Memorial Hermann Advantage PPO 2016 Summary of Benefits

Memorial Hermann Advantage PPO 2016 Summary of Benefits 16E1-APPO-SBC

Memorial Hermann Advantage PPO 2016 Summary of Benefits Standard and Supplemental plan benefits enclosed. January 1, 2016 - December 31, 2016 H2968-001 Y0110_PRE_PPO_SB_0815 CMS Accepted 9/16/15 16E1-APPO-SBC

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SUMMARY OF BENEFITS January 1, 2016 - December 31, 2016 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." You have choices about how to get your Medicare benefits 1 One choice is to get your Medicare benefits through Original Medicare (fee-for-service Medicare). Original Medicare is run directly by the Federal government. 1 Another choice is to get your Medicare benefits by joining a Medicare health plan (such as Memorial Hermann Advantage (PPO)). Tips for comparing your Medicare choices This Summary of Benefits booklet gives you a summary of what Memorial Hermann Advantage (PPO) covers and what you pay. 1 If you want to compare our plan with other Medicare health plans, ask the other plans for their Summary of Benefits booklets. Or, use the Medicare Plan Finder on http://www.medicare.gov. 1 If you want to know more about the coverage and costs of Original Medicare, look in your current "Medicare & You" handbook. View it online at http://www.medicare.gov or get a copy by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. Sections in this booklet 1 Things to Know About Memorial Hermann Advantage (PPO) 1 Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services 1 Covered Medical and Hospital Benefits 1 Prescription Drug Benefits 1 Optional Benefits (you must pay an extra premium for these benefits) This document 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 (844) 550-6896. Este documento está disponible en otros formatos como Braille y en letra grande. Este documento puede estar disponible en un idioma diferente al inglés. Para información adicional, llámenos al (844) 550-6896. Things to Know About Memorial Hermann Advantage (PPO) Hours of Operation 1 From October 1 to February 14, you can call us 7 days a week from 8:00 a.m. to 8:00 p.m Central time. 1 From February 15 to September 30, you can call us Monday through Friday from 8:00 a.m. to 8:00 p.m. Central time. Memorial Hermann Advantage (PPO) Phone Numbers and Website 1 If you are a member of this plan, call toll-free (844) 550-6896. 1 If you are not a member of this plan, call toll-free (888) 624-4540. 3 Page

SUMMARY OF BENEFITS 1 Our website: healthplan.memorialhermann.org/medicare Who can join? To join Memorial Hermann Advantage (PPO), 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 Texas: Fort Bend, Harris, and Montgomery. Which doctors, hospitals, and pharmacies can I use? Memorial Hermann Advantage (PPO) has a network of doctors, hospitals, pharmacies, and other providers. If you use the providers in our network, you may pay less for your covered services. But if you want to, you can also use providers that are not in our network. You must generally use network pharmacies to fill your prescriptions for covered Part D drugs. You can see our plan's provider and pharmacy directory at our website (healthplan.memorialhermann.org/medicare). Or, call us and we will send you a copy of the provider and pharmacy directories. What do we cover? Like all Medicare health plans, we cover everything that Original Medicare covers - and more. 1 Our plan members get all of the benefits covered by Original Medicare. For some of these benefits, you may pay more in our plan than you would in Original Medicare. For others, you may pay less. 1 Our plan members also get more than what is covered by Original Medicare. Some of the extra benefits are outlined in this booklet. We cover Part D drugs. In addition, we cover Part B drugs such as chemotherapy and some drugs administered by your provider. 1 You can see the complete plan formulary (list of Part D prescription drugs) and any restrictions on our website, healthplan.memorialhermann.org/medicare. 1 Or, call us and we will send you a copy of the formulary. How will I determine my drug costs? Our plan groups each medication into one of five "tiers." You will need to use your formulary to locate what tier your drug is on to determine how much it will cost you. The amount you pay depends on the drug's tier and what stage of the benefit you have reached. Later in this document we discuss the benefit stages that occur after you meet your deductible: Initial Coverage, Coverage Gap, and Catastrophic Coverage. 4 Page

Summary of Benefits January 1, 2016 - December 31, 2016 Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services How much is the monthly premium? How much is the deductible? Is there any limit on how much I will pay for my covered services? Is there a limit on how much the plan will pay? $0 per month. In addition, you must keep paying your Medicare Part B premium. $100 per year for Part D prescription drugs. Yes. Like all Medicare health plans, our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care. Your yearly limit(s) in this plan: 1 $6,700 for services you receive from in-network providers. 1 $7,000 for services you receive from any provider. Your limit for services received from in-network providers will count toward this limit. If you reach the limit on out-of-pocket costs, you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year. Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs. Our plan has a coverage limit every year for certain benefits from any provider. Contact us for services that apply. Memorial Hermann Advantage PPO is a health plan with a Medicare contract. Enrollment in Memorial Hermann Advantage PPO depends on contract renewal. Memorial Hermann Health Solutions, Inc. is the parent company of Memorial Hermann Health Insurance Company and Memorial Hermann Health Plan, Inc., both of which are Medicare Advantage organizations. 5 Page

Covered Medical and Hospital Benefits Note: 1 Services with a 1 may require prior authorization. 1 Services with a 2 may require a referral from your doctor. Outpatient Care and Services Acupuncture Not covered Ambulance 1 Chiropractic Care Dental Services 1 Diabetes Supplies and Services 1 In-network: $250 copay 1 Out-of-network: $250 copay Non-emergent transportation prior authorization required. Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): 1 In-network: $20 copay Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): 1 In-network: $75 copay In general, preventive dental services (such as cleaning, routine dental exams, and dental x-rays) are not covered by Original Medicare. We cover: Medicare-covered dental services limited to surgery of the jaw or facial bones, extraction of teeth to prepare the jaw for radiation treatments of neoplastic cancer disease, or services that would be covered when provided by a physician. Diabetes monitoring supplies: Diabetes self-management training: Therapeutic shoes or inserts: Certain limitations or conditions may apply 6 Page

Diagnostic Tests, Lab and Radiology Services, and X-Rays (Costs for these services may be different if received in an outpatient surgery setting) 1 Diagnostic radiology services (such as MRIs, CT scans): 1 In-network: $300 copay Diagnostic tests and procedures: Lab services: Outpatient x-rays: 1 In-network: $15 copay Therapeutic radiology services (such as radiation treatment for cancer): 1 In-network: $35 copay Doctor's Office Visits Durable Medical Equipment (wheelchairs, oxygen, etc.) 1 Emergency Care Foot Care (podiatry services) 1 Primary care physician visit: Specialist visit: 1 In-network: $40 copay Cost share may apply for Part B injectable. 1 In-network: 20% of the cost $75 copay If you are admitted to the hospital within 24 hours, 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. Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: 1 In-network: $40 copay Limitations may apply 7 Page

Hearing Services Exam to diagnose and treat hearing and balance issues: 1 In-network: $40 copay Routine hearing exam: 1 In-network: $0 copay Hearing aid: 1 In-network: $0 copay 1 Out-of-network: $0 copay Our plan pays up to $500 every two years for hearing aids from an in-network provider and an additional $500 every two years from an out-of-network provider. Home Health Care 1 Mental Health Care 1 Inpatient visit: The copays for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you're admitted as an inpatient and ends when you haven't received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There's no limit to the number of benefit periods. Our plan covers an unlimited number of days for an inpatient hospital stay. 1 In-network: 4 $250 copay per day for days 1 through 5 4 You pay nothing per day for days 6 through 90 4 You pay nothing per day for days 91 and beyond 1 Out-of-network: 4 40% of the cost per stay Outpatient group therapy visit: 1 In-network: $40 copay Outpatient individual therapy visit: 1 In-network: $40 copay 8 Page

Outpatient Rehabilitation 1 Outpatient Substance Abuse Outpatient Surgery 1 Over-the-Counter Items Prosthetic Devices (braces, artificial limbs, etc.) 1 Renal Dialysis 1 Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): Occupational therapy visit: 1 In-network: $35 copay Physical therapy and speech and language therapy visit: 1 In-network: $35 copay Other limitations may apply. Group therapy visit: 1 In-network: $40 copay Individual therapy visit: 1 In-network: $40 copay Ambulatory surgical center: 1 In-network: $225 copay Outpatient hospital: 1 In-network: $225 copay Not Covered Prosthetic devices: 1 In-network: 20% of the cost Related medical supplies: 1 In-network: 20% of the cost 1 In-network: $30 copay 1 Out-of-network: 20% of the cost 9 Page

Transportation Urgently Needed Services Vision Services Not covered $40 copay Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): 1 In-network: $40 copay Routine eye exam: 1 In-network: $0-40 copay, depending on the service Contact lenses: 1 In-network: $0 copay 1 Out-of-network: $100 copay Eyeglasses (frames and lenses): 1 In-network: $0 copay 1 Out-of-network: $100 copay Eyeglass frames: 1 In-network: $0 copay 1 Out-of-network: $100 copay Eyeglass lenses: 1 In-network: $0 copay 1 Out-of-network: $100 copay Eyeglasses or contact lenses after cataract surgery: 1 In-network: $0 copay Our plan pays up to $100 every two years for eyewear from an in-network provider and an additional $100 every two years from an out-of-network provider. 10 Page

Preventive Care Hospice Our plan covers many preventive services, including: 1 Abdominal aortic aneurysm screening 1 Alcohol misuse counseling 1 Bone mass measurement 1 Breast cancer screening (mammogram) 1 Cardiovascular disease (behavioral therapy) 1 Cardiovascular screenings 1 Cervical and vaginal cancer screening 1 Colorectal cancer screenings (Colonoscopy, Fecal occult blood test, Flexible sigmoidoscopy) 1 Depression screening 1 Diabetes screenings 1 HIV screening 1 Medical nutrition therapy services 1 Obesity screening and counseling 1 Prostate cancer screenings (PSA) 1 Sexually transmitted infections screening and counseling 1 Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease) 1 Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots 1 "Welcome to Medicare" preventive visit (one-time) 1 Yearly "Wellness" visit Any additional preventive services approved by Medicare during the contract year will be covered. You pay nothing for hospice care from a Medicare-certified hospice. You may have to pay part of the costs for drugs and respite care. Hospice is covered outside of our plan. Please contact us for more details. 11 Page

Inpatient Care Inpatient Hospital Care 1 The copays for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you're admitted as an inpatient and ends when you haven't received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There's no limit to the number of benefit periods. Our plan covers an unlimited number of days for an inpatient hospital stay. 1 In-network: 4 $250 copay per day for days 1 through 5 4 You pay nothing per day for days 6 through 90 4 You pay nothing per day for days 91 and beyond 1 Out-of-network: 4 40% of the cost per stay Inpatient Mental Health Care Skilled Nursing Facility (SNF) 1 For inpatient mental health care, see the "Mental Health Care" section of this booklet. Our plan covers up to 100 days in a SNF. 1 In-network: 4 You pay nothing per day for days 1 through 20 4 $150 copay per day for days 21 through 100 Prescription Drug Benefits How much do I pay? 1 Out-of-network: 4 40% of the cost per stay For Part B drugs such as chemotherapy drugs: 1 In-network: 20% of the cost Other Part B drugs: 1 In-network: 20% of the cost 12 Page

Initial Coverage After you pay your yearly deductible, you pay the following until your total yearly drug costs reach $3,310. Total yearly drug costs are the total drug costs paid by both you and our Part D plan. You may get your drugs at network retail pharmacies and mail order pharmacies. Standard Retail Cost-Sharing Tier Tier 1 (Preferred Generic) Tier 2 (Generic) Tier 3 (Preferred Brand) Tier 4 (Non-Preferred Brand) Tier 5 (Specialty Tier) One-month supplytwo-month supply $0 $5 copay $47 copay $95 copay 30% of the cost $0 $10 copay $94 copay $190 copay 30% of the cost Three-month supply $0 $12.50 copay $117.50 copay $237.50 copay 30% of the cost Standard Mail Order Cost-Sharing Tier Tier 1 (Preferred Generic) Tier 2 (Generic) Tier 3 (Preferred Brand) Tier 4 (Non-Preferred Brand) Tier 5 (Specialty Tier) Three-month supply $0 $10 copay $94 copay $190 copay 30% of the cost If you reside in a long-term care facility, you pay the same as at a retail pharmacy. You may get drugs from an out-of-network pharmacy at the same cost as an in-network pharmacy. 13 Page

Coverage Gap Most Medicare drug plans have a coverage gap (also called the "donut hole"). This means that there's a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $3,310. After you enter the coverage gap, you pay 45% of the plan's cost for covered brand name drugs and 58% of the plan's cost for covered generic drugs until your costs total $4,850, which is the end of the coverage gap. Not everyone will enter the coverage gap. Under this plan, you may pay even less for the brand and generic drugs on the formulary. Your cost varies by tier. You will need to use your formulary to locate your drug's tier. See the chart that follows to find out how much it will cost you. Standard Retail Cost-Sharing Tier Drugs Covered Tier 1 (Preferred Generic) All Tier 2 (Generic) All One-month supply $0 $5 copay Two-month supply $0 $10 copay Three-month supply $0 $12.50 copay Standard Mail Order Cost-Sharing Tier Drugs Covered Tier 1 (Preferred Generic) All Tier 2 (Generic) All Three-month supply $0 $10 copay Catastrophic Coverage After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4,850, you pay the greater of: 1 5% of the cost, or 1 $2.95 copay for generic (including brand drugs treated as generic) and a $7.40 copayment for all other drugs. Optional Benefits (you must pay an extra premium each month for these benefits) Package 1: Memorial Hermann Advantage Pack Benefits include: 1 Worldwide Emergency/Urgent Coverage 1 Chiropractic Services 1 Preventive Dental 1 Comprehensive Dental 1 Eyewear 1 Hearing Aids How much is the monthly premium? Additional $49.00 per month. You must keep paying your Medicare Part B premium and your $0 monthly plan premium. 14 Page

How much is the deductible? Is there a limit on how much the plan will pay? This package does not have a deductible. Our plan pays up to $2,225 every year. Our plan has additional coverage limits for certain benefits. ADDITIONAL INFORMATION ABOUT MEMORIAL HERMANN ADVANTAGE (PPO) Includes 24/7 Nursing Hotline, Fitness Program and Readmission Prevention Care. Nurse Line 1 24/7 Nurseline: 1 Our plan offers Nurse triage 24 hours, 7 days a week Fitness Center Membership 1 You may choose to purchase additional buy-up services. Contact your exercise center 1 The Silver&Fit Home Fitness program if you cannot get to a fitness facility or prefer to work out at home 1 Healthy Aging classes (online or DVD) 1 The Silver Slate newsletter 4 times a year 1 The Silver&Fit website 1 A toll-free telephone hotline to answer questions about the program Available contracted fitness club location must be utilized throughout service area. Specific class offerings will vary by location. Readmission Prevention Our plan offers a Home Health Aide service available to all members transitioning from an acute, skilled, or other inpatient setting to home. The goals are to safely transition to a home setting and to prevent readmission. These services are not duplicate to Medicare-covered benefits as no skilled need exists. Services will be initiated immediately (e.g. within 1 week) of a member's discharge and provided on a limited and specified period of time not to exceed 4 weeks per authorized period. Readmission Prevention Care is provided to members upon discharge from a facility or SNF. $10.00 copay per visit (in-a-home setting) with a maximum benefit of $500.00 per year. (Services can not exceed 4 weeks per authorization period) 15 Page

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