Summary of Benefits. Join the WELLfluent Miami-Dade County AvMed Medicare Circle HMO H1016, Plan 023 GET FIT. EAT RIGHT. CONNECT. GROW.

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1 Join the WELLfluent GET FIT. EAT RIGHT. CONNECT. GROW. Summary of Benefits 2019 Miami-Dade County AvMed Medicare Circle HMO H1016, Plan 023 This is a summary of drug and health services covered by AvMed Medicare Circle (HMO) January 1, December 31, 2019 AvMed Medicare Plan is a Medicare Advantage HMO plan with a Medicare contract. Enrollment in the Plan depends on contract renewal. The benefit information provided does not list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, please request the Evidence of Coverage. To join AvMed Medicare (HMO), you must be entitled to Medicare Part A, be enrolled in Medicare Part B, and live in our service area. Our service area includes the following county in Florida: Miami-Dade If you use the providers that are not in our network, we may not pay for these services. For coverage and costs of Original Medicare, look in your current Medicare & You handbook. View it online at or get a copy by calling MEDICARE ( ).TTY users should call This document is available in other formats such as braille, large print or audio. For more information, please call us at (TTY users should call 711), or visit us at From October 1 to March 31, you can call us 7 days a week from 8:00 a.m. to 8:00 p.m. Eastern. From April 1 to September 30, you can call us Monday through Friday from 8:00 a.m. to 8:00 p.m. and Saturdays 9:00 a.m. to 1:00 p.m. Eastern.

2 Premiums and Benefits AvMed Medicare Circle Plan HMO What You Should Know Monthly Plan Premium You pay nothing You must continue to pay your Medicare Part B premium. Deductible You pay nothing This plan does not have a deductible. Maximum Out-of-Pocket Responsibility (does not include prescription drugs) $6,700 annually Includes copays and other costs for medical services for the year. Inpatient Coverage $0 copay per day for days 1 through 5 $0 copay per day days 6 through 20 You pay nothing per day for days and beyond Outpatient Hospital Coverage $50 non-hospital affiliated $175 hospital affiliated 20% of the cost per treatment per day for radiation therapy Doctor Visits Primary Specialists Preventive Care (e.g., flu vaccine, diabetic screenings) copay per PCP visit copay per specialist visit You pay nothing Our plan covers an unlimited number of days for an inpatient hospital stay. Requires prior authorizations in inpatient. May require prior authorization Referral from your PCP may be required for specialist visit. Any additional preventive services approved by Medicare during the contract year will be covered. There are some covered services that have a cost. Emergency Care You pay $90 copay per visit If you are admitted to the hospital within 24 hours, you do not have to pay your share of the cost for emergency care. Urgently Needed Services You pay $10 copay per visit Diagnostic Services/Labs/ Imaging Diagnostic radiology service (e.g. MRI) Lab services Diagnostic tests and procedures Outpatient x-rays PET scans Hearing Services Hearing exam Hearing aid copay per visit copay copay copay You pay 20% of the cost copay for each Medicare-covered diagnostic hearing exam Up to $500 per ear toward hearing aids Prior authorization is required for some services by your doctor, other network provider or health plan. Please contact the plan for more information. 2 MEDICARE SUMMARY OF BENEFITS

3 January 1, December 31, 2019 Premiums and Benefits AvMed Medicare Circle Plan HMO What You Should Know Dental Services Oral exam X-rays Cleaning Vision Services Routine eye exam Eyeglasses (frames and lenses) Mental Health Services Inpatient visit Outpatient group therapy visit Outpatient individual therapy visit - $25 (depending on the service) - $35 (depending on the service) - $45 (depending on the service) $0 routine eye exam $0 for diabetic eye exam $200 eyewear allowance You pay $150 per day for days 1-9 per day for days You pay $15 outpatient group therapy visit You pay $15 outpatient individual therapy visit Skilled Nursing Facility (SNF) You pay nothing per day for days 1through 20 You pay $160 copay per day for days 21 through 62 copay per day for days 63 through 100 Physical Therapy Occupational therapy visit Physical therapy and speech and language therapy visit Ambulance Transportation Medicare Part B Drugs Foot Care (podiatry services) Foot exams and treatment Routine foot care Medical Equipment/Supplies Durable Medical Equipment (e.g., wheelchairs, oxygen) Prosthetics (e.g., braces, artificial limbs) Diabetes supplies Over-the-Counter (OTC) Items copay copay You pay $145 copay per one-way trip $0 copay for transportation up to 8 round trips yearly 10-20% of the cost for chemotherapy drugs 10-20% of the cost for other Part B drugs You pay $5 copay You pay $5 copay You pay 10% of the cost You pay nothing $0 copay for diabetic supplies 20% for diabetic shoes/inserts You pay nothing $25 quarterly allowance toward the purchase of select OTC items. Please see Delta Dental Description of Benefits and Copayments. - No annual maximum - No waiting periods Our plan covers up to 100 days in an SNF per benefit period. Transportation provided by contracted vendor to planapproved locations. 10% in office or non-hospital affiliated 20% hospital affiliated Please visit our plan website to see our list of covered OTC items. 3

4 Premiums and Benefits AvMed Medicare Circle Plan HMO What You Should Know Wellness Programs Fitness Health education Nursing Hotline SilverSneakers You pay nothing For more information on Wellness Programs, please call us or access our Evidence of Coverage online. Part D Stages Outpatient Prescription Drugs Initial Coverage: You pay the following until your total yearly drug costs reach $4,000. Total yearly drug costs are the total drug costs paid by both you and our Part D plan. You may get your drugs at network retail pharmacies and mail order pharmacies. Preferred Network Rx 30-day /Mail 90-day Standard Network Rx 30-day 90-day Mail 90-day Tier 1: Cost-Sharing may Preferred change depending Generic on the pharmacy you choose and Tier 2: Non- You pay $10 You pay $25 You pay $30 when you enter Preferred another phase Generic of the Part D Benefit. For more Tier 3: You pay $30 You pay You pay $45 You pay You pay information on Preferred $75 $ $135 the additional Brand pharmacy specific cost-sharing and Tier 4: Non- You pay $65 You pay You pay $85 You pay You pay the phases of the Preferred $ $ $255 benefit, please Drug call us or access our Evidence of Tier 5: You pay 33% Not offered You pay 33% Not offered Not offered Coverage online. Specialty Tier If you reside in a long-term care facility, you pay the same as at a retail pharmacy. You may get drugs from an out-of-network pharmacy, but may pay more than you pay at an in-network pharmacy. 4 MEDICARE SUMMARY OF BENEFITS

5 January 1, December 31, 2019 Part D Stages Coverage Gap: The coverage gap begins after the total yearly drug cost (including what you pay and the plan pays) reaches $4,000. After you enter the coverage gap, you pay $0 for a one month for tier one drugs, and $0-$10 for tier 2 drugs. For brand name drugs in tier three, four, and five, you pay 25% of the price. For generic drugs in tier three, four, and five, you pay 37%. Preferred Network Rx Standard Network Rx /Mail 30-day /Mail 90-day 30-day 90-day Mail 90-day Tier 1: Preferred Generic Tier 2: Non-Preferred Generic You pay $10 You pay $25 You pay $30 Catastrophic Coverage: After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $5,100, you pay the greater of: 5% of the costs, or $3.40 for a generic (including brand drugs tr eated as a generic) and $8.50 for all others. If you want to know more about the coverage and costs of Original Medicare, look in your current Medicare & You handbook. View it online at or get a copy by calling MEDICARE ( ), 24 hours a day, 7 days a week. TTY users should call This document is available in other formats such as braille, large print or audio. 5

6 For more information, please call us at the phone number below or visit us at Toll-free ,TTY users should call 711. From October 1 to March 31, you can call us 7 days a week from 8:00 a.m. to 8:00 p.m. Eastern. From April 1 to September 30, you can call us Monday through Friday from 8:00 a.m. to 8:00 p.m. You can see our plan s provider and pharmacy directory at our website at We cover Part D drugs. In addition, we cover Part B drugs such as chemotherapy and some drugs administered by your provider. You can see the complete plan formulary (list of Part D prescription drugs) and any restrictions on our website at 6 MEDICARE SUMMARY OF BENEFITS

7 January 1, December 31, 2019 Notes 7

8 MEDPRF-968 (09/18)