It s all about you enrollment booklet. AdvantageOptimum Plan (HMO) Central California. H5928_15_058_MK Accepted

Transcription

1 It s all about you 2015 enrollment booklet Central California H5928_15_058_MK Accepted

2 Health Plan 601 Potrero Grande Drive Monterey Park, CA Dear Prospective Member, We are honored that you are considering enrolling in one of Medicare Advantage Health Plans (HMO, HMO SNP). Trusting to provide your healthcare is something we take seriously. It s important you know that Health Plan was created by physicians with the belief that our members needs come first. Twenty years later, this philosophy still guides the way our physicians and clinical teams care for our members. Today, partners with more than 12,000 primary care physicians and 100 hospitals so our members have access to the level of medical treatment they deserve. We look forward to providing all of our members with quality health care. This can be seen in the way our medical management team focuses on issues that affect quality and delivery of care to our members. To yield more satisfactory outcomes, employs its own pharmacy team. This allows for better collaboration between your physician, our Utilization Management staff and our Member Services team to quickly resolve any pharmacy issues that might arise. In addition, you play an important role in your own health care. Each year, we encourage you to proactively visit your primary care physician and complete a health risk assessment, so you and your physician can discuss the best course of treatment for you. Not only do we strive to keep you healthy, but we also want to lower your healthcare expenses. The benefit information inside this book will help you decide how Health Plan can meet both your healthcare needs and save you money. Once you ve compared your current health coverage to, we will be happy to assist you with enrollment. We look forward to welcoming you to the family. Jorge Weingarten, M.D. Chief Medical Officer Health Plan is an HMO and an HMO SNP plan with a Medicare contract and a contract with the California State Medicaid Program. Enrollment in Health Plan depends on contract renewal. This information is available for free in other languag es. Please contact Member Services: (TTY : 711), 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30, except holidays. Esta información está disponible gratuitamente en otros idiomas. Comuníquese con Servicios para los Miembros: (TTY: 711), de 8 a.m. a 8 p.m., los siete días de la semana del 1 de octubre al 14 de febrero, excepto el Día de Acción de Gracias y Navidad, y de 8 a.m. a 8 p.m., de lunes a viernes, del 15 de febrero al 30 de septiembre, excepto los días festivos. 請聯絡會員服務熱線電話 : 聽障和語障人士可致電 711 從 10 月 1 日至 2 月 14 日, 上午 8 點至下午 8 點, 每週七天, 除感恩節和聖誕節外 從 2 月 15 日至 9 月 30 日, 上午 8 點至下午 8 點, 週一至週五, 假日除外 H5928_15_016_MK Accepted

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4 Scope of Sales Appointment Confirmation Form The Centers for Medicare and Medicaid Services requires agents to document the scope of a marketing appointment prior to any face-to-face sales meeting to ensure understanding of what will be discussed between the agent and the Medicare beneficiary (or their authorized representative). All information provided on this form is confidential and should be completed by each person with Medicare or his/her authorized representative. Please initial below beside the type of product(s) you want the agent to discuss. Stand-alone Medicare Prescription Drug Plans (Part D) Medicare Prescription Drug Plan (PDP) A stand-alone drug plan that adds prescription drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private-Fee-for-Service Plans, and Medicare Medical Savings Account Plans. Medicare Advantage Plans (Part C) and Cost Plans Medicare Health Maintenance Organization (HMO) A Medicare Advantage Plan that provides all Original Medicare Part A and Part B health coverage and sometimes covers Part D prescription drug coverage. In most HMOs, you can only get your care from doctors or hospitals in the plan s network (except in emergencies). Medicare Preferred Provider Organization (PPO) Plan A Medicare Advantage Plan that provides all Original Medicare Part A and Part B health coverage and sometimes covers Part D prescription drug coverage. PPOs have network doctors and hospitals but you can also use out-ofnetwork providers, usually at a higher cost. INSERTed Form ncr Medicare Private Fee-For-Service (PFFS) Plan A Medicare Advantage Plan in which you may go to any Medicare-approved doctor, hospital and provider that accepts the plan s payment, terms and conditions and agrees to treat you not all providers will. If you join a PFFS Plan that has a network, you can see any of the network providers who have agreed to always treat plan members. You will usually pay more to see out-of-network providers. Medicare Special Needs Plan (SNP) A Medicare Advantage Plan that has a benefit package designed for people with special health care needs. Examples of the specific groups served include people who have both Medicare and Medicaid, people who reside in nursing homes, and people who have certain chronic medical conditions. Medicare Medical Savings Account (MSA) Plan MSA Plans combine a high deductible health plan with a bank account. The plan deposits money from Medicare into the account. You can use it to pay your medical expenses until your deductible is met. Medicare Cost Plan In a Medicare Cost Plan, you can go to providers both in and out of network. If you get services outside of the plan s network, your Medicare-covered services will be paid for under Original Medicare but you will be responsible for Medicare coinsurance and deductibles. H5928_15_033_MK Accepted

5 By signing this form, you agree to a meeting with a sales agent to discuss the types of products you initialed above. Please note, the person who will discuss the products is either employed or contracted by a Medicare plan. They do not work directly for the Federal government. This individual may also be paid based on your enrollment in a plan. Signing this form does NOT obligate you to enroll in a plan, affect your current enrollment, or enroll you in a Medicare plan. Beneficiary or Authorized Representative Signature and Signature Date: Signature: Signature Date: If you are the authorized representative, please sign above and print below: Representative s Name: Your Relationship to the Beneficiary: Agent Name: Beneficiary Name: Beneficiary Address (Optional): Initial Method of Contact: (Indicate here if beneficiary was a walk-in.) Agent s Signature: Plan(s) the agent represented during this meeting: Date Appointment Completed: [Plan Use Only:] To be completed by Agent: Agent Phone: Beneficiary Phone (Optional): INSERTed Form ncr *Scope of Appointment documentation is subject to CMS record retention requirements * Agent, if the form was signed by the beneficiary at time of appointment, provide explanation why SOA was not documented prior to meeting: Health Plan is an HMO and an HMO SNP plan with a Medicare contract and a contract with the California State Medicaid Program. Enrollment in Health Plan depends on contract renewal.

6 Thank you for Your Interest in TABLE OF CONTENTS Welcome Letter Scope of Sales Appointment Confirmation Form Thank you for Your Interest in / Table of Contents 2015 Service Area Map Understanding Enrollment Periods - explanation of the different times of year when you can enroll or make changes to your plan Benefit Highlights Booklet - some of the benefits you will receive as a member. Delta Dental Flyer - important information about the dental program and provider. Nurse Advice Line Ready to Enroll - guidelines and instructions to help you through the enrollment process. Enrollment Form What to Expect After Enrollment - providing details about the enrollment process and timelines. Multi Language Information - if you require enrollment information in another language, please follow the instructions provided. Medicare Plan Ratings Summary of Benefits Transportation Information CenCal H5928_15_018_MK Accepted

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8 SERvice AREAS San AlamedaJoaquin Merced (Partial) (Partial) San Stanislaus Francisco Fresno Santa Clara (Partial) El Paso TEXAS CaliFORNia HMO & HMO SNP HMO Plan Only Call Member Services for questions about service areas: TTY/TDD users call a.m. to 8 p.m., seven days a week from October 1 through February 14, except Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30, except holidays. Los Angeles Orange (Partial) San Bernardino (Partial) Riverside (Partial) San Diego Health Plan is an HMO and an HMO SNP plan with a Medicare contract and a contract with the California State Medicaid Program. Enrollment in Health Plan depends on contract renewal. This information is available for free in other languages. Please contact Member Services: (TTY: 711), 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30, except holidays. Esta información está disponible gratuitamente en otros idiomas. Comuníquese con Servicios para los Miembros: (TTY: 711), de 8 a.m. a 8 p.m., los siete días de la semana del 1 de octubre al 14 de febrero, excepto el Día de Acción de Gracias y Navidad, y de 8 a.m. a 8 p.m., de lunes a viernes, del 15 de febrero al 30 de septiembre, excepto los días festivos. 請聯絡會員服務熱線電話 : 聽障和語障人士可致電 711 從 10 月 1 日至 2 月 14 日, 上午 8 點至下午 8 點, 每週七天, 除感恩節和聖誕節外 從 2 月 15 日至 9 月 30 日, 上午 8 點至下午 8 點, 週一至週五, 假日除外 H5928_15_019_MK Accepted

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10 ServiCE AREA ZIP CODES CALIFORNIA Alameda County 94501, 94502, 94601, 94602, 94603, 94604, 94605, 94606, 94607, 94608, 94609, 94610, 94611, 94612, 94613, 94614, 94617, 94618, 94619, 94620, 94621, 94623, 94624, 94661, 94662, 94701, 94702, 94703, 94704, 94705, 94706, 94707, 94708, 94709, 94710, 94712, Fresno County 93242, 93606, 93609, 93611, 93612, 93613, 93616, 93619, 93625, 93626, 93630, 93648, 93650, 93652, 93657, 93662, 93667, 93701, 93702, 93703, 93704, 93705, 93706, 93707, 93708, 93709, 93710, 93711, 93712, 93714, 93715, 93716, 93717, 93718, 93720, 93721, 93722, 93723, 93724, 93725, 93726, 93727, 93728, 93729, 93730, 93737, 93740, 93744, 93745, 93747, 93750, 93755, 93761, 93765, 93771, 93772, 93773, 93774, 93775, 93776, 93777, 93778, 93779, 93786, 93790, 93791, 93792, 93793, Los Angeles County All ZIP Codes Orange County 90620, 90621, 90622, 90623, 90624, 90630, 90631, 90632, 90633, 90638, 90680, 90720, 90740, 90742, 90743, 92609, 92610, 92617, 92619, 92620, 92626, 92637, 92646, 92647, 92648, 92649, 92655, 92657, 92673, 92683, 92685, 92694, 92697, 92698, 92701, 92702, 92703, 92704, 92705, 92706, 92707, 92708, 92725, 92735, 92801, 92802, 92803, 92804, 92805, 92806, 92807, 92808, 92809, 92812, 92814, 92815, 92816, 92817, 92821, 92822, 92823, 92825, 92831, 92832, 92833, 92834, 92835, 92836, 92837, 92838, 92840, 92841, 92842, 92843, 92844, 92845, 92846, 92850, 92868, 92870, 92871, 92885, 92886, 92887, Merced County 93610, 93620, 93661, 93665, 95301, 95303, 95312, 95315, 95317, 95322, 95324, 95333, 95334, 95340, 95341, 95343, 95344, 95348, 95365, 95369, 95374, 95380, Riverside 91718, 91719, 91720, 91752, 91760, 92028, 92201, 92202, 92203, 92210, 92211, 92220, 92223, 92230, 92234, 92235, 92236, 92240, 92241, 92247, 92248, 92253, 92254, 92255, 92258, 92260, 92261, 92262, 92263, 92264, 92270, 92274, 92276, 92282, 92292, 92320, 92324, 92373, 92399, 92501, 92502, 92503, 92504, 92505, 92506, 92507, 92508, 92509, 92513, 92514, 92515, 92516, 92517, 92518, 92519, 92521, 92522, 92530, 92531, 92532, 92536, 92539, 92543, 92544, 92545, 92546, 92548, 92549, 92551, 92552, 92553, 92554, 92555, 92556, 92557, 92561, 92562, 92563, 92564, 92567, 92570, 92571, 92572, 92581, 92582, 92583, 92584, 92585, 92586, 92587, 92589, 92590, 92591, 92592, 92593, 92595, 92596, 92599, 92860, 92877, 92878, 92879, 92880, 92881, 92882, San Bernardino: 91701, 91708, 91709, 91710, 91730, 91737, 91739, 91761, 91762, 91763, 91764, 91784, 91786, 92301, 92307, 92308, 92313, 92316, 92318, 92324, 92334, 92335, 92336, 92337, 92344, 92345, 92346, 92350, 92354, 92357, 92359, 92368, 92369, 92371, 92373, 92374, 92376, 92377, 92392, 92394, 92395, 92399, 92401, 92402, 92403, 92404, 92405, 92406, 92407, 92408, 92410, 92411, 92412, 92413, 92414, 92415, 92418, 92420, 92423, 92424, San Diego County All ZIP Codes San Francisco County All ZIP Codes San Joaquin County All ZIP Codes Santa Clara County All ZIP Codes Stanislaus County All ZIP Codes TEXAS El Paso County All ZIP Codes

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12 Understanding Medicare Enrollment Periods OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG SEP OCT Annual Election Period Oct 15 - Dec 7 Medicare Advantage Disenrollment Period Jan 1 - Feb 14 Lock-In Period Feb 14 - Oct 14 Special Election Period and Initial Coverage Election Period, for those that qualify, is open all year. Open Enrollment Period for Institutionalized Individuals is open all year. There are different types of enrollment periods throughout the year when individuals may enroll or make changes to their Medicare plan. ANNUal ELECTION Period (AEP) Available October 15th through December 7th During this time you may join, drop or switch to the Medicare Advantage plan that is best for you. Your change in enrollment will become effective January 1, Medicare ADVantage disenrollment Period (MADP) Available January 1st through February 14th During this period if you have a Medicare Advantage plan you can leave your plan and return to Original Medicare. If you make the choice to switch to Original Medicare, you have until February 14th to sign up for a prescription drug plan. During the Disenrollment Period you cannot switch from Original Medicare to a Medicare Advantage plan or switch from one Medicare Advantage plan to another. H5928_15_020_MK Accepted

13 Understanding Medicare Enrollment Periods LOCK IN Period February 14th through October 14th During this time you cannot make requests to change your Medicare plan unless you meet the requirements for the Special Election Period or Open Enrollment for Institutionalized Individuals. SPecial ELECTION Period (SEP) Available all year to qualifying individuals During this time you may join, drop or switch your Medicare Advantage plan if you move out of the plan s service area, lose your employer or union coverage, you enroll in a PACE program or have a chronic condition that allows you to enroll in a Special Needs Plan designed to specifically treat individuals with your condition. See the last page of the enrollment form for a list of common qualifying events. INITIAL COVerage ELECTION PERIOD (ICEP) Available all year to qualifying individuals This election period revolves around an individual s 65th birthday or the 25th month of disability. It is associated to one s entitlement to both Medicare Part A, B and D. This period begins three months before the individual s first entitlement to both Medicare Part A, B and D and ends on the later of: 1. The last day of the month preceding entitlement to both Part A, B and D, or; 2. The last day of the individual s Part B initial enrollment period. OPEN ENROLLMent Period For INSTITUTIONALIZED individuals (OEPI) Available all year to qualifying individuals If you are institutionalized and need to enroll in or disenroll from a Medicare Advantage Special Needs Plan for institutionalized individuals. Call Member Services for questions about eligibility: (TTY/TDD users call 711) 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30, except holidays. Health Plan is an HMO and an HMO SNP plan with a Medicare contract and a contract with the California State Medicaid Program. Enrollment in Health Plan depends on contract renewal. This information is available for free in other languages. Please contact Member Services: (TTY: 711), 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30, except holidays. Esta información está disponible gratuitamente en otros idiomas. Comuníquese con Servicios para los Miembros: (TTY: 711), de 8 a.m. a 8 p.m., los siete días de la semana del 1 de octubre al 14 de febrero, excepto el Día de Acción de Gracias y Navidad, y de 8 a.m. a 8 p.m., de lunes a viernes, del 15 de febrero al 30 de septiembre, excepto los días festivos. 請聯絡會員服務熱線電話 : 聽障和語障人士可致電 711 從 10 月 1 日至 2 月 14 日, 上午 8 點至下午 8 點, 每週七天, 除感恩節和聖誕節外 從 2 月 15 日至 9 月 30 日, 上午 8 點至下午 8 點, 週一至週五, 假日除外 H5928_15_020_MK Accepted

14 Its all about you 2015 benefit highlights H5928_15_052B_MK Accepted central california

15 (HMO) Must reside in Merced County Must have Medicare Part A and Part B * Health Plan s policy is NOT to disenroll you from the Plan or refer you to a collection agency for non-payment of your plan premium Benefit Highlights Page 2 (HMO) (HMO) (HMO) Service Area Must reside in San Joaquin County Must reside in Stanislaus County Must reside in Fresno County Other Eligibility Requirements Must have Medicare Part A and Part B Must have Medicare Part A and Part B Must have Medicare Part A and Part B Maximum Out of Pocket $3,400 $3,400 $3,400 $3,400 Part C Monthly Premium $29* $45* $0 $0 Part D Monthly Premium $0 $0 $0 $0

16 (HMO) Lab Work $0 $0 $0 $0 X-Rays $0 $0 $0 $ Benefit Highlights Page 3 (HMO) (HMO) (HMO) Primary Care Office Visit $0 $0 $0 $0 Specialist Office Visit $5 $0 $5 $5 Complex Diagnostics (MRI, CT-Scan) $0 $0 $0 $0

17 (HMO) 2015 Benefit Highlights Page 4 (HMO) (HMO) (HMO) Diabetes Supplies $0 $5 $0 $0 Standard Medicare Durable Medical Equipment 20% 20% $0 20% Rehabilitation Services $10 $10 $10 $10 Outpatient Mental Health Group Session $10 $10 $10 $10 Outpatient Mental Health Individual Session $10 $10 $10 $10

18 (HMO) $100 per day, days 1-8, $0 for days 9-90 $100 per day, days 1-5, $0 for days 6-90, ($0 unlimited additional days) $25 per day, days 1-20, $100 per day, days Benefit Highlights Page 5 (HMO) (HMO) (HMO) Inpatient Mental Health $100 per day, days 1-8, $0 for days 9-90 $150 per day, days 1-8, $0 for days 9-90 $50 per day, days 1-8, $0 for days 9-90 Outpatient Surgery at Ambulatory Surgical Center $50 $50 $50 $50 Hospital Outpatient $50 $50 $50 $50 Inpatient Hospitalization $100 per day, days 1-5, $0 for days 6-90, ($0 unlimited additional days) $150 per day, days 1-5, $0 for days 6-90, ($0 unlimited additional days) $50 per day, days 1-3, $0 for days 4-90, ($0 unlimited additional days) Skilled Nursing Facility $25 per day, days 1-20, $100 per day, days $0 per day, days 1-20, $50 per day, days $0 per day, days 1-20, $50 per day, days

19 (HMO) Home Health Care $0 $0 $0 $0 $0 24 one-way trips $65 (Waived if admitted) 2015 Benefit Highlights Page 6 (HMO) (HMO) (HMO) Transportation to Plan Approved Medical Providers $0 24 one-way trips $0 24 round trips $0 24 round trips Urgent Care Visit In Network $15 $15 $15 $15 Annual Maximum on Worldwide Emergency Coverage $25,000 per year $25,000 per year $25,000 per year $25,000 per year Emergency Room Visit $65 (Waived if admitted) $65 (Waived if admitted) $65 (Waived if admitted)

20 (HMO) $125 (Waived if admitted) $500 limit every year $0 (1 every year) 2015 Benefit Highlights Page 7 (HMO) (HMO) (HMO) Ambulance Services $140 (Waived if admitted) $190 (Waived if admitted) $125 (Waived if admitted) Routine Podiatry $5 $5 $5 $5 Routine Hearing Exam $10 $10 $10 $10 Hearing Aid Allowance $500 limit every year $500 limit every year $500 limit every year Routine Eye Exam $0 (1 every year) $0 (1 every year) $0 (1 every year)

21 (HMO) $150 every 2 years 20% coinsurance 2015 Benefit Highlights Page 8 (HMO) (HMO) (HMO) Annual Eyewear Allowance (Includes contacts) $150 every 2 years $150 every 2 years $150 every 2 years Drugs covered under Medicare Part B 20% coinsurance 20% coinsurance 20% coinsurance Initial Coverage Limit for Part D Drugs $2,960 $2,960 $2,960 $2,960 Tier 1 Preferred Generic Drugs 30 Day Supply Tier 2 Non Preferred Generic Drugs 30 Day Supply $0 $0 $0 $0 $5 $5 $5 $5

22 (HMO) 2015 Benefit Highlights Page 9 (HMO) (HMO) (HMO) Tier 3 Preferred Brand Drugs 30 Day Supply Tier 4 Non-Preferred Brand Drugs 30 Day Supply $30 $40 $40 $30 $50 $80 $80 $50 Tier 5 Specialty Drugs 30 Day Supply 33% coinsurance 33% coinsurance 33% coinsurance 33% coinsurance Coverage in the Gap Tier 1 Tier 2 Tier 1 Tier 2 Tier 1 Tier 2 Tier 1 Tier 2 Catastrophic Coverage After yearly out-of-pocket costs reach $4,700, you pay the greater of: 5% of the cost, or $2.65 for generic (including brand drugs treated as generic) and $6.60 for all other drugs.

23 (HMO) 2015 Benefit Highlights Page 10 (HMO) (HMO) (HMO) Nurse Advice Hotline $0 $0 $0 $0 Comprehensive Dental Coverage $0 Monthly Premium (Please see Dental Plan Fee Schedule Insert)

24 Health Plan is an HMO and an HMO SNP plan with a Medicare contract and a contract with the California State Medicaid Program. Enrollment in Health Plan depends on contract renewal. The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Benefits, formulary, pharmacy network, premium and/or co-payments/co-insurance may change on January 1 of each year. Limitations, ments, and restrictions may apply. You must continue to pay your Medicare Part B premium. Depending on your level of Medicaid eligibility, you may not have any cost-sharing responsibility for your part D premium. This information is available for free in other languages. Please contact Member Services: (TTY 711), 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30, except holidays. Servicios para los Miembros: (TTY 711) de 8 a.m. a 8 p.m., los siete días de la semana del 1 de octubre al 14 de febrero, excepto el Día de Acción de Gracias y Navidad, y de 8 a.m. a 8 p.m., de lunes a viernes, del 15 de febrero al 30 de septiembre, excepto los días festivos. 從 10 月 1 日至 2 月 14 日, 會員服務部代表將從上午 8 點至下午 8 點接聽您的來電, 每週七天, 除感恩節和聖誕節外 從 2 月 15 日至 9 月 30 日, 會員服務代表將從上午 8 點至下午 8 點接聽您的來電, 週一至週五, 假日除外 H5928_15_052B_MK Accepted

25 care1st Benefit highlights book 2015 Central California Health Plan 601 Potrero Grande Dr. #200, Monterey Park, CA For enrollment inquiries Please Call (TTY users should call 711) From October 1 through February 14, Member Services representatives will be available to answer your call from 8 a.m. to 8 p.m., seven days a week, except Thanksgiving and Christmas. From February 15 through September 30, Member Services representatives will be available to answer your call from 8 a.m. to 8 p.m., Monday through Friday, except holidays. Health Plan is an HMO and an HMO SNP plan with a Medicare contract and a contract with the California State Medicaid Program. Enrollment in Health Plan depends on contract renewal.

26 DeltaCare USA provided by Delta Dental of California We ll do do whatever it it takes and then some. Find a DeltaCare USA dentist Select from among the many conveniently located DeltaCare USA contracted general dentists. To find the most current listing of DeltaCare USA dental offices you can: Visit our website at deltadentalins.com/ enrollees Click on Find a Dentist on our home page Select DeltaCare USA as your plan network Or call Customer Service at (TTY/TDD users call 711 for help in finding a DeltaCare USA dentist Plan CAD56 - Los Angeles, Orange, San Diego, San Bernardino, Riverside, Fresno, Santa Clara, San Joaquin, Stanislaus, Alameda, San Francisco, Merced Counties. Welcome to DeltaCare USA quality, convenience, predictable costs DeltaCare USA (administered by Delta Dental Insurance Company) provides you with quality dental benefits at an affordable cost. DeltaCare USA is designed to encourage you to visit the dentist regularly to maintain your dental health. When you enroll, you select a contract dentist to provide services. The DeltaCare USA network consists of private practice dental facilities that have been carefully screened for quality and have agreed to participate in this program. With DeltaCare USA you ll enjoy these features: Quality Extensive benefits for you No restrictions on pre existing conditions covered, except for work in progress Large, stable network of dentists, so you can enjoy a long term relationship with your dentist TotalDual Plan (HMO SNP) - San Diego County Convenience No claim forms to complete Easy access to specialty care Expanded business hours for toll free customer service, from 5 a.m. to 6 p.m., Pacific time Predictable costs No deductibles Out of pocket costs are clearly defined Out of area dental emergency coverage up to $100 per emergency No annual or lifetime dollar maximums Administered by Delta Dental Insurance Company H5928_15_038_DENTAL Accepted 79204_HL_DCU_CAD56_6719-1_V15_

27 Highlights of your DeltaCare USA Program How your DeltaCare USA program works What if I have questions about my DeltaCare USA Program? Your selected contract dentist will take care of your dental care needs. If you require treatment from a specialist, your contract dentist will handle the referral for you. After you have enrolled, you will receive a Delta Dental membership packet that includes an identification card and a Benefit Booklet that fully describes the benefits of your dental program. Also included in this packet are the name, address and phone number of your contract dentist. Simply call the dental facility to make an appointment. Under the DeltaCare USA program, many services are covered at no cost, while others have ments (amount you pay your contract dentist) for certain benefits. See the Description of Benefits and Copayments for a list of your benefits. Please note: Dental services that are not performed by your selected contract dentist, or are not covered under provisions for emergency care below, must be preauthorized by Delta Dental to be covered by your DeltaCare USA program. Provisions for emergency care Under your DeltaCare USA program, you are covered for out-ofnetwork dental emergencies. Your program pays up to $100 for out-of-network emergency dental expenses per emergency. My dentist is a Delta Dental dentist but is not on the list of DeltaCare USA dentists. Can I still receive treatment from this dentist? You must receive treatment from your selected DeltaCare USA contract dentist. Please note that Delta Dental dentists are not necessarily DeltaCare USA dentists. With more than 3,800 general and specialist dentists, the DeltaCare USA network is one of the largest dental networks in California. Can I change my contract dentist? You may change contract dentists by notifying us either by phone or in writing, or by visiting our website (deltadentalins.com). If you contact us by the 21st of the month, the change will become effective the first of the following month

28 Highlights Plan CAM61of your DeltaCare USA Program Description of Benefits and Co-payments How long does it take to get an appointment with a DeltaCare USA dentist? Two to four weeks is a reasonable amount of time to wait for a routine, non-urgent appointment. If you require a specific time, you may have to wait longer. Most DeltaCare USA dentists are in private group practices, which means greater appointment availability and extended office hours. Are pre-existing dental conditions and work in progress covered? Treatment for pre-existing conditions, such as extracted teeth, is covered under the DeltaCare USA program. However, benefits are not provided for any dental treatment started before joining the program (that is, work in progress, such as preparations for crowns, root canals and impressions for dentures). How does the DeltaCare USA program encourage preventive care? Your DeltaCare USA program is designed to encourage regular visits to the dentist by having no ments (fees you pay to the contract dentist) on most diagnostic and preventive benefits. See the enclosed Description of Benefits and Copayments. Does my DeltaCare USA program cover specialists services? Your contract dentist will coordinate your specialty care needs for oral surgery, endodontics or periodontics with an approved contract specialist. If there is no contract specialist within your service area, a referral to an out-of-network specialist will be authorized at no extra cost, other than the applicable ment. If you are assigned to a dental school clinic for specialty services, those services may be provided by a dentist, a dental student, a clinician or a dental instructor. What if I have questions about my DeltaCare USA program? Call Delta Dental Customer Service at (TTY/TDD users call ). We have multilingual representatives available from 5 a.m. to 6 p.m. Pacific time, Monday through Friday. Our Customer Service representatives can answer benefits questions, as well as arrange facility transfers and urgent care referrals. Our Customer Service representatives have worked in dental facilities and can answer benefits questions, as well as arrange facility transfers and urgent care referrals

29 Plan CAD56 Description of Benefits and Co-payments SCHEDULE A Description of Benefits and Copayments The benefits shown below are performed as deemed appropriate by the attending Contract Dentist subject to the limitations and exclusions of the program. Please refer to the DeltaCare USA Limitations and Exclusions section for further clarification of benefits. Enrollees should discuss all treatment options with their Contract Dentist prior to services being rendered. Text that appears in italics below is specifically intended to clarify the delivery of benefits under the DeltaCare USA program and is not to be interpreted as CDT-2015 procedure codes, descriptors or nomenclature that are under copyright by the American Dental Association. The American Dental Association may periodically change CDT codes or definitions. Such updated codes, descriptors and nomenclature may be used to describe these covered procedures in compliance with federal legislation. CODE DESCRIPTION ENROLLEE PAYS D0100-D0999 I. DIAGNOSTIC D0120 Periodic oral evaluation - established patient...no Cost D0140 Limited oral evaluation - problem focused...no Cost D0150 Comprehensive oral evaluation - new or established patient...no Cost D0160 Detailed and extensive oral evaluation - problem focused, by report...no Cost D0170 Re-evaluation - limited, problem focused (established patient; not post-operative visit)...no Cost D0171 Re-evaluation - post-operative office visit... $8.00 D0180 Comprehensive periodontal evaluation - new or established patient...no Cost D0190 Screening of a patient...no Cost D0191 Assessment of a patient...no Cost D0210 Intraoral - complete series of radiographic images - limited to 1 series every 24 months...no Cost D0220 Intraoral - periapical first radiographic image...no Cost D0230 Intraoral - periapical each additional radiographic image...no Cost D0240 Intraoral - occlusal radiographic image...no Cost D0250 Extraoral - first radiographic image...no Cost D0260 Extraoral - each additional radiographic image...no Cost D0270 Bitewing - single radiographic image...no Cost D0272 Bitewings - two radiographic images...no Cost D0273 Bitewings three radiographic images...no Cost D0274 Bitewings - four radiographic images - limited to 1 series every 6 months...no Cost D0277 Vertical bitewings - 7 to 8 radiographic images... $5.00 D0330 Panoramic radiographic image...no Cost D0460 Pulp vitality tests...no Cost D0470 Diagnostic casts...no Cost D0999 Unspecified diagnostic procedure, by report - includes office visit, per visit (in addition to other services)...no Cost - 3 -

30 Plan CAD56 Description of Benefits and Co-payments D1000-D1999 II. PREVENTIVE D1110 Prophylaxis cleaning - adult - 1 per 6 month period...no Cost D1208 Topical application of fluoride - excluding varnish - 1 D1206 or D1208 per 6 month period... $5.00 D1510 Space maintainer - fixed - unilateral...no Cost D1515 Space maintainer - fixed - bilateral...no Cost D1520 Space maintainer - removable - unilateral...no Cost D1525 Space maintainer - removable - bilateral...no Cost D1550 Re-cement or re-bond space maintainer...no Cost D1555 Removal of fixed space maintainer...no Cost D2000-D2999 III. RESTORATIVE - Includes polishing, all adhesives and bonding agents, indirect pulp capping, bases, liners and acid etch procedures. - When there are more than six crowns in the same treatment plan, an Enrollee may be charged an additional $ per crown, beyond the 6th unit. - Replacement of crowns, inlays and onlays requires the existing restoration to be 5+ years old. * The provider may charge an additional fee up to $ for noble or high noble metal. D2140 Amalgam - one surface, primary or permanent... $24.00 D2150 Amalgam - two surfaces, primary or permanent... $26.00 D2160 Amalgam - three surfaces, primary or permanent... $28.00 D2161 Amalgam - four or more surfaces, primary or permanent... $30.00 D2330 Resin-based composite - one surface, anterior... $25.00 D2331 Resin-based composite - two surfaces, anterior... $31.00 D2332 Resin-based composite - three surfaces, anterior... $35.00 D2335 Resin-based composite - four or more surfaces or involving incisal angle (anterior)... $47.00 D2391 Resin-based composite - one surface, posterior... $75.00 D2392 Resin-based composite - two surfaces, posterior... $85.00 D2393 Resin-based composite - three surfaces, posterior... $95.00 D2394 Resin-based composite - four or more surfaces, posterior... $ D2510 Inlay - metallic - one surface*... $ D2520 Inlay - metallic - two surfaces*... $ D2530 Inlay - metallic - three or more surfaces*... $ D2542 Onlay - metallic - two surfaces*... $ D2543 Onlay - metallic - three surfaces*... $ D2544 Onlay - metallic - four or more surfaces*... $ D2610 Inlay - porcelain/ceramic - one surface... $ D2620 Inlay - porcelain/ceramic - two surfaces... $ D2630 Inlay - porcelain/ceramic - three or more surfaces... $ D2642 Onlay - porcelain/ceramic - two surfaces... $ D2643 Onlay - porcelain/ceramic - three surfaces... $ D2644 Onlay - porcelain/ceramic - four or more surfaces... $ D2650 Inlay - resin-based composite - one surface... $ D2651 Inlay - resin-based composite - two surfaces... $

31 Plan CAD56 Description of Benefits and Co-payments D2652 Inlay - resin-based composite - three or more surfaces... $ D2662 Onlay - resin-based composite - two surfaces... $ D2663 Onlay - resin-based composite - three surfaces... $ D2664 Onlay - resin-based composite - four or more surfaces... $ D2710 Crown - resin-based composite (indirect)... $ D2712 Crown - ¾ resin-based composite (indirect)... $ D2720 Crown - resin with high noble metal*... $ D2721 Crown - resin with predominantly base metal... $ D2722 Crown - resin with noble metal*... $ D2740 Crown - porcelain/ceramic substrate... $ D2750 Crown - porcelain fused to high noble metal*... $ D2751 Crown - porcelain fused to predominantly base metal... $ D2752 Crown - porcelain fused to noble metal*... $ D2780 Crown - ¾ cast high noble metal*... $ D2781 Crown - ¾ cast predominantly base metal... $ D2782 Crown - ¾ cast noble metal*... $ D2790 Crown - full cast high noble metal*... $ D2791 Crown - full cast predominantly base metal... $ D2792 Crown - full cast noble metal*... $ D2794 Crown - titanium*... $ D2910 Re-cement or re-bond inlay, onlay, veneer or partial coverage restorations... $20.00 D2915 Re-cement or re-bond indirectly fabricated or prefabricated post and core... $20.00 D2920 Re-cement or re-bond crown... $25.00 D2921 Reattachment of tooth fragment, incisal edge or cusp (anterior)... $47.00 D2931 Prefabricated stainless steel crown - permanent tooth... $75.00 D2940 Protective restoration... $16.00 D2941 Interim therapeutic restoration - primary dentition... $16.00 D2949 Restorative foundation for an indirect restoration... $50.00 D2950 Core buildup, including any pins when required... $50.00 D2951 Pin retention - per tooth, in addition to restoration... $40.00 D2952 Post and core in addition to crown, indirectly fabricated - includes canal preparation... $85.00 D2953 Each additional indirectly fabricated post - same tooth - includes canal preparation... $85.00 D2954 Prefabricated post and core in addition to crown - base metal post; D2957 includes canal preparation... $75.00 Each additional prefabricated post - same tooth - base metal post; includes canal preparation... $75.00 D2970 Temporary crown (fractured tooth) - palliative treatment only... $35.00 D2980 Crown repair necessitated by restorative material failure... $45.00 D2981 Inlay repair necessitated by restorative material failure... $45.00 D2982 Onlay repair necessitated by restorative material failure... $45.00 D2983 Veneer repair necessitated by restorative material failure... $45.00 D3000-D3999 IV. ENDODONTICS D3110 Pulp cap - direct (excluding final restoration)... $15.00 D3120 Pulp cap - indirect (excluding final restoration)... $15.00 D3220 Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the - 5 -

32 Plan CAD56 Description of Benefits and Co-payments dentinocemental junction and application of medicament... $35.00 D3221 Pulpal debridement, primary and permanent teeth... $55.00 D3222 Partial pulpotomy for apexogenesis - permanent tooth with incomplete root development... $35.00 D3310 Root canal - endodontic therapy, anterior tooth (excluding final restoration)... $ D3320 Root canal - endodontic therapy, bicuspid tooth (excluding final restoration)... $ D3330 Root canal - endodontic therapy, molar (excluding final restoration)... $ D3346 Retreatment of previous root canal therapy - anterior... $ D3347 Retreatment of previous root canal therapy - bicuspid... $ D3348 Retreatment of previous root canal therapy - molar... $ D3351 Apexification/recalcification - initial visit (apical closure/calcific repair of perforations, root resorption, etc.)... $90.00 D3352 Apexification/recalcification - interim medication replacement (apical closure/calcific repair of perforations, root resorption, pulp space disinfection, etc.)... $75.00 D3353 Apexification/recalcification - final visit (includes completed root canal therapy - apical closure/calcific repair of perforations, root resorption, etc.)... $ D3410 Apicoectomy - anterior... $ D3421 Apicoectomy - bicuspid (first root)... $ D3425 Apicoectomy - molar (first root)... $ D3426 Apicoectomy (each additional root)... $ D3427 Periradicular surgery without apicoectomy... $ D3430 Retrograde filling - per root... $50.00 D3450 Root amputation - per root... $85.00 D4000-D4999 V. PERIODONTICS - Includes preoperative and postoperative evaluations and treatment under a local anesthetic. D4210 Gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant... $ D4211 Gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant... $60.00 D4212 Gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth... $60.00 D4240 Gingival flap procedure, including root planing - four or more contiguous teeth or tooth bounded spaces per quadrant... $ D4241 Gingival flap procedure, including root planing - one to three contiguous teeth or tooth bounded spaces per quadrant... $ D4260 Osseous surgery (including elevation of a full thickness flap and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant... $ D4261 Osseous surgery (including elevation of a full thickness flap and closure) - one to three contiguous teeth or tooth bounded spaces per quadrant... $ D4341 Periodontal scaling and root planing - four or more teeth per quadrant - limited to 4 quadrants during any 12 consecutive months... $85.00 D4342 Periodontal scaling and root planing - one to three teeth per quadrant - limited to 4 quadrants during any 12 consecutive months... $85.00 D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis - limited to 1 treatment in any 12 consecutive months... $

33 Plan CAD56 Description of Benefits and Co-payments D4910 Periodontal maintenance - limited to 1 treatment each 6 month period... $65.00 D4921 Gingival irrigation - per quadrant...no Cost D5000-D5899 VI. PROSTHODONTICS (removable) - For all listed dentures and partial dentures, Copayment includes after delivery adjustments and tissue conditioning, if needed, for the first six months after placement. The Enrollee must continue to be eligible, and the service must be provided at the Contract Dentist s facility where the denture was originally delivered. - Rebases, relines and tissue conditioning are limited to 1 per denture during any 12 consecutive months. - Replacement of a denture or a partial denture requires the existing denture to be 5+ years old. D5110 Complete denture - maxillary... $ D5120 Complete denture - mandibular... $ D5130 Immediate denture - maxillary... $ D5140 Immediate denture - mandibular... $ D5211 Maxillary partial denture - resin base (including any conventional clasps, rests and teeth)... $ D5212 Mandibular partial denture - resin base (including any conventional clasps, rests and teeth)... $ D5213 Maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth)... $ D5214 Mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth)... $ D5225 Maxillary partial denture - flexible base (including any clasps, rests and teeth)... $ D5226 Mandibular partial denture - flexible base (including any clasps, rests and teeth)... $ D5410 Adjust complete denture - maxillary... $15.00 D5411 Adjust complete denture - mandibular... $15.00 D5421 Adjust partial denture - maxillary... $15.00 D5422 Adjust partial denture - mandibular... $15.00 D5510 Repair broken complete denture base... $35.00 D5520 Replace missing or broken teeth - complete denture (each tooth)... $35.00 D5610 Repair resin denture base... $35.00 D5620 Repair cast framework... $35.00 D5630 Repair or replace broken clasp... $35.00 D5640 Replace broken teeth - per tooth... $35.00 D5650 Add tooth to existing partial denture... $20.00 D5660 Add clasp to existing partial denture... $20.00 D5710 Rebase complete maxillary denture... $ D5711 Rebase complete mandibular denture... $ D5720 Rebase maxillary partial denture... $ D5721 Rebase mandibular partial denture... $ D5730 Reline complete maxillary denture (chairside)... $85.00 D5731 Reline complete mandibular denture (chairside)... $85.00 D5740 Reline maxillary partial denture (chairside)... $85.00 D5741 Reline mandibular partial denture (chairside)... $85.00 D5750 Reline complete maxillary denture (laboratory)... $

34 Plan CAD56 Description of Benefits and Co-payments D5751 Reline complete mandibular denture (laboratory)... $ D5760 Reline maxillary partial denture (laboratory)... $ D5761 Reline mandibular partial denture (laboratory)... $ D5820 Interim partial denture (maxillary) - limited to 1 in any 12 consecutive months... $ D5821 Interim partial denture (mandibular) - limited to 1 in any 12 consecutive months... $ D5850 Tissue conditioning, maxillary... $35.00 D5851 Tissue conditioning, mandibular... $35.00 D5900-D5999 D6000-D6199 VII. MAXILLOFACIAL PROSTHETICS - Not Covered VIII. IMPLANT SERVICES - Not Covered D6200-D6999 IX. PROSTHODONTICS, fixed (each retainer and each pontic constitutes a unit in a fixed partial denture [bridge]) - When a crown and/or pontic exceeds six units in the same treatment plan, an Enrollee may be charged an additional $ per unit, beyond the 6th unit. - Replacement of a crown, pontic, inlay, onlay or stress breaker requires the existing bridge to be 5+ years old. D6210 Pontic - cast high noble metal... $ D6211 Pontic - cast predominantly base metal... $ D6212 Pontic - cast noble metal... $ D6214 Pontic - titanium... $ D6240 Pontic - porcelain fused to high noble metal... $ D6241 Pontic - porcelain fused to predominantly base metal... $ D6242 Pontic - porcelain fused to noble metal... $ D6245 Pontic - porcelain/ceramic... $ D6250 Pontic - resin with high noble metal... $ D6251 Pontic - resin with predominantly base metal... $ D6252 Pontic - resin with noble metal... $ D6600 Inlay - porcelain/ceramic, two surfaces... $ D6601 Inlay - porcelain/ceramic, three or more surfaces... $ D6602 Inlay - cast high noble metal, two surfaces... $ D6603 Inlay - cast high noble metal, three or more surfaces... $ D6604 Inlay - cast predominantly base metal, two surfaces... $ D6605 Inlay - cast predominantly base metal, three or more surfaces... $ D6606 Inlay - cast noble metal, two surfaces... $ D6607 Inlay - cast noble metal, three or more surfaces... $ D6608 Onlay - porcelain/ceramic, two surfaces... $ D6609 Onlay - porcelain/ceramic, three or more surfaces... $ D6610 Onlay - cast high noble metal, two surfaces... $ D6611 Onlay - cast high noble metal, three or more surfaces... $ D6612 Onlay - cast predominantly base metal, two surfaces... $ D6613 Onlay - cast predominantly base metal, three or more surfaces... $ D6614 Onlay - cast noble metal, two surfaces... $ D6615 Onlay - cast noble metal, three or more surfaces... $ D6720 Crown - resin with high noble metal... $

35 Plan CAD56 Description of Benefits and Co-payments D6721 Crown - resin with predominantly base metal... $ D6722 Crown - resin with noble metal... $ D6740 Crown - porcelain/ceramic... $ D6750 Crown - porcelain fused to high noble metal... $ D6751 Crown - porcelain fused to predominantly base metal... $ D6752 Crown - porcelain fused to noble metal... $ D6780 Crown - ¾ cast high noble metal... $ D6781 Crown - ¾ cast predominantly base metal... $ D6782 Crown - ¾ cast noble metal... $ D6790 Crown - full cast high noble metal... $ D6791 Crown - full cast predominantly base metal... $ D6792 Crown - full cast noble metal... $ D6794 Crown - titanium... $ D6930 Re-cement or re-bond fixed partial denture... $45.00 D6940 Stress breaker... $ D6980 Fixed partial denture repair necessitated by restorative material failure... $85.00 D7000-D7999 X. ORAL AND MAXILLOFACIAL SURGERY - Includes preoperative and postoperative evaluations and treatment under a local anesthetic. D7111 Extraction, coronal remnants - deciduous tooth... $20.00 D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal)... $20.00 D7210 Surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated... $75.00 D7220 Removal of impacted tooth - soft tissue... $75.00 D7230 Removal of impacted tooth - partially bony... $ D7240 Removal of impacted tooth - completely bony... $ D7241 Removal of impacted tooth - completely bony, with unusual surgical complications... $ D7250 Surgical removal of residual tooth roots (cutting procedure)... $65.00 D7286 Incisional biopsy of oral tissue - soft - does not include pathology laboratory procedures... $45.00 D7310 Alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant... $ D7311 Alveoloplasty in conjunction with extractions - one to three teeth or tooth spaces, per quadrant... $ D7320 Alveoloplasty not in conjunction with extractions - four or more teeth or tooth spaces, per quadrant... $ D7321 Alveoloplasty not in conjunction with extractions - one to three teeth or tooth spaces, per quadrant... $ D7471 Removal of lateral exostosis (maxilla or mandible)... $ D7510 Incision and drainage of abscess - intraoral soft tissue... $45.00 D7960 Frenulectomy - also known as frenectomy or frenotomy - separate procedure not incidental to another procedure...no Cost D7970 Excision of hyperplastic tissue - per arch... $ D7971 Excision of pericoronal gingiva... $

36 Plan CAD56 Description of Benefits and Co-payments D8000-D8999 XI. ORTHODONTICS - The listed Copayment for each phase of orthodontic treatment (limited, interceptive or comprehensive) covers up to 24 months of active treatment. Beyond 24 months, an additional monthly fee, not to exceed $125.00, may apply. - The retention ment includes adjustments and/or office visits up to 24 months. The benefit for pre-treatment records and diagnostic services includes: D8040 Limited orthodontic treatment of the adult dentition - adults, including covered dependent adult children... $1, D8090 Comprehensive orthodontic treatment of the adult dentition - adults, including covered dependent adult children... $1, D8660 Pre-orthodontic treatment examination to monitor growth and development... $25.00 D8670 Periodic orthodontic treatment visit...no Cost D8680 Orthodontic retention (removal of appliances, construction and placement of removable retainers)...no Cost D8999 Unspecified orthodontic procedure, by report - includes treatment planning session... $ D9000-D9999 XII. ADJUNCTIVE GENERAL SERVICES D9110 Palliative (emergency) treatment of dental pain - minor procedure... $35.00 D9211 Regional block anesthesia...no Cost D9212 Trigeminal division block anesthesia...no Cost D9215 Local anesthesia in conjunction with operative or surgical procedures...no Cost D9219 Evaluation for deep sedation or general anesthesia...no Cost D9310 Consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician... $65.00 D9430 Office visit for observation (during regularly scheduled hours) - no other services performed... $8.00 D9440 Office visit - after regularly scheduled hours... $50.00 D9450 Case presentation, detailed and extensive treatment planning...no Cost D9931 Cleaning and inspection of a removable appliance...no Cost D9951 Occlusal adjustment, limited... $55.00 D9952 Occlusal adjustment, complete... $ D9986 Missed appointment - without 24 hour notice - per 15 minutes of appointment time... $15.00 D9987 Canceled appointment - without 24 hour notice - per 15 minutes of appointment time... $15.00 If services for a listed procedure are performed by the assigned Contract Dentist, the Enrollee pays the specified Copayment. Listed procedures which require a Dentist to provide Specialist Services, and are referred by the assigned Contract Dentist, must be authorized by the Plan. The Enrollee pays the Copayment specified for such services. Procedures not listed above are not covered, however, may be available at the Contract Dentist s filed fees. Filed fees means the Contract Dentist s fees on file with Delta Dental. Questions regarding these fees should be directed to Delta Dental s Customer Service department at (TTY/TDD users call 711)

37 Plan CAD56 Limitations and Exclusions of Benefits SCHEDULE B Limitations of Benefits 1. The frequency of certain Benefits is limited. All frequency limitations are listed in Schedule A, Description of Benefits and Copayments. 2. If the Enrollee accepts a treatment plan from the Contract Dentist that includes any combination of more than six crowns, bridge pontics and/or bridge retainers, the Enrollee may be charged an additional $ above the listed Copayment for each of these services after the sixth unit has been provided. 3. The cost to an Enrollee receiving orthodontic treatment whose coverage is cancelled or terminated for any reason will be based on the Contract Orthodontist s usual fee for the treatment plan. The Contract Orthodontist will prorate the amount for the number of months remaining to complete treatment. The Enrollee makes payment directly to the Contract Orthodontist as arranged. Exclusions of Benefits 1. Any procedure that is not specifically listed under Schedule A, Description of Benefits and Copayments. 2. Any procedure that in the professional opinion of the Contract Dentist: a. has poor prognosis for a successful result and reasonable longevity based on the condition of the tooth or teeth and/or surrounding structures, or b. is inconsistent with generally accepted standards for dentistry. 3. Services solely for cosmetic purposes or for conditions that are a result of hereditary or developmental defects, such as cleft palate, upper and lower jaw malformations, congenitally missing teeth and teeth that are discolored or lacking enamel. 4. Lost or stolen appliances including, but not limited to, full or partial dentures, crowns and fixed partial dentures (bridges). 5. Procedures, appliances or restoration if the purpose is to change vertical dimension, or to diagnose or treat abnormal conditions of the temporomandibular joint (TMJ). 6. Precious metal for removable appliances, metallic or permanent soft bases for complete dentures, porcelain denture teeth, precision abutments for removable partials or fixed partial dentures (overlays, implants, and appliances associated therewith) and personalization and characterization of complete and partial dentures. 7. Implant-supported dental appliances and attachments, implant placement, maintenance, removal and all other services associated with a dental implant. 8. Consultations for non-covered benefits

38 Plan CAD56 Limitations and Exclusions of Benefits 9. Dental services received from any dental facility other than the assigned Contract Dentist, a preauthorized dental specialist, or a Contract Orthodontist except for Emergency Services as described in the Contract and/or Benefit booklet. 10. All related fees for admission, use, or stays in a hospital, out-patient surgery center, extended care facility, or other similar care facility. 11. Prescription drugs. 12. Dental expenses incurred in connection with any dental or orthodontic procedure started before the Enrollee s eligibility with the DeltaCare USA program. Examples include: teeth prepared for crowns, root canals in progress, full or partial dentures for which an impression has been taken and orthodontics. 13. Changes in orthodontic treatment necessitated by accident of any kind. 14. Myofunctional and parafunctional appliances and/or therapies. 15. Composite or ceramic brackets, lingual adaptation of orthodontic bands and other specialized or cosmetic alternatives to standard fixed and removable orthodontic appliances. 16. Extraction of teeth, when teeth are asymptomatic/non-pathologic (no signs or symptoms of pathology or infection), including but not limited to the removal of third molars and orthodontic extractions. 17. Interim partial dentures (stayplates), in conjunction with fixed or removable appliances, are limited to the replacement of extracted anterior teeth for adults during a healing period when the teeth cannot be added to an existing partial denture. 18. Benefits for a soft tissue management program are limited to those parts, which are listed covered services listed on Schedule A. If an Enrollee declines non-covered services within a soft tissue management program, it does not eliminate or alter other covered benefits. 19. Treatment or appliances that are provided by a Dentist whose practice specializes in prosthodontic services

39 SmileWay Wellness program Find all of our dental health resources, including risk assessment quizzes, articles, videos and a free e-newsletter subscription, at: mysmileway.com. Connect with us! facebook.com/deltadentalins twitter.com/deltadentalins youtube.com/deltadentalins DeltaCare USA Customer Service (TTY/TDD users call 711). Health Plan is an HMO and an HMO SNP plan with a Medicare contract and a contract with the California State Medicaid Program. Enrollment in Health Plan depends on contract renewal. The benefit information provided is a brief summary, not a complete description of benefits. For more information, contact the plan. Benefits, provider network and/or co-payments may change on January 1 of each year. Limitations, ments, and restrictions may apply. Health Plan Member Services (TTY users should call 711) hours are from 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30, except holidays. This information is available for free in other languages. Please contact our Member Services number at for additional information. (TTY users should call 711). Esta información está disponible gratis en otros idiomas. Si desea información adicional, comuníquese con Servicios para Miembros al para obtener más información. (Los usuarios de TTY deben llamar al 711). 我們可免費以其它語言為您提供這資訊 若需要獲得更多資訊, 請聯絡我們的會員服務部 ( 聽障和語障人士可致電 711) TotalDual Plan HMO SNP This plan is available to anyone who has both Medical Assistance from the State and Medicare. NOTE: THIS IS ONLY A BRIEF SUMMARY OF THE PLAN. The Group Dental Service Contract must be consulted to determine the exact terms and conditions of coverage. A Delta Dental Evidence of Coverage will be sent to you upon enrollment. If you wish to review a Delta Dental Evidence of Coverage prior to enrollment, you may request a copy by calling the Customer Service department at (TTY/TDD users call 711). In California, DeltaCare USA is underwritten by Delta Dental of California and administered by Delta Dental Insurance Company. These companies are financially responsible for their own products. Customer Service (TTY/TDD users call 711) Monday through Friday 5 a.m. to 6 p.m., Pacific time Provided by: Delta Dental of California Park Plaza Drive, Suite 200 Cerritos, CA Administered by: Delta Dental Insurance Company P.O. Box 1803 Alpharetta, GA deltadentalins.com/enrollees A REGISTERED MARK OF DELTA DENTAL PLANS ASSOCIATION

40 Transportation Services 0 $ for each one-way to plan-approved locations.* is proud to offer transportation services to our members. Transportation is provided as needed for nonemergency healthcare visits. Note: Call to reserve your ride. *Reservations must be made at least 24 hours in advance. Call to reserve your ride: 1-87-RIDEC1ST ( ) TTY/TDD users call a.m. to 8 p.m., seven days a week from October 1 through February 14, except Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30, except holidays. Health Plan is an HMO and an HMO SNP plan with a Medicare contract and a contract with the California State Medicaid Program. Enrollment in Health Plan depends on contract renewal. The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Benefits and/or co-payments/co-insurance may change on January 1 of each year. Limitations, ments, and restrictions may apply. The number of approved round or one-way trips vary by plan and market. This information is available for free in other languages. Please contact Member Services: (TTY: 711), 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30, except holidays. Esta información está disponible gratuitamente en otros idiomas. Comuníquese con Servicios para los Miembros: (TTY: 711), de 8 a.m. a 8 p.m., los siete días de la semana del 1 de octubre al 14 de febrero, excepto el Día de Acción de Gracias y Navidad, y de 8 a.m. a 8 p.m., de lunes a viernes, del 15 de febrero al 30 de septiembre, excepto los días festivos. 請聯絡會員服務熱線電話 聽障和語障人士可致電 711 從10月1日至2月14日 上午8點至 下午8點 每週七天 除感恩節和聖誕節外 從2月15日至9月30日 上午8點至下午8點 週一至週五 假日除外 H5928_15_023_MK Accepted

41

42 Nurse Advice Hotline The Nurse Advice Line is a service available to all members. The call is free and easy. A caring nurse will listen to your health problem. The nurse can help you decide: If you need to see the doctor. If it is safe to wait or if you need care right away. What to do if your symptoms get worse. What you can start doing at home to feel better. For life-or-limb threatening emergencies, always call 911 or your local emergency services. You do not have to call the Nurse Advice Line before receiving healthcare. Call the Nurse Advice Line at: TTY/TDD users call a.m. to 8 p.m., seven days a week from October 1 through February 14, except Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30, except holidays. Health Plan is an HMO and an HMO SNP plan with a Medicare contract and a contract with the California State Medicaid Program. Enrollment in Health Plan depends on contract renewal. The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Benefits and/or co-payments/co-insurance may change on January 1 of each year. Limitations, ments, and restrictions may apply. This information is available for free in other languages. Please contact Member Services: (TTY: 711), 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30, except holidays. Esta información está disponible gratuitamente en otros idiomas. Comuníquese con Servicios para los Miembros: (TTY: 711), de 8 a.m. a 8 p.m., los siete días de la semana del 1 de octubre al 14 de febrero, excepto el Día de Acción de Gracias y Navidad, y de 8 a.m. a 8 p.m., de lunes a viernes, del 15 de febrero al 30 de septiembre, excepto los días festivos. 請聯絡會員服務熱線電話 : 聽障和語障人士可致電 711 從 10 月 1 日至 2 月 14 日, 上午 8 點至下午 8 點, 每週七天, 除感恩節和聖誕節外 從 2 月 15 日至 9 月 30 日, 上午 8 點至下午 8 點, 週一至週五, 假日除外 H5928_15_024_MK Accepted

43

44 Are You Ready To Enroll? Steps to get yourself ready to enroll How to apply Pick Your PCP Pick your Primary Care Physician (PCP). Use our Provider Directory, or visit us online at or call us for a list of PCPs near you. Review Rx Index Take a moment to review our drug index provided to ensure that your medications are covered. Or visit our website to review our drug formulary or call us for verification of our drug listing. Apply by Phone Call at (TTY/TDD users call 711) 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30, except holidays. Apply in Person Meet with your local authorized sales agent. Locate Medicare ID Card When you are applying, make sure to have your Medicare ID card available, or some form of proof that you are entitled to Medicare. If you have questions about becoming a member, call: (TTY/TDD users call 711) 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30, except holidays. Apply by Mail Fill out the enclosed application form completely and mail to: Health Plan ATTN: ENROLLMENT DEPT 601 Potrero Grande Drive Monterey Park, CA Apply Online Medicare beneficiaries may also enroll in through the CMS Medicare Online Enrollment Center located at Health Plan is an HMO and an HMO SNP plan with a Medicare contract and a contract with the California State Medicaid Program. Enrollment in Health Plan depends on contract renewal. This information is available for free in other languages. Please contact Member Services: (TTY: 711), 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30, except holidays. Esta información está disponible gratuitamente en otros idiomas. Comuníquese con Servicios para los Miembros: (TTY: 711), de 8 a.m. a 8 p.m., los siete días de la semana del 1 de octubre al 14 de febrero, excepto el Día de Acción de Gracias y Navidad, y de 8 a.m. a 8 p.m., de lunes a viernes, del 15 de febrero al 30 de septiembre, excepto los días festivos. 請聯絡會員服務熱線電話 : 聽障和語障人士可致電 711 從 10 月 1 日至 2 月 14 日, 上午 8 點至下午 8 點, 每週七天, 除感恩節和聖誕節外 從 2 月 15 日至 9 月 30 日, 上午 8 點至下午 8 點, 週一至週五, 假日除外 H5928_15_025_MK Accepted

45

46 MEDICARE ADVANTAGE INDIVIDUAL ENROLLMENT ELECTION FORM Step 1: Please fill out the application completely. Use a ballpoint pen and press hard to make two copies. Step 2: Sign and date the last page of the application. Step 3: Keep the bottom yellow copy for your file. If you have any questions regarding this application, please call: Marketing Department: (TTY 711) From October 1 through February 14, Marketing representatives will be available to answer your call from 8 a.m. to 8 p.m., seven days a week, except Thanksgiving and Christmas. From February 15 through September 30, Marketing representatives will be available to answer your call from 8 a.m. to 8 p.m., Monday through Friday, except holidays. INSERTed Form ncr Health Plan P. O. Box 4549 Montebello, CA Member Services: (TTY 711) From October 1 through February 14, Member Services representatives will be available to answer your call from 8 a.m. to 8 p.m., seven days a week, except Thanksgiving and Christmas. From February 15 through September 30, Member Services representatives will be available to answer your call from 8 a.m. to 8 p.m., Monday through Friday, except holidays. WHITE Enrollment Copy YELLOW Member s Copy H5928_15_004_EN Approved

47 2015 MEDICARE ADVANTAGE INDIVIDUAL ENROLLMENT ELECTION FORM Please contact if you need information in another language or format (Braille). To Enroll in, Please Provide the Following Information: Los Angeles/Orange $0/month San Joaquin $29/month Stanislaus $45/month San Bernardino/Riverside $0/month San Diego $0/month Santa Clara $19/month El Paso $0/month Alameda $0/month Fresno $0/month Merced $0/month San Francisco $29/month Coordinated Choice Los Angeles, Orange, San Diego, $28.80/month* San Bernardino, Riverside, Santa Clara, Alameda, Fresno LAST Name: FIRST Name: Middle Initial: Mr. Mrs. Ms. Birth Date: Sex: Home Phone: Alternate Phone Number: ( / / ) (MM/DD/YYYY) M F ( ) ( ) Permanent Residence Street Address (P.O. Box is not allowed): City: State: ZIP Code: County: Mailing Address (only if different from your Permanent Residence Address): Street Address: City: State: ZIP Code: Emergency contact: Phone Number: Relationship to You: Address: Please Provide Your Medicare Insurance Information. Please take out your Medicare card to complete this section. TotalDual Plan (HMO SNP) This plan is designed for people who meet specific enrollment criteria. You may be eligible to join this plan if you receive assistance from the State. San Diego $28.80/month* Los Angeles $27/month* Alameda/San Francisco/ $28.80/month* Santa Clara Orange/San Bernardino $27.50/month* *Premiums may vary based on the level of Extra Help you receive. Please contact the plan for further details. INSERTed Form ncr Please fill in these blanks so they match your red, white and blue Medicare card. - OR - Attach a copy of your Medicare card or your letter from Social Security or Railroad Retirement Board. SAMPLE ONLY Name: Medicare Claim Number Sex You must have Medicare Part A and Part B to join a Medicare Advantage plan. Is Entitled To HOSPITAL (Part A) MEDICAL (Part B) Effective Date WHITE Enrollment Copy YELLOW Member s Copy H5928_15_004_EN Approved

48 Paying Your Plan Premium You can pay your monthly plan premium (including any late enrollment penalty that you currently have or may owe) by mail each month. You can also choose to pay your premium by automatic deduction from your Social Security or Railroad Retirement Board (RRB) benefit check each month. If you are assessed a Part- D-Income related Monthly Adjustment Amount, you will be notified by the Social Security Administration. You will be responsible for paying this extra amount in addition to your plan premium. You will either have the amount withheld from your Social Security benefit check or be billed directly by Medicare or the RRB. DO NOT pay the Part D-IRMAA. People with limited incomes may qualify for extra help to pay for their prescription drug costs. If eligible, Medicare could pay for 75% or more of your drug costs including monthly prescription drug premiums, annual deductibles, and co-insurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don t even know it. For more information about this extra help, contact your local Social Security office, or call Social Security at TTY users should call You can also apply for extra help online at If you qualify for extra help with your Medicare prescription drug coverage costs, Medicare will pay all or part of your plan premium. If Medicare pays only a portion of this premium, we will bill you for the amount that Medicare doesn t cover. If you don t select a payment option, you will get a coupon book. Please select a premium payment option: Get a coupon book. Automatic deduction from your monthly Social Security or Railroad Retirement Board (RRB) benefit check. (The Social Security/RRB deduction may take two or more months to begin after Social Security or RRB approves the deduction. In most cases, if Social Security or RRB accepts your request for automatic deduction, the first deduction from your Social Security or RRB benefit check will include all premiums due from your enrollment effective date up to the point withholding begins. If Social Security or RRB does not approve your request for automatic deduction, we will send you a paper bill for your monthly premiums.) Please read and answer these important questions. 1. Do you have End-Stage Renal Disease (ESRD)? Yes No If you have had a successful kidney transplant and/or you don t need regular dialysis any more, please attach a note or records from your doctor showing you have had a successful kidney transplant or you don t need dialysis, otherwise we may need to contact you to obtain additional information. 2. Some individuals may have other medical or drug coverage, including work, other private insurance, TRICARE, Federal employee health benefits coverage, VA benefits, or State pharmaceutical assistance programs. Will you have other medical or prescription drug coverage in addition to? Yes No If yes, please list your other coverage and your identification (ID) number(s) for this coverage: Name of other medical coverage: ID# for this medical coverage: Group# for this medical coverage: Name of other drug coverage: ID# for this drug coverage: Group# for this drug coverage: INSERTed Form ncr 3. Are you a resident in a long-term care facility, such as a nursing home? Yes No If yes, please provide the following information: Name of Institution: Address and Phone Number of Institution (number and street): 4. Are you enrolled in your State Medicaid program? Yes No If yes, please provide your Medicaid number: 5. Do you or your spouse work? Yes No Please choose the name of a Primary Care Physician (PCP), clinic or health center: Physician s Name ID Number Medical Group / IPA Name Are you an existing patient of this doctor? Yes No WHITE Enrollment Copy YELLOW Member s Copy H5928_15_004_EN Approved

49 Please Read This Important Information If you currently have health coverage from an employer or union, joining could affect your employer or union health benefits. You could lose your employer or union health coverage if you join. Read the communications your employer or union sends you. If you have questions, visit their website, or contact the office listed in their communications. If there isn t any information on whom to contact, your benefits administrator or the office that answers questions about your coverage can help. Please Read and Sign Below By completing this enrollment application, I agree to the following: is a Medicare Advantage plan and has a contract with the Federal government. I will need to keep my Medicare Parts A and B. I can be in only one Medicare Advantage plan at a time, and I understand that my enrollment in this plan will automatically end my enrollment in another Medicare health plan or prescription drug plan. It is my responsibility to inform you of any prescription drug coverage that I have or may get in the future. Enrollment in this plan is generally for the entire year. Once I enroll, I may leave this plan or make changes only at certain times of the year when an enrollment period is available (Example: October 15 - December 7 of every year), or under certain special circumstances. serves a specific service area. If I move out of the area that serves, I need to notify the plan so I can disenroll and find a new plan in my new area. Once I am a member of, I have the right to appeal plan decisions about payment or services if I disagree. I will read the Evidence of Coverage document from when I get it to know which rules I must follow to get coverage with this Medicare Advantage plan. I understand that people with Medicare aren t usually covered under Medicare while out of the country except for limited coverage near the U.S. border. I understand that beginning on the date coverage begins, I must get all of my health care from, except for emergency or urgently needed services or out-of-area dialysis services. Services authorized by and other services contained in my Evidence of Coverage document (also known as a member contract or subscriber agreement) will be INSERTed Form ncr covered. Without authorization, NEITHER MEDICARE NOR WILL PAY FOR THE SERVICE. I understand that if I am getting assistance from a sales agent, broker, or other individual employed by or contracted with, he/she may be paid based on my enrollment in. Release of Information: By joining this Medicare health plan, I acknowledge that will release my information to Medicare and other plans as is necessary for treatment, payment and health care operations. I also acknowledge that will release my information including my prescription drug event data to Medicare, who may release it for research and other purposes which follow all applicable Federal statutes and regulations. The information on this enrollment form is correct to the best of my knowledge. I understand that if I intentionally provide false information on this form, I will be disenrolled from the plan. I understand that my signature (or the signature of the person authorized to act on my behalf under the laws of the State where I live) on this application means that I have read and understand the contents of this application. If signed by an authorized individual (as described above), this signature certifies that 1) this person is authorized under State law to complete this enrollment and 2) documentation of this authority is available upon request from Medicare. WHITE Enrollment Copy YELLOW Member s Copy H5928_15_004_EN Approved

50 Please check one of the boxes below if you would prefer us to send you information in a language other than English or in another format: Spanish Chinese Vietnamese Contact us if you need a format like Braille, audiotape or large print. Please contact at if you need information in another format or language than what is listed above. From October 1 through February 14, Member Services representatives will be available to answer your call from 8 a.m. to 8 p.m., seven days a week, except Thanksgiving and Christmas. From February 15 through September 30, Member Services representatives will be available to answer your call from 8 a.m. to 8 p.m., Monday through Friday, except holidays. TTY users should call 711. Attestation of Eligibility for an Enrollment Period Typically you may enroll in a Medicare Advantage plan only during the Annual Enrollment Period from October 15 through December 7 of each year. There are exceptions that may allow you to enroll in a Medicare Advantage plan outside of this period. Please read the following statements carefully and check the box if the statement applies to you. By checking any of the following boxes you are certifying that, to the best of your knowledge, you are eligible for an enrollment period. If we later determine that this information is incorrect, you may be disenrolled. I am a new Medicare beneficiary. I recently moved outside of the service are for my current plan or I recently moved and this plan is a new option for me. I moved on / /. I have both Medicare and Medi-Cal or my state helps pay for my Medicare premiums. I get Extra Help paying for Medicare prescription drug coverage. I no longer qualify for Extra Help paying for my Medicare prescription drugs. I stopped receiving Extra Help on / /. I am moving into, live in, or recently moved out of a long-term care facility (for example, a nursing home). I moved/will move into/out of the facility on / /. I recently left a PACE program on / /. I recently involuntarily lost my creditable prescription drug coverage (coverage as good as Medicare s). I lost my coverage on / /. I am leaving employer or union coverage on / /. I belong to a pharmacy assistance program provided by my state or I am long/recently lost participation in such a program on / /. My plan is ending its contract with Medicare, or Medicare is ending its contract with my plan. I was enrolled in a Special Needs Plan (SNP) but I have lost the special needs qualification required to be in that plan. I was disenrolled from the SNP on / /. If none of these statements applies to you or you re not sure, please contact Health Plan at , from 8:00 a.m. to 6:00 p.m., Monday through Friday. Between October 1 and February 14, representatives are available from 8:00 a.m. to 8:00 p.m., seven days a week. TTY users should call 711. Signature: Today s Date: INSERTed Form ncr If you are the authorized representative, you must sign above and provide the following information: Name: Address: Phone Number: ( ) Relationship to Enrollee: Broker / Sales Use Only Agent Name: Agent ID: Form Received On: Agent Phone/ Agent Signature: Date: Name of staff member/agent/broker (if assisted in enrollment): Effective Date of Coverage: ICEP/IEP AEP SEP (type): Not Eligible: Enrollment Office Use Only Confirmation ID: Enrollee ID: WHITE Enrollment Copy YELLOW Member s Copy H5928_15_004_EN Approved

51 What to Expect After Enrollment Enrollment Forms Received Your enrollment is sent to by phone, mail, fax, agent or via the Internet. Confirmation Within 10 days of enrollment, you will receive a confirmation of enrollment letter in the mail. This letter will also serve as confirmation that Medicare has approved your enrollment forms. 5 Welcome Package You will receive a package containing important plan documents. They include the Evidence of Coverage, Drug Formulary and Provider Directory. Premium Assistance If you qualify for the state s Extra Help, you will receive a LIS (Low Income Subsidy) letter within 10 days of verified enrollment. 3 Member ID Card Within 10 days of your confirmed enrollment you will receive your Member ID card. You need to bring your new Member ID card with you to all doctor, hospital and pharmacy visits. If you have questions about enrollment, call: (TTY/TDD users call 711) 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30, except holidays. Health Plan is an HMO and an HMO SNP plan with a Medicare contract and a contract with the California State Medicaid Program. Enrollment in Health Plan depends on contract renewal. This information is available for free in other languages. Please contact Member Services: (TTY: 711), 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30, except holidays. Esta información está disponible gratuitamente en otros idiomas. Comuníquese con Servicios para los Miembros: (TTY: 711), de 8 a.m. a 8 p.m., los siete días de la semana del 1 de octubre al 14 de febrero, excepto el Día de Acción de Gracias y Navidad, y de 8 a.m. a 8 p.m., de lunes a viernes, del 15 de febrero al 30 de septiembre, excepto los días festivos. 請聯絡會員服務熱線電話 : 聽障和語障人士可致電 711 從 10 月 1 日至 2 月 14 日, 上午 8 點至下午 8 點, 每週七天, 除感恩節和聖誕節外 從 2 月 15 日至 9 月 30 日, 上午 8 點至下午 8 點, 週一至週五, 假日除外 H5928_15_026B_MK Accepted

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53 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. H5928_15_002_MK Accepted

54 Multi-language Interpreter Services 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 إننا نقدم خدمات المترجم الفوري المجانية لإلجابة عن أي أسئلة تتعلق بالصحة أو جدول األدوية لدينا. للحصول على مترجم فوري ليس عليك سوى االتصال بنا على سيقوم شخص ما يتحدث العربية بمساعدتك. هذه خدمة مجانية Hindi हम र स 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 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, 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. 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 H5928_15_002_MK Accepted

55 Health Plan - H Medicare Star Ratings* The Medicare Program rates all health and prescription drug plans each year, based on a plan s quality and performance. Medicare Star Ratings help you know how good a job our plan is doing. You can use these Star Ratings to compare our plan s performance to other plans. The two main types of Star Ratings are: 1. An Overall Star Rating that combines all of our plan s scores. 2. Summary Star Rating that focuses on our medical or our prescription drug services. Some of the areas Medicare reviews for these ratings include: How our members rate our plan s services and care; How well our doctors detect illnesses and keep members healthy; How well our plan helps our members use recommended and safe prescription medications. For 2014, Health Plan received the following Overall Star Rating from Medicare. 3.5 Stars We received the following Summary Star Rating for Health Plan s health/drug plan services: Health Plan Services: Drug Plan Services: 3.5 Stars 3.5 Stars The number of stars shows how well our plan performs. excellent above average average below average poor Learn more about our plan and how we are different from other plans at You may also contact us Sunday, Monday, Tuesday, Wednesday, Thursday, Friday, Saturday, 7:00 a.m. - 8:00 p.m. Pacific at (toll-free) or 711 (TTY). Current members please call (toll-free) or 711 (TTY). *Star Ratings are based on 5 Stars. Star Ratings are assessed each year and may change from one year to the next. H5928_14_263_MK Accepted

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57 H5928_15_029_SB_CTCA_2 Accepted Summary of BenefItS January 1, December 31, 2015 health plan California: Fresno, Merced, Stanislaus and San Joaquin Counties