MMM ELA FLEX BRONCE. Summary of Benefits 2017 HMO-POS

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1 MMM ELA FLEX BRONCE HMO-POS Summary of Benefits 2017 MMM Healthcare, LLC is an HMO plan with a Medicare contract. Enrollment in MMM depends on contract renewal. MMM Healthcare, LLC, complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. H4003 MMM Healthcare, LLC BRONCE Revised Authorized by the State Elections Comission CEE-SA

2 MMM ELA Flex Bronce 2017 Summary of Benefits The benefit information provided is a summary of what we cover and what you pay. It 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. This information is not a complete description of benefits. Contact the plan for more information. Benefits, and/or co-payments/coinsurance may change on January 1 of each year. Limitations, copayments and restrictions may apply. The formulary, pharmacy network, and/or providers may change at any time.you will receive notice when necessary. This information is available in other formats such as Braille and large print. This document may be available in a non-english language. For additional information, call us at (toll free), TTY. You can call us 7 days a week from 8:00 a.m. to 8:00 p.m.atlantic time. Or you can check our website at Este documento puede estar disponible en un idioma que no sea inglés. Para información adicional, puede comunicarse con nosotros al (libre de cargos), TTY. Nos puede llamar los 7 días de la semana desde las 8:00 am hasta las 8:00 pm, hora del Atlántico. O puede visitar nuestra página de internet en

3 This Summary of Benefits booklet gives you a summary of what MMM ELA Flex Bronce (HMO POS) covers and what you pay. If you want to know 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 MMM ELA Flex Bronce (HMO POS) has a network of doctors, hospitals, pharmacies, and other providers. If you use the providers that are not in our network, the plan may not pay for these services. You must generally use network pharmacies to fill your prescriptions for covered Part D drugs. You can see our plan s prescription drugs formulary and provider and pharmacy directory at our website ( or if you want a printed copy, call us and we will send you the requested document. To join MMM ELA Flex Bronce (HMO POS) you must be entitled to Medicare Part A, be enrolled in Medicare Part B, live in our service area and be an ELA retiree that receives employer contribution through the Central Retirement System Office or Retirement for Teachers System.The direct and optional dependants with Medicare Parts A and B are also eligible to ELA Flex - Bronce (HMO- POS). Our service area includes the 78 municipalities of Puerto Rico.

4 Covered services, hospital and prescription drug benefits Services with a 1 may require prior authorization. Services with a 2 have an Out-of-Network benefit: PR Out-of-network: 20% of the cost (covered by reimbursement based on contracted providers rates minus the applicable coinsurance). US Point of Service: 35% of the cost, up to a maximum limit per year of $10,000. Premiums and Benefits MMM ELA Flex Bronce What you should Know HMO POS Monthly Plan Premium $65.00 Deductible Maximum Out-of-Pocket responsibility (does not include prescription drugs) Inpatient Hospital Coverage 1, 2 This plan does not have a deductible. $3,250 $25 copay $0 per month, after employers' contribution of $65.00.The monthly premium will be paid by your employer s contribution. The $65.00 monthly plan premium for each eligible dependant (direct or optional) is deducted from the retiree s pension. You must keep paying your Medicare Part B premium. For services received from network providers. Our plan covers an unlimited number of days for an inpatient hospital stay. Doctor Visits 2 Primary Specialists Preventive Care 2 Emergency Care $50 copay $0 copay (medical office) Worldwide emergency coverage:$25 copay Any additional preventive services approved by Medicare during the contract year will be covered. If you are admitted to the hospital within 1 day because of the same condition, you do not have to pay your share of the cost for emergency care. See the Inpatient Hospital Care section of this booklet for other costs.

5 Premiums and Benefits MMM ELA Flex Bronce HMO POS What you should Know Urgently Needed Services. Worldwide emergency coverage: $25 copay Diagnostic Services/Labs/Imaging 1, 2 Diagnostic radiology service (e.g., MRI) Lab services Diagnostic tests and procedures Outpatient X-rays Hearing Services 1, 2 Supplementary hearing exam Hearing aid Dental Services 1, 2 Preventive Services Restorative Services Prostodonthia Vision Services 1, 2 Routine eye exam Supplementary Eyeglasses (frames and lenses) Mental Health Services 1, 2 Inpatient visit Outpatient group therapy visit Outpatient individual therapy visit Skilled Nursing Facility 1, 2 / 10% coinsurance, with a maximum of up to $65* 5% coinsurance *10% coinsurance, with a maximum of up to $65 for the following services: MRA, MRI, CT Scan, Stress Test, SPECT and PET Scan Our plan pays up to $250 every two years for hearing aids. Maximum benefit amount for hearing aids applies for both ears combined. Plan s coverage maximum limit is $1,000 for prosthodontia. Up to one (1) routine visual exam per year Maximum benefit of $200 every two years. Our plan covers up to 100 days in an SNF. No previous hospitalization is required.

6 Premiums and Benefits MMM ELA Flex Bronce HMO POS What you should Know Rehabilitation Services 1, 2 Occupational therapy visit Physical therapy and speech and language therapy visit Ambulance 1, 2 Transportation 1 Not covered Foot Care (podiatry services) 1, 2 Foot exams and treatment Routine foot care Medical Equipment/Supplies 1, 2 Durable Medical Equipment (e.g., wheelchairs, oxygen) Prosthetics (e.g., braces, artificial limbs) Diabetes supplies Wellness Programs (e.g., fitness) 1, 2 a Up to one(1) routine (supplementary) visit per year. Medicare Part B Drugs 1, 2 10% coinsurance

7 Premiums and Benefits MMM ELA Flex Bronce HMO POS What you should Know Over the counter items (OTC) $100 every three months.the plan covers: 1. Minerals and vitamins. 2. First Aid supplies. 3. Medicines, ointment and sprays with active medical ingredients that alleviate symptoms. 4. Mouth care. 5. Incontinence Supplies (Adult Diapers and Under pads) Outpatient Prescription Drugs Phase 1: Initial Coverage Standard Retail Cost-Sharing 30-day supply Standard Retail Cost-Sharing 90-day supply Mail Order 90-day supply Tier 1: Preferred Generic $5 copay $15 copay $10 copay Tier 2: Non-Preferred Generic $20 copay $60 copay $40 copay $40 copay $120 copay $80 copay Tier 3: Preferred Brand Tier 4: Non-Preferred Brand 25% of cost 25% of cost 25% of cost Cost-Sharing may change when you enter another phase of the Part D benefit. For more information on the additional pharmacy-specific cost-sharing and the phases of the benefit, please call us or access our Evidence of Coverage online. 10% coinsurance for erectile dysfunction medications ( up to 6 pills per month)

8 What makes you happy, makes you healthy. MMM-MKD-MIS E