HealthPartners Freedom Plan

HealthPartners Freedom Plan Group Summary of Benefits Emeriti 2007 H2462

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Table of Contents Group Plan Information..................5 Introduction............................8 Summary of Benefits...................10 - Inpatient Care........................10 - Outpatient Care.......................14 - Outpatient Medical Services and Supplies.........................20 - Preventive Services...................22 - Additional Benefits (What Original Medicare does NOT cover).............30 HealthPartners is a health plan with a Medicare contract. 3

Choice - Control - Affordability The HealthPartners Freedom Group plan is being offered to you through your employer. Your employer understands the importance of having more than just Original Medicare. This document is designed to provide you with basic details regarding your coverage. If you should have any questions that are not answered within this document, please contact HealthPartners. Join the Freedom Frequent Fitness Program at no additional cost to you As a HealthPartners Freedom Group plan Medicare member, when you enroll and work out at least eight times a month at one of the participating fitness clubs, you can enjoy the Freedom Frequent Fitness Program at no additional cost. HealthPartners pays the full cost of your monthly membership! 4

HealthPartners Freedom Group Plan Information Great health care coverage The family of HealthPartners Freedom Group plan offers all the benefits that are available under Original Medicare and more. No referral required This plan features an open access network. That means you can see any network provider without a referral. The extensive network includes most Minnesota doctors and hospitals. It s likely you'll be able to keep your current doctor. If you do not call to activate the Extended Absence coverage before your trip, you will still be able to use your Original Medicare benefits when obtaining care outside the plan s network, but will be responsible for Medicare deductibles, coinsurance and any additional charges not covered by Medicare. Emergency and urgently needed services are an exception to this requirement and are covered anywhere in the world. When you travel, take your health plan with you at no extra cost With the Extended Absence benefit, you can get your plan's level of coverage while you are away from Minnesota for up to nine months. You will need to call HealthPartners each time before you receive services outside of Minnesota to activate the coverage. Once activated, coverage begins immediately. The Extended Absence benefit coverage is the same as in-network coverage. The Extended Absence benefit can only be used outside the state of Minnesota and within the United States. The out-of-state providers you see must participate in the Medicare program. They will bill Medicare first for Medicareeligible services. These providers may require you to pay for non-medicare covered services at the time they are provided. You may then submit a claim to HealthPartners for payment of services covered by HealthPartners. 5

Coverage for emergency and urgentlyneeded care anywhere in the world A medical emergency is when you reasonably believe that your health is in serious danger when every second counts. A medical emergency includes severe pain, a bad injury, a serious illness, or a medical condition that is quickly getting much worse. Urgently needed services are also covered wherever you need them. These are the health care services which you need and which cannot be delayed, as a result of unforeseen illness, injury or condition under circumstances that make it unreasonable to obtain services in the network. If you need urgent care while you are in the service area, go to your clinic or any of the network s urgent care centers. Emergency services are covered worldwide, whenever you need them. In an emergency call 911, or go to the nearest hospital or emergency medical center. Attention Persons with Diabetes: If you have diabetes and enroll in a Medicare Part D Prescription Drug plan, your syringes, oral or injectable insulin, alcohol, swabs and gauze will be covered under your Medicare Part D plan and NOT your Medicare Part B coverage. All other diabetes supplies will remain covered by your Durable Medical Equipment benefit under Medicare Part B coverage. See Page 22 for details. 6

Enrollment is easy 1 2 Compare the HealthPartners Freedom Group plan options in the enclosed Summary of Benefits with the limitations of Original Medicare. Mail your completed enrollment form(s) to HealthPartners in the enclosed postage-paid envelope. Or call us at the number listed below. Completed enrollment forms that are received by HealthPartners by the last working day of the month are generally effective the first day of the next calendar month. For example: a completed enrollment form received by HealthPartners on January 30, 2007, is effective February 1, 2007. HealthPartners contract with CMS is renewed annually and the availability of coverage beyond the end of the current contract year is not guaranteed. Eligibility for plan membership is based on eligibility for Medicare Parts A and B or Part B only. It is not based on age, health status, prior or anticipated use of health services, or preexisting conditions. There is no health screening. Just complete the application forms in this packet and mail them in the enclosed envelope with a copy of your Medicare card. In general, you cannot be a member of two Medicare HMO plans or Medicare Prescription Drug Plans at the same time. You automatically cancel membership in other Medicare HMO (Medicare Advantage or Cost) plans and Medicare Prescription Drug Plans when you join this plan. Automatic cancellation does not apply to Medicare Select/Supplemental plans. You must live in Minnesota. You must not have End Stage Renal Disease (ESRD) and cannot be in a Medicare hospice program. (The ESRD eligibility condition does not apply if you are already a HealthPartners member and are within one month of enrolling in Medicare Parts A and B or Part B only.) If you have Medicare Part B only and are enrolling in this plan, please note that you will only have coverage for Medicare Part B services. You will not have coverage for hospital, skilled nursing facilities, and related services covered by Medicare Part A. You may contact the Social Security Office at 1-800-772-1213 if you wish to purchase Medicare Part A coverage. For questions regarding medical and dental plan options, call 952-883-5601 or 1-800-247-7015, Monday - Friday, 8 a.m. to 6 p.m. TTY users should call 952-883-6060 or 1-800-443-0156. For questions about Medicare Part D prescription drug benefits, including copayments, deductibles and network pharmacies, call 952-883-5601 or 1-800-247-7015, 7 days a week, 8 a.m. to 8 p.m. TTY users should call 952-883-6060 or 1-800-443-0156. Or visit us at healthpartners.com/medicare. 7

Introduction to the Summary of Benefits for HealthPartners Freedom Group Plan January 1, 2007 - December 31, 2007 Thank you for your interest in HealthPartners Freedom Group plan. Our plan is offered by HEALTHPARTNERS, a Medicare Cost Managed Care plan. This Summary of Benefits tells you some features of our plan. It doesn't list every service that we cover, every limitation, or every exclusion. To get a complete list of our benefits, please call HealthPartners 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 group health plan, like HealthPartners Freedom Group plan. You may have other options too. You make the choice. No matter what you decide, you are still in the Medicare Program. You may join or leave a plan only at certain times. Please call HealthPartners at the number listed at the end of this introduction or 1-800-MEDICARE (1-800-633-4227) for more information. TTY users should call 1-877-486-2048. You can call this number 24 hours a day, 7 days a week. HOW CAN I COMPARE MY OPTIONS? You can compare HealthPartners Freedom Group plan 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. WHERE IS HEALTHPARTNERS FREEDOM PLAN AVAILABLE? The service area for this plan includes the following counties: Aitkin, Anoka, Becker, Beltrami, Benton, Big Stone, Blue Earth, Brown, Carlton, Carver, Cass, Chippewa, Chisago, Clay, Clearwater, Cook, Cottonwood, Crow Wing, Dakota, Dodge, Douglas, Faribault, Fillmore, Freeborn, Goodhue, Grant, Hennepin, Houston, Hubbard, Isanti, Itasca, Jackson, Kanabec, Kandiyohi, Kittson, Koochiching, Lac qui Parle, Lake, Lake of the Woods, Le Sueur, Lincoln, Lyon, Mahnomen, Marshall, Martin, McLeod, Meeker, Mille Lacs, Morrison, Mower, Murray, Nicollet, Nobles, Norman, Olmsted, Otter Tail, Pennington, Pine, Pipestone, Polk, Pope, Ramsey, Red Lake, Redwood, Renville, Rice, Rock, Roseau, Scott, Sherburne, Sibley, St. Louis, Stearns, Steele, Stevens, Swift, Todd, Traverse, Wabasha, Wadena, Waseca, Washington, Watonwan, Wilkin, Winona, Wright, and Yellow Medicine counties. You must live in one of these places to join the plan. WHO IS ELIGIBLE TO JOIN HEALTHPARTNERS FREEDOM PLAN? You can join HealthPartners Freedom plan 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 (ESRD) are not eligible to enroll in HealthPartners Freedom plan. 8

CAN I CHOOSE MY DOCTORS? HealthPartners has formed a network of doctors, specialists, and hospitals. You can use any doctor who is part of our network. You may also go to doctors outside of our network. The health providers in our network can change at any time. You can ask for a current Provider Directory for an up-to-date list or visit us at healthpartners.com/medicare. Our number is listed at the end of this introduction. WHAT HAPPENS IF I GO TO A DOCTOR WHO'S NOT IN YOUR NETWORK? You can always choose to go to a doctor outside our network. We may not pay for the services you receive outside of our network, but Medicare will pay for its share of charges it approves. You will be responsible for Medicare Part B deductible and coinsurance. DOES MY PLAN COVER MEDICARE PART B AND MEDICARE PART D DRUGS? HealthPartners Freedom Group plan covers both Medicare Part B and Medicare Prescription Drug Program Part D drugs. WHAT TYPES OF DRUGS MAY BE COVERED UNDER MEDICARE PART B? The following outpatient prescription drugs may be covered under Medicare Part B. This may include, but is not limited to, the following types of drugs. Contact HealthPartners 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 drugs for osteoporosis for certain women with Medicare. -- Erythropoietin (Epoetin alpha or Epogen ): By injection if you have end-stage 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 physician s service. -- Immunosuppressive Drugs: Immunosuppressive drug therapy for transplant patients if the transplant was paid for by Medicare, or paid by a private insurance that paid as a primary payer to your Medicare Part A coverage, in a Medicare-certified facility. -- 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 provided through DME. Please call HealthPartners for more information about this plan.visit us at healthpartners.com/medicare or call us: Member Services hours: Sunday, Monday, Tuesday, Wednesday, Thursday, Friday, Saturday, 8:00 a.m. - 8:00 p.m. Central. Current members should call 1-800-233-9645 ( TTY/TDD 1-800-443-0156). Prospective members should call 1-800-247-7015 (TTY/TDD 1-800-443-0156) For more information about Medicare, call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You can call 24 hours a day, 7 days a week. Or, visit www.medicare.gov on the web. If you have special needs, this document may be available in other formats. 9

If you have any questions about this plan s benefits or costs, please contact HealthPartners. Benefit Original Medicare Plan I Important Information 1 Premium and Other Important Information 2 Doctor and Hospital Choice (For more information, see Emergency #15 and Urgently Needed Care #16) Most people will pay the standard monthly Part B premium of $93.50. However, starting January 1, 2007, some people will have to pay a higher premium because of their yearly income (over $80,000 for singles, $160,000 for married couples). For more information on Part B premiums based on income, call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. You may go to any doctor, specialist or hospital that accepts Medicare You will continue to pay the Medicare Part B premium of $93.50 each month. (This is the 2007 amount and may change January 1, 2008.) There is a $1,500 maximum out-of-pocket limit every year for all plan services. You pay an additional premium of $218.30 per month. You do NOT need a referral to go to network doctors, specialists and hospitals. You can use any doctor who is part of our network. You may also go to doctors outside of our network. You are covered for U.S. visitor/travel benefits. Summary of Benefits Inpatient Care 3 Inpatient Hospital Care (Includes Substance Abuse and Rehabilitation Services) You pay for each benefit period: (3) Days 1-60: an initial deductible of $992 Days 61-90: $248 each day Days 91-150: $496 each lifetime reserve day (4) (These are 2007 amounts and may change January 1, 2008.) Please call 1-800-MEDICARE (1-800-633-4227) for information about lifetime reserve days (4) You pay $100 per benefit period. Except in an emergency, your provider must obtain authorization from HealthPartners. (1) Each year, you pay a total of one $131 deductible. (2) If a doctor or supplier chooses not to accept an assignment, their costs are often higher, which means you may pay more. 10

Plan II You will continue to pay the Medicare Part B premium of $93.50 each month. (This is the 2007 amount and may change January 1, 2008.) There is a $3,000 maximum out-of-pocket limit every year for all plan services. You pay an additional premium of $137.30 per month. You do NOT need a referral to go to network doctors, specialists and hospitals. You can use any doctor who is part of our network. You may also go to doctors outside of our network. You are covered for U.S. visitor/travel benefits. You pay $100 per benefit period. Except in an emergency, your provider must obtain authorization from HealthPartners. (3) A benefit period begins the day you go to the hospital or skilled nursing facility. The benefit period ends when you have not received hospital or skilled nursing care for 60 days in a row. 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 the benefit periods you can have. (4) Lifetime reserve days can only be used once. 11

If you have any questions about this plan s benefits or costs, please contact HealthPartners. Benefit Original Medicare Plan I 4 Inpatient Mental Health Care You pay the same deductible and copayments as inpatient hospital care (see Page 10) except Medicare beneficiaries may only receive 190 days in a Psychiatric Hospital in a lifetime. You pay $100 per benefit period. Medicare beneficiaries may only receive 190 days in a Psychiatric Hospital in a lifetime. Except in an emergency, your provider must obtain authorization from HealthPartners. 5 Skilled Nursing Facility (In a Medicare-certified skilled nursing facility) You pay for each benefit period (3), following at least a 3-day covered hospital stay: Days 1-20: $0 for each day. Days 21-100: $124 for each day There is no copayment for services in a Skilled Nursing Facility. Three day prior hospital stay is required. You are covered for 100 days each benefit period. (These are the 2007 amounts and may change January 1, 2008.) There is a limit of 100 days for each benefit period. (3) 6 Home Health Care (Includes medically necessary intermittent skilled nursing care, home health aide services, and rehabilitation services, etc.) There is no copayment for all covered home health visits. There is no copayment for Medicare-covered home health visits. (1) Each year, you pay a total of one $131 deductible. (2) If a doctor or supplier chooses not to accept an assignment, their costs are often higher, which means you pay more. 12

Plan II You pay $100 per benefit period. Medicare beneficiaries may only receive 190 days in a Psychiatric Hospital in a lifetime. Except in an emergency, your provider must obtain authorization from HealthPartners. There is no copayment for services in a Skilled Nursing Facility. Three day prior hospital stay is required. You are covered for 100 days each benefit period. There is no copayment for Medicare-covered home health visits. (3) A benefit period begins the day you go to the hospital or skilled nursing facility. The benefit period ends when you have not received hospital or skilled nursing care for 60 days in a row. 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 the benefit periods you can have. (4) Lifetime reserve days can only be used once. 13

If you have any questions about this plan s benefits or costs, please contact HealthPartners. Benefit Original Medicare Plan I Outpatient Care 7 Hospice You pay part of the cost for outpatient drugs and inpatient respite care. You must receive care from a Medicarecertified hospice. You must receive care from a Medicarecertified hospice. 8 Doctor Office Visits You pay 20% of Medicare-approved amounts. (1) (2) You pay $15 for each primary care or specialty care office visit for Medicarecovered services. See 32-Physical Exams for more information. 9 Chiropractic Services You are covered for manual manipulation of the spine to correct subluxation, provided by chiropractors and other qualified providers. You pay 100% for routine care. You pay 20% of Medicare-approved amounts. (1) (2) You pay $15 for each Medicare-covered visit (manual manipulation of the spine to correct subluxation). (1) Each year, you pay a total of one $131 deductible. (2) If a doctor or supplier chooses not to accept an assignment, their costs are often higher, which means you pay more. 14

Plan II You must receive care from a Medicare-certified hospice. You pay $20 for each primary care or specialty care office visit for Medicare-covered services. See 32-Physical Exams for more information. You pay $20 for each Medicare-covered visit (manual manipulation of the spine to correct subluxation). (3) A benefit period begins the day you go to the hospital or skilled nursing facility. The benefit period ends when you have not received hospital or skilled nursing care for 60 days in a row. 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 the benefit periods you can have. (4) Lifetime reserve days can only be used once. 15

If you have any questions about this plan s benefits or costs, please contact HealthPartners. Benefit Original Medicare Plan I 10 Podiatry Services You pay 20% of Medicare-approved amounts. (1) (2) You are covered for medically necessary foot care, including care for medical conditions affecting the lower limbs. You pay 100% for routine care. You pay $15 for each Medicare-covered visit (medically-necessary foot care). You pay $15 for each routine visit. Authorization rules may apply for services. 11 Outpatient Mental Health Care You pay 50% of Medicare-approved amounts with the exception of certain situations and services for which you pay 20% of approved charges. (1) (2) For Medicare-covered Mental Health services, you pay $15 for each individual therapy session and $7.50 for each group therapy session. Authorization rules may apply for services. 12 Outpatient Substance Abuse Care You pay 20% of Medicare-approved amounts. (1) (2) For Medicare-covered services, you have 100% coverage of the cost of each individual/group session. There is a 75-hour limit for treatment per calendar year. Except in an emergency, your provider must obtain authorization from HealthPartners. (1) Each year, you pay a total of one $131 deductible. (2) If a doctor or supplier chooses not to accept an assignment, their costs are often higher, which means you pay more. 16

Plan II You pay $20 for each Medicare-covered visit (medically necessary foot care). You pay $20 for each routine visit. For Medicare-covered Mental Health services, you pay $20 for each individual therapy session and $10 for each group therapy session. For Medicare-covered services, you have 100% coverage of the cost of each individual/group session. There is a 75 hour limit for treatment per calendar year. Except in an emergency, your provider must obtain authorization from HealthPartners. (3) A benefit period begins the day you go to the hospital or skilled nursing facility. The benefit period ends when you have not received hospital or skilled nursing care for 60 days in a row. 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 the benefit periods you can have. (4) Lifetime reserve days can only be used once. 17

If you have any questions about this plan s benefits or costs, please contact HealthPartners. Benefit Original Medicare Plan I 13 Outpatient Services/Surgery You pay 20% of Medicare-approved amounts for the doctor. (1) (2) 100% coverage for each Medicare-covered visit to an ambulatory surgical center. You pay 20% of outpatient facility charges. (1) (2) 100% coverage for each Medicare-covered visit to an outpatient hospital facility. Authorization rules may apply for services. 14 Ambulance Services (Medically necessary ambulance services) You pay 20% of Medicare-approved amounts or applicable fee schedule charges. (1) (2) 100% coverage for Medicare-covered ambulance services. You pay 20% of the charges incurred outside the United States. Authorization rules may apply for services. 15 Emergency Care (You may go to any emergency room if you reasonably believe you need emergency care.) You pay 20% of the facility charge or applicable copayment for each emergency room visit; you do NOT pay this amount if you are admitted to the hospital for the same condition within 3 days of the emergency room visit. (1) (2) You pay 20% of doctor charges. (1) (2) NOT covered outside the U.S. except under limited circumstances. You pay $50 for each Medicare-covered emergency room visit; however, the copay is waived if you are admitted to the hospital within 24 hours with the same condition. You pay 20% of the cost for each emergency room visit outside the United States. (1) Each year, you pay a total of one $131 deductible. (2) If a doctor or supplier chooses not to accept an assignment, their costs are often higher, which means you pay more. 18

Plan II 100% coverage for each Medicare-covered visit to an ambulatory surgical center. 100% coverage for each Medicare-covered visit to an outpatient hospital facility. 100% coverage for Medicare-covered ambulance services. You pay 20% of the charges incurred outside the United States. You pay $50 for each Medicare-covered emergency room visit; however, the copay is waived if you are admitted to the hospital within 24 hours with the same condition. You pay 20% of the cost for each emergency room visit outside the United States. (3) A benefit period begins the day you go to the hospital or skilled nursing facility. The benefit period ends when you have not received hospital or skilled nursing care for 60 days in a row. 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 the benefit periods you can have. (4) Lifetime reserve days can only be used once. 19

If you have any questions about this plan s benefits or costs, please contact HealthPartners. Benefit 16 Urgently Needed Care (This is NOT emergency care, and in most cases, is out of the service area) Original Medicare You pay 20% of Medicare-approved amounts or applicable copayment. (1) (2) NOT covered outside the U.S. except under limited circumstances. You pay $15 for each Medicare-covered urgently needed care visit. You pay 20% of the cost for each urgently needed care visit outside of the United States. Worldwide coverage. Plan I Outpatient Medical Services and Supplies 17 Outpatient You pay 20% of Medicare-approved Rehabilitation amounts. (1) (2) Services (Occupational Therapy caps include: therapy, Physical - Physical and speech therapy at $1,740 per therapy, Speech calendar year. and Language - Occupational therapy at $1,740 per therapy) calendar year. 100% coverage for each Medicare-covered Occupational Therapy and/or Physical Therapy session. You pay $15 for each Medicare-covered Speech/Language therapy session. 18 Durable Medical Equipment (Includes wheelchairs, oxygen, etc.) You pay 20% of Medicare-approved amounts. (1) (2) You pay 10% of the cost for each Medicare-covered item. (1) Each year, you pay a total of one $131 deductible. (2) If a doctor or supplier chooses not to accept an assignment, their costs are often higher, which means you pay more. 20

You pay $20 for each Medicare-covered urgently needed care visit. You pay 20% of the cost for each urgently needed care visit outside of the United States. Worldwide coverage. Plan II You have 100% coverage for each Medicarecovered Occupational Therapy and/or Physical Therapy session. You pay $20 for each Medicare-covered Speech/Language therapy session. Contact plan for details You pay 10% of the cost for each Medicarecovered item. (3) A benefit period begins the day you go to the hospital or skilled nursing facility. The benefit period ends when you have not received hospital or skilled nursing care for 60 days in a row. 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 the benefit periods you can have. (4) Lifetime reserve days can only be used once. 21

If you have any questions about this plan s benefits or costs, please contact HealthPartners. Benefit Original Medicare Plan I 19 Prosthetic Devices (Includes braces, artificial limbs and eyes, etc.) You pay 20% of Medicare-approved amounts. (1) (2) You pay 10% of the cost for each Medicarecovered item. 20 Diabetes Self- You pay 20% of Medicare-approved Monitoring amounts. (1) (2) Training and Supplies (Includes coverage for glucose monitors, test strips, lancets, screening tests and selfmanagement training) 21 Diagnostic Tests, X-Rays and Lab Services You pay 20% of Medicare-approved amounts, except for approved lab services. (1) (2) There is no copayment for Medicareapproved lab services. You pay $15 of the cost for diabetes selfmonitoring training. You pay 10% of the cost for each Medicarecovered diabetes supply item. Please refer to page 6 for more information on diabetes supplies. You have: - 100% coverage for each Medicare-covered clinical/diagnostic lab service. - 100% coverage for each Medicare-covered radiation therapy service. - 100% coverage for each Medicare-covered X-ray visit. (1) Each year, you pay a total of one $131 deductible. (2) If a doctor or supplier chooses not to accept an assignment, their costs are often higher, which means you pay more. 22

Plan II You pay 10% of the cost for each Medicarecovered item. You pay $20 of the cost for Medicare-covered Diabetes self-monitoring training. You pay 10% of the cost for each Medicarecovered Diabetes supply item. Please refer to page 6 for more information on Diabetes supplies. You pay: - 100% coverage for each Medicare-covered clinical/diagnostic lab service. - 100% coverage for each Medicare-covered radiation therapy service. - 100% coverage for each Medicare-covered X-ray visit. See page 34 for additional information about lab services. (3) A benefit period begins the day you go to the hospital or skilled nursing facility. The benefit period ends when you have not received hospital or skilled nursing care for 60 days in a row. 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 the benefit periods you can have. (4) Lifetime reserve days can only be used once. 23

If you have any questions about this plan s benefits or costs, please contact HealthPartners. Benefit Original Medicare Plan I Preventive Services 22 Bone Mass You pay 20% of Medicare-approved Measurement (For amounts. (1) (2) people with Medicare who are at risk) 23 Colorectal You pay 20% of Medicare-approved Screening Exams amounts. (1) (2) (For people with Medicare age 50 and older) 24 Immunizations (Flu There is no copayment for the pneumonia vaccine, Hepatitis B and flu vaccines. vaccine - for people with You pay 20% of Medicare-approved amounts for the Hepatitis B vaccine. (1) Medicare who are at (2) risk, pneumonia You may only need the pneumonia vaccine) vaccine once in your lifetime. Please contact your doctor for further details. 25 Mammograms (Annual Screening) (For women with Medicare age 40 and older) 26 Pap Smears and Pelvic Exams (For women with Medicare) You pay 20% of Medicare-approved amounts. (2) No referral necessary for Medicarecovered screenings. There is no copayment for a Pap smear once every 2 years, annually for beneficiaries at high risk. (2) You pay 20% of Medicare-approved amounts for pelvic exams. (2) 100% coverage for each Medicarecovered Bone Mass measurement. Authorization rules may apply for services. 100% coverage for each Medicarecovered Colorectal screening exam. Authorization rules may apply for services. There is no copayment for the pneumonia and flu vaccines. No referral necessary for Medicare-covered influenza and pneumonia vaccines. There is no copayment for the Hepatitis B vaccine. Authorization rules may apply for services. There is no copayment for Medicarecovered screening Mammograms. Authorization rules may apply for services. No referral necessary for Medicarecovered screenings. There is no copayment for Medicarecovered Pap smears and pelvic exams. Authorization rules may apply for services. 27 Prostate Cancer Screening Exams (For men with Medicare age 50 and older) There is no copayment for approved lab services and a copayment of 20% of Medicare-approved amounts for other related services. (1)(2) There is no copayment for Medicarecovered Prostate Cancer screening exams. Authorization rules may apply for services. (1) Each year, you pay a total of one $131 deductible. (2) If a doctor or supplier chooses not to accept an assignment, their costs are often higher, which means you pay more. 24

Plan II 100% coverage for each Medicare-covered Bone Mass measurement. 100% coverage for each Medicare-covered Colorectal screening exam. There is no copayment for the pneumonia and flu vaccines. No referral necessary for Medicare-covered influenza and pneumonia vaccines. There is no copayment for the Hepatitis B vaccine. There is no copayment for Medicare-covered screening Mammograms. No referral necessary for Medicare-covered screenings. There is no copayment for Medicare-covered Pap smears and pelvic exams. There is no copayment for Medicare-covered Prostate Cancer screening exams. (3) A benefit period begins the day you go to the hospital or skilled nursing facility. The benefit period ends when you have not received hospital or skilled nursing care for 60 days in a row. 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 the benefit periods you can have. (4) Lifetime reserve days can only be used once. 25

If you have any questions about this plan s benefits or costs, please contact HealthPartners. Benefit Original Medicare Plan I 28 Prescription Drugs Drugs covered under Medicare Part B (Original Medicare) Drugs covered under Medicare Part D (Prescription Drug Benefit) Deductible Initial Coverage In-Network Retail Pharmacy You pay 100% for most prescription drugs, unless you enroll in the Medicare Prescription Drug program. You pay 20% of the cost for Part B-covered drugs. This plan uses a formulary. A formulary is a list of drugs covered by your plan to meet patient needs. We may periodically add, remove, 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 enrollees before the change is made. We will send a formulary to you and you can see our complete formulary on our website at healthpartners.com/medicare. People who have limited incomes, who live in long term care facilities, or who have access to Indian/Tribal/Urban (Indian Health Service) facilities may have different out-of-pocket drug costs. There is no deductible. You pay the following for prescription drugs: - $12 for a one month (30-day) supply of formulary generic drugs. - $24 for a one month (30-day) supply for formulary brand name drugs. - 25% coinsurance for a one month (30-day) supply of formulary specialty drugs. (1) Each year, you pay a total of one $131 deductible. (2) If a doctor or supplier chooses not to accept an assignment, their costs are often higher, which means you pay more. 26

Plan II You pay 20% of the cost for Part B-covered drugs. This plan uses a formulary. A formulary is a list of drugs covered by your plan to meet patient needs. We may periodically add, remove, 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 enrollees before the change is made. We will send a formulary to you and you can see our complete formulary on our website at healthpartners.com/medicare. People who have limited incomes, who live in long term care facilities, or who have access to Indian/Tribal/Urban (Indian Health Service) facilities may have different out-of-pocket drug costs. Contact plan for details. There is no deductible. You pay the following for prescription drugs: - $10 for a one month (30-day) supply of formulary generic drugs. - $31 for a one month (30-day) supply for formulary brand name drugs. - 25% coinsurance for a one month (30-day) supply of formulary specialty drugs. - $30 for a three month (90-day) supply of formulary generic drugs. - $93 for a three month (90-day) supply of formulary brand name drugs. (3) A benefit period begins the day you go to the hospital or skilled nursing facility. The benefit period ends when you have not received hospital or skilled nursing care for 60 days in a row. 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 the benefit periods you can have. (4) Lifetime reserve days can only be used once. 27

If you have any questions about this plan s benefits or costs, please contact HealthPartners. Benefit Original Medicare Plan I Mail Order Coverage After You Reach Your Initial Coverage Limit Catastrophic Coverage General Information - $12 for a one month (30-day) supply of formulary generic drugs. - $24 for a one month (30-day) supply of formulary brand name drugs. - 25% coinsurance for a one month (30- day) supply of formulary specialty drugs. - $24 for a three month (90-day) supply of formulary generic drugs. - $48 for a three month (90-day) supply of formulary brand name drug. Coverage remains the same. After your yearly out-of-pocket drug costs reach $3,850, you pay the greater of: - $2.15 for generic (including brand name drugs treated as generic) and $5.35 for all other drugs; or - 5% coinsurance. You may incur a cost in addition to the copay if you select a higher drug when a lesser cost drug is available. In some cases, the plan requires you to first try one drug to treat your medical condition before they will cover another drug for that condition. Certain prescription drugs will have maximum quantity limits. Your provider must get prior authorization from your plan for certain prescription drugs. Covered Part D drugs are available at out-of-network pharmacies in special circumstances including illness while traveling outside the plan s service area where there is no network pharmacy. You may also incur an additional cost for drugs received at an out-of-network pharmacy. Please contact you plan for details. 28

Plan II - $10 for a one month (30-day) supply of formulary generic drugs. - $31 for a one month (30-day) supply of formulary brand name drugs. - 25% coinsurance for a one month (30-day) supply of formulary specialty drugs. - $20 for a three month (90-day) supply of formulary generic drugs. - $62 for a three month (90-day) supply of formulary brand name drug. After the total yearly drug costs (paid by both you and your plan) reach $2,400, you pay 100% of your prescription drug costs until your yearly out-of-pocket drug costs reach $3,850. After your yearly out-of-pocket drug costs reach $3,850, you pay the greater of: - $2.15 for generic (including brand name drugs treated as generic) and $5.35 for all other drugs; or - 5% coinsurance. You may incur a cost in addition to the copay if you select a higher drug when a lesser cost drug is available. In some cases, the plan requires you to first try one drug to treat your medical condition before they will cover another drug for that condition. Certain prescription drugs will have maximum quantity limits. Your provider must get prior authorization from your plan for certain prescription drugs. Covered Part D drugs are available at out-of-network pharmacies in special circumstances including illness while traveling outside the plan s service area where there is no network pharmacy. You may also incur an additional cost for drugs received at an out-of-network pharmacy. Please contact you plan for details. 29

If you have any questions about this plan s benefits or costs, please contact HealthPartners. Benefit Original Medicare Plan I Additional Benefits (what Original Medicare does not cover) 29 Dental Services In general, you pay 100% for preventive dental services. You pay 100% for preventive dental services. Authorization rules may apply for services. 30 Hearing Services You pay 100% for routine hearing exams and hearing aids. In general, you have 100% coverage for routine hearing exams. You pay 20% of Medicare-approved amounts for diagnostic hearing exams. (1) (2) You pay 50% of the charges incurred up to $1,000 maximum every two years for hearing aids. Authorization rules may apply for services. 31 Vision Services You are covered for one pair of eyeglasses or contact lenses after each cataract surgery. (1) (2) For people with Medicare who are at risk, you are covered for annual glaucoma screenings. (1) (2) You pay 20% of Medicare-covered amounts for diagnosis and treatment of diseases and conditions of the eye. (1) (2) You pay 100% for routine eye exams and glasses. You have 100% coverage for routine eye exams. There is no copayment for the following items: - Eye wear frames or lenses for the postoperative treatment of cataracts. You pay: - $15 copay for each Medicare-covered eye exam (diagnosis and treatment for diseases and conditions of the eye). (1) Each year, you pay a total of one $131 deductible. (2) If a doctor or supplier chooses not to accept an assignment, their costs are often higher, which means you pay more. 30

Plan II You pay 100% for preventive dental services. In general, you have 100% coverage for routine hearing exams. You pay 50% of the charges incurred up to $1,000 maximum every two years for hearing aids. You have 100% coverage for routine eye exams. There is no copayment for the following items: - Eye wear frames or lenses for the postoperative treatment of cataracts. You pay: - $20 copay for each Medicare-covered eye exam (diagnosis and treatment for diseases and conditions of the eye). (3) A benefit period begins the day you go to the hospital or skilled nursing facility. The benefit period ends when you have not received hospital or skilled nursing care for 60 days in a row. 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 the benefit periods you can have. (4) Lifetime reserve days can only be used once. 31

If you have any questions about this plan s benefits or costs, please contact HealthPartners. Benefit Original Medicare Plan I 32 Physical Exams If your coverage for Medicare Part B begins on or after January 1, 2005, you may receive a one-time physical exam within the first six months of your new Part B coverage. This will not include laboratory tests. Please contact your plan for further details. You pay 20% of the Medicare-approved amount. (1) (2) 33 Health/Wellness You pay 100%. Education If your coverage for Medicare Part B begins on or after January 1, 2005, you may receive a one-time physical exam within the first six months of your new Part B coverage. This will not include laboratory tests. Please contact your plan for further details. There is no copayment for routine physical exams. You are covered for the following: - Written health education materials, including a newsletter. - Smoking cessation. - Health club membership/fitness classes. - Nursing hotline. Authorization rules may apply for services. 34 Acupuncture You pay 100%. You pay $15 for each acupuncture visit. Authorization rules may apply for services. (1) Each year, you pay a total of one $131 deductible. (2) If a doctor or supplier chooses not to accept an assignment, their costs are often higher, which means you pay more. 32

Plan II If your coverage for Medicare Part B begins on or after January 1, 2005, you may receive a onetime physical exam within the first six months of your new Part B coverage. This will not include laboratory tests. Please contact your plan for further details. There is no copayment for routine physical exams. You are covered for the following: - Written health education materials, including a newsletter. - Smoking cessation. - Health club membership/fitness classes. - Nursing hotline. You pay $20 for each acupuncture visit. (3) A benefit period begins the day you go to the hospital or skilled nursing facility. The benefit period ends when you have not received hospital or skilled nursing care for 60 days in a row. 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 the benefit periods you can have. (4) Lifetime reserve days can only be used once. 33

HealthPartners 8170 33rd Avenue South P. O. Box 1309 Minneapolis, MN 55440-1309 healthpartners.com 2006 HealthPartners HP420199 (9/06) Emeriti