SUMMARY OF BENEFITS CARE1ST HEALTH PLAN. Care1st TotalDual Plan (HMO SNP) California: Los Angeles County. January 1, December 31, 2018

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1 SUMMARY OF BENEFITS January 1, December 31, 2018 CARE1ST HEALTH PLAN This booklet gives you a summary of what we cover and what you pay. It doesn t list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, call us and ask for the Evidence of Coverage. Care1st TotalDual Plan (HMO SNP) California: Los Angeles County Care1st is an independent licensee of the Blue Shield Association H5928_18_005_SB_TD_001 V2 Accepted

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3 2018 SUMMARY OF BENEFITS Care1st TotalDual Plan (HMO SNP) Los Angeles County, Plan 001 This is a summary of drug and health services covered by Care1st TotalDual Plan (HMO SNP) January 1, December 31, Care1st TotalDual Plan (HMO SNP) 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 Care1st TotalDual Plan (HMO SNP), you must be entitled to Medicare Part A, be enrolled in Medicare Part B, and live in our service area. Our service area includes the following counties in California: Los Angeles. For coverage and costs of Original Medicare, look in your current Medicare & You handbook. View it online at gov 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), 8am 8pm, seven days a week or visit us at If you use the providers that are not in our network, we may not pay for these services. 3

4 Premiums and Benefits Care1st TotalDual Plan (HMO SNP) Monthly Plan Premium You pay $35.50 You must continue to pay your Medicare Part B premium. Deductible No deductible Maximum Out-of-Pocket You pay no more than $6,700 annually Responsibility (does not include Includes copays and other costs for medical services for the year. prescription drugs) Inpatient Hospital Medicare-defined cost shares 2018 Medicare-defined cost shares For 2017: $1,316 Deductible Days 1-60 $329 copay Days Outpatient Hospital Doctor Visits Primary Specialists Preventive Care (Mammography/influenza vaccines no referral) Emergency Care Urgently Needed Services Diagnostic Services/Labs/ Imaging Procedures/Tests Lab services Therapeutic radiology services (such as radiation treatment for cancer) Hearing Services Routine hearing exam Hearing aid Dental Services Unlimited Oral exams every year Cleaning, one every 6 months Fluoride treatment, one every six months X-ray, one every two years Vision Services Routine exam (every year) Eyewear coverage limit Mental Health Services Outpatient group therapy/ individual therapy visit Other preventive services are available. There are some covered services that have a cost. Not Waived if addmitted Not Waived if addmitted Medicare covered benefits; for routine exams (1 every year); for fitting/evaluation for Hearing Aid for (2) hearing aids every year $1,500 limit every year You pay $5 $300 limit for glasses and contacts every year 1 refraction test every two years 4

5 Skilled Nursing Facility Medicare-defined cost shares 2018 Medicare-defined cost shares For 2017: $1,316 Deductible Days 1-60 $329 copay Days Physical Therapy Ambulance Services 20% Not waived if admitted Transportation Services 48 one-way trips to plan approved locations. Transportation must be arranged 24 hours in advance. Medicare Part B Drugs for chemotherapy drugs for other Part B drugs Outpatient Prescription Drugs Deductible You pay $405 Initial Coverage Phase (After you pay your deductible, if applicable, up to the initial coverage limit of $3,750) Tier Initial Coverage Tier 1: Preferred Generic Tier 2: Non-Preferred Generic Tier 3: Preferred Brand Tier 4: Non-Preferred Brand Tier 5: Specialty Tier Coverage Gap Phase (After the total drug costs paid by you and the plan reach $3750, up to the out-of-pocket threshold of $5000) Catastrophic Coverage Phase (When your annual out-ofpocket costs exceed $5000) Standard Retail Rx 30-day supply Mail Order 90-day supply $0 - $3.35 or 15% or 25% coinsurance $0 - $3.35 or 15% or 25% coinsurance $0 - $3.35 or 15% or 25% coinsurance $0 - $3.35 or 15% or 25% coinsurance $0 - $8.35 or 15% or 25% coinsurance $0 - $8.35 or 15% or 25% coinsurance $0 - $8.35 or 15% or 25% coinsurance $0 - $8.35 or 15% or 25% coinsurance $0 - $8.35 or 15% or 25% coinsurance $0 - $8.35 or 15% or 25% coinsurance Generic (Tier 1 & 2): 56% discount on Generic drugs. You paid 44% of the retail cost for generics. Brand Name (Tier 3-5): 65% discount on Brand-name drugs. You paid 35% of your plan s negotiated retail cost for brand-name prescription Extra Help (LIS): GAP doesn t apply Generic drugs: Greater of 5% or $3.35 copay Brand-name drugs: Greater of 5% or $8.35 copay Health Club/Fitness Nurse Advice Line Worldwide Emergency/Urgent Care Routine Chiropractic Acupuncture Over-the-Counter Optional Supplemental Benefits ; unlimited gym visits Worldwide Emergency/Urgent Coverage up to $25,000 per year (Not Waived if addmitted) $0 copay /15 visits per year $0 copay /15 visits per year $175 / Quarterly 5

6 Care1st Health Plan is an HMO and an HMO SNP plan with a Medicare contract and a contract with the California State Medicaid Program. Enrollment in Care1st Health Plan depends on contract renewal. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, formulary, premium and/or copayments/co-insurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium. The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. This information is available for free in other languages. Please contact Member Services: (TTY 711), 8 a.m. to 8 p.m., seven days a week. Esta información está disponible gratuitamente en otros idiomas. Comuníquese con Servicios para los Miembros: (TTY 711), de 8:00 a.m. a 8:00 p.m., los 7 días de la semana. 這項免費資訊以其它語言提供 懇請聯絡會員服務處 : 免費熱線 ( 聽障及語障人士專線 711) 每週七天辦公, 早上 8:00 點至晚上 8:00 點 Care1st Health Plan complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Care1st Health Plan cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo. Care1st Health Plan 遵守適用的聯邦民權法律規定, 不因種族 膚色 民族血統 年齡 殘障或性別而歧視任何人 H5928_18_005_SB_TD_001 V2 Accepted

7 English: ATTENTION: If you speak a language other than English, language assistance services, free of charge, are available to you. Call (TTY: 711) for Medicare, (TTY: 711) for Cal MediConnect. Care1st Health Plan (CA) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. If you believe that Care1st has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance. Grievances must be submitted to the Grievance Coordinator at Care1st Grievance Department within 60 calendar days from the time you have become aware of any alleged discrimination action. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at y.jsf, or by mail or phone within 180 days from the date of the alleged discrimination at: U.S. Department of Health and Human Services: 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C , (TDD) Mailing Address: Dirección postal: 郵寄地址 : ATTN: Civil Rights Coordinator Grievances Department - Care1st Health Plan 601 Potrero Grande Dr. Monterey Park, CA Fax Number: Número de fax: 傳真號碼 : Non-discrimination and Language Availability Statements Español (Spanish): ATENCION:Si usted habla un idioma diferente al español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: 711) para Medicare, (TTY: 711) para Cal MediConnect. Care1st Health Plan cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo. Si considera que Care1st no le proporcionó estos servicios o lo discriminó de otra manera por motivos de raza, color, nacionalidad, edad, discapacidad o sexo, puede presentar un reclamo. Los reclamos deben enviarse al coordinador de reclamos del Departamento de Reclamos de Care1st, dentro de los 60 días calendario posteriores al momento en que haya tenido conocimiento de cualquier supuesto acto de discriminación. También puede presentar un reclamo de derechos civiles ante la Office for Civil Rights (Oficina de Derechos Civiles) del Department of Health and Human Services (Departamento de Salud y Servicios Humanos) de EE. UU. de manera electrónica a través de Office for Civil Rights Complaint Portal, disponible en y.jsf, o bien, por correo postal a la siguiente dirección o por teléfono a los números que figuran a continuación: U.S. Department of Health and Human Services: 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C , (TDD) 繁體中文 (Chinese): 注意..如果你會說中文以外的文字, 語言援助服務, 免費的是可供您使用 調用 (TTY: 711) Medicare, (TTY: 711) Cal MediConnect. Care1st Health Plan 遵守適用的聯邦民權法律規定, 不因種族 膚色 民族血統 年齡 殘障或性別而歧視任何人 如果您認為第一健保 (Care1st) 沒有提供這些服務或因為種族 膚色 原始國籍 年齡 殘疾或性別而有其他方式的歧視, 您可以提出申訴. 您必須在察覺到任何歧視行為的 60 個曆日內向第一健保 (Care1st) 申訴部門的申訴協調員提出申訴 投訴必須是書面, 或口頭報告, 包括您的姓名與地址 您也可以向美國健康與公眾服務部民權辦公室提出民權投訴, 只要前往民權投訴辦公室入口網站 ocrportal.hhs.gov/ocr/portal/lobby.jsf, 或寫信或打電話提出投, 聯絡資訊 : U.S. Department of Health and Human Services: 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C , (TDD) Telephone Number: Número de teléfono: 電話號碼 : (TTY: 711) from 7am to 8pm, Monday through Friday, de 7am a 8pm, de lunes a viernes, 週一至週五早上 7 至晚上 8 Address: Dirección de correo electrónico: 電子郵件地址 : CRC@care1st.com IMPORTANT NOTE: To view important information on Non-Discrimination requirements, you can go to our website at *Calling this number will direct you to a licensed insurance agent. **Free without Obligation. Care1st Health Plan is an HMO and an HMO SNP plan with a Medicare contract and a contract with the California State Medicaid Program. Enrollment in Care1st Health Plan depends on contract renewal. A sales person will be present with information and applications. H5928_18_227_MK Accepted

8 SUMMARY OF BENEFITS Care1st TotalDual Plan (HMO SNP) Los Angeles County CARE1ST HEALTH PLAN 601 Potrero Grande Dr., Monterey Park, CA FOR ENROLLMENT INQUIRIES PLEASE CALL (TTY users should call 711) Member Services representatives will be available to answer your call from 8 a.m. to 8 p.m., seven days a week. Care1st is an independent licensee of the Blue Shield Association