2019 Summary of Benefits PrimeTime Health Plan School Employees Retirement System (HMO-POS) E10120

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1 2019 Summary of Benefits PrimeTime Health Plan School Employees Retirement System (HMO-POS) E10120 This is a summary of drug and health services covered by PrimeTime Health Plan SERS for January 1, 2019 December 31, This Summary of Benefits doesn't list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, please call Customer Service at the numbers below and request the Evidence of Coverage. To join PrimeTime Health Plan SERS, 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 Ohio: Carroll, Columbiana, Harrison, Holmes, Jefferson, Mahoning, Stark, Summit, Tuscarawas, & Wayne. PrimeTime Health Plan has a network of doctors, hospitals, pharmacies, and other providers. You must receive your care from a network provider. In most cases, care you receive from an out-ofnetwork provider (a provider who is not part of our plan s network) will not be covered. Exceptions are noted in italics in the chart below. To find participating providers and pharmacies, please call us or visit our website at Out-of-network/non-contracted providers are under no obligation to treat PrimeTime Health Plan members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost- sharing that applies to out-ofnetwork services. For coverage and costs of Original Medicare, look in your current Medicare & You handbook. View it online or get a copy by calling MEDICARE ( ) 24 hours a day, 7 days a week. TTY users should call This information is not a complete description of benefits. Call or (TTY users or ) for more Our Call Center is open Monday through Friday, from 8:00 a.m. to 8:00 p.m. From October 1 through March 31, the Call Center is open seven days a week, from 8:00 a.m. to 8:00 p.m. Or visit our website at PrimeTime Health Plan is an HMO-POS plan with a Medicare contract. Enrollment in PrimeTime Health Plan depends on contract renewal. This information is available in alternative formats such as large print, audio CD, or other alternate formats. Please call Customer Service if you need plan information in another format or language. H3664_SERSSumB19_M

2 Benefit category What you pay What you should know Monthly plan premium Contact SERS at You must continue to pay your Medicare Part B premium. Medical deductible No deductible This plan does not have a Maximum Out-of-Pocket responsibility (does not include prescription drugs) Inpatient hospital coverage* Outpatient hospital coverage* $3,000 annually Days 1-5: $150 copay per day Days 6 and beyond: $0 copay You pay a $200 copay for each outpatient surgery or ambulatory surgical service deductible. The maximum you will pay in copays and coinsurance for the year. Our plan covers an unlimited number of days for an inpatient hospital stay. Annual maximum out-of-pocket cost of $400 applies to outpatient surgery and ambulatory surgical center services. Doctor visits Primary Care Physician You pay a $20 copay per visit Specialist You pay a $30 copay per visit Preventive care $0 copay Any additional preventive services approved by Medicare during the contract year will be covered. Emergency care The plan covers emergency care that you get from an out-of-network provider. Urgently needed services The plan covers urgently needed services that you get from an out-of-network provider. Diagnostic services/labs/ imaging Diagnostic radiology services (such as MRIs, CT scans)* You pay a $100 copay per visit You pay a $40 copay per visit You pay a $0 copay Diagnostic tests and You pay a $0 copay procedures* Lab services* 1 You pay a $0 copay Outpatient x-rays* You pay a $0 copay Therapeutic radiology services (such as radiation treatment for cancer)* You pay 0% of the cost If you are admitted to the hospital within 23 hours, you do not have to pay your share of the cost for emergency care. World-wide coverage. If you are admitted to the hospital within 23 hours, you do not have to pay your share of the cost for urgently needed services. World-wide coverage. 1 For lab services, you may use any qualified provider.

3 Benefit category What you pay What you should know Hearing services For hearing exams, you must see a Medical exam 1 You pay a $30 copay network provider. For hearing Routine exam 2 You pay a $30 copay aids, you may see the qualified Hearing aids In-network or Out-of-network: provider of your choice. Reimbursement up to $500 every 3 1 Exam to diagnose and treat years hearing and balance issues. 2 You are covered for up to one routine hearing exam every three years. Dental services For medical exams, you must see a Medical exam* You pay a $30 copay network provider. For Supplemental dental In-network or Out-of-network: supplemental dental services, you coverage Reimbursement for non-medicare may see the qualified provider of covered dental services up to a your choice. maximum of $200 annually * Limited dental services (this does combined with non-medicare not include services in connection covered vision. with care, treatment, filling, removal, or replacement of teeth). Prior authorization may be required for these services. Please contact the plan for more Vision services Medical exam 1 Eyeglasses or contact lenses after cataract surgery You pay a $30 copay You pay 20% of the cost Annual routine exam You pay a $30 copay Supplemental vision coverage Mental health services Inpatient visit* Outpatient group therapy visit Outpatient individual therapy visit Skilled nursing facility* (SNF) In-network or Out-of-network: Reimbursement for non-medicare covered vision services up to a maximum of $200 annually combined with non-medicare covered dental. Days 1-5: You pay a $150 copay per day Days 6 and beyond: $0 copay You pay a $30 copay per visit You pay a $30 copay per visit Days 1-15: $0 copay Days 16-30: You pay a $20 copay per day Days : $0 copay You must see a network provider for exams and glasses/contacts after cataract surgery. For supplemental vision services, you may use any qualified vision provider. 1 Exam to diagnose and treat diseases and conditions of the eye (including annual diabetic retinopathy exam). Our plan covers an unlimited number of days for an inpatient hospital stay. Our plan covers up to 100 days in a SNF.

4 Benefit category What you pay What you should know Physical therapy visit Ambulance* You pay a $5 copay per visit You pay a $80 copay per trip Transportation Not covered Medicare Part B drugs In-Network: Chemotherapy drugs* You pay 0% of the cost Other Part B drugs* You pay 0% of the cost Annual maximum out-of-pocket cost of $150 applies to occupational, physical, and speech and language therapies combined. required for non-emergency services. Please contact the plan for more World-wide emergency coverage. Medical equipment/ supplies Durable medical equipment (wheelchairs, oxygen, etc)* You pay 20% of the cost Prosthetics/Medical You pay 20% of the cost supplies* Diabetes supplies* You pay 20% of the cost Health and Wellness Education Programs Tele-monitoring Services 1 Stroke Prevention Program 2 24 Hour Nursing Hotline Silver&Fit Exercise & Healthy Aging Program 3 $0 copay 1 Enrollees diagnosed with any of the conditions below may be eligible: o Heart Failure o Diabetes o Chronic Obstructive Pulmonary Disease (COPD) o Behavioral Health Conditions 2 Offered to members who have health conditions that put them at higher risk for stroke. 3 Offers members access to a participating fitness center or select YMCA at no additional cost. Contact the plan for more information on these programs.

5 Outpatient Part D Prescription Drugs Cost-sharing may change when you enter a new stage of the Part D benefit. For more information on the stages of the benefit, please contact the plan. Phase 1: Deductible Because there is no deductible for the plan, this payment stage does not apply to Stage you. Phase 2: Initial Coverage Stage During this stage, the plan pays its share of the cost of your generic drugs and you pay your share of the cost. You pay the following copays until your total yearly drug costs reach $3,820. Total yearly drug costs are the total drug costs paid by both you and our Part D plan. The below copays/coinsurance are for prescriptions purchased from a network retail pharmacy or our mail-order pharmacy. Long-Term Care (LTC) pharmacies can fill up to a 31 day supply at the 30 day copays/coinsurance listed below. Tier/Drug Description 30 Day Supply 90 Day Supply Tier 1: Generic You pay $7.50 You pay $15 Tier 2: Preferred Brand You pay 25% of the cost, $25 minimum-$100 maximum Insulin $30 copay You pay 25% of the cost, $45 minimum-$200 maximum Insulin $60 copay Tier 3: Non-preferred Drugs You pay 50% of the cost Insulin $45 copay You pay 50% of the cost Insulin $115 copay Tier 4: Specialty Tier You pay 25% of the cost, $25 minimum-$100 maximum 90 day supply not available for Tier 4 Specialty Drugs Phase 3: Coverage Gap Stage Phase 4: Catastrophic Coverage Stage The Coverage Gap begins after the total yearly drug cost reaches $3,820. After you enter the Coverage Gap, you pay 25% of the plan s cost for covered brand name drugs and a portion of the dispensing fee and 37% of the plan s cost for covered generic drugs until your costs total $5,100, which is the end of the Coverage Gap. Not everyone will enter the Coverage Gap. SERS has provided additional coverage during the Coverage Gap Stage. Please contact the plan for additional information, including your copays, during this stage. 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 cost, or $3.40 copay for generic (including brand drugs treated as generic) and an $8.50 copayment for all other drugs. If you reach the Catastrophic Coverage Stage, you will stay in this payment stage until the end of the calendar year. SERS has provided additional coverage during the Catastrophic Coverage Stage. Please contact the plan for additional information, including your copays, during this stage.

6 Multi-language Interpreter Services English: ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call (TTY ). Español (Spanish): ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY ). 繁體中文 (Chinese): 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致 電 (TTY ). Deutsch (German): ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (TTY ). (Arabic): العربية ملحوظة: إذا كنت تتحدث اذكر اللغة فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم )رقم هاتف الصم والبكم: (. Wann du [Deitsch (Pennsylvania German / Dutch)] schwetzscht, kannscht du mitaus Koschte ebber gricke, ass dihr helft mit die englisch Schprooch. Ruf selli Nummer uff: Call (TTY: ). Русский (Russian): ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: ). Français (French): ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (ATS : ). Tiếng Việt (Vietnamese): CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY: ). Oroomiffa (Chushite-Oromo): XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa (TTY: ). 한국어 (Korean): 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실 수있습니다 (TTY: ) 번으로전화해주십시오. Italiano (Italian): ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero (TTY: ). H3664_MLND18_C

7 日本語 (Japanese): 注意事項 : 日本語を話される場合 無料の言語支援をご利用いただ けます (TTY ). まで お電話にてご連絡ください Nederlands (Dutch): AANDACHT: Als u nederlands spreekt, kunt u gratis gebruikmaken van de taalkundige diensten. Bel (TTY: ). Українська (Ukrainian): УВАГА! Якщо ви розмовляєте українською мовою, ви можете звернутися до безкоштовної служби мовної підтримки. Телефонуйте за номером (телетайп: ). Română (Romanian): ATENȚIE: Dacă vorbiți limba română, vă stau la dispoziție servicii de asistență lingvistică, gratuit. Sunați la (TTY: ). Non-discrimination Notice PrimeTime 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. PrimeTime Health Plan does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. PrimeTime Health Plan provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters and written information in other formats (large print, audio, accessible electronic formats, other formats). PrimeTime Health Plan provides free language services to people whose primary language is not English, such as: Qualified interpreters and information written in other languages. If you need these services, or if you believe that PrimeTime Health Plan 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 contact or file a grievance with the: PrimeTime Health Plan Civil Rights Coordinator, th St. S.W. Canton, OH 44710, , CivilRightsCoordinator@aultcare.com. You can file a grievance in person or by mail, fax, or . If you need help filing a grievance, our Civil Rights staff is available to help you. 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 or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C , (TDD). Complaint forms are available at H3664_MLND18_C