Group UCare for Seniors Bloomington Schools Retirees

Effective January 1, 2016 through December 31, 2016

Group UCare for Group UCare for Group UCare for Benefit Category Seniors Seniors Seniors High Option Core Option Basic Option Premium: $316.00 $149.00 $65.00 monthly, per person Preventive Care (i.e. physicals, eye & 100% coverage 100% coverage 100% coverage Hearing exams, flu shots) 100% coverage for 100% coverage for 100% coverage for three cleanings per year three cleanings per year three cleanings per year Preventive Dental at participating dental at participating dental at participating dental offices. offices. offices.

Comprehensive Dental $24/month $24/month $24/month

Eyewear $75 annual allowance $75 annual allowance Not covered Office Visits: $15 copay per visit $15 copay per visit $15 copay per visit Primary $15 copay per visit $30 copay per visit $40 copay per visit Specialist $300/day copay $100 copay $200 copay for days 1-5; Inpatient Hospital per admission per admission 100% coverage thereafter. Outpatient Surgery $200 copay $250 copay $250 copay $50 copay per hospital $75 copay per hospital $75 copay per hospital Emergency Services emergency visit; emergency visit; emergency visit; (Worldwide -may travel up 100% coverage 100% coverage 100% coverage to 6 months) thereafter. thereafter. thereafter. Ambulance Services $100 copay $100 copay $200 copay $3,400 per calendar year. $3,400 per calendar year. $3,400 per calendar year. Medical Out-of-Pocket Once met, all services are Once met, all services are Once met, all services are Maximum for Part A & covered 100% for the rest covered 100% for the rest covered 100% for the rest B Services of the year. of the year. of the year.

Please see reverse side for more information Group UCare for Group UCare for Group UCare for Benefit Category Seniors Seniors Seniors High Option Core Option Basic Option Prescription Drug Coverage: $75 annual deductible Tier 1 – Generic $10 copay $12 copay $15 copay Tier 2 – Preferred $30 copay $40 copay $45 copay Brand Name Tier 3 – Other Brand $60 copay $80 copay $90 copay Name Tier 4 – Specialty Drugs 25% coinsurance 28% coinsurance 31% coinsurance

Up to a 30-day supply for Coverage through the After total yearly drug After total yearly drug 1 copay. prescription drug gap, costs reach $3,310, Tier costs reach $3,310 you or the “donut hole.” 1 Generics will continue pay 58% of Tier 1 and 90-day supply for 2 Medicare catastrophic to be covered with a Tier 4 Generics and 45% copays through mail drug coverage begins $12 copay and you will of Brand Name drugs. order. once the $4,850 out-of- pay 45% of Brand Name Medicare catastrophic pocket maximum is drugs. Medicare drug coverage begins High Option only: met. catastrophic drug once the $4,850 out-of- 90-day supply for 2 (See Summary of coverage begins once pocket maximum is met. copays also available at Benefits for catastrophic the $4,850 out-of-pocket (See Summary of participating local costs). maximum is met. (See Benefits for catastrophic pharmacies. Summary of Benefits costs). for catastrophic costs). Medicare Part B Drugs 80% coverage 80% coverage 80% coverage $75 copay per visit for $75 copay per visit for $75 copay per visit for Medicare-covered Part B Medicare-covered Part B Medicare-covered Part B chemotherapy drugs chemotherapy drugs chemotherapy drugs Chemotherapy infused/administered in a infused/administered in a infused/administered in a doctor’s office or doctor’s office or doctor’s office or outpatient setting for the outpatient setting for the outpatient setting for the treatment of cancer. treatment of cancer. treatment of cancer.

SilverSneakers® SilverSneakers® SilverSneakers® Fitness Programs Health Club Savings Health Club Savings Health Club Savings

 Service area includes the entire state of Minnesota & 26 counties in western Wisconsin.

 Enrollees must carry both Parts A and B of Medicare; automatic enrollment in Part D.

 Worldwide emergency coverage for up to 6 months out-of-area.

 See Group UCare for Seniors Summary of Benefits for full plan description.

 Website: www.ucare.org.

Contact the Group UCare for Seniors Sales Team at: 612-676-6900 or toll free at 1-877-598-6574 (TTY users: 1-800-688-2534) UCare Minnesota and UCare Health, Inc. are Medicare Advantage plans with Medicare contracts. Enrollment in UCare Minnesota and UCare Health, Inc. depends on contract renewal.

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