DeanCare Gold (Cost) 2014

Transcription

1 A subsidiary of Dean Health Insurance, Inc. (Cost) 2014 Dean Health Plan, Inc Deming Way Madison, Wisconsin (8 8 8) T T Y Users Dial Dean Health Plan, Inc. H5264_2030v4_0713 CMS Approved

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3 Dear Medicare Recipient: Thank you for your interest in (Cost). Providing you quality health care is important to us, and the insurance plan offers three excellent Medicare plan choices for Medicare-eligible residents in Columbia, Dane, Dodge, Grant, Iowa, Jefferson, Rock and Sauk Counties. The enclosed materials will help you choose the coverage option that fits you best, whether it s a Enhanced, Shared Value or Basic plan. For your convenience, a Dean Health Plan Medicare representative will be available in your area to answer questions and help you complete the application forms. The enclosed schedule of clinic rotations (see page 3) will help you find a time and location that is convenient for you to drop in and receive individual attention for any questions you may have. Until then, if you have any questions about and live in Dodge, Sauk, Columbia or Dane counties, please call Mary Olson at , or if you live in Jefferson, Iowa, Grant, Rock or Dane counties, please call Laura Iverson at Our Customer Care Center is also here to help. Please call or TTY users dial 711 or call You may also visit our website at For more information about Medicare benefits and services, including general information regarding Medicare health and prescription drug benefits, please call MEDICARE ( ) or TTY , 24 hours a day, seven days a week. We look forward to hearing from you. Sincerely, Mary Olson & Laura Iverson Medicare Marketing Staff, Dean Health Plan About : is a Medicare-approved Cost Plan. You must use plan providers, except for emergent and urgent care, or when you receive a referral to a non-plan provider. You may receive services from non-plan providers in situations other than these, but you will be responsible for payment of all Medicare deductibles and co-insurance, as well as any other charges prescribed by the Medicare program. materials are available in alternative formats. Please note that the Marketing Representative that may be discussing plan options with you is a licensed insurance agent who is either employed by or contracted with Dean Health Plan, Inc. and may be compensated based on your enrollment in. 1

4 Benefits Effective January 1, 2014 Enhanced (Cost) Shared Value (Cost) Basic (Cost) Monthly Premium $113 $68 $108 Office Copay (per visit) $0 $10 $0 Hospital Copay (per visit) $0 $200 $0 Emergency Room Copay (per visit) $0 $50 $0 All Required Medicare Benefits Coverage for Urgent and Emergency Care Foreign Travel $250 deductible then 80% coverage up to $50,000 max Eyeglass Benefit $250 every 2 years See plan providers on page 32 Hearing Aid Benefit $500 every 3 years See plan providers on page 33. Wellness Program Routine Physicals & Eye Exams What are the Benefits? Considering? Get Help with Your Decision. Meet with a Licensed Sales Representative. No Appointments Necessary. To speak with a Dean Health Plan representative in person, simply stop by one of our clinic rotations listed below by location and day of the month. You may drop in at any point during the hours listed for each rotation for individual assistance no appointment necessary. A sales person will be present with information and applications. You may also visit our office in Madison at 1277 Deming Way by appointment. Let our licensed agents help guide you through the plan selection process, face to face. Schedule effective October 1, 2013 through October 1, Baraboo Beaver Dam Columbus Dodgeville 1st Thursday & 4th Friday of each month Dean Clinic - Baraboo (Medical Associates) 1700 Tuttle St. Baraboo 9:30 a.m. to Noon 3rd Wednesday of each month Dean Clinic - Beaver Dam 705 S. University Ave. Beaver Dam 10:00 a.m. to Noon 1st Tuesday of each month Dean Clinic - Columbus 1513 Park Ave. Columbus 10:00 a.m. to Noon Edgerton Fort Atkinson Janesville Madison 3rd Thursday of each month Edgerton Clinic N. Sherman Rd. Edgerton 9:00 a.m. to Noon 2nd Wednesday of each month Fort Atkinson Senior Center 307 Robert St. Fort Atkinson 9:30 a.m. to Noon 1st Wednesday & 2nd Tuesday of each month Dean Clinic - Janesville East 3200 E. Racine St. Janesville 9:00 a.m. to Noon 3rd Tuesday of each month Dean Clinic - Dodgeville 833 S. Iowa St., Ste 102, Dodgeville 10:00 a.m. to Noon 1st Friday of each month Dean Clinic - East 1821 S. Stoughton Rd. Madison 10:00 a.m. to Noon Madison Platteville Portage Prairie du Sac 4th Thursday of each month Dean Clinic - Fish Hatchery 1313 Fish Hatchery Rd. Madison 10:00 a.m. to Noon 4th Tuesday of each month Dean Clinic - Platteville 1450 Eastside Rd., Ste 110, Platteville 10:00 a.m. to Noon 3rd Friday of each month Dean Clinic - Portage 2825 Hunters Trail, Portage 10:00 a.m. to Noon 2nd Friday of each month Dean Clinic - Sauk Prairie Specialty Services 35 Prairie Ave., Ste 325, Prairie du Sac 10:00 a.m. to Noon For full information on benefits, please call our Customer Care Center at TTY users dial 711 or call Call Center Hours: February 15, 2013 September 30, :00 a.m. to 8:00 p.m. Monday Friday October 1, 2013 February 14, :00 a.m. to 8:00 p.m. Monday Sunday February 15, 2014 September 30, :00 a.m. to 8:00 p.m. Monday Friday Or, visit Dean Health Plan s contract with the Center for Medicare and Medicaid Services is renewed annually, and the availability of coverage beyond the end of the current contract year is not guaranteed. You may switch between Plan benefit options. Please contact our Customer Care Center for further details. Stoughton Sun Prairie In the event of inclement weather or other 2nd Thursday of each month Dean Clinic - Stoughton 225 Church St. Stoughton 10:00 a.m. to Noon 4th Wednesday of each month Dean Clinic - Sun Prairie 10 Tower Dr. Sun Prairie 10:00 a.m. to Noon Laura Iverson Medicare Marketing Representative (608) or (800) ext laura.iverson@deancare.com emergency, please call the location the day of the visit for any potential schedule changes. Scheduled visits on national holidays will be postponed until the following month. For accomodations of persons with special needs at sales meetings call TTY dial 711 or call Mary Olson Medicare Marketing Representative (608) or (800) ext mary.olson@deancare.com 2 3

5 About : Limitations, copayments and restrictions may apply. Benefits, network premium and/or copayments/co-insurance may change on January 1 of each year. You must continue to pay your Part B premium. The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Dean Health Plan contracts with the federal government. is a Medicare-approved Cost plan. For full information on benefits, please call our Customer Care Center at TTY users diall 711 or call Call Center Hours: February 15, 2013 September 30, :00 a.m. to 8:00 p.m. Monday Friday October 1, 2013 February 14, :00 a.m. to 8:00 p.m. Monday Sunday February 15, 2014 September 30, :00 a.m. to 8:00 p.m. Monday Friday Or, visit Introduction to the Summary of Benefits for, and January 1, 2014 December 31, 2014 Thank you for your interest in, Shared Value (Cost) or. Our plans are offered by DEAN HEALTH PLAN, INC., a Medicare Cost organization that contracts with the federal government. This Summary of Benefits tells you some features of our plans. It doesn t list every service that we cover or list every limitation or exclusion. To get a complete list of our benefits, please call Enhanced (Cost), or and ask for the Evidence of Coverage. You can have choices in your healthcare. As a Medicare beneficiary, you can choose from different Medicare options. One option is the Original (Fee-for-Service) Medicare Plan. Another option is a Medicare health plan, like, DeanCare Gold or. You may have other options too. You make the choice. No matter what you decide, you are still in the Medicare Program. You may be able to join or leave a plan only at certain times. Please call, Shared Value (Cost) and at the number listed at the end of this introduction or MEDICARE ( ) for more information. TTY/TDD users should call You can call this number 24 hours a day, 7 days a week. How can I compare my options? You can compare Enhanced (Cost), and and the Original Medicare Plan using this Summary of Benefits. The charts in this booklet list some important health benefits. For each benefit, you can see what our plan covers and what the Original Medicare Plan covers. Section 1 Our members receive all of the benefits that the Original Medicare Plan offers. We also offer more benefits, which may change from year to year. Where are Enhanced (Cost), Shared Value (Cost) and Basic (Cost) available? The service area for this plan includes: Columbia, Dane, Dodge, Grant, Iowa, Jefferson, Rock, Sauk Counties, WI. You must live in one of these areas to join the plan. Who is eligible to join, or? You can join Enhanced (Cost), or if you are entitled to Medicare Part A and enrolled in Medicare Part B or enrolled in Medicare Part B only and live in the service area. However, individuals with End-Stage Renal Disease generally are not eligible to enroll in, Shared Value (Cost) or unless they are members of our organization and have been since their dialysis began. 4 5

6 Can I choose my doctors?, DeanCare Gold or has formed a network of doctors, specialists, and hospitals. You can use any doctor who is part of our network. You may also go to doctors outside of our network. The health providers in our network can change at any time. You can ask for a current provider directory. For an updated list, visit us at Our Customer Care Center number is listed at the end of this introduction. What happens if I go to a doctor who s not in your network? You can always choose to go to a doctor outside our network. We may not pay for the services you receive outside of our network, but Medicare will pay for its share of charges it approves. You will be responsible for Medicare Part B deductible and co-insurance. Does my plan cover Medicare Part B or Part D drugs?, DeanCare Gold and DeanCare Gold do cover Medicare Part B prescription drugs., Shared Value (Cost) and do NOT cover Medicare Part D prescription drugs. What are my protections in this plan? All Medicare Cost Plans agree to stay in the program for a full calendar year at a time. Plan benefits and cost-sharing may change from calendar year to calendar year. Each year, plans can decide whether to continue for another year. A plan may continue in their entire service area (geographic area where the plan accepts members) or choose to continue only in certain areas. Also, Medicare may decide to end a contract with a plan. Even if your Medicare Cost Plan leaves the program, you will not lose Medicare coverage. If a plan decides not to continue for an additional calendar year, it must send you a letter at least 60 days before your coverage will end. The letter will explain your options for Medicare coverage in your area. As a member of Enhanced (Cost), Shared Value (Cost) or, you have the right to request an organization determination, which includes the right to file an appeal if we deny coverage for an item or service, and the right to file a grievance. You have the right to request an organization determination if you want us to provide or pay for an item or service that you believe should be covered. If we deny coverage for your requested item or service, you have the right to appeal and ask us to review our decision. You may ask us for an expedited (fast) coverage determination or appeal if you believe that waiting for a decision could seriously put your life or health at risk, or affect your ability to regain maximum function. If your doctor makes or supports the expedited request, we must expedite our decision. Finally, you have the right to file a grievance with us if you have any type of problem with us or one of our network providers that does not involve coverage for an item or service. If your problem involves quality of care, you also have the right to file a grievance with the Quality Improvement Organization (QIO) for your state. Please refer to the Evidence of Coverage (EOC) for the QIO contact information. What types of drugs may be covered by Medicare Part B? ff Some outpatient prescription drugs may be covered under Medicare Part B. These may include, but are not limited to, the following types of drugs. Contact, Shared Value (Cost) or for more details. Some Antigens: If they are prepared by a doctor and administered by a properly ff ff ff ff ff ff ff ff instructed person (who could be the patient) under doctor supervision. Osteoporosis Drugs: Injectable osteoporosis drugs for some women. Erythropoietin: By injection if you have end-stage renal disease (permanent kidney failure requiring either dialysis or transplantation) and need this drug to treat anemia. Hemophilia Clotting Factors: Self-administered clotting factors if you have hemophilia. Injectable Drugs: Most injectable drugs administered incident to a physician s service. Immunosuppressive Drugs: Immunosuppressive drug therapy for transplant patients if the transplant took place in a Medicare-certified facility and was paid for by Medicare or by a private insurance company that was the primary payer for Medicare Part A coverage. Some Oral Cancer Drugs: If the same drug is available in injectable form. Oral Anti-Nausea Drugs: If you are part of an anti-cancer chemotherapeutic regimen. Inhalation and Infusion Drugs administered through Durable Medical Equipment Where can I find information on plan ratings? The Medicare program rates how well plans perform in different categories (for example, detecting and preventing illness, ratings from patients and customer service). If you have access to the web, you may use the web tools on and select Health and Drug Plans then Compare Drug and Health Plans to compare the plan ratings for Medicare plans in your area. You can also call us directly to obtain a copy of the plan ratings for this plan. Our Customer Care Center number is listed at right. Please call Dean Health Plan, Inc. for more information about, and. Visit or call: Current members should call toll-free (TTY/TTD dial 711 or call ). Prospective members should call toll-free (TTY/TTD dial 711 or call ). Current and prospective members should call locally for questions related to the Medicare Cost Plan (TTY/TTD dial 711 or call ). Customer Care Center Hours: February 15, 2013 September 30, :00 a.m. to 8:00 p.m. Monday Friday October 1, 2013 February 14, :00 a.m. to 8:00 p.m. Monday Sunday February 15, 2014 September 30, :00 a.m. to 8:00 p.m. Monday Friday For more information about Medicare, please call Medicare at MEDICARE ( ). TTY users should call You can call 24 hours a day, seven days a week. Or, visit on the web. This document may be available in other formats such as Braille, large print or other alternate formats. This document may be available in a non-english language. For additional information, call the Customer Care Center at the phone number listed above. 6 7 Section 1

7 Section 2, and Summary of Benefits Benefit Original Medicare Important Information Important Information 1 - Premium and Other Important Information In 2013 the monthly Part B Premium was $ and may change for 2014 and the annual Part B deductible amount was $147 and may change for If a doctor or supplier does not accept assignment, their costs are often higher, which means you pay more. Most people will pay the standard monthly Part B premium. However, some people will pay a higher premium because of their yearly income (over $85,000 for singles, $170,000 for married couples). For more information about Part B premiums based on income, call Medicare at MEDICARE ( ). TTY users should call You may also call Social Security at TTY users should call $113 monthly plan premium in addition to your monthly Medicare Part B premium. Most people will pay the standard monthly Part B premium in addition to their plan premium. However, some people will pay a higher premium because of their yearly income (over $85,000 for singles, $170,000 for married couples). For more information about Part B premiums based on income, call Medicare at MEDICARE ( ). TTY users should call You may also call Social Security at TTY users should call $68 monthly plan premium in addition to your monthly Medicare Part B premium. Most people will pay the standard monthly Part B premium in addition to their plan premium. However, some people will pay a higher premium because of their yearly income (over $85,000 for singles, $170,000 for married couples). For more information about Part B premiums based on income, call Medicare at MEDICARE ( ). TTY users should call You may also call Social Security at TTY users should call $108 monthly plan premium in addition to your monthly Medicare Part B premium. Most people will pay the standard monthly Part B premium in addition to their plan premium. However, some people will pay a higher premium because of their yearly income (over $85,000 for singles, $170,000 for married couples). For more information about Part B premiums based on income, call Medicare at MEDICARE ( ). TTY users should call You may also call Social Security at TTY users should call Doctor and Hospital Choice (For more information, see Emergency Care - #15 and Urgently Needed Care - #16.) You may go to any doctor, specialist or hospital that accepts Medicare. No referral required for network doctors, specialists, and hospitals. In- and Out-of-Network You can use any network doctor. If you go to out-of-network doctors the plan may not cover the services but Medicare will pay its share for Medicare-covered services. When Medicare pays its share, you pay the Medicare Part B deductible and co-insurance. No referral required for network doctors, specialists, and hospitals. In- and Out-of-Network You can use any network doctor. If you go to out-of-network doctors the plan may not cover the services but Medicare will pay its share for Medicare-covered services. When Medicare pays its share, you pay the Medicare Part B deductible and co-insurance. No referral required for network doctors, specialists, and hospitals. In- and Out-of-Network You can use any network doctor. If you go to out-of-network doctors the plan may not cover the services but Medicare will pay its share for Medicare-covered services. When Medicare pays its share, you pay the Medicare Part B deductible and co-insurance. 8 9 Section 2

8 If you have any questions about plan benefits or costs, please contact Dean Health Plan, Inc at Benefit Original Medicare Inpatient Care Inpatient Care 3 - Inpatient Hospital Care (includes Substance Abuse and Rehabilitation Services) In 2013 the amounts for each benefit period were: Days 1-60: $1,184 deductible Days 61-90: $296 per day Days : $592 per lifetime reserve day These amounts may change for Call MEDICARE ( ) for information about lifetime reserve days. Lifetime reserve days can only be used once. A benefit period starts the day you go into a hospital or skilled nursing facility. It ends when you go for 60 days in a row without hospital or skilled nursing care. If you go into the hospital after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods you can have. No limit to the number of days covered by the plan each hospital stay No limit to the number of days covered by the plan each hospital stay Plan covers 90 days each benefit period. $0 copay $200 copay for each hospital stay $200 copay for additional non- Medicare-covered hospital days. $0 copay 4 - Inpatient Mental Health Care In 2013 the amounts for each benefit period were: Days 1-60: $1,184 deductible Days 61-90: $296 per day Days : $592 per lifetime reserve day These amounts may change for You get up to 190 days of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital. You get up to 190 days of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital. Contact the plan for details about coverage in a Psychiatric Hospital beyond 190 days. You get up to 190 days of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital. Contact the plan for details about coverage in a psychiatric hospital beyond 190 days. $0 copay $200 copay for each Medicare-covered hospital stay Plan covers 60 lifetime reserve days. $200 copay for additional non- Medicare-covered hospital days. You get up to 190 days of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital. $0 copay 5 - Skilled Nursing Facility (SNF) (in a Medicare-certified skilled nursing facility) In 2013 the amounts for each benefit period after at least a 3-day Medicarecovered hospital stay were: Days 1-20: $0 per day Days : $148 per day These amounts may change for days for each benefit period. A benefit period starts the day you go into a hospital or SNF. It ends when you go for 60 days in a row without hospital or skilled nursing care. If you go into the hospital after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods you can have. Plan covers up to 100 days each benefit period. $0 copay for SNF services Plan covers up to 100 days each benefit period. $0 copay for SNF services Plan covers up to 100 days each benefit period. $0 copay for SNF services Section 2

9 If you have any questions about plan benefits or costs, please contact Dean Health Plan, Inc at Benefit Original Medicare Inpatient Care Inpatient Care 6 - Home Health Care (includes medically necessary intermittent skilled nursing care, home health aide services and rehabilitation services, etc.) $0 copay home health visits home health visits home health visits 7 - Hospice You pay part of the cost for outpatient drugs and inpatient respite care. You must get care from a Medicare-certified hospice. You must get care from a Medicarecertified hospice. You must consult with your plan before you select hospice. You must get care from a Medicarecertified hospice. You must consult with your plan before you select hospice. You must get care from a Medicarecertified hospice. You must consult with your plan before you select hospice. Outpatient Care Outpatient Care 8 - Doctor Office Visits 20% co-insurance primary care doctor visit specialist visit $10 copay for each Medicare-covered primary care doctor visit $10 copay for each Medicare-covered specialist visit primary care doctor visit specialist visit 9 - Chiropractic Services Supplemental routine care not covered 20% co-insurance for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part). Medicare-covered chiropractic visits Supplemental routine chiropractic visits. $10 copay for each Medicare-covered chiropractic visit $10 copay for each supplemental routine chiropractic visit Medicare-covered chiropractic visits Supplemental routine chiropractic visits. Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part) Podiatry Services Supplemental routine care not covered. 20% co-insurance for medically necessary foot care, including care for medical conditions affecting the lower limbs. podiatry visits $10 copay for each Medicare-covered podiatry visit podiatry visits Medicare-covered podiatry visits are for medically-necessary foot care Section 2

10 If you have any questions about plan benefits or costs, please contact Dean Health Plan, Inc at Benefit Original Medicare Outpatient Care Outpatient Care 11 - Outpatient Mental Health Care 20% co-insurance for most outpatient mental health services Specified copayment for outpatient partial hospitalization program services furnished by a hospital or community mental health center (CMHC). Copay cannot exceed the Part A inpatient hospital deductible. Partial hospitalization program is a structured program of active outpatient psychiatric treatment that is more intense than the care received in your doctor s or therapist s office and is an alternative to inpatient hospitalization. each Medicare-covered individual therapy visit each Medicare-covered group therapy visit each Medicare-covered individual therapy visit with a psychiatrist each Medicare-covered group therapy visit with a psychiatrist partial hospitalization program services each Medicare-covered individual therapy visit each Medicare-covered group therapy visit each Medicare-covered individual therapy visit with a psychiatrist each Medicare-covered group therapy visit with a psychiatrist partial hospitalization program services each Medicare-covered individual therapy visit each Medicare-covered group therapy visit each Medicare-covered individual therapy visit with a psychiatrist each Medicare-covered group therapy visit with a psychiatrist partial hospitalization program services 12 - Outpatient Substance Abuse Care 20% co-insurance each Medicare-covered individual substance abuse outpatient treatment visit each Medicare-covered group substance abuse outpatient treatment visit each Medicare-covered individual substance abuse outpatient treatment visit each Medicare-covered group substance abuse outpatient treatment visit each Medicare-covered individual substance abuse outpatient treatment visit each Medicare-covered group substance abuse outpatient treatment visit 13 - Outpatient Services 20% co-insurance for the doctor s services Specified copayment for outpatient hospital facility services Copay cannot exceed the Part A inpatient hospital deductible. ambulatory surgical center visit ambulatory surgical center visit ambulatory surgical center visit 20% co-insurance for ambulatory surgical center facility services outpatient hospital facility visit outpatient hospital facility visit outpatient hospital facility visit 14 - Ambulance Services (medically necessary ambulance services) 20% co-insurance ambulance benefits ambulance benefits ambulance benefits 15 - Emergency Care (You may go to any emergency room if you reasonably believe you need emergency care.) 20% co-insurance for the doctor s services Specified copayment for outpatient hospital facility emergency services. Emergency services copay cannot exceed Part A inpatient hospital deductible for each service provided by the hospital. You don t have to pay the emergency room copay if you are admitted to the hospital as an inpatient for the same condition within 3 days of the emergency room visit. Not covered outside the U.S. except under limited circumstances. emergency room visits If you are admitted to the hospital within 3-days for the same condition, you pay $0 for the emergency care visit. $50,000 plan coverage limit for supplemental emergency services outside the U.S. and its territories $50 copay for Medicare-covered emergency room visits If you are admitted to the hospital within 3-days for the same condition, you pay $0 for the emergency care visit. $50,000 plan coverage limit for supplemental emergency services outside the U.S. and its territories emergency room visits If you are admitted to the hospital within 3-days for the same condition, you pay $0 for the emergency care visit. Not covered outside the U.S. and its territories except under limited circumstances. Contact the plan for details Section 2

11 If you have any questions about plan benefits or costs, please contact Dean Health Plan, Inc at Benefit Original Medicare Outpatient Care Outpatient Care 16 - Urgently Needed Care (This is NOT emergency care and in most cases, is out of the service area.) 20% co-insurance, or a set copay If you are admitted to the hospital within 3 days for the same condition, you pay $0 for the urgently-needed-care visit. NOT covered outside the U.S. except under limited circumstances. urgently-needed-care visits $50,000 plan coverage limit for supplemental urgently-needed-care services outside the U.S. and its territories. $10 copay for Medicare-covered urgently-needed- care visits If you are admitted to the hospital within 3 days for the same condition, you pay $0 for the urgently-neededcare visit. $50,000 plan coverage limit for supplemental urgently-needed-care services outside the U.S. and its territories. urgently-needed-care visits 17 - Outpatient Rehabilitation Services (Occupational Therapy, Physical Therapy, Speech and Language Therapy) 20% co-insurance Medically necessary physical therapy, occupational therapy, and speech and language pathology services are covered. Medically necessary physical therapy, occupational therapy, and speech and language pathology services are covered. Medically necessary physical therapy, occupational therapy, and speech and language pathology services are covered. Medically necessary physical therapy, occupational therapy, and speech and language pathology services are covered. Occupational Therapy visits Occupational Therapy visits Occupational Therapy visits Physical Therapy and/or Speech and Language Pathology visits Physical Therapy and/or Speech and Language Pathology visits Physical Therapy and/or Speech and Language Pathology visits Outpatient Medical Services and Supplies Outpatient Medical Services and Supplies 18 - Durable Medical Equipment (includes wheelchairs, oxygen, etc.) 20% co-insurance durable medical equipment durable medical equipment durable medical equipment : diabetes monitoring supplies therapeutic shoes or inserts : diabetes monitoring supplies therapeutic shoes or inserts : diabetes monitoring supplies therapeutic shoes or inserts 19 - Prosthetic Devices (includes braces, artificial limbs and eyes, etc.) 20% co-insurance 20% co-insurance for Medicare-covered medical supplies related to prosthetics, splints, and other devices : prosthetic devices medical supplies related to prosthetics, splints, and other devices : prosthetic devices medical supplies related to prosthetics, splints, and other devices : prosthetic devices medical supplies related to prosthetics, splints, and other devices Section 2

12 If you have any questions about plan benefits or costs, please contact Dean Health Plan, Inc at Benefit Original Medicare Outpatient Medical Services and Supplies Outpatient Medical Services and Supplies 20 - Diabetes Programs and Supplies 20% co-insurance for diabetes self-management training 20% co-insurance for diabetes supplies 20% co-insurance for diabetic therapeutic shoes or inserts Diabetes self-management training Diabetes self-management training If the doctor provides you services in addition to Diabetes selfmanagement training, separate cost sharing of $10 may apply. Diabetes self-management training 21 - Diagnostic Tests, X-rays, Lab Services and Radiology Services 20% co-insurance for diagnostic tests and x-rays lab services Lab Services: Medicare covers medically necessary diagnostic lab services that are ordered by your treating doctor when they are provided by a Clinical Laboratory Improvement Amendments (CLIA) certified laboratory that participates in Medicare. Diagnostic lab services are done to help your doctor diagnose or rule out a suspected illness or condition. Medicare does not cover most supplemental routine screening tests, like checking your cholesterol. : lab services diagnostic procedures and tests X-rays diagnostic radiology services (not including X-rays) therapeutic radiology services : lab services diagnostic procedures and tests X-rays diagnostic radiology services (not including X-rays) therapeutic radiology services If the doctor provides you services in addition to Outpatient Diagnostic Procedures, Tests and Lab Services, separate cost sharing of $10 may apply. : lab services diagnostic procedures and tests X-rays diagnostic radiology services (not including X-rays) therapeutic radiology services If the doctor provides you services in addition to Outpatient Diagnostic and Therapeutic Radiology Services, separate cost sharing of $10 may apply Cardiac and Pulmonary Rehabilitation Services 20% co-insurance Cardiac Rehabilitation services 20% co-insurance for Pulmonary Rehabilitation services 20% co-insurance for Intensive Cardiac Rehabilitation services Medicare-covered Cardiac Rehabilitation Services Medicare-covered Intensive Cardiac Rehabilitation Services Medicare-covered Pulmonary Rehabilitation Services Medicare-covered Cardiac Rehabilitation Services Medicare-covered Intensive Cardiac Rehabilitation Services Medicare-covered Pulmonary Rehabilitation Services Medicare-covered Cardiac Rehabilitation Services Medicare-covered Intensive Cardiac Rehabilitation Services Medicare-covered Pulmonary Rehabilitation Services Section 2

13 If you have any questions about plan benefits or costs, please contact Dean Health Plan, Inc at Benefit Original Medicare Preventive Services Preventive Services 23 - Preventive Services No co-insurance, copayment or deductible for the following: Abdominal Aortic Aneurysm Screening Bone Mass Measurement Covered once every 24 months (more often if medically necessary) if you meet certain medical conditions. Cardiovascular Screening Cervical and Vaginal Cancer Screening Covered once every 2 years. Covered once a year for women with Medicare at high risk. Colorectal Cancer Screening Diabetes Screening Influenza Vaccine Hepatitis B Vaccine for people with Medicare who are at risk HIV Screening $0 copay for the HIV screening, but you generally pay 20% of the Medicare-approved amount for the doctor s visit. HIV screening is covered for people with Medicare who are pregnant and people at increased risk for the infection, including anyone who asks for the test. Medicare covers this test once every 12 months or up to three times during a pregnancy. Breast Cancer Screening (Mammogram) Medicare covers screening mammograms once every 12 months for all women with Medicare age 40 and older. Medicare covers one baseline mammogram for women between ages Medical Nutrition Therapy Services Nutrition therapy is for people who have diabetes or kidney disease (but aren t on dialysis or haven t had a kidney transplant) when referred by a doctor. These services can be given by a registered dietitian and may include a nutritional assessment and counseling to help you manage your diabetes or kidney disease. Personalized Prevention Plan Services (Annual Wellness Visits) Pneumococcal Vaccine You may only need the Pneumonia vaccine once in your lifetime. Call your doctor for more information. Prostate Cancer Screening Prostate Specific Antigen (PSA) test only Covered once a year for all men with Medicare over age 50. Smoking and Tobacco Use Cessation (counseling to stop smoking and tobacco use) Covered if ordered by your doctor. Includes two counseling attempts within a 12-month period. Each counseling attempt includes up to four face-to-face visits. Screening and behavioral counseling interventions in primary care to reduce alcohol misuse $0 copay for all preventive services covered under Original Medicare at zero cost sharing. Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare. $0 copay for a supplemental annual physical exam $0 copay for all preventive services covered under Original Medicare at zero cost sharing. Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare. $0 copay for a supplemental annual physical exam $0 copay for all preventive services covered under Original Medicare at zero cost sharing. Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare. $0 copay for a supplemental annual physical exam DHP will cover an annual physical exam that is medically appropriate for the patient s age, gender and medical circumstances. The covered services include a comprehensive evaluation of the member s medical history, examination, appropriate lab testing, counseling for health and wellness and a plan of care for any future follow up testing and examinations Section 2

14 If you have any questions about plan benefits or costs, please contact Dean Health Plan, Inc at Benefit Original Medicare Preventive Services Preventive Services 23 - Preventive Services (continued) (continued from previous page) Screening for depression in adults Screening for sexually transmitted infections (STI) and high-intensity behavioral counseling to prevent STIs Intensive behavioral counseling for Cardiovascular Disease (bi-annual) Intensive behavioral therapy for obesity Welcome to Medicare Preventive Visits (initial preventive physical exam) When you join Medicare Part B, then you are eligible as follows: During the first 12 months of your new Part B coverage, you can get either a Welcome to Medicare Preventive Visit or an Annual Wellness Visit. After your first 12 months, you can get one Annual Wellness Visit every 12 months. $0 copay for all preventive services covered under Original Medicare at zero cost sharing. Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare. $0 copay for a supplemental annual physical exam $0 copay for all preventive services covered under Original Medicare at zero cost sharing. Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare. $0 copay for a supplemental annual physical exam $0 copay for all preventive services covered under Original Medicare at zero cost sharing. Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare. $0 copay for a supplemental annual physical exam 24 - Kidney Disease and Conditions 20% co-insurance for renal dialysis 20% co-insurance for kidney disease education services Cost plan members pay Original Medicare cost sharing for out-of-area dialysis. Cost plan members pay Original Medicare cost sharing for out-of-area dialysis. Cost plan members pay Original Medicare cost sharing for out-of-area dialysis. renal dialysis renal dialysis renal dialysis kidney disease education services kidney disease education services kidney disease education services Prescription Drug Benefits Prescription Drug Benefits 25 - Outpatient Prescription Drugs Most drugs are not covered under Original Medicare. You can add prescription drug coverage to Original Medicare by joining a Medicare Prescription Drug Plan, or you can get all your Medicare coverage, including prescription drug coverage, by joining a Medicare Advantage Plan or a Medicare Cost Plan that offers prescription drug coverage. Drugs covered under Medicare Part B: Most drugs not covered. Drugs covered under Medicare Part B: Most drugs not covered. Drugs covered under Medicare Part B: Most drugs not covered. Drugs Covered under Medicare Part D: Drugs Covered under Medicare Part D: Drugs Covered under Medicare Part D: This plan does not offer prescription drug coverage. This plan does not offer prescription drug coverage. This plan does not offer prescription drug coverage Section 2

15 If you have any questions about plan benefits or costs, please contact Dean Health Plan, Inc at Benefit Original Medicare Outpatient Medical Services and Supplies Outpatient Medical Services and Supplies 26 - Dental Services Preventive dental services (such as cleaning) not covered. dental benefits In general, preventive dental benefits (such as cleaning) are not covered. dental benefit In general, preventive dental benefits (such as cleaning) are not covered. dental benefit In general, preventive dental benefits (such as cleaning) are not covered Hearing Services Supplemental routine hearing exams and hearing aids are not covered. 20% co-insurance for diagnostic hearing exams. Medicare-covered diagnostic hearing exams up to one supplemental routine hearing exam(s) every year up to one fitting-evaluation(s) for a supplemental hearing aid every three years $0 copay for up to one supplemental hearing aid(s) every three years Medicare-covered diagnostic hearing exams up to one supplemental routine hearing exam(s) every year up to one fitting-evaluation(s) for a supplemental hearing aid every three years $0 copay for up to one supplemental hearing aid(s) every three years In general, supplemental routine hearing exams and hearing aids not covered. Medicare covered diagnostic hearing exams $500 plan coverage limit for supplemental hearing aids every three years $500 plan coverage limit for supplemental hearing aids every three years 28 - Vision Services 20% co-insurance for diagnosis and treatment of diseases and conditions of the eye, including an annual glaucoma screening for people at risk Supplemental routine eye exams and eyeglasses (lenses and frames) not covered. Medicare pays for one pair of eyeglasses or contact lenses after cataract surgery. Medicare-covered diagnosis and treatment for diseases and conditions of the eye, including an annual glaucoma screening for people at risk up to one supplemental routine eye exam(s) every year $0 copay for one pair of Medicare-covered eyeglasses (lenses and frames) or contact lenses after cataract surgery up to one pair(s) of eyeglasses (lenses and frames) every two years $250 plan coverage limit for supplemental eyewear every two years Medicare-covered diagnosis and treatment for diseases and conditions of the eye, including an annual glaucoma screening for people at risk up to one supplemental routine eye exam(s) every year $0 copay for one pair of Medicare-covered eyeglasses (lenses and frames) or contact lenses after cataract surgery up to one pair(s) of eyeglasses (lenses and frames) every two years $250 plan coverage limit for supplemental eyewear every two years This plan offers only Medicarecovered eye care and eyewear. $0 copay for Medicare-covered diagnosis and treatment for diseases and conditions of the eye, including an annual glaucoma screening exam for people at risk one pair of Medicare-covered eyeglasses (lenses and frames) or contact lenses after cataract surgery Section 2

16 If you have any questions about plan benefits or costs, please contact Dean Health Plan, Inc at Benefit Original Medicare Outpatient Medical Services and Supplies Outpatient Medical Services and Supplies Wellness/Education and Other Supplemental Benefit Programs Not covered. The plan covers the following supplemental education/wellness programs: The plan covers the following supplemental education/wellness programs: The plan covers the following supplemental education/wellness programs: Health Education Health Education Health Education Nutritional Benefit Nutritional Benefit Nutritional Benefit Health Club Membership/Fitness Classes Health Club Membership/Fitness Classes Health Club Membership/Fitness Classes Nursing Hotline Nursing Hotline Nursing Hotline $0 copay for Health Education and Nutritional Benefit. Contact the plan for details. $0 copay for Health Education and Nutritional Benefit. Contact the plan for details. $0 copay for Health Education and Nutritional Benefit. Contact the plan for details. You may claim reimbursement for up to $100 for acupuncture services, gym memberships, nutritional education program fees such as Weight Watchers and Jenny Craig under the WIN program. Over-the-Counter Items Not covered. The plan does not cover over-the-counter items. The plan does not cover over-the-counter items. The plan does not cover over-the-counter items. Transportation (Routine) Not covered. This plan does not cover supplemental routine transportation. This plan does not cover supplemental routine transportation. This plan does not cover supplemental routine transportation. Acupuncture and Other Alternative Therapies Not covered. $0 copay for acupuncture and other alternative therapies $0 copay for acupuncture and other alternative therapies $0 copay for acupuncture and other alternative therapies Section 2

17 Section 3, and Additional Benefit Information Benefit Category 4 - Inpatient Mental Health Care and You pay $0 for an additional 175 days per lifetime in a plan facility. Not covered Medicare Cost Insurance The Wisconsin Insurance Commissioner has set minimum standards for Medicare Cost insurance. This plan meets these standards. For an example of these standards and other important information, see the Wisconsin Guide to Health Insurance for People with Medicare, given to you when you applied for this plan. Do not buy this plan if you did not get that guide. 5 - Skilled Nursing Facility You pay $0 for 30 days of Skilled Nursing care, if your Skilled Nursing stay is NOT covered by Medicare. Not covered 6 - Home Health Care You pay $0 for a total of 365 home health visits per year, including those covered by Medicare. Not covered 9 - Chiropractic Services You pay $0 for medically necessary chiropractic services Emergency Care World-wide coverage. You pay 20%, after a $250 deductible, up to a combined $50,000 lifetime maximum, for urgently needed care and emergency care received outside the U.S Urgently Needed Care 23 - Health/Wellness Education World-wide coverage. You pay 20%, after a $250 deductible, up to a combined $50,000 lifetime maximum, for urgently needed care and emergency care received outside the U.S. Nursing Hotline Not covered Not covered Not covered Dean Health Plan, Inc. provides a free (24 hours/7 days a week) Nursing Hotline NURSE ( ) Wellness Incentives Now (WIN) Please see page 30 for information about this well-being program. DEAN HEALTH PLAN, INC. is contracted with Medicare to provide Medicare benefits. offers three plans, an plan, a Shared Value (Cost) plan and a plan. The Basic plan provides only basic Medicarecovered hospital and physician benefits. The Enhanced and Shared Value plans also provide basic Medicare-covered benefits, but include benefits beyond those provided by Medicare (such as, but not limited to, routine hearing and vision tests, routine physical exams and hearing aids). Please contact our Customer Care Center, at the number shown in the Introduction, for additional information about these plans. Disclosure Use this summary to compare benefits and premiums among policies and plans. Read your Evidence of Coverage carefully. This is only a summary describing DeanCare Gold s most important features. The Evidence of Coverage is the insurance contract. You must read the Evidence of Coverage itself to understand all of the rights and duties of both you and Dean Health Plan, Inc. Right to disenroll from plan You may disenroll from at any time for any reason. However, it may take a few weeks to process your disenrollment, update your Medicare record and return you to the Original Medicare program. Your disenrollment will become effective on the day you return to Original Medicare or enroll in another Medicare plan. You will receive written confirmation from Dean Health Plan, Inc. of your disenrollment effective date and Dean Health Plan, Inc. will return any paid, unused premium to you Section 3

18 Additional Health and Wellness & Education Benefits Information About DEANCARE GOLD As your health care partner, your overall health and wellness is our number one priority. Our innovative approach to wellness has allowed us to help you manage your health across the entire continuum of care from the well to the chronically ill. The main goal of our wellness offerings is to help reduce your preventable health risks and keep you well. For more information on wellness offerings from Dean Health Plan go to Wellness Incentives Now (WIN) Under Dean Health Plan s Wellness Incentives Now (WIN) Program you may claim reimbursement for up to $100 per calendar year for participating in health-related activities such as acupuncture services, gym memberships and nutritional education program fees such as Weight Watchers and Jenny Craig to name a few. For more information on Dean Health Plan s WIN program or to request a reimbursement form, please call our Customer Care Center. You may also visit our website at deancare. com/medicare for more information. Medical Management We understand that some of our members have complex health needs and we want to be there to help. If you require some extra help navigating your health care or managing Dean On Call Dean On Call is a complimentary telephone service that s available to members 24 hours a day, 365 days a year. Experienced registered nurses at Dean On Call are always available to answer your questions and concerns. Due to licensing regulations, Dean On Call s triage services are only available to residents of Wisconsin. You may call them at NURSE ( ). your condition, we are here for you. There is no charge for this service. Our goal is to make your care plan seamless and effective. Your provider can help you get set up with these services, or you can opt in by contacting the Customer Care Center. Healthy Partners Check out a list of fitness clubs that partner with Dean Health Plan to offer our members discounts. Quit For Life The Quit For Life Program is completely free to Dean Health Plan Medicare members. Using a mix of medication and phone-based coaching, it can help you down the path to quit smoking and overcome physical, psychological and behavioral addictions to tobacco. There are also services that are limited or not covered by, DeanCare Gold and Basic (Cost). These services include, but are not limited to: homemaker services; private duty nursing; surgical treatment for morbid obesity, unless medically necessary and covered under Original Medicare; routine dental care; routine foot care; and custodial care, such as help in walking, getting in and out of bed, eating, dressing, bathing and taking medicine. For a complete list of limited or excluded services, please contact our Customer Care Center at the number shown in the Introduction. NOTICE Dean Health Plan, Inc. is contracted with Medicare to provide Medicare benefits. is subject to limitations in choice of providers and service area and may not cover all of your medical costs. uses plan/network providers. This means we have arranged with certain providers to coordinate or provide covered services to members. All services must be provided or authorized by Dean Health Plan, Inc., except for emergency or urgently needed care. If you go to a provider outside of Dean Health Plan who accepts Medicare patients your coverage would be the same as Original Medicare. Original Medicare deductibles and co-insurance apply. REFERRALS You do not need a referral to see a provider. You will need an approved referral if you seek medical services outside the service area (except for emergency or urgently needed care when you are temporarily out of the service area). Your referral must be submitted to Dean Health Plan, Inc. by your referring provider and Dean Health Plan, Inc. must approve the referral before you receive services. If you go to a provider outside of Dean Health Plan who accepts Medicare patients your coverage would be the same as Original Medicare. Original Medicare deductibles and coinsurance apply. COVERED SERVICES Covered services means the medical care, services, supplies and equipment covered by. The benefit chart lists some of the covered services. There are some conditions that apply in order to get covered services. Covered services are covered only when all requirements listed below are met: Services must be provided according to Medicare coverage guidelines, established by the Medicare program and according to Dean Health Plan, Inc. guidelines. The medical care, services, supplies and equipment listed as covered services must be medically necessary. EVIDENCE OF COVERAGE The Evidence of Coverage (EOC), also referred to as the policy, is the insurance contract. You must read the EOC itself to understand all the benefits, limitations and exclusions of the plan. PLAN PREMIUM may change its plan premiums on January 1 of each year. If the plan premiums change, the new plan premium amount, for each plan, will apply to all plan members equally Section 3

19 Enhanced (Cost) and Plan Eyeglass Benefit Dean Health Plan will cover up to $250 every two years for a complete set of Medicare-approved eyeglasses. In order to receive this benefit, you must obtain your eyeglasses from a provider listed below. NOTE: This benefit does not apply to the Basic plan. Enhanced (Cost) and Plan Hearing Aid Benefit Dean Health Plan will cover up to $500 every three years for hearing aids. In order to receive this benefit, you must obtain your hearing aids from a provider designated to dispense hearing aids. NOTE: This benefit does not apply to the Basic plan. BARABOO Davis Duehr Dean - Baraboo th St. Baraboo, WI (608) BEAVER DAM Beaver Dam Eye Clinic 705 S University Ave Beaver Dam, WI (920) Shopko Optical Beaver Dam 822 Park Ave Beaver Dam, WI (920) COLUMBUS Columbus 1341 Park Ave. Columbus, WI (920) DEFOREST Essential Family Vision Care 101 S Main St. Deforest, WI (608) DODGEVILLE Dodgeville 305 Elaine s Court Dodgeville, WI (608) EDGERTON Edgerton Vision Center 1110 N Main St. Edgerton, WI (608) FORT ATKINSON Fort Atkinson 740 Reena Ave, STE B Fort Atkinson, WI (920) JANESVILLE Janesville East 3200 E Racine St Janeville, WI (608) LANCASTER Lancaster 500 S Madison St., STE 2 Lancaster, WI (608) MADISON Regent Street 1025 Regent St. Madison, WI (608) East 1821 S Stoughton Rd. Madison, WI West 752 N High Point Rd. Madison, WI MOUNT HOREB Samuelson Eyecare 428 W Main St. Mount Horeb, WI (608) PLATTEVILLE Platteville 1450 East Side Rd., STE 120 Platteville, WI (608) PORTAGE Portage 2825 Hunters Trail, STE 3 Portage, WI (608) PRAIRIE DU SAC Sauk Prairie 1110 Prairie St. Prairie du Sac, WI (608) REEDSBURG Reedsburg st St. Reedsburg, WI (608) SPRING GREEN Spring Green Vision Center 150 East Jefferson St. Spring Green, WI (608) STOUGHTON Stoughton 225 Church St. Stoughton, WI SUN PRAIRIE Sun Prairie 10 Tower Dr. Sun Prairie, WI WATERTOWN Shopko Optical Watertown 701 S. Church St. Watertown, WI (920) WAUPUN Waupun Eye Clinic 10 Beaver Dam St. Waupun, WI (920) WHITEWATER Whitewater 128 N Tratt St. Whitewater, WI (262) WISCONSIN DELLS Dells Delton 1302 E Broadway Rd. Wisconsin Dells, WI (608) BARABOO St. Clare Hospital th St. Baraboo, WI BEAVER DAM Beaver Dam Family Hearing Center 705 South University Ave., Suite 170 Beaver Dam, WI BELOIT Beloit Clinic 1905 Huebbe Pkwy Beloit, WI Beloit Memorial Hospital 1969 W Hart Rd. Beloit, WI Beloit Hearing 2797 Prairie Ave Beloit, WI BLACK EARTH Black Earth Medical Clinic 1529 State St. Black Earth, WI BOSCOBEL Associated Balance & Hearing Clinics, LLC 109 E. Bluff St. Boscobel, WI COLUMBUS Columbus Community Hospital 1515 Park Ave. Columbus, WI DELAVAN Dean Clinic - Delavan 540 Bowers Blvd Delavan, WI DODGEVILLE Upland Hills Health 800 Compassion Way Dodgeville, WI DUBUQUE Dubuque ENT Head & Neck Surgery 310 N Grandview Ave Dubuque, IA FORT ATKINSON Fort Healthcare Ear, Nose & Throat 512 Wilcox St. Fort Atkinson, WI JANESVILLE Dean Clinic Janesville East 3200 E Racine St Janesville, WI LANCASTER Grant Regional Health Center 507 S Monroe St. Lancaster, WI LODI Lodi Medical Clinic 601 Clark St. Lodi, WI MADISON Dean Clinic Fish Hatchery 1313 Fish Hatchery Rd. Madison, WI Dean Clinic - East 1821 S Stoughton Rd. Madison, WI Dean Clinic - West 752 N High Point Rd. Madison, WI PLAIN Plain Medical Clinic 825 Main St. Plain, WI PLATTEVILLE Southwest Health Center 1400 East Side Rd. Platteville, WI PORTAGE Divine Savior Hospital 2817 New Pinery Rd. Portage, WI PRAIRIE DU SAC Sauk Prairie Memorial Hospital 80 First St. Prairie du Sac, WI REEDSBURG Reedsburg Area Medical Center 2000 N. Dewey Ave. Reedsburg, WI STOUGHTON Dean Clinic - Stoughton 225 Church St. Stoughton, WI SUN PRAIRIE Dean Clinic - Sun Prairie 10 Tower Dr. Sun Prairie, WI WATERTOWN Hearing Services Ltd. 123 Hospital Dr. Watertown, WI is a Medicare Approved Cost Plan Section 3

20 Multi-language Interpreter Services English: We have free interpreter services to answer any questions you may have about our health or drug plan. To get an interpreter, just call us at Someone who speaks English/Language can help you. This is a free service. Spanish: Tenemos servicios de intérprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos. Para hablar con un intérprete, por favor llame al Alguien que hable español le podrá ayudar. Este es un servicio gratuito. Chinese Mandarin: 我们提供免费的翻译服务, 帮助您解答关于健康或药物保险的任何疑问 如果您需要此翻译服务, 请致电 我们的中文工作人员很乐意帮助您 这是一项免费服务 Chinese Cantonese: 您對我們的健康或藥物保險可能存有疑問, 為此我們提供免費的翻譯服務 如需翻譯服務, 請致電 我們講中文的人員將樂意為您提供幫助 這是一項免費服務 Tagalog: Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot. Upang makakuha ng tagasaling-wika, tawagan lamang kami sa Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog. Ito ay libreng serbisyo. French: Nous proposons des services gratuits d'interprétation pour répondre à toutes vos questions relatives à notre régime de santé ou d'assurance-médicaments. Pour accéder au service d'interprétation, il vous suffit de nous appeler au Un interlocuteur parlant Français pourra vous aider. Ce service est gratuit. Vietnamese: Chúng tôi có dịch vụ thông dịch miễn phí để trả lời các câu hỏi về chương sức khỏe và chương trình thuốc men. Nếu quí vị cần thông dịch viên xin gọi sẽ có nhân viên nói tiếng Việt giúp đỡ quí vị. Đây là dịch vụ miễn phí. German: Unser kostenloser Dolmetscherservice beantwortet Ihren Fragen zu unserem Gesundheits- und Arzneimittelplan. Unsere Dolmetscher erreichen Sie unter Man wird Ihnen dort auf Deutsch weiterhelfen. Dieser Service ist kostenlos. Korean: 당사는의료보험또는약품보험에관한질문에답해드리고자무료통역서비스를제공하고있습니다. 통역서비스를이용하려면전화 번으로문의해주십시오. 한국어를하는담당자가도와드릴것입니다. 이서비스는무료로운영됩니다. Russian: Если у вас возникнут вопросы относительно страхового или медикаментного плана, вы можете воспользоваться нашими бесплатными услугами переводчиков. Чтобы воспользоваться услугами переводчика, позвоните нам по телефону Вам окажет помощь сотрудник, который говорит по-pусски. Данная услуга бесплатная. إننا نقدم خدمات المترجم الفوري المجانية لإلجابة عن أي أسئلة تتعلق بالصحة أو جدول األدوية لدينا. للحصول على Arabic: بمساعدتك. هذه مترجم فوري ليس عليك سوى االتصال بنا على ] [. سيقوم شخص ما يتحدث العربية.خدمة مجانية Italian: È disponibile un servizio di interpretariato gratuito per rispondere a eventuali domande sul nostro piano sanitario e farmaceutico. Per un interprete, contattare il numero Un nostro incaricato che parla Italianovi fornirà l'assistenza necessaria. È un servizio gratuito. Portugués: Dispomos de serviços de interpretação gratuitos para responder a qualquer questão que tenha acerca do nosso plano de saúde ou de medicação. Para obter um intérprete, contacte-nos através do número Irá encontrar alguém que fale o idioma Português para o ajudar. Este serviço é gratuito. French Creole: Nou genyen sèvis entèprèt gratis pou reponn tout kesyon ou ta genyen konsènan plan medikal oswa dwòg nou an. Pou jwenn yon entèprèt, jis rele nou nan Yon moun ki pale Kreyòl kapab ede w. Sa a se yon sèvis ki gratis. Polish: Umożliwiamy bezpłatne skorzystanie z usług tłumacza ustnego, który pomoże w uzyskaniu odpowiedzi na temat planu zdrowotnego lub dawkowania leków. Aby skorzystać z pomocy tłumacza znającego język polski, należy zadzwonić pod numer Ta usługa jest bezpłatna. Hindi: हम र स व स य य दव क य जन क ब र म आपक ककस भ प रश न क जव ब द न क ल ए हम र प स म फ त द भ ष य स व ए उप ब ध ह. एक द भ ष य प र प त करन क ल ए, बस हम पर फ न कर. क ई व यक तत ज हहन द ब त ह आपक मदद कर सकत ह. यह एक म फ त स व ह. Japanese: 当社の健康 健康保険と薬品 処方薬プランに関するご質問にお答えするために 無料の通訳サービスがありますございます 通訳をご用命になるには にお電話ください 日本語を話す人 者 が支援いたします これは無料のサービスです 34 35

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