MVP Health Care 2015 MEDICARE ADVANTAGE HEALTH PLANS. Central New York / Vermont Region Benefits at a Glance

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1 MVP Health Care 2015 MEDICARE ADVANTAGE HEALTH PLANS Central New York / Vermont Region Benefits at a Glance Y0051_2371 Accepted 09/10/2014

2 2015 CENTRAL NEW YORK / VERMONT REGION Your Medical Benefits (Medicare Part C) with MVP the Value Page 2015 Benefit Highlights ORIGINAL MEDICARE Amounts may change for 2015 GoldValue with Part D (HMO-POS) Gold PPO with Part D (PPO) IN=In-Network OUT=Out-of-Network BasiCare with Part D (PPO) IN=In-Network OUT=Out-of-Network Monthly Plan Premium Quality score Medicare Star Rating (out of 5 stars) Your Part B premium. Part D not available. Not Rated. $ with Part D $ with Part D $49.70 with Part D DOCTOR VISITS Primary Care 20% coinsurance. $20 IN $25; OUT $60 IN $35; OUT $60 Specialist 20% coinsurance. $40 IN $50; OUT $60 IN $50; OUT $60 Chiropractic visit 20% coinsurance. $20 IN - $20; OUT - $20 IN $20; OUT $20 Medicare Part B Prescription Drugs includes chemotherapy 20% coinsurance. 20% IN - 20%; OUT- 40% IN - 20%; OUT- 40% Hearing Exam and Vision Exam 20% coinsurance. $40 IN $50; OUT $60 IN $50; OUT $60 Radiation Therapy may apply. HOSPITAL SERVICES 20% coinsurance. Covered in full. IN covered in full. IN covered in full. Inpatient Hospital Stays and worldwide Emergency Hospitalization Inpatient Mental Health Care (190 days per lifetime) For 2014: Days 1-60: $1,216 deductible. Days 61-90: $304 per day. Days : $608 per lifetime reserve day. $295/day for days 1-5; $0/day for days 6+ IN $750 per admission up to 3 times per calendar year; you pay $0 thereafter. OUT 40% coinsurance for non-emergency admissions. IN $295/day for days 1-5; $0/day for days 6+. OUT 40% coinsurance for non-emergency admissions. Observation Stays 20% coinsurance. $300 IN $500 IN $600 OUTPATIENT SERVICES Ambulatory Surgical Center same day surgery and other services 20% coinsurance. $150 IN $250 IN $300 Outpatient Hospital same day surgery and other services 20% for doctor services. 20% - 40% for outpatient facility services. $300 IN $500 IN $600 EMERGENCY CARE Emergency Room Care worldwide coverage Urgently Needed Care coverage anywhere in the U.S. 20% coinsurance. Not covered outside U.S. except under limited circumstances. 20% coinsurance or set copay. $65 $65 $65 $40 $50 $50 Ambulance Transportation 20% coinsurance. $125 $125 $200 DIAGNOSTIC SERVICES office visit copay may apply X-ray (Radiology) 20% coinsurance. $40 IN $50; OUT $60 IN $50; OUT $60 CT scans, PET scans, MRIs, Nuclear Medicine 20% coinsurance. $100 IN $60. IN $100. Lab $0 - preventive/diagnostic. Maintenance not covered. $0 preventive. $10 maintenance. IN $0 preventive. $10 maintenance. IN $0 preventive. $20 maintenance. REHABILITATION Skilled Nursing Facility (post-acute rehabilitation center) For 2014: $0/day for days 1-20; $152/day for days Days 1-20 covered in full. $150/day for days IN Days 1-20 covered in full. $150/day for days IN Days 1-20 covered in full. $150/day for days Physical, Speech and Occupational Therapy visits 20% coinsurance. $40 IN - $40; OUT- $60 IN - $40; OUT- $60 Home Health Care medically necessary Covered in full. Covered in full. IN Covered in full. IN Covered in full. PLUS EVEN MORE VALUE FOR YOUR MONTHLY PREMIUM! SilverSneakers Fitness Program N/A Basic fitness center Basic fitness center Basic fitness center HealthDollars SM allowance for healthy activities No coverage. $100 per year. $100 per year. $100 per year. Diabetic blood glucose test strips - OneTouch, Freestyle and Precision brands 20% coinsurance. 10% coinsurance. 10% coinsurance. 10% coinsurance. Dental allowance for preventive services Any unused portion of this benefit will not carry over to the next calendar year. No coverage. $240 per year. N/A N/A Eye wear allowance No coverage. $75 every 2 years. N/A N/A OUT-OF-NETWORK COVERAGE For planned non-urgent and non-emergency services, such as office visits, elective outpatient surgery, X-ray, lab, mammograms, durable medical equipment, and physical, speech & occupational therapies 20% coinsurance after Medicare deductible. MVP pays 70% up to $5,000/year. You pay 30%. $60 for office visits. 40% coinsurance for most other services. $60 for office visits. 40% coinsurance for most other services. MEMBER PROTECTION you pay no more than the following: Maximum Out-Of-Pocket protection includes Part B drugs. Does not include monthly premium, acupuncture and Part D cost. No Out-of-Pocket protection. $6,000 maximum out-ofpocket for your protection. IN and OUT - $10,000 IN ONLY - $4,000 IN and OUT - $10,000 IN ONLY - $4,000

3 HOW MEDICARE PART D WORKS The following information does not apply to all Medicare Part D members. If you qualify for Low Income Subsidy or have both Medicare and Medicaid, you may be eligible for extra help with Part D drug costs. If your coverage is through an employer sponsored plan, check with the former employer for benefit information. GoldValue with Part D $ For a 30-day supply your copay is: Tier 1 - $3 Tier 2 - $15 Tier 3 - $45 Tier 4 - $95 Gold PPO with Part D $ For a 30-day supply your copay is: Tier 1 - $0 Tier 2 - $10 Tier 3 - $35 Tier 4 - $90 BasiCare with Part D $49.70 You will pay 100% of the cost of your drugs until you have met your $320 deductible. Once you ve spent $320: All drugs in all Tiers are 25%. For a 90-day supply your copay is: Tier 1 - $6 Tier 2 - $30 Tier 3 $90 Tier 4 $190 For a 90-day supply your copay is: Tier 1 - $0 Tier 2 - $20 Tier 3 - $70 Tier 4 - $180 Coverage in the Gap If your total drug costs in 2015 reach $2,960, you will pay 65% for generic drugs and 45% for Medicare-contracted brands. When your out-of-pocket drug costs reach $4,700 in 2015, your cost for prescriptions is reduced to the greater of 5% or $2.65 for generics and $6.60 for brand-name drugs. If you choose GoldValue with Part D and are taking a Tier 1 drug, you will pay $3 maximum all year (in the initial coverage phase, the coverage gap, and the catastrophic phase). If you choose Gold PPO with Part D and you are taking a Tier 1 or Tier 6 drug, it will be $0 all year. You will pay 100% of the cost of your drugs until you have met your $320 deductible. Once you ve spent $320: All drugs in all tiers are 25%. Coverage in the Gap If your total drug costs in 2015 reach $2,960, you will pay 65% for generic drugs and 45% for Medicare-contracted brands. When your out-of-pocket drug costs reach $4,700 in 2015, your cost for prescriptions is reduced to the greater of 5% or $2.65 for generics and $6.60 for brand-name drugs. When you obtain a Medicare-contracted brand drug in the coverage gap, 97.5% of the cost of your drug counts toward your out-of-pocket drug costs, not just the amount that you pay. This is to your benefit it will help you reach the catastrophic coverage level faster. Good news! If the cost of the drug is less than the copay or coinsurance, you pay the lower amount.

4 Things to remember about Part D coverage Not all Part D drugs are available through the mail. Refer to the MVP Formulary (list of Part D covered drugs) for more details. You pay a 10% coinsurance for OneTouch, Freestyle and Precision brand blood glucose test strips. All other blood glucose test strips have a 20% coinsurance. Drugs purchased outside the U.S. are not Medicare approved and are not covered. Medicare rules Medicare allows you to be a member of only one Medicare Advantage plan at a time. MVP offers the convenience of both medical coverage and Part D coverage together in one plan! If you join an MVP Medicare Advantage plan and later choose a Part D drug plan from another insurance or pharmacy company, Medicare will: 1) Enroll you in that drug plan for your Part D drug coverage, 2) Automatically disenroll you out of your MVP plan, and 3) Enroll you into Original Medicare (Parts A and B only) for your medical coverage for the remainder of the year, along with the drug plan you chose. Note: If you do not join a Medicare Part D plan when you first become eligible, or do not have coverage as good as Medicare s, you may have to pay a penalty if you join at a later date. The penalty can be 1% of the current premium for every month you delay enrollment. This penalty will apply for as long as you are enrolled in Part D coverage. Programs that may help save you money on your Part D drugs Getting Extra Help Low Income Subsidy (LIS) You may be able to get Extra Help also called Low Income Subsidy to help reduce your monthly prescription drug premium and drug copays. To see if you qualify for Extra Help, call MEDICARE ( ) or TTY at , 24 hours a day/ 7 days a week; or the Social Security Office at , from 7 am to 7 pm Monday Friday (TTY: ). Or call your state Medicaid office. Part D and VA If you receive VA benefits, you are not required to join Medicare Part D. But, some drugs may not be covered under your VA plan. Call your local VA office for more information. State Pharmaceutical Assistance Program New York State: You may be eligible for New York State s EPIC (Elderly Pharmaceutical Insurance Coverage) program. EPIC members may pay lower copays. Call EPIC at for more information. Vermont: You may be eligible for a Vermont Prescription Assistance Program. Call for more information. If your coverage is through an employer-sponsored plan, check with the former employer for your benefit information. This is not a contract. Benefit charts that follow are for general reference only. All benefits are subject to federal Medicare program medical necessity guidelines. A complete summary of benefits is available upon request. MVP Health Plan, Inc. is an HMO-POS/PPO organization with a Medicare contract. Enrollment in MVP Health Plan depends on contract renewal. The benefit information provided is a brief summary, not a complete description of benefits. For more information, contact the plan. Limitations, copayments, and restrictions apply. Benefits, formulary, pharmacy network, provider network, premium and/or copayments/coinsurance may change on January 1 of each year. You must continue to pay your Part B premium. Medicare evaluates plans based on a 5-star rating system. Star Ratings are calculated each year and may change from one year to the next.

5 New to MVP? Call with questions and to enroll over the phone in minutes! Monday Friday, 8 am 5 pm Eastern Time. Free informational meetings! Call us to reserve your seat and also for accommodation of persons with special needs at sales meetings. A sales person will be present with information and applications. Enroll online anytime! Visit to enroll online day or night. Already an MVP member? Call MVP s Medicare Customer Care Center: , Monday Friday, 8 am to 8 pm. From Oct. 1 Feb. 14, call us seven days a week from 8 am to 8 pm. TTY: LIVE HEALTHY. SAVE MONEY. These benefits are included with MVP Medicare Advantage plans at no added cost to you! $0-cost SilverSneakers Membership Get healthy with a complimentary gym membership, designed exclusively for Medicareeligible adults. $100 Allowance Start every year with $100 HealthDollars SM to spend on healthy activities! Low or No Cost Generic Drugs MVP Medicare Advantage plans feature low or no copays on lots of popular prescriptions! $0-cost Medication Review An MVP pharmacist will review the drugs you are taking and discuss lower-cost alternatives. $0-cost Preventive Services MVP s got you covered in full for annual physicals and preventive screenings