Make your next chapter your best chapter. Anthem Blue Cross Life and Health Insurance Company Anthem Medicare Preferred (PPO) with Senior Rx Plus

Transcription

1 Make your next chapter your best chapter A complete benefits guide for your retirement Anthem Blue Cross Life and Health Insurance Company Anthem Medicare Preferred (PPO) with Senior Rx Plus 2018 Group Plan The Aerospace Corporation

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3 Here s what s inside Introduction... 2 First Impressions Welcome Team... 3 Medicare benefits explanation... 4 Benefit highlights... 5 Plan basics: medical coverage... 6 Choosing providers and using benefits... 7 Plan basics: drug benefits... 8 Special health programs, tools and resources SpecialOffers/How to save Benefit Charts Appendix Required Information for 2018 Y0114_18_31748_I_007 06/30/ MUSENMUB_007

4 Introduction Welcome! Good news! With your health and well-being in mind, The Aerospace Corporation has chosen to offer you this Anthem Medicare Preferred (PPO) with Senior Rx Plus plan from Anthem Blue Cross Life and Health Insurance Company. Look around and explore all we have to offer This guide will explain the benefits, services and resources we offer to help you find a doctor, pharmacy or other health services and enjoy your retirement to the fullest. Here are just some of the things we think you ll appreciate about this plan: $0 copay for an annual physical exam Freedom to see any doctor who accepts Medicare and our plan Prescription drug benefits with an extensive covered drug list $0 copay for Select Generics A comprehensive nationwide pharmacy network An award-winning mobile app to help manage your prescriptions and find a pharmacy on the go Cost transparency to help you become a better health care consumer A dedicated Member Services team focused on you and your needs Please understand that the information provided here is just a summary. It does not list every service we cover, nor every limitation or exclusion. For a complete list of services, look in the Evidence of Coverage (EOC) you ll receive after you enroll. Our First Impressions Welcome Team is also here to answer any questions before you enroll. Also, keep in mind that only eligible retirees can enroll in the Anthem Medicare Preferred (PPO) with Senior Rx Plus plan. If you need information about the premiums you ll pay, contact your Group Administrator. FYI You may have received this guide while you re still working and not yet ready to retire. We hope it helps you look forward to retirement. When you are ready to consider retiring, please ask us for an updated Enrollment Guide at least 90 days prior to your retirement date. 2

5 First Impressions Welcome Team Excellent service is our priority We aim to make a great First Impression (and a lasting one, too) At Anthem Blue Cross Life and Health Insurance Company, our goal is to provide you with great health benefits. We also strive to provide exceptional service. Our First Impressions Welcome Team members are on your side. They know the ins and outs of Medicare, are experts on your plan and can answer any questions you may have as you decide on the plan that s just right for you. Call and you ll talk to a live, friendly person (not a machine), located right here in the United States. Call our First Impressions Welcome Team at , TTY: 711, Monday through Friday, 8 a.m. to 9 p.m. ET, except holidays. Read, enroll and retire well When you are ready to enroll, complete and mail the application included in the back of this guide. Then get ready for a rewarding next chapter. Our goal is to give you exceptional service and to leave a lasting impression that doesn t end when you enroll. Your expert, dedicated Member Services team knows your plan and is eager to help and answer your questions. We don t read scripts We want to have a real conversation with you and we can t do that with a script. You ll talk with a live person not a machine. Plus, our team of experts knows Medicare and your plan inside and out. We re always prepared and ready to serve you! 3

6 Medicare benefits explanation What you should know about Medicare Medicare is a federal government health insurance program offered to: People 65 years of age or older. People under age 65 with certain disabilities. Anyone with end-stage renal disease (ESRD). Medicare benefits are divided into separate parts. Original Medicare provided through the government: PART A PART B Covers inpatient care in hospitals and skilled nursing facilities, hospice care and some home health care services. Helps cover costs for doctors services, hospital outpatient care, some home health care services and some physical and occupational therapy. Offered by private insurers like Anthem Blue Cross Life and Health Insurance Company: PART C PART D Offers benefits in addition to what you can get from Original Medicare. Medicare Parts A and B can be replaced with Part C, also called a Medicare Advantage plan. Your Anthem Blue Cross Life and Health Insurance Company plan is one of these. Outpatient prescription drug coverage. Your plan includes this coverage. Learn more about Medicare. Download Medicare & You at Or you can order a printed copy by calling MEDICARE ( ), 24 hours a day, 7 days a week. TTY users, call FYI To enroll in this plan you must already be signed up for Parts A and B. 4

7 Benefit highlights The big picture: Your medical and drug benefit highlights Your medical benefit highlights Our Anthem Medicare Preferred (PPO) with Senior Rx Plus plan offers a wealth of benefits designed to help you take advantage of many health resources while keeping expenses down, so you can enjoy a great retirement. See the full Benefit Charts for all the details. You ll enjoy: Your choice of doctors, specialists and hospitals in- or out-of-network without a referral $0 copay: An annual routine physical exam Flu and pneumonia vaccines Most health screenings Emergency and urgent care SilverSneakers fitness program Doctors anytime, anywhere with LiveHealth Online A 24/7 NurseLine And more! Your drug benefit highlights The medications you need at a price you can afford or at no cost at all. Our prescription drug plan includes coverage for the brand-name and generic drugs you use the most and offers extra-convenient ways to get them. You ll enjoy: Retail drug coverage from over 69,000 pharmacies nationwide. Select Generics coverage. Coverage of Generic and Brand drugs, including high-cost Specialty drugs, which goes beyond the minimum standard Medicare requires. Coverage for lifestyle drugs not normally covered by Medicare Part D, including medication for erectile dysfunction. Mail-order drug coverage usually at a lower cost. 5

8 Plan basics: medical coverage The basics and more: Your medical benefits explained Your Anthem Medicare Preferred (PPO) with Senior Rx Plus plan is a Preferred Provider Organization (PPO) plan. As a PPO plan member, you can go to any of our nationwide network of providers who accept Medicare, as long as the care you get is covered and medically needed. Unlike an HMO or other plans, PPO plans like this one let you pay the same copay or coinsurance percentage when seeing either in- or out-of-network providers. That means you can see doctors in your plan and doctors not in your plan. In-Network Out-of-Network Is my plan accepted by doctors and hospitals? Yes Yes, provided they accept Medicare and this plan Do I need to choose a Primary Care Provider (PCP)? No No Are referrals required for specialty care? No No Is emergency and urgent care covered? Yes Yes What am I charged for services? Standard copay or Standard copay or coinsurance only coinsurance only Do my medical services have an annual Yes Yes out-of-pocket limit? Anthem Blue Cross Life and Health Insurance Company can t pay a doctor or facility that does not accept, or has opted out of, Medicare. So if you receive care from one of these providers, you ll have to pay the full medical bill. Get a list of Medicare-contracted providers at There s more! Discover all of your medical benefits. Read the full Benefit Charts later in this guide. Did you know? This plan lets you see any doctor who accepts Medicare and our plan. You re covered in and out of network! 6

9 Choosing providers and using benefits How to best use your benefits One card is all you need Your Anthem Blue Cross Life and Health Insurance Company Medicare Advantage membership card is all you need to see a doctor, get prescription drugs at your pharmacy, be admitted to a hospital or enjoy all of the many covered benefits this plan offers. Tip: Although you don t need your red, white and blue Medicare card to take advantage of these benefits, you should still keep it in case you need it. Make sure doctors and facilities are part of your plan As a PPO plan member, you can go to any doctor or facility that accepts Medicare and our plan, in or out of Anthem Blue Cross Life and Health Insurance Company s network, as long as the care you get is covered and medically needed. You may choose to use a doctor or facility in your plan or not in your plan. The best way to make sure you re getting high-quality care without high out-of-pocket costs is to: Ask if your doctors and specialists accept Medicare. Confirm that the hospitals and urgent care facilities you choose are part of this Anthem Medicare Preferred (PPO) with Senior Rx Plus plan. We go where you go Since Anthem Blue Cross Life and Health Insurance Company is a member of the Blue Cross Blue Shield Association, you can get in-network medical care and prescription drugs from any Blue Medicare Advantage PPO provider while traveling or living anywhere in the U.S. and Puerto Rico. 7

10 Plan basics: drug benefits The basics and more: Your prescription drug benefits explained If you re taking prescription medications, you ll be happy to hear that your Anthem Medicare Preferred (PPO) with Senior Rx Plus plan includes coverage for many of the drugs used to address common health conditions, all at a low cost, and many Select Generics with a $0 copay. Plus, our pharmacy network includes most national chains and local pharmacies over 69,000 locations. There s sure to be one near you. $0 copay for Select Generics Over 69,000 pharmacies This plan gives you access to some of the most commonly prescribed and proven generic drugs treating things like diabetes, hypertension and high cholesterol with zero out-of-pocket expenses. Also, note those shown in bold, which we ve recently added. Get the drugs you need fast With our Anthem BC Anywhere app and the Express Scripts companion app, you can: Find a pharmacy near you. Quickly refill prescriptions with Express Scripts. Compare costs. Track your order and much more. Download it now! There s more! Discover more about your drug benefits. Read the full Benefit Charts later in this guide. 8

11 $0 copay Select Generics Name of drug Atenolol tablet Atenolol/chlorthalidone tablet Benazepril hcl tablet Benazepril hcl/hydrochlorothiazide tablet Bisoprolol/hydrochlorothiazide tablet Captopril tablet Captopril/hydrochlorothiazide tablet Chlorthalidone tablet Enalapril maleate tablet Enalapril/hydrochlorothiazide tablet Hydrochlorothiazide capsule/tablet Irbesartan tablet Irbesartan/hydrochlorothiazide tablet Lisinopril tablet Lisinopril/hydrochlorothiazide tablet Losartan potassium tablet Losartan potassium/hydrochlorothiazide tablet Metoprolol tartrate tablet Ramipril tablet Valsartan tablet Valsartan/hydrochlorothiazide tablet Lovastatin tablet Pravastatin sodium tablet Simvastatin tablet Glimepiride tablet Glipizide ER tablet Glipizide tablet Glipizide/metformin hcl tablet Metformin hcl ER tablet Metformin hcl tablet Alendronate sodium tablet Type of drug Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cardiovascular Cholesterol Cholesterol Cholesterol Diabetes Diabetes Diabetes Diabetes Diabetes Diabetes Osteoporosis We re here to help every step of the way. Call , TTY: 711, Monday through Friday, 8 a.m. to 9 p.m. ET, except holidays, or visit 9

12 Plan basics: drug benefits Do we cover the drugs you need? Chances are good. The list below shows just a few of the drugs you might be taking that are covered by this plan. 2 Top 50 commonly used drugs covered by this plan Atorvastatin Levothyroxine sodium tablet Amlodipine Lisinopril Simvastatin Metformin hydrochloride Metoprolol succinate Losartan potassium Omeprazole Hydrochlorothiazide Furosemide Tamsulosin hydrochloride Metoprolol tartrate Pravastatin sodium Gabapentin Pantoprazole Potassium chloride Atenolol Clopidogrel Carvedilol Warfarin sodium Rosuvastatin calcium Hydrocodone-acetaminophen* Allopurinol Valsartan Montelukast Escitalopram Sertraline Finasteride Latanoprost Fluticasone propionate HYZAAR Prednisone Diltiazem hydrochloride Lansoprazole Alprazolam Duloxetine Glipizide ZESTORETIC Donepezil hydrochloride Tramadol hydrochloride tablet Alendronic acid Trazodone hydrochloride Fenofibrate* Meloxicam LANTUS JANUVIA Glimepiride DIOVAN HCT Citalopram 10 Generic drugs are shown in lowercase italics (e.g., Lisinopril), and brand-name drugs are shown in capital letters (e.g., JANUVIA). * Not all dosages are covered at the generic cost share. There s more! Get the full Formulary (List of Covered Drugs) and Extra Covered Drug List. Contact the First Impressions Welcome Team at , TTY: 711, for more information.

13 Plan basics: drug benefits Ways you can save on prescription drugs With your Anthem Medicare Preferred (PPO) with Senior Rx Plus plan, you ll always get the lowest price available on prescription drugs, even if it s less than your copay. Here are some other smart ways to save money: Choose pharmacies in your plan To receive the most prescription drug plan benefits and savings, you should always try to use one of the pharmacies in your plan whenever you can. These include more than 69,000 locations covering most national chains and local pharmacies across the U.S. Use mail-order pharmacies Mail-order pharmacies can offer significant cost savings, plus save you time. For prescriptions that you take on an ongoing basis such as long-term or maintenance drugs you may choose the convenience of ordering through your plan s mail-order pharmacy. Easy ways to find a pharmacy in your plan Use our Anthem BC Anywhere mobile app Download it from Google Play or the Apple App Store. Request a pharmacy directory Call our First Impressions Welcome Team at , TTY: 711. Visit How do we keep drug costs low? With Anthem Blue Cross Life and Health Insurance Company s strength and reputation, we ve made it so your cost will always be the least of your copay, the retail price of the drug or our negotiated price with the pharmacy. 11

14 Plan basics: drug benefits Get Extra Help from Medicare You may be able to get assistance to pay for prescription drug premiums and costs, as well as other Medicare costs. If you qualify for Medicare s Extra Help and are enrolled in a Part D plan like this one, Medicare can pay up to 100% of your prescribed drug costs. These can help offset: Your drug plan s monthly payment. Your yearly deductible. Coinsurance and copays for covered prescription drugs. Extra Help can also eliminate any drug coverage gaps and late-enrollment penalties. If you re not eligible for Extra Help, you still may be able to enroll in a Medicare prescription drug plan. For information about enrollment periods, visit or or call: MEDICARE ( ) 24 hours a day, 7 days a week. TTY users should call The Social Security Administration at Monday to Friday, 7 a.m. to 7 p.m. TTY users: Your State Medicaid Office. Have questions about prescription drugs? We have answers. Q. How do drug tiers work? A. Drugs are divided into different cost levels or tiers, with higher tiers including higher costs. Your full Benefit Charts, included at the back of this guide, will tell you how many tiers are in your plan. Q. How do I estimate my prescription drug out-of-pocket costs? A. Costs depend on the tier number associated with the prescription drug you want. You can also use the mobile app to compare retail prescription drug costs between local pharmacies. Q. Can I have more than one Medicare prescription drug plan (PDP)? A. No. If you enroll in another Medicare prescription drug plan, or a Medicare Advantage plan that includes prescription drug coverage, we would be required by Medicare to disenroll you from this Anthem Blue Cross Life and Health Insurance Company plan. More questions? Call our First Impressions Welcome Team at , TTY: Need assistance paying for meds? Get Extra Help. On a limited income? Extra Help from Medicare could assist you with 75% or more of your drug costs. There s no penalty for applying, and you can re-apply every year. Call MEDICARE ( ) 24 hours a day, 7 days a week. TTY users:

15 Special health programs, tools and resources We support your health in so many ways Good health choices not only add to the quality of life for you and your family, they may also lower your health care costs. You ll be happy to know your Anthem Medicare Preferred (PPO) with Senior Rx Plus plan includes a lot of programs, tools and other resources to help make those decisions a whole lot easier. All at no cost to you. SilverSneakers * Get in shape or stay in shape with this popular program that includes: Access to more than 13,000 fitness locations nationwide, with all basic amenities and signature SilverSneakers classes. SilverSneakers FLEX classes at neighborhood locations offering activities like tai chi, yoga, dance and walking groups. Online tools for meal planning and healthy recipes, plus the SilverSneakers blog. Find a location near you. Visit SilverSneakers.com. Or call SilverSneakers at , TTY: 711, Monday to Friday, 8 a.m. to 8 p.m. ET. Annual health exams and preventive care Anthem Blue Cross Life and Health Insurance Company cares about your health and well-being. That s why your plan offers the following and more at no additional cost, as long as you see a doctor who accepts Medicare and our plan. Annual routine physical Preventive care services Flu and pneumonia shots Tobacco cessation counseling * The SilverSneakers fitness program is provided by Tivity Health, Inc., an independent company. Tivity Health, SilverSneakers and SilverSneakers FLEX are registered trademarks or trademarks of Tivity Health, Inc., and/or its subsidiaries and/or affiliates in the USA and/or other countries Tivity Health, Inc. All rights reserved. Please consult with your doctor before beginning any physical activity program. 13

16 Special health programs, tools and resources 24/7 NurseLine When health issues arise after hours, or if it s inconvenient or impractical to see a provider, you can still get the answers and assurance you need right away. Our 24/7 NurseLine puts you in touch with a registered nurse any time of the day or night. Call our 24/7 NurseLine at (TTY: 711). MyHealth Advantage Anthem Blue Cross Life and Health Insurance Company never stops looking out for your best health interests. MyHealth Advantage securely uses your health information to find and suggest ways to both improve your health and help save you money, including: Regular reminders about needed care, tests or preventive health steps you can take. Prescription drug cost-cutting tips. Free access to health specialists ready to answer your questions. Use your pharmacy benefits whenever and wherever Try our mobile app With your Anthem Medicare Preferred (PPO) with Senior Rx Plus plan, managing your prescription drug needs couldn t be easier thanks to the Anthem BC Anywhere app and Express Scripts companion app. It saves you lots of time and trouble by enabling you to: Find an in-network pharmacy near you or switch to home delivery. Compare retail prescription drug costs. Quickly refill and renew your prescriptions. Get personalized reminders with Pharmacy Care Alerts. Track your order. Research drug interactions and potential side effects. You can download the Anthem BC Anywhere app from Google Play (Android) or the Apple App Store (ios). 14

17 Special health programs, tools and resources Online health & tools 3 With your Anthem Medicare Preferred (PPO) with Senior Rx Plus plan, you re always just a click away from information that can help you: Take control of your health. Stay fit. Avoid getting sick. Did you know? This plan offers a $0 copay for preventive care. Our online resources provide 24/7 access to thousands of helpful articles and videos to help you learn all about self-care and medicines, plus various conditions, tests and treatments. LiveHealth Online* When your own doctor isn t available or you are traveling, LiveHealth Online is a quick and easy way to visit with a doctor or therapist through live, two-way video on your computer or mobile device. Use LiveHealth Online to visit with a doctor in minutes, 24/7, or to talk to a therapist by appointment seven days a week. Online visits using LiveHealth Online are covered at a $0 copay per visit on your Anthem Medicare Preferred (PPO) with Senior Rx Plus plan. Sign up today online at livehealthonline.com or on the free mobile app. Vital Decisions** For members who qualify, Anthem Blue Cross Life and Health Insurance Company offers Vital Decisions, a service to those facing advanced stages of illness. Vital Decisions is available at no additional cost. This program offers thoughtful, compassionate support and coaching by highly trained specialists. These specialists help improve the quality of the communication and shared decision-making processes that exist among advanced illness members, their family and their physicians so that members are empowered to incorporate their personal wishes in end-of-life decision-making. * LiveHealth Online is the trade name of Health Management Corporation, a separate company providing telehealth services on behalf of this plan. LiveHealth Online may not be available in all states. ** Services provided by Vital Decisions, an independent company. 15

18 SpecialOffers/How to save Stay well and save money with SpecialOffers * Saving money is good. Saving money on things that are good for you is even better. With SpecialOffers, you can get discounts on products and services that help promote better health and well-being. These are just a few of the many offers available to Anthem Blue Cross Life and Health Insurance Company members. Vision and hearing CONTACTS or Glasses.com Get contact lenses or the latest brand-name frames quickly and easily and for a fraction of the cost of typical retailers. You ll also enjoy discounts only available to our members, like $20 off orders of $100 or more and free shipping. TruVision or Premier LASIK Save 15% on LASIK with all in-network providers Enjoy prices as low as $695 per eye with select providers. Amplifon or Beltone With Amplifon, you may qualify for 25% off, plus an extra $50 off one hearing aid, or $125 off two. You ll also receive a three-year repair/loss/damage warranty and a free two-year supply of batteries. With Beltone, you can get hearing screenings and free in-home service, plus up to 50% off all Beltone hearing aids. 16 * SpecialOffers is a discount program that is not part of your health coverage plan. It is a value-added online service we provide to give our Medicare Advantage members access to discounts offered by different vendors. Vendors and offers are subject to change without prior notice. Anthem Blue Cross Life and Health Insurance Company does not endorse and is not responsible for the products, services or information provided by SpecialOffers vendors. Arrangements and discounts were negotiated between vendors and Anthem Blue Cross Life and Health Insurance Company for the benefit of our members. The products and services described on this page are not part of our contract with Medicare. They are not subject to the Medicare appeals process. Any disputes about these products or services may be subject to the Anthem Blue Cross Life and Health Insurance Company grievance process.

19 SpecialOffers/How to save Fitness and healthy living ChooseHealthy Take advantage of preferred pricing on fitness club memberships and a free one-week trial. Enjoy discounts on dieticians, acupuncture, chiropractors and massages, plus 40% off select wellness products. Garmin Save 20% on the vívofit 2, vívosmart, vívoactive or Forerunner 15 wearable activity trackers. GlobalFit Save on gym memberships at places like Curves, Anytime Fitness and 24-Hour Fitness, along with purchases of home fitness equipment and GlobalFit s Virtual Gym. SelfHelpWorks Choose one of the online Living programs and get a 40% discount to help you lose weight, manage stress or treat alcohol-related issues. Lindora Save 20% on weight-loss programs. Jenny Craig Join and get 50% off All-Access Enrollment, plus 5% off all Jenny Craig food. Puritan s Pride Receive 10% off on vitamins, supplements and minerals. LifeMart Get great deals on beauty/skin care, diet plans, fitness clubs, spas, yoga, sports gear and more! Family and home HelpCare Plus NEW! Now you can enjoy discounts on dental services, plus chiropractic and other Senior Care benefits, for just $13.25 a month from HelpCare Plus. National Allergy Supply Get a 15% discount on mattress covers, compressors and air filtration systems. Allergy Control Products Save 25% on Allergy Control encasings for your bed. Plus, save 20% on a variety of doctor-recommended products for a healthier home. Your orders of $150 or more will be shipped free. 23andMe Get $40 off each Health + Ancestry Service Kit. Your DNA says a lot about you. Save 20% on a 23andMe kit and learn about your wellness, ancestry and more! 17

20 Benefit Charts Here they are! Your complete Benefit Charts The next section gives you all of the details about the many medical and prescription drug benefits this Anthem Medicare Preferred (PPO) with Senior Rx Plus plan offers, including: What we cover. The amount of your copay, if any. Out-of-pocket costs. Coinsurance amounts. Look for the apple! It shows a preventive service. Just as Original Medicare does, we cover these services at no cost if you see a doctor who accepts Medicare and our plan. 18 Questions? Our First Impressions Welcome Team is ready to help. Call , TTY: 711, Monday through Friday, 8 a.m. to 9 p.m. ET, except holidays, or visit

21 Doctor and hospital choice You may go to doctors, specialists, and hospitals in or out of the network. You do not need a referral. However, some benefits may require authorization. Your 2018 Medical Benefit Chart Local PPO Plan 5P The Aerospace Corporation Effective January 1, 2018 Annual deductible $0 The deductible applies to as noted within each category below, prior to the copay or coinsurance, if any, being applied. Combined in-network and out-of-network Inpatient services Inpatient hospital care Includes inpatient acute, inpatient rehabilitation, long-term care hospitals, and other types of inpatient hospital services. Inpatient hospital care starts the day you are formally admitted to the hospital with a doctor s order. The day before you are discharged is your last inpatient day. Covered services include but are not limited to: Semi-private room (or a private room if medically necessary) Meals, including special diets Regular nursing services Costs of special care units (such as intensive or coronary care units) Drugs and medications Lab tests X-rays and other radiology services Necessary surgical and medical supplies Use of appliances, such as wheelchairs Your provider must get an approval from the plan before you are admitted to a hospital for a procedure, rehabilitation, substance abuse, or transplant that you and your doctor planned ahead. This is called getting prior authorization. You or your provider are encouraged to get prior approval from the plan before you are admitted to a hospital for a procedure, rehabilitation, substance abuse, or transplant that you and your doctor planned ahead. Claims received without approval are subject to review and may include a medical necessity evaluation Custom LPPO 5P_HUSAPP1500X36_LHO 08/29/2017 The Aerospace Corporation

22 Inpatient hospital care (con t) Operating and recovery room costs Physical therapy, occupational therapy, and speech language therapy Inpatient substance abuse services Inpatient dialysis treatments (if you are admitted as an inpatient to a hospital for special care) Under certain conditions, the following types of transplants are covered: corneal, kidney, kidneypancreatic, heart, liver, lung, heart/lung, bone marrow, stem cell, and intestinal/multivisceral. If you need a transplant, we will arrange to have your case reviewed by a Medicare-approved transplant center that will decide whether you are a candidate for a transplant. Transplant providers may be local or outside of the service area. If our in-network transplant services are outside the community pattern of care, you may choose to go locally as long as the local transplant providers are willing to accept the Original Medicare rate. If the plan provides transplant services at a location outside the pattern of care for transplants in your community and you choose to obtain transplants at this distant location, we will arrange or pay for appropriate lodging and transportation costs for you and a companion. The reimbursement for transportation costs are while you and your companion are traveling to and from the medical providers for services related to the transplant care. The plan defines the distant location as a location that is outside of the member s service area AND a minimum of 75 miles from the member s home. Transportation and lodging costs will be reimbursed for travel mileage and lodging consistent with current IRS travel mileage and lodging guidelines. Accommodations for lodging will be reimbursed at the lesser of: 1) billed charges, or 2) $50 per day per covered person up to a maximum of $100 per day per covered person consistent with IRS guidelines. Blood including storage and administration. Coverage of whole blood, packed red cells, and all other components of blood begins with the first pint. Physician services For Medicarecovered hospital stays: $100 copay per admission The inpatient hospital out-ofpocket maximum is $300 per year combined with inpatient mental health care and combined innetwork and out-ofnetwork. No limit to the number of days covered by the plan. $0 copay for physician services received while an inpatient during a hospital stay For Medicarecovered hospital stays: $100 copay per admission The inpatient hospital out-ofpocket maximum is $300 per year combined with inpatient mental health care and combined innetwork and out-ofnetwork. No limit to the number of days covered by the plan. $0 copay for physician services received while an inpatient during a hospital stay If you receive authorized inpatient care at an out-ofnetwork hospital after your emergency condition is stabilized, your cost is the cost-sharing you would pay at an in-network hospital.

23 Inpatient hospital care (con t) In-network providers should notify us within one business day of any planned, and if possible, unplanned admissions or transfers, including to or from a hospital, skilled nursing facility, long term acute care hospital, or acute rehabilitation center. Note: To be an inpatient, your provider must write an order to admit you formally as an inpatient of the hospital. Even if you stay in the hospital overnight, you might still be considered an outpatient. If you are not sure if you are an inpatient, you should ask the hospital staff. You can also find more information in a Medicare fact sheet called Are You a Hospital Inpatient or Outpatient? If You Have Medicare Ask! This fact sheet is available on the Web at or by calling MEDICARE ( ). TTY users call You can call these numbers for free, 24 hours a day, 7 days a week.

24 Inpatient mental health care Covered services include mental health care services that require a hospital stay in a psychiatric hospital or the psychiatric unit of a general hospital. In-network providers should notify us within one business day of any planned, and if possible unplanned admissions or transfers, including to or from a hospital, skilled nursing facility, long term acute care hospital, or acute rehabilitation center. Your provider must get an approval from the plan before you are admitted to a hospital for a mental condition, drug or alcohol abuse, or rehabilitation. This is called getting prior authorization. You or your provider are encouraged to get prior approval from the plan before you are admitted to a hospital for a mental condition, drug or alcohol abuse, or rehabilitation. Claims received without approval are subject to review and may include a medical necessity evaluation. For Medicarecovered hospital stays: $100 copay per admission The inpatient mental health care out-of-pocket maximum is $300 per year combined with inpatient hospital care and combined innetwork and out-ofnetwork. No limit to the number of days covered by the plan. For Medicarecovered hospital stays: $100 copay per admission The inpatient mental health care out-of-pocket maximum is $300 per year combined with inpatient hospital care and combined innetwork and out-ofnetwork. No limit to the number of days covered by the plan.

25 Inpatient mental health care (con t) $0 copay for physician services received while an inpatient during a hospital stay $0 copay for physician services received while an inpatient during a hospital stay

26 Skilled nursing facility (SNF) care Inpatient skilled nursing facility (SNF) coverage is limited to 180 days each benefit period. A benefit period begins on the first day you go to a inpatient hospital or a SNF. The benefit period ends when you have not been an inpatient at any hospital or SNF for 60 days in a row. Covered services include but are not limited to: Semi-private room (or a private room if medically necessary) Meals, including special diets Skilled nursing services Physical therapy, occupational therapy, and speech language therapy Drugs administered to you as part of your plan of care (this includes substances that are naturally present in the body, such as blood clotting factors) Blood including storage and administration. Coverage of whole blood, packed red cells, and all other components of blood begins with the first pint. Medical and surgical supplies ordinarily provided by SNFs Laboratory tests ordinarily provided by SNFs X-rays and other radiology services ordinarily provided by SNFs Use of appliances such as wheelchairs ordinarily provided by SNFs Physician/Practitioner services Generally, you will receive your SNF care from plan facilities. However, under certain conditions listed below, you may be able to pay in-network cost-sharing for a facility that isn t a plan provider, if the facility accepts our plan s amounts for payment. Your provider must get an approval from the plan before you get skilled nursing care. This is called getting prior authorization. For Medicarecovered SNF stays: $10 copay per day for days and $0 copay for days per benefit period No prior hospital stay required. You or your provider are encouraged to get prior approval from the plan before you get skilled nursing care. Claims received without approval are subject to review and may include a medical necessity evaluation. For Medicarecovered SNF stays: $10 copay per day for days and $0 copay for days per benefit period No prior hospital stay required. A nursing home or continuing care retirement community where you were living right before you went to the hospital (as long as it provides skilled nursing facility care)

27 Skilled nursing facility (SNF) care (con t) A SNF where your spouse is living at the time you leave the hospital In-network providers should notify us within one business day of any planned, and if possible unplanned admissions or transfers, including to or from a hospital, skilled nursing facility, long term acute care hospital, or acute rehabilitation center. Inpatient services covered when the hospital or SNF days are not covered or are no longer covered If you have exhausted your inpatient benefits or if the inpatient stay is not reasonable and necessary, we will not cover your inpatient stay. However, in some cases, we will cover certain services you receive while you are in the hospital or a skilled nursing facility (SNF). Covered services include, but are not limited to: Physician services Diagnostic tests (like lab tests) X-ray, radium, and isotope therapy including technician materials and services Surgical dressings Splints, casts, and other devices used to reduce fractures and dislocations Prosthetic and orthotic devices (other than dental) that replace all or part of an internal body organ (including contiguous tissue), or all or part of the function of a permanently inoperative or malfunctioning internal body organ, including replacement or repairs of such devices Leg, arm, back and neck braces, trusses and artificial legs, arms, and eyes including adjustments, repairs and replacements required because of breakage, wear, loss, or a change in the patient's physical condition Physical therapy, occupational therapy, and speech language therapy Your provider may need an approval from the plan before you get services. This is called getting prior authorization. Ask your provider or call the plan to learn more. After your SNF day limits are used up, this plan will still pay for covered physician services and other medical services outlined in this benefit chart at the deductible and/or cost share amounts indicated.

28 Home health agency care Prior to receiving home health services, a doctor must certify that you need home health services and will order home health services to be provided by a home health agency. You must be homebound, which means leaving home is a major effort. Covered services include, but are not limited to: Part-time or intermittent skilled nursing and home health aide services (to be covered under the home health care benefit, your skilled nursing and home health aide services combined must total fewer than 8 hours per day and 35 hours per week) Physical therapy, occupational therapy, and speech language therapy Medical and social services Medical equipment and supplies Your provider may need an approval from the plan before you get home health care. This is called getting prior authorization. Ask your provider or call the plan to learn more. $0 copay for home health visits Durable Medical Equipment (DME) copay or coinsurance, if any, may apply. You or your provider are encouraged to get prior approval from the plan before you get home health care. Claims received without approval are subject to review and may include a medical necessity evaluation. $0 copay for home health visits Durable Medical Equipment (DME) copay or coinsurance, if any, may apply.

29 Hospice care You may receive care from any Medicare-certified hospice program. You are eligible for the hospice benefit when your doctor and the hospice medical director have given you a terminal prognosis certifying that you re terminally ill and have six months or less to live if your illness runs its normal course. Your hospice doctor can be an in-network provider or an out-ofnetwork provider. For hospice services and for services that are covered by Medicare Part A or B and are related to your terminal prognosis: Original Medicare (rather than this plan) will pay for your hospice services and any Part A and Part B services related to your terminal prognosis. While you are in the hospice program, your hospice provider will bill Medicare for the services that Original Medicare pays for. Services covered by Original Medicare include: Drugs for symptom control and pain relief You must receive care from a Medicare-certified hospice. When you enroll in a Medicare-certified hospice program, your hospice services and your Part A and B services are paid for by Original Medicare, not this plan. $0 copay for the one time only hospice consultation You must receive care from a Medicare-certified hospice. When you enroll in a Medicare-certified hospice program, your hospice services and your Part A and B services are paid for by Original Medicare, not this plan. $0 copay for the one time only hospice consultation Short-term respite care Home care Our plan covers hospice consultation services (one time only) for a terminally ill person who hasn t elected the hospice benefit. For services that are covered by Medicare Part A or B and are not related to your terminal prognosis: If you need nonemergency, nonurgently needed services that are covered under Medicare Part A or B and that are not related to your terminal prognosis, your cost for these services depends on whether you use a provider in our plan s network: If you obtain the from an in-network provider, you only pay the plan cost-sharing amount for in-network services. If you obtain the from an out-ofnetwork provider, you pay the plan cost-sharing for outof-network services.

30 Hospice care (con t) For services that are covered by this plan but are not covered by Medicare Part A or B: This plan will continue to cover plancovered services that are not covered under Part A or B whether or not they are related to your terminal prognosis. You pay your plan cost-sharing amount for these services. If you have Part D prescription drug coverage, some drugs may be covered under your Part D benefit. Drugs are never covered by both hospice and your Part D plan at the same time. Note: If you need non-hospice care (care that is not related to your terminal prognosis), you should contact us to arrange the services.

31 Outpatient services Physician services, including doctor s office visits Covered services include: Office visits, including medical and surgical services in a physician s office Consultation, diagnosis, and treatment by a specialist Retail health clinics Basic diagnostic hearing and balance exams, if your doctor orders it to see if you need medical treatment, when furnished by a physician, audiologist, or other qualified provider Telehealth office visits, including consultation, diagnosis, and treatment by a specialist Second opinion by another in-network provider prior to surgery Physician services rendered in the home Outpatient hospital services Non routine dental care ( are limited to surgery of the jaw or related structures, setting fractures of the jaw or facial bones, extraction of teeth to prepare the jaw for radiation treatments of neoplastic cancer disease, or services that would be covered when provided by a physician) Allergy testing and allergy injections You may need an approval from the plan before you get care. This is called getting prior authorization. Ask your provider or call the plan to learn more. $5 copay per visit to an in-network Primary Care Physician (PCP) for services $20 copay per visit to an in-network specialist for services $5 copay per visit to an in-network retail health clinic for services $0 copay for allergy testing You or your provider are encouraged to get prior approval from the plan before you get care. Claims received without approval are subject to review and may include a medical necessity evaluation. $5 copay per visit to an out-of-network Primary Care Physician (PCP) for services $20 copay per visit to an out-ofnetwork specialist for Medicarecovered services $5 copay per visit to an out-of-network retail health clinic for Medicarecovered services $0 copay for allergy testing

32 Physician services, including doctor s office visits (con t) $0 copay for allergy injections $0 copay for allergy injections See antigen cost share in Part B drug section. See antigen cost share in Part B drug section. Chiropractic services We cover only manual manipulation of the spine to correct subluxation. Podiatry services Covered services include: Diagnosis and the medical or surgical treatment of injuries and disease of the feet (such as hammer toe or heel spurs) in an office setting routine foot care for members with certain medical conditions affecting the lower limbs A foot exam covered every six months for people with diabetic peripheral neuropathy and loss of protective sensations Your provider may need an approval from the plan before you get chiropractic services. This is called getting prior authorization. Ask your provider or call the plan to learn more. $20 copay for each visit Your provider must get an approval from the plan before you get podiatry services. This is called getting prior authorization. $20 copay for each visit You or your provider are encouraged to get prior approval from the plan before you get chiropractic services. Claims received without approval are subject to review and may include a medical necessity evaluation. $20 copay for each visit You or your provider are encouraged to get prior approval from the plan before you get podiatry services. Claims received without approval are subject to review and may include a medical necessity evaluation. $20 copay for each visit

33 Outpatient mental health care, including partial hospitalization services Covered services include: Mental health services provided by a state-licensed psychiatrist or doctor, clinical psychologist, clinical social worker, clinical nurse specialist, nurse practitioner, physician assistant, or other Medicare-qualified mental health care professional as allowed under applicable state laws Partial hospitalization is a structured program of active psychiatric treatment provided as a hospital outpatient service that is more intense than the care received in your doctor s or therapist s office and is an alternative to inpatient hospitalization. Your provider must get an approval from the plan before you get intensive outpatient mental health services or partial hospitalization for mental health. This is called getting prior authorization. You or your provider are encouraged to get prior approval from the plan before you get intensive outpatient mental health services or partial hospitalization for mental health. Claims received without approval are subject to review and may include a medical necessity evaluation. $20 copay for each professional individual therapy visit $20 copay for each professional group therapy visit $20 copay for each professional partial hospitalization visit $0 copay for each outpatient hospital facility individual therapy visit $20 copay for each professional individual therapy visit $20 copay for each professional group therapy visit $20 copay for each professional partial hospitalization visit $0 copay for each outpatient hospital facility individual therapy visit

34 Outpatient mental health care, including partial hospitalization services (con t) $0 copay for each outpatient hospital facility group therapy visit $0 copay for each outpatient hospital facility group therapy visit $0 copay for each partial hospitalization facility visit $0 copay for each partial hospitalization facility visit

35 Outpatient substance abuse services, including partial hospitalization services Partial hospitalization is a structured program of active psychiatric treatment provided as a hospital outpatient service that is more intense than the care received in your doctor s or therapist s office and is an alternative to inpatient hospitalization. Your provider must get an approval from the plan before you get intensive outpatient substance abuse services or partial hospitalization for substance abuse. This is called getting prior authorization. You or your provider are encouraged to get prior approval from the plan before you get intensive outpatient substance abuse services or partial hospitalization for substance abuse. Claims received without approval are subject to review and may include a medical necessity evaluation. $20 copay for each professional individual therapy visit $20 copay for each professional group therapy visit $20 copay for each professional partial hospitalization visit $0 copay for each outpatient hospital facility individual therapy visit $20 copay for each professional individual therapy visit $20 copay for each professional group therapy visit $20 copay for each professional partial hospitalization visit $0 copay for each outpatient hospital facility individual therapy visit

36 Outpatient substance abuse services, including partial hospitalization services (con t) $0 copay for each outpatient hospital facility group therapy visit $0 copay for each outpatient hospital facility group therapy visit $0 copay for each partial hospitalization facility visit $0 copay for each partial hospitalization facility visit Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers Facilities where surgical procedures are performed and the patient is released the same day. Note: If you are having surgery in a hospital, you should check with your provider about whether you will be an inpatient or outpatient. Unless the provider writes an order to admit you as an inpatient to the hospital, you are an outpatient and pay the costsharing amounts for outpatient surgery. Even if you stay in the hospital overnight, you might still be considered an outpatient. You can also find more information in a Medicare fact sheet called Are You a Hospital Inpatient or Outpatient? If You Have Medicare Ask! This fact sheet is available on the Web at or by calling MEDICARE ( ). TTY users call You can call these numbers for free, 24 hours a day, 7 days a week. Your provider must get an approval from the plan before you get select outpatient surgeries and procedures. This is called getting prior authorization. Ask your provider or call the plan to learn more. $50 copay for each outpatient hospital facility or ambulatory surgical center visit for surgery $50 copay for each outpatient observation room visit You or your provider are encouraged to get prior approval from the plan before you get select outpatient surgeries and procedures. Claims received without approval are subject to review and may include a medical necessity evaluation. $50 copay for each outpatient hospital facility or ambulatory surgical center visit for surgery $50 copay for each outpatient observation room visit