Classic Plan (HMO-POS) Value Plan (HMO) Rewards Plan (HMO)

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1 January 1, 2016 December 31, 2016 Classic Plan Value Plan Rewards Plan SECTION I INTRODUCTION 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 One choice is to get your Medicare benefits through Original Medicare (feefor-service Medicare). Original Medicare is run directly by the Federal government. Another choice is to get your Medicare benefits by joining a Medicare health plan such as Health First s Classic Plan, Value Plan, and Rewards Plan. Tips for comparing your Medicare choices This Summary of Benefits booklet gives you a summary of what Health First s Classic Plan, Value Plan, and Rewards Plan covers and what you pay. 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 If you want to know more about the coverage and s of Original Medicare, look in your current Medicare & You handbook. View it online at or get a copy by calling MEDICARE ( ), 24 hours a day, 7 days a week. TTY users should call Sections in this booklet Things to Know About Health First s Classic Plan, Value Plan, and Rewards Plan Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services Covered Medical and Hospital Benefits Prescription Drug 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 (TDD/TTY relay: ). Y0089_EL4831 Accepted Page 1 of 22

2 Things to Know About Health First s Classic Plan, Value Plan, and Rewards Plan Hours of Operation From October 1 to February 14, you can call us 7 days a week from 8:00 a.m. to 8:00 p.m. Eastern time. From February 15 to September 30, you can call us Monday from 8:00 a.m. to 8:00 p.m. Eastern time, Tuesday from 8:00 a.m. to 8:00 p.m. Eastern time, Wednesday from 8:00 a.m. to 8:00 p.m. Eastern time, Thursday from 8:00 a.m. to 8:00 p.m. Eastern time, Friday from 8:00 a.m. to 8:00 p.m. Eastern time, Saturday from 8:00 a.m. to 12:00 p.m. Eastern time. Health First s Classic Plan (HMO- POS), Value Plan, and Rewards Plan Phone Numbers and Website If you are a member of this plan, call tollfree (TDD/TTY relay: ). If you are not a member of this plan, call toll-free (TDD/TTY relay: ). Our website: myhfhp.org Who can join? To join Health First s Classic Plan, Value Plan, and Rewards Plan, 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 Florida: Brevard and Indian River. Which doctors, hospitals, and pharmacies can I use? Health First s Classic Plan (HMO- POS), Value Plan, and Rewards Plan have a network of doctors, hospitals, pharmacies, and other providers. For some services you can 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 (myhfhp.org). 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. 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. 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. You can see the complete plan formulary (list of Part D prescription drugs) and any restrictions on our website, myhfhp.org. Or, call us and we will send you a copy of the formulary. How will I determine my drug s? 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 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: Initial Coverage, Coverage Gap, and Catastrophic Coverage. Y0089_EL4831 Accepted Page 2 of 22

3 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? $0 per month. In addition, you must keep paying your Medicare Part B premium. This plan does not have a deductible. Yes. Like all Medicare health plans, our plan protects you by having yearly limits on your outof-pocket s for medical and hospital care. Your yearly limit(s) in this plan: $6,650 for services you receive from in-network providers. If you reach the limit on out-ofpocket s, you keep getting covered hospital and medical services and we will pay the full for the rest of the year. Please note that you will still need to pay your monthly premiums and -sharing for your Part D prescription drugs. $27 per month. In addition, you must keep paying your Medicare Part B premium. This plan does not have a deductible. Yes. Like all Medicare health plans, our plan protects you by having yearly limits on your outof-pocket s for medical and hospital care. Your yearly limit(s) in this plan: $4,950 for services you receive from in-network providers. If you reach the limit on out-ofpocket s, you keep getting covered hospital and medical services and we will pay the full for the rest of the year. Please note that you will still need to pay your monthly premiums and -sharing for your Part D prescription drugs. $87 per month. In addition, you must keep paying your Medicare Part B premium. This plan does not have a deductible. Yes. Like all Medicare health plans, our plan protects you by having yearly limits on your outof-pocket s for medical and hospital care. Your yearly limit(s) in this plan: $3,750 for services you receive from in-network providers. $10,000 for services you receive from out-of-network providers. If you reach the limit on out-ofpocket s, you keep getting covered hospital and medical services and we will pay the full for the rest of the year. Please note that you will still need to pay your monthly premiums and -sharing for your Part D prescription drugs. Y0089_EL4831 Accepted Page 3 of 22

4 Is there a limit on how much the plan will pay? No. There are no limits on how much our plan will pay. Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply. Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply. Health First Health Plans is an HMO plan with a Medicare contract. Enrollment in Health First Health Plans depends on contract renewal. OUTPATIENT CARE AND SERVICES Acupuncture and Other Alternative Therapies Covered Medical and Hospital Benefits Note: Services with a 1 may require prior authorization. Not covered Not covered Not covered Ambulance 1 $275 $225 In-network: $175 Out-of-network: 20% of the Chiropractic Care Dental Services 1 Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): $20 Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): $40 Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): $20 Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): $30 Preventive dental services: Cleaning: $0 Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): In-network: $20 Out-of-network: 20% of the Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): Y0089_EL4831 Accepted Page 4 of 22 In-network: $20 Out-of-network: 20% of the

5 OUTPATIENT CARE AND SERVICES Dental x-ray(s): $0 Fluoride treatment: $0 Oral exam: $0 Our plan pays up to $125 every year for preventive dental services. Preventive dental services: Cleaning: In-network: $0 You are covered for up to 1 every year. Dental x-ray(s): In-network: $0 You are covered for up to 1 every year. Fluoride treatment: In-network: $0 You are covered for up to 1 every year Oral exam: In-network: $0 You are covered for up to 1 every year. Our plan pays up to $200 every year for preventive dental services from an in-network provider. Diabetes Supplies and Services 1 Diabetes monitoring supplies: 20% of the Diabetes self-management training: You pay nothing Therapeutic shoes or inserts: 20% of the Diabetes monitoring supplies: 10% of the Diabetes self-management training: You pay nothing Therapeutic shoes or inserts: 10% of the Continuous glucose monitoring: 10% of the Diabetes monitoring supplies: In-network: You pay nothing Out-of-network: 20% of the Diabetes self-management training: In-network: You pay nothing Out-of-network: 20% of the Therapeutic shoes or inserts: In-network: You pay nothing Out-of-network: 20% of the Y0089_EL4831 Accepted Page 5 of 22

6 OUTPATIENT CARE AND SERVICES Continuous glucose monitoring: In-network: You pay nothing Diagnostic Tests, Lab and Radiology Services, and X-Rays 1 Diagnostic radiology services (such as MRIs, CT scans): $300 Diagnostic tests and procedures: $35 Lab services: You pay nothing Outpatient X-rays: $35 Therapeutic radiology services (such as radiation treatment for cancer): You pay nothing Diagnostic radiology services (such as MRIs, CT scans): $200 Diagnostic tests and procedures: $30 Lab services: You pay nothing Outpatient X-rays: $30 Therapeutic radiology services (such as radiation treatment for cancer): You pay nothing Diagnostic radiology services (such as MRIs, CT scans): In-network: $100 Out-of-network: 20% of the Diagnostic tests and procedures: In-network: You pay nothing Out-of-network: 20% of the Lab services: In-network: You pay nothing Out-of-network: 20% of the Outpatient X-rays: In-network: You pay nothing Out-of-network: 20% of the Therapeutic radiology services (such as radiation treatment for cancer): In-network: You pay nothing Out-of-network: 20% of the Doctor s Office Visits Primary care physician visit: $10 Specialist visit: $40 Primary care physician visit: $5 Specialist visit: $35 Primary care physician visit: In-network: You pay nothing Out-of-network: 20% of the Specialist visit: In-network: $20 Out-of-network: 20% of the Y0089_EL4831 Accepted Page 6 of 22

7 OUTPATIENT CARE AND SERVICES Durable Medical Equipment (wheelchairs, oxygen, etc.) 1 20% of the 20% of the In-network: 20% of the Out-of-network: 20% of the Emergency Care $75 $75 $50 If you are admitted to the hospital If you are admitted to the hospital If you are admitted to the hospital within 24 hours, you do not have to pay your share of the for emergency care. See the Inpatient Hospital Care section of this booklet for other s. within 24 hours, you do not have to pay your share of the for emergency care. See the Inpatient Hospital Care section of this booklet for other s. within 24 hours, you do not have to pay your share of the for emergency care. See the Inpatient Hospital Care section of this booklet for other s. Foot Care (podiatry services) Hearing Services Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: $40 Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: $30 conditions: Exam to diagnose and treat Exam to diagnose and treat hearing and balance issues: hearing and balance issues: $40 $30 Y0089_EL4831 Accepted Page 7 of 22 Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain In-network: $20 Out-of-network: 20% of the Exam to diagnose and treat hearing and balance issues: In-network: $15 Out-of-network: 20% of the Routine hearing exam: In-network: $15. You are covered for up to 1 every year. Hearing aid: In-network: You pay nothing Our plan pays up to $250 every year for hearing aids from an innetwork provider.

8 OUTPATIENT CARE AND SERVICES Home Health Care 1 You pay nothing You pay nothing In-network: You pay nothing Out-of-network: 20% of the Mental Health Care 1 Inpatient visit: Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital. The s 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 90 days for an inpatient hospital stay. Our plan also covers 60 lifetime reserve days. These are extra days that we cover. If your hospital stay is longer than 90 days, you can use these extra Inpatient visit: Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital. The s 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 90 days for an inpatient hospital stay. Our plan also covers 60 lifetime reserve days. These are extra days that we cover. If your hospital stay is longer than 90 days, you can use these extra Inpatient visit: Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital. The s 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 90 days for an inpatient hospital stay. Our plan also covers 60 lifetime reserve days. These are extra days that we cover. If your hospital stay is longer than 90 days, you can use these extra Y0089_EL4831 Accepted Page 8 of 22

9 OUTPATIENT CARE AND SERVICES Outpatient Rehabilitation 1 days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days. $200 per day for days 1 through 7 You pay nothing per day for days 8 through 90 Outpatient group therapy visit: $40 Outpatient individual therapy visit: $40 Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): $40 Occupational therapy visit: $40 Physical therapy and speech and language therapy visit: $40 days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days. $200 per day for days 1 through 7 You pay nothing per day for days 8 through 90 Outpatient group therapy visit: $30 Outpatient individual therapy visit: $30 Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): $30 Occupational therapy visit: $30 Physical therapy and speech and language therapy visit: $30 days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days. In-network: $180 per day for days 1 through 7 You pay nothing per day for days 8 through 90 Out-of-network: 20% of the per stay Outpatient group therapy visit: In-network: $20 Out-of-network: 20% of the Outpatient individual therapy visit: In-network: $20 Out-of-network: 20% of the Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): In-network: $20 Out-of-network: 20% of the Occupational therapy visit: In-network: $20 Out-of-network: 20% of the Physical therapy and speech and language therapy visit: In-network: $20 Y0089_EL4831 Accepted Page 9 of 22

10 OUTPATIENT CARE AND SERVICES Out-of-network: 20% of the Outpatient Substance Abuse 1 Group therapy visit: $40 Individual therapy visit: $40 Group therapy visit: $30 Individual therapy visit: $30 Group therapy visit: In-network: $20 Out-of-network: 20% of the Individual therapy visit: In-network: $20 Out-of-network: 20% of the Outpatient Surgery 1 Ambulatory surgical center: $350 Outpatient hospital: $350 Ambulatory surgical center: $225 Outpatient hospital: $225 Ambulatory surgical center: In-network: $150 Out-of-network: 20% of the Outpatient hospital: In-network: $150 Out-of-network: 20% of the Over-the-Counter Items Not Covered Not Covered Not Covered Prosthetic Devices (braces, artificial limbs, etc.) 1 Prosthetic devices: 20% of the Related medical supplies: 20% of the Prosthetic devices: 20% of the Related medical supplies: 20% of the Prosthetic devices: In-network: 20% of the Out-of-network: 20% of the Related medical supplies: In-network: 20% of the Out-of-network: 20% of the Renal Dialysis 20% of the 20% of the In-network: 20% of the Out-of-network: 20% of the Transportation Not covered Not covered Not covered Y0089_EL4831 Accepted Page 10 of 22

11 OUTPATIENT CARE AND SERVICES Urgently Needed Services Vision Services $45 $35 $25 Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): $40 Eyeglasses or contact lenses after cataract surgery: You pay nothing Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): $30 Routine eye exam (for up to 1 every year): $30 Contact lenses: You pay nothing Eyeglasses (frames and lenses): You pay nothing Eyeglasses or contact lenses after cataract surgery: You pay nothing. Our plan pays up to $75 every year for contact lenses and eyeglasses (frames and lenses). Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): In-network: $20 Out-of-network: 20% of the Routine eye exam: In-network: $0 You are covered for up to 1 every year. Contact lenses: In-network: $0 Eyeglasses (frames and lenses): In-network: $0 Eyeglasses or contact lenses after cataract surgery: In-network: $0 Out-of-network: 20% of the Our plan pays up to $125 every year for contact lenses and eyeglasses (frames and lenses) from an in-network provider. PREVENTIVE CARE Preventive Care You pay nothing Our plan covers many preventive services, including: You pay nothing Our plan covers many preventive services, including: In-network: You pay nothing Out-of-network: 20% of the Our plan covers many preventive Y0089_EL4831 Accepted Page 11 of 22

12 PREVENTIVE CARE Abdominal aortic aneurysm screening Alcohol misuse counseling Bone mass measurement Breast cancer screening (mammogram) Cardiovascular disease (behavioral therapy) screening Cardiovascular screenings Cervical and vaginal cancer Colonoscopy Colorectal cancer screenings Depression screening Diabetes screenings Fecal occult blood test Flexible sigmoidoscopy HIV screening Medical nutrition therapy services Obesity screening and counseling Prostate cancer screenings (PSA) Sexually transmitted infections screening and counseling Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease) Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots Welcome to Medicare Abdominal aortic aneurysm screening Alcohol misuse counseling Bone mass measurement Breast cancer screening (mammogram) Cardiovascular disease (behavioral therapy) screening Cardiovascular screenings Cervical and vaginal cancer Colonoscopy Colorectal cancer screenings Depression screening Diabetes screenings Fecal occult blood test Flexible sigmoidoscopy HIV screening Medical nutrition therapy services Obesity screening and counseling Prostate cancer screenings (PSA) Sexually transmitted infections screening and counseling Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease) Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots Welcome to Medicare services, including: Abdominal aortic aneurysm screening Alcohol misuse counseling Bone mass measurement Breast cancer screening (mammogram) Cardiovascular disease (behavioral therapy) screening Cardiovascular screenings Cervical and vaginal cancer Colonoscopy Colorectal cancer screenings Depression screening Diabetes screenings Fecal occult blood test Flexible sigmoidoscopy HIV screening Medical nutrition therapy services Obesity screening and counseling Prostate cancer screenings (PSA) Sexually transmitted infections screening and counseling Tobacco use cessation counseling (counseling for people with no sign of tobaccorelated disease) Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots Y0089_EL4831 Accepted Page 12 of 22

13 PREVENTIVE CARE preventive visit (one-time) preventive visit (one-time) Yearly "Wellness" visit Yearly "Wellness" visit Any additional preventive Any additional preventive services approved by Medicare services approved by Medicare during the contract year will be during the contract year will be covered. covered. Welcome to Medicare preventive visit (one-time) Yearly "Wellness" visit Any additional preventive services approved by Medicare during the contract year will be covered. HOSPICE Hospice You pay nothing for hospice care from a Medicare-certified hospice. You may have to pay part of the s for drugs and respite care. Hospice is covered outside of our plan. Please contact us for more details. You pay nothing for hospice care from a Medicare-certified hospice. You may have to pay part of the s for drugs and respite care. Hospice is covered outside of our plan. Please contact us for more details. You pay nothing for hospice care from a Medicare-certified hospice. You may have to pay part of the s for drugs and respite care. Hospice is covered outside of our plan. Please contact us for more details. INPATIENT CARE Inpatient Hospital Care 1 The s 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 The s 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 The s 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 Y0089_EL4831 Accepted Page 13 of 22

14 Inpatient Mental Health Care Skilled Nursing Facility (SNF) 1 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 90 days for an inpatient hospital stay. Our plan also covers 60 lifetime reserve days. These are extra days that we cover. If your hospital stay is longer than 90 days, you can use these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days. $275 per day for days 1 through 7 You pay nothing per day for days 8 through 90 For inpatient mental health care, see the "Mental Health Care" section of this booklet. Our plan covers up to 100 days in a SNF. You pay nothing per day for days 1 though 20 $150 per day for days 21 though 100 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 90 days for an inpatient hospital stay. Our plan also covers 60 lifetime reserve days. These are extra days that we cover. If your hospital stay is longer than 90 days, you can use these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days. $195 per day for days 1 through 7 You pay nothing per day for days 8 through 90 For inpatient mental health care, see the "Mental Health Care" section of this booklet. Our plan covers up to 100 days in a SNF. You pay nothing per day for days 1 though 20 $75 per day for days 21 though 100 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 90 days for an inpatient hospital stay. Our plan also covers 60 lifetime reserve days. These are extra days that we cover. If your hospital stay is longer than 90 days, you can use these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days. In-network: $180 per day for days 1 through 7. You pay nothing per day for days 8 through 90 Out-of-network: 20% of the per stay For inpatient mental health care, see the "Mental Health Care" section of this booklet. Our plan covers up to 100 days in a SNF. In-network: You pay nothing per day for days 1 though 20 $40 per day for days 21 though 100 Out-of-network: 20% of the per stay Y0089_EL4831 Accepted Page 14 of 22

15 How much do I pay? Initial Coverage For Part B drugs such as chemotherapy drugs 1 : 20% of the Other Part B drugs 1 : 20% of the You pay the following until your total yearly drug s reach $3,310. Total yearly drug s are the total drug s 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 1 (Preferred Generic): One-month supply: $0 Three-month supply: $0 Tier 2 (Generic): One-month supply: $10 Three-month supply: $30 Tier 3 (Preferred Brand): One-month supply: $45 Three-month supply: $135 Tier 4 (Non-Preferred Brand): One-month supply: $95 Prescription Drug Benefits For Part B drugs such as chemotherapy drugs 1 : 20% of the Other Part B drugs 1 : 20% of the You pay the following until your total yearly drug s reach $3,310. Total yearly drug s are the total drug s 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 1 (Preferred Generic): One-month supply: $0 Three-month supply: $0 Tier 2 (Generic): One-month supply: $10 Three-month supply: $30 Tier 3 (Preferred Brand): One-month supply: $45 Three-month supply: $135 Tier 4 (Non-Preferred Brand): One-month supply: $90 For Part B drugs such as chemotherapy drugs 1 : In-network: 20% of the Out-of-network: 20% of the Other Part B drugs 1 : In-network: 20% of the Out-of-network: 20% of the You pay the following until your total yearly drug s reach $3,310. Total yearly drug s are the total drug s 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 1 (Preferred Generic): One-month supply: $0 Three-month supply: $0 Tier 2 (Generic): One-month supply: $10 Three-month supply: $30 Tier 3 (Preferred Brand): One-month supply: $45 Three-month supply: $135 Tier 4 (Non-Preferred Brand): One-month supply: $90 Y0089_EL4831 Accepted Page 15 of 22

16 Three-month supply: $285 Tier 5 (Specialty Tier): One-month supply: 33% of the Three-month supply: Not offered Three-month supply: $270 Tier 5 (Specialty Tier): One-month supply: 33% of the Three-month supply: Not offered Three-month supply: $270 Tier 5 (Specialty Tier): One-month supply: 33% of the Three-month supply: Not offered Standard Mail Order Cost- Sharing: Tier 1 (Preferred Generic): Three-month supply: $0 Tier 2 (Generic): Three-month supply: $20 Tier 3 (Preferred Brand): Three-month supply: $ Tier 4 (Non-Preferred Brand): Three-month supply: $ Standard Mail Order Cost- Sharing: Tier 1 (Preferred Generic): Three-month supply: $0 Tier 2 (Generic): Three-month supply: $20 Tier 3 (Preferred Brand): Three-month supply: $ Tier 4 (Non-Preferred Brand): Three-month supply: $225 Standard Mail Order Cost- Sharing: Tier 1 (Preferred Generic): Three-month supply: $0 Tier 2 (Generic): Three-month supply: $20 Tier 3 (Preferred Brand): Three-month supply: $ Tier 4 (Non-Preferred Brand): Three-month supply: $225 If you reside in a long-term care facility, you pay the same as at a retail pharmacy. You may get drugs from an outof-network pharmacy at the same as an in-network pharmacy. If you reside in a long-term care facility, you pay the same as at a retail pharmacy. You may get drugs from an outof-network pharmacy at the same as an in-network pharmacy. If you reside in a long-term care facility, you pay the same as at a retail pharmacy. You may get drugs from an outof-network pharmacy at the same as an in-network pharmacy. 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 (including what our plan has paid and what 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 (including what our plan has paid and what 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 (including what our plan has paid and what Y0089_EL4831 Accepted Page 16 of 22

17 you have paid) reaches $3,310. After you enter the coverage gap, you pay 45% of the plan's for covered brand name drugs and 58% of the plan's for covered generic drugs until your s total $4,850, which is the end of the coverage gap. Not everyone will enter the coverage gap. you have paid) reaches $3,310. After you enter the coverage gap, you pay 45% of the plan's for covered brand name drugs and 58% of the plan's for covered generic drugs until your s 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 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 you. Standard Retail Cost- Sharing: Tier 1 (Preferred Generic): Drugs Covered: All One-month supply: $0 Three-month supply: $0 Standard Mail Order Cost- Sharing: Tier 1 (Preferred Generic): Drugs Covered: All Three-month supply: $0 you have paid) reaches $3,310. After you enter the coverage gap, you pay 45% of the plan's for covered brand name drugs and 58% of the plan's for covered generic drugs until your s 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 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 you. Standard Retail Cost- Sharing: Tier 1 (Preferred Generic): Y0089_EL4831 Accepted Page 17 of 22 Drugs Covered: All One-month supply: $0 Three-month supply: $0 Tier 2 (Generic): Drugs Covered: All One-month supply: $10 Three-month supply: $30 Standard Mail Order Cost- Sharing: Tier 1 (Preferred Generic): Drugs Covered: All Three-month supply: $0

18 Catastrophic Coverage After your yearly out-of-pocket drug s (including drugs purchased through your retail pharmacy and through mail order) reach $4,850, you pay the greater of: 5% of the, or $2.95 for generic (including brand drugs treated as generic) and a $7.40 ment for all other drugs. After your yearly out-of-pocket drug s (including drugs purchased through your retail pharmacy and through mail order) reach $4,850, you pay the greater of: 5% of the, or $2.95 for generic (including brand drugs treated as generic) and a $7.40 ment for all other drugs. Tier 2 (Generic): Drugs Covered: All Three-month supply: $20 After your yearly out-of-pocket drug s (including drugs purchased through your retail pharmacy and through mail order) reach $4,850, you pay the greater of: 5% of the, or $2.95 for generic (including brand drugs treated as generic) and a $7.40 ment for all other drugs. Y0089_EL4831 Accepted Page 18 of 22

19 Obtaining Covered Medical Care How do I get medical and behavioral health care? The way you obtain routine medical care will depend on the type of plan you have. General provisions HMO Plans: Generally speaking, HMO plans require you to see participating providers for covered services, except for urgent care, emergency care and dialysis outside the service area. All other out-of-network services must be authorized in advance by Health First Health Plans (HFHP) or they will not be covered. It is important to remember this provision, especially when you are outside our service area for any reason. If you are enrolled in an HMO plan, it is very important that you know whether or not your provider participates with HFHP so you don t incur charges for services that may not be covered. Be sure to check your Summary of Benefits, Evidence of Coverage, visit our website or contact us to determine if services are covered. HMO-POS Plans: You may see non-participating providers but your s may be higher than if you receive the services innetwork from participating providers. These types of plans offer more choices in the delivery of health care, but typically include higher premiums and out-of-pocket s. Be sure to check your Summary of Benefits, Evidence of Coverage, visit our website or contact us to determine if services are covered. Regardless of which general type of plan you have, benefits and -sharing requirements will vary depending on the plan you re enrolled in. Primary care To access primary care, simply contact your doctor to make an appointment. For after-hours care, you can also call your doctor s answering service 24 hours a day for instructions. You may be directed to an urgent care center or to make an appointment when your physician s office is open. You may also be directed to an emergency room, if you think you have a medical emergency. Emergency care If you have a medical emergency, have someone take you to the closest emergency room. If you cannot get to the emergency room safely and quickly, call 911. Be sure to show your HFHP member ID card. If you are admitted to the hospital or need help coordinating your care after you are stabilized, have someone contact HFHP and your local doctor for assistance. We cover emergency medical care anywhere in the world and will help arrange for your transfer home if necessary. Urgently-needed care If you need care after hours or urgently, but it is not an emergency, participating urgent care centers are open evenings and weekends. They are listed in your Provider Directory and on our website. Avoiding unnecessary trips to a hospital emergency room can save you time and money. You may also contact Nurse24 at if you have a question that you would like answered by a health care professional. This toll-free line is available 24 hours per day, 7 days per week. If you are outside the service area, you are covered for unforeseen illnesses or injuries that need to be treated before you return. Simply locate an urgent care clinic or other physician for the initial treatment and contact your local doctor to obtain any necessary follow-up services. If at all possible, try to locate a provider that is part of our contracted national provider network, as we have negotiated preferred pricing through this network for out-of-area care. You can locate one of these providers by contacting us for assistance. Hospital care If you need to be hospitalized and it s not an emergency, your doctor must get authorization from us first and coordinate your admission. Authorizations may be required for some outpatient services performed at a hospital, but if you see a Y0089_EL4831 Accepted Page 19 of 22

20 participating doctor, he or she will know if that s necessary and can take care of it for you. You never need authorization for emergency care at any hospital. If you are admitted to a non-participating hospital as part of your emergency care, please have someone contact us at so we can help coordinate your care as soon as possible. Mental (behavioral) health services Mental health services can be accessed directly without a physician referral as with other specialty care. If you are enrolled in an HMO plan, you can arrange for the appropriate services by calling Magellan Health Services directly at HFHP (4347); TTY/TDD users should call or visiting their website at A mental health professional will assist you with obtaining the help you need. HMO-POS members can access the provider of their choice and applicable -sharing amounts will apply. When do I need a referral or authorization? To make it easy for you to obtain medical care, HFHP does not require members to get a referral to see participating specialists for covered services. However, some specialists may require you to be referred by your primary doctor to ensure your care is coordinated properly. To locate a participating provider for specialty care, please see your Provider Directory or contact us for assistance. While most covered medical care can be obtained without our involvement, some services require prior authorization by our Medical Management staff to ensure the right care is provided in the right setting. Your physician will assist you by contacting us for services that require prior authorization. Also, remember that referrals and prior-authorized services are still subject to plan exclusions and limitations. Check our current Authorization List to see if approval is required in advance and to ensure you don t incur any unexpected expenses for services that may not be covered. You can get the Authorization List from our website or by calling us. Certain services require prior authorization to be covered and POS members obtaining care from non-participating providers are responsible to ensure authorization is obtained. A few examples that require prior authorization include MRI, PET, CT scans and nuclear cardiology studies, but other services require authorization and the list is subject to change. If you are using a provider who does not participate in the Health First Health Plans network, including our contracted national provider network, please be sure you discuss the authorization process with your provider, notify HFHP and make sure the service is approved before receiving it. You are responsible for notifying your non-participating physician that authorization is required for these procedures. If your physician has any questions or needs instructions on how to obtain prior authorization, he or she may contact our Customer Service department for additional information. What if I need a second opinion? For HMO and POS members, a second medical opinion related to the need for surgery or a major non-surgical diagnosis/therapeutic procedure with a HFHP participating provider does not require prior authorization. In network office share would apply. For HMO members, a second opinion with an out of network provider requires prior authorization. Please contact Health First Health Plans to submit a prior authorization request. For POS members, the out of network office share will apply if prior authorization is not obtained prior to seeing an out of network provider. All third opinions require prior authorization. Health First Health Plans has a limit of three opinions per medical condition per calendar year. Y0089_EL4831 Accepted Page 20 of 22

21 Decision making at HFHP HFHP assures providers, practitioners and members that all decisions involving HFHP coverage are based on the appropriateness of care and service. We do not compensate practitioners or any other individuals for making decisions that could result in denials of care. Denials are based on medical necessity or contract provisions. HFHP works to prevent inappropriate decision making by regularly monitoring all medical claims and request for care. We are committed to providing you access to quality care. Health management When it comes to your health, sometimes you need more information and a little support making a decision. Sometimes you just need someone to talk to one-on-one about how to live a healthier life in body and mind. Health First Health Plans is committed to providing members a complete managed care network which delivers the highest quality, most effective care possible. The Health Plan looks at the inpatient and ambulatory care (including: pre-service, concurrent, or post-service authorization) using utilization review criteria to make sure this is appropriate and timely. Health First Health Plans considers multiple factors when making coverage decisions, including member benefit contracts, laws and regulations, and the medical necessity of a requested item or service regarding the member s unique clinical situation. The Health Plan involves appropriate professionals in the development, adoption, and review of criteria and medical coverage policies. When available, Medical Policies will be used to make medical necessity decisions. If there is no Medical Policy, the following evidence-based resources will be applied by appropriate reviewers: Centers for Medicare & Medicaid Services (CMS), Milliman Care Guidelines, Hayes Technology Assessments, Peer-reviewed published medical literature, Clinical guidelines from nationally recognized authorities and FDA approval status (approval does not imply medical necessity). The Health Plan uses the approved new medical technologies or new uses of existing technologies after a complete review of the literature and recommendations from our specialists. Health First Health Plans measures and reviews professional and member satisfaction with Utilization Management services and takes action on identified opportunities for improvement. Health Coaches When it comes to your health, sometimes you need more information and a little support making a decision. Sometimes you just need someone to talk to one-on-one about how to live a healthier life in body and mind. HFHP offers access to a personal Health Coach, at no additional by phone, or chat 24 hours a day, 7 days a week. A Health Coach is a trained, healthcare professional (a nurse, dietician or respiratory therapist) who can provide you with oneon-one information on a variety of health issues, help you monitor your health needs and help you work more closely with your doctor. Health Coaches can also help you identify incremental goals to sustain long-term behavior changes in the following areas: Improve your diet You can: Feel and look better Manage stress Gain confidence Reach a healthy weight Have more energy Improve your fitness level Talk with a Health Coach anytime, day or night for information about enrolling or if you have any questions. Just call to speak with a knowledgeable and caring healthcare professional. Once you have signed up for the program, you will get a Health Coaching workbook which includes goal setting resources that promote healthy behavior changes. Receive personalized monthly check-in calls. Also, you can or call your coach any other time. Use online services featuring 24/7 access to health and decision support tools by logging into our website at Y0089_EL4831 Accepted Page 21 of 22

22 myhfhp.org/myportal. Other online health management services There are many other health management services you should take advantage of by logging into our website at myhfhp.org/myportal. This information is available 24/7 and is designed to empower you to be more accountable for your own health. Through our Healthy Living program (online module), you can get information about disease conditions and help meeting wellness goals you might have such as smoking cessation. Disease Management/Chronic Care Access your up-to-date health information by logging into our website at myhfhp.org/myportal. You can take the Health Assessment to learn about your own health risks and what you can do to lower them. You can also access in-depth information on more than 1,900 health topics including medical tests and medications. There are also many videos and DVDs available to you, at no charge, on conditions such as breast cancer, prostate cancer, back pain and osteoporosis. Need someone to talk to about a health issue? Call a healthcare professional at for caring support from someone who will take the time to listen to your concerns and answer your questions. They are ready to assist you with general health information, and support on managing a chronic illness such as: Diabetes Heart disease Congestive heart failure Asthma Coronary artery disease COPD Complex Case Management For our members coping with complex or serious medical conditions, a life-changing accident or experiencing frustration or roadblocks in trying to get the care you feel you need, HFHP offers a personal RN-Case Manager to work one-on-one with you, your family and/or caregivers to help navigate the sometimes confusing world of healthcare. These highly trained and professional nurses work closely with your medical team to make sure you understand your condition, the best treatment options available and how to connect with any support you may need during this challenging time in your life. We have highly skilled social workers available to assist with community resources or financial problem solving as well. Members undergoing transplants, cancer treatments or any other complex medical condition are appropriate for this service. Please contact Customer Service to access our Complex Case Management services. Additional Management Programs Physician Home Visiting Program You may be referred to a Physician Home Visiting Program if you are unable to get to the doctor s office due to illness. If you meet requirements for this program, you have access to a doctor or nurse practitioner 24 hours per day, 7 days per week. These health care professionals may come to your home and are able to provide medical care, many times preventing emergency room visits and admissions to the hospital. These professionals work closely with you and your family or caregivers, doctors and our Health Plans staff to help keep you in the best possible health and teach you how to cope with your illness. Transition of Care Program Some medical conditions are known to cause frequent trips to the hospital. Members who are hospitalized with one of these conditions may qualify for the Transition of Care Program. An RN from the Case Management team reaches out to these members within the first week after discharge from the hospital to assess and manage their immediate care needs, or to see if extra care from a doctor in the home might help them to understand their medicines, discharge instructions and illness. Some of the illnesses that would qualify someone for this program include, but are not limited to, congestive heart failure, heart disease and diabetes. Y0089_EL4831 Accepted Page 22 of 22

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