PROFESSIONAL SERVICES 1199SEIU HIP VIP MEDICARE PLAN INPATIENT HOSPITAL SERVICES OUTPATIENT FACILITY SERVICES. Annual physical exam/preventive care

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1 PROFESSIONAL SERVICES PCP office visits Specialist office visits Annual physical exam/preventive care Physical, Speech & Occupational Therapy Flu & Pneumonia Vaccinations Diagnostic Services X-ray, etc. Lab Tests Routine Foot Care (Up to 4 visits per year) Chiropractic Care INPATIENT HOSPITAL SERVICES Surgeon & physician fees Semi-private room and board Anesthesia Nursing care (hospital provided) X-ray & Lab tests Prescribed drugs Operating & recovery room fees Intensive Care Unit Therapy (physical, radiation, chemotherapy) per visit OUTPATIENT FACILITY SERVICES Ambulatory surgery $50 copay per visit Emergency room fees $50 copay per visit (waived when admitted to the hospital) Ambulance service to the hospital $50 copay per service Renal dialysis X-ray (outpatient) per visit Lab tests (outpatient) per visit Diagnostic Services including MRI s, MRA s, PET and CAT Scans Outpatient Hospital Facility Services $50 copay per visit

2 Radiation Therapy MENTAL HEALTH AND ALCOHOL AND SUBSTANCE ABUSE CARE Mental Health Care Inpatient: no limit in a general hospital; 190- day lifetime limit in a psychiatric facility Outpatient therapy Alcohol and Substance Abuse Care Inpatient: based on medical necessity, up to Medicare limits Inpatient Detoxification Outpatient therapy PRESCRIPTION DRUGS When prescribed by a HIP Participating Provider and filled at a Participating Pharmacy per admission per admission per admission Initial Benefit (up to $2,610 pharmacy benefit) Tier 1: per prescription for Tier 2: per prescription for Tier 3: Member co-insurance of 18% with a cap of $75 for 30-day supply for tier 3 drugs; $150 for 60-day supply; $225 for 90-day supply (retail or mail service). Tier 4: per prescription for

3 Gap Benefit (after $2,610 pharmacy benefit) Tier 1: per prescription for Tier 2: per prescription for Tier 3: Member co-insurance of 18% with a cap of $75 for 30-day supply for tier 3 drugs; $150 for 60-day supply; $225 for 90-day supply (retail or mail service). Tier 4: per prescription for Catastrophic Coverage: When a Member reaches $4,750 of true out-of-pocket (TrOOP) costs for the calendar year, the Member will pay the greater of $2.65 copay for generic, $6.60 copay for brand, or 5% coinsurance. PART B DRUGS OTHER BENEFITS Skilled Nursing Facility Care Up to 100 days per benefit period Home Health Care (non-custodial) Hospice Care Provided by Medicare-certified hospice. Covered for 180 days plus unlimited 60-day extension if Medicare guidelines are met. Urgent Care 0% coinsurance (days 1-20) $25 copay per day (days ) Covered by Medicare per visit

4 Routine Vision Care One eye exam per calendar year by a HIP Participating provider. One pair of eyeglasses every 12 months when chosen from a select group of frames at a participating optical provider. Corrective lenses after cataract surgery Hearing Exam and Aid One routine hearing exam per calendar year by a HIP Participating provider. Hearing Aid Preventive Dental Care HIP Participating Dentist must be used Durable Medical Equipment $15 copay per visit $15 copay per visit One hearing aid or a $500 credit towards the purchase of a hearing aid every 36 months Dental Maintenance Organization Comprehensive dental program. Diagnostic, preventive, minor restorative and minor oral surgery have $0 co-payment. All other services have a co-payment according to set fee schedules. 20% coinsurance FOOTNOTES Durable Medical Equipment must be Medically Necessary, in accordance with Medicare guidelines and prescribed by a HIP Participating Medical Provider, to be covered. Please note prior approval for customized Durable Medical Equipment must be obtained through the CMP program. Maximum Out of Pocket Costs - $3,400 annual out of pocket maximum. Once met, medical and hospital services have no cost sharing. Out of pocket maximum does not apply to supplemental benefits not covered by Medicare such as hearing aids and preventive dental care. Your benefit will be made up of two plans Your benefit consists of a primary Medicare Advantage plan and a secondary supplemental plan for the Coverage Gap Stage only. Your pharmacy will only need to submit your prescription once to the Emblem Health 1199SEIU VIP (HMO) Medicare Plan. During the Coverage Gap Stage, if your prescription is identified as an applicable drug typically brand-name drugs the prescription will automatically process under the secondary supplemental coverage. This ensures the correct copayment is applied to your prescription in all stages of the benefit. All of the information needed to process your prescription is included on your member ID card. To ensure your coverage is applied correctly, present your ID card each time you fill a prescription. For more information on the Medicare Coverage Gap Discount Program refer to the benefits table above. This benefit design does not apply if you are receiving Extra Help from Medicare.

5 HIP Health Plan of New York is an EmblemHealth Company, an HMO operating with Medicare Advantage contract. Enrolled members must use HIP Participating Providers for all medical and hospital services except for emergency care or urgently needed care. If you receive medical or hospital care that is not provided or authorized by HIP (other than emergency care or urgently needed care as defined in your contract) neither HIP nor Medicare will pay for that service and you will be responsible for payment of care. This benefit package is subject to change annually at the plan's contracted renewal time with the Centers for Medicare & Medicaid Services. (CMS) (Effective through )