Health Partners Medicare. Your family. Our focus Summary of Benefits. Value and Prime (HMO) Plans

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1 Yur family Our fcus 2017 Summary f Benefits Health Partners Medicare Value and Prime (HMO) Plans

2 Summary f Benefits Health Partners Medicare (H9207) (plan 009) (plan 010) This is a summary f drug and health services cvered by Health Partners Medicare Value and Health Partners Medicare Prime fr the plan year: January 1, 2017 December 31, The benefit infrmatin prvided is a summary f what we cver and what yu pay. It des nt list every service that we cver r list every limitatin r exclusin. T get a cmplete list f services we cver, please request the Evidence f Cverage. This infrmatin is available fr free in ther languages. This dcument is available in ther frmats such as Braille and large print. Please call ur Member Relatins number at (TTY 711), 24 hurs a day, seven days a week. Esta infrmación está dispnible sin cst en trs idimas. Este dcument pdría estar dispnible en trs frmats cm Braille y letra grande. Llame a nuestr númer de teléfn de Servicis para Miembrs al (TTY 711), las 24 hras del día, ls siete días de la semana. Health Partners Medicare has a netwrk f dctrs, hspitals, pharmacies and ther prviders. If yu use prviders that are nt in ur netwrk, the plan may nt pay fr these services. Fr infrmatin abut prescriptin drugs cvered, please see the plan s Frmulary. Fr infrmatin abut prviders and pharmacies in ur netwrk, see ur Prvider & Pharmacy Directry. These dcuments are available at r by calling the plan at (TTY 711). Yu can call 24 hurs a day, seven days a week. T jin Health Partners Medicare Value r Health Partners Medicare Prime, yu must be entitled t Medicare Part A, be enrlled in Medicare Part B, and live in ur service area. Our service area includes the fllwing cunties in Pennsylvania: Lancaster, Lehigh, and Nrthamptn. T learn mre abut the cverage and csts f Original Medicare, lk in yur current Medicare & Yu handbk. View it nline at r get a cpy by calling MEDICARE ( ), 24 hurs a day, seven days a week. TTY users shuld call Health Partners Medicare is an HMO plan with Medicare and Pennsylvania State Medicaid prgram cntracts. Enrllment in Health Partners Medicare depends n cntract renewal. This infrmatin is nt a cmplete descriptin f benefits. Cntact the plan fr mre infrmatin. Limitatins, cpayments, and restrictins may apply. Benefits, premiums and/r cpayments/cinsurance may change n January 1 f each year. H9207_HPM Accepted 9/2016 SB-17-3CTY-E 1 1

3 Premiums and Benefits What Yu Shuld Knw Mnthly Plan Premium Yu pay $0 Deductible Yu pay $0 Yu pay $39.40 Yu pay $0 Yu must cntinue t pay yur Medicare Part B premium. These plans d nt have a deductible fr medical services. There is a $350 deductible fr prescriptin drugs. Drugs in Tier 1 and Tier 2 are excluded frm the deductible in the Prime plan. Maximum Out-f-Pcket Respnsibility (des nt include prescriptin drugs) $6,700 annually $6,700 annually The mst yu pay fr cpays, cinsurance and ther csts fr medical services fr the year. Inpatient Hspital Cverage Yu pay a $295 cpay each day fr days 1-6; $180 cpay fr day 7; $0 cpay each day fr days 8+ Yu pay a $240 cpay each day fr days 1-7; $0 cpay each day fr days 8+ Our plans cver an unlimited number f days fr an inpatient hspital stay. All elective inpatient admissins require prir authrizatin. All ther admissins will be reviewed fr medical necessity and authrizatin. Dctr Visits Primary Care Prvider Yu pay a $10 cpay each visit Specialist Yu pay a $50 cpay each visit Yu pay $0 cpay each visit Yu pay a $45 cpay each visit N referral is required fr specialist visits. Authrizatin is nly required fr a nnparticipating physician specialist. nn- Preventive Care Yu pay nthing Yu pay nthing Any additinal preventive services apprved by Medicare during the cntract year will be cvered. There are sme items nt cvered at $0 cst. Emergency Care Yu pay a $75 cpay each visit Yu pay a $75 cpay each visit Cpay is waived if yu are admitted within 24 hurs t the same facility as the Emergency Rm visit. Urgently Needed Services Yu pay a $45 cpay each visit Yu pay a $45 cpay each visit 2 3 3

4 Premiums and Benefits What Yu Shuld Knw Diagnstic Services/Labs/ Imaging Prir authrizatin is required fr certain services prvided by yur dctr r ther netwrk prvider. Please cntact the plan fr mre infrmatin. PCP r Specialist cpay als applies if service is prvided during an ffice visit. Lab services Yu pay $0 cpay Yu pay $0 cpay Medicare-cvered diagnstic tests and prcedures Yu pay $0 cpay Yu pay $0 cpay Outpatient diagnstic imaging tests (such as X-rays, ultrasund and mammgraphy) Yu pay a $35 cpay Yu pay a $30 cpay Advanced radilgy services (such as MRI, PET, CT, Nuclear Medicine) Yu pay a $275 cpay Yu pay a $225 cpay Therapeutic radilgy (such as radiatin treatment fr cancer) Yu pay 20% cinsurance Yu pay 20% cinsurance Hearing Services Medicare-cvered hearing exam Yu pay a $50 cpay Yu pay a $45 cpay Rutine hearing exam Yu pay $0 cpay Yu pay $0 cpay Rutine hearing exams are cvered nce a year. Hearing aids are nt cvered. Dental Services Preventive (such as ral exam & cleaning) Nt cvered $0 cpay fr 2 ral exams/cleanings a year. One set f X-rays a year. One fluride treatment a year. Medicare-cvered dental services Yu pay a $50 cpay Yu pay $0 cpay Prir authrizatin may be required. Supplemental cmprehensive dental services Nt cvered $800 a year tward supplemental cmprehensive dental services (after a $50 deductible) 4 5 5

5 Premiums and Benefits What Yu Shuld Knw Visin Services Medicare-cvered visin services Yu pay a $50 cpay Medicare-cvered eyewear Yu pay $0 cpay fr ne pair f Medicare-cvered eyeglasses (lenses and frames) r cntact lenses after cataract surgery Yu pay a $45 cpay Yu pay $0 cpay fr ne pair f Medicare-cvered eyeglasses (lenses and frames) r cntact lenses after cataract surgery Rutine visin exam Yu pay $0 cpay Supplemental eyewear Nt cvered Yu pay $0 cpay $260 plan cverage limit fr eyewear every tw years Rutine visin exams are cvered nce a year. Mental Health Services Inpatient Yu pay a $215 cpay each day fr days 1-7; $0 cpay each day fr days 8-90 Yu pay a $215 cpay each day fr days 1-7; $0 cpay each day fr days 8-90 Prir authrizatin is required. Outpatient individual and grup therapy visits Yu pay a $40 cpay each visit fr utpatient individual and grup therapy Yu pay a $40 cpay each visit fr utpatient individual and grup therapy Prir authrizatin is required. Skilled Nursing Facility Yu pay $0 cpay each day fr days 1-20; $ cpay each day fr days Yu pay $0 cpay each day fr days 1-20; $ cpay each day fr days Prir authrizatin is required. Our plans cver up t 100 days in a Skilled Nursing Facility. Rehabilitatin Services Occupatinal therapy, physical therapy and speech and language therapy visits Yu pay a $40 cpay Yu pay a $40 cpay Prir authrizatin is required. Medicare-cvered cardiac rehabilitatin Yu pay a $50 cpay Yu pay a $45 cpay Medicare-cvered pulmnary rehabilitatin Yu pay a $30 cpay Yu pay a $30 cpay Ambulance Yu pay a $200 cpay Yu pay a $200 cpay Authrizatin is required n nn- nnemergency ambulance transprtatin nly

6 Premiums and Benefits What Yu Shuld Knw Transprtatin (rutine) Nt cvered Nt cvered Ft Care (pdiatry services) Medicare-cvered ft care Yu pay a $50 cpay Rutine ft care Nt cvered Yu pay a $50 cpay Nt cvered Medical Equipment/Supplies Durable Medical Equipment (such as wheelchairs, xygen) Yu pay 20% f the ttal cst Yu pay 20% f the ttal cst Prir authrizatin is required fr Durable Medical Equipment csting mre than $500. Prsthetics (such as braces, artificial limbs) Yu pay 20% f the ttal cst Yu pay 20% f the ttal cst Prir authrizatin is required. Diabetes supplies Yu pay 0% t 20% f the ttal cst Wellness Prgrams Fitness Yu pay $0 fr membership at netwrk fitness centers Yu pay 0% t 20% f the ttal cst Yu pay $0 fr membership at netwrk fitness centers 0% cinsurance will apply t diabetes mnitring supplies frm preferred manufacturers; 20% cinsurance will apply t diabetes mnitring supplies frm nn-preferred manufacturers. Prir authrizatin is required fr nn-preferred manufacturers. 20% cinsurance will apply t all ther Part B diabetic supplies. Weight Watchers $2 a visit $2 a visit Weight Watchers benefit cvers up t 50 weeks a year. Medicare Part B Drugs Yu pay $0 r 20% f the ttal cst fr chemtherapy drugs and ther Part B drugs Yu pay $0 r 20% f the ttal cst fr chemtherapy drugs and ther Part B drugs Prir authrizatin may be required

7 Once yu are in the Catastrphic Cverage Stage, yu will stay in this payment stage until the end f the calendar year. During this stage, the plan will pay mst f the cst fr yur drugs. Yur share f the cst fr a cvered drug will be either cinsurance r a cpayment, whichever is the larger amunt: either cinsurance f 5% f the cst f the drug r $3.30 fr a generic drug r a drug that is treated like a generic and $8.25 fr all ther drugs. Our plan pays the rest f the cst. When yu are in the Cverage Gap Stage, the Medicare Cverage Gap Discunt Prgram prvides manufacturer discunts n brand name drugs. Yu pay 40% f the negtiated price and a prtin f the dispensing fee fr brand name drugs. Bth the amunt yu pay and the amunt discunted by the manufacturer cunt tward yur ut-f-pcket csts as if yu had paid them and mves yu thrugh the cverage gap. Yu als receive sme cverage fr generic drugs. Yu pay n mre than 51% f the cst fr generic drugs and the plan pays the rest. Fr generic drugs, the amunt paid by the plan (49%) des nt cunt tward yur ut-f-pcket csts. Only the amunt yu pay cunts and mves yu thrugh the cverage gap. Initial Cverage Stage (After yu pay yur deductible) Tier 1: Preferred Generic Tier 2: Generic Tier 3: Preferred Brand Tier 4: Nn-Preferred Drug Tier 5: Specialty Tier Once yu are in the Catastrphic Cverage Stage, yu will stay in this payment stage until the end f the calendar year. During this stage, the plan will pay mst f the cst fr yur drugs. Yur share f the cst fr a cvered drug will be either cinsurance r a cpayment, whichever is the larger amunt: either cinsurance f 5% f the cst f the drug r $3.30 fr a generic drug r a drug that is treated like a generic and $8.25 fr all ther drugs. Our plan pays the rest f the cst. When yu are in the Cverage Gap Stage, the Medicare Cverage Gap Discunt Prgram prvides manufacturer discunts n brand name drugs. Yu pay 40% f the negtiated price and a prtin f the dispensing fee fr brand name drugs. Bth the amunt yu pay and the amunt discunted by the manufacturer cunt tward yur ut-f-pcket csts as if yu had paid them and mves yu thrugh the cverage gap. Yu als receive sme cverage fr generic drugs. Yu pay n mre than 51% f the cst fr generic drugs and the plan pays the rest. Fr generic drugs, the amunt paid by the plan (49%) des nt cunt tward yur ut-fpcket csts. Only the amunt yu pay cunts and mves yu thrugh the cverage gap. OUTPATIENT PRESCRIPTION DRUGS Deductible Stage Yu pay $350 per year fr Part D prescriptin drugs. Yu pay $350 per year fr Part D prescriptin drugs except fr drugs listed n Tier 1 and Tier 2, which are excluded frm the deductible. Initial Cverage Stage (After yu pay yur deductible) Standard Retail Rx 30-day supply Mail Order 90-day supply Standard Retail Rx 30-day supply Mail Order 90-day supply Tier 1: Preferred Generic $2 cpay $4 cpay $7 cpay $14 cpay Tier 2: Generic $20 cpay $40 cpay $20 cpay $40 cpay Tier 3: Preferred Brand $47 cpay $94 cpay $47 cpay $94 cpay Tier 4: Nn-Preferred Drug 34% f the ttal cst 34% f the ttal cst 35% f the ttal cst 35% f the ttal cst Tier 5: Specialty Tier 26% f the ttal cst A lng-term supply is nt available fr drugs in Tier 5. Cverage Gap Stage (After the ttal amunt fr the prescriptin drugs yu have filled and refilled reaches $3,700) Catastrphic Cverage Stage (After yur ut-f-pcket csts have reached the $4,950 limit fr the calendar year) When yu are in the Cverage Gap Stage, the Medicare Cverage Gap Discunt Prgram prvides manufacturer discunts n brand name drugs. Yu pay 40% f the negtiated price and a prtin f the dispensing fee fr brand name drugs. Bth the amunt yu pay and the amunt discunted by the manufacturer cunt tward yur ut-f-pcket csts as if yu had paid them and mves yu thrugh the cverage gap. Yu als receive sme cverage fr generic drugs. Yu pay n mre than 51% f the cst fr generic drugs and the plan pays the rest. Fr generic drugs, the amunt paid by the plan (49%) des nt cunt tward yur ut-f-pcket csts. Only the amunt yu pay cunts and mves yu thrugh the cverage gap. Once yu are in the Catastrphic Cverage Stage, yu will stay in this payment stage until the end f the calendar year. During this stage, the plan will pay mst f the cst fr yur drugs. Yur share f the cst fr a cvered drug will be either cinsurance r a cpayment, whichever is the larger amunt: either cinsurance f 5% f the cst f the drug r $3.30 fr a generic drug r a drug that is treated like a generic and $8.25 fr all ther drugs. Our plan pays the rest f the cst. 26% f the ttal cst A lng-term supply is nt available fr drugs in Tier 5. When yu are in the Cverage Gap Stage, the Medicare Cverage Gap Discunt Prgram prvides manufacturer discunts n brand name drugs. Yu pay 40% f the negtiated price and a prtin f the dispensing fee fr brand name drugs. Bth the amunt yu pay and the amunt discunted by the manufacturer cunt tward yur ut-f-pcket csts as if yu had paid them and mves yu thrugh the cverage gap. Yu als receive sme cverage fr generic drugs. Yu pay n mre than 51% f the cst fr generic drugs and the plan pays the rest. Fr generic drugs, the amunt paid by the plan (49%) des nt cunt tward yur ut-f-pcket csts. Only the amunt yu pay cunts and mves yu thrugh the cverage gap. Once yu are in the Catastrphic Cverage Stage, yu will stay in this payment stage until the end f the calendar year. During this stage, the plan will pay mst f the cst fr yur drugs. Yur share f the cst fr a cvered drug will be either cinsurance r a cpayment, whichever is the larger amunt: either cinsurance f 5% f the cst f the drug r $3.30 fr a generic drug r a drug that is treated like a generic and $8.25 fr all ther drugs. Our plan pays the rest f the cst

8 Yur csts may vary in lng-term care r hme infusin settings. Fr mre infrmatin, please see the plan s Evidence f Cverage at r call us at (TTY 711). Yu can call 24 hurs a day, seven days a week. Yur csts may vary in lng-term care r hme infusin settings. Fr mre infrmatin, please see the plan s Evidence f Cverage at r call us at (TTY 711). Yu can call 24 hurs a day, seven days a week. Lng-term Care Pharmacy and Outf-netwrk Pharmacy Cverage Yur csts may vary in lng-term care r hme infusin settings. Fr mre infrmatin, please see the plan s Evidence f Cverage at r call us at (TTY 711). Yu can call 24 hurs a day, seven days a week. Yur csts may vary in lng-term care r hme infusin settings. Fr mre infrmatin, please see the plan s Evidence f Cverage at r call us at (TTY 711). Yu can call 24 hurs a day, seven days a week. Other Benefits Other Benefits What Yu Shuld Knw Chirpractr Visits Yu pay a $20 cpay Yu pay a $20 cpay Limited t Medicare-cvered chirpractic visits. Prir authrizatin is required. Hme Health Care Yu pay $0 cpay Yu pay $0 cpay Prir authrizatin is required. Hspice Yu pay $0 cpay Yu pay $0 cpay Services must be prvided by a Medicare-certified hspice. Yu may have t pay part f the csts fr drugs and respite care. Hspice is cvered utside f ur plan. Cntact us fr mre details. Outpatient Surgery Ambulatry surgical center Yu pay a $200 cpay Outpatient hspital Yu pay 25% f the ttal cst Yu pay a $175 cpay Yu pay a $275 cpay Prir authrizatin may be required. Prir authrizatin may be required

9 Health Partners Medicare 901 Market Street, Suite 500 Philadelphia, PA Visit us at HPPMedicare.cm H9207_HPM Accepted 9/2016 SB-17-3CTY-E