San Francisco HICAP- Part D Intake 407 Sansome Street, 4 th Floor San Francisco, CA 94111 415-677-7520 (Phone) 415-296-0313 (Fax) HICAP Disclosure statement Please check box after reading HICAP counseling services are provided by Counselors registered by the California Department of Aging who are acting in good faith to provide information about health insurance policies and benefits to you, the client. Any information shall not be construed to be legal advice, and the volunteer HICAP Counselor is generally not liable for acts and omissions in providing counseling to recipients of this service. (W&I Code, Section 9541(f).) If you choose a plan and have difficulty in completing the necessary forms or process for enrollment, the HICAP Counselor will assist you. However, you will be responsible for the actual plan contract. The HICAP Counselor will NOT choose your plan for you. Name Address Phone Number Language Male Female Marital status Single Married Divorced Separated Widowed Medicare Claim # Date of Birth Part A Effective Date OR Part B Effective Date I do not have Part A.
Current Medicare Coverage (Check all that apply) Medi-Cal Medi-Cal with Share of Cost Veterans Benefits Original Medicare Medigap Part D Medicare Advantage Plan (HMO/ PPO) You may qualify for Extra Help for Part D. Please ask HICAP if your monthly income is Less than $1,369/month and have assets less than $13,070 (single) Less than $1,891/month and have assets less than $26,120 (married) Enter your Prescription Drugs. You may attach a drug list print-out from your pharmacy. Generic alternatives may save money. Drug Name Dosage (e.g. ml, mg) Frequency (e.g. twice daily) Monthly supply (e.g. 30, 60, 90) Is there a pharmacy you prefer to use? No Yes (if yes, please provide the name and address of your preferred pharmacy)
2013 Medicare Part D Stand-Alone Prescription Drug Plans HICAP (800) 434-0222 or 1-800-Medicare Beneficiary must have Medicare Part A and/or B to enroll in a Prescription Drug Plan. medicare.gov Monthly Low Drug Plan Organization Name Plan Name Plan Annual Co-Payments after deductible has been met Gap Mail Income Quality Enrollment Telephone Number Premium Deductible and prior to reaching $2,970 in full drug cost Coverage Order Subsidy Rating Website Information and Enrollment Tier 1 Tier 2 Tier 3 Tier 4 Tier 5/6 Plan Aetna Medicare Rx Plans CVS Pharmacy Plan $28.60 $325 $2 $5 $45 47% 25% No Yes Yes 3.5 800-832-2640 aetnamedicare.co Premier Plan $118.40 $0 $5 $33 $45 49% 33% Many Generics Some Brands Yes 3.5 Anthem Blue Cross Standard $41.30 $325 $2 $6 $39 $85 25% No Yes 3.0 800-261-8667 Plus $76.80 $0 $2 $7 $45 $90 $95 / 33% Few Generics Yes 3.0 anthem.com/ca/medicare Gold $113.00 $0 $2 $7 $45 $90 $95 / 33% Many Generic Some Brands Yes 3.0 Blue Shield Basic $53.40 $325 $4 $37 $76 25% 25% No Yes 4.0 800-488-8000 blueshieldca.co Enhanced $72.50 $0 $5 $45 $90 25% 33% No Yes 4.0 Cigna 800-735-1459 cignamedicarerx.c Plan One 55.80 $325 $0 $8 $28 $70 25% No Yes 3.0 Envision Silver Plan $29.10 $325 25% 25% 23% 28% 25% No No Yes 3.0 800-250-2005 envisionrxplus.co Gold Plan $54.00 $150 $2 or 1% $5 or 1% $25 or 1% 30% 29% Some Generics Yes 3.0 Express Scripts Value $61.00 $325 $4 $6 25% 27%-50% 25% No Yes 4.0 866-477-5704 express-scriptsmedicare.c Choice $91.60 $200 $8 $45 $95 28% 28% Many Generics Yes 4.0 First Health Value Plus $24.20 $0 $0 $35 $70 33% 33% No Yes 3.0 877-815-8163 Premier $47.90 $325 $1 $25 43% N/A N/A No Yes 3.0 myfirsthealthpland.com Premier Plus $102.40 $0 $0 $20 25% 43% 33% Some Generics Some Brands Yes 3.5 HealthMarkets Medicare Reader's Digest Value Plan 888-625-5531 hmic-medicare.c $32.30 $325 $1 $2.50 $37 27% N/A No Yes new Health Spring 877-357-1685 myhealthspring.c Humana Health Spring Drug Plan Wal Mart Plan 46.90 $18.50 $325 $325 25% $1 25% $3 25% 20% 25% 35% 25% 25% No No Yes Yes Yes 2.5 3.5 800-706-0872 Enhancd $47.50 $0 $2 $5 $44 $90 33% No Yes 3.5 humana-medicare.com Complete $118.60 $0 $5 $37 $69 $33 33% Some Generics Some Brands Yes 3.5 Rev.10/15/2012 Information subject to change.contact plans to verify information. Tier 1 = Preferred GenericsTier 2 = Non Preferred GenericsTier 3 = Preferred BrandsTiers 4 = Non Preferred Brands Tier 5 = Specialty Drugs
Logo Here :-) 2013 Medicare Part D Stand-Alone Prescription Drug Plans HICAP (800) 434-0222 or 1-800-Medicare Beneficiary must have Medicare Part A and/or B to enroll in a Prescription Drug Plan. medicare.gov Monthly Low Drug Plan Organization Name Plan Annual Co-Payments after deductible has been met Gap Mail Income Quality Enrollment Telephone Number Plan Name Premium Deductible and prior to reaching $2,970 in full drug cost Coverage Order Subsidy Rating Website Information and Enrollment Tier 1 Tier 2 Tier 3 Tier 4 Tier 5/6 Plan Silver Script Basic $30.60 $325 $2 21% 43% 25% N/A No Yes Yes 3.0 866-552-6106 Choice $29.10 $0 $0 $34 35% 33% N/A No Yes 3.0 silverscript.com Plus $113.10 $0 $0 $34 35% 33% N/A Many Generics Some Brands Yes 3.0 Smart Rx Saver $31.40 $325 $0 $20 $32 $85 25% No Yes Yes new -976-2781 smartdrx.com Plus $73.00 $0 $0 $20 $32 $85 25% Some Generics Yes new United American Select $36.50 $325 $1 $4 $37 $95 25% No Yes 3.5 866-524-4169 uamedicarepartd.c Enhanced $60.80 $80 $1 $7 $40 $95 29% No Yes 3.5 United Health Care - AARP MedicareRx Saver Plus $15.00 $325 $1 $2 $25 $45 25% No Yes Yes 3.0 888-867-5575 MedicareRx Preferred $47.90 $0 $3 $5 $40 $85 33% No Yes 3.0 aarpmedicarerx.com MedicareRx Enhanced $98.00 $0 $2 $5 $40 $76 33% Some Generics Some Brands Yes 3.0 Well Care Classic $33.00 $0 $6 $45 $95 33% 33% No Yes 3.0 888-293-5151 wellcarepdp.c Extra $49.00 0 $0 25% 25% 50% 33% Many Generics Yes 3.0 Used by permission from Council of Aging Orange County
San Francisco 2013 Medicare Advantage Plans Page 1 of 2 Care1st Chinese Com. Health Plan Health Net of California Humana Humana Kaiser Permanente Plan Name Care1st AdvantageOptimum Plan (H5928-026) HMO Senior Program (H0571-001) HMO Health Net Healthy Heart (H0562-009) HMO Humana Gold Plus (H0108-028) HMO Humana Gold Plus (H0108-027) HMO Senior Advantage (H0524-032) HMO Monthly Premium $28, MOOP $3400 $40, MOOP $3400 $89, MOOP $6700 $32, MOOP $5000 $62, MOOP $3400 $76, MOOP $3400 Phone Number 1-800-847-1222 Prospective Members 1-888-775-7888 ext. 3282 Prospective Members 1-800-977-6738 Prospective Members 1-800-833-2364 Prospective Members 1-800-833-2364 Prospective Members 1-800-777-1238 Prospective Members 1-800-544-0088 Current Members 1-888-775-7888 Current Members 1-800-275-4737 Current Members 1-800-457-4708 Current Members 1-800-457-4708 Current Members 1-800-443-0815 Current Members Web Site Address www.care1st.com/ca/ www.cchphmo.com www.healthnet.com www.humana-medicare.com www.humana-medicare.com www.kp.org/medicare Network Provider Brown and Toland Chinese Community Health Plan Physicians Brown and Toland; Hill Physicians Kaiser Network Network Hospital CPMC CPMC, Chinese Hospital, St. Francis, St. Mary's CPMC, UCSF, St. Francis, St. Mary's CPMC CMPC Kaiser Permanente Physician Visit $0 primary care. $10 specialist. $15 primary care, specialist, urgent care. $10 primary care, specialist or in-network urgent care. $0 primary care. $10 specialist. $0 primary care. $5 specialist. $25 primary care. $25 specialist. Inpatient Hospital Outpatient Surgery $100/day for days 1-5; $0 for days 6-90 and beyond. Unlimited days each benefit period. Except in an emergency, your doctor must notify plan of admission. $20-$75 for each visit to outpatient surgical center. $20-50 for each visit to outpatient hospital facility. $195-295/day for days 1-7;$0 for days 7-90 and beyond. Unlimited days each benefit period. Except in an emergency, your doctor must notify plan of admission. $195-295 for each visit to the surgical center or outpatient hospital facility. Authorization rules may apply. $320/day for days 1-5; $0 for days 6-90 and beyond. Unlimited days each benefit period. Except in an emergency, your doctor must notify plan of admission. $125 for each visit to outpatient surgical center. $250 for each visit to outpatient hospital facility. $125/day for days 1-8; $0 for days 9-90 and beyond. Unlimited days each benefit period. Except in an emergency, your doctor must notify plan of admission. $150 for each visit to outpatient surgical center. $10-$200 (or 20% of cost) for each visit to outpatient hospital facility. $100/day for days 1-8; $0 for days 9-90 and beyond. Unlimited days each benefit period. Except in an emergency, your doctor must notify plan of admission. $50 for each visit to outpatient surgical center. $5-$125 (or 20% of cost) for each visit to outpatient hospital facility. $255/day for days 1-7; $0/day for days 8-90; $0 copay for additional days. Except in emergency. Doctor must tell the plan you are being admitted into a hospital. $250 for each outpatient surgical center visit. $0-$250 for each visit to hospital facility. Mental Health Inpatient : Days 1-8 $100/day; Days 9-90 $0/day, Inpatient : Days 1-7 $250/day; Days 8-90 $0/day. except in an emergency, doctors must inform the plan. Additional days are $0 except, in emergency, doctor Outpatient : Individual therapy w/ psychiatrist and must inform plan. without & group therapy w/ psychiatrist and without Outpatient : Individual therapy w/ psychiatrist and $10; Partial hospitalized program $0. without & group therapy w/ psychiatrist and without $25; Partial hospitalized program services $0. Inpatient : Part of 190 lifetime days inpatient hospital care; $900/day. In an emergency, doctor must inform plan. Outpatient : Individual therapy w/ psychiatrist and without & group therapy w/ psychiatrist and without $25; Partial hospitalized program $0. Inpatient : Days 1-8 $125/day; Days 9-90 $0/day, except in an emergency, doctors must inform the plan. Outpatient : Individual therapy w/ psychiatrist and without & group therapy w/ psychiatrist and without $10; Partial hospitalized program $25. Inpatient : Days 1-8 $100/day; Days 9-90 $0/day, except in an emergency, doctors must inform the plan. Outpatient : Individual therapy w/ psychiatrist and without & group therapy w/ psychiatrist and without $5; Partial hospitalized program $25. Inpatient : Days 1-7 $255/day; Days 8-90 $0/day. Additional days are $0, except in an emergency, doctors must inform the plan. Outpatient : Individual therapy w/ psychiatrist and without $25. Group therapy w/ psychiatrist and without $12; Partial hospitalized program services $0. Ambulance Service $100; if admitted into the hospital you pay $0. $175 for Medicare-covered ambulance services. Authorization rules may apply. $275 for Medicare-covered ambulance services. Authorization rules may apply. $150 for Medicare-covered ambulance services. Authorization rules may apply. $150 for Medicare-covered ambulance services. Authorization rules may apply. $200 for Medicare-covered ambulance visit. Emergency Care $50; $25,000 plan coverage limit for supplemental emergency services outside the U.S. every year; if immediately admitted into the hospital you pay $0. $65; waived if admitted within 24 hours for the same condition. Worldwide coverage. $65; waived if admitted immediately. Worldwide coverage. Annual $50,000 limit for emergency services outside the U.S. $65; if immediately admitted into the hospital you pay $0. Worldwide coverage. $65; if immediately admitted into the hospital you pay $0. Worldwide coverage. $65; if immediately admitted into the hospital you pay $0. Worldwide coverage. Diagnostic Test, X- Ray & Lab Service $0 for Medicare-covered x-rays, clinical/ diagnostic lab tests and diagnostic radiology services. 10% for Medicare-covered therapeutic radiology services. $0 for x-rays, clinical/ diagnostic lab tests and therapeutic radiology service. $0-100 for diagnostic radiology services. $0 for x-rays, lab services & diagnostic procedures & tests. $60 for diagnostic & therapeutic radiology services, not including x-ray. $0-$10 for lab services & diagnostic procedures & tests. $0-$125 (or 20% cost) for diagnostic, not including x-ray services. $0-$10 (or 10% cost) for x- rays. $10 (or 20% cost) copay for therapeutic radiology services. $0-$5 for lab services. $0-$10 for x-rays, diagnostic procedures & tests. $0-$125 for diagnostic services, not including x-rays. $5 (or 20% cost) copay for therapeutic radiology services. $0-$30 for lab services, diagnostic procedures and tests. $30 for x-rays. $145 copay diagnostic radiology services, not including x-ray. Prescription Drugs Copay Tier 1: Preferred generic $0/ 30 day supply Tier 2: Non-preferred generic $5/ 30 day supply Tier 3: Preferred generic $30 /30 day supply Tier 4: Non-preferred generic $50 /30 day supply Tier 5: Specialty 30% coinsurance /30 day supply Tier 1: Generic $10 /30 day supply Tier 2: Brand name $40 /30 day supply Tier 3: Specialty 20% coinsurance /30 day supply Tier 1: Preferred generic $3 /30 day supply Tier 2: Non-preferred generic $12 /30 day supply Tier 3: Preferred Brand $45 /30 day supply Tier 4: Non-preferred brand $95 /30 day supply Tier 5: 33% coinsurance /30 day supply Tier 1: Preferred generic $5 /30 day supply Tier 2: Non-Preferred generic $10 /30 day supply Tier 3: Preferred brand $45 /30 day supply Tier 4: Non-Preferred brand $45 /30 day supply Tier 5: Specialty Tier 33% coinsurance /30 day supply Tier 1: Preferred Generic $0/ 30 day supply Tier 2: Non-Preferred generic $10 /30 day supply Tier 3: Preferred brand $45 /30 day supply Tier 4: Non-preferred brand $95 /30 day supply Tier 5: Specialty Tier 33% coinsurance /30 day supply Tier 1: Preferred generic $5 /30 day supply Tier 2: Generic $10 /30 day-supply Tier 3: Preferred brand name $45 /30 day supply Tier 4: Non-Preferred brand name $65 /30 day supply Tier 5: 25% coinsurance /30 day supply Tier 6: Injectable Part D vaccines /no charge Dental Vision $0 copay for 1 cleaning every six months and 1 dental x-ray every 2 years. $0-$570 copay for Medicarecovered dental benefits. $5 copay for 1 fluoride treatment a year. $0 copay for 1 pair of Medicare-covered eyeglasses or contact lenses after cataract surgery. $0 copay for Medicare-covered eye exams to look at eye condition. $5 copay for up to 1 supplemental routine eye exams every year. Optional Supplemental Package: $14.60 monthly premium includes preventive and comprehensive dental. No additional rider. Two Optional Supplemental Packages: $19 or $29 monthly premium includes preventive and comprehensive dental, chiropractic, acupuncture, eye wear, and education and wellness programs. 3 Optional Supplemental Packages: $10-$28 monthly premium includes eye exam, eye wear, preventative dental, comprehensive dental. 3 Optional Supplemental Packages: $10-$28 monthly premium includes eye exam, eye wear, preventative dental, comprehensive dental. 3 Optional Supplemental Packages: $10-$28 monthly premium includes eye exam, eye wear, preventative dental, comprehensive dental. 3 Optional Supplemental Packages: $10-$28 monthly premium includes eye exam, eye wear, preventative dental, comprehensive dental. Optional Supplemental Package: Advantage Plus - $20 monthly premium includes preventive and comprehensive dental, eye wear, and hearing aids. For more information, call San Francisco HICAP 415-677-7520, or Medicare 1-800-633-4227 or www.medicare.gov, or contact plan directly. DRAFT Updated 10/17/2012
San Francisco 2013 Medicare Advantage Plans Page 2 of 2 SCAN Health Plan SCAN Health Plan United Healthcare Health Net of California Anthem Blue Cross Plan Name Plus (H5425-041) HMO Classic (H5425-019) HMO AARP Medicare Complete (H0543-085) HMO Health Net Seniority Plus Green (H0562-045) HMO Anthem Medicare Preferred Standard (H8522-008-0) PPO Monthly Premium $27.50, MOOP $3000 $49, MOOP $3400 $0, MOOP $6700 **NO Part D. $99, MOOP $3400 $85, MOOP $3800 Phone Number 1-800-915-7226 Prospective Members 1-800-915-7226 Prospective Members 1-800-547-5514 Prospective Members 1-800-977-6738 Prospective Members 1-800-797-96439 Prospective Members 1-800-559-3500 Current Members 1-800-559-3500 Current Members 1-800-950-9355 Current Members 1-800-275-4737 Current Members 1-877-811-3107 Current Members Web Site Address www.scanhealthplan.com www.scanhealthplan.com www.aarpmedicareplans.com www.healthnet.com www.anthem.com/ca/medicare Network Provider Brown and Toland; Hill Physicians Brown and Toland; Hill Physicians Brown and Toland; Hill Physicians Brown and Toland; Hill Physicians Lower copayments for in-network providers than for out-of-network providers. You may go to any doctor, specialist or hospital out-of-network. Network Hospital CPMC, St. Francis, St. Mary's CPMC, St. Francis, St. Mary's CPMC, St. Mary's, UCSF, UCSF Cancer Center CPMC, UCSF, St. Francis, St. Mary's Physician Visit Inpatient Hospital Outpatient Surgery Mental Health Ambulance Service 20% of the cost for each Medicare-covered primary care visit, specialist visit, urgent care. 1-90 days covered each benefit period. Will not be charged additional sharing for professional services. In an emergency, doctor must tell plan you will be admitted into the hospital. 20% for each visit to outpatient surgical center or outpatient hospital facility. Inpatient : Inpatient psychiatric services count toward 190-day lifetime inpatient psychiatric hospital care in a lifetime. Outpatient : Individual therapy w/ psychiatrist and without & group therapy w/ psychiatrist and without 35% of cost. Partial hospitalized program services 20% of cost. $5 primary care. $10 specialist. $5 primary care. $10 specialist. $10 primary care or specialist. In-Network : $15 primary care. $45 for specialist. Out-of-Network : $35 primary care. $55 for specialist. $125 for days 1-8; $0 for days 9-90. $0 copay for $395/day for days 1-4. $0 for days 5-90. Unlimited $275/day for days 1-7; $0 for days 8-90 and beyond. additional days, except in emergency. Doctor must tell days each benefit period. Except in an emergency, Unlimited days each benefit period. Except in an the plan you are being admitted into a hospital. your doctor must notify plan of admission. emergency, your doctor must notify plan of admission. $175 for each visit to outpatient surgical center. $200 for each visit to outpatient hospital facility. Inpatient : Days 1-8 $125/day; Days 9-90 $0/day. Additional days are $0 except in an emergency, doctors must inform plan. Outpatient : Individual therapy w/ psychiatrist and without & group therapy w/ psychiatrist and without $25. Partial hospitalized program services $25. 20% for each visit to outpatient surgical center or outpatient hospital facility. Inpatient : Days 1-7 $255/day; Days 8-90 $0/day; Additional days are $0; except in emergency, doctor must inform plan. Outpatient : Individual therapy w/ psychiatrist & without $25. Group Therapy w/ psychiatrist and without $12; Partial hospitalized Medicare program services $60. $125 for each visit to outpatient surgical center. $275 for each visit to outpatient hospital facility. Inpatient : Part of 190 lifetime days inpatient hospital care; $900/day; in an emergency, doctor must inform plan. Outpatient : Individual therapy w/ psychiatrist and without & group therapy w/ psychiatrist and without $25; Partial hospitalized program $0. 20% of Medicare-approved cost. $150 for Medicare-covered ambulance benefits. $200 for Medicare-covered ambulance service. $125 for Medicare-covered ambulance services. Authorization rules may apply. Emergency Care 20% of the cost (up to $65). $65; if immediately admitted into the hospital you pay $0. $65; waive if admitted within 24 hours for same condition. Worldwide coverage. $50; waived if admitted immediately. Worldwide coverage. Yearly $50,000 limit for emergency services outside the U.S. In-Network : $695 copay for each Medicare-covered stay. Out-of-Network : 15% of the cost of each stay. Unlimited days each benefit period. Except in an emergency, your doctor must authorize. In-Network : 15% of cost for each Medicare-covered ambulatory surgical center visit; $0- $45 copay (or 15% of the cost) for each Medicare-covered outpatient hospital facility visit. Authorization rules may apply. Out-of Network : 25% of cost for each ambulatory surgical center or outpatient hospital facility visit. Inpatient: In-Network: 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. $695 copay for each hospital stay. Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital. Out-of-Network : 15% of the cost for each hospital stay. Outpatient: In-Network : Individual therapy w/ psychiatrist and without & group therapy w/ psychiatrist and without $40. Out-of-Network : 30% of the cost for Mental Health visits w/ psychiatrist and without. 30% of the cost for partial hospitalization program services. In- or Out-of-Network : $200 for Medicare-covered ambulance service. Authorization rules may apply. $65 for Medicare-covered ER visits; waived if admitted within 72 hours for same condition. Worldwide coverage. Diagnostic Test, X- Ray & Lab Service Prescription Drugs Copay 20% of cost for diagnostic tests, x-rays and lab services. Tier 1: Preferred Generic $0 /31 day supply Tier 2: Non- Preferred Generic $0 /31 day supply Tier 3: Preferred brand 25% of cost /31 day supply Tier 4: Non- Preferred brand 25% of cost /31 day supply Tier 5: Specialty 25% coinsurance /31 day supply Tier 6: Select Care $10 /31 day supply $0 for lab services, diagnostic procedures and tests. 20% of costs for x-rays. Tier 1: Preferred generic drugs $5 /31 day supply Tier 2: Non-Preferred generic drugs $10 /31 day supply Tier 3: Preferred brand drugs $45 /31 day supply Tier 4: Non-Preferred brand drugs $75 /31 day supply Tier 5: Specialty drugs 33% of cost /31 day supply Tier 6: Select care drugs $10 /31 day supply $13 for lab tests. $15 for x-rays. 20% for diagnostic procedures & tests, including therapeutic radiology services. Tier 1: Preferred Generic $5 /31 day supply Tier 2: Non-Preferred Generic $8 /31 day supply Tier 3: Preferred brand $45 /31 day supply Tier 4: Non-Preferred brand $95 /31 day supply Tier 5: Specialty Tier 33% coinsurance /31 day supply $0 for x-rays, lab services & diagnostic procedures & tests. $60 for diagnostic, not including x-ray & therapeutic radiology services. This plan does not offer prescription drug coverage. Note: You cannot enroll in a Part D, in addition to this plan. 20% of cost for Part B-covered drugs. In-network : $0 copay for Medicare-covered lab services. $65- $200 copay for Medicare-covered diagnostic radiology services (not including x-rays). 20% of the cost for Medicare-covered therapeutic radiology services. $0- $200 copay for Medicare-covere diagnostic procedures and tests. $65 copay for Medicare-covered x-rays. Out-of-Network : 30% of the cost for Medicare-covered therapeutic radiology services, Medicare-covered outpatient x-rays, Medicare-covered diagnostic radiology services, Medicare-covered diagnostic procedures, tests, and lab services. In-Network: $90 deductible on all drugs, except Tiers 1, 5, and 6. Tier 1: Preferred Generic $4 /30 day supply Tier 2: Non-preferred Generic $8 /30 day supply Tier 3: Preferred Brand: $40 /30 day supply Tier 4: Non-preferred Brand: $90 /30 day supply Tier 5: Injectable Drugs: 33% coinsurance /30 day supply Tier 6: Specialty: 33% coinsurance /30 day supply Dental Optional Supplemental Package: $15 monthly premium in addition to the monthly plan premium. Includes preventative dental. Optional Supplemental Benefits: #1: Basic Options- $8 monthly premium includes preventive dental. #2: High Option- $15 monthly premium includes preventative dental. Two Optional Supplemental Packages: #1: Deluxe Rider- $37 monthly premium includes preventive and comprehensive, dental, vision & 2 Optional Supplemental Packages: $19 or $29 monthly premium includes preventive and comprehensive dental, chiropractic, acupuncture, eye wear, and education and wellness programs. hearing aids. Vision No additional rider. 2 Optional Supplemental Packages: $19 or $29 #2: Dental 467 Rider- $15 monthly premium includes monthly premium includes preventive and preventive dental. comprehensive dental, chiropractic, acupuncture, eye wear, and education and wellness programs. 20% of cost for Part B-covered drugs for in-network and out-of-network. 3 Optional Supplemental Packages: #1: Preventive Dental - $12 monthly premium includes preventive dental. #2: Comprehensive Dental & Vision - $31 monthly premium includes preventive and comprehensive dental, eye exams, eye wear. #3: Combination Package - $36 monthly premium includes preventive and comprehensive dental, eye exams, eye wear, chiropractic, and acupuncture. For more information, call San Francisco HICAP 415-677-7520, or Medicare 1-800-633-4227 or www.medicare.gov, or contact plan directly. DRAFT Updated 10/17/2012