2019 Summary of Benefits. Clover Health Classic (HMO-002) Available in the following counties: Atlantic, Bergen, Essex, Hudson, Passaic, and Union

Transcription

1 Clver New Jersey 2019 Summary f Benefits Clver Health Classic (HMO-002) Available in the fllwing cunties: Atlantic, Bergen, Essex, Hudsn, Passaic, and Unin Clver Health Value (HMO-003) Available in the fllwing cunties: Atlantic, Bergen, Essex, Hudsn, Passaic, Unin, and Middlesex

2 2019 Summary f Benefits New Jersey Clver Health Classic (H8010) (plan 002) and Clver Health Value (H8010) (plan 003) This is a summary f drug and health services cvered by the New Jersey Clver Health Classic and Clver Health Value fr the plan year: January 1, 2019 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 refer t yur Evidence f Cverage (EOC). Yu may access the EOC nline at r cntact ur Member Services Department at (TTY 711) t request a cpy be mailed t yu. This infrmatin is available fr free in ther languages. This dcument is available in ther frmats such as large print. Please call ur Member Services Department at (TTY users shuld call 711). Hurs are 8am 8pm, lcal time, 7 days a week. Frm April 1 thrugh September 30, alternate technlgies (fr example, vic ) will be used n the weekends and hlidays. Yu can als find this dcument as well as mre helpful infrmatin n ur website, Esta infrmación está dispnible de frma gratuita en trs idimas. Póngase en cntact cn nuestr departament de Servicis al Cliente al (ls usuaris de TTY/TDD deben llamar al 711) para más infrmación. Nuestr hrari de atención es de 8 am a 8 pm (hra del este), ls 7 días de la semana. Entre el 15 de febrer y el 30 de septiembre tecnlgías alternativas (pr ejempl, crre de vz) serán utilizads ls fines de semana y días festivs. Clver Health has a netwrk f dctrs, hspitals, pharmacies, and ther prviders. If yu use prviders that are nt in ur netwrk, yu may have a higher cst share respnsibility. Fr infrmatin abut prescriptin drugs cvered, please see the plan s Frmulary. Fr infrmatin abut prviders and pharmacies in ur netwrk, yu can ask fr a current directry t be mailed t yu by calling Member Services (phne number is listed abve), r yu can search fr a prvider r dwnlad a prvider directry by visiting T jin New Jersey Clver Health Classic r Clver Health Value, 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 New Jersey Clver Health Classic : Atlantic, Bergen, Essex, Hudsn, Passaic, and Unin Clver Health Value : Atlantic, Bergen, Essex, Hudsn, Middlesex, Passaic, and Unin 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, 7 days a week. TTY users shuld call Clver Health is a Health Maintenance Organizatin plan with a Medicare cntract. Enrllment in Clver Health depends n cntract renewal.

3 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. WHAT TO EXPECT FROM CLOVER Clver plans prvide benefits designed with yur health in mind, different frm thse ffered by Original Medicare. We re here t help yu understand yur cverage and care. Yur Evidence f Cverage (EOC) dcument is the surce f truth fr what s cvered by yur plan. This Summary f Benefits explains hw t learn mre abut yur plan and cverage: Medical (Part C), Supplemental Benefits, and Pharmacy (Part D). Each sectin cntains infrmatin abut the benefits f yur plan, fllwed by a table summarizing thse benefits and their share f cst. If yu have additinal questins, please cntact Clver s Member Services Department at fr further assistance. Hw t Cntact Us Clver cmmunicates with members by telephne and mail. We are able t receive cmmunicatin frm members by fax. We prvide free aids and services t peple wh need additinal help t cmmunicate effectively with us, such as: Written infrmatin in ther frmats (large print, audi, accessible electrnic frmats, ther frmats) Free language services t peple whse primary language is nt English, such as: Qualified interpreters Infrmatin written in ther languages If yu need these services, cntact Member Services at TTY users shuld call 711. Hurs are 8am 8pm, lcal time, 7 days a week. Frm April 1 thrugh September 30, alternate technlgies (fr example, vic ) will be used n the weekends and hlidays. Clver Clinical Team Our Clinical Team wrks in yur cmmunity and is available t visit yu in yur hme, r ther place yu chse, t address yur unique health cncerns. Clver s clinical staff ffers a persnalized apprach, and a different kind f health care service than yu might receive in yur prvider's ffice. Clver Care Visit (CCV) T supprt yur health, Clver ffers an annual check-in called a Clver Care Visit (CCV). Our care team includes nurse practitiners, medical assistants, and ther licensed clinicians. In the cmfrt f yur wn hme, r ther private lcatin f yur chice, ur team delivers a ne-hur ne-n-ne wellness assessment t help yu better understand yur medical needs. This may include a physical examinatin, a review f current and past diagnses and medicatins, and an pprtunity t address yur cncerns and questins. T schedule a CCV with ne f ur staff, please call us at

4 Mre Clinical Prgrams If yu find yu need mre care than yu're able t receive with yur regular prviders, let us knw. Clver als makes available additinal care beynd what's described here in certain circumstances. SUPPLEMENTAL BENEFITS Clver plans prvide all the benefits f Original Medicare, plus access t supplemental benefits that include sme f the services and items ur members use the mst ften t stay healthy. These benefits supplement r diagnstic services fr visin, hearing, r dental, s please refer t yur plan's EOC fr specific services, csts, and prir authrizatin requirements. See the supplemental benefits yu may receive by Clver in the categries belw. Supplemental Visin Clver cvers ne rutine eye exam per year and a yearly allwance fr glasses frames, lenses, r cntact lenses thrugh ur vendr, EyeQuest. Hw much yu pay fr glasses r cntacts depends n the cst f the eyewear yu chse. Supplemental Hearing While Original Medicare desn't cver rutine hearing services, mst Clver plans d. We believe in treating hearing lss early. Clver wrks with TruHearing t prvide valuable hearing aid services at a lw cst. T see if yur plan has this benefit and assciated cst shares, please refer t thse benefits utlined in yur EOC r speak t ur Member Services Department at Supplemental Dental Quality dental care is an essential part f yur verall health. Clver has partnered with DentaQuest t ffer rutine dental services. Fr additinal services treating a dental cnditin, disease, r injury in a hspital setting, please refer t yur EOC. Gym All Clver members receive access t Silver Sneakers gym lcatins. Silver Sneakers' gyms ffer recreatinal swimming, aerbics, weight management services, nutritin cunseling, and individualized fitness prgrams. T learn mre abut the prgram and see gyms in yur area, visit r call ur Member Services Department at Transprtatin Yu are cvered fr up t 10 ne-way nn-emergent trips fr Clver Health Classic and Clver Health Value within the plan service area t any health-related lcatin. Each ne-way trip must nt exceed 50 miles. Please cntact Clver Member Services at (TTY users shuld call 711) fr infrmatin n hw t arrange a ride. Arrangements shuld be made 24 hurs in advance. 3

5 MEDICAL BENEFITS CHART The amunt yu pay fr sme services des nt cunt tward yur maximum ut-f-pcket amunt. These services are marked with an asterisk in the Medical Benefits Chart belw and in the EOC. Cvered services that need apprval in advance t be cvered as in-netwrk services are marked in bld in the Medical Benefits Chart. Premiums and Benefits Clver Health Classic Clver Health Value What Yu Shuld Knw Mnthly Plan Premium Yu pay $0 Yu pay $37.20 Yu must cntinue t pay yur Medicare Part B premium. Deductible Yu pay $0 Yu pay $0 These plans d nt have a deductible fr medical services. There is a deductible fr prescriptin drugs in ur plans with Part D cverage. Please refer t the prescriptin drug sectin fr mre infrmatin. Maximum Out-f-Pcket Respnsibility (des nt include prescriptin drugs) $6,700 annually $6,400 annually The mst yu pay fr cpays, cinsurance and ther csts fr medical services fr the year. Inpatient Hspital Cverage Yu pay a $290 cpay per day fr days 1-6. Yu pay a $170 cpay per day fr days 1-6. Yu pay a $0 cpay per day fr days Yu pay a $0 cpay per day fr days Outpatient Hspital Cverage Observatin services Yu pay a $90 cpay fr each bservatin service and a $325 cpay fr each bservatin service that leads t utpatient surgery. Yu pay a $90 cpay fr each bservatin service and a $175 cpay fr each bservatin service that leads t utpatient surgery. Surgery Yu pay a $325 cpay fr each utpatient surgery. Yu pay a $175 cpay fr each utpatient surgery. Surgery cpay will be waived if there is a surgical prcedure during a screening clnscpy. 4

6 Premiums and Benefits Clver Health Classic Clver Health Value What Yu Shuld Knw Dctr Visits Primary Care Prvider each visit. each visit. Specialists Yu pay a $25 cpay fr each visit. Yu pay a $5 cpay fr each visit. Preventive Care (e.g., flu vaccine, diabetic screenings) Yu pay nthing. Yu pay nthing. Any additinal preventive services apprved by Medicare during the cntract year will be cvered. Emergency Care Yu pay a $90 cpay each visit. Yu pay a $90 cpay each visit. Cpay is waived if yu are admitted t the hspital within 24 hurs. If yu receive emergency care at an ut-f-netwrk hspital and need inpatient care after yur emergency cnditin is stabilized, yu must return t a netwrk hspital in rder fr yur care t cntinue t be cvered OR yu must have yur inpatient care at the ut-f-netwrk hspital authrized by the plan and yur cst is the cst sharing yu wuld pay at a netwrk hspital. Urgently Needed Services Yu pay a $40 cpay each visit. Yu pay a $40 cpay each visit. Cpay is waived if yu are admitted t the hspital within 24 hurs. Diagnstic Services/Labs/ Imaging Lab Services Yu pay up t a $10 cpay. Yu pay up t a $0 cpay. 5

7 Premiums and Benefits Clver Health Classic Clver Health Value What Yu Shuld Knw diagnstic tests and prcedures Yu pay up t a $35 cpay fr each utpatient diagnstic prcedure and test in an ffice setting and up t a $150 cpay fr each utpatient diagnstic prcedure and test in an utpatient facility. Yu pay up t a $30 cpay fr each utpatient diagnstic prcedure and test in an ffice setting and up t a $150 cpay fr each utpatient diagnstic prcedure and test in an utpatient facility. Diagnstic Mammgram cpay will be waived if there is a Screening Mammgram n the same day. Outpatient diagnstic imaging tests (such as X- rays) Yu pay up t a $30 cpay fr each X- ray in an ffice setting r utpatient facility. Yu pay up t a $30 cpay fr each X- ray in an ffice setting r utpatient facility. Advanced radilgy services (such as MRI, PET, CT, Nuclear Medicine) Yu pay a up t a $35 cpay fr each diagnstic radilgy service in an ffice setting and a $150 cpay fr each diagnstic radilgy service in an utpatient facility. Yu pay a up t a $30 cpay fr each diagnstic radilgy service in an ffice setting and a $150 cpay fr each diagnstic radilgy service in an utpatient facility. Therapeutic radilgy (such as radiatin treatment fr cancer) Yu pay a $60 cpay fr each Medicarecvered therapeutic radilgy service in an ffice setting r utpatient facility. Yu pay a $60 cpay fr each Medicarecvered therapeutic radilgy service in an ffice setting r utpatient facility. Hearing Services hearing exam Yu pay a $25 cpay. Yu pay a $5 cpay. Rutine hearing exam* Yu pay a $0 cpay, up t 1 rutine hearing exam every year. Yu pay a $0 cpay, up t 1 rutine hearing exam every year. Yu must see a TruHearing prvider t use the rutine hearing exam benefit. 6

8 Premiums and Benefits Clver Health Classic Clver Health Value What Yu Shuld Knw Hearing aids* Yu pay a $699 cpay fr each Flyte Advanced hearing aid r a $999 cpay fr each Flyte Premium hearing aid, up t 2 hearing aids per year (1 per ear per year). Yu pay a $699 cpay fr each Flyte Advanced hearing aid r a $999 cpay fr each Flyte Premium hearing aid, up t 2 hearing aids per year (1 per ear per year). Yu must see a TruHearing prvider t use the hearing aid benefit. Dental Services Preventive ral exams* each dental exam, up t 2 every year. each dental exam, up t 2 every year. Yu must see a DentaQuest prvider t use this benefit. Preventive cleanings* each dental cleaning, up t 2 every year. each dental cleaning, up t 2 every year. Preventive X-rays* each dental X-ray, up t 1 every year. each dental X-ray, up t 1 every year. Preventive fluride treatments* each dental fluride treatment, up t 2 every year. each dental fluride treatment, up t 2 every year. cmprehensive dental services cmprehensive dental services. cmprehensive dental services. 7

9 Premiums and Benefits Clver Health Classic Clver Health Value What Yu Shuld Knw Supplemental cmprehensive dental services*: Nn-rutine services Diagnstic services Restrative services Enddntics Peridntics Extractins Prsthdntics Other Oral /Maxillfacial Surgery Our plan cvers up t $1,000 every year fr nn-medicare cvered cmprehensive dental services after yu pay a $20 cpay fr each service. Our plan cvers up t $1,000 every year fr nn-medicare cvered cmprehensive dental services after yu pay a $20 cpay fr each service. Visin Services visin services Yu pay a $25 cpay fr exams t diagnse and treat diseases and cnditins f the eye. Yu pay a $5 cpay fr exams t diagnse and treat diseases and cnditins f the eye. eyewear 1 pair f eyeglasses r cntact lenses after each cataract surgery. 1 pair f eyeglasses r cntact lenses after each cataract surgery. Rutine visin exam* 1 rutine eye exam per year. 1 rutine eye exam per year. Yu must see an EyeQuest prvider t use this benefit. Supplemental eyewear* Our plan will pay up t $100 per year fr rutine eyewear r cntacts. Our plan will pay up t $100 per year fr rutine eyewear r cntacts. Yu must see an EyeQuest prvider t use this benefit. 8

10 Premiums and Benefits Clver Health Classic Clver Health Value What Yu Shuld Knw Mental Health Services Inpatient Yu pay a $275 cpay per day fr days 1-6 fr each stay. Yu pay a $0 cpay per day fr days 7-90 fr each stay. Yu pay a $170 cpay per day fr days 1-6 fr each stay. Yu pay a $0 cpay per day fr days 7-90 fr each stay. Our plan cvers up t 190 days in a lifetime fr inpatient mental health care in a psychiatric hspital. The inpatient hspital care limit des nt apply t inpatient mental services prvided in a general hspital. Outpatient individual and grup therapy visits Yu pay a $25 cpay fr each visit. Yu pay a $5 cpay fr each visit. Skilled Nursing Facility Yu pay a $0 cpay per day fr days 1-20 fr each stay. Yu pay a $172 cpay per day fr days fr each stay. Yu pay a $0 cpay per day fr days 1-20 fr each stay. Yu pay a $172 cpay per day fr days fr each stay. Our plan cvers up t 100 days each benefit perid. N prir hspitalizatin stay is required. Physical Therapy (rehabilitatin services) Physical therapy, ccupatinal therapy, and speech and language therapy visits Yu pay a $25 cpay. Yu pay a $5 cpay. cardiac rehabilitatin Yu pay a $25 cpay. Yu pay a $5 cpay. pulmnary rehabilitatin Yu pay a $25 cpay. Yu pay a $5 cpay. 9

11 Premiums and Benefits Clver Health Classic Clver Health Value What Yu Shuld Knw Supervised Exercise Therapy (SET) fr Peripheral Artery Disease (PAD) Yu pay a $25 cpay. Yu pay a $5 cpay. Ambulance Grund and air transprtatin Yu pay a $250 cpay. Yu pay a $200 cpay. Prir authrizatin rules apply fr nn-emergency ambulance services. Transprtatin Yu pay a $0 cpay. Yu pay a $0 cpay. Yu are cvered fr up t 10 ne-way nnemergent trips within the plan service area t any health-related lcatin. Each ne-way trip must nt exceed 50 miles. Please cntact Clver Member Services at (TTY users shuld call 711) fr infrmatin n hw t arrange a ride. Arrangements shuld be made 24 hurs in advance. Medicare Part B Drugs Ft Care (pdiatry services) Yu pay 20% f the ttal cst fr chemtherapy drugs and ther Part B drugs. Yu pay 20% f the ttal cst fr chemtherapy drugs and ther Part B drugs. ft care Yu pay a $25 cpay. Yu pay a $5 cpay. Rutine ft care Nt cvered Nt cvered 10

12 Premiums and Benefits Clver Health Classic Clver Health Value What Yu Shuld Knw Medical Equipment/Supplies Durable Medical Equipment (such as wheelchairs, xygen) Yu pay 20% f the ttal cst. Yu pay 20% f the ttal cst. Prsthetics (such as braces, artificial limbs) Yu pay 20% f the ttal cst. Yu pay 20% f the ttal cst. Diabetes supplies Yu pay a $0 cpay. Yu pay a $0 cpay. Health and Wellness Prgrams Gym membership Yu pay a $0 cpay. Yu pay a $0 cpay. Visit fr mre infrmatin. 11

13 PART D BENEFITS Yur Clver plan includes Medicare Part D prescriptin drug cverage. Clver s cmprehensive frmulary lists all brand name and generic drugs that are cvered by yur plan. We als have relatinships with a netwrk f pharmacies. In many cases, yu'll save mney at an in-netwrk pharmacy. Our frmulary is divided int five tiers. Cvered drugs have different cst shares depending n what tier they're assigned t. The grid n the fllwing pages can help yu understand yur cst share fr each medicatin yu take. T estimate yur share f cst: knw what drugs yu take lk them up in the frmulary t learn what tier they're assigned t use the grid n the fllwing pages t learn yur cst share fr each tier All Medicare Part D plans have fur phases f cverage described in the grid n the fllwing pages. Yur share f the drug cst is different in each phase. If yu need any assistance determining yur drug csts thrughut the year, please call Member Services. 100-Day Fills Clver's plans cver 100-day fills f cmmn maintenance medicatins. Yu can take advantage f this benefit as lng as yur prvider feels that 100-day fills are suitable fr yur circumstances. Yu can fill these prescriptins at a preferred retail pharmacy, r by mail rder thrugh CVS Caremark Mail Order Pharmacy. Lng-Term Care Facilities & ther circumstances If yu reside in a lng-term care facility, yu pay the same fr a 31-day supply as a 30-day supply at a standard retail pharmacy. Please see yur Evidence f Cverage dcument fr mre infrmatin. If the drugs in ur frmulary dn t meet yur needs r if yu take a drug that isn't cvered by ur frmulary, call ur Member Services Department at t learn mre abut alternatives. Yu may be able t take an alternative medicatin r request a frmulary exceptin. If the share f cst is t high fr a drug yu need, yu can request that Clver cver that drug at a lwer tier. Fr mre infrmatin abut frmulary r tier exceptins, refer t yur Evidence f Cverage dcument. State Pharmaceutical Assistance Prgram (SPAP) Card State Pharmaceutical Assistance Prgrams (SPAPs) are state-run prgrams that help qualifying lwincme senirs r adults with disabilities pay fr prescriptin drugs by cvering premiums r cpayments. SPAP cverage varies by state, s reach ut t yur state gvernment ffice t see whether yu're eligible, and t understand the details f yur state's cverage. Access the prgram cntact infrmatin by state at r call ur Member Services Department at fr additinal questins. 12

14 Prescriptin Drug Cverage Stages Premiums and Benefits Clver Health Classic Clver Health Value Deductible Stage Initial Cverage Stage (After yu pay yur deductible, if applicable) Cverage Gap Stage (After the ttal amunt fr the prescriptin drugs yu have filled and refilled reaches $3,820) During this stage, yu pay the full cst f yur Tier 3, 4, and 5 drugs. Yu stay in this stage until yu have paid $150 fr yur Tier 3, 4, and 5 drugs. After yu pay yur yearly deductible, yu pay the cpays r cinsurance until yur ttal yearly drug csts reach $3,820. Ttal yearly drug csts are the ttal drug csts paid by bth yu and Clver Health. Yu may get yur drugs at netwrk retail pharmacies and mail rder pharmacies. Mst Medicare drug plans have a cverage gap (als called the dnut hle ). This means that there s a temprary change in what yu will pay fr yur drugs. The cverage gap begins after the ttal yearly drug cst (including what ur plan has paid and what yu have paid) reaches $3,820. Nt everyne will enter the cverage gap. Brand name drugs: yu pay 25% f the negtiated price and a prtin f the dispensing fee. Bth the amunt yu pay and the amunt discunted by the manufacturer cunt tward yur ut-f-pcket csts. Generic drugs: yu pay n mre than 37% f the cst, and the plan pays the rest. The amunt paid by the plan 63% des nt cunt tward yur ut-f-pcket csts. Only the amunt yu pay cunts and mves yu thrugh the cverage gap. When yur ttal ut-f-pcket csts fr the year reach $5,100, yur cverage mves int the Catastrphic Stage and yu pay less. During this stage, yu pay the full cst f yur Tier 2, 3, 4, and 5 drugs. Yu stay in this stage until yu have paid $415 fr yur Tier 2, 3, 4, and 5 drugs. After yu pay yur yearly deductible, yu pay the cpays r cinsurance until yur ttal yearly drug csts reach $3,820. Ttal yearly drug csts are the ttal drug csts paid by bth yu and Clver Health. Yu may get yur drugs at netwrk retail pharmacies and mail rder pharmacies. Mst Medicare drug plans have a cverage gap (als called the dnut hle ). This means that there s a temprary change in what yu will pay fr yur drugs. The cverage gap begins after the ttal yearly drug cst (including what ur plan has paid and what yu have paid) reaches $3,820. Nt everyne will enter the cverage gap. Brand name drugs: yu pay 25% f the negtiated price and a prtin f the dispensing fee. Bth the amunt yu pay and the amunt discunted by the manufacturer cunt tward yur ut-f-pcket csts. Generic drugs: yu pay n mre than 37% f the cst, and the plan pays the rest. The amunt paid by the plan 63% des nt cunt tward yur ut-f-pcket csts. Only the amunt yu pay cunts and mves yu thrugh the cverage gap. When yur ttal ut-f-pcket csts fr the year reach $5,100, yur cverage mves int the Catastrphic Stage and yu pay less. 13

15 Premiums and Benefits Clver Health Classic Clver Health Value Catastrphic Cverage Stage (After yur ut-f-pcket csts have reached the $5,100 limit fr the calendar year) After yur yearly ut-f-pcket drug csts (including drugs purchased thrugh yur retail pharmacy and thrugh mail rder) reach $5,100, yu pay the greater f: cinsurance f 5% f the cst f the drug, r $3.40 fr a generic drug r a drug that is treated like a generic and $8.50 fr all ther drugs. Our plan pays the rest f the cst. After yur yearly ut-f-pcket drug csts (including drugs purchased thrugh yur retail pharmacy and thrugh mail rder) reach $5,100, yu pay the greater f: cinsurance f 5% f the cst f the drug, r $3.40 fr a generic drug r a drug that is treated like a generic and $8.50 fr all ther drugs. Our plan pays the rest f the cst. 14

16 Cst Shares During the Initial Cverage Stage Standard Retail Pharmacy Tier Clver Health Classic Clver Health Value Tier 1: Preferred Generic Tier 2: Generic Tier 3: Preferred Brand Tier 4: Nn-Preferred Drugs Tier 5: Specialty Tier Yu pay a $5 cpay per prescriptin fr a 30-day supply Yu pay a $10 cpay per prescriptin fr a 60-day supply Yu pay a $15 cpay per prescriptin fr Yu pay a $15 cpay per prescriptin fr a 30-day supply Yu pay a $30 cpay per prescriptin fr a 60-day supply Yu pay a $45 cpay per prescriptin fr Yu pay a $47 cpay per prescriptin fr a 30-day supply Yu pay a $94 cpay per prescriptin fr a 60-day supply Yu pay a $141 cpay per prescriptin fr Yu pay a $95 cpay per prescriptin fr a 30-day supply Yu pay a $190 cpay per prescriptin fr a 60-day supply Yu pay a $285 cpay per prescriptin fr Yu pay 30% cinsurance per prescriptin fr a 30-day supply Yu pay 30% cinsurance per prescriptin fr a 60-day supply Yu pay 30% cinsurance per prescriptin fr Yu pay a $12 cpay per prescriptin fr a 30-day supply Yu pay a $24 cpay per prescriptin fr a 60-day supply Yu pay a $36 cpay per prescriptin fr Yu pay a 25% cinsurance per prescriptin fr a 30-day supply Yu pay a 25% cinsurance per prescriptin fr a 60-day supply Yu pay a 25% cinsurance per prescriptin fr Yu pay a 25% cinsurance per prescriptin fr a 30-day supply Yu pay a 25% cinsurance per prescriptin fr a 60-day supply Yu pay a 25% cinsurance per prescriptin fr Yu pay a 25% cinsurance per prescriptin fr a 30-day supply Yu pay a 25% cinsurance per prescriptin fr a 60-day supply Yu pay a 25% cinsurance per prescriptin fr Yu pay 25% cinsurance per prescriptin fr a 30-day supply Yu pay 25% cinsurance per prescriptin fr a 60-day supply Yu pay 25% cinsurance per prescriptin fr 15

17 Preferred Retail Pharmacy Tier Clver Health Classic Clver Health Value Tier 1: Preferred Generic Tier 2: Generic Tier 3: Preferred Brand Tier 4: Nn-Preferred Drugs Tier 5: Specialty Tier Yu pay a $0 cpay per prescriptin fr a 30-day supply Yu pay a $0 cpay per prescriptin fr a 60-day supply Yu pay a $0 cpay per prescriptin fr a 100-day supply Yu pay a $10 cpay per prescriptin fr a 30-day supply Yu pay a $20 cpay per prescriptin fr a 60-day supply Yu pay a $30 cpay per prescriptin fr Yu pay a $37 cpay per prescriptin fr a 30-day supply Yu pay a $74 cpay per prescriptin fr a 60-day supply Yu pay a $111 cpay per prescriptin fr Yu pay a $85 cpay per prescriptin fr a 30-day supply Yu pay a $170 cpay per prescriptin fr a 60-day supply Yu pay a $255 cpay per prescriptin fr Yu pay 30% cinsurance per prescriptin fr a 30-day supply Yu pay 30% cinsurance per prescriptin fr a 60-day supply Yu pay 30% cinsurance per prescriptin fr Yu pay a $0 cpay per prescriptin fr a 30-day supply Yu pay a $0 cpay per prescriptin fr a 60-day supply Yu pay a $0 cpay per prescriptin fr a 100-day supply Yu pay a 22% cinsurance per prescriptin fr a 30-day supply Yu pay a 22% cinsurance per prescriptin fr a 60-day supply Yu pay a 22% cinsurance per prescriptin fr Yu pay a 22% cinsurance per prescriptin fr a 30-day supply Yu pay a 22% cinsurance per prescriptin fr a 60-day supply Yu pay a 22% cinsurance per prescriptin fr Yu pay a 25% cinsurance per prescriptin fr a 30-day supply Yu pay a 25% cinsurance per prescriptin fr a 60-day supply Yu pay a 25% cinsurance per prescriptin fr Yu pay 25% cinsurance per prescriptin fr a 30-day supply Yu pay 25% cinsurance per prescriptin fr a 60-day supply Yu pay 25% cinsurance per prescriptin fr 16

18 Mail Order Pharmacy Tier Clver Health Classic Clver Health Value Tier 1: Preferred Generic Tier 2: Generic Tier 3: Preferred Brand Tier 4: Nn-Preferred Drugs Tier 5: Specialty Tier Yu pay a $0 cpay per prescriptin fr a 100-day supply Yu pay a $20 cpay per prescriptin fr Yu pay a $74 cpay per prescriptin fr Yu pay a $170 cpay per prescriptin fr Yu pay a 30% cinsurance per prescriptin fr Yu pay a $0 cpay per prescriptin fr a 100-day supply Yu pay a 25% cinsurance per prescriptin fr Yu pay a 25% cinsurance per prescriptin fr Yu pay a 25% cinsurance per prescriptin fr Yu pay a 25% cinsurance per prescriptin fr 17

19 Clver is here fr yu (TTY 711) 8 am 8 pm lcal time, 7 days/week* Visit us at clverhealth.cm/enrll *Between April 1st and September 30th, alternate technlgies (fr example, vic ) will be used n the weekends and hlidays. Clver Health is a Preferred Prvider Organizatin (PPO) plan and a Health Maintenance Organizatin plan with a Medicare cntract. Enrllment in Clver Health depends n cntract renewal. This infrmatin is nt a cmplete descriptin f benefits. Call (TTY 711) fr mre infrmatin. Out-f-netwrk/nn-cntracted prviders are under n bligatin t treat Clver members, except in emergency situatins. Please call ur custmer service number r see yur Evidence f Cverage fr mre infrmatin, including the cst-sharing that applies t ut-f-netwrk services. Clver Health cmplies with applicable Federal civil rights laws and des nt discriminate n the basis f race, clr, natinal rigin, age, disability, r sex. ATTENTION: If yu speak English, language assistance services, free f charge, are available t yu. Call (TTY 711). Clver Health cumple cn las leyes federales de derechs civiles aplicables y n discrimina pr mtivs de raza, clr, nacinalidad, edad, discapacidad sex. ATENCIÓN: Si usted habla españl, tenems servicis de asistencia lingüística dispnibles para usted sin cst algun. Llame al (TTY 711). Clver Health 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 小贴士 : 如果您说普通话, 欢迎使用免费语言协助服务 请拨 (TTY 711) Y0129_8EX015A3_M