cost-sharing tier. Cost-Sharing Tier 2 (Non-Preferred Generic Drugs) incudes non-preferred generic drugs. Cost-Sharing Tier 3 (Preferred Brand Drugs) incudes ony generic & preferred brand drugs. Cost-Sharing Tier 4 (Non-Preferred Brand Drugs) incudes generic & non-preferred brand drugs. Cost-Sharing Tier 5 (Speciaty Tier Drugs) incudes generic & brand drugs. This is the highest cost-sharing tier. To find out which cost-sharing tier your drug is in, ook it up in the pan s Drug List. The amount you pay for drugs in each cost-sharing tier is shown in Chapter 6 (What you pay for your Part D prescription drugs). Section 3.3 How can you find out if a specific drug is on the Drug List? You have three ways to find out: 1. Check the most recent Drug List we sent you in the mai. (Pease note: The Drug List we send incudes information for the covered drugs that are most commony used by our members. However, we cover additiona drugs that are not incuded in the printed Drug List. If one of your drugs is not isted in the Drug List, you shoud visit our website or contact Customer Service to find out if we cover it.) 2. Visit the pan s website ( The Drug List on the website is aways the most current.

120 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 5: Using the pan's coverage for your Part D prescription drugs Ca Customer Service to find out if a particuar drug is on the pan s Drug List or to ask for a copy of the ist. (Phone numbers for Customer Service are printed on the back cover of this booket.) SECTION 4 Section 4.1 There are restrictions on coverage for some drugs Why do some drugs have restrictions? For certain prescription drugs, specia rues restrict how and when the pan covers them. A team of doctors and pharmacists deveoped these rues to hep our members use drugs in the most effective ways. These specia rues aso hep contro overa drug costs, which keeps your drug coverage more affordabe. In genera, our rues encourage you to get a drug that works for your medica condition and is safe and effective. Whenever a safe, ower-cost drug wi work just as we medicay as a higher-cost drug, the pan s rues are designed to encourage you and your provider to use that ower-cost option. We aso need to compy with Medicare s rues and reguations for drug coverage and cost-sharing. If there is a restriction for your drug, it usuay means that you or your provider wi have to take extra steps in order for us to cover the drug. If you want us to waive the restriction for you, you wi need to use the coverage decision process and ask us to make an exception. We may or may not agree to waive the restriction for you. (See Chapter 9, Section 6.2 for information about asking for exceptions.) Pease note that sometimes a drug may appear more than once in our drug ist. This is because different restrictions or cost-sharing may appy based on factors such as the strength, amount, or form of the drug prescribed by your heath care provider (for instance, 10 mg versus 100 mg; one per day versus two per day; tabet versus iquid). Section 4.2 What kinds of restrictions? Our pan uses different types of restrictions to hep our members use drugs in the most effective ways. The sections beow te you more about the types of restrictions we use for certain drugs. Restricting brand name drugs when a generic version is avaiabe Generay, a generic drug works the same as a brand name drug and usuay costs ess. In most cases, when a generic version of a brand name drug is avaiabe,

121 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 5: Using the pan's coverage for your Part D prescription drugs 119 our network pharmacies wi provide you the generic version. We usuay wi not cover the brand name drug when a generic version is avaiabe. However, if your provider has tod us the medica reason that neither the generic drug nor other covered drugs that treat the same condition wi work for you, then we wi cover the brand name drug. (Your share of the cost may be greater for the brand name drug than for the generic drug.) Getting pan approva in advance For certain drugs, you or your provider need to get approva from the pan before we wi agree to cover the drug for you. This is caed prior authorization. Sometimes the requirement for getting approva in advance heps guide appropriate use of certain drugs. If you do not get this approva, your drug might not be covered by the pan. Trying a different drug first This requirement encourages you to try ess costy but just as effective drugs before the pan covers another drug. For exampe, if Drug A and Drug B treat the same medica condition, the pan may require you to try Drug A first. If Drug A does not work for you, the pan wi then cover Drug B. This requirement to try a different drug first is caed step therapy. Quantity imits For certain drugs, we imit the amount of the drug that you can have. For exampe, the pan might imit how many refis you can get, or how much of a drug you can get each time you fi your prescription. For exampe, if it is normay considered safe to take ony one pi per day for a certain drug, we may imit coverage for your prescription to no more than one pi per day. Section 4.3 Do any of these restrictions appy to your drugs? The pan s Drug List incudes information about the restrictions described above. To find out if any of these restrictions appy to a drug you take or want to take, check the Drug List. For the most up-to-date information, ca Customer Service (phone numbers are printed on the back cover of this booket) or check our website ( If there is a restriction for your drug, it usuay means that you or your provider wi have to take extra steps in order for us to cover the drug. If there is a restriction on the drug you want to take, you shoud contact Customer Service to earn

122 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 5: Using the pan's coverage for your Part D prescription drugs 120 what you or your provider woud need to do to get coverage for the drug. If you want us to waive the restriction for you, you wi need to use the coverage decision process and ask us to make an exception. We may or may not agree to waive the restriction for you. (See Chapter 9, Section 6.2 for information about asking for exceptions.) SECTION 5 Section 5.1 What if one of your drugs is not covered in the way you d ike it to be covered? There are things you can do if your drug is not covered in the way you d ike it to be covered Suppose there is a prescription drug you are currenty taking, or one that you and your provider think you shoud be taking. We hope that your drug coverage wi work we for you, but it s possibe that you might have a probem. For exampe: What if the drug you want to take is not covered by the pan? For exampe, the drug might not be covered at a. Or maybe a generic version of the drug is covered but the brand name version you want to take is not covered. What if the drug is covered, but there are extra rues or restrictions on coverage for that drug? As expained in Section 4, some of the drugs covered by the pan have extra rues to restrict their use. For exampe, you might be required to try a different drug first, to see if it wi work, before the drug you want to take wi be covered for you. Or there might be imits on what amount of the drug (number of pis, etc.) is covered during a particuar time period. In some cases, you may want us to waive the restriction for you. For exampe, you might want us to cover a certain drug for you without having to try other drugs first. Or you may want us to cover more of a drug (number of pis, etc.) than we normay wi cover. What if the drug is covered, but it is in a cost-sharing tier that makes your cost-sharing more expensive than you think it shoud be? The pan puts each covered drug into one of five different cost-sharing tiers. How much you pay for your prescription depends in part on which cost-sharing tier your drug is in. There are things you can do if your drug is not covered in the way that you d ike it to be covered. Your options depend on what type of probem you have: If your drug is not on the Drug List or if your drug is restricted, go to Section 5.2 to earn what you can do. If your drug is in a cost-sharing tier that makes your cost more expensive than you think it shoud be, go to Section 5.3 to earn what you can do.

123 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 5: Using the pan's coverage for your Part D prescription drugs 121 Section 5.2 What can you do if your drug is not on the Drug List or if the drug is restricted in some way? If your drug is not on the Drug List or is restricted, here are things you can do: You may be abe to get a temporary suppy of the drug (ony members in certain situations can get a temporary suppy). This wi give you and your provider time to change to another drug or to fie a request to have the drug covered. You can change to another drug. You can request an exception and ask the pan to cover the drug or remove restrictions from the drug. You may be abe to get a temporary suppy Under certain circumstances, the pan can offer a temporary suppy of a drug to you when your drug is not on the Drug List or when it is restricted in some way. Doing this gives you time to tak with your provider about the change in coverage and figure out what to do. To be eigibe for a temporary suppy, you must meet the two requirements beow: 1. The change to your drug coverage must be one of the foowing types of changes: 2. You must be in one of the situations described beow: For those members who were in the pan ast year and aren t in a ong-term care (LTC) faciity: We wi cover a temporary suppy of your drug during the first 90-days of the caendar year. This temporary suppy wi be for a maximum of 30-days. If your prescription is written for fewer days, we aow mutipe fis to provide up to a maximum of a 30-day suppy of medication. The prescription must be fied at a network pharmacy. The drug you have been taking is no onger on the pan s Drug List. -- or -- the drug you have been taking is now restricted in some way (Section 4 in this chapter tes about restrictions). For those members who are new to the pan and aren't in a ong-term care (LTC) faciity:

124 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 5: Using the pan's coverage for your Part D prescription drugs 122 We wi cover a temporary suppy of your drug during the first 93-days of your membership in the pan. This temporary suppy wi be for a maximum of 31-days. If your prescription is written for fewer days, we aow mutipe fis to provide up to a maximum of a 31-day suppy of medication. The prescription must be fied at a network pharmacy. For those members who were in the pan ast year and reside in a ong-term care (LTC) faciity: We wi cover a temporary suppy of your drug during the first 98 days of the caendar year. The tota suppy wi be for a maximum of 98 days. If your prescription is written for fewer days, we wi aow mutipe fis to provide up to a maximum of 98 days of medication. (Pease note that the ong-term care pharmacy may provide the drug in smaer amounts at a time to prevent waste.) For those members who are new to the pan and reside in a ong-term care (LTC) faciity: We wi cover a temporary suppy of your drug during the first 98-days of your membership in the pan. The tota suppy wi be for a maximum of 98-day suppy. If your prescription is written for fewer days, we aow mutipe fis to provide up to a maximum of a 98-day suppy of medication. (Pease note that the ong-term care pharmacy may provide the drug in smaer amounts at a time to prevent waste.) For those members who have been in the pan for more than 98-days and reside in a ong-term (LTC) care faciity and need a suppy right away: We wi cover one 31-day suppy, or ess if your prescription is written for fewer days. This is in addition to the above ong-term care transition suppy. For those current members who experience a eve of care change: There are times when a member may experience an unpanned eve of care change transition (such as being discharged or admitted to a ong-term care faciity, discharged or admitted to hospitas, nursing faciity ski eve changes, etc.). In these instances, we wi provide an emergency suppy of non-formuary medications (incuding Part D medications that are on the formuary, but require prior authorization or step therapy under our utiization management rues). This emergency suppy wi be for at east 3 days of medication, uness the prescription is written for fewer days. The emergency suppy is to ensure that members receive their medications whie an exception has been requested through the pan. To ask for a temporary suppy, ca Customer Service (phone numbers are printed on the back cover of this booket).

125 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 5: Using the pan's coverage for your Part D prescription drugs 123 During the time when you are getting a temporary suppy of a drug, you shoud tak with your provider to decide what to do when your temporary suppy runs out. You can either switch to a different drug covered by the pan or ask the pan to make an exception for you and cover your current drug. The sections beow te you more about these options. You can change to another drug Start by taking with your provider. Perhaps there is a different drug covered by the pan that might work just as we for you. You can ca Customer Service to ask for a ist of covered drugs that treat the same medica condition. This ist can hep your provider find a covered drug that might work for you. (Phone numbers for Customer Service are printed on the back cover of this booket.) You can ask for an exception You and your provider can ask the pan to make an exception for you and cover the drug in the way you woud ike it to be covered. If your provider says that you have medica reasons that justify asking us for an exception, your provider can hep you request an exception to the rue. For exampe, you can ask the pan to cover a drug even though it is not on the pan s Drug List. Or you can ask the pan to make an exception and cover the drug without restrictions. If you are a current member and a drug you are taking wi be removed from the formuary or restricted in some way for next year, we wi aow you to request a formuary exception in advance for next year. We wi te you about any change in the coverage for your drug for next year. You can ask for an exception before next year and we wi give you an answer within 72 hours after we receive your request (or your prescriber s supporting statement). If we approve your request, we wi authorize the coverage before the change takes effect. If you and your provider want to ask for an exception, Chapter 9, Section 6.4 tes what to do. It expains the procedures and deadines that have been set by Medicare to make sure your request is handed prompty and fairy. Section 5.3 What can you do if your drug is in a cost-sharing tier you think is too high? If your drug is in a cost-sharing tier you think is too high, here are things you can do: You can change to another drug

126 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 5: Using the pan's coverage for your Part D prescription drugs 124 If your drug is in a cost-sharing tier you think is too high, start by taking with your provider. Perhaps there is a different drug in a ower cost-sharing tier that might work just as we for you. You can ca Customer Service to ask for a ist of covered drugs that treat the same medica condition. This ist can hep your provider to find a covered drug that might work for you. (Phone numbers for Customer Service are printed on the back cover of this booket.) You can ask for an exception For drugs in Tier 2 (Non-Preferred Generic Drugs) and Tier 4 (Non-Preferred Brand Drugs), you and your provider can ask the pan to make an exception in the cost-sharing tier for the drug so that you pay ess for it. If your provider says that you have medica reasons that justify asking us for an exception, your provider can hep you request an exception to the rue. If you and your provider want to ask for an exception, Chapter 9, Section 6.4 tes what to do. It expains the procedures and deadines that have been set by Medicare to make sure your request is handed prompty and fairy. Drugs in some of our cost-sharing tiers are not eigibe for this type of exception. We do not ower the cost-sharing amount for drugs in Tier 1 (Preferred Generic Drugs), Tier 3 (Preferred Brand Drugs) or Tier 5 (Speciaty Tier Drugs). SECTION 6 Section 6.1 What if your coverage changes for one of your drugs? The Drug List can change during the year Most of the changes in drug coverage happen at the beginning of each year (January 1). However, during the year, the pan might make many kinds of changes to the Drug List. For exampe, the pan might: Add or remove drugs from the Drug List. New drugs become avaiabe, incuding new generic drugs. Perhaps the government has given approva to a new use for an existing drug. Sometimes, a drug gets recaed and we decide not to cover it. Or we might remove a drug from the ist because it has been found to be ineffective. Move a drug to a higher or ower cost-sharing tier. Add or remove a restriction on coverage for a drug (for more information about restrictions to coverage, see Section 4 in this chapter). Repace a brand name drug with a generic drug.

127 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 5: Using the pan's coverage for your Part D prescription drugs 125 In amost a cases, we must get approva from Medicare for changes we make to the pan s Drug List. Section 6.2 What happens if coverage changes for a drug you are taking? How wi you find out if your drug s coverage has been changed? If there is a change to coverage for a drug you are taking, the pan wi send you a notice to te you. Normay, we wi et you know at east 60 days ahead of time. Once in a whie, a drug is suddeny recaed because it s been found to be unsafe or for other reasons. If this happens, the pan wi immediatey remove the drug from the Drug List. We wi et you know of this change right away. Your provider wi aso know about this change, and can work with you to find another drug for your condition. Do changes to your drug coverage affect you right away? If any of the foowing types of changes affect a drug you are taking, the change wi not affect you unti January 1 of the next year if you stay in the pan: If we move your drug into a higher cost-sharing tier. If we put a new restriction on your use of the drug. If we remove your drug from the Drug List, but not because of a sudden reca or because a new generic drug has repaced it. If any of these changes happens for a drug you are taking, then the change won t affect your use or what you pay as your share of the cost unti January 1 of the next year. Unti that date, you probaby won t see any increase in your payments or any added restriction to your use of the drug. However, on January 1 of the next year, the changes wi affect you. In some cases, you wi be affected by the coverage change before January 1: If a brand name drug you are taking is repaced by a new generic drug, the pan must give you at east 60 days notice or give you a 60-day refi of your brand name drug at a network pharmacy. During this 60-day period, you shoud be working with your provider to switch to the generic or to a different drug that we cover. Or you and your provider can ask the pan to make an exception and continue to cover the brand name drug for you. For information on how to

128 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 5: Using the pan's coverage for your Part D prescription drugs 126 ask for an exception, see Chapter 9 (What to do if you have a probem or compaint (coverage decisions, appeas, compaints)). Again, if a drug is suddeny recaed because it s been found to be unsafe or for other reasons, the pan wi immediatey remove the drug from the Drug List. We wi et you know of this change right away. Your provider wi aso know about this change, and can work with you to find another drug for your condition. SECTION 7 Section 7.1 What types of drugs are not covered by the pan? Types of drugs we do not cover This section tes you what kinds of prescription drugs are excuded. This means Medicare does not pay for these drugs. If you get drugs that are excuded, you must pay for them yoursef. We won t pay for the drugs that are isted in this section. The ony exception: If the requested drug is found upon appea to be a drug that is not excuded under Part D and we shoud have paid for or covered it because of your specific situation. (For information about appeaing a decision we have made to not cover a drug, go to Chapter 9, Section 6.5 in this booket.) Here are three genera rues about drugs that Medicare drug pans wi not cover under Part D: Our pan s Part D drug coverage cannot cover a drug that woud be covered under Medicare Part A or Part B. Our pan cannot cover a drug purchased outside the United States and its territories. Our pan usuay cannot cover off-abe use. Off-abe use is any use of the drug other than those indicated on a drug s abe as approved by the Food and Drug Administration. Generay, coverage for off-abe use is aowed ony when the use is supported by certain reference books. These reference books are the American Hospita Formuary Service Drug Information, the DRUGDEX Information System, and the USPDI or its successor. If the use is not supported by any of these reference books, then our pan cannot cover its off-abe use. Aso, by aw, these categories of drugs are not covered by Medicare drug pans:

129 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 5: Using the pan's coverage for your Part D prescription drugs 127 Non-prescription drugs (aso caed over-the-counter drugs) Drugs when used to promote fertiity Drugs when used for the reief of cough or cod symptoms Drugs when used for cosmetic purposes or to promote hair growth Prescription vitamins and minera products, except prenata vitamins and fuoride preparations Drugs when used for the treatment of sexua or erectie dysfunction, such as Viagra, Ciais, Levitra, and Caverject Drugs when used for treatment of anorexia, weight oss, or weight gain Outpatient drugs for which the manufacturer seeks to require that associated tests or monitoring services be purchased excusivey from the manufacturer as a condition of sae If you receive Extra Hep paying for your drugs, your state Medicaid program may cover some prescription drugs not normay covered in a Medicare drug pan. Pease contact your state Medicaid program to determine what drug coverage may be avaiabe to you. (You can find phone numbers and contact information for Medicaid in Chapter 2, Section 6.) SECTION 8 Section 8.1 Show your pan membership card when you fi a prescription Show your membership card To fi your prescription, show your pan membership card at the network pharmacy you choose. When you show your pan membership card, the network pharmacy wi automaticay bi the pan for our share of your covered prescription drug cost. You wi need to pay the pharmacy your share of the cost when you pick up your prescription. Section 8.2 What if you don t have your membership card with you? If you don t have your pan membership card with you when you fi your prescription, ask the pharmacy to ca the pan to get the necessary information. If the pharmacy is not abe to get the necessary information, you may have to pay the fu cost of the prescription when you pick it up. (You can then ask us to reimburse you for our share. See Chapter 7, Section 2.1 for information about how to ask the pan for reimbursement.)

130 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 5: Using the pan's coverage for your Part D prescription drugs 128 SECTION 9 Section 9.1 Part D drug coverage in specia situations What if you re in a hospita or a skied nursing faciity for a stay that is covered by the pan? If you are admitted to a hospita or to a skied nursing faciity for a stay covered by the pan, we wi generay cover the cost of your prescription drugs during your stay. Once you eave the hospita or skied nursing faciity, the pan wi cover your drugs as ong as the drugs meet a of our rues for coverage. See the previous parts of this section that te about the rues for getting drug coverage. Chapter 6 (What you pay for your Part D prescription drugs) gives more information about drug coverage and what you pay. Pease Note: When you enter, ive in, or eave a skied nursing faciity, you are entited to a Specia Enroment Period. During this time period, you can switch pans or change your coverage. (Chapter 10, Ending your membership in the pan, tes when you can eave our pan and join a different Medicare pan.) Section 9.2 What if you re a resident in a ong-term care (LTC) faciity? Usuay, a ong-term care faciity (such as a nursing home) has its own pharmacy, or a pharmacy that suppies drugs for a of its residents. If you are a resident of a ong-term care faciity, you may get your prescription drugs through the faciity s pharmacy as ong as it is part of our network. Check your Provider & Pharmacy Directory to find out if your ong-term care faciity s pharmacy is part of our network. If it isn t, or if you need more information, pease contact Customer Service (phone numbers are printed on the back cover of this booket). What if you re a resident in a ong-term care (LTC) faciity and become a new member of the pan? If you need a drug that is not on our Drug List or is restricted in some way, the pan wi cover a temporary suppy of your drug during the first 98 days of your membership. The tota suppy wi be for a maximum of 98 days, or ess if your prescription is written for fewer days. (Pease note that the ong-term care (LTC) pharmacy may provide the drug in smaer amounts at a time to prevent waste.)

131 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 5: Using the pan's coverage for your Part D prescription drugs 129 If you have been a member of the pan for more than 98 days and need a drug that is not on our Drug List or if the pan has any restriction on the drug s coverage, we wi cover one 31-day suppy, or ess if your prescription is written for fewer days. During the time when you are getting a temporary suppy of a drug, you shoud tak with your provider to decide what to do when your temporary suppy runs out. Perhaps there is a different drug covered by the pan that might work just as we for you. Or you and your provider can ask the pan to make an exception for you and cover the drug in the way you woud ike it to be covered. If you and your provider want to ask for an exception, Chapter 9, Section 6.4 tes what to do. Section 9.3 What if you re aso getting drug coverage from an empoyer or retiree group pan? Do you currenty have other prescription drug coverage through your (or your spouse s) empoyer or retiree group? If so, pease contact that group s benefits administrator. He or she can hep you determine how your current prescription drug coverage wi work with our pan. In genera, if you are currenty empoyed, the prescription drug coverage you get from us wi be secondary to your empoyer or retiree group coverage. That means your group coverage woud pay first. Specia note about creditabe coverage : Each year your empoyer or retiree group shoud send you a notice that tes if your prescription drug coverage for the next caendar year is creditabe and the choices you have for drug coverage. If the coverage from the group pan is creditabe, it means that the pan has drug coverage that is expected to pay, on average, at east as much as Medicare s standard prescription drug coverage. Keep these notices about creditabe coverage, because you may need them ater. If you enro in a Medicare pan that incudes Part D drug coverage, you may need these notices to show that you have maintained creditabe coverage. If you didn t get a notice about creditabe coverage from your empoyer or retiree group pan, you can get a copy from your empoyer or retiree pan s benefits administrator or the empoyer or union.

132 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 5: Using the pan's coverage for your Part D prescription drugs 130 Section 9.4 What if you re in Medicare-certified hospice? Drugs are never covered by both hospice and our pan at the same time. If you are enroed in Medicare hospice and require an anti-nausea, axative, pain medication or antianxiety drug that is not covered by your hospice because it is unreated to your termina iness and reated conditions, our pan must receive notification from either the prescriber or your hospice provider that the drug is unreated before our pan can cover the drug. To prevent deays in receiving any unreated drugs that shoud be covered by our pan, you can ask your hospice provider or prescriber to make sure we have the notification that the drug is unreated before you ask a pharmacy to fi your prescription. In the event you either revoke your hospice eection or are discharged from hospice our pan shoud cover a your drugs. To prevent any deays at a pharmacy when your Medicare hospice benefit ends, you shoud bring documentation to the pharmacy to verify your revocation or discharge. See the previous parts of this section that te about the rues for getting drug coverage under Part D Chapter 6 (What you pay for your Part D prescription drugs) gives more information about drug coverage and what you pay. SECTION 10 Section 10.1 Programs on drug safety and managing medications Programs to hep members use drugs safey We conduct drug use reviews for our members to hep make sure that they are getting safe and appropriate care. These reviews are especiay important for members who have more than one provider who prescribes their drugs. We do a review each time you fi a prescription. We aso review our records on a reguar basis. During these reviews, we ook for potentia probems such as: Possibe medication errors Drugs that may not be necessary because you are taking another drug to treat the same medica condition Drugs that may not be safe or appropriate because of your age or gender Certain combinations of drugs that coud harm you if taken at the same time Prescriptions written for drugs that have ingredients you are aergic to Possibe errors in the amount (dosage) of a drug you are taking

133 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 5: Using the pan's coverage for your Part D prescription drugs 131 If we see a possibe probem in your use of medications, we wi work with your provider to correct the probem. Section 10.2 Medication Therapy Management (MTM) program to hep members manage their medications We have a program that can hep our members with specia situations. For exampe, some members have severa compex medica conditions or they may need to take many drugs at the same time, or they coud have very high drug costs. This program is vountary and free to members. A team of pharmacists and doctors deveoped the program for us. This program can hep make sure that our members are using the drugs that work best to treat their medica conditions and hep us identify possibe medication errors. Our program is caed a Medication Therapy Management (MTM) program. Some members who take severa medications for different medica conditions may quaify. A pharmacist or other heath professiona wi give you a comprehensive review of a your medications. You can tak about how best to take your medications, your costs, or any probems you re having. You get a written summary of this discussion. The summary has a medication action pan that recommends what you can do to make the best use of your medications, with space for you to take notes or write down any foow-up questions. You aso get a persona medication ist that wi incude a the medications you re taking and why you take them. It s a good idea to schedue your medication review before your yeary Weness visit, so you can tak to your doctor about your action pan and medication ist. Bring your action pan and medication ist with you to your visit or anytime you tak with your doctors, pharmacists, and other heath care providers. Aso, take your medication ist with you if you go to the hospita or emergency room. If we have a program that fits your needs, we wi automaticay enro you in the program and send you information. If you decide not to participate, pease notify us and we wi withdraw you from the program. If you have any questions about these programs, pease contact Customer Service (phone numbers are printed on the back cover of this booket).

134 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 6: What you pay for your Part D prescription drugs 132 Chapter 6. What you pay for your Part D prescription drugs SECTION 1 Introduction Section 1.1 Use this chapter together with other materias that expain your drug coverage Section 1.2 Types of out-of-pocket costs you may pay for covered drugs SECTION 2 What you pay for a drug depends on which drug payment stage you are in when you get the drug Section 2.1 What are the drug payment stages for WeCare Rx (HMO) members? SECTION 3 We send you reports that expain payments for your drugs and which payment stage you are in Section 3.1 We send you a monthy report caed the Part D Expanation of Benefits (the "Part D EOB") Section 3.2 Hep us keep our information about your drug payments up to date.137 SECTION 4 There is no deductibe for WeCare Rx (HMO) Section 4.1 You do not pay a deductibe for your Part D drugs SECTION 5 During the Initia Coverage Stage, the pan pays its share of your drug costs and you pay your share Section 5.1 What you pay for a drug depends on the drug and where you fi your prescription Section 5.2 A tabe that shows your costs for a one-month suppy of a drug Section 5.3 If your doctor prescribes ess than a fu month s suppy, you may not have to pay the cost of the entire month s suppy Section 5.4 A tabe that shows your costs for a ong-term (up to a 90-day) suppy of a drug Section 5.5 You stay in the Initia Coverage Stage unti your tota drug costs for the year reach $2, SECTION 6 During the Coverage Gap Stage, you receive a discount on brand name drugs and pay no more than 65% of the costs of generic drugs...145

135 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 6: What you pay for your Part D prescription drugs 133 Section 6.1 You stay in the Coverage Gap Stage unti your out-of-pocket costs reach $4, Section 6.2 How Medicare cacuates your out-of-pocket costs for prescription drugs SECTION 7 During the Catastrophic Coverage Stage, the pan pays most of the cost for your drugs Section 7.1 Once you are in the Catastrophic Coverage Stage, you wi stay in this stage for the rest of the year SECTION 8 What you pay for vaccinations covered by Part D depends on how and where you get them Section 8.1 Our pan has separate coverage for the Part D vaccine medication itsef and for the cost of giving you the vaccination shot Section 8.2 You may want to ca us at Customer Service before you get a vaccination SECTION 9 Do you have to pay the Part D ate enroment penaty? Section 9.1 What is the Part D ate enroment penaty? Section 9.2 How much is the Part D ate enroment penaty? Section 9.3 In some situations, you can enro ate and not have to pay the penaty Section 9.4 What can you do if you disagree about your ate enroment penaty? SECTION 10 Do you have to pay an extra Part D amount because of your income? Section 10.1 Who pays an extra Part D amount because of income? Section 10.2 How much is the extra Part D amount? Section 10.3 What can you do if you disagree about paying an extra Part D amount? Section 10.4 What happens if you do not pay the extra Part D amount?...155

136 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 6: What you pay for your Part D prescription drugs 134? Did you know there are programs to hep peope pay for their drugs? There are programs to hep peope with imited resources pay for their drugs. These incude Extra Hep and State Pharmaceutica Assistance Programs. For more information, see Chapter 2, Section 7. Are you currenty getting hep to pay for your drugs? If you are in a program that heps pay for your drugs, some information in this Evidence of Coverage about the costs for Part D prescription drugs may not appy to you. We have incuded a separate insert, caed the Evidence of Coverage Rider for Peope Who Get Extra Hep Paying for Prescription Drugs (aso known as the "Low Income Subsidy Rider" or the "LIS RIder"), which tes you about your drug coverage. If you don t have this insert, pease ca Customer Service and ask for the LIS Rider". (Phone numbers for Customer Service are printed on the back cover of this booket.) SECTION 1 Section 1.1 Introduction Use this chapter together with other materias that expain your drug coverage This chapter focuses on what you pay for your Part D prescription drugs. To keep things simpe, we use drug in this chapter to mean a Part D prescription drug. As expained in Chapter 5, not a drugs are Part D drugs some drugs are covered under Medicare Part A or Part B and other drugs are excuded from Medicare coverage by aw. To understand the payment information we give you in this chapter, you need to know the basics of what drugs are covered, where to fi your prescriptions, and what rues to foow when you get your covered drugs. Here are materias that expain these basics: The pan s List of Covered Drugs (Formuary). To keep things simpe, we ca this the Drug List. This Drug List tes which drugs are covered for you. It aso tes which of the five cost-sharing tiers the drug is in and whether there are any restrictions on your coverage for the drug. If you need a copy of the Drug List, ca Customer Service (phone numbers are printed on the back cover of this booket). You can aso find the Drug List on our website at The Drug List on the website is aways the most current.

137 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 6: What you pay for your Part D prescription drugs 135 Chapter 5 of this booket. Chapter 5 gives the detais about your prescription drug coverage, incuding rues you need to foow when you get your covered drugs. Chapter 5 aso tes which types of prescription drugs are not covered by our pan. The pan s Provider & Pharmacy Directory. In most situations you must use a network pharmacy to get your covered drugs (see Chapter 5 for the detais). The Provider & Pharmacy Directory has a ist of pharmacies in the pan s network. It aso tes you which pharmacies in our network can give you a ong-term suppy of a drug (such as fiing a prescription for a three-month s suppy). Section 1.2 Types of out-of-pocket costs you may pay for covered drugs To understand the payment information we give you in this chapter, you need to know about the types of out-of-pocket costs you may pay for your covered services. The amount that you pay for a drug is caed cost-sharing, and there are three ways you may be asked to pay. The deductibe is the amount you must pay for drugs before our pan begins to pay its share. Co-payment means that you pay a fixed amount each time you fi a prescription. Coinsurance means that you pay a percent of the tota cost of the drug each time you fi a prescription.

138 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 6: What you pay for your Part D prescription drugs 136 SECTION 2 Section 2.1 What you pay for a drug depends on which drug payment stage you are in when you get the drug What are the drug payment stages for WeCare Rx (HMO) members? As shown in the tabe beow, there are drug payment stages for your prescription drug coverage under our pan. How much you pay for a drug depends on which of these stages you are in at the time you get a prescription fied or refied. Keep in mind you are aways responsibe for the pan s monthy premium regardess of the drug payment stage. Stage 1 Yeary Deductibe Stage Stage 2 Initia Coverage Stage Stage 3 Coverage Gap Stage Stage 4 Catastrophic Coverage Stage Because there is no deductibe for the pan, this payment stage does not appy to you. You begin in this stage when you fi your first prescription of the year. During this stage, the pan pays its share of the cost of your drugs and you pay your share of the cost. You stay in this stage unti your year-to-date tota drug costs (your payments pus any Part D pan s payments) tota $2,960. During this stage, you pay 45% of the price for brand name drugs pus a portion of the dispensing fee) and 65% of the price for generic drugs. You stay in this stage unti your year-to-date out-of-pocket costs (your payments) reach a tota of $4,700. This amount and rues for counting costs toward this amount have been set by Medicare. During this stage, the pan wi pay most of the cost of your drugs for the rest of the caendar year (through December 31, 2015). (Detais are in Section7ofthis chapter.)

139 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 6: What you pay for your Part D prescription drugs 137 Stage 1 Yeary Deductibe Stage Stage 2 Initia Coverage Stage Stage 3 Coverage Gap Stage Stage 4 Catastrophic Coverage Stage (Detais are in Section 5 of this chapter.) (Detais are in Section 6 of this chapter.) SECTION 3 Section 3.1 We send you reports that expain payments for your drugs and which payment stage you are in We send you a monthy report caed the Part D Expanation of Benefits (the "Part D EOB") Our pan keeps track of the costs of your prescription drugs and the payments you have made when you get your prescriptions fied or refied at the pharmacy. This way, we can te you when you have moved from one drug payment stage to the next. In particuar, there are two types of costs we keep track of: We keep track of how much you have paid. This is caed your out-of-pocket cost. We keep track of your tota drug costs. This is the amount you pay out-of-pocket or others pay on your behaf pus the amount paid by the pan. Our pan wi prepare a written report caed the Part D Expanation of Benefits (it is sometimes caed the Part D EOB ) when you have had one or more prescriptions fied through the pan during the previous month. It incudes: Information for that month. This report gives the payment detais about the prescriptions you have fied during the previous month. It shows the tota drug costs, what the pan paid, and what you and others on your behaf paid. Totas for the year since January 1. This is caed year-to-date information. It shows you the tota drug costs and tota payments for your drugs since the year began. Section 3.2 Hep us keep our information about your drug payments up to date

140 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 6: What you pay for your Part D prescription drugs 138 To keep track of your drug costs and the payments you make for drugs, we use records we get from pharmacies. Here is how you can hep us keep your information correct and up to date: Show your membership card when you get a prescription fied. To make sure we know about the prescriptions you are fiing and what you are paying, show your pan membership card every time you get a prescription fied. Make sure we have the information we need. There are times you may pay for prescription drugs when we wi not automaticay get the information we need to keep track of your out-of-pocket costs. To hep us keep track of your out-of-pocket costs, you may give us copies of receipts for drugs that you have purchased. (If you are bied for a covered drug, you can ask our pan to pay our share of the cost for the drug. For instructions on how to do this, go to Chapter 7, Section 2 of this booket.) Here are some types of situations when you may want to give us copies of your drug receipts to be sure we have a compete record of what you have spent for your drugs: When you purchase a covered drug at a network pharmacy at a specia price or using a discount card that is not part of our pan s benefit. When you made a co-payment for drugs that are provided under a drug manufacturer patient assistance program. Any time you have purchased covered drugs at out-of-network pharmacies or other times you have paid the fu price for a covered drug under specia circumstances. Send us information about the payments others have made for you. Payments made by certain other individuas and organizations aso count toward your out-of-pocket costs and hep quaify you for catastrophic coverage. For exampe, payments made by a State Pharmaceutica Assistance Program, an AIDS drug assistance program (ADAP), the Indian Heath Service, and most charities count toward your out-of-pocket costs. You shoud keep a record of these payments and send them to us so we can track your costs. Check the written report we send you. When you receive a Part D Expanation of Benefits ("Part D EOB") in the mai, pease ook it over to be sure the information is compete and correct. If you think something is missing from the report, or you have any questions, pease ca us at Customer Service (phone numbers are printed on the back cover of this booket). Be sure to keep these reports. They are an important record of your drug expenses.

141 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 6: What you pay for your Part D prescription drugs 139 SECTION 4 Section 4.1 There is no deductibe for WeCare Rx (HMO) You do not pay a deductibe for your Part D drugs. There is no deductibe for WeCare Rx (HMO). You begin in the Initia Coverage Stage when you fi your first prescription of the year. See Section 5 for information about your coverage in the Initia Coverage Stage. SECTION 5 Section 5.1 During the Initia Coverage Stage, the pan pays its share of your drug costs and you pay your share What you pay for a drug depends on the drug and where you fi your prescription During the Initia Coverage Stage, the pan pays its share of the cost of your covered prescription drugs, and you pay your share (your co-payment or coinsurance amount). Your share of the cost wi vary depending on the drug and where you fi your prescription. The pan has five cost-sharing tiers Every drug on the pan s Drug List is in one of five cost-sharing tiers. In genera, the higher the cost-sharing tier number, the higher your cost for the drug: Cost-Sharing Tier 1 (Preferred Generic Drugs) incudes preferred generic drugs. This is the owest cost-sharing tier. Cost-Sharing Tier 2 (Non-Preferred Generic Drugs) incudes ony non-preferred generic drugs. Cost-Sharing Tier 3 (Preferred Brand Drugs) incudes generic & preferred brand drugs. Cost-Sharing Tier 4 (Non-Preferred Brand Drugs) incudes generic & non-preferred brand drugs. Cost-Sharing Tier 5 (Speciaty Tier Drugs) incudes generic & brand drugs. This is the highest cost-sharing tier. To find out which cost-sharing tier your drug is in, ook it up in the pan s Drug List. Your pharmacy choices How much you pay for a drug depends on whether you get the drug from:

142 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 6: What you pay for your Part D prescription drugs 140 A network retai pharmacy that offers standard cost-sharing A network retai pharmacy that offers preferred cost-sharing A pharmacy that is not in the pan s network The pan s mai service pharmacy For more information about these pharmacy choices and fiing your prescriptions, see Chapter 5 in this booket and the pan s Provider & Pharmacy Directory. Generay, we wi cover your prescriptions ony if they are fied at one of our network pharmacies. Some of our network pharmacies aso offer preferred cost-sharing. You may go to either network pharmacies that offer preferred cost-sharing or other network pharmacies that offer standard cost-sharing to receive your covered prescription drugs. Your costs may be ess at pharmacies that offer preferred cost-sharing. Section 5.2 A tabe that shows your costs for a one-month suppy of a drug During the Initia Coverage Stage, your share of the cost of a covered drug wi be either a co-payment or coinsurance. Co-payment means that you pay a fixed amount each time you fi a prescription. Coinsurance means that you pay a percent of the tota cost of the drug each time you fi a prescription. As shown in the tabes beow, the amount of the co-payment or coinsurance depends on which cost-sharing tier your drug is in. Pease note: If your covered drug costs ess than the co-payment amount isted in the chart, you wi pay that ower price for the drug. You pay either the fu price of the drug or the co-payment amount, whichever is ower. We cover prescriptions fied at out-of-network pharmacies in ony imited situations. Pease see Chapter 5, Section 2.5 for information about when we wi cover a prescription fied at an out-of-network pharmacy. Your share of the cost when you get a one-month suppy of a covered Part D prescription drug:

143 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 6: What you pay for your Part D prescription drugs 141 Cost-Sharing Tier 1 (Preferred Generic Drugs), which incudes preferred generic drugs Cost-Sharing Tier 2 (Non-Preferred Generic Drugs), which incudes non-preferred generic drugs Cost-Sharing Tier 3 (Preferred Brand Drugs), which incudes generic & preferred brand drugs Standard retai and mai service cost-sharing (in-network) (uptoa 30-day suppy) Preferred retai cost-sharing (in-network) (uptoa 30-day suppy) Preferred mai service cost-sharing (up to a 30-day suppy) Long-term care (LTC) cost-sharing (uptoa 31-day suppy) Out-ofnetwork cost-sharing (Coverage is imited to certain situations; see Chapter 5 for detais.) (uptoa 30-day suppy) $10.00 $6.00 $6.00 $10.00 $10.00 $33.00 $29.00 $29.00 $33.00 $33.00 $45.00 $40.00 $40.00 $45.00 $45.00

144 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 6: What you pay for your Part D prescription drugs 142 Cost-Sharing Tier 4 (Non-Preferred Brand Drugs), which incudes generic & non-preferred brand drugs Cost-Sharing Tier 5 (Speciaty Tier Drugs), which incudes generic & brand drugs Section 5.3 Standard retai and mai service cost-sharing (in-network) (uptoa 30-day suppy) Preferred retai cost-sharing (in-network) (uptoa 30-day suppy) Preferred mai service cost-sharing (up to a 30-day suppy) Long-term care (LTC) cost-sharing (uptoa 31-day suppy) Out-ofnetwork cost-sharing (Coverage is imited to certain situations; see Chapter 5 for detais.) (uptoa 30-day suppy) $95.00 $90.00 $90.00 $95.00 $ % 33% 33% 33% 33% If your doctor prescribes ess than a fu month s suppy, you may not have to pay the cost of the entire month s suppy Typicay, you pay a co-pay to cover a fu month s suppy of a covered drug. However your doctor can prescribe ess than a month s suppy of drugs. There may be times when you want to ask your doctor about prescribing ess than a month s suppy of a drug (for exampe, when you are trying a medication for the first time that is known to have serious side effects). If your doctor agrees, you wi not have to pay for the fu month s suppy for certain drugs.

145 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 6: What you pay for your Part D prescription drugs 143 The amount you pay when you get ess than a fu month s suppy wi depend on whether you are responsibe for paying coinsurance (a percentage of the tota cost) or a co-payment (a fat doar amount). If you are responsibe for coinsurance, you pay a percentage of the tota cost of the drug. You pay the same percentage regardess of whether the prescription is for a fu month s suppy or for fewer days. However, because the entire drug cost wi be ower if you get ess than a fu month s suppy, the amount you pay wi be ess. If you are responsibe for a co-payment for the drug, your co-pay wi be based on the number of days of the drug that you receive. We wi cacuate the amount you pay per day for your drug (the daiy cost-sharing rate ) and mutipy it by the number of days of the drug you receive. Here s an exampe: Let s say the co-pay for your drug for a fu month s suppy (a 30-day suppy) is $30. This means that the amount you pay per day for your drug is $1. If you receive a 7 days suppy of the drug, your payment wi be $1 per day mutipied by 7 days, for a tota payment of $7. You shoud not have to pay more per day just because you begin with ess than a month s suppy. Let s go back to the exampe above. Let s say you and your doctor agree that the drug is working we and that you shoud continue taking the drug after your 7 days suppy runs out. If you receive a second prescription for the rest of the month, or 23 days more of the drug, you wi sti pay $1 per day, or $23. Your tota cost for the month wi be $7 for your first prescription and $23 for your second prescription, for a tota of $30 the same as your co-pay woud be for a fu month s suppy. Daiy cost-sharing aows you to make sure a drug works for you before you have to pay for an entire month s suppy. Section 5.4 A tabe that shows your costs for a ong-term (uptoa90-day) suppy of a drug For some drugs, you can get a ong-term suppy (aso caed an extended suppy ) when you fi your prescription. A ong-term suppy is up to a 90-day suppy. (For detais on where and how to get a ong-term suppy of a drug, see Chapter 5, Section 2.4) The tabe beow shows what you pay when you get a ong-term (up to a 90-day) suppy of a drug.

146 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 6: What you pay for your Part D prescription drugs 144 Pease note: If your covered drug costs ess than the co-payment amount isted in the chart, you wi pay that ower price for the drug. You pay either the fu price of the drug or the co-payment amount, whichever is ower. Your share of the cost when you get a ong-term (90-day) suppy of a covered Part D prescription drug from: Cost-Sharing Tier 1 (Preferred Generic Drugs), which incudes preferred generic drugs Cost-Sharing Tier 2 (Non-Preferred Generic Drugs), which incudes non-preferred generic drugs Cost-Sharing Tier 3 (Preferred Brand Drugs), which incudes generic & preferred brand drugs Cost-Sharing Tier 4 (Non-Preferred Brand Drugs), which incudes generic & non-preferred brand drugs Cost-Sharing Tier 5 (Speciaty Tier Drugs), which incudes generic & brand drugs Standard retai and mai service cost-sharing (in-network) (uptoa 90-day suppy) Preferred retai cost-sharing (in-network) (up to a 90-day suppy) Preferred mai service cost-sharing (uptoa 90-day suppy) $30.00 $18.00 $0.00 $99.00 $87.00 $72.50 $ $ $ $ $ $ A ong-term suppy is not avaiabe for drugs in Tier 5 A ong-term suppy is not avaiabe for drugs in Tier 5 A ong-term suppy is not avaiabe for drugs in Tier 5

147 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 6: What you pay for your Part D prescription drugs 145 Section 5.5 You stay in the Initia Coverage Stage unti your tota drug costs for the year reach $2,960 You stay in the Initia Coverage Stage unti the tota amount for the prescription drugs you have fied and refied reaches the $2,960 imit for the Initia Coverage Stage. Your tota drug cost is based on adding together what you have paid and what any Part D pan has paid: What you have paid for a the covered drugs you have gotten since you started with your first drug purchase of the year. (See Section 6.2 for more information about how Medicare cacuates your out-of-pocket costs.) This incudes: The tota you paid as your share of the cost for your drugs during the Initia Coverage Stage. What the pan has paid as its share of the cost for your drugs during the Initia Coverage Stage. (If you were enroed in a different Part D pan at any time during 2015, the amount that pan paid during the Initia Coverage Stage aso counts toward your tota drug costs.) The Part D Expanation of Benefits (Part D EOB) that we send to you wi hep you keep track of how much you and the pan, as we as any third parties, have spent on your behaf during the year. Many peope do not reach the $2,960 imit in a year. We wi et you know if you reach this $2,960 amount. If you do reach this amount, you wi eave the Initia Coverage Stage and move on to the Coverage Gap Stage. SECTION 6 Section 6.1 During the Coverage Gap Stage, you receive a discount on brand name drugs and pay no more than 65% of the costs of generic drugs You stay in the Coverage Gap Stage unti your out-of-pocket costs reach $4,700 When you are in the Coverage Gap Stage, the Medicare Coverage Gap Discount Program provides manufacturer discounts on brand name drugs. You pay 45% of the negotiated price (excuding the dispensing fee and vaccine administration fee, if any) for brand name drugs. Both the amount you pay and the amount discounted by the manufacturer count toward your out-of-pocket costs as if you had paid them and moves you through the coverage gap.

148 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 6: What you pay for your Part D prescription drugs 146 You aso receive some coverage for generic drugs. You pay no more than 65% of the cost for generic drugs and the pan pays the rest. For generic drugs, the amount paid by the pan (35%) does not count toward your out-of-pocket costs. Ony the amount you pay counts and moves you through the coverage gap. You continue paying the discounted price for brand name drugs and no more than 65% of the costs of generic drugs unti your yeary out-of-pocket payments reach a maximum amount that Medicare has set. In 2015, that amount is $4,700. Medicare has rues about what counts and what does not count as your out-of-pocket costs. When you reach an out-of-pocket imit of $4,700, you eave the Coverage Gap Stage and move on to the Catastrophic Coverage Stage. Section 6.2 How Medicare cacuates your out-of-pocket costs for prescription drugs Here are Medicare s rues that we must foow when we keep track of your out-of-pocket costs for your drugs. These payments are incuded in your out-of-pocket costs When you add up your out-of-pocket costs, you can incude the payments isted beow (as ong as they are for Part D covered drugs and you foowed the rues for drug coverage that are expained in Chapter 5 of this booket): The amount you pay for drugs when you are in any of the foowing drug payment stages: The Initia Coverage Stage. The Coverage Gap Stage. Any payments you made during this caendar year as a member of a different Medicare prescription drug pan before you joined our pan. It matters who pays: If you make these payments yoursef, they are incuded in your out-of-pocket costs. These payments are aso incuded if they are made on your behaf by certain other individuas or organizations. This incudes payments for your drugs

149 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 6: What you pay for your Part D prescription drugs 147 made by a friend or reative, by most charities, by AIDS drug assistance programs, by a State Pharmaceutica Assistance Program that is quaified by Medicare, or by the Indian Heath Service. Payments made by Medicare s Extra Hep Program are aso incuded. Some of the payments made by the Medicare Coverage Gap Discount Program are incuded. The amount the manufacturer pays for your brand name drugs is incuded. But the amount the pan pays for your generic drugs is not incuded. Moving on to the Catastrophic Coverage Stage: When you (or those paying on your behaf) have spent a tota of $4,700 in out-of-pocket costs within the caendar year, you wi move from the Coverage Gap Stage to the Catastrophic Coverage Stage. These payments are not incuded in your out-of-pocket costs When you add up your out-of-pocket costs, you are not aowed to incude any of these types of payments for prescription drugs: The amount you pay for your monthy premium. Drugs you buy outside the United States and its territories. Drugs that are not covered by our pan. Drugs you get at an out-of-network pharmacy that do not meet the pan s requirements for out-of-network coverage. Non-Part D drugs, incuding prescription drugs covered by Part A or Part B and other drugs excuded from coverage by Medicare. Payments you make toward prescription drugs not normay covered in a Medicare Prescription Drug Pan Payments made by the pan for your brand or generic drugs whie in the Coverage Gap. Payments for your drugs that are made by group heath pans incuding empoyer heath pans. Payments for your drugs that are made by certain insurance pans and government-funded heath programs such as TRICARE and the Veteran s Administration. Payments for your drugs made by a third-party with a ega obigation to pay for prescription costs (for exampe, Worker s Compensation).

150 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 6: What you pay for your Part D prescription drugs 148 Reminder: If any other organization such as the ones isted above pays part or a of your out-of-pocket costs for drugs, you are required to te our pan. Ca Customer Service to et us know (phone numbers are printed on the back cover of this booket). How can you keep track of your out-of-pocket tota? We wi hep you. The Part D Expanation of Benefits (Part D EOB) report we send to you incudes the current amount of your out-of-pocket costs (Section 3 in this chapter tes about this report). When you reach a tota of $4,700 in out-of-pocket costs for the year, this report wi te you that you have eft the Coverage Gap Stage and have moved on to the Catastrophic Coverage Stage. Make sure we have the information we need. Section 3.2 tes what you can do to hep make sure that our records of what you have spent are compete and up to date. SECTION 7 Section 7.1 During the Catastrophic Coverage Stage, the pan pays most of the cost for your drugs Once you are in the Catastrophic Coverage Stage, you wi stay in this stage for the rest of the year You quaify for the Catastrophic Coverage Stage when your out-of-pocket costs have reached the $4,700 imit for the caendar year. Once you are in the Catastrophic Coverage Stage, you wi stay in this payment stage unti the end of the caendar year. During this stage, the pan wi pay most of the cost for your drugs. Your share of the cost for a covered drug wi be either coinsurance or a co-payment, whichever is the arger amount: either coinsurance of 5% of the cost of the drug or $2.65 for a generic drug or a drug that is treated ike a generic and $6.60 for a other drugs. Our pan pays the rest of the cost. SECTION 8 What you pay for vaccinations covered by Part D depends on how and where you get them

151 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 6: What you pay for your Part D prescription drugs 149 Section 8.1 Our pan has separate coverage for the Part D vaccine medication itsef and for the cost of giving you the vaccination shot Our pan provides coverage of a number of Part D vaccines. We aso cover vaccines that are considered medica benefits. You can find out about coverage of these vaccines by going to the Medica Benefits Chart in Chapter 4, Section 2.1. There are two parts to our coverage of Part D vaccinations: The first part of coverage is the cost of the vaccine medication itsef. The vaccine is a prescription medication. The second part of coverage is for the cost of giving you the vaccination shot. (This is sometimes caed the administration of the vaccine.) What do you pay for a Part D vaccination? What you pay for a Part D vaccination depends on three things: 1. The type of vaccine (what you are being vaccinated for). Some vaccines are considered medica benefits. You can find out about your coverage of these vaccines by going to Chapter 4, Medica Benefits Chart (what is covered and what you pay). Other vaccines are considered Part D drugs. You can find these vaccines isted in the pan s List of Covered Drugs (Formuary). 2. Where you get the vaccine medication. 3. Who gives you the vaccination shot. What you pay at the time you get the Part D vaccination can vary depending on the circumstances. For exampe: Sometimes when you get your vaccination shot, you wi have to pay the entire cost for both the vaccine medication and for getting the vaccination shot. You can ask our pan to pay you back for our share of the cost.

152 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 6: What you pay for your Part D prescription drugs 150 Other times, when you get the vaccine medication or the vaccination shot, you wi pay ony your share of the cost. To show how this works, here are three common ways you might get a Part D vaccination shot. Remember you are responsibe for a of the costs associated with vaccines (incuding their administration) during the Coverage Gap Stage of your benefit. Situation 1: You buy the Part D vaccine at the pharmacy and you get your vaccination shot at the network pharmacy. (Whether you have this choice depends on where you ive. Some states do not aow pharmacies to administer a vaccination.) You wi have to pay the pharmacy the amount of your coinsurance or co-payment for the vaccine and the cost of giving you the vaccination shot. Our pan wi pay the remainder of the costs. Situation 2: You get the Part D vaccination at your doctor s office. When you get the vaccination, you wi pay for the entire cost of the vaccine and its administration. You can then ask our pan to pay our share of the cost by using the procedures that are described in Chapter 7 of this booket (Asking us to pay our share of a bi you have received for covered medica services or drugs). You wi be reimbursed the amount you paid ess your norma coinsurance or co-payment for the vaccine (incuding administration) ess any difference between the amount the doctor charges and what we normay pay. (If you get Extra Hep, we wi reimburse you for this difference.) Situation 3: You buy the Part D vaccine at your pharmacy, and then take it to your doctor s office where they give you the vaccination shot. You wi have to pay the pharmacy the amount of your coinsurance or co-payment for the vaccine itsef. When your doctor gives you the vaccination shot, you wi pay the entire cost for this service. You can then ask our pan to

153 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 6: What you pay for your Part D prescription drugs 151 pay our share of the cost by using the procedures described in Chapter 7 of this booket. You wi be reimbursed the amount charged by the doctor for administering the vaccine ess any difference between the amount the doctor charges and what we normay pay. (If you get Extra Hep, we wi reimburse you for this difference.) Section 8.2 You may want to ca us at Customer Service before you get a vaccination The rues for coverage of vaccinations are compicated. We are here to hep. We recommend that you ca us first at Customer Service whenever you are panning to get a vaccination. (Phone numbers for Customer Service are printed on the back cover of this booket). We can te you about how your vaccination is covered by our pan and expain your share of the cost. We can te you how to keep your own cost down by using providers and pharmacies in our network. If you are not abe to use a network provider and pharmacy, we can te you what you need to do to get payment from us for our share of the cost. SECTION 9 Section 9.1 Do you have to pay the Part D ate enroment penaty? What is the Part D ate enroment penaty? Note: If you receive Extra Hep from Medicare to pay for your prescription drugs, you wi not pay a ate enroment penaty. The ate enroment penaty is an amount that is added to you Part D premium. You may owe a ate enroment penaty if at any time after your initia enroment period is over, there is a period of 63 days or more in a row when you did not have Part D or other creditabe prescription drug coverage. Creditabe prescription drug coverage is coverage that meets Medicare s minimum standards since it is expected to pay, on average, at east as much as Medicare s standard prescription drug coverage. The amount of the penaty depends on how ong you waited to enro in a creditabe prescription drug coverage pan any time after the end of your initia enroment period

154 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 6: What you pay for your Part D prescription drugs 152 or how many fu caendar months you went without creditabe prescription drug coverage. You wi have to pay this penaty for as ong as you have Part D Coverage. The penaty is added to your monthy premium. When you first enro in our pan, we et you know the amount of the penaty. Your ate enroment penaty is considered part of your pan premium. Section 9.2 How much is the Part D ate enroment penaty? Medicare determines the amount of the penaty. Here is how it works: First count the number of fu months that you deayed enroing in a Medicare drug pan, after you were eigibe to enro. Or count the number of fu months in which you did not have creditabe prescription drug coverage, if the break in coverage was 63 days or more. The penaty is 1% for every month that you didn t have creditabe coverage. For our exampe, if you go 14 months without coverage, the penaty wi be 14%. Then Medicare determines the amount of the average monthy premium for Medicare drug pans in the nation from the previous year. For 2014, this average premium amount was $ This amount may change for To cacuate your monthy penaty, you mutipy the penaty percentage and the average monthy premium and then round it to the nearest 10 cents. In the exampe here it woud be 14% times $32.42, which equas $ This rounds to $4.50. This amount woud be added to the monthy premium for someone with a ate enroment penaty. There are three important things to note about this monthy ate-enroment penaty: First, the penaty may change each year, because the average monthy premium can change each year. If the nationa average premium (as determined by Medicare) increases, your penaty wi increase. Second, you wi continue to pay a penaty every month for as ong as you are enroed in a pan that has Medicare Part D drug benefits. Third, if you are under 65 and currenty receiving Medicare benefits, the ate enroment penaty wi reset when you turn 65. After age 65, your ate enroment penaty wi be based ony on the months that you don t have coverage after your initia enroment period for aging into Medicare.

155 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 6: What you pay for your Part D prescription drugs 153 Section 9.3 In some situations, you can enro ate and not have to pay the penaty Even if you have deayed enroing in a pan offering Medicare Part D coverage when you were first eigibe, sometimes you do not have to pay the ate enroment penaty. You wi not have to pay a penaty for ate enroment if you are in any of these situations: If you aready have prescription drug coverage that is expected to pay, on average, at east as much as Medicare s standard prescription drug coverage. Medicare cas this creditabe drug coverage. Pease note: Creditabe coverage coud incude drug coverage from a former empoyer or union, TRICARE, or the Department of Veterans Affairs. Your insurer or your human resources department wi te you each year if your drug coverage is creditabe coverage. This information may be sent to you in a etter or incuded in a newsetter from the pan. Keep this information, because you may need it if you join a Medicare drug pan ater. u Pease note: If you receive a certificate of creditabe coverage when your heath coverage ends, it may not mean your prescription drug coverage was creditabe. The notice must state that you had creditabe prescription drug coverage that expected to pay as much as Medicare s standard prescription drug pan pays. The foowing are not creditabe prescription drug coverage: prescription drug discount cards, free cinics, and drug discount websites. For additiona information about creditabe coverage, pease ook in your Medicare & You 2015 Handbook or ca Medicare at MEDICARE ( ). TTY users ca You can ca these numbers for free, 24 hours a day, 7 days a week. If you were without creditabe coverage, but you were without it for ess than 63 days in a row. If you are receiving Extra Hep from Medicare. Section 9.4 What can you do if you disagree about your ate enroment penaty?

156 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 6: What you pay for your Part D prescription drugs 154 If you disagree about your ate enroment penaty, you or your representative can ask for a review of the decision about your ate enroment penaty. Generay, you must request this review within 60 days from the date on the etter you receive stating you have to pay a ate enroment penaty. Ca Customer Service to find out more about how to do this (phone numbers are printed on the back cover of this booket). SECTION 10 Section 10.1 Do you have to pay an extra Part D amount because of your income? Who pays an extra Part D amount because of income? Most peope pay a standard monthy Part D premium. However, some peope pay an extra amount because of their yeary income. If your income is $85,000 or above for an individua (or married individuas fiing separatey) or $170,000 or above for married coupes, you must pay an extra amount directy to the government for your Medicare Part D coverage. If you have to pay an extra amount, Socia Security, not your Medicare pan, wi send you a etter teing you what that extra amount wi be and how to pay it. The extra amount wi be withhed from your Socia Security, Rairoad Retirement Board, or Office of Personne Management benefit check, no matter how you usuay pay your pan premium, uness your monthy benefit isn t enough to cover the extra amount owed. If your benefit check isn t enough to cover the extra amount, you wi get a bi from Medicare. You must pay the extra amount to the government. It cannot be paid with your monthy pan premium. Section 10.2 How much is the extra Part D amount? If your modified adjusted gross income (MAGI) as reported on your IRS tax return is above a certain amount, you wi pay an extra amount in addition to your monthy pan premium. The chart beow shows the extra amount based on your income.

157 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 6: What you pay for your Part D prescription drugs 155 If you fied an individua tax return and your income in 2013 was: If you were married but fied a separate tax return and your income in 2013 was: If you fied a joint tax return and your income in 2013 was: This is the monthy cost of your extra Part D amount (to be paid in addition to your pan premium) Equa to or ess than $85,000 Equa to or ess than $85,000 Equa to or ess than $170,000 $0 Greater than $85,000 and ess than or equa to $107,000 Greater than $170,000 and ess than or equa to $214,000 $12.30 Greater than $107,000 and ess than or equa to $160,000 Greater than $214,000 and ess than or equa to $320,000 $31.80 Greater than $160,000 and ess than or equa to $214,000 Greater than $85,000 and ess than or equa to $129,000 Greater than $320,000 and ess than or equa to $428,000 $51.30 Greater than $214,000 Greater than $129,000 Greater than $428,000 $70.80 Section 10.3 What can you do if you disagree about paying an extra Part D amount? If you disagree about paying an extra amount because of your income, you can ask Socia Security to review the decision. To find out more about how to do this, contact the Socia Security Administration at (TTY ). Section 10.4 What happens if you do not pay the extra Part D amount?

158 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 6: What you pay for your Part D prescription drugs 156 The extra amount is paid directy to the government (not your Medicare pan) for your Medicare Part D coverage. If you are required to pay the extra amount and you do not pay it, you wi be disenroed from the pan and ose prescription drug coverage.

159 2015 Evidence of Coverage for WeCare Rx (HMO) 157 Chapter 7: Asking us to pay our share of a bi you have received for covered medica services or drugs Chapter 7. Asking us to pay our share of a bi you have received for covered medica services or drugs SECTION 1 Situations in which you shoud ask us to pay our share of the cost of your covered services or drugs Section 1.1 If you pay our pan s share of the cost of your covered services or drugs, or if you receive a bi, you can ask us for payment SECTION 2 How to ask us to pay you back or to pay a bi you have received Section 2.1 How and where to send us your request for payment SECTION 3 We wi consider your request for payment and say yes or no Section 3.1 We check to see whether we shoud cover the service or drug and how much we owe Section 3.2 If we te you that we wi not pay for a or part of the medica care or drug, you can make an appea SECTION 4 Other situations in which you shoud save your receipts and send copies to us Section 4.1 In some cases, you shoud send copies of your receipts to us to hep us track your out-of-pocket drug costs

160 2015 Evidence of Coverage for WeCare Rx (HMO) 158 Chapter 7: Asking us to pay our share of a bi you have received for covered medica services or drugs SECTION 1 Section 1.1 Situations in which you shoud ask us to pay our share of the cost of your covered services or drugs If you pay our pan s share of the cost of your covered services or drugs, or if you receive a bi, you can ask us for payment Sometimes when you get medica care or a prescription drug, you may need to pay the fu cost right away. Other times, you may find that you have paid more than you expected under the coverage rues of the pan. In either case, you can ask our pan to pay you back (paying you back is often caed reimbursing you). It is your right to be paid back by our pan whenever you ve paid more than your share of the cost for medica services or drugs that are covered by our pan. There may aso be times when you get a bi from a provider for the fu cost of medica care you have received. In many cases, you shoud send this bi to us instead of paying it. We wi ook at the bi and decide whether the services shoud be covered. If we decide they shoud be covered, we wi pay the provider directy. Here are exampes of situations in which you may need to ask our pan to pay you back or to pay a bi you have received. 1. When you ve received emergency or urgenty needed medica care from a provider who is not in our pan s network You can receive emergency services from any provider, whether or not the provider is a part of our network. When you receive emergency or urgenty needed care from a provider who is not part of our network, you are ony responsibe for paying your share of the cost, not for the entire cost. You shoud ask the provider to bi the pan for our share of the cost. If you pay the entire amount yoursef at the time you receive the care, you need to ask us to pay you back for our share of the cost. Send us the bi, aong with documentation of any payments you have made. At times you may get a bi from the provider asking for payment that you think you do not owe. Send us this bi, aong with documentation of any payments you have aready made. If the provider is owed anything, we wi pay the provider directy. If you have aready paid more than your share of the cost of the service, we wi determine how much you are owed and pay you back for our share of the cost.

161 2015 Evidence of Coverage for WeCare Rx (HMO) 159 Chapter 7: Asking us to pay our share of a bi you have received for covered medica services or drugs 2. When a network provider sends you a bi you think you shoud not pay Network providers shoud aways bi the pan directy, and ask you ony for your share of the cost. But sometimes they make mistakes, and ask you to pay more than your share. You ony have to pay your cost-sharing amount when you get services covered by our pan. We do not aow providers to add additiona separate charges, caed baance biing. This protection (that you never pay more than your cost-sharing amount) appies even if we pay the provider ess than the provider charges for a service and even if there is a dispute and we don t pay certain provider charges. For more information about baance biing, go to Chapter 4, Section 1.3. Whenever you get a bi from a network provider that you think is more than you shoud pay, send us the bi. We wi contact the provider directy and resove the biing probem. If you have aready paid a bi to a network provider, but you fee that you paid too much, send us the bi aong with documentation of any payment you have made and ask us to pay you back the difference between the amount you paid and the amount you owed under the pan. 3. If you are retroactivey enroed in our pan. Sometimes a person s enroment in the pan is retroactive. (Retroactive means that the first day of their enroment has aready passed. The enroment date may even have occurred ast year.) If you were retroactivey enroed in our pan and you paid out-of-pocket for any of your covered services or drugs after your enroment date, you can ask us to pay you back for our share of the costs. You wi need to submit paperwork for us to hande the reimbursement. Pease ca Customer Service for additiona information about how to ask us to pay you back and deadines for making your request. (Phone numbers for Customer Service are printed on the back cover of this booket.) 4. When you use an out-of-network pharmacy to get a prescription fied If you go to an out-of-network pharmacy and try to use your membership card to fi a prescription, the pharmacy may not be abe to submit the caim directy to us. When that happens, you wi have to pay the fu cost of your prescription. (We

162 2015 Evidence of Coverage for WeCare Rx (HMO) 160 Chapter 7: Asking us to pay our share of a bi you have received for covered medica services or drugs cover prescriptions fied at out-of-network pharmacies ony in a few specia situations. Pease go to Chapter 5, Sec. 2.5 to earn more.) Save your receipt and send a copy to us when you ask us to pay you back for our share of the cost. 5. When you pay the fu cost for a prescription because you don t have your pan membership card with you If you do not have your pan membership card with you, you can ask the pharmacy to ca the pan or to ook up your pan enroment information. However, if the pharmacy cannot get the enroment information they need right away, you may need to pay the fu cost of the prescription yoursef. Save your receipt and send a copy to us when you ask us to pay you back for our share of the cost. 6. When you pay the fu cost for a prescription in other situations You may pay the fu cost of the prescription because you find that the drug is not covered for some reason. For exampe, the drug may not be on the pan s List of Covered Drugs (Formuary); or it coud have a requirement or restriction that you didn t know about or don t think shoud appy to you. If you decide to get the drug immediatey, you may need to pay the fu cost for it. Save your receipt and send a copy to us when you ask us to pay you back. In some situations, we may need to get more information from your doctor in order to pay you back for our share of the cost. A of the exampes above are types of coverage decisions. This means that if we deny your request for payment, you can appea our decision. Chapter 9 of this booket (What to do if you have a probem or compaint (coverage decisions, appeas, compaints)) has information about how to make an appea. SECTION 2 Section 2.1 How to ask us to pay you back or to pay a bi you have received How and where to send us your request for payment

163 2015 Evidence of Coverage for WeCare Rx (HMO) 161 Chapter 7: Asking us to pay our share of a bi you have received for covered medica services or drugs Send us your request for payment, aong with your bi and documentation of any payment you have made. It s a good idea to make a copy of your bi and receipts for your records. To make sure you are giving us a the information we need to make a decision, you can fi out our caim form to make your request for payment. You don t have to use the form, but it wi hep us process the information faster. Either downoad a copy of the form from our website ( or ca Customer Service and ask for the form. (Phone numbers for Customer Service are printed on the back cover of this booket.) Mai your request for payment together with any bis or receipts to us at this address: For Prescription Reimbursements ony: WeCare Heath Pans Pharmacy - Prescription Reimbursement Department P.O. Box Tampa, FL For Medica Reimbursements ony: WeCare Heath Pans Medica Reimbursement Department P.O. Box Tampa, FL You must submit your caim to us within 365 days of the date you received the service, item or drug. Contact Customer Service if you have any questions (phone numbers are printed on the back cover of this booket). If you don t know what you shoud have paid, or you receive bis and you don t know what to do about those bis, we can hep. You can aso ca if you want to give us more information about a request for payment you have aready sent to us. SECTION 3 Section 3.1 We wi consider your request for payment and say yes or no We check to see whether we shoud cover the service or drug and how much we owe When we receive your request for payment, we wi et you know if we need any additiona information from you. Otherwise, we wi consider your request and make a coverage decision. If we decide that the medica care or drug is covered and you foowed a the rues for getting the care or drug, we wi pay for our share of the cost. If you have aready paid for the service or drug, we wi mai your reimbursement of

164 2015 Evidence of Coverage for WeCare Rx (HMO) 162 Chapter 7: Asking us to pay our share of a bi you have received for covered medica services or drugs our share of the cost to you. If you have not paid for the service or drug yet, we wi mai the payment directy to the provider. (Chapter 3 expains the rues you need to foow for getting your medica services covered. Chapter 5 expains the rues you need to foow for getting your Part D prescription drugs covered.) If we decide that the medica care or drug is not covered, or you did not foow a the rues, we wi not pay for our share of the cost. Instead, we wi send you a etter that expains the reasons why we are not sending the payment you have requested and your rights to appea that decision. Section 3.2 If we te you that we wi not pay for a or part of the medica care or drug, you can make an appea If you think we have made a mistake in turning down your request for payment or you don't agree with the amount we are paying, you can make an appea. If you make an appea, it means you are asking us to change the decision we made when we turned down your request for payment. For the detais on how to make this appea, go to Chapter 9 of this booket (What to do if you have a probem or compaint (coverage decisions, appeas, compaints)). The appeas process is a forma process with detaied procedures and important deadines. If making an appea is new to you, you wi find it hepfu to start by reading Section 4 of Chapter 9. Section 4 is an introductory section that expains the process for coverage decisions and appeas and gives definitions of terms such as appea. Then after you have read Section 4, you can go to the section in Chapter 9 that tes what to do for your situation: If you want to make an appea about getting paid back for a medica service, go to Section 5.3 in Chapter 9. If you want to make an appea about getting paid back for a drug, go to Section 6.5 of Chapter 9. SECTION 4 Section 4.1 Other situations in which you shoud save your receipts and send copies to us In some cases, you shoud send copies of your receipts to us to hep us track your out-of-pocket drug costs There are some situations when you shoud et us know about payments you have made for your drugs. In these cases, you are not asking us for payment. Instead, you are teing us about your payments so that we can cacuate your out-of-pocket costs

165 2015 Evidence of Coverage for WeCare Rx (HMO) 163 Chapter 7: Asking us to pay our share of a bi you have received for covered medica services or drugs correcty. This may hep you to quaify for the Catastrophic Coverage Stage more quicky. Here are two situations when you shoud send us copies of receipts to et us know about payments you have made for your drugs: 1. When you buy the drug for a price that is ower than our price Sometimes when you are in the Coverage Gap Stage you can buy your drug at a network pharmacy for a price that is ower than our price. For exampe, a pharmacy might offer a specia price on the drug. Or you may have a discount card that is outside our benefit that offers a ower price. Uness specia conditions appy, you must use a network pharmacy in these situations and your drug must be on our Drug List. Save your receipt and send a copy to us so that we can have your out-of-pocket expenses count toward quaifying you for the Catastrophic Coverage Stage. Pease note: If you are in the Coverage Gap Stage, we wi not pay for any share of these drug costs. But sending a copy of the receipt aows us to cacuate your out-of-pocket costs correcty and may hep you quaify for the Catastrophic Coverage Stage more quicky. 2. When you get a drug through a patient assistance program offered by a drug manufacturer Some members are enroed in a patient assistance program offered by a drug manufacturer that is outside the pan benefits. If you get any drugs through a program offered by a drug manufacturer, you may pay a co-payment to the patient assistance program. Save your receipt and send a copy to us so that we can have your out-of-pocket expenses count toward quaifying you for the Catastrophic Coverage Stage. Pease note: Because you are getting your drug through the patient assistance program and not through the pan s benefits, we wi not pay for any share of these drug costs. But sending a copy of the receipt aows us to cacuate your out-of-pocket costs correcty and may hep you quaify for the Catastrophic Coverage Stage more quicky. Since you are not asking for payment in the two cases described above, these situations are not considered coverage decisions. Therefore, you cannot make an appea if you disagree with our decision.

166 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 8: Your rights and responsibiities 164 Chapter 8. Your rights and responsibiities SECTION 1 Our pan must honor your rights as a member of the pan Section 1.1 We must provide information in a way that works for you (in anguages other than Engish, in Braie, or other aternate formats, etc.) Section 1.2 We must treat you with fairness, respect, and dignity at a times..166 Section 1.3 We must ensure that you get timey access to your covered services and drugs Section 1.4 We must protect the privacy of your persona heath information Section 1.5 We must give you information about the pan, its network of providers, your covered services and your rights and responsibiities Section 1.6 We must support your right to make decisions about your care Section 1.7 You have the right to make compaints and to ask us to reconsider decisions we have made Section 1.8 What can you do if you beieve you are being treated unfairy or your rights are not being respected? Section 1.9 You have the right to make recommendations as we as get more information about your rights and responsibiities SECTION 2 You have some responsibiities as a member of the pan Section 2.1 What are your responsibiities?

167 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 8: Your rights and responsibiities 165 SECTION 1 Section 1.1 Our pan must honor your rights as a member of the pan We must provide information in a way that works for you (in anguages other than Engish, in Braie, or other aternate formats, etc.) To get information from us in a way that works for you, pease ca Customer Service (phone numbers are printed on the back cover of this booket). Our pan has peope and free anguage interpreter services avaiabe to answer questions from non-engish speaking members. We aso have materias avaiabe in anguages other than Engish that are spoken in the pan s service area. We can aso give you information in Braie or other aternate formats if you need it. If you are eigibe for Medicare because of a disabiity, we are required to give you information about the pan s benefits that is accessibe and appropriate for you. If you have any troube getting information from our pan because of probems reated to anguage or disabiity, pease ca Medicare at MEDICARE ( ), 24 hours a day, 7 days a week, and te them that you want to fie a compaint. TTY users ca Para obtener información de nosotros de una manera comprensibe para usted, por favor ame a Servicio a Ciente (os números de teéfono están indicados en a parte posterior de este foeto). Nuestro pan tiene personas y servicios disponibes de interpretación a otros idiomas gratis para responder as preguntas de aqueos miembros que no haban ingés. También tenemos materiaes disponibes en idiomas diferentes de ingés que se haban en e área de servicio de pan. También podemos dare información en Braie u otros formatos aternativos si os necesita. Si usted es eegibe para Medicare por discapacidad, tenemos a obigación de brindare información sobre os beneficios de pan que sea accesibe y adecuada para usted. Si tiene probemas para obtener información sobre nuestro pan debido a idioma o discapacidad, por favor ame a Medicare a MEDICARE ( ) as 24 horas de día, os 7 días de a semana, y dígaes que desea presentar una queja. Los usuarios de TTY amen a

168 2015 Evidence of Coverage for WeCare Rx (HMO) Chapter 8: Your rights and responsibiities 166 Section 1.2 We must treat you with fairness, respect, and dignity at a times Our pan must obey aws that protect you from discrimination or unfair treatment. We do not discriminate based on a person s race, ethnicity, nationa origin, reigion, gender, age, menta or physica disabiity, heath status, caims experience, medica history, genetic information, evidence of insurabiity, or geographic ocation within the service area. If you want more information or have concerns about discrimination or unfair treatment, pease ca the Department of Heath and Human Services Office for Civi Rights (TTY ) or your oca Office for Civi Rights. If you have a disabiity and need hep with access to care, pease ca us at Customer Service (phone numbers are printed on the back cover of this booket). If you have a compaint, such as a probem with wheechair access, Customer Service can hep. Section 1.3 We must ensure that you get timey access to your covered services and drugs As a member of our pan, you have the right to choose a primary care provider (PCP) in the pan s network to provide and arrange for your covered services (Chapter 3 expains more about this). Ca Customer Service to earn which doctors are accepting new patients (phone numbers are printed on the back cover of this booket). You aso have the right to go to a women s heath speciaist (such as a gynecoogist) without a referra. As a pan member, you have the right to get appointments and covered services from the pan s network of providers within a reasonabe amount of time. This incudes the right to get timey services from speciaists when you need that care. You aso have