BENEFITS Summary of. Toll-Free , TTY a.m. 8 p.m. local time, 7 days a week.

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1 2017 Summary of BENEFITS UnitedHealthcare Dual Complete ONE (HMO SNP) H Our service area includes the following counties in: New Jersey: Atlantic, Bergen, Burlington, Camden, Essex, Gloucester, Hudson, Hunterdon, Mercer, Middlesex, Monmouth, Morris, Ocean, Passaic, Somerset, Union counties This is a summary of drug coverages and health services provided by UnitedHealthcare Dual Complete ONE (HMO SNP) January 1st, 2017 December 31st, 2017 For more information, please contact Customer Service at: Toll-Free , TTY a.m. 8 p.m. local time, 7 days a week Y0066_SB_H3113_005_2017 Accepted

2 Summary of Benefits January 1, 2017 December 31, 2017 We re dedicated to providing clear and simple information about your plan so you always stay fully informed. The following information is a breakdown of what we cover. Keep in mind that this isn t a full list of benefits we cover, it s just an overview. To get a complete list of benefits and services, visit our website at to see the Evidence of Coverage or call customer service with any questions or to order a copy of the Evidence of Coverage. About this plan. To join UnitedHealthcare Dual Complete ONE (HMO SNP), you must be entitled to Medicare Part A, be enrolled in Medicare Part B, entitled to full Medicaid, live in our service area as listed on the cover, and be a United States citizen or are lawfully present in the United States. UnitedHealthcare Dual Complete ONE (HMO SNP) is a Dual Eligible Special Needs Plan (D-SNP) for individuals who do not have any cost sharing responsibility. What s inside? Plan Premiums and Benefits See plan costs including the monthly plan premium, deductible and maximum out-of-pocket limit. UnitedHealthcare Dual Complete ONE (HMO SNP) has a network of doctors, hospitals, pharmacies, and other providers. If you use providers or pharmacies that are not in our network, the plan may not pay for these services or drugs. You can search for a network provider or pharmacy in the online directories at www. UHCCommunityPlan.com. Drug Coverage We provide coverage for many Part D drugs. In addition, we provide coverage for certain Part B drugs, such as chemotherapy and some drugs administered by your provider. Look to see what drugs are covered along with any restrictions in our plan formulary (list of Part D prescription drugs) found at

3 UnitedHealthcare Dual Complete ONE (HMO SNP) Premiums and Benefits Monthly Plan Premium Annual Medical Deductible There is no monthly premium for this plan. This plan does not have a deductible. Maximum Out-of-pocket Amount (does not include prescription drugs) As a UnitedHealthcare Dual Complete ONE (HMO SNP) member, you have no out-of-pocket expenses. You will not be responsible for any co-payments or co-insurance for drugs or other covered services provided by plan providers.

4 UnitedHealthcare Dual Complete ONE (HMO SNP) No prior authorizations or referrals are needed for covered services from plan providers. Benefits Inpatient Hospital Coverage Doctor Visits Primary Specialists Preventive Care Medicare-covered Routine physical ; 1 per year Emergency Care Urgently Needed Services for worldwide coverage per visit Diagnostic Tests, Lab and Radiology Services, and X-rays Diagnostic radiology services (e.g., MRI) Lab services Diagnostic tests and procedures Therapeutic Radiology Outpatient X-rays per service per service per service per service per service Hearing Services Routine hearing exams, exams to diagnose and treat hearing and balance issues, exams for the purpose of fitting hearing aids, follow-up exams and adjustments, and repairs after warranty expiration. Hearing aids, as well as associated accessories and supplies, are covered.

5 Benefits Dental Services Includes diagnostic, preventive, restorative, endodontic, periodontal, prosthetic, and oral and maxillofacial surgical services, including routine dental exams, cleanings, dental X-rays, fillings, dentures and fixed prosthodontics. Vision Services Covers medically necessary eye care services for detection and treatment of disease or injury to the eye, including a comprehensive eye exam once per year. Optometric services and optical appliances are covered, including 1 pair of lenses/frames or contact lenses every 24 months for those age 19 through 59, and once per year for those 18 years of age or younger and those 60 years of age or older. Artificial eyes, low vision devices, vision training devices, and intraocular lenses are also covered. Standard eyewear after cataract surgery is also covered.

6 Benefits Mental Health Care Inpatient Services Covers services in a general hospital, psychiatric unit of an acute care hospital, Short Term Care Facility, or critical access hospital. Inpatient psychiatric services in State, private, or county hospitals are covered for those under age 21, and those age 65 and older. Inpatient psychiatric services in a general hospital are covered for patients of any age. Inpatient mental health services are covered for all members by the plan for up to 190 days. Inpatient mental health services beyond 190 days are covered for members by Medicaid Fee-for-Service. Partial Hospitalization/Acute Partial Hospitalization is covered for all members by the plan. Inpatient Substance Abuse Treatment: Detoxification in a medical acute care inpatient setting is covered by the plan. Residential Substance Abuse Treatment: Treatment in a facility licensed to provide residential alcohol and substance abuse services is covered for members by Medicaid Fee-for-Service.

7 Benefits Mental Health Care (cont.) Outpatient Services Outpatient psychiatric services in general hospitals and private psychiatric hospitals are covered for members of all ages. The plan covers mental health services in hospital-based and community-based settings. The plan covers mental health screenings, referrals, prescription drugs, and treatment of conditions. The plan covers outpatient psychiatric services in private psychiatric hospitals for members of all ages. The plan covers outpatient psychiatric services in general hospitals for members of all ages. Skilled Nursing Facility (SNF) Care in a Skilled Nursing Facility is covered for all members, and that coverage includes long-term (custodial) care, beyond Medicare limits. Rehabilitation Services Ambulance Occupational therapy Physical therapy, speech and language therapy, and cognitive rehabilitation Routine Transportation Covered by Medicaid fee-for-service for routine/non-emergent ground transportation to medically necessary services.

8 Benefits Foot Care (podiatry services) Covers routine exams and medically necessary podiatric services, as well as therapeutic shoes or inserts for those with severe diabetic foot disease, and exams to fit those shoes or inserts. Routine hygienic foot care, such as the treatment of corns and calluses, trimming of nails, and care such as cleaning or soaking feet, is only covered when medically necessary as treatment for an associated condition. Medical Equipment/ Supplies Wellness Programs Medicare Part B Drugs Durable Medical Equipment (e.g., wheelchairs, oxygen) Prosthetics (e.g., braces, artificial limbs) Fitness program through SilverSneakers Chemotherapy drugs Other Part B drugs Basic membership in a Fitness Program at a network location Prescription Drugs Annual pharmacy deductible Since you have no deductible, this doesn t apply. 30-day supply from retail network pharmacy Generic (including brand drugs treated as generic) All other drugs

9 Additional Benefits Acupuncture Clinical Trials Covered for services rendered beyond Medicare Part B limits. Covered for Medicaid approved services. Diabetes Management Diabetes monitoring supplies Diabetes Selfmanagement training Therapeutic shoes or inserts We only cover blood glucose monitors and test strips from the following brands: OneTouch Ultra 2 System, OneTouch Ultra Mini, OneTouch Verio, OneTouch Verio Sync, OneTouch Verio IQ, OneTouch Verio Flex System Kit, ACCU-CHEK Nano SmartView, ACCU-CHEK Aviva Plus. Family Planning Services and Supplies Covered services include medical history and physical examination (including pelvis and breast), diagnostic and laboratory tests, drugs and biologicals, medical supplies and devices (including pregnancy test kits, condoms, diaphragms, Depo-Provera injections, and other contraceptive supplies and devices), counseling, continuing medical supervision, continuity of care and genetic counseling. Covered for services rendered beyond Medicare Part B limits. Services furnished by out-ofnetwork providers are covered by Medicaid Fee-for-Service.

10 Additional Benefits Home Health Care Covered for services rendered beyond Medicare Parts A and B limits. Includes nursing services and home health aide services. Physical therapy, speech-language pathology, and occupational therapy are also covered as part of this benefit. Hospice Covered in the community as well as in institutional settings. Room and board services are included only when services are delivered in institutional (non-private residence) setting. Hospice care for children under 21 years of age shall cover both palliative and curative care. Managed Long Term Services and Supports (MLTSS) Managed Long Term Services and Supports (MLTSS) is a program that provides Home and Community Based services for members that require the level of care typically provided in a Nursing Facility, and allows them to receive necessary care in a residential or community setting. MLTSS services include (but are not limited to): assisted living services; cognitive, speech, occupational, and physical therapy; chore services; home-delivered meals; residential modifications (such as the installation of ramps or grab bars); vehicle modifications; social adult day care; and non-medical transportation. MLTSS is available to members who meet certain clinical and financial requirements. For more information on MLTSS, call Customer Service (phone numbers are printed on the back cover of this booklet).

11 Additional Benefits Medical Day Care Provides preventive, diagnostic, therapeutic and rehabilitative services under medical and nursing supervision in an ambulatory care setting to meet the needs of individuals with physical and/or cognitive impairments in order to support their community living. NurseLine SM Nurse Midwife Services Outpatient Substance Abuse Outpatient group therapy visit Outpatient individual therapy visit Methadone cost, administration, and maintenance are covered by Medicaid Fee-for-Service; except for members with MLTSS, for whom it is covered by the plan. Outpatient Surgery Over-the-Counter Benefit Health Products Benefit Renal Dialysis Personal Care Assistant Covers health related tasks performed by a qualified individual in a beneficiary s home, under the supervision of a registered professional nurse, as certified by a physician in accordance with a beneficiary s written plan of care. Speak with a registered nurse (RN) 24 hours a day, 7 days a week $141 credit per quarter on a debit card for approved products at network retail locations $175 credit per quarter to use on approved health products that can be ordered online or by mail.

12 Additional Benefits Personal Emergency Response Private Duty Nursing When authorized, available for members up to 21 years of age. This benefit is also available to Managed Long Term Services and Supports (MLTSS) members of any age. for emergency response services through an electronic monitoring system 24 hours a day, seven days a week.

13 Eligibility Requirements Below are the categories of people who can enroll in UnitedHealthcare Dual Complete ONE (HMO SNP): Qualified Medicare Beneficiary Plus (QMB+): You get Medicaid coverage of Medicare costshare and are also eligible for full Medicaid benefits. Medicaid pays your Part A and Part B premiums, deductibles, co-insurance and co-payment amounts. Full Benefits Dual Eligible (FBDE): Medicaid provides assistance with Medicare cost-sharing. Medicaid also provides full Medicaid benefits. If you are a QMB+ or FBDE: You are eligible for Medicare benefits, as well as full Medicaid benefits. As a member of the plan, you will have no cost-shares for covered services or Part D prescription drugs. You will have no premiums, deductibles, coinsurance, or co-payments. You must recertify your Medicaid eligibility every year to remain a member of this plan. You must also live in our Service Area which is shown on the front cover of this Summary of Benefits.

14 This information is not a complete description of benefits. Contact the plan for more information. Limitations and restrictions may apply. Benefits may change on January 1 of each year. This information is available for free in other languages. Please call our customer service number at , TTY 711, 8 a.m. - 8 p.m. local time, 7 days a week. Esta información está disponible sin costo en otros idiomas. Comuníquese con nuestro Servicio al Cliente al número , TTY 711, de 8 a.m. 8 p.m. hora local, los 7 días de la semana. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. This plan is available to anyone who has both Medicare and full Medicaid eligibility. Premiums are covered for enrollees of UnitedHealthcare Dual Complete ONE (HMO SNP). Plans are insured through UnitedHealthcare or one of its affiliated companies, a Medicare Advantage organization with a Medicare contract and a contract with the State Medicaid Program. Enrollment in the plan depends on the plan s contract renewal with Medicare. If you want to know more about the coverage and costs of Original Medicare, look in your current Medicare & You handbook. View it online at or get a copy by calling MEDICARE ( ), 24 hours a day, 7 days a week. TTY users should call 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 (TTY 711) if you are not a member, or call us at (TTY 711) if you are already a member.

15 The company does not discriminate on the basis of race, color, national origin, sex, age, or disability in health programs and activities. We provide free services to help you communicate with us. Such as, letters in other languages or large print. Or, you can ask for an interpreter. To ask for help, please call the toll-free phone number listed on your ID card TTY 711, Monday through Friday, 8 a.m. to 8 p.m. ATENCIÓN: Si habla español (Spanish), hay servicios de asistencia de idiomas, sin cargo, a su disposición. Llame al número de teléfono gratuito que aparece en su tarjeta de identificación. 請注意 : 如果您說中文 (Chinese), 我們免費為您提供語言協助服務 請撥打會員卡所列的免付費會員電話號碼 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.

16 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. Arabic: Hindi: हम र स व स थ य य दव क य जन क ब र म आपक क स 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 उपलब 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 त ज ह न द ब लत ह आपक मदद कर सकत ह. यह एक म फ त स व ह. 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, contactenos 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. 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

17 Vendor Information Before contacting any of the providers below you must be fully enrolled in UnitedHealthcare Dual Complete ONE (HMO SNP). Benefit Type Vendor Name Contact Information Nurse Line NurseLine SM , TTY hours a day, 7 days a week Health Products Benefit Catalog Over-the-Counter Benefit Personal Emergency Response FirstLine Medical , TTY a.m. 7 p.m. Central Standard Time, Monday Friday; 7 a.m. 4 p.m. Central Standard Time, Saturday UnitedHealthcare , TTY a.m. 8 p.m. local time, 7 days a week Tunstall Americas , TTY a.m. 8 p.m. local time, 7 days a week Fitness Membership SilverSneakers Fitness program , TTY a.m. 8 p.m. Eastern Standard Time, Monday Friday silversneakers.com UHNJ17HM _003