PROFESSIONAL SERVICES INPATIENT HOSPITAL SERVICES. 1199SEIU VIP Premier (HMO) Medicare. 1199SEIU VIP Premier (HMO) Medicare

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1 PROFESSIONAL SERVICES PCP office visits Specialist office visits Annual physical exam/preventive care Physical, Speech & Occupational Therapy Cardiac/Pulmonary Rehab Flu & Pneumonia Vaccinations Diagnostic Services including X-ray, EKG's Lab Tests Routine Foot Care (Up to 4 visit per year) Chiropractic Care 1199SEIU VIP Premier (HMO) MEDICARE PLAN $20 copay per visit $20 copay per visit $20 copay per visit INPATIENT HOSPITAL SERVICES Surgeon & physician fees Semi-private room and board Anesthesia Nursing care (hospital provided) X-ray & Lab tests (inpatient) Prescribed drugs Operating & recovery room fees Intensive Care Unit Therapy (physical, speech and occupational therapy) OUTPATIENT FACILITY SERVICES Ambulatory surgery Outpatient surgery Emergency room fees Ambulance service to the hospital (Non-emergent ambulance transportation requires authorization) Renal dialysis X-ray (outpatient) Lab tests (outpatient) Diagnostic Services including MRI's, MRA s, PET, and CAT Scans Radiation Therapy $225 copay per day (days 1-7) $250 copay per visit $250 copay per visit $75 copay per visit (waived if admitted within 1 day) $175 copay per service $20 copay per visit $100 copay per visit H3330_ Group 11/8/2016

2 1199SEIU VIP Premier (HMO) MEDICARE PLAN 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 Preferred** Deductible: $0 Initial Coverage Limit (ICL): $3,700 Retail: Preferred Generic: Generic: Preferred Brand: Non-Preferred Drug: Member coinsurance of 18% with a cap of $75 for 30-day supply; $150 for 60-day supply; $225 for 90-day supply Specialty: Standard Deductible: $0 Initial Coverage Limit (ICL): $3,700 Retail: Preferred Generic: $5 copay per 30-day supply, $10 copay per 60-day supply, $15 copay per 90-day supply Generic: $20 copay per 30-day supply, $40 copay per 60-day supply, $60 copay per 90-day supply Preferred Brand: $45 copay per 30-day supply, $90 copay per 60-day supply, $135 copay per 90-day supply Non-Preferred Drug: Member coinsurance of 18% with a cap of $75 for 30-day supply; $150 for 60-day supply; $225 for 90-day supply Specialty: 25% coinsurance

3 When prescribed by a participating provider and filled by a participating mail order vendor. 1199SEIU VIP Premier (HMO) MEDICARE PLAN Mail Order: Preferred Generic: Generic: Preferred Brand: Non-Preferred Drug: Member coinsurance of 18% with a cap of $75 for 30-day supply; $150 for 60-day supply; $225 for 90-day supply Specialty: Coverage Gap: Member pays copays and coinsurance listed above until reaching a benefit limit of $3,700. Member pays above copays for formulary generic drugs for drug costs from $3,700 to $4,950. Member will receive a discount on brand name drugs and generally pay no more than 40% of the plan s cost for brand name drug until your yearly out-of-pocket cost reaches $4,950. PART B DRUGS Catastrophic Coverage: When a member reaches $4,950 of true out-ofpocket (TrOOP) costs for the calendar year, the member will pay the greater of $3.30 copay for generic, $8.25 copay for brand, or 5% coinsurance. 20% coinsurance

4 OTHER BENEFITS Skilled Nursing Facility Care Up to 100 days per benefit period 1199SEIU VIP Premier (HMO) MEDICARE PLAN $20 copay per day (days 1-20) 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 Routine Vision Care One eye exam per calendar year by a Participating Provider. One pair of eyeglasses per calendar year when chosen from a select group of frames at a participating optical provider. Hearing Exam and Aid One routine hearing exam per calendar year by a Participating Provider. Hearing Aid Comprehensive Dental HIP Participating Dentist must be used Dental Discount*** Durable Medical Equipment Private Duty Nursing Dialysis Transportation (For end-stage renal disease/kidney related diseases to/from dialysis centers only) Transitional Health Care Services (Members will receive home health aide services and personal care services (ADL S) performed by a home health aide for up to 30 days after their discharge from a hospital. $50 copay per day (days ) Covered by Medicare $30 copay $50 copay $30 copay $5 for one examination (comprehensive or periodic) every 6 months. $10 per visit for one prophylaxis (cleaning) every 6 months. Additional services, including but not limited to X-rays, fillings, crowns or dentures will be provided at a discounted rate subject to a fee schedule. 20% coinsurance

5 1199SEIU VIP Premier (HMO) MEDICARE PLAN Over the Counter Medication (OTC) Cough and Cold PPI (Proton Pump Inhibitors) Axid, Prilosec, etc. Analgesics (includes aspirins) Anti-Acid (Mylanta, Bismuth) 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. **Member receives reduced cost-sharing when filling prescriptions at a Preferred Pharmacy Network. ***This is not a plan benefit, this is a dental discount offered to all Medicare enrollees. Maximum Out of Pocket Costs $3,400 annual out of pocket maximum. Once met, medical and hospital services have no cost sharing. The out of pocket maximum does not apply to supplemental benefits not covered by Medicare such as hearing aids and preventive dental care. Your pharmacy 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 EmblemHealth VIP Premier (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 description above. This benefit design does not apply if you are receiving Extra Help from Medicare. HIP Health Plan of New York (HIP) is an HMO plan with a Medicare contract. Enrollment in HIP depends on contract renewal. HIP is an EmblemHealth company. 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 the full payment for the care you received. 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 ).

6 1199SEIU VIP Premier (HMO) MEDICARE PLAN The information contained in the Summary is intended to provide a general overview of the benefits available in the Medicare HMO Plan. For an actual description of your benefits including exclusions, limitations or specific conditions that may modify the benefits described in this Summary see your 2017 Medicare EOC. In the event of a discrepancy between the information contained in this Summary and the provisions of your 2017 Medicare EOC, the specific provisions of the EOC shall prevail over the overview provided in this Summary. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums, and/or copayments/coinsurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium. The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. This information is available for free in other languages. Please call our customer service number at ; TTY call 711 during Monday to Sunday, 8 am to 8 pm. ATTENTION: If you speak other languages, language assistance services, free of charge, are available to you. Call (TTY: 711), seven days a week from 8 am to 8 pm. ATENCIÓN: Si usted habla español, tiene a su disposición, gratis, servicios de ayuda para idiomas. Llame al (TTY: 711)

7 ATTENTION: If you speak other languages, language assistance services, free of charge, are available to you. Call (TTY/TDD: 711). Español (Spanish) ATENCIÓN: Si usted habla español, tiene a su disposición, gratis, servicios de ayuda para idiomas. Llame al (TTY/TDD: 711). 中文 (Traditional Chinese) 注意 : 如果您講中文, 我們免費提供相關的語言協助服務 請致電 (TTY/TDD: 711) Pусский (Russian) ВНИМАНИЕ! Если Вы говорите на русском языке, Вам доступны бесплатные услуги переводчика. Звоните по тел (служба текстового телефона, TTY/TDD: 711). Kreyòl Ayisyen (Haitian Creole) ATANSYON: Si ou pale Kreyòl Ayisyen, gen sèvis èd nan lang gratis ki disponib pou ou. Rele nimewo (TTY/TDD: 711). 한국어 (Korean) 주의 : 귀하가한국어를사용하는경우, 귀하에게언어지원서비스가무료로제공됩니다 (TTY/TDD: 711) 로전화하십시오. Italiano (Italian) ATTENZIONE: Sono disponibili servizi gratuiti di assistenza linguistica in italiano. Chiamare il numero (TTY/TDD: 711). שידיא (Yiddish) (Yiddish) אידיש טפור.ךייא ראפ ןעמוקאב וצ אד ןענייז,זיירפ ןייק ןהא,סעסיוורעס ףליה ךארפש,שידיא טדער ריא ביוא :גנוטכא אכטונג: אויב איר רעדט אידיש, שפראך הילף סערוויסעס, אהן קיין פרייז, זיינען דא צו באקומען פאר אייך. רופט <X-XXX-XXX-XXXX> (TTY/TDD: <XXX>)..(TTY/TDD:.(TTY/TDD: <XXX>) <X-XXX-XXX-XXXX> 711) ব ল (Bengali) দ ষ ট আকর ষণ করছ : আপন যদ ব ল ভ ষ হন, আপন র জন য ব ন ম ল য ভ ষ স ক র ন ত পর ষ ব র ব যবস থ থ কব <X-XXX-XXX-XXXX> নম বর (TTY/TDD: <XXX>) ফ ন কর ন :, 1-xxx-xxx-xxxx (TTY/TDD: 711) Polski (Polish) UWAGA: Dla osób mówiących po polsku dostępna jest bezpłatna pomoc językowa. Proszę zadzwonić pod numer (TTY/TDD: 711). (ARABIC) (Arabic) ةيبرعلا مقرلاب لصتا, اناجم ةيوغللا ةدعاسملا تامدخ كل رفوتت ةيبرعلا ةغللا ملكتت تنك اذإ :هابتنالا ىجري وأ جى لانتبا : كن تتكل <X-XXX-XXX-XXXX> ب تت ف ل خ ا ساع مجانا, تص بال ق (TTY/TDD: 711) Y0026_ Accepted 8/29/16 Group Health Incorporated (GHI), HIP Health Plan of New York (HIP), HIP Insurance Company of New York and EmblemHealth Services Company, LLC are EmblemHealth companies. EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies /16

8 Français (French) ATTENTION : si vous parlez français, une assistance d interprétation gratuite est à votre disposition. Veuillez composer le (Sourds et malentendants : 711). ودرا( Urdu ) ںیہ بایتسد تفم تامدخ یک ددم قلعتم ےس نابز ےیل ےک پآ وت ںیہ ےتلوب ودرا پآ رگا :ںید ہجوت ) : کے سے کی ںیرک لاک رپ (< XXX >:یڈ یڈ یٹ /یئاو یٹ یٹ) <X-XXX-XXX-XXXX> (<XXX>: 711 / Tagalog (Tagalog) NANANAWAGAN NG PANSIN: Kung nagsasalita ka ng Tagalog, mayroon kang magagamit na mga serbisyo para sa tulong sa wika nang walang bayad. Tawagan ang (TTY/TDD: 711). Ελληνικά (Greek) ΠΡΟΣΟΧΗ: Εάν μιλάτε Ελληνικά, διατίθενται για σας υπηρεσίες γλωσσικής βοήθειας, δωρεάν. Καλέστε (για άτομα με προβλήματα ακοής/tty/tdd: 711). Shqip (Albanian) VINI RE: Nëse flisni Shqip, shërbimi i asistencës për gjuhën do të jetë në dispozicionin tuaj, pa pagesë. Telefononi (Shërbimi i teletekstit TTY/TDD: 711). Notice of Nondiscrimination Policy EmblemHealth complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. EmblemHealth does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. EmblemHealth: Provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: Qualified interpreters Information written in other languages If you need these services, contact If you believe that EmblemHealth has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with EmblemHealth Grievance and Appeals Department, PO Box 2844, New York, NY 10116, or call (Dial 711 for TTY/ TDD services.) You can file a grievance in person, by mail or by phone. If you need help filing a grievance, EmblemHealth s Grievance and Appeals Department is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office of Civil Rights electronically through the Office of Civil Rights Complaint Portal, available at ocrportal.hhs.gov/ocr/portal/lobby.jsf or by mail or phone at U.S. Department of Health and Human Services, 200 Independence Avenue SW, Room 509F, HHH Building, Washington, DC 20201; , (dial for TTY services). Complaint forms are available at hhs.gov/ocr/office/file/index.html. Y0026_ NM