CARE1ST TotalDual Plan (HMO SNP)

Transcription

1 CARE1ST TotalDual Plan PRE-Enrollment Book 2014 ALAMEDA, LOS ANGELES, ORANGE, SAN BERNARDINO, SAN FRANCISCO, SANTA CLARA H5928_14_109_MKB2 Accepted H5928_14_093_MK Accepted

2 Thank you for Your Interest in Care1st TABLE OF CONTENTS 1. Thank you for Your Interest in Care1st / Table of Contents 2. Welcome Letter 3. Medicare Plan Rating 4. Care1st Health Plan 2014 Service Area Map 5. Frequently Asked Questions and Answers about Medicare Advantage Plans Care1st Benefit Chart - a condensed list of some of the benefits you will receive as a Care1st member. 7. Nurse Advice Line 8. Transportation Information 9. Silver Sneakers Fitness Program 10. Over-the-Counter Benefits 11. Understanding Enrollment Periods - explanation of the different times of year when you can enroll or make changes to your plan. 13. Sample Enrollment Form - demonstrates the information you need to include on your application. 14. Summary of Benefits 15. Drug List - a comprehensive list of the drugs covered by Care1st and their tier levels. 16. Delta Dental Flyer - important information about the Care1st dental program and provider. 17. Outbound Education & Verification (OEV) Call 18. What to Expect After Enrollment - providing details about the enrollment process and timelines. 19. Visit Us Online - information about our website at Multi Language Information - if you require enrollment information in another language, please follow the instructions provided. 12. Ready to Enroll - guidelines and instructions to help you through the enrollment process. SNP

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4 Dear Medicare Beneficiary: Care1st Health Plan P.O. Box 4239, Montebello, CA Thank you for considering one of Care1st Medicare Advantage Health Plans (HMO, HMO SNP) for your healthcare needs. Taking charge of your health is one of the many ways that you can control your health and healthcare options. The information enclosed will help you to explore the benefits of being a Care1st member. Like most people, we know that you are looking for healthcare coverage that meets your needs and is affordable. With that in mind, we have designed our Medicare Advantage and Special Needs Plans around YOU! You will get more of the benefits you want and need to keep you healthy while maintaining your lifestyle. By choosing Care1st, you ll receive the benefits of a great company with proven leadership, integrity, and a dedicated staff that is ready to serve you. And, there s more! Care1st was created and is still run today by doctors. We believe our members needs come first. We focus on caring for the whole you so that you can live a healthier daily life. With over 10,000 physicians and 100 hospitals in our network, we re certain that you will find the doctor that is right for you and your specific needs. The information in this folder will help you to explore the benefits of being a Care1st member. As a guide, we encourage you to review the Summary of Benefits as it provides detailed coverage that our plans offer. Are you ready to enroll? Simply complete the Individual Enrollment Form and return it to Care1st. Choosing healthcare coverage is a big decision and can be confusing. We are happy to help answer any questions you may have. Don t hesitate to call. No question is too big or too small. Yes, it is all about you. If you re ready to enroll, simply complete the Individual Enrollment Form and return it to Care1st or you can call us and we can help you enroll telephonically. Marketing Department (TTY/TDD users call 711) 8:00 a.m. to 8:00 p.m., seven days a week We look forward to welcoming you to the Care1st family. Dawn Maroney Chief Medicare Officer Care1st Health Plan 601 Potrero Grande Drive, Monterey Park, CA Care1st is a Medicare Advantage HMO plan with a Federal Government and State Medicaid contract in Arizona and California. Enrollment in Care1st Health Plan depends on contract renewal. H5928_14_142_MK Accepted

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6 Care1st Medicare Advantage Plan - H5928 CY 2013 Medicare Plan Ratings The Medicare Program rates all health and prescription drug plans each year, based on a plan s quality and performance. Medicare Plan Ratings help you know how good a job our plan is doing. You can use this Plan Rating to compare our plan s performance to other plans. Examples of the areas covered by this rating 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 2013, Care1st Medicare Advantage Plan received the following overall Plan Rating from Medicare. 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, 8:00 a.m. - 8:00 p.m. Pacific at (toll-free) or (TTY/TDD). Current members please call (toll-free) or (TTY/TDD). H5928_13_039_MK Accepted

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8 Service Areas El Paso San Joaquin Alameda (Partial) Stanislaus San Francisco Fresno Santa Clara (Partial) TEXAS California HMO & HMO SNP Kern (Partial) HMO Plan Only Los Angeles Orange (Partial) Call Member Services for questions or benefit information: San Bernardino (Partial) Riverside (Partial) San Diego TTY/TDD users call 711 8:00 a.m. to 8:00 p.m., seven days a week facebook/mycare1st H5928_14_143_MK Accepted

9 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; Kern County 93203; 93206; 93220; 93241; 93250; 93263; 93276; 93280; 93301; 93302; 93303; 93304; 93305; 93306; 93307; 93308; 93309; 93311; 93312; 93313; 93314; 93380; 93383; 93384; 93385; 93386; 93387; 93388; 93389; 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; 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, 92883

10 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 Care1st is a Medicare Advantage HMO plan with a Federal Government and State Medicaid contract in Arizona and California. Enrollment in Care1st Health Plan depends on contract renewal. This information is available for free in other languages. Please contact Member Services: (TTY: 711), 8:00 a.m. to 8:00 p.m., seven days a week. Esta información está disponible gratuitamente en otros idiomas. Comuníquese con Servicios para los Miembros: (TTY 711), de 8:00 a.m. a 8:00 p.m., los siete días de la semana. 請聯絡會員服務熱線電話 聽障和語障人士可致電 711 我們的辦公時間為每週七天 早 上8:00點至晚上8:00點 H5928_14_143_MK Accepted

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12 Do You Have Medicare Questions? Care1st (HMO, HMO SNP) has answers. What are the different parts of Medicare A, B, C and D? Medicare Part A covers inpatient hospital care, skilled nursing facility, home healthcare and hospice care. Medicare Part B covers outpatient care, such as doctor s office visits, specialist s office visits, lab services, durable medical equipment and preventive services. You pay a Part B premium each month. Medicare Part C are Medicare Advantage plans which are approved by Medicare and offered by private companies. Medicare Advantage Plans provide all of your Part A and Part B coverage. Medicare Advantage plans may offer extra coverage, such as vision, hearing, dental and/or health and wellness programs. Medicare Part D is your prescription drug coverage. To get prescription drug coverage you must join a plan such as Care1st. Each plan can vary in cost and drugs covered. How do I join Care1st Medicare Advantage Plans? Call Care1st at and a representative can assist you right over the phone. (TTY) 711. Seven days a week, 8:00 a.m. to 8:00 p.m. PST. Can I obtain specialty services? When you need specialty care or additional services your PCP cannot provide, he or she will give you a referral. There are certain services which you can get on your own, without a referral, as long as you get them from a network provider. What should I do if I m out of Care1st s coverage area and need emergency services? Care1st provides worldwide emergency coverage. If you have an emergency when you are not in our service area, you can obtain emergency services at the nearest emergency facility (doctor s office, clinic or hospital). Emergency services do not require a referral or an okay from your PCP doctor. Can I obtain care after normal business hours? It is important you always carry your Care1st ID card with you. If you think that you have an emergency, call 911 or go to the nearest emergency room. Call your doctor if you need medical care, and he or she can help you arrange care. Care1st also offers a Nurse Advice Line. The call is free and easy. You get advice right away. A nurse will ask about your health problem. You do not have to call the Nurse Advice Line before getting healthcare. What if I m a Medicare member with Care1st and also have Medicaid benefits elsewhere? If you are a Medicaid member and eligible for Medicare, then it is important to know that Medicare, not Medicaid is your primary insurance. If you are interested in combining your benefits, please call Member Services for more information on the additional benefits available. H5928_14_144_MK Accepted

13 How is my private health information protected? There are federal and state laws that protect the privacy of your medical records and personal health information. We protect your personal health information under these laws. Any personal health information that you give us when you enroll is protected. We will make sure that unauthorized people don t see or change your records. What benefits and services are not covered? Care1st plans cover all of the medically-necessary services that are covered by Medicare Part A and Part B. The following items and services aren t covered under the Original Medicare Plan or by our plans: Services that aren t reasonable and necessary, according to the standards of the Original Medicare Plan, unless these services are otherwise listed by our Plan as a covered service Experimental or investigational medical and surgical procedures, equipment and medications, unless covered by the Original Medicare Plan or unless, for certain services, the procedures are covered under an approved clinical trial Surgical treatment of morbid obesity unless medically necessary and covered under the Original Medicare plan Private room in a hospital, unless medically necessary Private duty nurses Personal convenience items, such as a telephone or television in your room at a hospital or skilled nursing facility Nursing care on a full-time basis in your home Custodial care unless it is provided in conjunction with covered skilled nursing care and/or skilled rehabilitation services. This includes care that helps people with activities of daily living like walking, getting in and out of bed, bathing, dressing, eating and using the bathroom, preparation of special diets, and supervision of medication that is usually self-administered Homemaker services Charges imposed by immediate relatives or members of your household Elective or voluntary enhancement procedures, services, supplies and medications including but not limited to: Weight loss, hair growth, sexual performance, athletic performance, cosmetic purposes, anti-aging and mental performance unless medically necessary Cosmetic surgery or procedures, unless needed because of accidental injury or to improve the function of a malformed part of the body. All stages of reconstruction are covered for a breast after a mastectomy, as well as for the unaffected breast to produce a symmetrical appearance Chiropractic care is generally not covered, (with the exception of manual manipulation of the spine), and is limited according to Medicare guidelines Orthopedic shoes unless they are part of a leg brace and are included in the cost of the brace. Exception: Therapeutic shoes are covered for people with diabetic foot disease Supportive devices for the feet. Exception: Orthopedic or therapeutic shoes are covered for people with diabetic foot disease Radial keratotomy, LASIK surgery, vision therapy and other low vision aids and services Self-administered prescription medication for the treatment of sexual dysfunction, including erectile dysfunction, impotence, and anorgasmy or hyporgasmy Reversal of sterilization procedures, sex change operations, and non-prescription contraceptive supplies and devices Naturopath services Non-emergency services provided to veterans in Veterans Affairs (VA) facilities. However, in the case of emergency services received at a VA hospital, if the VA cost-sharing is more than the cost-sharing required under our Plan, we will reimburse veterans for the difference. Members are still responsible for our Plan cost-sharing amount

14 Any of the services listed above that aren t covered will remain not covered even if received at an emergency facility. For example, non-authorized, routine conditions that do not appear to a reasonable person to be based on a medical emergency are not covered if received at an emergency facility How can I assign a representative to act in my behalf? You have the right to ask someone such as a family member or friend to help you with decisions about your healthcare. If you want to, you can use a special form to give someone the legal authority to make decisions for you if you ever become unable to make decisions for yourself. If you want to have an advance directive, you can get a form from your lawyer, from a social worker or from some office supply stores, or from other sources including the internet and advocacy groups. If you only wish to give the authority to represent you in dealings with Care1st for enrollment, claims and other administrative matters, you can visit our website download and complete the Appointment of Representative. Please note that copies of an advance directive, Appointment of Representative, or similar documents must be sent to Care1st to be effective for Care1st purposes. What can I do if I move out of your service area? If you move out of the service area or are away from the service area for more than six months, you cannot remain a member of our Plan. Please call Member Services to find out if the place you are moving to or traveling to is in our Plan s service area. A Medicare approved HMO plan Call Member Services for questions or benefit information: TTY/TDD users call 711 8:00 a.m. to 8:00 p.m., seven days a week facebook/mycare1st Care1st is a Medicare Advantage HMO plan with a Federal Government and State Medicaid contract in Arizona and California. Enrollment in Care1st 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, co-payments, and restrictions may apply. This information is available for free in other languages. Please contact Member Services: (TTY: 711), 8:00 a.m. to 8:00 p.m., seven days a week. Esta información está disponible gratuitamente en otros idiomas. Comuníquese con Servicios para los Miembros: (TTY 711), de 8:00 a.m. a 8:00 p.m., los siete días de la semana. 請聯絡會員服務熱線電話 : 聽障和語障人士可致電 711 我們的辦公時間為每週七天, 早上 8:00 點至晚上 8:00 點 H5928_14_144_MK Accepted

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16 2014 BENEFITS CHART TotalDual Plan BENEFIT ORANGE ALAMEDA / LOS ANGELES SAN BERNARDINO SAN FRANCISCO SANTA CLARA Premium $0* $0* Primary Care / Specialist $0 copay $0 copay Physician Hearing Aid $0 copay Medicare covered $0 copay Medicare covered benefits / $0 copay for (2) benefits / $0 copay for (2) hearing aids every two years; hearing aids every two years; $1,000 limit every year $1,000 limit every year Inpatient Hospitalization $0 copay / unlimited $0 copay / unlimited Emergency Care $0 copay $50 copay Worldwide coverage up to Worldwide coverage up to $25,000 per year $25,000 per year Ambulance $0 copay $0 copay Durable Medical Equipment $0 copay $0 copay (DME) Health Club / $0 copay / unlimited $0 copay / unlimited Fitness Classes Membership Transportation $0 copay $0 copay 48 one-way trips to plan 48 one-way trips to plan approved locations approved locations Dental Services Covered Covered Refer to your Summary of Refer to your Summary of Benefits for details Benefits for details *Part D Premium Disclaimer: Depending on your level of Medicaid eligibility, you may not have any cost-sharing responsibility for your part D premium. H5928_14_075_MK Accepted

17 2014 BENEFITS CHART TotalDual Plan BENEFIT ORANGE ALAMEDA / LOS ANGELES SAN BERNARDINO SAN FRANCISCO SANTA CLARA Eye Exam Routine $0 copay routine eye exams $0 copay routine eye exams (1 every year) (1 every year) Eyewear $0 copay - $150 limit for glasses $0 copay - $200 limit for glasses every 2 years / refraction test every year / refraction test covered covered Over-the-Counter (OTC) Items $50 quarterly $50 quarterly (limited to Medicare eligible items) Preferred Generic Drugs, T1 $0 $0 Non-Preferred Generic Drugs, T2 $0, $1.20 or $2.55 based on $0, $1.20 or $2.55 based on Low Income Subsidy Low Income Subsidy Preferred Brand Drugs, T3 $0, $3.60 or $6.35 based on $0, $3.60 or $6.35 based on Low Income Subsidy Low Income Subsidy Non-Preferred Brand Drugs, T4 $0, $1.20, $2.25, $3.60 or $6.35 $0, $1.20, $2.25, $3.60 or $6.35 based on Low Income Subsidy based on Low Income Subsidy Specialty Tier Drugs, T5 $0, $3.60 or $6.35 based on $0, $3.60 or $6.35 based on Low Income Subsidy Low Income Subsidy Individuals not meeting Individuals not meeting full Medicaid are covered full Medicaid are covered at the Standard Medicare at the Standard Medicare benefit or Low Income benefit or Low Income Subsidy; Information provided Subsidy; Information provided is based on 30-day supply is based on 30-day supply

18 2014 BENEFITS CHART TotalDual Plan If you have questions about becoming a Care1st member, call: TTY/TDD users call 711 8:00 a.m. to 8:00 p.m., seven days a week /mycare1st Care1st is a Medicare Advantage HMO plan with a Federal Government and State Medicaid contract in Arizona and California. Enrollment in Care1st 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, copayments, and restrictions may apply. You must continue to pay your Medicare Part B premium. This information is available for free in other languages. Please contact Member Services: (TTY 711), 8am 8pm, 7 days a week. Esta información está disponible gratuitamente en otros idiomas. Comuníquese con Servicios para los Miembros: (TTY 711), de 8:00 a.m. a 8:00 p.m., los siete días de la semana. 請聯絡會員服務熱線電話 : 聽障和語障人士可致電 711 我們的辦公時間為每週七天, 早上 8:00 點至晚上 8:00 點 Thông tin này cũng được trình bày bằng những ngôn ngữ khác và cung cấp miễn phí cho hội viên. Vui lòng liên lạc với ban Dịch vụ Hội viên: (người dùng TTY xin gọi số ), 8 giờ sáng 8 giờ tối, 7 ngày trong tuần.

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20 Nurse Advice Hotline The Care1st (HMO, HMO SNP) Nurse Advice Line is a service available to all Care1st members. A Medicare approved HMO plan 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 getting healthcare. Call the Care1st Nurse Advice Line at: TTY/TDD users call 711 8:00 a.m. to 8:00 p.m., seven days a week facebook/mycare1st Care1st is a Medicare Advantage HMO plan with a Federal Government and State Medicaid contract in Arizona and California. Enrollment in Care1st 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, copayments, and restrictions may apply. This information is available for free in other languages. Please contact Member Services: (TTY: 711), 8:00 a.m. to 8:00 p.m., seven days a week. Esta información está disponible gratuitamente en otros idiomas. Comuníquese con Servicios para los Miembros: (TTY 711), de 8:00 a.m. a 8:00 p.m., los siete días de la semana. 請聯絡會員服務熱線電話 聽障和語障人士可致電 711 我們的辦公時間為每週七天 早上8:00點至晚上8:00點 H5928_14_145_MK Accepted

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22 Transportation Services 0 $ copay for each round trip to plan-approved locations.* Care1st (HMO, HMO SNP) is proud to offer transportation services to our members. Transportation is provided as needed for non-emergency healthcare visits. Note: Call Care1st 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 711 8:00 a.m. to 8:00 p.m., seven days a week facebook/mycare1st Care1st is a Medicare Advantage HMO plan with a Federal Government and State Medicaid contract in Arizona and California. Enrollment in Care1st 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, copayments, and restrictions may apply. This information is available for free in other languages. Please contact Member Services: (TTY: 711), 8:00 a.m. to 8:00 p.m., seven days a week. Esta información está disponible gratuitamente en otros idiomas. Comuníquese con Servicios para los Miembros: (TTY 711), de 8:00 a.m. a 8:00 p.m., los siete días de la semana. 請聯絡會員服務熱線電話 聽障和語障人士可致電 711 我們的辦公時間為每週七天 早 上8:00點至晚上8:00點 H5928_14_046_MKSD Accepted

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24 A Medicare approved HMO plan Get more benefits by being a Care1st (HMO, HMO SNP) Medicare Member! Healthways SilverSneakers Fitness Program Here s your opportunity to get fit with the SilverSneakers Fitness Program. SilverSneakers includes: Free membership at a fitness center in your area. Group exercise classes designed to increase strength, flexibility, and energy. Personalized, friendly service from your advisor at the fitness center. For more information, you can visit SilverSneakers.com. (Please check with your physician before starting a fitness program.) For questions about Care1st Fitness Center Benfit call: TTY/TDD users call 711 8:00 a.m. to 8:00 p.m., seven days a week facebook/mycare1st Care1st is a Medicare Advantage HMO plan with a Federal Government and State Medicaid contract in Arizona and California. Enrollment in Care1st 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, copayments, and restrictions may apply. Availability varies by plan and market. Fitness center listing is subject to change and may vary depending on location, change in centers, and geographic service areas served. Additional services outside of the basic fitness center membership, such as personal trainers, special classes, sports participation, massage therapy, etc., are not part of the Care1st benefit and may require additional out-of-pocket costs. This information is available for free in other languages. Please contact Member Services: (TTY: 711), 8:00 a.m. to 8:00 p.m., seven days a week. Esta información está disponible gratuitamente en otros idiomas. Comuníquese con Servicios para los Miembros: (TTY 711), de 8:00 a.m. a 8:00 p.m., los siete días de la semana. 請聯絡會員服務熱線電話 : 聽障和語障人士可致電 711 我們的辦公時間為每週七天, 早上 8:00 點至晚上 8:00 點 H5928_14_146_MK Accepted

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26 Over-the-counter Benefits 2014 As a member of our you have a quarterly Over-the-Counter (OTC) benefit in the amount of $50.00, which allows you to purchase OTC products you may need. We hope that you take advantage of this valuable benefit each quarter. A Medicare approved HMO plan A brief sample of your available Over-the-Counter products. Allergy All Day Allergy Tablets $7.90 Nasal Saline Spray $9.50 Analygesics/Antipyretics Acetaminophen $8.60 Aspirin $4.90 Ibuprofen, 100 tabs $8.70 Antiacids & Acid reducers Alka-Seltzer $15.20 Gas-X $8.60 Milk of Magnesia $8.40 Anti-Arthritic Glucosamine/ $13.30 Joint Muscle Anticandial Micanozole 3 Day Treat. $16.90 Antidiarrheal & Laxatives Beano $9.40 Ex-Lax $8.20 Pepto-Bismol $15.40 Antihistamines Children s Dimaphen $ 6.10 Generic Children s Benadryl $6.60 Cold & Flu Nasal Decongestant Spray $9.50 Vapor Rub $8.40 Cold Head Congestion $8.40 Denture Polident Denture Cream $11.20 Fiber Supplements Fiber Tabs $13.70 First Aid Bandage $8.00 Hot/Cold Pack $8.50 First Aid Kit $10.60 Lactose Intolerance Lactase $12.30 Migraine Relief Migraine Relief, 100 tabs $9.90 Wellpatch Migraine $11.10 Care1st Over-the-Counter Center: TTY/TDD Users Call: 711 8:00 a.m. to 8:00 p.m., seven days a week facebook/mycare1st Care1st is a Medicare Advantage HMO plan with a Federal Government and State Medicaid contract in Arizona and California. Enrollment in Care1st 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, copayments, and restrictions may apply. This information is available for free in other languages. Please contact Member Services: (TTY 711), 8:00 a.m. to 8:00 p.m., seven days a week. Esta información está disponible gratuitamente en otros idiomas. Comuníquese con Servicios para los Miembros: (TTY 711), de 8:00 a.m. a 8:00 p.m., los siete días de la semana. 我們可免費以其它語言為您提供這資訊 請致電會員服務部免費熱線 : ( 聽障和語障人士可致電 711), 由 10 月 1 日至 2 月 14 日, 我們的辦公時間為每週七天, 上午 8:00 點至晚上 8:00 點 由 2 月 15 日至 9 月 30 日, 我們的辦公時間為週一至週五, 上午 8:00 點至晚上 8:00 點 H5928_14_041_MKB Accepted

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28 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. 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_14_147_MK Accepted

29 Understanding Medicare Enrollment Periods LOCK IN PERIOD February 14th through October 14th During this time you cannot make changes to 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. 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 or benefit information: (TTY/TDD users call 711) 8:00 a.m. to 8:00 p.m., seven days a week facebook/mycare1st Care1st is a Medicare Advantage HMO plan with a Federal Government and State Medicaid contract in Arizona and California. Enrollment in Care1st Health Plan depends on contract renewal. This information is available for free in other languages. Please contact Member Services: (TTY: 711), 8:00 a.m. to 8:00 p.m., seven days a week. Esta información está disponible gratuitamente en otros idiomas. Comuníquese con Servicios para los Miembros: (TTY 711), de 8:00 a.m. a 8:00 p.m., los siete días de la semana. 請聯絡會員服務熱線電話 : 聽障和語障人士可致電 711 我們的辦公時間為每週七天, 早上 8:00 點至晚上 8:00 點 H5928_14_147_MK Accepted

30 Are You Ready To Enroll? A Medicare approved HMO plan Steps to take to get yourself ready to enroll 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. Apply by Phone Call Care1st at (TTY/TDD users call 711) 8:00 a.m. to 8:00 p.m., seven days a week 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 in Person Meet with your local Care1st representative. 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 Care1st member, call: (TTY/TDD users call 711) 8:00 a.m. to 8:00 p.m., seven days a week facebook/mycare1st Apply by Mail Fill out the enclosed application form completely and mail to: Care1st Health Plan ATTN: ENROLLMENT DEPT 601 Potrero Grande Drive Monterey Park, CA Apply Online Medicare beneficiaries may also enroll in Care1st through the CMS Medicare Online Enrollment Center located at Care1st is a Medicare Advantage HMO plan with a Federal Government and State Medicaid contract in Arizona and California. Enrollment in Care1st Health Plan depends on contract renewal. This information is available for free in other languages. Please contact Member Services: (TTY: 711), 8:00 a.m. to 8:00 p.m., seven days a week. Esta información está disponible gratuitamente en otros idiomas. Comuníquese con Servicios para los Miembros: (TTY 711), de 8:00 a.m. a 8:00 p.m., los siete días de la semana. 請聯絡會員服務熱線電話 : 聽障和語障人士可致電 711 我們的辦公時間為每週七天, 早上 8:00 點至晚上 8:00 點 H5928_14_148_MK Accepted

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32 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) Hours: 8:00 a.m. to 8:00 p.m. Seven days a week Care1st Health Plan P. O. Box 4549 Montebello, CA Member Services: (TTY 711) Hours: 8:00 a.m. to 8:00 p.m. Seven days a week WHITE Enrollment Copy YELLOW Member s Copy H5928_14_088_EN Approved

33 MEDICARE ADVANTAGE INDIVIDUAL ENROLLMENT ELECTION FORM Please contact Care1st if you need information in another language or format (Braille). To Enroll in Care1st, Please Provide the Following Information: Care1st AdvantageOptimum Plan (HMO) Los Angeles/Orange $0/month San Joaquin $0/month Stanislaus $0/month San Bernardino/Riverside/ Fresno $0/month San Diego $0/month Santa Clara $0/month El Paso $0/month San Francisco/Alameda $28/month smarthmo Plan Beneficiaries selecting this plan are exclusively enrolled with the AllCare network of providers. San Joaquin $0/month Coordinated Choice Plan (HMO) Los Angeles, Orange, San Diego, $26.30/month* San Bernardino, Riverside, Santa Clara, Stanislaus, Alameda, San Francisco, Fresno, El Paso 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 $26.90/month* Los Angeles $20.70/month* Alameda/San Francisco/ $28.10/month* Santa Clara Orange/San Bernardino $21.80/month* *Premiums may vary based on the level of Extra Help you receive. Please contact the plan for further details. LAST Name: Doe FIRST Name: John Middle Initial: R. Mr. Mrs. Ms. Birth Date: Sex: Home Phone: Alternate Phone Number: ( 03 / 23 1/ ) (MM/DD/YYYY) M F ( 555 ) ( 555 ) Permanent Residence Street Address (P.O. Box is not allowed): 222 Anywhere St. City: Any Town State: CA ZIP Code: County: Stanislaus Mailing Address (only if different from your Permanent Residence Address): Street Address: City: State: ZIP Code: Emergency contact: Jane Doe Phone Number: Relationship to You: Wife Address: johnrdoe@website.com Please Provide Your Medicare Insurance Information. Please take out your Medicare card to complete this section. 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. You must have Medicare Part A and Part B to join a Medicare Advantage plan. SAMPLE ONLY Name: John R. Doe Medicare Claim Number Sex Is Entitled To HOSPITAL (Part A) MEDICAL (Part B) M Effective Date MM-DD-YYYY MM-DD-YYYY WHITE Enrollment Copy YELLOW Member s Copy H5928_14_088_EN Approved

34 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 Care1st 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 Care1st? 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: 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 Dr. Robert Jones Are you an existing patient of this doctor? Misc. Medical Group Yes No WHITE Enrollment Copy YELLOW Member s Copy H5928_14_088_EN Approved

35 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 Care1st at if you need information in another format or language than what is listed above. Our office hours are from 8:00 a.m. to 8:00 p.m. seven days a week. TTY users should call 711. Please Read This Important Information If you currently have health coverage from an employer or union, joining Care1st could affect your employer or union health benefits. You could lose your employer or union health coverage if you join Care1st. 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: Care1st 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. Care1st serves a specific service area. If I move out of the area that Care1st 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 Care1st, I have the right to appeal plan decisions about payment or services if I disagree. I will read the Evidence of Coverage document from Care1st 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 Care1st coverage begins, I must get all of my health care from Care1st, except for emergency or urgently needed services or out-of-area dialysis services. Services authorized by Care1st and other services contained in my Care1st Evidence of Coverage document (also known as a member contract or subscriber agreement) will be covered. Without authorization, NEITHER MEDICARE NOR Care1st 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 Care1st, he/she may be paid based on my enrollment in Care1st. WHITE Enrollment Copy YELLOW Member s Copy H5928_14_088_EN Approved

36 Release of Information: By joining this Medicare health plan, I acknowledge that Care1st will release my information to Medicare and other plans as is necessary for treatment, payment and health care operations. I also acknowledge that Care1st 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. Signature: John R. Doe Today s Date: MM-DD-YYYY 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: Form Received On: Care1st Agent ID: Agent Phone/ Agent Signature: Date: Care1st Enrollment Office Use Only Name of staff member/agent/broker (if assisted in enrollment): Enrollee ID: Effective Date of Coverage: ICEP/IEP AEP SEP (type): Not Eligible: WHITE Enrollment Copy YELLOW Member s Copy H5928_14_088_EN Approved

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38 INTRODUCTION TO SUMMARY OF BENEFITS SECTION 1 Summary of BenefItS January 1, December 31, 2014 Care1st health plan Care1st TotalDual Plan California: Los Angeles, Orange, San Bernardino, Alameda, San Francisco, and Santa Clara Counties 1 H5928_14_126_TDSB_LASBOCSCALSF Accepted

39 INTRODUCTION TO SUMMARY OF BENEFITS SECTION 1 Thank you for your interest in. Our plan is offered by CARE1ST HEALTH PLAN, a Medicare Advantage Health Maintenance Organization (HMO) Special Needs Plan (SNP) that contracts with the Federal government. 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 and Medicare. All cost sharing in this summary of benefits is based on your level of Medicaid eligibility. Please call to find out if you are eligible to join. Our number is listed at the end of this introduction. This Summary of Benefits tells you some features of our plan. It doesn t list every service we cover or list every limitation or exclusion. To get a complete list of our benefits, please call and ask for the Evidence of Coverage. YOU HAVE ChoICES IN your HEALTH Care As a Medicare beneficiary, you can choose from different Medicare options. One option is the Original (Fee-for-Service) Medicare Plan. Another option is a Medicare health plan, like. You may have other options too. You make the choice. No matter what you decide, you are still in the Medicare Program. If you are eligible for both Medicare and Medicaid (dual eligible) you may join or leave a plan at any time. Please call at the number listed at the end of this introduction or MEDICARE ( ) for more information. TTY/TDD users should call You can call this number 24 hours a day, 7 days a week. HOW Can I Compare MY options? You can compare (HMO SNP) and the Original Medicare Plan using this Summary of Benefits. The charts in this booklet list some important health benefits. For each benefit, you can see what our plan covers and what the Original Medicare Plan covers. Our members receive all of the benefits that the Original Medicare Plan offers. We also offer more benefits, which may change from year to year. 2 Where IS Care1st TotalDual Plan (HMO Snp) AVAIlaBle? The service area for this plan includes: Los Angeles, Orange*, San Bernardino*, Alameda*,San Francisco, and Santa Clara Counties, CA. You must live in one of these areas to join the plan. * denotes partial county ORANGE 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,

40 INTRODUCTION TO SUMMARY OF BENEFITS SECTION 1 ORANGE continued 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, 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, ALAMEDA 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, Who IS ELIGIBle TO JOIN (HMO SNP)? You can join if you are entitled to Medicare Part A and enrolled in Medicare Part B and live in the service area. However, individuals with End-Stage Renal Disease generally are not eligible to enroll in unless they are members of our organization and have been since their dialysis began. You must also receive assistance from the state to join this plan. Please call the plan to see if you are eligible to join. Can I ChooSE MY DOCtorS? has formed a network of doctors, specialists, and hospitals. You can only use doctors who are part of our network. The health providers in our network can change at any time. You can ask for a current provider directory. For an updated list, visit us at care1stmedicare.com. Our customer service number is listed at the end of this introduction. What HAPPENS IF I GO TO A DOCtor Who S NOT IN your NETWorK? If you choose to go to a doctor outside of our network, you must pay for these services yourself. Neither the plan nor the Original Medicare Plan will pay for these services except in limited situations (for example, emergency care). Where Can I GET MY prescriptions IF I JOIN this PLAN? has formed a network of pharmacies. You must use a network pharmacy to receive plan benefits. We may not pay for your prescriptions if you use an out-ofnetwork pharmacy, except in certain cases. The pharmacies in our network can change at any time. You can ask for a pharmacy directory or visit us at Our customer service number is listed at the end of this introduction. What IF MY DOCtor prescribes LESS THAN A month S Supply? In consultation with your doctor or pharmacist, you may receive less than a month s supply of certain drugs. Also, if you live in a long-term care facility, you will receive less than a month s 3

41 INTRODUCTION TO SUMMARY OF BENEFITS SECTION 1 supply of certain brand [and generic] drugs. Dispensing fewer drugs at a time can help reduce cost and waste in the Medicare Part D program, when this is medically appropriate. The amount you pay in these circumstances will depend on whether you are responsible for paying coinsurance (a percentage of the cost of the drug) or a copay (a flat dollar amount for the drug). If you are responsible for coinsurance for the drug, you will continue to pay the applicable percentage of the drug cost. If you are responsible for a copay for the drug, a daily cost-sharing rate will be applied. If your doctor decides to continue the drug after a trial period, you should not pay more for a month s supply than you otherwise would have paid. Contact your plan if you have questions about cost-sharing when less than a one-month supply is dispensed. DoeS MY PLAN COVER medicare PART B OR PART D DruGS? does cover both Medicare Part B prescription drugs and Medicare Part D prescription drugs. What IS A PRESCRIptIon DruG FORMULARY? uses a formulary. A formulary is a list of drugs covered by your plan to meet patient needs. We may periodically add, remove, or make changes to coverage limitations on certain drugs or change how much you pay for a drug. If we make any formulary change that limits our members ability to fill their prescriptions, we will notify the affected members before the change is made. We will send a formulary to you and you can see our complete formulary on our website at If you are currently taking a drug that is not on our formulary or subject to additional requirements or limits, you may be able to get a temporary supply of the drug. You can contact us to request an exception or switch to an alternative drug listed on our formulary with your physician s help. Call us to see if you can get a temporary supply of the drug or for more details about our drug transition policy. HOW Can I GET EXtra HELP WITH MY prescription DruG plan COSTS OR GET EXtra HELP WITH OTHER medicare COSTS? You may be able to get extra help to pay for your prescription drug premiums and costs as well as get help with other Medicare costs. To see if you qualify for getting extra help, call: MEDICARE ( ). TTY/ TDD users should call , 24 hours a day/7 days a week; and see Programs for People with Limited Income and Resources in the publication Medicare & You. The Social Security Administration at between 7 a.m. and 7 p.m., Monday through Friday. TTY/TDD users should call ; or Your State Medicaid Office. What ARE MY protections IN THIS plan? All Medicare Advantage Plans agree to stay in the program for a full calendar year at a time. Plan benefits and cost-sharing may change from calendar year to calendar year. Each year, plans can decide whether to continue to participate with Medicare Advantage. A plan may continue in their entire service area (geographic area where the plan accepts members) or choose to continue only in certain areas. Also, Medicare may decide to end a contract with a plan. Even if your Medicare Advantage Plan leaves the program, you will not lose Medicare coverage. If a plan decides not to continue for an additional calendar year, it must send you a letter at least 90 days before your coverage will end. The letter will explain your options for Medicare coverage in your area. 4

42 INTRODUCTION TO SUMMARY OF BENEFITS SECTION 1 As a member of, you have the right to request an organization determination, which includes the right to file an appeal if we deny coverage for an item or service, and the right to file a grievance. You have the right to request an organization determination if you want us to provide or pay for an item or service that you believe should be covered. If we deny coverage for your requested item or service, you have the right to appeal and ask us to review our decision. You may ask us for an expedited (fast) coverage determination or appeal if you believe that waiting for a decision could seriously put your life or health at risk, or affect your ability to regain maximum function. If your doctor makes or supports the expedited request, we must expedite our decision. Finally, you have the right to file a grievance with us if you have any type of problem with us or one of our network providers that does not involve coverage for an item or service. If your problem involves quality of care, you also have the right to file a grievance with the Quality Improvement Organization (QIO) for your state. Please refer to the Evidence of Coverage (EOC) for the QIO contact information. As a member of (HMO SNP), you have the right to request a coverage determination, which includes the right to request an exception, the right to file an appeal if we deny coverage for a prescription drug, and the right to file a grievance. You have the right to request a coverage determination if you want us to cover a Part D drug that you believe should be covered. An exception is a type of coverage determination. You may ask us for an exception if you believe you need a drug that is not on our list of covered drugs or believe you should get a non-preferred drug at a lower out-of-pocket cost. You can also ask for an exception to cost utilization rules, such as a limit on the quantity of a drug. If you think you need an exception, you should contact us before you try to fill your prescription at a pharmacy. Your doctor must provide a statement to support your exception request. If we deny coverage for your prescription drug(s), you have the right to appeal and ask us to review our decision. Finally, you have the right to file a grievance if you have any type of problem with us or one of our network pharmacies that does not involve coverage for a prescription drug. If your problem involves quality of care, you also have the right to file a grievance with the Quality Improvement Organization (QIO) for your state. Please refer to the Evidence of Coverage (EOC) for the QIO contact information. What IS A MEDICatIon therapy MANAGement (MTM) PROGram? A Medication Therapy Management (MTM) Program is a free service we offer. You may be invited to participate in a program designed for your specific health and pharmacy needs. You may decide not to participate but it is recommended that you take full advantage of this covered service if you are selected. Contact Care1st TotalDual Plan for more details. What TYPES OF DruGS may BE COVereD UNDER medicare PART B? Some outpatient prescription drugs may be covered under Medicare Part B. These may include, but are not limited to, the following types of drugs. Contact for more details. -- Some Antigens: If they are prepared by a doctor and administered by a properly instructed person (who could be the patient) under doctor supervision. -- Osteoporosis Drugs: Injectable osteoporosis drugs for some women. -- Erythropoietin: By injection if you have endstage renal disease (permanent kidney failure requiring either dialysis or transplantation) and need this drug to treat anemia. -- Hemophilia Clotting Factors: Self-administered clotting factors if you have hemophilia. -- Injectable Drugs: Most injectable drugs administered incident to a physicians service. -- Immunosuppressive Drugs: Immunosuppressive drug therapy for transplant patients if the transplant took place in a Medicare-certified 5

43 INTRODUCTION TO SUMMARY OF BENEFITS SECTION 1 facility and was paid for by Medicare or by a private insurance company that was the primary payer for Medicare Part A coverage. -- Some Oral Cancer Drugs: If the same drug is available in injectable form. -- Oral Anti-Nausea Drugs: If you are part of an anti-cancer chemotherapeutic regimen. -- Inhalation and Infusion Drugs administered through Durable Medical Equipment. Where Can I FIND InformatION ON PLAN ratings? The Medicare program rates how well plans perform in different categories (for example, detecting and preventing illness, ratings from patients and customer service). If you have access to the web, you can find the plan ratings information by using the find health and drug plans web tool on to compare the plan ratings for Medicare plans in your area. You can also call us directly to obtain a copy of the plan ratings for this plan. Our customer service number is listed below. Please call Care1st Health Plan for more information about (HMO Snp). Visit us at or, call us: Customer Service Hours for October 1 February 14: Sunday, Monday, Tuesday, Wednesday, Thursday, Friday, Saturday, 8:00 a.m. - 8:00 p.m. Pacific Customer Service Hours for February 15 September 30: Monday, Tuesday, Wednesday, Thursday, Friday, 8:00 a.m. - 8:00 p.m. Pacific Current members should call toll-free (800) for questions related to the Medicare Advantage Program. (TTY/TDD 711) Prospective members should call toll-free (800) for questions related to the Medicare Advantage Program. (TTY/TDD 711) Current members should call locally (800) for questions related to the Medicare Advantage Program. (TTY/TDD 711) Prospective members should call locally (800) for questions related to the Medicare Advantage Program. (TTY/TDD 711) Current members should call toll-free (800) for questions related to themedicare Part D Prescription Drug program. (TTY/TDD 711) Prospective members should call toll-free (800) for questions related to the Medicare Part D Prescription Drug program.(tty/ TDD 711) Current members should call locally (800) for questions related to the Medicare Part D Prescription Drug program. (TTY/TDD 711) Prospective members should call locally (800) for questions related to the Medicare Part D Prescription Drug program. (TTY/TDD 711) For more information about Medicare, please call Medicare at MEDICARE ( ). TTY users should call You can call 24 hours a day, 7 days a week. Or, visit on the web. This document may be available in other formats such as Braille, large print or other alternate formats. This document may be available in a non- English language. For additional information, call customer service at the phone number listed above. Este documento puede ser disponible en un idioma que no sea inglés. Para obtener más información, llame al servicio al cliente al número de teléfono indicado arriba. 此文件包括其他語言 若需要獲得更多資訊, 請撥打以上所列的電話號碼聯絡我們的會員服務部 6

44 SUMMARY OF BENEFITS SECTION 2 Summary of BenefItS Section 2 - If you have any questions about this plan s benefits or costs, please contact Care1st Health Plan for details. Alameda, San Francisco and Santa Clara Counties BENEFIT ORIGINAL MEDICARE Los Angeles County Orange and San Bernardino Counties IMPORTANT INFORMATION 1 Premium and Other ImporTANT Information The Medicare cost sharing amount may vary based on your level of Medicaid eligibility. In 2013 the monthly Part B Premium was $0 or $ and may change for 2014 and the annual Part B deductible amount was $0 or $147 and may change for 2014.* If a doctor or supplier does not accept assignment, their costs are often higher, which means you pay more. * Depending on your level of Medicaid eligibility, you may not have any cost-sharing responsibility for Original Medicare services $20.70 monthly plan premium in addition to your monthly Medicare Part B premium.* $1 out-of-pocket limit for Medicare-covered services.* * Depending on your level of Medicaid eligibility, you may not have any cost-sharing responsibility for Original Medicare services $21.80 monthly plan premium in addition to your monthly Medicare Part B premium.* $1 out-of-pocket limit for Medicare-covered services.* * Depending on your level of Medicaid eligibility, you may not have any cost-sharing responsibility for Original Medicare services $28.10 monthly plan premium in addition to your monthly Medicare Part B premium.* $1 out-of-pocket limit for Medicare-covered services.* 7

45 SUMMARY OF BENEFITS SECTION 2 Alameda, San Francisco and Santa Clara Counties You must go to network doctors, specialists, and hospitals. Referral required for network hospitals and specialists (for certain benefits). No limit to the number of days covered by the plan each hospital stay. $0 copay Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital. BENEFIT ORIGINAL MEDICARE Los Angeles County Orange and San Bernardino Counties IMPORTANT INFORMATION (Continued) 2 Doctor and Hospital Choice (For more information, see Emergency Care #15 and Urgently Needed Care -#16.) You may go to any doctor, specialist or hospital that accepts Medicare. You must go to network doctors, specialists, and hospitals. Referral required for network hospitals and specialists (for certain benefits). You must go to network doctors, specialists, and hospitals. Referral required for network hospitals and specialists (for certain benefits). INPATIENT CARE 3 Inpatient Hospital Care (includes Substance Abuse and Rehabilitation Services) In 2013 the amounts for each benefit period were $0 or: Days 1-60: $1,184 deductible* Days 61-90: $296 per day* Days : $592 per lifetime reserve day* These amounts may change for No limit to the number of days covered by the plan each hospital stay. $0 copay Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital. No limit to the number of days covered by the plan each hospital stay. $0 copay Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital. 8

46 SUMMARY OF BENEFITS SECTION 2 Alameda, San Francisco and Santa Clara Counties BENEFIT ORIGINAL MEDICARE Los Angeles County Orange and San Bernardino Counties INPATIENT CARE (Continued) 3 Inpatient Hospital Care (includes Substance Abuse and Rehabilitation Services) (continued) Call MEDICARE ( ) for information about lifetime reserve days. Lifetime reserve days can only be used once. A benefit period starts the day you go into a hospital or skilled nursing facility. It ends when you go for 60 days in a row without hospital or skilled nursing care. If you go into the hospital after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods you can have. 9

47 SUMMARY OF BENEFITS SECTION 2 Alameda, San Francisco and Santa Clara Counties You get up to 190 days of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital. $0 copay Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital. BENEFIT ORIGINAL MEDICARE Los Angeles County Orange and San Bernardino Counties INPATIENT CARE (Continued) 4 Inpatient Mental Health Care In 2013 the amounts for each benefit period were $0 or: Days 1-60: $1,184 deductible* Days 61-90: $296 per day* Days : $592 per lifetime reserve day* These amounts may change for You get up to 190 days of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital. You get up to 190 days of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital. $0 copay Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital. You get up to 190 days of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital. $0 copay Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital. 10

48 SUMMARY OF BENEFITS SECTION 2 Alameda, San Francisco and Santa Clara Counties Authorization rules may apply. Plan covers up to 100 days each benefit period No prior hospital stay is required. $0 copay for SNF services BENEFIT ORIGINAL MEDICARE Los Angeles County Orange and San Bernardino Counties INPATIENT CARE (Continued) 5 Skilled Nursing Facility (SNF) (in a Medicare-certified skilled nursing facility) In 2013 the amounts for each benefit period after at least a 3-day Medicare-covered hospital stay were: Days 1-20: $0 per day* Days : $0 or $148 per day* These amounts may change for days for each benefit period. Authorization rules may apply. Plan covers up to 100 days each benefit period No prior hospital stay is required. $0 copay for SNF services Authorization rules may apply. Plan covers up to 100 days each benefit period No prior hospital stay is required. $0 copay for SNF services 11

49 SUMMARY OF BENEFITS SECTION 2 Alameda, San Francisco and Santa Clara Counties Authorization rules may apply. $0 copay for Medicarecovered home health visits* BENEFIT ORIGINAL MEDICARE Los Angeles County Orange and San Bernardino Counties INPATIENT CARE (Continued) 5 Skilled Nursing Facility (SNF) (in a Medicare-certified skilled nursing facility) (continued) A benefit period starts the day you go into a hospital or SNF. It ends when you go for 60 days in a row without hospital or skilled nursing care. If you go into the hospital after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods you can have. 6 Home Health Care (includes medically necessary intermittent skilled nursing care, home health aide services, and rehabilitation services, etc.) $0 copay. Authorization rules may apply. $0 copay for Medicarecovered home health visits* Authorization rules may apply. $0 copay for Medicarecovered home health visits* 12

50 SUMMARY OF BENEFITS SECTION 2 Alameda, San Francisco and Santa Clara Counties You must get care from a Medicare-certified hospice. You must consult with your plan before you select hospice. BENEFIT ORIGINAL MEDICARE Los Angeles County Orange and San Bernardino Counties INPATIENT CARE (Continued) 7 Hospice You pay part of the cost for outpatient drugs and inpatient respite care. You must get care from a Medicare-certified hospice. You must get care from a Medicare-certified hospice. You must consult with your plan before you select hospice. You must get care from a Medicare-certified hospice. You must consult with your plan before you select hospice. 13

51 SUMMARY OF BENEFITS SECTION 2 Alameda, San Francisco and Santa Clara Counties Authorization rules may apply. $0 copay for each Medicarecovered primary care doctor visit.* $0 copay for each Medicarecovered specialist visit.* Authorization rules may apply. $0 copay for Medicarecovered chiropractic visits* up to 15 supplemental routine chiropractic visit(s) every year Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part). BENEFIT ORIGINAL MEDICARE Los Angeles County Orange and San Bernardino Counties OUTPATIENT CARE 8 Doctor Office Visits 0% or 20% coinsurance. Authorization rules may apply. $0 copay for each Medicarecovered primary care doctor visit.* $0 copay for each Medicarecovered specialist visit.* Authorization rules may apply. $0 copay for each Medicarecovered primary care doctor visit.* $0 copay for each Medicarecovered specialist visit.* 9 Chiropractic Services Supplemental routine care not covered 0% or 20% coinsurance for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part) if you get it from a chiropractor or other qualified providers. Authorization rules may apply. $0 copay for Medicarecovered chiropractic visits* up to 15 supplemental routine chiropractic visit(s) every year Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part). Authorization rules may apply. $0 copay for Medicarecovered chiropractic visits* up to 15 supplemental routine chiropractic visit(s) every year Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part). 14

52 SUMMARY OF BENEFITS SECTION 2 Alameda, San Francisco and Santa Clara Counties Authorization rules may apply. $0 copay for Medicarecovered podiatry visits* supplemental routine podiatry visits Medicare-covered podiatry visits are for medically necessary foot care. Authorization rules may apply. $0 copay for: -each Medicare-covered individual therapy visit* -each Medicare-covered group therapy visit* BENEFIT ORIGINAL MEDICARE Los Angeles County Orange and San Bernardino Counties OUTPATIENT CARE (Continued) 10 Podiatry Services Supplemental routine care not covered. 0% or 20% coinsurance for medically necessary foot care, including care for medical conditions affecting the lower limbs. Authorization rules may apply. $0 copay for Medicarecovered podiatry visits* Authorization rules may apply. $0 copay for Medicarecovered podiatry visits* supplemental routine podiatry visits supplemental routine podiatry visits Medicare-covered podiatry visits are for medically necessary foot care. Medicare-covered podiatry visits are for medically necessary foot care. 11 Outpatient Mental Health Care 0% or 20% coinsurance for most outpatient mental health services 0% or 20% coinsurance of the Medicareapproved amount for each service you get from a qualified professional as part of a Partial Hospitalization Program. Authorization rules may apply. $0 copay for: -each Medicare-covered individual therapy visit* -each Medicare-covered group therapy visit* Authorization rules may apply. $0 copay for: -each Medicare-covered individual therapy visit* -each Medicare-covered group therapy visit* 15

53 SUMMARY OF BENEFITS SECTION 2 Alameda, San Francisco and Santa Clara Counties $0 copay for: -each Medicare-covered individual therapy visit with a psychiatrist* -each Medicare-covered group therapy visit with a psychiatrist* $0 copay for Medicarecovered partial hospitalization program services* Authorization rules may apply. $0 copay for: -each Medicare-covered individual substance abuse outpatient treatment visit* BENEFIT ORIGINAL MEDICARE Los Angeles County Orange and San Bernardino Counties OUTPATIENT CARE (Continued) 11 Outpatient Mental Health Care (continued) Partial hospitalization program is a structured program of active outpatient psychiatric treatment that is more intense than the care received in your doctor s or therapist s office and is an alternative to inpatient hospitalization. $0 copay for: -each Medicare-covered individual therapy visit with a psychiatrist* -each Medicare-covered group therapy visit with a psychiatrist* $0 copay for Medicarecovered partial hospitalization program services* $0 copay for: -each Medicare-covered individual therapy visit with a psychiatrist* -each Medicare-covered group therapy visit with a psychiatrist* $0 copay for Medicarecovered partial hospitalization program services* 12 Outpatient Substance Abuse Care 0% or 20% coinsurance. Authorization rules may apply. $0 copay for: -each Medicare-covered individual substance abuse outpatient treatment visit* Authorization rules may apply. $0 copay for: -each Medicare-covered individual substance abuse outpatient treatment visit* 16

54 SUMMARY OF BENEFITS SECTION 2 Alameda, San Francisco and Santa Clara Counties - each Medicare-covered group substance abuse outpatient treatment visit* Authorization rules may apply. $0 copay for each Medicarecovered ambulatory surgical center visit* $0 copay for each Medicarecovered outpatient hospital facility visit* BENEFIT ORIGINAL MEDICARE Los Angeles County Orange and San Bernardino Counties OUTPATIENT CARE (Continued) 12 Outpatient Substance Abuse Care (continued) - each Medicare-covered group substance abuse outpatient treatment visit* - each Medicare-covered group substance abuse outpatient treatment visit* 13 Outpatient SERVICES 0% or 20% coinsurance for the doctor s services Specified copayment for outpatient hospital facility services Copay cannot exceed the Part A inpatient hospital deductible. 0% or 20% coinsurance for ambulatory surgical center facility services Authorization rules may apply. $0 copay for each Medicarecovered ambulatory surgical center visit* $0 copay for each Medicarecovered outpatient hospital facility visit* Authorization rules may apply. $0 copay for each Medicarecovered ambulatory surgical center visit* $0 copay for each Medicarecovered outpatient hospital facility visit* 17

55 SUMMARY OF BENEFITS SECTION 2 Alameda, San Francisco and Santa Clara Counties Authorization rules may apply. $0 copay for Medicarecovered ambulance benefits.* $0 copay for Medicarecovered emergency room visits* $25,000 plan coverage limit for supplemental emergency services outside the U.S. and its territories every year. BENEFIT ORIGINAL MEDICARE Los Angeles County Orange and San Bernardino Counties OUTPATIENT CARE (Continued) 14 Ambulance Services (medically necessary ambulance services) 0% or 20% coinsurance Authorization rules may apply. $0 copay for Medicarecovered ambulance benefits.* Authorization rules may apply. $0 copay for Medicarecovered ambulance benefits.* 15 Emergency Care (You may go to any emergency room if you reasonably believe you need emergency care.) 0% or 20% coinsurance for the doctor s services Specified copayment for outpatient hospital facility emergency services. Emergency services copay cannot exceed Part A inpatient hospital deductible for each service provided by the hospital. $0 copay for Medicarecovered emergency room visits* $25,000 plan coverage limit for supplemental emergency services outside the U.S. and its territories every year. $0 copay for Medicarecovered emergency room visits* $25,000 plan coverage limit for supplemental emergency services outside the U.S. and its territories every year. 18

56 SUMMARY OF BENEFITS SECTION 2 Alameda, San Francisco and Santa Clara Counties $0 copay for Medicarecovered urgently-neededcare visits* BENEFIT ORIGINAL MEDICARE Los Angeles County Orange and San Bernardino Counties OUTPATIENT CARE (Continued) 15 Emergency Care (You may go to any emergency room if you reasonably believe you need emergency care.) (continued) You don t have to pay the emergency room copay if you are admitted to the hospital as an inpatient for the same condition within 3 days of the emergency room visit. Not covered outside the U.S. except under limited circumstances. 16 0% or 20% coinsurance Urgently-Needed Care (This is NOT emergency care, and in most cases, is out of the service area.) If you are admitted to the hospital within 3 days for the same condition, you pay $0 for the urgently-needed-care visit. NOT covered outside the U.S. except under limited circumstances. $0 copay for Medicarecovered urgently-neededcare visits* $0 copay for Medicarecovered urgently-neededcare visits* 19

57 SUMMARY OF BENEFITS SECTION 2 Alameda, San Francisco and Santa Clara Counties Authorization rules may apply. Medically necessary physical therapy, occupational therapy, and speech and language pathology services are covered. $0 copay for Medicarecovered Occupational Therapy visits* $0 copay for Medicarecovered Physical Therapy and/or Speech and Language Pathology visits* BENEFIT ORIGINAL MEDICARE Los Angeles County Orange and San Bernardino Counties OUTPATIENT CARE (Continued) 17 0% or 20% coinsurance. Outpatient Rehabilitation Services (Occupational Therapy, Physical Therapy, Speech and Language Therapy) Medically necessary physical therapy, occupational therapy, and speech and language pathology services are covered. Authorization rules may apply. Medically necessary physical therapy, occupational therapy, and speech and language pathology services are covered. Authorization rules may apply. Medically necessary physical therapy, occupational therapy, and speech and language pathology services are covered. $0 copay for Medicarecovered Occupational Therapy visits* $0 copay for Medicarecovered Occupational Therapy visits* $0 copay for Medicarecovered Physical Therapy and/or Speech and Language Pathology visits* $0 copay for Medicarecovered Physical Therapy and/or Speech and Language Pathology visits* 20

58 SUMMARY OF BENEFITS SECTION 2 Alameda, San Francisco and Santa Clara Counties Authorization rules may apply. $0 copay for Medicarecovered durable medical equipment* Authorization rules may apply. $0 copay for Medicarecovered: -prosthetic devices* - medical supplies related to prosthetics, splints, and other devices* BENEFIT ORIGINAL MEDICARE Los Angeles County Orange and San Bernardino Counties OUTPATIENT MEDICAL SERVICES AND SUPPLIES 18 Durable Medical Equipment (includes wheelchairs, oxygen, etc.) 0% or 20% coinsurance. Authorization rules may apply. $0 copay for Medicarecovered durable medical equipment* Authorization rules may apply. $0 copay for Medicarecovered durable medical equipment* 19 0% or 20% coinsurance. Prosthetic Devices (includes braces, artificial limbs and eyes, etc.) 0% or 20% coinsurance for Medicare-covered medical supplies related to prosthetics, splints, and other devices. Authorization rules may apply. $0 copay for Medicarecovered: Authorization rules may apply. $0 copay for Medicarecovered: -prosthetic devices* -prosthetic devices* - medical supplies related to prosthetics, splints, and other devices* - medical supplies related to prosthetics, splints, and other devices* 21

59 SUMMARY OF BENEFITS SECTION 2 Alameda, San Francisco and Santa Clara Counties Authorization rules may apply. $0 copay for Medicarecovered Diabetes selfmanagement training* $0 copay for Medicarecovered: -Diabetes monitoring supplies* -Therapeutic shoes or inserts* BENEFIT ORIGINAL MEDICARE Los Angeles County Orange and San Bernardino Counties OUTPATIENT MEDICAL SERVICES AND SUPPLIES (Continued) 20 Diabetes Programs and Supplies 0% or 20% coinsurance for diabetes self-management training 0% or 20% coinsurance for diabetes supplies 0% or 20% coinsurance for diabetic therapeutic shoes or inserts Authorization rules may apply. $0 copay for Medicarecovered Diabetes selfmanagement training* Authorization rules may apply. $0 copay for Medicarecovered Diabetes selfmanagement training* $0 copay for Medicarecovered: -Diabetes monitoring supplies* -Therapeutic shoes or inserts* $0 copay for Medicarecovered: -Diabetes monitoring supplies* -Therapeutic shoes or inserts* 22

60 SUMMARY OF BENEFITS SECTION 2 Alameda, San Francisco and Santa Clara Counties Authorization rules may apply. $0 copay for Medicarecovered: - lab services* - diagnostic procedures and tests* - X-rays* - diagnostic radiology services (not including X-rays)* -therapeutic radiology services* BENEFIT ORIGINAL MEDICARE Los Angeles County Orange and San Bernardino Counties OUTPATIENT MEDICAL SERVICES AND SUPPLIES (Continued) 21 Diagnostic Tests, X-Rays, Lab Services, and Radiology Services 0% or 20% coinsurance for diagnostic tests and x-rays $0 copay for Medicarecovered lab services Lab Services: Medicare covers medically necessary diagnostic lab services that are ordered by your treating doctor when they are provided by a Clinical Laboratory Improvement Amendments (CLIA) certified laboratory that participates in Medicare. Diagnostic lab services are done to help your doctor diagnose or rule out a suspected illness or condition. Medicare does not cover most supplemental routine screening tests, like checking your cholesterol. Authorization rules may apply. $0 copay for Medicarecovered: - lab services* - diagnostic procedures and tests* - X-rays* - diagnostic radiology services (not including X-rays)* - therapeutic radiology services* Authorization rules may apply. $0 copay for Medicarecovered: - lab services* - diagnostic procedures and tests* - X-rays* - diagnostic radiology services (not including X-rays)* - therapeutic radiology services* 23

61 SUMMARY OF BENEFITS SECTION 2 Alameda, San Francisco and Santa Clara Counties Authorization rules may apply. $0 copay for: -Medicare-covered Cardiac Rehabilitation Services* -Medicare-covered Intensive Cardiac Rehabilitation Services* - Medicare-covered Pulmonary Rehabilitation Services* BENEFIT ORIGINAL MEDICARE Los Angeles County Orange and San Bernardino Counties OUTPATIENT MEDICAL SERVICES AND SUPPLIES (Continued) 22 Cardiac and Pulmonary Rehabilitation Services 0% or 20% coinsurance for Cardiac Rehabilitation services 0% or 20% coinsurance for Pulmonary Rehabilitation services 0% or 20% coinsurance for Intensive Cardiac Rehabilitation services Authorization rules may apply. $0 copay for: -Medicare-covered Cardiac Rehabilitation Services* -Medicare-covered Intensive Cardiac Rehabilitation Services* Authorization rules may apply. $0 copay for: -Medicare-covered Cardiac Rehabilitation Services* -Medicare-covered Intensive Cardiac Rehabilitation Services* - Medicare-covered Pulmonary Rehabilitation Services* - Medicare-covered Pulmonary Rehabilitation Services* 24

62 SUMMARY OF BENEFITS SECTION 2 Alameda, San Francisco and Santa Clara Counties Authorization rules may apply. $0 copay for all preventive services covered under Original Medicare at zero cost sharing. Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare. Authorization rules may apply. Plan covers a physical exam annually. BENEFIT ORIGINAL MEDICARE Los Angeles County Orange and San Bernardino Counties PREVENTIVE SERVICES 23 Preventive Services No coinsurance, copayment or deductible for the following: - Abdominal Aortic Aneurysm Screening - Bone Mass Measurement. Covered once every 24 months (more often if medically necessary) if you meet certain medical conditions. - Cardiovascular Screening - Cervical and Vaginal Cancer Screening. Covered once every 2 years. Covered once a year for women with Medicare at high risk. - Colorectal Cancer Screening - Diabetes Screening - Influenza Vaccine - Hepatitis B Vaccine for people with Medicare who are at risk Authorization rules may apply. $0 copay for all preventive services covered under Original Medicare at zero cost sharing. Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare. Authorization rules may apply. Plan covers a physical exam annually. Authorization rules may apply. $0 copay for all preventive services covered under Original Medicare at zero cost sharing. Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare. Authorization rules may apply. Plan covers a physical exam annually. 25

63 SUMMARY OF BENEFITS SECTION 2 Alameda, San Francisco and Santa Clara Counties BENEFIT ORIGINAL MEDICARE Los Angeles County Orange and San Bernardino Counties PREVENTIVE SERVICES 23 Preventive Services (continued) - HIV Screening. $0 copay for the HIV screening, but you generally pay 20% of the Medicare-approved amount for the doctors visit. HIV screening is covered for people with Medicare who are pregnant and people at increased risk for the infection, including anyone who asks for the test. Medicare covers this test once every 12 months or up to three times during a pregnancy. - Breast Cancer Screening (Mammogram). Medicare covers screening mammograms once every 12 months for all women with Medicare age 40 and older. Medicare covers one baseline mammogram for women between ages

64 SUMMARY OF BENEFITS SECTION 2 Alameda, San Francisco and Santa Clara Counties BENEFIT ORIGINAL MEDICARE Los Angeles County Orange and San Bernardino Counties PREVENTIVE SERVICES (Continued) 23 Preventive Services (continued) - Medical Nutrition Therapy Services Nutrition therapy is for people who have diabetes or kidney disease (but arent on dialysis or havent had a kidney transplant) when referred by a doctor. These services can be given by a registered dietitian and may include a nutritional assessment and counseling to help you manage your diabetes or kidney disease. - Personalized Prevention Plan Services (Annual Wellness Visits). - Pneumococcal Vaccine. You may only need the Pneumonia vaccine once in your lifetime. Call your doctor for more information. - Prostate Cancer Screening 27

65 SUMMARY OF BENEFITS SECTION 2 Alameda, San Francisco and Santa Clara Counties BENEFIT ORIGINAL MEDICARE Los Angeles County Orange and San Bernardino Counties PREVENTIVE SERVICES (Continued) 23 Preventive Services (continued) - Prostate Specific Antigen (PSA) test only. Covered once a year for all men with Medicare over age Smoking and Tobacco Use Cessation (counseling to stop smoking and tobacco use). Covered if ordered by your doctor. Includes two counseling attempts within a 12-month period. Each counseling attempt includes up to four face-toface visits. Screening and behavioral counseling interventions in primary care to reduce alcohol misuse - Screening for depression in adults - Screening for sexually transmitted infections (STI) and high-intensity behavioral counseling to prevent STIs 28

66 SUMMARY OF BENEFITS SECTION 2 Alameda, San Francisco and Santa Clara Counties BENEFIT ORIGINAL MEDICARE Los Angeles County Orange and San Bernardino Counties PREVENTIVE SERVICES (Continued) 23 Preventive Services (continued) - Intensive behavioral counseling for Cardiovascular Disease (biannual) - Intensive behavioral therapy for obesity - Welcome to Medicare Preventive Visits (initial preventive physical exam) When you join Medicare Part B, then you are eligible as follows. During the first 12 months of your new Part B coverage, you can get either a Welcome to Medicare Preventive Visits or an Annual Wellness Visit. After your first 12 months, you can get one Annual Wellness Visit every 12 months. 29

67 SUMMARY OF BENEFITS SECTION 2 Alameda, San Francisco and Santa Clara Counties Authorization rules may apply. $0 copay for Medicarecovered renal dialysis* $0 copay for Medicarecovered kidney disease education services* Drugs covered under Medicare Part B $0 yearly deductible for Medicare Part B drugs.* $0 copay for Medicare Part B drugs. $0 copay for Part B chemotherapy drugs and other Part-B drugs.* BENEFIT ORIGINAL MEDICARE Los Angeles County Orange and San Bernardino Counties PREVENTIVE SERVICES (Continued) 24 Kidney Disease and Conditions 0% or 20% coinsurance for renal dialysis 0% or 20% coinsurance for kidney disease education services Authorization rules may apply. $0 copay for Medicarecovered renal dialysis* Authorization rules may apply. $0 copay for Medicarecovered renal dialysis* $0 copay for Medicarecovered kidney disease education services* $0 copay for Medicarecovered kidney disease education services* PRESCRIPTION DRUG BENEFITS 25 Outpatient Prescription Drugs Most drugs are not covered under Original Medicare. You can add prescription drug coverage to Original Medicare by joining a Medicare Prescription Drug Plan, or you can get all your Medicare coverage, including prescription drug coverage, by joining a Medicare Advantage Plan or a Medicare Cost Plan that offers prescription drug coverage. Drugs covered under Medicare Part B $0 yearly deductible for Medicare Part B drugs.* $0 copay for Medicare Part B drugs. $0 copay for Part B chemotherapy drugs and other Part-B drugs.* Drugs covered under Medicare Part B $0 yearly deductible for Medicare Part B drugs.* $0 copay for Medicare Part B drugs. $0 copay for Part B chemotherapy drugs and other Part-B drugs.* 30

68 SUMMARY OF BENEFITS SECTION 2 Alameda, San Francisco and Santa Clara Counties Drugs covered under Medicare Part D This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at on the web. Different out-of-pocket costs may apply for people who - have limited incomes, - live in long term care facilities, or - have access to Indian/ Tribal/Urban (Indian Health Service) providers. The plan offers national in-network prescription coverage (i.e., this would include 50 states and the District of Columbia). This means that you will pay the same costsharing amount for your prescription drugs BENEFIT ORIGINAL MEDICARE Los Angeles County Orange and San Bernardino Counties PRESCRIPTION DRUG BENEFITS (Continued) 25 Outpatient Prescription Drugs (continued) Drugs covered under Medicare Part D This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at on the web. Different out-of-pocket costs may apply for people who - have limited incomes, - live in long term care facilities, or - have access to Indian/ Tribal/Urban (Indian Health Service) providers. The plan offers national in-network prescription coverage (i.e., this would include 50 states and the District of Columbia). This means that you will pay the same costsharing amount for your prescription drugs Drugs covered under Medicare Part D This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at on the web. Different out-of-pocket costs may apply for people who - have limited incomes, - live in long term care facilities, or - have access to Indian/ Tribal/Urban (Indian Health Service) providers. The plan offers national in-network prescription coverage (i.e., this would include 50 states and the District of Columbia). This means that you will pay the same costsharing amount for your prescription drugs 31

69 SUMMARY OF BENEFITS SECTION 2 Alameda, San Francisco and Santa Clara Counties if you get them at an innetwork pharmacy outside of the plan s service area (for instance when you travel). Total yearly drug costs are the total drug costs paid by you, the plan, and Medicare. The plan may require you to first try one drug to treat your condition before it will cover another drug for that condition. Some drugs have quantity limits. Your provider must get prior authorization from Care1st TotalDual Plan for certain drugs. The plan will pay for certain over-the-counter drugs as part of its utilization management program. BENEFIT ORIGINAL MEDICARE Los Angeles County Orange and San Bernardino Counties PRESCRIPTION DRUG BENEFITS (Continued) 25 Outpatient Prescription Drugs (continued) if you get them at an innetwork pharmacy outside of the plan s service area (for instance when you travel). Total yearly drug costs are the total drug costs paid by you, the plan, and Medicare. The plan may require you to first try one drug to treat your condition before it will cover another drug for that condition. Some drugs have quantity limits. Your provider must get prior authorization from Care1st TotalDual Plan for certain drugs. The plan will pay for certain over-the-counter drugs as part of its utilization management program. if you get them at an innetwork pharmacy outside of the plan s service area (for instance when you travel). Total yearly drug costs are the total drug costs paid by you, the plan, and Medicare. The plan may require you to first try one drug to treat your condition before it will cover another drug for that condition. Some drugs have quantity limits. Your provider must get prior authorization from Care1st TotalDual Plan for certain drugs. The plan will pay for certain over-the-counter drugs as part of its utilization management program. 32

70 SUMMARY OF BENEFITS SECTION 2 Alameda, San Francisco and Santa Clara Counties Some over-the-counter drugs are less expensive than prescription drugs and work just as well. Contact the plan for details. You must go to certain pharmacies for a very limited number of drugs, due to special handling, provider coordination, or patient education requirements that cannot be met by most pharmacies in your network. These drugs are listed on the plan s website, formulary, printed materials, as well as on the Medicare Prescription Drug Plan Finder on Medicare.gov. If the actual cost of a drug is less than the normal costsharing amount for that drug, you will pay the actual cost, not the higher cost-sharing amount. BENEFIT ORIGINAL MEDICARE Los Angeles County Orange and San Bernardino Counties PRESCRIPTION DRUG BENEFITS (Continued) 25 Outpatient Prescription Drugs (continued) Some over-the-counter drugs are less expensive than prescription drugs and work just as well. Contact the plan for details. You must go to certain pharmacies for a very limited number of drugs, due to special handling, provider coordination, or patient education requirements that cannot be met by most pharmacies in your network. These drugs are listed on the plan s website, formulary, printed materials, as well as on the Medicare Prescription Drug Plan Finder on Medicare.gov. If the actual cost of a drug is less than the normal costsharing amount for that drug, you will pay the actual cost, not the higher cost-sharing amount. Some over-the-counter drugs are less expensive than prescription drugs and work just as well. Contact the plan for details. You must go to certain pharmacies for a very limited number of drugs, due to special handling, provider coordination, or patient education requirements that cannot be met by most pharmacies in your network. These drugs are listed on the plan s website, formulary, printed materials, as well as on the Medicare Prescription Drug Plan Finder on Medicare.gov. If the actual cost of a drug is less than the normal costsharing amount for that drug, you will pay the actual cost, not the higher cost-sharing amount. 33

71 SUMMARY OF BENEFITS SECTION 2 Alameda, San Francisco and Santa Clara Counties If you request a formulary exception for a drug and approves the exception, you will pay the generic cost share for generic drugs and the brand cost share for brand drugs. You pay a $0 annual deductible. Initial Coverage Depending on your income and institutional status, you pay the following: For generic drugs (including brand drugs treated as generic), either: - A $0 copay; or - A $1.20 copay; or - A $2.55 copay BENEFIT ORIGINAL MEDICARE Los Angeles County Orange and San Bernardino Counties PRESCRIPTION DRUG BENEFITS (Continued) 25 Outpatient Prescription Drugs (continued) If you request a formulary exception for a drug and approves the exception, you will pay the generic cost share for generic drugs and the brand cost share for brand drugs. You pay a $0 annual deductible. Initial Coverage Depending on your income and institutional status, you pay the following: For generic drugs (including brand drugs treated as generic), either: - A $0 copay; or - A $1.20 copay; or - A $2.55 copay If you request a formulary exception for a drug and approves the exception, you will pay the generic cost share for generic drugs and the brand cost share for brand drugs. You pay a $0 annual deductible. Initial Coverage Depending on your income and institutional status, you pay the following: For generic drugs (including brand drugs treated as generic), either: - A $0 copay; or - A $1.20 copay; or - A $2.55 copay 34

72 SUMMARY OF BENEFITS SECTION 2 Alameda, San Francisco and Santa Clara Counties For all other drugs, either: - A $0 copay; or - A $3.60 copay; or - A $6.35 copay. Tier 1: Preferred Generic $0 copay for drugs in this tier Retail Pharmacy Contact your plan if you have questions about costsharing or billing when less than a one-month supply is dispensed. You can get drugs the following way(s): - one-month (30-day) supply - three-month (90-day) supply BENEFIT ORIGINAL MEDICARE Los Angeles County Orange and San Bernardino Counties PRESCRIPTION DRUG BENEFITS (Continued) 25 Outpatient Prescription Drugs (continued) For all other drugs, either: - A $0 copay; or - A $3.60 copay; or - A $6.35 copay. Tier 1: Preferred Generic $0 copay for drugs in this tier Retail Pharmacy Contact your plan if you have questions about costsharing or billing when less than a one-month supply is dispensed. You can get drugs the following way(s): - one-month (30-day) supply - three-month (90-day) supply For all other drugs, either: - A $0 copay; or - A $3.60 copay; or - A $6.35 copay. Tier 1: Preferred Generic $0 copay for drugs in this tier Retail Pharmacy Contact your plan if you have questions about costsharing or billing when less than a one-month supply is dispensed. You can get drugs the following way(s): - one-month (30-day) supply - three-month (90-day) supply 35

73 SUMMARY OF BENEFITS SECTION 2 Alameda, San Francisco and Santa Clara Counties Long Term Care Pharmacy Long term care pharmacies must dispense brand name drugs in amounts less than a 14 days supply at a time. They may also dispense less than a month s supply of generic drugs at a time. Contact your plan if you have questions about costsharing or billing when less than a one-month supply is dispensed. You can get drugs the following way(s): - one-month (31-day) supply of drugs Mail Order Contact your plan if you have questions about costsharing or billing when less than a one-month supply is dispensed. You can get drugs the following way(s): - three-month (90-day) supply BENEFIT ORIGINAL MEDICARE Los Angeles County Orange and San Bernardino Counties PRESCRIPTION DRUG BENEFITS (Continued) 25 Outpatient Prescription Drugs (continued) Long Term Care Pharmacy Long term care pharmacies must dispense brand name drugs in amounts less than a 14 days supply at a time. They may also dispense less than a month s supply of generic drugs at a time. Contact your plan if you have questions about costsharing or billing when less than a one-month supply is dispensed. You can get drugs the following way(s): - one-month (31-day) supply of drugs Mail Order Contact your plan if you have questions about costsharing or billing when less than a one-month supply is dispensed. You can get drugs the following way(s): - three-month (90-day) supply Long Term Care Pharmacy Long term care pharmacies must dispense brand name drugs in amounts less than a 14 days supply at a time. They may also dispense less than a month s supply of generic drugs at a time. Contact your plan if you have questions about costsharing or billing when less than a one-month supply is dispensed. You can get drugs the following way(s): - one-month (31-day) supply of drugs Mail Order Contact your plan if you have questions about costsharing or billing when less than a one-month supply is dispensed. You can get drugs the following way(s): - three-month (90-day) supply 36

74 SUMMARY OF BENEFITS SECTION 2 Alameda, San Francisco and Santa Clara Counties Catastrophic Coverage After your yearly out-ofpocket drug costs reach $4,550, you pay a $0 copay. Out-of-Network Plan drugs may be covered in special circumstances, for instance, illness while traveling outside of the plan s service area where there is no network pharmacy. You may have to pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy. In addition, you will likely have to pay the pharmacy s full charge for the drug and submit documentation to receive reimbursement from. BENEFIT ORIGINAL MEDICARE Los Angeles County Orange and San Bernardino Counties PRESCRIPTION DRUG BENEFITS (Continued) 25 Outpatient Prescription Drugs (continued) Catastrophic Coverage After your yearly out-ofpocket drug costs reach $4,550, you pay a $0 copay. Catastrophic Coverage After your yearly out-ofpocket drug costs reach $4,550, you pay a $0 copay. Out-of-Network Plan drugs may be covered in special circumstances, for instance, illness while traveling outside of the plan s service area where there is no network pharmacy. You may have to pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy. In addition, you will likely have to pay the pharmacy s full charge for the drug and submit documentation to receive reimbursement from. Out-of-Network Plan drugs may be covered in special circumstances, for instance, illness while traveling outside of the plan s service area where there is no network pharmacy. You may have to pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy. In addition, you will likely have to pay the pharmacy s full charge for the drug and submit documentation to receive reimbursement from. 37

75 SUMMARY OF BENEFITS SECTION 2 Alameda, San Francisco and Santa Clara Counties You can get out-of-network drugs the following way: - one-month (30-day) supply Out-of-Network Initial Coverage Depending on your income and institutional status, you will be reimbursed by up to the plan s cost of the drug minus the following: For generic drugs purchased out-of-network (including brand drugs treated as generic), either: - A $0 copay; or - A $1.20 copay; or - A $2.55 copay BENEFIT ORIGINAL MEDICARE Los Angeles County Orange and San Bernardino Counties PRESCRIPTION DRUG BENEFITS (Continued) 25 Outpatient Prescription Drugs (continued) You can get out-of-network drugs the following way: - one-month (30-day) supply Out-of-Network Initial Coverage Depending on your income and institutional status, you will be reimbursed by up to the plan s cost of the drug minus the following: For generic drugs purchased out-of-network (including brand drugs treated as generic), either: - A $0 copay; or - A $1.20 copay; or - A $2.55 copay You can get out-of-network drugs the following way: - one-month (30-day) supply Out-of-Network Initial Coverage Depending on your income and institutional status, you will be reimbursed by up to the plan s cost of the drug minus the following: For generic drugs purchased out-of-network (including brand drugs treated as generic), either: - A $0 copay; or - A $1.20 copay; or - A $2.55 copay 38

76 SUMMARY OF BENEFITS SECTION 2 Alameda, San Francisco and Santa Clara Counties For all other drugs purchased out-of-network, either: - A $0 copay; or - A $3.60 copay; or - A $6.35 copay. Tier 1: Preferred Generic $0 copay for drugs in this tier Out-of-Network Catastrophic Coverage After your yearly outof-pocket drug costs reach $4,550, you will be reimbursed in full for drugs purchased out-of-network. BENEFIT ORIGINAL MEDICARE Los Angeles County Orange and San Bernardino Counties PRESCRIPTION DRUG BENEFITS (Continued) 25 Outpatient Prescription Drugs (continued) For all other drugs purchased out-of-network, either: - A $0 copay; or - A $3.60 copay; or - A $6.35 copay. Tier 1: Preferred Generic $0 copay for drugs in this tier Out-of-Network Catastrophic Coverage After your yearly outof-pocket drug costs reach $4,550, you will be reimbursed in full for drugs purchased out-of-network. For all other drugs purchased out-of-network, either: - A $0 copay; or - A $3.60 copay; or - A $6.35 copay. Tier 1: Preferred Generic $0 copay for drugs in this tier Out-of-Network Catastrophic Coverage After your yearly outof-pocket drug costs reach $4,550, you will be reimbursed in full for drugs purchased out-of-network. 39

77 SUMMARY OF BENEFITS SECTION 2 Alameda, San Francisco and Santa Clara Counties $0 or $5 to $415 copay for Medicare-covered dental benefits* $5 copay for supplemental oral exams $5 copay for up to 1 supplemental cleaning(s) every six months $5 copay for up to 1 supplemental fluoride treatment(s) every six months $5 copay for up to 1 supplemental dental x-ray(s) every two years Plan offers additional supplemental comprehensive dental benefits. See page 45 for additional information about Dental Services. BENEFIT ORIGINAL MEDICARE Los Angeles County Orange and San Bernardino Counties OUTPATIENT MEDICAL SERVICES AND SUPPLIES 26 Dental Services Preventive dental services (such as cleaning) not covered. $0 or $5 to $415 copay for Medicare-covered dental benefits* $0 or $5 to $415 copay for Medicare-covered dental benefits* $5 copay for supplemental oral exams $5 copay for supplemental oral exams $5 copay for up to 1 supplemental cleaning(s) every six months $5 copay for up to 1 supplemental cleaning(s) every six months $5 copay for up to 1 supplemental fluoride treatment(s) every six months $5 copay for up to 1 supplemental fluoride treatment(s) every six months $5 copay for up to 1 supplemental dental x-ray(s) every two years $5 copay for up to 1 supplemental dental x-ray(s) every two years Plan offers additional supplemental comprehensive dental benefits. Plan offers additional supplemental comprehensive dental benefits. See page 45 for additional information about Dental Services. See page 45 for additional information about Dental Services. 40

78 SUMMARY OF BENEFITS SECTION 2 Alameda, San Francisco and Santa Clara Counties Authorization rules may apply. $0 copay for: Medicare-covered diagnostic hearing exams* - up to 1 supplemental routine hearing exam(s) every year - up to 1 fitting-evaluation(s) for a supplemental hearing aid every year $0 copay for up to 2 supplemental hearing aid(s) every two years $1,000 plan coverage limit for supplemental hearing aids every year. BENEFIT ORIGINAL MEDICARE Los Angeles County Orange and San Bernardino Counties OUTPATIENT MEDICAL SERVICES AND SUPPLIES (Continued) 27 Hearing Services Supplemental routine hearing exams and hearing aids not covered. 0% to 20% coinsurance for diagnostic hearing exams. Authorization rules may apply. $0 copay for: Authorization rules may apply. $0 copay for: Medicare-covered diagnostic hearing exams* Medicare-covered diagnostic hearing exams* - up to 1 supplemental routine hearing exam(s) every year - up to 1 supplemental routine hearing exam(s) every year - up to 1 fitting-evaluation(s) for a supplemental hearing aid every year - up to 1 fitting-evaluation(s) for a supplemental hearing aid every year $0 copay for up to 2 supplemental hearing aid(s) every two years $0 copay for up to 2 supplemental hearing aid(s) every two years $1,000 plan coverage limit for supplemental hearing aids every year. $1,000 plan coverage limit for supplemental hearing aids every year. 41

79 SUMMARY OF BENEFITS SECTION 2 Alameda, San Francisco and Santa Clara Counties $0 copay for: Medicare-covered diagnosis and treatment for diseases and conditions of the eye, including an annual glaucoma screening for people at risk* up to 1 supplemental routine eye exam(s) every year $0 copay for - one pair of Medicarecovered eyeglasses (lenses and frames) or contact lenses after cataract surgery * - up to 1 pair(s) of eyeglasses (lenses and frames) every year $200 plan coverage limit for supplemental eyewear every year See page 45 for additional information about Vision Services. BENEFIT ORIGINAL MEDICARE Los Angeles County Orange and San Bernardino Counties OUTPATIENT MEDICAL SERVICES AND SUPPLIES (Continued) 28 Vision Services 0% or 20% coinsurance for diagnosis and treatment of diseases and conditions of the eye, including an annual glaucoma screening for people at risk Supplemental routine eye exams and eyeglasses (lenses and frames) not covered. Medicare pays for one pair of eyeglasses or contact lenses after cataract surgery. $0 copay for: Medicare-covered diagnosis and treatment for diseases and conditions of the eye, including an annual glaucoma screening for people at risk* up to 1 supplemental routine eye exam(s) every year $0 copay for - one pair of Medicarecovered eyeglasses (lenses and frames) or contact lenses after cataract surgery * - up to 1 pair(s) of eyeglasses (lenses and frames) every year $200 plan coverage limit for supplemental eyewear every year See page 45 for additional information about Vision Services. $0 copay for: Medicare-covered diagnosis and treatment for diseases and conditions of the eye, including an annual glaucoma screening for people at risk* up to 1 supplemental routine eye exam(s) every year $0 copay for - one pair of Medicarecovered eyeglasses (lenses and frames) or contact lenses after cataract surgery * - up to 1 pair(s) of eyeglasses (lenses and frames) every two years. $150 plan coverage limit for supplemental eyewear every two years. See page 45 for additional information about Vision Services. 42

80 SUMMARY OF BENEFITS SECTION 2 Alameda, San Francisco and Santa Clara Counties The plan covers the following supplemental education/wellness programs: - Health Education - Health Club Membership/ Fitness Classes - Nursing Hotline See page 45 for additional information about Wellness/ Education and other Supplemental Benefits & Services. Please visit our plan website to see our list of covered Over-the- Counter items. OTC items may be purchased only for the enrollee. Please contact the plan for specific instructions for using this benefit. BENEFIT ORIGINAL MEDICARE Los Angeles County Orange and San Bernardino Counties OUTPATIENT MEDICAL SERVICES AND SUPPLIES (Continued) Wellness/ Education and Other Supplemental Benefits & Services Over-the-Counter Items Not covered. The plan covers the following supplemental education/wellness programs: - Health Education - Health Club Membership/ Fitness Classes - Nursing Hotline See page 45 for additional information about Wellness/ Education and other Supplemental Benefits & Services. Not covered. Please visit our plan website to see our list of covered Over-the- Counter items. OTC items may be purchased only for the enrollee. Please contact the plan for specific instructions for using this benefit. The plan covers the following supplemental education/wellness programs: - Health Education - Health Club Membership/ Fitness Classes - Nursing Hotline See page 45 for additional information about Wellness/ Education and other Supplemental Benefits & Services. Please visit our plan website to see our list of covered Over-the- Counter items. OTC items may be purchased only for the enrollee. Please contact the plan for specific instructions for using this benefit. 43

81 SUMMARY OF BENEFITS SECTION 2 Alameda, San Francisco and Santa Clara Counties See page 46 for additional information about Over-the- Counter items. Authorization rules may apply. $0 copay for up to 24 round trip(s) to plan-approved location every year See page 46 for additional information about Transportation. Authorization rules may apply. $0 copay for up to 15 visit(s) for acupuncture and other alternative therapies every year BENEFIT ORIGINAL MEDICARE Los Angeles County Orange and San Bernardino Counties OUTPATIENT MEDICAL SERVICES AND SUPPLIES (Continued) Over-the-Counter Items (continued) See page 46 for additional information about Over-the- Counter items. See page 46 for additional information about Over-the- Counter items. Transportation (Routine) Acupuncture and Other Alternative Therapies Not covered. Authorization rules may apply. Not covered. $0 copay for up to 24 round trip(s) to plan-approved location every year See page 46 for additional information about Transportation. Authorization rules may apply. $0 copay for up to 15 visit(s) for acupuncture and other alternative therapies every year Authorization rules may apply. $0 copay for up to 24 round trip(s) to plan-approved location every year See page 46 for additional information about Transportation. Authorization rules may apply. $0 copay for up to 15 visit(s) for acupuncture and other alternative therapies every year 44

82 SUMMARY OF BENEFITS SECTION 3 This section provides additional details on some of the benefits listed in Section 2. The numbered items below correspond to the same numbers in Section 2. For more information, please call at the phone numbers listed on page 6, or visit ADDITIonal PLAN InformatIon 26 Dental Services (see page 40) Routine Dental Benefits Co-payment of $5 applies to each office visit if no additional services are provided. Co-payments for services are provided in accordance to the dental schedule of benefits. $0 copay for oral exams, cleaning and x-rays apply to services received from a general dentist. Additional copays may apply for full set of dental x-rays received more often than every two years, and/or specialized diagnostic x-rays such as multiple vertical bitewing views. Refer to the current Dental Member Handbook for details. Comprehensive Dental Benefits Plan authorization/referral applies only to Medicare-covered Dental Services. No plan authorization/referral is required for all other Comprehensive Dental Services. Prior benefit authorization may be required from your dental benefit provider for certain dental services. Refer to the current Dental Member Handbook for details Vision Services (see page 42) For Los Angeles, Alameda, San Francisco, Santa Clara Counties Care1st covers the refraction test once every year when the eye doctor has determined that the member may need prescription glasses. Member has the option to pay for additional upgrade items such as progressive lenses, lens coating or tinting, and frames not classified as standard. For San Bernardino and Orange Counties Care1st covers the refraction test once every two years when the eye doctor has determined that the member may need prescription glasses. Member has the option to pay for additional upgrade items such as progressive lenses, lens coating or tinting, and frames not classified as standard. Wellness/Education and other Supplemental Benefit Programs (see page 43) No authorization is required for fitness programs provided at plan-approved locations. Gym membership includes access to amenities and classes including, facility and equipment orientation. No authorization required for health educational classes offered by Care1st Health Plan. There is no copay for educational classes provided by plan-approved locations. There is no limit to the number of educational classes for the plan year. Authorization rules apply to health educational classes not sponsored by Care1st Health Plan. 45

83 SUMMARY OF BENEFITS SECTION 3 Routine Transportation (see page 44) Care1st offers 24 round-trip transportation services per year to plan-approved locations such as doctors offices in order to access medical services. Transportation must be arranged 24 hours in advance by contacting the Care1st Member Services Department at 1-87-RIDEC1ST ( ) (TTY ), 8 a.m. to 6 p.m. Monday through Friday. Over-the-Counter Items (see page 43) As a member of the Care1st TotaDual Plan you have an allowance of $50 each quarter that you are enrolled with the plan (January, April, July, October) that you can use to purchase items such as aspirin, vitamins, over-the-counter medications, first-aid supplies, tooth brushes/ toothpaste, etc. This allowance does not accumulate from quarter to quarter. Any amount that is not spent each quarter is forfeited. See our plan website ( to see our list of OTC items. 46

84 SUMMARY OF BENEFITS SECTION 4 The tables in this section show the benefits that Medi-Cal offers to eligible beneficiaries. For each benefit, you can see what Original Medi-Cal (Medi-Cal alone) covers and what our plan covers. You may not qualify for all of the Medi-Cal benefits listed. If you qualify for a Medi-Cal benefit that (HMO SNP) does not offer, then please contact our Member Services department. We may be able to help you find the right provider and coordinate the benefit for you. Please review Section II of this Summary of Benefits for more information on the benefits you will receive as part of. 2. Outpatient hospital services $0 copay for Medi-Cal covered services $0 copay for each Medicare-covered outpatient hospital facility visit. 3. Rural health clinic services $0 copay for Medi-Cal covered services Not covered beyond Original Medicare. Covered under Medicare effective with the date of clinic s approval for participation. 5. Laboratory services $0 copay for Medi-Cal covered services $0 copay for Medicare-covered lab services, and diagnostic procedures and tests. 6. X-rays $0 copay for Medi-Cal covered services $0 copay for Medicare-covered X-rays, diagnostic radiology services (not including X-rays), and therapeutic radiology services. All Members Who Qualify for Full Medi-Cal May Receive the Following Medi-Cal and Health Plan Services: State of California Medi-Cal Program Covered Benefits for Dual Eligible (Medicare and Medi-Cal Beneficiaries) BENEFIT CATEGORY MEDI-CAL 1. Inpatient hospital services $0 copay for Medi-Cal covered services $0 copay 4. Federally qualified health center services $0 copay for Medi-Cal covered services Not covered beyond Original Medicare. 7. Skilled nursing facility care for over 21 years of age - Subacute care $0 copay for Medi-Cal covered services $0 copay for Skilled Nursing Facility (SNF) services 47

85 SUMMARY OF BENEFITS SECTION 4 BENEFIT CATEGORY MEDI-CAL 9. Physician services $0 copay for Medi-Cal covered services $0 copay for each primary care doctor visit for Medicare-covered benefits. $0 copay for each specialist doctor visit for Medicarecovered benefits. 11. Ophthalmologist services $0 copay for Medi-Cal covered services $0 copay for diagnosis and treatment for diseases and conditions of the eye, and up to 1 routine eye exam(s) every year. 12. Optometry services $0 copay for Medi-Cal covered services $0 copay for diagnosis and treatment for diseases and conditions of the eye, and up to 1 routine eye exam(s) every year. 13. Nurse anesthetist services $0 copay for Medi-Cal covered services $0 copay for Medicare-covered benefits 15. Durable medical equipment $0 copay for Medi-Cal covered services $0 copay for Medicare-covered items. State of California Medi-Cal Program Covered Benefits for Dual Eligible (Medicare and Medi-Cal Beneficiaries) 8. Family planning services & supplies $0 copay for Medi-Cal covered services Not covered beyond Original Medicare. 10. Medical & surgical dental services $0 copay for Medi-Cal covered services For Los Angeles, Orange, San Bernardino, Alameda, Santa Clara, and San Francisco Counties: $0, or $5 - $415 copay for Medicare-covered dental benefits. 14. Medical supplies (does not include incontinence creams and washes) $0 copay for Medi-Cal covered services $0 copay for Medicare-covered medical supplies 48

86 SUMMARY OF BENEFITS SECTION Hearing aids $0 copay for Medi-Cal covered services $0 copay for up to 2 hearing aid(s) every two years. $1000 plan coverage limit for hearing aids every year. 17. Enteral formula $0 copay for Medi-Cal covered services $0 copay for Medicare-covered benefits. 18. Licensed midwife services $0 copay for Medi-Cal covered services Not covered beyond Original Medicare. State of California Medi-Cal Program Covered Benefits for Dual Eligible (Medicare and Medi-Cal Beneficiaries) BENEFIT CATEGORY MEDI-CAL 19. Home health services through a home health agency (including home health nursing and aide services, physical and occupational therapy, speech pathology and audiology services, intermittent nursing, home health aid care, medical supplies, equipment and appliances) $0 copay for Medi-Cal covered services $0 copay for Medicare-covered home health services. 20. Physical therapy and related services $0 copay for Medi-Cal covered services $0 copay for Medicare-covered Physical Therapy visits. 21. Rehabilitation facilities $0 copay for Medi-Cal covered services $0 copay 22. Clinic (Organized outpatient clinic, indian Health Services, alternate birthing centers, ambulatory surgical centers) $0 copay for Medi-Cal covered services $0 copay for Medicare-covered visits. 49

87 SUMMARY OF BENEFITS SECTION 4 BENEFIT CATEGORY MEDI-CAL 23. Occupational therapy $0 copay for Medi-Cal covered services $0 copay for Medicare-covered Occupational Therapy visits. 27. Adult day health care $0 copay for Medi-Cal covered services Not covered beyond Original Medicare. State of California Medi-Cal Program Covered Benefits for Dual Eligible (Medicare and Medi-Cal Beneficiaries) 24. Pharmaceutical services and prescribed drugs $0 copay for drugs excluded from Medicare Part D coverage Initial Coverage Generic drugs, either a $0, $1.20 or $2.55 copay, or a 15% coinsurance All other drugs, either a $0, $3.60 or $6.35 copay, or a 15% coinsurance Catastrophic Coverage $0 copay after yearly out-of-pocket costs reach $4, Prosthetic appliances (Orthotic appliances) prosthetic eyes $0 copay for Medi-Cal covered services $0 copay for Medicare-covered items 26. Comprehensive Perinatal services Program (Preventive services) $0 copay for Medi-Cal covered services Not covered beyond Original Medicare. 28. Chronic dialysis services $0 copay for Medi-Cal covered services $0 copay for renal dialysis. 50

88 SUMMARY OF BENEFITS SECTION 4 BENEFIT CATEGORY MEDI-CAL 31. Intermediate Care Facility $0 copay for Medi-Cal covered services $0 copay for Medicare-covered benefits. 32. Nurse midwife $0 copay for Medi-Cal covered services $0 copay for Medicare-covered benefits. 33. Hospice $0 copay for Medi-Cal covered services You must get care from a Medicare-certified hospice. $0 copay for one-time hospice consultation services. 34. TB-related services $0 copay for Medi-Cal covered services Not covered beyond Original Medicare. 36. Family nurse practitioner $0 copay for Medi-Cal covered services $0 copay for Medicare-covered services State of California Medi-Cal Program Covered Benefits for Dual Eligible (Medicare and Medi-Cal Beneficiaries) 29. Rehabilitation services (CBAS, chronic dialysis, outpatient heroin detoxification, rehabilitative mental health, drug Medi-Cal, independent rehabilitation centers) $0 copay for Medi-Cal covered services $0 copay for Medicare-covered visits. 30. Institutes for Mental Diseases (for under 21 years of age and over 65 years of age, including inpatient psychiatric care). $0 copay for Medi-Cal covered services $0 copay for Medicare-covered benefits 35. Respiratory care for ventilatordependent patients $0 copay for Medi-Cal covered services Not covered beyond Original Medicare. 51

89 SUMMARY OF BENEFITS SECTION 4 BENEFIT CATEGORY MEDI-CAL 37. Rural primary care hospital $0 copay for Medi-Cal covered services $0 copay for Medicare-covered services 38. Nonmedical health facilities $0 copay for Medi-Cal covered services $0 copay for care received in a religious non-medical health care institution 39. Emergency hospital services $0 copay for Medi-Cal covered services $0 copay for Medicare-covered emergency room visits. $25,000 limit for emergency services outside the U.S. every year. State of California Medi-Cal Program Covered Benefits for Dual Eligible (Medicare and Medi-Cal Beneficiaries) 40. Transportation (State provides emergency and non-emergency medical transportation. Meets federal requirement for assurance of transportation to medically necessary services) $0 copay for Medi-Cal covered services Ambulance: $0 copay for Medicare-covered ambulance benefits. For Los Angeles, Orange, San Bernardino, Alameda, Santa Clara, and San Francisco Counties: Routine Transportation: $0 copay for each round trip to plan-approved location. Up to 24 round-trips per year. 52

90 SUMMARY OF BENEFITS SECTION 4 *Note: You must meet specific eligibility criteria in order to receive benefits under the early & periodic screening, diagnosis, and treatment (EPSDT) program or through other Medi-Cal Waiver programs. Members Who Qualify for Medi-Cal Waiver Programs or Meet Specific Medical Eligibility Criteria May Also Receive the Following Medi-Cal Services* State of California Medi-Cal Program Covered Benefits for Dual Eligible (Medicare and Medi-Cal Beneficiaries) BENEFIT CATEGORY MEDI-CAL 1. Private duty nursing (Waiver only) $0 copay for Medi-Cal covered services Not covered. 2. Home and community care for functionally disabled elderly (Waiver only) $0 copay for Medi-Cal covered services Not covered beyond Original Medicare. 3. Community-supported living arrangements (Waiver only) $0 copay for Medi-Cal covered services Not covered. 4. Personal care services $0 copay for Medi-Cal covered services Not covered. 5. Services for pregnant women that treat a condition that may impact the woman and/or the fetus (Not specifically stated as a benefit but is a mandated provision under federal regulations) 6. Marriage and family counselor services (Early & periodic screening, diagnosis, and treatment services & waiver only) $0 copay for Medi-Cal covered services Not covered beyond Original Medicare. $0 copay for Medi-Cal covered services $0 copay for Medicare-covered services. 53

91 SUMMARY OF BENEFITS SECTION 4 State of California Medi-Cal Program Covered Benefits for Dual Eligible (Medicare and Medi-Cal Beneficiaries) BENEFIT CATEGORY MEDI-CAL 7. Licensed clinical social worker services (Early & periodic screening, diagnosis, and treatment services & waiver only) $0 copay for Medi-Cal covered services Not covered beyond Original Medicare. 8. Case management (Early & periodic screening, diagnosis, and treatment services & waiver only) 9. Private duty nursing agency services (Early & periodic screening, diagnosis, and treatment services & waiver only) 10. Individual nurse provider services (Early & periodic screening, diagnosis, and treatment services & waiver only) 11. Nonmedical services (Waiver only) $0 copay for Medi-Cal covered services $0 copay for Medicare-covered services. $0 copay for Medi-Cal covered services Not covered. $0 copay for Medi-Cal covered services Not covered. $0 copay for Medi-Cal covered services Not covered beyond Original Medicare. 12. Pediatric nursing facility care for under 21 years of age - subacute services (Early & periodic screening, diagnosis, and treatment supplemental services) $0 copay for Medi-Cal covered services Not covered beyond Original Medicare. (EPSDT) program or through other Medi-Cal Waiver programs. 54

92 SUMMARY OF BENEFITS SECTION 4 BENEFIT CATEGORY MEDI-CAL 1. Psychology services $0 copay for Medi-Cal covered services $0 copay for Medicare-covered Mental health visits. Certain Members Who Have Full Medi-Cal May Also Receive the Following Benefits**: State of California Medi-Cal Program Covered Benefits for Dual Eligible (Medicare and Medi-Cal Beneficiaries) 2. Optician and optical fabricating lab services $0 copay for Medi-Cal covered services $0 copay for one pair of eyeglasses or contact lenses after cataract surgery. $0 copay for up to 1 pair(s) of glasses every year. For Los Angeles, Alameda, San Francisco and Santa Clara Counties: $200 limit for eye wear every year. For Orange and San Bernardino Counties: $150 limit for eye wear every two years. 3. Dental services $0 copay for Medi-Cal covered services For Los Angeles, Orange, San Bernardino, Alameda, San Francisco, and Santa Clara Counties: Preventive (Routine): $0 copay for: unlimited oral exams every year; *1 cleaning every 6 mos; *1 x-ray every two years; *1 fluoride treatment every 6 months; $0, or $5 -$415 copay for Medicare-covered dental benefits; *Copays may apply for additional dental benefits. 55

93 SUMMARY OF BENEFITS SECTION 4 BENEFIT CATEGORY MEDI-CAL 4. Eyeglasses, other eye appliances $0 copay for Medi-Cal covered services $0 copay for one pair of eyeglasses or contact lenses after cataract surgery. $0 copay for up to 1 pair(s) of glasses every year. For Los Angeles, Alameda, San Francisco and Santa Clara Counties: $200 limit for eye wear every year. For Orange and San Bernardino Counties: $150 limit for eye wear every two years. **Note: Legislation enacted in July 2009 added Section of the W&I Code to exclude several optional benefit categories from coverage under the Medi-Cal program. The optional benefits indicated are excluded from coverage under the Medi-Cal program effective July 1, The optional benefits exclusion policy does not apply to the following beneficiaries: 1) beneficiaries under 21 years of age for services rendered pursuant to EPSDT program; 2) beneficiaries residing in a skilled nursing facility (Nursing Facilities Level A and Level B, including subacute care facilities; 3) beneficiaries who are pregnant (pregnancy-related benefits and services; other benefits and services to treat conditions that, if left untreated, might cause difficulties for the pregnancy); 4) California Children s Services beneficiaries; and 5) beneficiaries enrolled in the Program of All-Inclusive Care for the Elderly. Most claims for excluded optional benefit services billed by a physician or physician group remain reimbursable on or after July 1, However, these claims will be denied if the rendering provider is not a physician, but one of the optional benefit providers. More information on the reduced benefits and services affected by this new legislation is available on the California Department of Health Care Services website at State of California Medi-Cal Program Covered Benefits for Dual Eligible (Medicare and Medi-Cal Beneficiaries) 56

94 2014 DRUG LISTING A Medicare approved HMO plan 8-MOP Caps, T3 A A-Hydrocort Inject, T2 A-Methapred Inject, T2 Abacavir Tabs, T2 ABELCET Inject IV, T3 ABILIFY DISCMELT Tabs, T5 ABILIFY Inject, T3 ABILIFY MAINTENA Inject, T5 ABILIFY Soln, T3 ABILIFY Tabs, T5 Acarbose Tabs, T2 Acebutolol HCL Caps, T2 Acetaminophen-Codeine Soln, T2 Acetaminophen-Codeine Tabs, T2 Acetasol Hc Ear Drops, T2 ACETAZOLAMIDE Caps, T4 Acetazolamide Tabs, T2 ACTHIB Inject, T3 ACTIMMUNE Inject, T5 ACTONEL Tabs, T4 Acyclovir Caps, T2 ACYCLOVIR Oint, T3 Acyclovir Sodium Inject IV, T2 Acyclovir Suspension, T2 Acyclovir Tabs, T2 ADACEL Inject Syr, T3 # ADACEL Inject, T3 ADAGEN Inject, T5 Adapalene Cr, T2 Adapalene Gel, T2 ADCETRIS Inject IV, T5 ADCIRCA Tabs, T5 ADVAIR DISKUS Inhaler, T3 ADVAIR HFA Inhaler, T3 Afeditab Cr Tabs, T2 AFINITOR Tabs, T5 AGGRENOX Caps, T4 Ala-Cort Cr, T2 Ala-Scalp Lotion, T2 ALBENZA Tabs, T3 Albuterol Sulfate Inhale Soln, T2 Albuterol Sulfate Syrup, T2 Albuterol Sulfate Tabs, T2 Alcaine Eye Drops, T2 Alclometasone Dipropionate Cr, T2 Alclometasone Dipropionate Oint, T2 ALDURAZYME Inject IV, T5 Alendronate Sodium Tabs, T1 Alfuzosin HCL Tabs, T2 ALIMTA Inject IV, T5 ALINIA Tabs, T4 Allopurinol Tabs, T2 ALORA Patch, T3 ALPHAGAN P Eye Drops, T3 Alprazolam Tabs, T2 Altavera Tabs, T2 Alyacen Tabs, T2 Amantadine Caps, T2 Amantadine Syrup, T2 Amantadine Tabs, T2 AMBISOME Inject IV, T3 Amcinonide Cr, T2 Amcinonide Lotion, T2 Amcinonide Oint, T2 AMIFOSTINE Inject IV, T5 Amikacin Sulfate Inject, T2 Amiloride HCL Tabs, T2 Amiloride-Hydrochlorothiazide Tabs, T2 Aminocaproic Acid Inject IV, T2 Aminocaproic Acid Soln, T2 Aminocaproic Acid Tabs, T2 Aminophylline Soln, T2 Aminosyn Ii Inject IV, T2 AMINOSYN II Inject IV, T3 AMINOSYN Inject IV, T3 AMINOSYN-HBC Inject IV, T3 AMINOSYN-PF Inject IV, T3 Amiodarone HCL Tabs, T2 AMITIZA Caps, T3 Amitriptyline HCL Tabs, T2 Amlodipine Besylate Tabs, T1 Brand-name drugs are listed in upper case. Generic drugs are listed in lower case. Pharmacy Benefits are subject to a covered list which is subject to change. Limitations, copayments, and restrictions may apply. Refer to the Care1st Comprehensive formulary and Evidence of Coverage for more information. T1 = Tier 1 T2 = Tier 2 T3 = Tier 3 T4 = Tier 4 T5 = Tier 5 H5928_14_141_MK Accepted 1

95 Amlodipine Besylate-Benazepril Caps, T1 Ammonium Lactate Cr, T2 Ammonium Lactate Lotion, T2 AMNESTEEM Caps, T4 Amox Tr-Potassium Clavulanate Suspension, T2 Amox Tr-Potassium Clavulanate Tabs Chew, T2 Amox Tr-Potassium Clavulanate Tabs, T2 Amoxapine Tabs, T2 Amoxicillin Caps, T2 Amoxicillin Suspension, T2 Amoxicillin Tabs Chew, T2 Amoxicillin Tabs, T2 Amphetamine Salt Combo Tabs, T2 Amphotericin B Inject, T2 AMPICILLIN SODIUM Inject, T3 Ampicillin Trihydrate Caps, T2 Ampicillin Trihydrate Suspension, T2 Ampicillin-Sulbactam Inject IV, T2 Ampicillin-Sulbactam Inject, T2 AMPYRA Tabs, T5 Anacaine Oint, T2 ANADROL-50 Tabs, T5 Anagrelide HCL Caps, T2 Anastrozole Tabs, T2 ANDRODERM Patch, T3 Android Caps, T2 Androxy Tabs, T2 Anergan 50 Inject, T2 ANTIVENIN LATRODECTUS MACTANS Inject, T5 ANTIVENIN MICRURUS FULVIUS Inject, T5 Anusol-Hc Rectal Cr, T2 Apexicon E Cr, T2 APOKYN Inject, T5 2 Apri Tabs, T2 APTIVUS Caps, T5 APTIVUS Soln, T5 Aranelle Tabs, T2 ARANESP 150MCG/0.3, 200MCG/0.4, 300MCG/0.6, 500MCG/ML Inject Syr, T5 ARANESP 200MCG/ML. 300MCG/ML Inject, T5 ARANESP 25MCG/0.45, 40MCG/0.4, 60MCG/0.3,100MCG/0.5 Inject Syr, T3 ARANESP 25MCG/ML, 40MCG/ML, 60MCG/ML,100MCG/ML Inject, T3 ARCALYST Inject, T5 ARICEPT Tabs, T3 ARZERRA Inject IV, T5 Ascomp With Codeine Caps, T2 ASMANEX Inhaler, T4 ASTRAMORPH-PF 0.5MG Inject, T3 Astramorph-PF 1MG Inject, T2 ATELVIA Tabs, T4 Atenolol Tabs, T1 Atenolol-Chlorthalidone Tabs, T1 ATGAM Inject IV, T3 Atorvastatin Calcium Tabs, T1 ATOVAQUONE-PROGUANIL HCL Tabs, T3 ATRIPLA Tabs, T5 ATROVENT HFA Inhaler, T3 AUBAGIO Tabs, T5 AUVI-Q Auto Inj, T3 AVANDIA Tabs, T3 AVASTIN Inject IV, T5 AVELOX ABC PACK Tabs, T4 AVELOX Tabs, T4 Aviane Tabs, T2 Avita Gel, T2 AVODART Caps, T4 AVONEX ADMINISTRATION PACK Inject Kit, T5 AVONEX Inject Kit, T5 Azathioprine Tabs, T2 Azelastine HCL Eye Drops, T2 Azelastine HCL Nasal Spray, T2 AZILECT 0.5MG Tabs, T4 AZILECT Tabs, T4 Azithromycin Inject IV, T2 Azithromycin Oral Pwd, T2 Azithromycin Suspension, T2 Azithromycin Tabs, T2 AZOPT Eye Susp, T3 Aztreonam Inject, T2 Azurette Tabs, T2 B Bacitracin Eye Ointment, T2 Bacitracin-Polymyxin Eye Ointment, T2 Baclofen Tabs, T2 BALSALAZIDE DISODIUM Caps, T4 Balziva Tabs, T2 BANZEL 200MG Tabs, T4 BANZEL 400MG Tabs, T5 BANZEL Suspension, T4 BARACLUDE Soln, T3 BARACLUDE Tabs, T5 Baycadron Soln, T2 BCG VACCINE (TICE STRAIN) Inject, T3 Benazepril HCL Tabs, T1 Benazepril-Hydrochlorothiazide Tabs, T1 Benztropine Mesylate Tabs, T2 Betamethasone Dipropionate Cr, T2 Betamethasone Dipropionate Gel, T2 Betamethasone Dipropionate Lotion, T2 Betamethasone Dipropionate Oint, T2 Betamethasone Valerate Cr, T2

96 Betamethasone Valerate Lotion, T2 Betamethasone Valerate Oint, T2 BETASERON Inject Kit, T5 Betaxolol HCL Eye Drops, T2 Betaxolol HCL Tabs, T2 Bethanechol Chloride Tabs, T2 Bicalutamide Tabs, T2 BICILLIN C-R Inject Syr, T3 BICILLIN L-A Inject Syr, T3 BILTRICIDE Tabs, T3 Bisoprolol Fumarate Tabs, T2 Bisoprolol-Hydrochlorothiazide Tabs, T2 BIVIGAM Inject IV, T5 Bleomycin Sulfate Inject, T2 Bleph-10 Eye Drops, T2 BOOSTRIX Inject Syr, T3 BOOSTRIX Inject, T3 BOSULIF Tabs, T5 BREVIBLOC Inject IV, T3 Briellyn Tabs, T2 Brimonidine Tartrate Eye Drops, T2 BROMFENAC SODIUM Eye Drops, T4 Bromocriptine Mesylate Caps, T2 Bromocriptine Mesylate Tabs, T2 Budeprion Sr Tabs, T2 BUDESONIDE EC Caps, T5 Bumetanide Inject, T2 Bumetanide Tabs, T2 BUPHENYL Tabs, T3 BUPRENORPHINE HCL Tabs Subl, T4 BUPRENORPHINE-NALOXONE Tabs Subl, T4 Buproban Tabs, T2 Bupropion HCL Sr Tabs, T2 Bupropion HCL Tabs, T2 Bupropion XL Tabs, T2 Bupropion XL 150MG Tabs, T2 Buspirone HCL Tabs, T2 Butalb-Caff-Acetaminoph-Codein Caps, T2 Butalbital Compound-Codeine Caps, T2 BYDUREON Inject, T4 BYETTA Inject Pen, T4 C Cabergoline Tabs, T2 Calcipotriene Cr, T2 Calcipotriene Topical Soln, T2 CALCITONIN-SALMON Nasal Spray, T4 Calcitriol Caps, T2 Calcium Acetate Caps, T2 Calcium Acetate Tabs, T2 Camila Tabs, T2 CAMPRAL Tabs, T4 CANASA Rectal Supp, T3 CANCIDAS Inject IV, T5 CAPASTAT SULFATE Inject, T3 CAPRELSA Tabs, T5 Captopril Tabs, T1 Captopril-Hydrochlorothiazide Tabs, T1 Carbamazepine Caps, T2 Carbamazepine Suspension, T2 Carbamazepine Tabs Chew, T2 Carbamazepine Tabs, T2 Carbamazepine XR Tabs, T2 Carbidopa-Levodopa Tabs, T2 CARBIDOPA-LEVODOPA-ENTACAPONE Tabs, T3 CARIMUNE NF NANOFILTERED Inject IV, T5 Carisoprodol Tabs, T2 Carteolol HCL Eye Drops, T2 Cartia Xt Caps, T2 Carvedilol Tabs, T1 CAYSTON Inhale Soln, T5 Caziant Tabs, T2 CEENU Caps, T3 Cefaclor Caps, T2 Cefaclor ER Tabs, T2 Cefaclor Suspension, T2 Cefadroxil Caps, T2 Cefadroxil Suspension, T2 Cefadroxil Tabs, T2 Cefazolin Inject IV, T2 Cefazolin Sodium Inject, T2 Cefdinir Caps, T2 Cefepime HCL Inject, T2 Cefotaxime Sodium Inject, T2 Cefpodoxime Proxetil Suspension, T2 Cefpodoxime Proxetil Tabs, T2 Cefprozil Suspension, T2 Cefprozil Tabs, T2 CEFTAZIDIME Inject IV, T3 Ceftazidime Inject, T2 Ceftriaxone Inject IV, T2 Ceftriaxone Inject, T2 Ceftriaxone IV-Froz Piggy, T2 Brand-name drugs are listed in upper case. Generic drugs are listed in lower case. Pharmacy Benefits are subject to a covered list which is subject to change. Limitations, copayments, and restrictions may apply. Refer to the Care1st Comprehensive formulary and Evidence of Coverage for more information. T1 = Tier 1 T2 = Tier 2 T3 = Tier 3 T4 = Tier 4 T5 = Tier 5 3

97 Cefuroxime Sodium Inject IV, T2 Cefuroxime Sodium Inject, T2 Cefuroxime Tabs, T2 CELEBREX Caps, T4 CELESTONE Soln, T3 CELLCEPT Suspension, T5 CELONTIN Caps, T3 CENESTIN Tabs, T3 Cephalexin Caps, T2 Cephalexin Suspension, T2 Cephalexin Tabs, T2 CEREZYME Inject IV, T5 CERVARIX Inject Syr, T3 CHANTIX Tabs, T4 CHLORAMPHENICOL SOD SUCCINATE Inject IV, T4 Chlordiazepoxide-Amitriptyline Tabs, T2 Chlorhexidine Gluconate Soln, T2 Chloroquine Phosphate Tabs, T2 Chlorothiazide Tabs, T2 Chlorpromazine HCL Inject, T2 Chlorpromazine HCL Oral Conc, T2 Chlorpromazine HCL Tabs, T2 Chlorthalidone Tabs, T2 Chlorzoxazone Tabs, T2 Cholestyramine Oral Pwd, T2 Choline Mag Trisalicylate Soln, T2 Chorionic Gonadotropin Inject, T2 Ciclopirox Cr, T2 Ciclopirox Gel, T2 Ciclopirox Topical Soln, T2 Ciclopirox Topical Susp, T2 Cilostazol Tabs, T2 Cimetidine HCL Soln, T2 Cimetidine Inject, T2 Cimetidine Tabs, T2 Ciprofloxacin ER Tabs, T2 4 Ciprofloxacin HCL Ear Drops, T2 Ciprofloxacin HCL Eye Drops, T2 Ciprofloxacin HCL Tabs, T2 Ciprofloxacin Inject IV, T2 Citalopram Hbr Soln, T2 Citalopram Hbr Tabs, T2 CLARAVIS Caps, T4 Clarithromycin ER Tabs, T2 Clarithromycin Suspension, T2 Clarithromycin Tabs, T2 Clemastine Fumarate Syrup, T2 Clemastine Fumarate Tabs, T2 Clindamax Gel, T2 Clindamax Lotion, T2 Clindamycin HCL Caps, T2 Clindamycin Phosphate Gel, T2 Clindamycin Phosphate Inject IV, T2 Clindamycin Phosphate Lotion, T2 Clindamycin Phosphate Swabs, T2 Clindamycin Phosphate Topical Soln, T2 Clindamycin Phosphate Vaginal Cr, T2 Clobetasol Propionate Cr, T2 Clobetasol Propionate Foam, T2 Clobetasol Propionate Gel, T2 Clobetasol Propionate Oint, T2 Clobetasol Propionate Topical Soln, T2 Clomipramine HCL Caps, T2 Clonazepam Tabs, T2 Clonidine HCL Tabs, T1 Clopidogrel Tabs, T1 Clorazepate Dipotassium Tabs, T2 Clotrimazole Cr, T2 Clotrimazole Topical Soln, T2 Clotrimazole Trouche, T2 Clotrimazole-Betamethasone Cr, T2 Clotrimazole-Betamethasone Lotion, T2 CLOZAPINE ODT Tabs, T3 Clozapine Tabs, T2 Co-Gesic Tabs, T2 Codeine Sulfate Tabs, T2 COLCRYS Tabs, T3 Colestipol HCL Oral Pwd, T2 Colestipol HCL Tabs, T2 Colistimethate Sodium Inject, T2 Colocort Enema, T2 COMBIPATCH Patch, T3 COMBIVENT Inhaler, T3 COMBIVENT RESPIMAT Inhaler, T3 COMETRIQ Caps, T5 COMPLERA Tabs, T5 Compro Rectal Supp, T2 COMVAX Inject, T3 Constulose Soln, T2 COPAXONE Inject Kit, T5 Cormax Topical Soln, T2 Cortisone Acetate Tabs, T2 COUMADIN Tabs, T3 CREON Caps, T3 CRIXIVAN Caps, T3 CROFAB Inject, T5 Cromolyn Sodium Eye Drops, T2 Cromolyn Sodium Inhale Soln, T2 CROMOLYN SODIUM Soln, T3 Cryselle Tabs, T2 CUBICIN Inject IV, T5 CUPRIMINE Caps, T3 Cyclafem Tabs, T2 Cyclobenzaprine HCL Tabs, T2 Cyclopentolate HCL Eye Drops, T2 Cyclophosphamide Tabs, T2 CYCLOSET Tabs, T4 Cyclosporine Caps, T2 Cyclosporine Modified Caps, T2 Cyclosporine Soln, T2

98 CYMBALTA Caps, T4 Cyproheptadine HCL Tabs, T2 CYSTADANE Oral Pwd, T3 CYSTAGON Caps, T3 CYTOGAM Inject IV, T5 Cytra-2 Soln, T2 Cytra-3 Soln, T2 Cytra-K Oral Pwd, T2 D DACOGEN Inject IV, T5 DALIRESP Tabs, T4 Danazol Caps, T2 Dantrolene Sodium Caps, T2 DAPSONE Tabs, T3 DAPTACEL Inject, T3 DARAPRIM Tabs, T3 Dasetta Tabs, T2 Deferoxamine Mesylate Inject, T2 DELZICOL Caps, T3 Demeclocycline HCL Tabs, T2 DENAVIR Cr, T3 Denta 5000 Plus Dental Cr, T2 Dentagel Dental Cr, T2 Depade Tabs, T2 DEPEN Tabs, T3 DEPO-MEDROL Inject, T4 DEPO-PROVERA Inject, T3 Desipramine HCL Tabs, T2 Desloratadine Tabs, T2 Desmopressin Acetate Nasal Soln, T2 Desmopressin Acetate Nasal Spray, T2 Desmopressin Acetate Tabs, T2 DESONATE Gel, T4 Desonide Cr, T2 Desonide Lotion, T2 Desonide Oint, T2 Desoximetasone Cr, T2 Desoximetasone Gel, T2 Desoximetasone Oint, T2 DESVENLAFAXINE ER Tabs, T4 DETROL LA Caps, T3 Dexamethasone Acetate Inject, T2 Dexamethasone Sodium Phosphate Eye Drops, T2 Dexamethasone Sodium Phosphate Inject, T2 Dexamethasone Soln, T2 Dexamethasone Tabs, T2 Dexmethylphenidate HCL Tabs, T2 Dextroamphetamine Sulfate Caps, T2 Dextroamphetamine Sulfate Tabs, T2 Dextroamphetamine-Amphetamine Caps, T2 Dextrose 5%-1/2Ns-Kcl Inject IV, T2 Dextrose 5%-1/3Ns-Kcl Inject IV, T2 Dextrose 5%-1/4Ns-Kcl Inject IV, T2 Dextrose 5%-Ns-Kcl Inject IV, T2 Dextrose 5%-Potassium Chloride Inject IV, T2 Dextrose In Lactated Ringers Inject IV, T2 Dextrose In Ringers Injection Inject IV, T2 Dextrose In Water Inject IV, T2 Dextrose In Water IV- Syr, T2 Dextrose With Sodium Chloride Inject IV, T2 Diazepam Rectal Kit, T2 Diazepam Soln, T2 Diazepam Tabs, T2 Diclofenac Potassium Tabs, T2 Diclofenac Sodium Eye Drops, T2 Diclofenac Sodium Tabs, T2 Dicloxacillin Sodium Caps, T2 Dicyclomine HCL Caps, T2 Dicyclomine HCL Tabs, T2 Didanosine Caps, T2 DIFFERIN Gel, T3 DIFFERIN Lotion, T3 DIFFERIN Swabs, T3 Diflorasone Diacetate Cr, T2 Diflorasone Diacetate Oint, T2 Diflunisal Tabs, T2 DIGIFAB Inject IV, T5 Digitek 125MCG Tabs, T1 Digitek 250MCG Tabs, T1 Digoxin 125MCG Tabs, T1 Digoxin 250MCG Tabs, T1 Digoxin Inject, T2 DIGOXIN Soln, T3 Dihydroergotamine Mesylate Inject, T2 DILANTIN Caps, T3 DILANTIN Tabs Chew, T3 DILANTIN-125 Suspension, T3 Dilt-Cd Caps, T2 Dilt-Xr Caps, T2 Diltia Xt Caps, T2 Diltiazem 24Hr Cd Caps, T2 Brand-name drugs are listed in upper case. Generic drugs are listed in lower case. Pharmacy Benefits are subject to a covered list which is subject to change. Limitations, copayments, and restrictions may apply. Refer to the Care1st Comprehensive formulary and Evidence of Coverage for more information. T1 = Tier 1 T2 = Tier 2 T3 = Tier 3 T4 = Tier 4 T5 = Tier 5 5

99 Diltiazem 24Hr ER Caps, T2 Diltiazem ER Caps, T2 Diltiazem HCL Tabs, T2 Diltzac ER Caps, T2 DIOVAN Tabs, T3 DIPENTUM Caps, T3 Diphenhydramine HCL Caps, T2 Diphenhydramine HCL Inject, T2 Diphenoxylate-Atropine Soln, T2 Diphenoxylate-Atropine Tabs, T2 DIPHTHERIA-TETANUS TOXOIDS-PED Inject, T3 Dipyridamole Tabs, T2 Disopyramide Phosphate Caps, T2 Disulfiram Tabs, T2 Divalproex Sodium Caps, T2 Divalproex Sodium ER Tabs, T2 Divalproex Sodium Tabs, T2 DOCETAXEL Inject IV, T5 Donepezil HCL Tabs, T2 Dorzolamide HCL Eye Drops, T2 Dorzolamide-Timolol Eye Drops, T2 Doxazosin Mesylate Tabs, T1 Doxepin HCL Caps, T2 Doxepin HCL Oral Conc, T2 Doxy-Lemmon Caps, T2 Doxy-Lemmon Tabs, T2 Doxycycline Hyclate Caps, T2 Doxycycline Hyclate Inject IV, T2 Doxycycline Hyclate Tabs, T2 Doxycycline Monohydrate Tabs, T2 DRONABINOL Caps, T4 Drospirenone-Ethinyl Estradiol Tabs, T2 DROXIA Caps, T3 6 E E.E.S. 400 Tabs, T2 Econazole Nitrate Cr, T2 Ed Doxy-Caps Caps, T2 Ed K+10 Tabs, T2 EDURANT Tabs, T5 Effer-K Tabs Eff, T2 ELAPRASE Inject IV, T5 ELELYSO Inject IV, T5 ELIDEL Cr, T3 ELIGARD Inject Syr, T3 Eliphos Tabs, T2 ELIQUIS Tabs, T4 ELITEK Inject IV, T5 Elixophyllin Soln, T2 EMCYT Caps, T3 EMEND Caps, T3 EMEND Inject IV, T3 Emoquette Tabs, T2 EMSAM Patch, T4 EMTRIVA Caps, T3 EMTRIVA Soln, T3 Enalapril Maleate Tabs, T1 Enalapril-Hydrochlorothiazide Tabs, T1 ENBREL Inject Pen, T5 ENBREL Inject Syr, T5 ENBREL Inject, T5 Endocet Tabs, T2 Endodan Tabs, T2 ENGERIX-B Inject Syr, T3 ENGERIX-B Inject, T3 ENOXAPARIN SODIUM 30MG/0.3ML, 40MG/0.4ML, 60MG/0.6ML Inject Syr, T3 ENOXAPARIN SODIUM 80MG/0.8ML, 100MG/ML, 120MG/0.8ML, 150MG/ ML Inject Syr, T5 ENOXAPARIN SODIUM Inject, T3 Enpresse Tabs, T2 Enskyce Tabs, T2 ENTACAPONE Tabs, T3 Epinephrine Inject Pen, T2 Epinephrine Inject Syr, T2 EPIPEN 2-PAK Inject Pen, T3 Epitol Tabs, T2 EPIVIR HBV Soln, T3 EPIVIR HBV Tabs, T3 EPIVIR Soln, T3 EPLERENONE Tabs, T4 EPOGEN 20000/ML Inject, T5 EPOGEN ALL OTHER STRENGTHS Inject, T3 EPOPROSTENOL SODIUM Inject IV, T5 EPZICOM Tabs, T5 ERAXIS (ALCOHOL DILUENT) Inject IV, T5 ERGOMAR Tabs Subl, T3 Ergotamine-Caffeine Tabs, T2 ERIVEDGE Caps, T5 Errin Tabs, T2 ERWINAZE Inject, T5 Ery Swabs, T2 Erythrocin Stearate Tabs, T2 Erythromycin Caps, T2 Erythromycin Ethylsuccinate Tabs, T2 Erythromycin Eye Ointment, T2 Erythromycin Gel, T2 Erythromycin Swabs, T2 Erythromycin Tabs, T2 Erythromycin Topical Soln, T2 Erythromycin-Benzoyl Peroxide Gel, T2 Erythromycin-Sulfisoxazole Suspension, T2 Escitalopram Oxalate Soln, T2 Escitalopram Oxalate Tabs, T2 Esmolol HCL IV- Syr, T2 Estradiol Patch, T2 Estradiol Tabs, T2

100 Estradiol-Norethindrone Acetat Tabs, T2 Estropipate Tabs, T2 Ethambutol HCL Tabs, T2 Ethosuximide Caps, T2 Ethosuximide Soln, T2 Etidronate Disodium Tabs, T2 Etodolac Caps, T2 Etodolac Tabs, T2 EVISTA Tabs, T3 EXELON Patch, T4 EXELON Soln, T3 Exemestane Tabs, T2 EXJADE 125MG Tabs, T3 EXJADE 250MG, 500MG Tabs, T5 EXTAVIA Inject Kit, T5 F FABRAZYME Inject IV, T5 Falmina Tabs, T2 Famotidine Inject IV, T2 Famotidine Tabs, T2 FANAPT Tabs, T4 FARESTON Tabs, T3 FASLODEX Inject Syr, T4 FAZACLO Tabs, T3 FELBAMATE Suspension, T4 FELBAMATE Tabs, T4 Felodipine ER Tabs, T2 Fenofibrate Caps, T2 Fenofibrate Tabs, T2 Fenoprofen Calcium Tabs, T2 FENTANYL CITRATE Loz, T4 Fentanyl Patch, T2 Finasteride Tabs, T2 FIRMAGON 120MG Inject, T5 FIRMAGON 80MG Inject, T4 Flecainide Acetate Tabs, T2 FLOVENT HFA Inhaler, T3 Fluconazole In Saline Inject IV, T2 Fluconazole Suspension, T2 Fluconazole Tabs, T2 Flucytosine Caps, T2 Fludrocortisone Acetate Tabs, T2 Flunisolide Nasal Spray, T2 Fluocinolone Acetonide Cr, T2 FLUOCINOLONE ACETONIDE OIL Ear Drops, T3 Fluocinolone Acetonide Oint, T2 Fluocinolone Acetonide Topical Soln, T2 Fluocinonide Cr, T2 Fluocinonide Gel, T2 Fluocinonide Oint, T2 Fluocinonide Topical Soln, T2 FLUOROMETHOLONE Eye Susp, T3 Fluorouracil Cr, T2 Fluorouracil Topical Soln, T2 Fluoxetine Dr Caps, T2 Fluoxetine HCL Caps, T2 Fluoxetine HCL Soln, T2 Fluoxetine HCL Tabs, T2 Fluphenazine Decanoate Inject, T2 Fluphenazine HCL Inject, T2 Fluphenazine HCL Oral Conc, T2 Fluphenazine HCL Soln, T2 Fluphenazine HCL Tabs, T2 Flurbiprofen Sodium Eye Drops, T2 Flurbiprofen Tabs, T2 Flutamide Caps, T2 Fluticasone Propionate Cr, T2 Fluticasone Propionate Nasal Spray, T2 Fluticasone Propionate Oint, T2 Fluvoxamine Maleate Tabs, T2 FOCALIN XR Caps, T4 FOLOTYN Inject IV, T5 FOMEPIZOLE Inject IV, T5 FONDAPARINUX SODIUM Inject Syr, T3 FORTAZ IN ISO-OSMOTIC DEXTROSE IV-Froz Piggy, T3 FORTEO Inject Pen, T5 FORTICAL Nasal Spray, T4 Fosinopril Sodium Tabs, T2 Fosinopril-Hydrochlorothiazide Tabs, T2 FRAGMIN Inject Syr, T4 FRAGMIN Inject, T4 FREAMINE HBC Inject IV, T3 FRUCTOSE Inject IV, T3 FULVICIN U/F Tabs, T3 Furosemide Inject Syr, T2 Furosemide Inject, T2 Furosemide Soln, T1 Furosemide Tabs, T1 FUZEON Inject, T5 Brand-name drugs are listed in upper case. Generic drugs are listed in lower case. Pharmacy Benefits are subject to a covered list which is subject to change. Limitations, copayments, and restrictions may apply. Refer to the Care1st Comprehensive formulary and Evidence of Coverage for more information. T1 = Tier 1 T2 = Tier 2 T3 = Tier 3 T4 = Tier 4 T5 = Tier 5 7

101 G Gabapentin Caps, T2 Gabapentin Soln, T2 Gabapentin Tabs, T2 GABITRIL Tabs, T4 GAMUNEX-C Inject, T3 GANCICLOVIR SODIUM Inject IV, T3 GARDASIL Inject Syr, T3 GARDASIL Inject, T3 GASTROCROM Soln, T3 Gavilyte-C Soln, T2 Gavilyte-N Soln, T2 GEMCITABINE HCL Inject IV, T5 Gemfibrozil Tabs, T2 Generlac Soln, T2 Gengraf Caps, T2 Gengraf Soln, T2 GENOTROPIN 0.2MG/0.25 Inject Syr, T3 GENOTROPIN ALL OTHER STRENGTHS Inject Syr, T5 GENOTROPIN Inject, T5 Gentak Eye Drops, T2 Gentak Eye Ointment, T2 Gentamicin Sulfate Eye Drops, T2 Gentamicin Sulfate Eye Ointment, T2 Gentamicin Sulfate Inject, T2 GEODON Inject, T3 Gildagia Tabs, T2 Gildess Fe Tabs, T2 Gildess Tabs, T2 GILENYA Caps, T5 GLEEVEC Tabs, T5 Glimepiride Tabs, T1 Glipizide ER Tabs, T1 Glipizide Tabs, T1 Glipizide-Metformin Tabs, T1 GLUCAGEN Inject Kit, T3 8 GLUCAGON EMERGENCY KIT Inject Kit, T3 Glyburide Micronized Tabs, T1 Glyburide Tabs, T1 Glyburide-Metformin HCL Tabs, T1 Glycopyrrolate Tabs, T2 GLYSET Tabs, T3 Granisetron HCL Inject IV, T2 GRANISETRON HCL Inject IV, T4 Granisetron HCL Tabs, T2 Griseofulvin Suspension, T2 Griseofulvin Tabs, T2 Griseofulvin Ultramicrosize Tabs, T2 Guanfacine HCL Tabs, T2 Guanidine HCL Tabs, T2 H HALAVEN Inject IV, T5 Halobetasol Propionate Cr, T2 Halobetasol Propionate Oint, T2 Haloperidol Decanoate Inject, T2 Haloperidol Lactate Inject, T2 Haloperidol Lactate Oral Conc, T2 Haloperidol Tabs, T2 HAVRIX Inject Syr, T3 HAVRIX Inject, T3 Hctz/Reserpine/Hydralazine Tabs, T2 Heather Tabs, T2 HECTOROL 0.5MCG, 1MCG Caps, T3 HECTOROL 2.5MCG Caps, T3 HECTOROL Inject IV, T3 HEPAGAM B Inject, T5 Heparin Sodium In 0.45% Nacl Inject IV, T2 Heparin Sodium Inject Syr, T2 Heparin Sodium Inject, T2 Heparin Sodium-D5W Inject IV, T2 Heparin Sodium-Ns Inject IV, T2 Hepatasol Inject IV, T2 HEPSERA Tabs, T5 HEXALEN Caps, T5 Homatropaire Eye Drops, T2 HUMALOG Inject, T3 HUMALOG Insulin Pen, T3 HUMALOG MIX Inject, T3 HUMALOG MIX Insulin Pen, T3 HUMALOG MIX Inject, T3 HUMALOG MIX Insulin Pen, T3 HUMATROPE 5MG, 12MG, 24MG Inject, T5 HUMATROPE 6MG Inject, T3 HUMIRA Inject Kit, T5 HUMORSOL Eye Drops, T3 HUMULIN Inject, T3 HUMULIN Insulin Pen, T3 HUMULIN N Inject, T3 HUMULIN N Insulin Pen, T3 HUMULIN R 500/ML Inject, T5 HUMULIN R Inject, T3 HUMULIN R Insulin Pen, T3 Hycort Oint, T2 Hydralazine HCL Tabs, T2 Hydralazine W/Hctz Caps, T2 Hydrochlorothiazide Caps, T1 Hydrochlorothiazide Tabs, T1 Hydrochlorothiazide/Reserpine Tabs, T2 Hydrocodone Bit-Ibuprofen Tabs, T2 Hydrocodone-Acetaminophen Soln, T2 Hydrocodone-Acetaminophen Tabs, T2 Hydrocodone-Ibuprofen Tabs, T2 Hydrocortisone Butyrate Cr, T2 Hydrocortisone Butyrate Oint, T2 Hydrocortisone Butyrate Topical Soln, T2 Hydrocortisone Cr, T2 Hydrocortisone Enema, T2

102 Hydrocortisone Lotion, T2 Hydrocortisone Oint, T2 Hydrocortisone Plus Cr, T2 Hydrocortisone Tabs, T2 Hydrocortisone Valerate Cr, T2 Hydrocortisone Valerate Oint, T2 Hydromorphone HCL Inject, T2 Hydromorphone HCL Tabs, T2 Hydroxychloroquine Sulfate Tabs, T2 Hydroxyurea Caps, T2 Hydroxyzine HCL Syrup, T2 Hydroxyzine HCL Tabs, T2 HYPERHEP B S-D Inject Syr, T5 HYPERHEP B S-D Inject, T5 HYPERLYTE CR Inject IV, T3 HYPERLYTE R Inject IV, T3 HYPERRAB S-D Inject Syr, T5 HYPERRHO S-D Inject Syr, T4 HYPERRHO S-D Inject Syr, T5 HYPERTET S-D Inject Syr, T5 I IBANDRONATE SODIUM Tabs, T4 Ibuprofen Tabs, T2 Ibuprohm Tabs, T2 ICLUSIG Tabs, T5 Imipenem-Cilastatin Sodium Inject IV, T2 Imipramine HCL Tabs, T2 Imipramine Pamoate Caps, T2 Imiquimod Cr, T2 IMOGAM RABIES-HT Inject, T5 IMOVAX RABIES VACCINE Inject, T3 INCIVEK Tabs, T5 INCRELEX Inject, T5 Indapamide Tabs, T2 Indomethacin Caps, T2 INFANRIX Inject, T3 INFANRIX PF Inject Syr, T3 INFERGEN Inject, T5 INLYTA Tabs, T5 Insulin Syringe Syringes, T2 INTELENCE Tabs, T5 INTRALIPID IV- Emulsion, T3 INTRON A 50MMU Inject, T5 INTRON A ALL OTHER STRENGTHS Inject, T3 INTRON A Inject Kit, T3 Introvale Tabs, T2 INTUNIV Tabs, T3 INVEGA 1.5MG, 3MG Tabs, T4 INVEGA 6MG, 9MG Tabs, T5 INVEGA SUSTENNA 117MG/0.75, 156MG/ML, 234MG/1.5ML Inject Syr, T5 INVEGA SUSTENNA 39MG/0.25ML, 78MG/0.5ML Inject Syr, T4 INVIRASE Caps, T3 INVIRASE Tabs, T5 INVOKANA Tabs, T4 IPOL Inject, T3 Ipratropium Bromide Inhale Soln, T2 Ipratropium Bromide Nasal Spray, T2 Ipratropium-Albuterol Inhale Soln, T2 ISENTRESS Tabs Chew, T3 ISENTRESS Tabs, T5 Isoniazid Soln, T2 Isoniazid Tabs, T2 Isopto Homatropine Eye Drops, T2 Isosorbide Dinitrate Tabs Subl, T1 Isosorbide Dinitrate Tabs, T1 Isosorbide Mononitrate ER Tabs, T2 Isosorbide Mononitrate Tabs, T2 Isradipine Caps, T2 ISTODAX Inject IV, T5 Itraconazole Caps, T2 IXIARO Inject Syr, T4 J JAKAFI Tabs, T5 Jantoven Tabs, T1 JANUMET Tabs, T3 JANUMET XR Tabs, T3 JANUVIA Tabs, T3 JE-VAX Inject, T3 JENTADUETO Tabs, T3 JEVTANA Inject IV, T5 Jolessa Tabs, T2 Jolivette Tabs, T2 Junel Fe Tabs, T2 Junel Tabs, T2 JUVISYNC Tabs, T3 K K Effervescent Tabs Eff, T2 KADCYLA Inject IV, T5 KALETRA 100MG-25MG Tabs, T3 KALETRA 200MG-50MG Tabs, T5 KALETRA Soln, T5 KAPVAY Tabs, T3 Brand-name drugs are listed in upper case. Generic drugs are listed in lower case. Pharmacy Benefits are subject to a covered list which is subject to change. Limitations, copayments, and restrictions may apply. Refer to the Care1st Comprehensive formulary and Evidence of Coverage for more information. T1 = Tier 1 T2 = Tier 2 T3 = Tier 3 T4 = Tier 4 T5 = Tier 5 9

103 Kariva Tabs, T2 Kelnor 1-35 Tabs, T2 KEPIVANCE Inject IV, T5 KETEK Tabs, T4 Ketoconazole Cr, T2 Ketoconazole Shampoo, T2 Ketoconazole Tabs, T2 Ketoprofen Caps, T2 Ketorolac Tromethamine Eye Drops, T2 Ketorolac Tromethamine Inject, T2 Ketorolac Tromethamine Tabs, T2 KINERET Inject Syr, T5 KINRIX Inject Syr, T3 KINRIX Inject, T3 Kionex Suspension, T2 Klor-Con 10 Tabs, T2 Klor-Con 8 Tabs, T2 Klor-Con M15 Tabs, T2 Klor-Con M20 Tabs, T2 Klor-Con Oral Pwd, T2 Klor-Con-EF Tabs Eff, T2 Kurvelo Tabs, T2 KUVAN Tabs, T5 KYPROLIS Inject IV, T5 L Labetalol HCL Tabs, T2 LACRISERT eye Insert, T3 LACTATED RINGERS Inject IV, T4 Lactulose Soln, T2 Lactulose Syrup, T2 LAMICTAL (BLUE) Tabs, T3 Lamivudine Tabs, T2 LAMIVUDINE-ZIDOVUDINE Tabs, T5 Lamotrigine Tabs, T2 LANOXIN PEDIATRIC Inject, T3 Lansoprazole Caps, T2 LANTUS Inject, T3 10 LANTUS SOLOSTAR Insulin Pen, T3 Latanoprost Eye Drops, T2 LATUDA Tabs, T4 LAZANDA Nasal Spray, T5 Leena Tabs, T2 Leflunomide Tabs, T2 Lessina Tabs, T2 LETAIRIS Tabs, T5 Letrozole Tabs, T2 Leucovorin Calcium Inject, T2 Leucovorin Calcium Tabs, T2 LEUKERAN Tabs, T3 LEUKINE Inject, T5 LEUPROLIDE ACETATE Inject Kit, T3 Levetiracetam Inject IV, T2 Levetiracetam Soln, T2 Levetiracetam Tabs, T2 Levetiracetam-Nacl Inject IV, T2 Levlen 28 Tabs, T2 Levobunolol HCL 0.25% Eye Drops, T1 Levobunolol HCL 0.5% Eye Drops, T1 Levofloxacin Soln, T2 Levofloxacin Tabs, T2 Levofloxacin-D5W Inject IV, T2 Levonest Tabs, T2 Levonorgestrel Tabs, T2 Levonorgestrel-Eth Estradiol Tabs, T2 Levora-28 Tabs, T2 LEVOTHROID Tabs, T3 Levothyroxine Sodium Tabs, T2 LEVOXYL Tabs, T3 LEVULAN Topical Soln, T3 LEXIVA Suspension, T3 LEXIVA Tabs, T5 Lidocaine HCL In 5% Dextrose Inject IV, T2 Lidocaine HCL Inject IV, T2 Lidocaine HCL Inject Syr, T2 Lidocaine HCL Inject, T2 Lidocaine HCL Oral Jel, T2 Lidocaine HCL Soln, T2 Lidocaine HCL Viscous Soln, T2 Lidocaine Oint, T2 Lidocaine-Prilocaine Cr, T2 LIDODERM Patch, T4 Lindane Lotion, T2 Lindane Shampoo, T2 Liothyronine Sodium Tabs, T2 LIPODOX Inject IV, T5 Lisinopril Tabs, T1 Lisinopril-Hydrochlorothiazide Tabs, T1 Lithium Carbonate Caps, T2 Lithium Carbonate Tabs, T2 Lithium Soln, T2 Lokara Lotion, T2 Loperamide Caps, T2 Lorazepam Tabs, T2 Losartan Potassium Tabs, T1 Losartan-Hydrochlorothiazide Tabs, T1 LOTEMAX Eye Susp, T3 LOTRONEX Tabs, T5 Lovastatin Tabs, T1 LOVAZA Caps, T4 Low-Ogestrel Tabs, T2 Loxapine Caps, T2 LUPRON DEPOT 3.75MG Inject Kit, T3 LUPRON DEPOT ALL OTHER STRENGTHS Inject Kit, T5 LUPRON DEPOT-PED Inject Kit, T5 Lutera Tabs, T2 LYRICA Caps, T4 LYRICA Soln, T4 LYSODREN Tabs, T3

104 M M-M-R II VACCINE Inject, T3 Maprotiline HCL Tabs, T2 Marlissa Tabs, T2 MARPLAN Tabs, T3 MATULANE Caps, T5 MAXIDEX Eye Susp, T3 Meclizine HCL Tabs, T2 Meclofenamate Sodium Caps, T2 Medroxyprogesterone Acetate Inject Syr, T2 Medroxyprogesterone Acetate Inject, T2 Medroxyprogesterone Acetate Tabs, T2 Mefloquine HCL Tabs, T2 Megestrol Acetate Suspension, T2 Megestrol Acetate Tabs, T2 MEKINIST Tabs, T5 Meloxicam Tabs, T2 MELPHALAN HCL Inject IV, T5 MENACTRA Inject, T3 MENEST Tabs, T3 MENOMUNE-A-C-Y-W-135 Inject, T3 MENVEO A-C-Y-W-135-DIP Inject Kit, T3 Meperidine HCL Soln, T2 Meperidine HCL Tabs, T2 MEPRON Suspension, T5 Mercaptopurine Tabs, T2 Mesalamine Rectal Kit, T2 MESNEX Tabs, T3 Metaproterenol Sulfate Syrup, T2 Metaproterenol Sulfate Tabs, T2 Metformin HCL ER Tabs, T1 Metformin HCL Tabs, T1 Methadone HCL Inject, T2 Methadone HCL Soln, T2 Methadone HCL Tabs, T2 Methadone Intensol Oral Conc, T2 Methadose Tabs, T2 Methazolamide Tabs, T2 Methimazole Tabs, T2 Methocarbamol Tabs, T2 Methotrexate Tabs, T2 Methyclothiazide Tabs, T2 Methyldopa Tabs, T2 Methyldopa-Hydrochlorothiazide Tabs, T2 Methylphenidate ER Tabs, T2 METHYLPHENIDATE ER Tabs, T3 Methylphenidate HCL Tabs, T2 Methylprednisolone Acetate Inject, T2 Methylprednisolone Sod Succ Inject IV, T2 Methylprednisolone Sod Succ Inject, T2 Methylprednisolone Tabs, T2 Metipranolol Eye Drops, T2 Metoclopramide HCL Inject, T2 Metoclopramide HCL Soln, T2 Metoclopramide HCL Tabs, T2 Metolazone Tabs, T2 Metoprolol Succinate Tabs, T2 Metoprolol Tartrate Tabs, T1 Metoprolol-Hydrochlorothiazide Tabs, T1 Metronidazole Cr, T2 Metronidazole Gel, T2 Metronidazole Inject IV, T2 Metronidazole Lotion, T2 Metronidazole Tabs, T2 Metronidazole Vaginal Gel, T2 Metryl Tabs, T2 Mexiletine HCL Caps, T2 Miconazole 3 Vaginal Supp, T2 MICRHOGAM PLUS Inject Syr, T3 Microgestin Fe Tabs, T2 Microgestin Tabs, T2 Midodrine HCL Tabs, T2 MIFEPREX Tabs, T3 Migergot Rectal Supp, T2 Milrinone In 5% Dextrose Inject IV, T2 Mimvey Tabs, T2 Minitran Patch, T2 Minocycline HCL Caps, T2 Minocycline HCL Tabs, T2 Minoxidil Tabs, T2 Mirtazapine Tabs, T2 Misoprostol Tabs, T2 Mitoxantrone HCL Inject IV, T2 MODAFINIL Tabs, T3 Moexipril HCL Tabs, T2 Mometasone Furoate Cr, T2 Mometasone Furoate Oint, T2 Mometasone Furoate Topical Soln, T2 Mono-Linyah Tabs, T2 Mononessa Tabs, T2 Montelukast Sodium Tabs Chew, T2 Montelukast Sodium Tabs, T2 Brand-name drugs are listed in upper case. Generic drugs are listed in lower case. Pharmacy Benefits are subject to a covered list which is subject to change. Limitations, copayments, and restrictions may apply. Refer to the Care1st Comprehensive formulary and Evidence of Coverage for more information. T1 = Tier 1 T2 = Tier 2 T3 = Tier 3 T4 = Tier 4 T5 = Tier 5 11

105 Morphine Sulfate ER All Other Strengths Tabs, T2 Morphine Sulfate Inject, T2 Morphine Sulfate Rectal Supp, T2 Morphine Sulfate Soln, T2 Morphine Sulfate Tabs, T2 MULTAQ Tabs, T4 Mupirocin Oint, T2 MYCOBUTIN Caps, T3 Myconel Cr, T2 Mycophenolate Mofetil Caps, T2 Mycophenolate Mofetil Tabs, T2 MYFORTIC 180MG Tabs, T3 MYFORTIC 360MG Tabs, T5 MYRBETRIQ Tabs, T4 MYTELASE Tabs, T3 Myzilra Tabs, T2 N NABI-HB Inject, T5 Nabumetone Tabs, T2 Nadolol Tabs, T1 Nafcillin Sodium Inject IV, T2 Nafcillin Sodium Inject, T2 NAGLAZYME Inject IV, T5 Nalidixic Acid Tabs, T2 Nallpen-Iso-Osmotic Dextrose IV-Froz Piggy, T2 NALOXONE HCL Inject Syr, T3 NALOXONE HCL Inject, T3 Naltrexone HCL Tabs, T2 NAMENDA Soln, T3 NAMENDA Tabs, T3 Naphazoline HCL Eye Drops, T2 Naphazoline HCL W/Antazoline Eye Drops, T2 Naproxen Sodium Tabs, T2 Naproxen Suspension, T2 Naproxen Tabs, T2 12 Nateglinide Tabs, T2 NEBUPENT Inhale Soln, T3 Necon Tabs, T2 Nefazodone HCL Tabs, T2 NEGGRAM Tabs, T3 Neomycin Sulfate Tabs, T2 Neomycin W/Dexamethasone Eye Drops, T2 Neomycin-Bacitracin-Poly-Hc Eye Ointment, T2 Neomycin-Bacitracin-Polymyxin Eye Ointment, T2 Neomycin-Polymyxin-Dexameth Eye Ointment, T2 Neomycin-Polymyxin-Dexameth Eye Susp, T2 Neomycin-Polymyxin-Gramicidin Eye Drops, T2 Neomycin-Polymyxin-Hc Ear Susp, T2 Neomycin-Polymyxin-Hc Eye Susp, T2 Neomycin-Polymyxin-Hydrocort Ear Soln, T2 NEPHRAMINE Inject IV, T3 NEULASTA Inject Syr, T5 NEUMEGA Inject, T5 NEUPOGEN Inject Syr, T5 NEUPOGEN Inject, T5 Nevirapine Suspension, T2 Nevirapine Tabs, T2 NEXAVAR Tabs, T5 Next Choice One Dose Tabs, T2 NIASPAN Tabs, T4 Nicardipine HCL Caps, T2 NICOTROL Inhaler, T3 NICOTROL NS Nasal Spray, T3 Nifediac Cc Tabs, T2 Nifedical Xl Tabs, T2 Nifedipine ER Tabs, T2 NILANDRON Tabs, T3 Nitrofurantoin Caps, T2 Nitroglycerin Patch Patch, T2 NITROSTAT Tabs Subl, T3 Nizatidine Caps, T2 Nora-Be Tabs, T2 NORDITROPIN FLEXPRO Inject Pen, T5 NORDITROPIN Inject, T5 NORDITROPIN NORDIFLEX Inject Pen, T5 Norethindrone Acetate Tabs, T2 Norethindrone Tabs, T2 Norgestimate-Ethinyl Estradiol Tabs, T2 Nortrel Tabs, T2 Nortriptyline HCL Caps, T2 Nortriptyline HCL Soln, T2 NORVIR Caps, T3 NORVIR Soln, T3 NORVIR Tabs, T3 NOVOLIN Inject, T3 NOVOLIN INNOLET Insulin Pen, T3 NOVOLIN N Inject, T3 NOVOLIN N INNOLET Insulin Pen, T3 NOVOLIN R Inject, T3 NOVOLIN R Insulin Pen, T3 NOVOLOG FLEXPEN Insulin Pen, T3 NOVOLOG Inject, T3 NOVOLOG MIX FLEXPEN Insulin Pen, T3 NOVOLOG MIX Inject, T3 NUEDEXTA Caps, T3 NULOJIX Inject IV, T5 NUTRILYTE II Inject IV, T3 NUTROPIN AQ Inject, T5 NUTROPIN AQ NUSPIN Inject, T5 NUTROPIN Inject, T5 Nyamyc Powder, T2 Nystatin Cr, T2

106 Nystatin Oint, T2 Nystatin Oral Pwd, T2 Nystatin Powder, T2 Nystatin Tabs, T2 Nystatin-Triamcinolone Cr, T2 Nystatin-Triamcinolone Oint, T2 Nystop Powder, T2 O Ofloxacin Ear Drops, T2 Ofloxacin Eye Drops, T2 Ofloxacin Tabs, T2 Ogestrel Tabs, T2 OLANZAPINE 20MG Tabs, T3 Olanzapine All Other Strengths Tabs, T2 Olanzapine Inject, T2 Olanzapine Odt Tabs, T2 Omeprazole Caps, T2 Ondansetron HCL Soln, T2 Ondansetron HCL Tabs, T2 Ondansetron Odt Tabs, T2 ONFI Tabs, T4 ONTAK Inject IV, T3 Oralone Dental Paste, T2 ORAP Tabs, T4 ORENCIA Inject IV, T5 ORFADIN Caps, T3 Orsythia Tabs, T2 Otimar Ear Soln, T2 Otimar Ear Susp, T2 Otomycet-Hc Ear Drops, T2 OXALIPLATIN Inject IV, T5 Oxandrolone Tabs, T2 Oxaprozin Tabs, T2 Oxcarbazepine Suspension, T2 Oxcarbazepine Tabs, T2 OXSORALEN Lotion, T3 OXSORALEN-ULTRA Caps, T3 Oxybutynin Chloride ER Tabs, T2 Oxybutynin Chloride Syrup, T2 Oxybutynin Chloride Tabs, T2 Oxycodone Concentrate Oral Conc, T2 Oxycodone HCL Caps, T2 Oxycodone HCL Soln, T2 Oxycodone HCL Tabs, T2 Oxycodone HCL-Acetaminophen Tabs, T2 Oxycodone HCL-Aspirin Tabs, T2 Oxycodone-Acetaminophen Caps, T2 Oxycodone-Acetaminophen Tabs, T2 OXYCONTIN Tabs, T4 P Pacerone Tabs, T2 Pamidronate Disodium Inject IV, T2 PANCREAZE Caps, T3 PANCRELIPASE 5,000 Caps, T3 PANRETIN Gel, T5 Pantoprazole Sodium Tabs, T2 Parcaine Eye Drops, T2 Paromomycin Sulfate Caps, T2 Paroxetine HCL Tabs, T2 PASER Oral Pwd, T4 PATANOL Eye Drops, T3 PAXIL Suspension, T3 Pedi-Dri Powder, T2 PEDIARIX Inject Syr, T3 PEDVAXHIB Inject, T3 Peg 3350-Electrolyte Soln, T2 Peg-3350 And Electrolytes Soln, T2 Peg-3350 With Flavor Packs Soln, T2 PEGANONE Tabs, T3 PEGASYS Inject Syr, T5 PEGASYS Inject, T5 PEGASYS PROCLICK Inject Pen, T5 PEGINTRON Inject Kit, T5 PEGINTRON REDIPEN Inject Kit, T5 Pen Needle Syringes, T2 Penicillin G Potassium Inject, T2 Penicillin G Sodium Inject, T2 Penicillin Gk-Iso-Osm Dextrose IV-Froz Piggy, T2 Penicillin V Potassium Soln, T2 Penicillin V Potassium Tabs, T2 PENTAM 300 Inject, T4 PENTAMIDINE ISETHIONATE Inject, T4 PENTASA Caps, T4 PENTAZOCINE-ACETAMINOPHEN Tabs, T4 Pentoxifylline Tabs, T2 Periogard Soln, T2 PERJETA Inject IV, T5 Permethrin Cr, T2 Perphenazine Tabs, T2 Perphenazine-Amitriptyline Tabs, T2 PFizerpen Inject, T2 Phenadoz Rectal Supp, T2 Phenelzine Sulfate Tabs, T2 Brand-name drugs are listed in upper case. Generic drugs are listed in lower case. Pharmacy Benefits are subject to a covered list which is subject to change. Limitations, copayments, and restrictions may apply. Refer to the Care1st Comprehensive formulary and Evidence of Coverage for more information. T1 = Tier 1 T2 = Tier 2 T3 = Tier 3 T4 = Tier 4 T5 = Tier 5 13

107 Phenobarbital Soln, T2 Phenobarbital Tabs, T2 Phenylephrine HCL Eye Drops, T2 PHENYTEK Caps, T3 Phenytoin Sodium Extended Caps, T2 Phenytoin Sodium Inject IV, T2 Phenytoin Sodium IV- Syr, T2 Phenytoin Suspension, T2 Phenytoin Tabs Chew, T2 Philith Tabs, T2 Phospha 250 Neutral Tabs, T2 PHOSPHOLINE IODIDE Eye Drops, T3 PICATO Gel, T5 Pilocarpine HCL Eye Drops, T2 Pilocarpine HCL Tabs, T2 PILOPINE HS Eye Gel, T3 Pindolol Tabs, T1 Pioglitazone HCL Tabs, T2 Pirmella Tabs, T2 Piroxicam Caps, T2 PODOCON-25 Liq, T3 Podofilox Topical Soln, T2 Polyethylene Glycol 3350 Oral Pwd, T2 Polymyxin B Sul-Trimethoprim Eye Drops, T2 POMALYST Caps, T5 Portia Tabs, T2 Potassium Bicarbonate Tabs Eff, T2 Potassium Chl-Normal Saline Inject IV, T2 Potassium Chloride Caps, T2 Potassium Chloride In D5Lr Inject IV, T2 Potassium Chloride Soln, T2 Potassium Chloride Tabs Eff, T2 Potassium Chloride Tabs, T2 Potassium Citrate Tabs, T2 POTIGA 200MG, 400MG Tabs, T5 POTIGA 300MG Tabs, T4 14 POTIGA 50MG Tabs, T4 PRADAXA Caps, T4 Pramipexole Dihydrochloride Tabs, T2 PRANDIN Tabs, T3 Pravastatin Sodium Tabs, T2 Prazosin HCL Caps, T2 Prednisolone Acetate Eye Susp, T2 Prednisolone Sodium Phosphate Eye Drops, T2 Prednisolone Sodium Phosphate Soln, T2 Prednisone Tabs, T2 PREMARIN Tabs, T3 PREMARIN Vaginal Cr, T3 Premasol Inject IV, T2 PREMPHASE Tabs, T3 PREMPRO Tabs, T3 Prenatal Plus Tabs, T2 Prevalite Oral Pwd, T2 Previfem Tabs, T2 PREZISTA 150MG Tabs, T3 PREZISTA 400MG, 60MG, 800MG Tabs, T5 PREZISTA 75MG Tabs, T3 PREZISTA Suspension, T3 PRIFTIN Tabs, T3 PRIMAQUINE Tabs, T3 PRIMAXIN I.M. Inject, T3 Primidone Tabs, T2 PRISTIQ ER Tabs, T4 PROAIR HFA Inhaler, T3 Probenecid Tabs, T2 Probenecid-Colchicine Tabs, T2 Procainamide HCL Caps, T2 Procainamide HCL Tabs, T2 Prochlorperazine Edisylate Inject, T2 Prochlorperazine Maleate Rectal Supp, T2 Prochlorperazine Maleate Tabs, T2 PROCRIT 10000/ML, 20000/ML, 40000/ML Inject, T5 PROCRIT 2000/ML, 3000/ML, 4000/ ML Inject, T3 Procto-Pak Rectal Cr, T2 Proctosol-Hc Rectal Cr, T2 Proctozone-Hc Rectal Cr, T2 Progesterone Caps, T2 PROGLYCEM Suspension, T3 PROGRAF Inject IV, T3 PROLEUKIN Inject IV, T5 PROLIA Inject Syr, T4 PROMACTA Tabs, T5 Promethazine HCL Inject, T2 Promethazine HCL Rectal Supp, T2 Promethazine HCL Syrup, T2 Promethazine HCL Tabs, T2 Promethegan Rectal Supp, T2 PRONESTYL Caps, T3 Propafenone HCL Tabs, T2 Proparacaine HCL Eye Drops, T2 Propranolol HCL Caps, T2 Propranolol HCL Tabs, T2 Propranolol-Hydrochlorothiazid Tabs, T2 Propylthiouracil Tabs, T2 PROQUAD Inject, T3 PROSTIGMIN Tabs, T3 PROTONIX IV Inject IV, T3 Protriptyline HCL Tabs, T2 PULMICORT FLEXHALER Inhaler, T4 PULMOZYME Inhale Soln, T5 Pyrazinamide Tabs, T2 Pyridostigmine Bromide Tabs, T2 Q Quasense Tabs, T2 Quetiapine Fumarate Tabs, T2 Quinapril HCL Tabs, T2

108 Quinapril-Hydrochlorothiazide Tabs, T2 Quinidine Gluconate Tabs, T2 Quinidine Sulfate Tabs, T2 QVAR Inhaler, T3 R RABAVERT Inject Kit, T3 Ramipril Caps, T2 RANEXA Tabs, T3 Ranitidine HCL Caps, T2 Ranitidine HCL Inject, T2 Ranitidine HCL Syrup, T2 Ranitidine HCL Tabs, T2 RAPAMUNE 0.5MG Tabs, T3 RAPAMUNE 1MG, 2MG Tabs, T5 RAPAMUNE Soln, T3 REBIF Inject Syr, T5 REBIF REBIDOSE Inject Pen, T5 Reclipsen Tabs, T2 RECOMBIVAX HB Inject Syr, T3 RECOMBIVAX HB Inject, T3 Rectasol-Hc Rectal Supp, T2 RELENZA Inhaler, T4 RELISTOR Inject Syr, T4 REMICADE Inject IV, T5 REMODULIN Inject, T5 RENAGEL Tabs, T4 RENVELA Tabs, T4 Reprexain Tabs, T2 RESCRIPTOR Tabs, T3 Reserpine 0.1MG Tabs, T2 Reserpine 0.25MG Tabs, T2 RESTASIS Eye Drops, T4 RETROVIR Inject IV, T3 REVATIO Inject IV, T5 REVLIMID Caps, T5 REYATAZ 100MG Caps, T3 REYATAZ 150MG, 200MG, 300MG Caps, T5 RHOGAM PLUS Inject Syr, T3 RHOPHYLAC Inject Syr, T4 Ribasphere Caps, T2 Ribasphere Tabs, T2 Ribavirin Caps, T2 Ribavirin Tabs, T2 RIDAURA Caps, T3 Rifampin Caps, T2 RIFAMPIN Inject IV, T4 RIFATER Tabs, T3 Riluzole Tabs, T2 Rimantadine HCL Tabs, T2 Ringers Injection Inject IV, T2 RISPERDAL CONSTA Inject Syr, T3 Risperidone M-Tab Tabs, T2 Risperidone Odt Tabs, T2 Risperidone Soln, T2 Risperidone Tabs, T2 RITUXAN Inject IV, T5 Rivastigmine Caps, T2 Rizatriptan Tabs, T2 Ropinirole HCL Tabs, T2 ROTATEQ Suspension, T3 Roxicet Tabs, T2 S SABRIL Oral Pwd, T5 SABRIL Tabs, T5 SAIZEN Inject, T5 Salsalate Tabs, T2 SANDOSTATIN LAR Inject Kit, T5 SANTYL Oint, T3 SAPHRIS Tabs Subl, T4 SAVELLA Tabs, T3 Selegiline HCL Caps, T2 Selegiline HCL Tabs, T2 Selenium Sulfide Topical Susp, T2 Selenos Shampoo, T2 SELZENTRY Tabs, T5 SENSIPAR 30MG Tabs, T3 SENSIPAR 60MG, 90MG Tabs, T5 SEREVENT DISKUS Inhaler, T3 SEROMYCIN Caps, T3 SEROSTIM Inject, T5 Sertraline HCL Oral Conc, T2 Sertraline HCL Tabs, T2 SF 5000 Plus Dental Gel, T2 Sildenafil Tabs, T2 Silver Sulfadiazine Cr, T2 SIMULECT Inject IV, T4 Simvastatin Tabs, T1 Single Use Swab Pads, T2 Sodium Bicarbonate Inject IV, T2 Sodium Bicarbonate IV- Syr, T2 Sodium Chloride Inject IV, T2 Sodium Chloride Irrigation, T2 Sodium Citrate & Citric Acid Soln, T2 Sodium Fluoride Dental Soln, T2 Brand-name drugs are listed in upper case. Generic drugs are listed in lower case. Pharmacy Benefits are subject to a covered list which is subject to change. Limitations, copayments, and restrictions may apply. Refer to the Care1st Comprehensive formulary and Evidence of Coverage for more information. T1 = Tier 1 T2 = Tier 2 T3 = Tier 3 T4 = Tier 4 T5 = Tier 5 15

109 SODIUM PHENYLBUTYRATE Oral Pwd, T3 SOLARAZE Gel, T5 SOLTAMOX Soln, T4 SOMATULINE DEPOT Inject Syr, T5 SOMAVERT Inject, T5 SORIATANE Caps, T5 Sorine Tabs, T2 Sotalol Af Tabs, T2 Sotalol Tabs, T2 SOTRET Caps, T4 SPIRIVA Inhaler, T3 Spironolactone Tabs, T2 Spironolactone-HCTZ Tabs, T2 Sprintec Tabs, T2 SPRYCEL Tabs, T5 Sps Suspension, T2 Sronyx Tabs, T2 SSD Cr, T2 Stagesic Caps, T2 STALEVO 100 Tabs, T3 STALEVO 125 Tabs, T3 STALEVO 150 Tabs, T3 STALEVO 200 Tabs, T3 STALEVO 50 Tabs, T3 STALEVO 75 Tabs, T3 Stannous Fluoride Dental Soln, T2 Stavudine Caps, T2 Stavudine Soln, T2 Sterile Pads Bandage, T2 STIVARGA Tabs, T5 STRATTERA Caps, T3 Streptomycin Sulfate Inject, T2 STRIBILD Tabs, T5 STROMECTOL Tabs, T3 SUBOXONE SL Film Tab, T4 SUCRAID Soln, T3 Sucralfate Suspension, T2 16 Sucralfate Tabs, T2 Sulfacetamide Sodium Eye Drops, T2 Sulfacetamide Sodium Eye Ointment, T2 Sulfacetamide-Prednisolone Eye Drops, T2 Sulfadiazine Tabs, T2 Sulfamethoxazole-Trimethoprim Inject IV, T2 Sulfamethoxazole-Trimethoprim Suspension, T2 Sulfamethoxazole-Trimethoprim Tabs, T2 Sulfasalazine DR Tabs, T2 Sulfasalazine Tabs, T2 Sulfazine Tabs, T2 Sulindac Tabs, T2 Sumatriptan Nasal Spray, T2 Sumatriptan Succinate Inject, T2 Sumatriptan Succinate Tabs, T2 SUPRAX Tabs, T3 Sure Comfort Syringes, T2 SUSTIVA Caps, T3 SUSTIVA Tabs, T3 SUTENT Caps, T5 SYLATRON 4-PACK Inject Kit, T5 SYMLIN Inject, T4 SYMLINPEN 120 Inject Pen, T4 SYMLINPEN 60 Inject Pen, T4 SYNAREL Nasal Spray, T5 SYNRIBO Inject, T5 SYNTHROID Tabs, T3 T TABLOID Tabs, T3 Tacrolimus 0.5MG, 1MG Caps, T2 TACROLIMUS 5MG Caps, T5 TAFINLAR Caps, T5 TAMIFLU Caps, T4 TAMIFLU Suspension, T4 Tamoxifen Citrate Tabs, T2 Tamsulosin HCL Caps, T2 TARCEVA Tabs, T5 TARGRETIN Caps, T5 TARGRETIN Gel, T5 TASIGNA Caps, T5 TASMAR Tabs, T3 Tazicef In Dextrose IV-Froz Piggy, T2 Tazicef Inject IV, T2 Tazicef Inject, T2 TAZORAC Cr, T4 TAZORAC Gel, T4 Taztia Xt Caps, T2 TE ANATOXAL BERNA Inject Syr, T3 TECFIDERA Caps, T5 TEGRETOL XR Tabs, T3 TEKTURNA HCT Tabs, T3 TEKTURNA Tabs, T3 Temazepam Caps, T2 TEMODAR Inject IV, T5 TENIVAC Inject Syr, T3 Terazosin HCL Caps, T2 Terbinafine HCL Tabs, T2 Terbutaline Sulfate Inject, T2 Terbutaline Sulfate Tabs, T2 Terconazole Vaginal Cr, T2 Terconazole Vaginal Supp, T2 TETANUS DIPHTHERIA TOXOIDS Inject, T3 Tetanus Toxoid Adsorbed Inject, T2 Tetcaine Eye Drops, T2 Tetracaine HCL Eye Drops, T2 Tetracycline HCL Caps, T2 THALOMID Caps, T5 THEO-24 Caps, T3 Theochron Tabs, T2 Theophylline Anhydrous Tabs, T2

110 Theophylline In 5% Dextrose Inject IV, T2 Theophylline Soln, T2 Theophylline Tabs, T2 THERACYS Inject, T3 Thermazene Cr, T2 THIOLA Tabs, T3 Thioridazine HCL Oral Conc, T2 Thioridazine HCL Tabs, T2 Thiothixene Caps, T2 THYROLAR-1 Tabs, T3 THYROLAR-1/2 Tabs, T3 THYROLAR-1/4 Tabs, T3 THYROLAR-2 Tabs, T3 THYROLAR-3 Tabs, T3 TIAGABINE HCL Tabs, T4 TICAR IN DEXTROSE Inject IV, T3 TICAR Inject IV, T3 TICAR Inject, T3 Ticlopidine HCL Tabs, T2 TIKOSYN Caps, T4 Tilia Fe Tabs, T2 TIMENTIN Inject IV, T3 Timolol Maleate Eye Drops, T1 Timolol Maleate Eye Gel, T2 Timolol Maleate Tabs, T2 TIROSINT Caps, T4 Tizanidine HCL Tabs, T2 TOBI Inhale Soln, T5 Tobramycin Eye Drops, T2 Tobramycin Sulfate Inject, T2 Tobramycin-Dexamethasone Eye Susp, T2 Tolazamide Tabs, T2 Tolbutamide Tabs, T2 Tolmetin Sodium Caps, T2 Tolmetin Sodium Tabs, T2 TOLTERODINE TARTRATE Tabs, T3 Topiragen Tabs, T2 Topiramate Caps, T2 Topiramate Tabs, T2 TOPOTECAN HCL Inject IV, T3 Torsemide Tabs, T2 TPN ELECTROLYTES Inject IV, T3 TRACLEER Tabs, T5 TRADJENTA Tabs, T3 Tramadol HCL Tabs, T2 Tramadol HCL-Acetaminophen Tabs, T2 Trandolapril Tabs, T2 TRANEXAMIC ACID Inject IV, T3 TRANEXAMIC ACID Tabs, T4 Tranylcypromine Sulfate Tabs, T2 TRAVAMULSION IV- Emulsion, T3 Travasol Inject IV, T2 TRAVATAN Z Eye Drops, T3 TRAVOPROST Eye Drops, T3 Trazodone HCL Tabs, T2 TRECATOR Tabs, T3 TRELSTAR Inject Syr, T5 TRELSTAR Inject, T5 TRETINOIN Caps, T5 Tretinoin Cr, T2 Tretinoin Gel, T2 Tri-Legest Fe Tabs, T2 Tri-Linyah Tabs, T2 Tri-Previfem Tabs, T2 Tri-Sprintec Tabs, T2 Triamcinolone 1% Cream Cr, T2 Triamcinolone Acetonide Cr, T2 Triamcinolone Acetonide Dental Paste, T2 Triamcinolone Acetonide Lotion, T2 Triamcinolone Acetonide Oint, T2 Triamterene-HCTZ Caps, T1 Triamterene-HCTZ Tabs, T1 Triamterene-Hydrochlorothiazid Tabs, T1 Triazolam Tabs, T2 Tricitrates Soln, T2 Triderm Cr, T2 Trifluoperazine HCL Tabs, T2 Trifluridine Eye Drops, T2 Trihexyphenidyl HCL Soln, T2 Trihexyphenidyl HCL Tabs, T2 TRILEPTAL Suspension, T3 Trilyte With Flavor Packets Soln, T2 Trimethoprim Tabs, T2 Trimipramine Maleate Caps, T2 Trinessa Tabs, T2 TRISENOX Inject IV, T3 Trivora-28 Tabs, T2 TRIZIVIR Tabs, T5 Trophamine Inject IV, T2 Tropicamide Eye Drops, T2 TRUVADA Tabs, T5 TUDORZA PRESSAIR Inhaler, T4 TWINRIX Inject, T3 TYGACIL Inject IV, T3 Brand-name drugs are listed in upper case. Generic drugs are listed in lower case. Pharmacy Benefits are subject to a covered list which is subject to change. Limitations, copayments, and restrictions may apply. Refer to the Care1st Comprehensive formulary and Evidence of Coverage for more information. T1 = Tier 1 T2 = Tier 2 T3 = Tier 3 T4 = Tier 4 T5 = Tier 5 17

111 TYKERB Tabs, T5 TYPHIM VI Inject, T3 TYSABRI Inject IV, T5 TYZEKA Tabs, T5 TYZINE Nasal Drops, T3 TYZINE Nasal Spray, T3 U U-Cort Cr, T2 UNITHROID Tabs, T3 Ursodiol Caps, T2 V Valacyclovir Tabs, T2 VALCYTE Tabs, T5 Valproate Sodium Inject IV, T2 Valproic Acid Caps, T2 Valproic Acid Soln, T2 Valsartan-Hydrochlorothiazide Tabs, T2 VANCOMYCIN HCL Caps, T5 Vancomycin HCL Inject IV, T2 VAQTA Inject Syr, T3 VAQTA Inject, T3 VARIVAX VACCINE Inject, T3 VASCEPA Caps, T4 VELCADE Inject, T5 VELETRI Inject IV, T5 Velivet Tabs, T2 Venlafaxine HCL ER Caps, T2 VENLAFAXINE HCL ER Tabs, T4 Venlafaxine HCL Tabs, T2 VENTOLIN Inhaler, T3 Verapamil ER Caps, T2 Verapamil ER Pm Caps, T2 Verapamil ER Tabs, T2 Verapamil HCL Caps, T2 Verapamil HCL Tabs, T2 VERDESO Foam, T4 Veripred 20 Soln, T2 VICTOZA 3-PAK Inject Pen, T4 VICTRELIS Caps, T5 VIDAZA Inject, T5 VIDEX Soln, T3 VIGAMOX Eye Drops, T4 VIIBRYD Tabs, T4 VIMPAT Inject IV, T4 VIMPAT Soln, T4 VIMPAT Tabs, T4 Viorele Tabs, T2 VIRACEPT Tabs, T5 VIRAMUNE Suspension, T3 VIRAMUNE XR Tabs, T3 VIREAD Oral Pwd, T5 VIREAD Tabs, T5 VIVOTIF BERNA Caps, T3 VORAXAZE Inject IV, T5 VORICONAZOLE Tabs, T5 VOTRIENT Tabs, T5 VPRIV Inject IV, T5 W Warfarin Sodium Tabs, T1 Water Irrigation, T2 WELCHOL Oral Pwd, T4 WELCHOL Tabs, T4 Wera Tabs, T2 WINRHO SDF Inject, T5 X XALKORI Caps, T5 XARELTO Tabs, T4 XELJANZ Tabs, T5 XENAZINE Tabs, T5 XGEVA Inject, T5 XOLAIR Inject, T5 XTANDI Caps, T5 XYREM Soln, T5 Y YERVOY Inject IV, T5 YF-VAX Inject, T3 Yodoxin Tabs, T2 Z Zafirlukast Tabs, T2 Zaleplon Caps, T2 ZALTRAP Inject IV, T5 ZAVESCA Caps, T5 Zazole Vaginal Cr, T2 ZELBORAF Tabs, T5 ZEMAIRA Inject IV, T5 ZEMPLAR Caps, T3 ZEMPLAR Inject IV, T3 Zenchent Fe Tabs Chew, T2 Zenchent Tabs, T2 ZENPEP Caps, T3 ZETIA Tabs, T3 ZIAGEN Soln, T3 Zidovudine Caps, T2 Zidovudine Syrup, T2 Zidovudine Tabs, T2 Ziprasidone HCL Caps, T2 ZMAX Suspension, T3 ZOLADEX Implant, T5 ZOLEDRONIC ACID Inject IV, T4 ZOLEDRONIC ACID IV-Infusion, T4 ZOLINZA Caps, T5 Zolpidem Tartrate Tabs, T2 ZOMETA IV-Infusion, T5 ZONALON Cr, T3 Zonisamide Caps, T2 ZORBTIVE Inject, T5 ZORTRESS 0.25MG Tabs, T4 ZORTRESS 0.5MG, 0.75MG Tabs, T5 18

112 ZOSTAVAX Inject, T3 Zovia 1-35E Tabs, T2 Zovia 1-50E Tabs, T2 ZOVIRAX Cr, T3 ZYTIGA Tabs, T5 ZYVOX Inject IV, T5 ZYVOX Suspension, T5 ZYVOX Tabs, T (TTY/TDD users call 711) 8:00 a.m. to 8:00 p.m., seven days a week facebook/mycare1st Care1st is a Medicare Advantage HMO plan with a Federal Government and State Medicaid contract in Arizona and California. Enrollment in Care1st Health Plan depends on contract renewal. The benefit information provided is a brief summary, not a complete description of benefits. Benefits and/or co-payments/co-insurance may change on January 1 of each year. Limitations, copayments, and restrictions may apply For more information contact the plan. This information is available for free in other languages. Please contact Member Services: (TTY: 711), 8:00 a.m. to 8:00 p.m., seven days a week. Esta información está disponible gratuitamente en otros idiomas. Comuníquese con Servicios para los Miembros: (TTY 711), de 8:00 a.m. a 8:00 p.m., los siete días de la semana. 請聯絡會員服務熱線電話 : 聽障和語障人士可致電 711 我們的辦公時間為每週七天, 早上 8:00 點至晚上 8:00 點 H5928_14_141_MK Accepted 19

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114 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 CA14A (HMO) Los Angeles, Orange, San Bernardino, Alameda, San Francisco, Santa Clara Counties. Coordinated Choice Plan (HMO) Los Angeles, Orange, San Diego, San Bernardino, Riverside, Santa Clara, Stanislaus, Alameda, San Francisco, Fresno 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 Convenience Extensive benefits for you No claim forms to No restrictions on complete pre existing conditions Easy access to covered, except for work in specialty care progress Expanded business Large, stable network of hours for toll free dentists, so you can enjoy customer service, a long term relationship from 5 a.m. to with your dentist 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_14_098_DENTAL_REV2 Accepted HL_DCU_CA14A_6719-2_V14_

115 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 copayments (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

116 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 copayments (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 copayment. 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 711). 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. Co-pay of $5 applies to each office visit. Co-payment is waived if additional services are provided. Our Customer Service representatives can answer benefits questions, as well as arrange facility transfers and urgent care referrals

117 Plan CA14A 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 Schedule B 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-2014 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 D0145 Oral evaluation for a patient under three years of age and counseling with primary caregiver... 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 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... No Cost D0330 Panoramic radiographic image... No Cost D0415 Collection of microorganisms for culture and sensitivity... No Cost D0425 Caries susceptibility tests... No Cost D0460 Pulp vitality tests... No Cost D0470 Diagnostic casts... No Cost D0472 Accession of tissue, gross examination, preparation and transmission of written report... No Cost - 3 -

118 Plan CA14A Description of Benefits and Co-payments D0473 D0474 D0601 D0602 D0603 D0999 Accession of tissue, gross and microscopic examination, preparation and transmission of written report... No Cost Accession of tissue, gross and microscopic examination, including assessment of surgical margins for presence of disease, preparation and transmission of written report... No Cost Caries risk assessment and documentation, with a finding of low risk... No Cost Caries risk assessment and documentation, with a finding of moderate risk... No Cost Caries risk assessment and documentation, with a finding of high risk... No Cost Unspecified diagnostic procedure, by report - includes office visit, per visit (in addition to other services)... No Cost D1000-D1999 II. PREVENTIVE D1110 Prophylaxis cleaning - adult - 1 per 6 month period... No Cost D1110 Additional prophylaxis cleaning - adult (within the 6 month period)...$45.00 D1120 Prophylaxis cleaning - child - 1 per 6 month period... No Cost D1120 Additional prophylaxis cleaning - child (within the 6 month period)...$35.00 D1206 Topical application of fluoride varnish - child to age 19; 1 per 6 month period... No Cost D1208 Topical application of fluoride - child to age 19; 1 per 6 month period... No Cost D1310 Nutritional counseling for control of dental disease... No Cost D1330 Oral hygiene instructions... No Cost D1351 Sealant - per tooth - limited to permanent molars through age 15...$10.00 D1352 Preventive resin restoration in a moderate to high caries risk patient - permanent tooth - limited to permanent molars through age 15...$10.00 D1510 Space maintainer - fixed - unilateral...$60.00 D1515 Space maintainer - fixed - bilateral...$60.00 D1520 Space maintainer - removable - unilateral...$70.00 D1525 Space maintainer - removable - bilateral...$70.00 D1550 Re-cementation of space maintainer...$12.00 D1555 Removal of fixed space maintainer...$12.00 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. D2140 Amalgam - one surface, primary or permanent... No Cost D2150 Amalgam - two surfaces, primary or permanent... No Cost D2160 Amalgam - three surfaces, primary or permanent... No Cost D2161 Amalgam - four or more surfaces, primary or permanent... No Cost D2330 Resin-based composite - one surface, anterior... $5.00 D2331 Resin-based composite - two surfaces, anterior...$10.00 D2332 Resin-based composite - three surfaces, anterior...$15.00 D2335 Resin-based composite - four or more surfaces or involving incisal angle (anterior)... $50.00 D2390 Resin-based composite crown, anterior...$

119 Plan CA14A Description of Benefits and Co-payments D2391 Resin-based composite - one surface, posterior...$55.00 D2392 Resin-based composite - two surfaces, posterior...$65.00 D2393 Resin-based composite - three surfaces, posterior...$75.00 D2394 Resin-based composite - four or more surfaces, posterior...$85.00 D2510 Inlay - metallic - one surface...$ 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...$ 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...$ D2783 Crown - ¾ porcelain/ceramic...$ D2790 Crown - full cast high noble metal...$ D2791 Crown - full cast predominantly base metal...$ D2792 Crown - full cast noble metal...$ D2794 Crown - titanium...$ D2910 Recement inlay, onlay or partial coverage restoration...$15.00 D2915 Recement cast or prefabricated post and core...$15.00 D2920 Recement crown...$15.00 D2921 Reattachment of tooth fragment, incisal edge or cusp (anterior)...$50.00 D2929 Prefabricated porcelain/ceramic crown - primary tooth - anterior primary tooth... $75.00 D2930 Prefabricated stainless steel crown - primary tooth...$65.00 D2931 Prefabricated stainless steel crown - permanent tooth...$

120 Plan CA14A Description of Benefits and Co-payments D2932 Prefabricated resin crown - anterior primary tooth...$85.00 D2933 Prefabricated stainless steel crown with resin window - anterior primary tooth... $75.00 D2940 Protective restoration...$15.00 D2941 Interim therapeutic restoration - primary dentition...$15.00 D2949 Restorative foundation for an indirect restoration...$65.00 D2950 Core buildup, including any pins when required...$65.00 D2951 Pin retention - per tooth, in addition to restoration...$10.00 D2952 Post and core in addition to crown, indirectly fabricated - includes canal preparation... $95.00 D2953 Each additional indirectly fabricated post - same tooth - includes canal preparation... $70.00 D2954 Prefabricated post and core in addition to crown - base metal post; includes canal preparation...$80.00 D2957 Each additional prefabricated post - same tooth - base metal post; includes canal preparation...$60.00 D2970 Temporary crown (fractured tooth) - palliative treatment only...$15.00 D2971 Additional procedures to construct new crown under existing partial denture framework...$55.00 D2980 Crown repair necessitated by restorative material failure...$25.00 D2981 Inlay repair necessitated by restorative material failure...$25.00 D2982 Onlay repair necessitated by restorative material failure...$25.00 D2990 Resin infiltration of incipient smooth surface lesions - limited to permanent molars through age 15...$10.00 D3000-D3999 IV. ENDODONTICS D3110 Pulp cap - direct (excluding final restoration)... No Cost D3120 Pulp cap - indirect (excluding final restoration)... No Cost D3220 Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament...$35.00 D3221 Pulpal debridement, primary and permanent teeth...$40.00 D3222 Partial pulpotomy for apexogenesis - permanent tooth with incomplete root development...$35.00 D3230 Pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final restoration)...$50.00 D3240 Pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final restoration)...$50.00 D3310 Root canal - endodontic therapy, anterior tooth (excluding final restoration)...$ D3320 Root canal - endodontic therapy, bicuspid tooth (excluding final restoration)...$ D3330 Root canal - endodontic therapy, molar (excluding final restoration)...$ D3331 Treatment of root canal obstruction; non-surgical access...$75.00 D3332 Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth... $75.00 D3333 Internal root repair of perforation defects...$75.00 D3346 Retreatment of previous root canal therapy - anterior...$ 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, pulp space disinfection, etc.)...$

121 Plan CA14A Description of Benefits and Co-payments D3352 D3353 D3410 D3421 D3425 D3426 D3427 D3430 D3450 D3920 Apexification/recalcification - interim medication replacement (apical closure/calcific repair of perforations, root resorption, pulp space disinfection, etc.)... $50.00 Apexification/recalcification - final visit (includes completed root canal therapy - apical closure/calcific repair of perforations, root resorption, etc.)...$50.00 Apicoectomy - anterior...$ Apicoectomy - bicuspid (first root)...$ Apicoectomy - molar (first root)...$ Apicoectomy (each additional root)...$90.00 Periradicular surgery without apicoectomy...$ Retrograde filling - per root...$70.00 Root amputation, per root...$80.00 Hemisection (including any root removal), not including root canal therapy...$70.00 D4000-D4999 V. PERIODONTICS - Includes preoperative and postoperative evaluations and treatment under a local anesthetic. D4210 Gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant...$ D4211 Gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant...$85.00 D4212 Gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth... $85.00 D4240 Gingival flap procedure, including root planing - four or more contiguous teeth or tooth bounded spaces per quadrant...$ D4241 Gingival flap procedure, including root planing - one to three contiguous teeth or tooth bounded spaces per quadrant...$90.00 D4245 Apically positioned flap...$ D4249 Clinical crown lengthening - hard tissue...$ D4260 Osseous surgery (including flap entry and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant...$ D4261 Osseous surgery (including flap entry and closure) - one to three contiguous teeth or tooth bounded spaces per quadrant...$ D4263 Bone replacement graft - first site in quadrant...$ D4264 Bone replacement graft - each additional site in quadrant...$75.00 D4270 Pedicle soft tissue graft procedure...$ D4274 Distal or proximal wedge procedure (when not performed in conjunction with surgical procedures in the same anatomical area)...$80.00 D4277 Free soft tissue graft procedure (including donor site surgery), first tooth or edentulous tooth position in graft...$ D4278 Free soft tissue graft procedure (including donor site surgery), each additional contiguous tooth or edentulous tooth position in same graft site...$ D4341 Periodontal scaling and root planing - four or more teeth per quadrant - limited to 4 quadrants during any 12 consecutive months...$55.00 D4342 Periodontal scaling and root planing - one to three teeth per quadrant - limited to 4 quadrants during any 12 consecutive months...$45.00 D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis - limited to 1 treatment in any 12 consecutive months...$55.00 D4910 Periodontal maintenance - limited to 1 treatment each 6 month period...$

122 Plan CA14A Description of Benefits and Co-payments D4910 D4921 Additional periodontal maintenance (within the 6 month period)...$55.00 Gingival irrigation - per quadrant... No Cost D5000-D5899 VI. PROSTHODONTICS (removable) - For all listed dentures and partial dentures, Copayment includes after delivery adjustments and tissue conditioning, if needed, for the first six months after placement. The Enrollee must continue to be eligible, and the service must be provided at the Contract Dentist s facility where the denture was originally delivered. - Rebases, relines and tissue conditioning are limited to 1 per denture during any 12 consecutive months. - Replacement of a denture or a partial denture requires the existing denture to be 5+ years old. D5110 Complete denture - maxillary...$ 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...$12.00 D5411 Adjust complete denture - mandibular...$12.00 D5421 Adjust partial denture - maxillary...$12.00 D5422 Adjust partial denture - mandibular...$12.00 D5510 Repair broken complete denture base...$45.00 D5520 Replace missing or broken teeth - complete denture (each tooth)...$25.00 D5610 Repair resin denture base...$50.00 D5620 Repair cast framework...$50.00 D5630 Repair or replace broken clasp...$50.00 D5640 Replace broken teeth - per tooth...$40.00 D5650 Add tooth to existing partial denture...$40.00 D5660 Add clasp to existing partial denture...$50.00 D5670 Replace all teeth and acrylic on cast metal framework (maxillary)...$ D5671 Replace all teeth and acrylic on cast metal framework (mandibular)...$ 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)...$55.00 D5731 Reline complete mandibular denture (chairside)...$55.00 D5740 Reline maxillary partial denture (chairside)...$55.00 D5741 Reline mandibular partial denture (chairside)...$

123 Plan CA14A Description of Benefits and Co-payments D5750 D5751 D5760 D5761 D5820 D5821 D5850 D5851 Reline complete maxillary denture (laboratory)...$90.00 Reline complete mandibular denture (laboratory)...$90.00 Reline maxillary partial denture (laboratory)...$90.00 Reline mandibular partial denture (laboratory)...$90.00 Interim partial denture (maxillary) - limited to 1 in any 12 consecutive months...$ Interim partial denture (mandibular) - limited to 1 in any 12 consecutive months...$ Tissue conditioning, maxillary...$25.00 Tissue conditioning, mandibular...$25.00 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...$ 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...$

124 Plan CA14A Description of Benefits and Co-payments D6721 D6722 D6740 D6750 D6751 D6752 D6780 D6781 D6782 D6783 D6790 D6791 D6792 D6930 D6940 D6980 Crown - resin with predominantly base metal...$ Crown - resin with noble metal...$ Crown - porcelain/ceramic...$ Crown - porcelain fused to high noble metal...$ Crown - porcelain fused to predominantly base metal...$ Crown - porcelain fused to noble metal...$ Crown - ¾ cast high noble metal...$ Crown - ¾ cast predominantly base metal...$ Crown - ¾ cast noble metal...$ Crown - ¾ porcelain/ceramic...$ Crown - full cast high noble metal...$ Crown - full cast predominantly base metal...$ Crown - full cast noble metal...$ Recement fixed partial denture...$20.00 Stress breaker...$45.00 Fixed partial denture repair necessitated by restorative material failure...$60.00 D7000-D7999 X. ORAL AND MAXILLOFACIAL SURGERY - Includes preoperative and postoperative evaluations and treatment under a local anesthetic. D7111 Extraction, coronal remnants - deciduous tooth... $5.00 D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal)... $8.00 D7210 Surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated...$50.00 D7220 Removal of impacted tooth - soft tissue...$60.00 D7230 Removal of impacted tooth - partially bony...$80.00 D7240 Removal of impacted tooth - completely bony...$ D7241 Removal of impacted tooth - completely bony, with unusual surgical complications...$ D7250 Surgical removal of residual tooth roots (cutting procedure)...$45.00 D7251 Coronectomy - intentional partial tooth removal...$ D7270 Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth...$ D7280 Surgical access of an unerupted tooth...$90.00 D7282 Mobilization of erupted or malpositioned tooth to aid eruption...$90.00 D7283 Placement of device to facilitate eruption of impacted tooth... No Cost D7286 Biopsy of oral tissue - soft - does not include pathology laboratory procedures...$30.00 D7310 Alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant...$85.00 D7311 Alveoloplasty in conjunction with extractions - one to three teeth or tooth spaces, per quadrant...$85.00 D7320 Alveoloplasty not in conjunction with extractions - four or more teeth or tooth spaces, per quadrant...$ D7321 Alveoloplasty not in conjunction with extractions - one to three teeth or tooth spaces, per quadrant...$ D7450 Removal of benign odontogenic cyst or tumor - lesion diameter up to 1.25 cm... No Cost D7451 Removal of benign odontogenic cyst or tumor - lesion diameter greater than 1.25 cm... No Cost D7471 Removal of lateral exostosis (maxilla or mandible)...$85.00 D7472 Removal of torus palatinus...$

125 Plan CA14A Description of Benefits and Co-payments D7473 D7510 D7960 D7970 D7971 Removal of torus mandibularis...$85.00 Incision and drainage of abscess - intraoral soft tissue... No Cost Frenulectomy - also known as frenectomy or frenotomy - separate procedure not incidental to another procedure...$15.00 Excision of hyperplastic tissue - per arch...$75.00 Excision of pericoronal gingiva...$75.00 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 $125.00, may apply. - The Retention Copayment includes adjustments and/or office visits up to 24 months. Pre and post orthodontic records include: The benefit for pre-treatment records and diagnostic services includes:...$ D0210 Intraoral - complete series of radiographic images D0322 Tomographic survey D0330 Panoramic radiographic image D0340 Cephalometric radiographic image D0350 Oral/facial photographic images obtained intraorally or extraorally D0470 Diagnostic casts The benefit for post-treatment records includes:...$70.00 D0210 Intraoral - complete series of radiographic images D0470 Diagnostic casts D8010 Limited orthodontic treatment of the primary dentition...$1, D8020 Limited orthodontic treatment of the transitional dentition - child or adolescent to age 19...$1, D8030 Limited orthodontic treatment of the adolescent dentition - adolescent to age 19...$1, D8040 Limited orthodontic treatment of the adult dentition - adults, including covered dependent adult children...$1, D8050 Interceptive orthodontic treatment of the primary dentition...$1, D8060 Interceptive orthodontic treatment of the transitional dentition...$1, D8070 Comprehensive orthodontic treatment of the transitional dentition - child or adolescent to age 19...$1, D8080 Comprehensive orthodontic treatment of the adolescent dentition - adolescent to age 19...$1, D8090 Comprehensive orthodontic treatment of the adult dentition - adults, including covered dependent adult children...$2, D8660 Pre-orthodontic treatment visit...$25.00 D8680 Orthodontic retention (removal of appliances, construction and placement of removable retainers)...$ 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...$15.00 D9211 Regional block anesthesia... No Cost D9212 Trigeminal division block anesthesia... No Cost

126 Plan CA14A Description of Benefits and Co-payments D9215 D9220 D9221 D9241 D9242 D9310 D9430 D9440 D9450 D9940 D9951 D9952 D9975 D9999 Local anesthesia in conjunction with operative or surgical procedures... No Cost Deep sedation/general anesthesia - first 30 minutes...$ Deep sedation/general anesthesia - each additional 15 minutes...$80.00 Intravenous conscious sedation/analgesia - first 30 minutes...$ Intravenous conscious sedation/analgesia - each additional 15 minutes...$80.00 Consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician...$25.00 Office visit for observation (during regularly scheduled hours) - no other services performed...$5.00 Office visit - after regularly scheduled hours...$35.00 Case presentation, detailed and extensive treatment planning... No Cost Occlusal guard, by report - limited to 1 in 3 years...$ Occlusal adjustment, limited...$50.00 Occlusal adjustment, complete...$ External bleaching for home application, per arch; includes materials and fabrication of custom trays - limited to one bleaching tray and gel for two weeks of self-treatment...$ Unspecified adjunctive procedure, by report - includes failed appointment without 24 hour notice - per 15 minutes of appointment time - up to an overall maximum of $ $10.00 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 preauthorized in writing by Delta Dental. 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)

127 Plan CA14A 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. anesthesia and/or intravenous sedation/analgesia is limited to treatment by a contracted oral surgeon and in conjunction with an approved referral for the removal of one or more partial or full bony impactions, (Procedures D7230, D7240, and D7241). 4. Benefits provided by a pediatric Dentist are limited to children through age seven following an attempt by the assigned Contract Dentist to treat the child and upon prior authorization by Delta Dental, less applicable Copayments. Exceptions for medical conditions, regardless of age limitation, will be considered on an individual basis. 5. 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. 6. Orthodontic treatment in progress is limited to new DeltaCare USA Enrollees who, at the time of their original effective date, are in active treatment started under their previous employer sponsored dental plan, as long as they continue to be eligible under the DeltaCare USA program. Active treatment means tooth movement has begun. Enrollees are responsible for all Copayments and fees subject to the provisions of their prior dental plan. Delta Dental is financially responsible only for amounts unpaid by the prior dental plan for qualifying orthodontic cases. 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

128 Plan CA14A Limitations and Exclusions of Benefits 3. Services solely for cosmetic purposes, with the exception of procedure D9975 (External bleaching for home application, per arch), 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, except for the treatment of newborn children with congenital defects or birth abnormalities. 4. Porcelain crowns, porcelain fused to metal, cast metal or resin with metal type crowns and fixed partial dentures (bridges) for children under 16 years of age. 5. Lost or stolen appliances including, but not limited to, full or partial dentures, space maintainers, crowns and fixed partial dentures (bridges). 6. Procedures, appliances or restoration if the purpose is to change vertical dimension, or to diagnose or treat abnormal conditions of the temporomandibular joint (TMJ). 7. 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. 8. Implant-supported dental appliances and attachments, implant placement, maintenance, removal and all other services associated with a dental implant. 9. Consultations for non-covered benefits. 10. 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 Evidence of Coverage. 11. All related fees for admission, use, or stays in a hospital, out-patient surgery center, extended care facility, or other similar care facility. 12. Prescription drugs. 13. 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 unless qualified for the orthodontic treatment in progress provision. 14. Lost, stolen or broken orthodontic appliances. 15. Changes in orthodontic treatment necessitated by accident of any kind. 16. Myofunctional and parafunctional appliances and/or therapies. 17. Composite or ceramic brackets, lingual adaptation of orthodontic bands and other specialized or cosmetic alternatives to standard fixed and removable orthodontic appliances. 18. Treatment or appliances that are provided by a Dentist whose practice specializes in prosthodontic services

129 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). Care1st Health Plan is an HMO plan with a Medicare contract and a contract with the California Medicaid program. Enrollment in Care1st 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, copayments, and restrictions may apply. Care1st Health Plan Member Services: (TTY/TDD users call 711)., 8am 8pm, 7 days a week. 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

130 A Medicare approved HMO plan Outbound Education & Verification (OEV) Call After receiving your application, a Care1st (HMO, HMO SNP) Health Plan representative will call you to review your application and answer any questions you may have. They will also explain Care1st guidelines and procedures. This call is required by Medicare and will not affect the status of your application. Your sales agent will not be present during the time of the call. Topics that will be discussed include: Care1st Health Plan is an HMO Plan. What does this mean for our members? Care1st is a Medicare Advantage Prescription Drug Plan. Care1st is not Original Medicare and it is not a Medigap or Medicare supplemental insurance plan. Use your Care1st member ID card for receiving services. Do not use your red, white and blue Medicare card. Care1st offers a list of services and their cost sharing amounts. We will make sure you have this list. Care1st offers a network of doctors, specialists, hospitals, and other providers that provide healthcare services to plan members. Familiarize yourself with these approved providers because you must use our in network providers to get your healthcare services. These healthcare providers in the plan s network can change at any time, so check our website at: or call Member services for the most up-to-date list. Care1st has a network of pharmacies. In most situations, we ll only pay for your prescriptions if you use a pharmacy in our network. We will explain Care1st s membership enrollment cancellation policy. H5928_14_149_MK Accepted

131 Your guide for Enrollment confirmation or verification Please review your personal checklist for reference around submitting your enrollment When submitting an enrollment or enrolling by the phone you re confirming that you understand the type of plan you re enrolling in. I will receive an outbound enrollment verification (0EV) call within the next 15 days to confirm my understanding and intent to enroll in the plan. Once my enrollment is approved by Medicare, Care1st will provide my Medicare health and/or prescription drug coverage. I understand that the plan I have chosen is NOT a Medicare supplement (Medigap) plan. Once my enrollment is approved by Medicare, I will receive a member ID card. I understand that I must use this member ID card instead of my Original Medicare card when I receive healthcare services or visit the pharmacy. I have reviewed the all the information available in this enrollment guide. I understand the plan s premium, deductible, covered benefits, copays and coinsurance amounts, if applicable. For additional information I can refer to the Evidence of Coverage, which I will receive in my Welcome Kit. I understand that I must continue to pay my Medicare Part B premium, if not otherwise paid for under Medicaid or by another third party. If a power of attorney (or any other person who assists in my healthcare decisions) should have been included with this enrollment process, they were present or contacted. I understand that my plan will only cover healthcare and services provided by physicians and hospitals in the plan s network. Except for emergencies, these plans do not cover care received outside the network. The agent verified whether any of my doctors are in the plan s network. For plans with prescription drug coverage I have reviewed all of my current prescription medications and have verified if they are covered within the plan s formulary. For my medications that are not listed in the plan s formulary, I understand they are not covered by the plan, unless an exception is granted. If I reach the coverage gap, I understand my cost and coverage may change, depending on my level of state assistance, if applicable. I understand that a late-enrollment penalty (LEP) will be added to my monthly Part D premium if I did not join a Medicare plan when I was first eligible. Care1st is a Medicare Advantage HMO plan with a Federal Government and State Medicaid contract in Arizona and California. Enrollment in Care1st 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. This information is available for free in other languages. Please contact Member Services: (TTY: 711), 8:00 a.m. to 8:00 p.m., seven days a week. Esta información está disponible gratuitamente en otros idiomas. Comuníquese con Servicios para los Miembros: (TTY 711), de 8:00 a.m. a 8:00 p.m., los siete días de la semana. 請聯絡會員服務熱線電話 : 聽障和語障人士可致電 711 我們的辦公時間為每週七天, 早上 8:00 點至晚上 8:00 點 H5928_14_149_MK Accepted

132 What to Expect After Enrollment Enrollment Forms Received Your enrollment is sent to Care1st (HMO, HMO SNP) 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. Verification Call Within 10 days of enrollment you will receive a phone call to confirm that your Medicare Advantage Plan was explained completely by your sales agent. During this call you will be asked to confirm that it was your intent to enroll in the plan. 5 6 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. 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. A Medicare approved HMO plan If you have questions about enrollment, call: (TTY/TDD users call 711) 8:00 a.m. to 8:00 p.m., seven days a week facebook/mycare1st Care1st is a Medicare Advantage HMO plan with a Federal Government and State Medicaid contract in Arizona and California. Enrollment in Care1st Health Plan depends on contract renewal. This information is available for free in other languages. Please contact Member Services: (TTY: 711), 8:00 a.m. to 8:00 p.m., seven days a week. Esta información está disponible gratuitamente en otros idiomas. Comuníquese con Servicios para los Miembros: (TTY 711), de 8:00 a.m. a 8:00 p.m., los siete días de la semana. 請聯絡會員服務熱線電話 : 聽障和語障人士可致電 711 我們的辦公時間為每週七天, 早上 8:00 點至晚上 8:00 點 H5928_14_150_MK Accepted

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134 Visit Us Online! Your Care1st (HMO, HMO SNP) Resource Site: A Medicare approved HMO plan Our website is your resource for the most up-to-date information. You ll find Provider listings for specialists and primary care physicians Retail Pharmacy list Drugs and formulary information Service area Member materials including Statement of Benefits, Evidence of Coverage and Annual Notice of Changes Out-of-Network Coverage information and much more... Bookmark our page or add us to your favorites for quick and easy access. For questions about our website, call: (TTY/TDD users call 711) 8:00 a.m. to 8:00 p.m., seven days a week facebook/mycare1st Care1st is a Medicare Advantage HMO plan with a Federal Government and State Medicaid contract in Arizona and California. Enrollment in Care1st Health Plan depends on contract renewal. This information is available for free in other languages. Please contact Member Services: (TTY: 711), 8:00 a.m. to 8:00 p.m., seven days a week. Esta información está disponible gratuitamente en otros idiomas. Comuníquese con Servicios para los Miembros: (TTY 711), de 8:00 a.m. a 8:00 p.m., los siete días de la semana. 請聯絡會員服務熱線電話 : 聽障和語障人士可致電 711 我們的辦公時間為每週七天, 早上 8:00 點至晚上 8:00 點 H5928_14_151_MK Accepted