BENEFITS WITHIN REACH

George K. Member since 2017 Summary of Benefits Northeast Core Region

SummaCare Medicare The SummaCare Medicare Topaz (HMO) plan is available to residents of the following counties in Ohio: Carroll, (HMO) (H3660_050) Columbiana, Cuyahoga, Geauga, Lake, Lorain, Mahoning, SummaCare Medicare 1 Medina, Portage, Stark, Summit, Trumbull and Wayne. (HMO) (H3660_053) The SummaCare Medicare Garnet 1 (HMO) plan is available to residents of the following counties in Ohio: SummaCare Medina, Portage, Stark, Summit and Wayne. Medicare Northeast The SummaCare Medicare Ruby (HMO) Northeast plan is available to residents of the following counties in Ohio: (HMO) (H3660_044) Ashland, Ashtabula, Carroll, Columbiana, Cuyahoga, Plan Year 1, 2020 through Geauga, Holmes, Lake, Lorain, Mahoning, Medina, Portage, December 31, 2020 Stark, Summit, Trumbull, Tuscarawas and Wayne.

SummaCare is an HMO and HMO-POS plan with a Medicare contract. Enrollment in SummaCare depends on contract renewal. H3660_20_42_M Accepted 09132019 Summary of Benefits KEY BENEFITS Acupuncture Services ...... 18 Ambulance ...... 16 Chiropractic Care ...... 20 Dental Services ...... 14, 23 Diabetes Supplies ...... 21 Diagnostic Services ...... 13 Doctor Visits ...... 11 Emergency Care ...... 13 Hearing Services ...... 14 Home Health Care ...... 20 Home Safety Devices ...... 19 Hospice ...... 20 Hospital – Inpatient ...... 11 Hospital – Outpatient ...... 11 Lab Services ...... 13 Medical Equipment/Supplies ...... 21 Mental Health Services ...... 15 Over-the-Counter (OTC) items ...... 22 Podiatry Services ...... 20 Part D Prescription Drugs ...... 17 Preventive Care ...... 12 Prosthetic Devices ...... 21 Radiology Services ...... 13 Rehabilitation and Physical Therapy ...... 16 Renal Dialysis ...... 22 Skilled Nursing Facility ...... 15 Substance Abuse – Outpatient ...... 21 Telehealth Services ...... 20 Therapeutic Massage Services ...... 19 Transportation ...... 16 Urgent Care ...... 13 Vision Services ...... 15 X-Rays ...... 13 Things to know about SummaCare Topaz, SummaCare Garnet 1 and SummaCare Ruby

What do we cover? Want to learn more? SummaCare Medicare Advantage plans cover Visit www.summacare.com/medicare to find everything Original Medicare covers and more. All more information about our plans. Or, call us of our plans include Medicare (Part D) prescription at 888.464.8440 (TTY 800.750.0750). From drugs. You can see the complete plan formulary October 1 through March 31, a representative is (list of covered drugs) and any restrictions on our available to take your call from 8:00 a.m. until website, www.summacare.com/medicare. Or, call 8:00 p.m., seven days a week. From April 1 through us and we will send you a copy of the formulary. September 30, a representative is available to take How will I determine my drug costs? your call from 8:00 a.m. until 8:00 p.m., Monday Our plan groups each medication into one of through Friday. Outside these hours, you may leave six “tiers.” You will need to use SummaCare’s us a message and a representative will return your Medicare formulary (list of covered drugs) to call the next business day. locate what tier your drug is in to determine To enroll in SummaCare, you must be entitled to how much it will cost you. The amount you pay Medicare Part A, be enrolled in Medicare Part B and depends on the drug’s tier and what stage of the live in our service area. This document is available in benefit you have reached. Later in this document, other formats such as Braille, large print or audio. we discuss the benefit stages that occur: Part D This is a summary document. The benefit information deductible, Initial Coverage Stage, Coverage Gap provided does not list every service that we cover or Stage and Catastrophic Coverage Stage. list every limitation or exclusion. To get a complete Which doctors, list of services we cover, please request the Evidence hospitals and pharmacies can I use? of Coverage (EOC). To request the EOC, please call 888.464.8440 (TTY 800.750.0750). SummaCare Medicare Topaz (HMO), SummaCare Medicare Garnet 1 (HMO) and SummaCare Medicare If you want to know more about the coverage Ruby (HMO) Northeast have a network of doctors, and costs of Original Medicare, look in your current hospitals, pharmacies and other providers. If you use “Medicare & You” handbook. View it online at providers that are not in our network, the plan may http://www.medicare.gov or order a copy by calling not pay for these services - except for emergency, 1.800.MEDICARE (1.800.633.4227), 24 hours a day, urgent and out-of-area renal dialysis services. Out-of- 7 days a week. TTY users should call 1.877.486.2048. network/non-contracted providers are under no People with limited incomes may qualify for extra obligation to treat SummaCare members, except help to pay for their prescription drug costs and medical in emergency situations. Please call our customer expenses. See if you qualify by calling: service number or request an Evidence of Coverage • 1. 800.MEDICARE (1.800.633.4227), 24 hours per document for more information, including the cost day/7 days a week. TTY/TDD users call 1.877.486.2048. sharing that applies to out-of-network services. You • The Social Security Administration at 1.800.772.1213, must generally use network pharmacies to fill your Monday through Friday, 7 a.m. to 7 p.m. TTY/TDD users prescriptions for covered Part D drugs. You can see our plan’s provider/pharmacy directory on our website, call 1.800.325.0778. www.summacare.com/medicare, or call us and we will send you a copy of the provider/pharmacy directory.

9 HMO Plans

With a SummaCare HMO plan, you Lake utilize the SCMedicare network of Geauga Cuyahoga providers for all your care, except Lorain Trumbull Portage Summit Medina in certain circumstances including Mahoning emergency and urgent care services Wayne Stark Columbiana and renal dialysis services. Carroll SummaCare Medicare Topaz (HMO) $0 Monthly Premium This plan is available to residents living in the 13 shaded counties on the map to the right. If you live in a county named on the map, you are eligible to enroll in this HMO plan.

SummaCare

Portage Summit Medicare Garnet 1 (HMO) Medina $29 Monthly Premium Wayne Stark This plan is available to residents living in the five shaded counties on the map to the left. If you live in a county named on the map, you are eligible to enroll in this HMO plan.

Lake Ashtabula

Geauga Cuyahoga Trumbull Lorain Portage Summit Medina Mahoning

Ashland Wayne Stark Columbiana

Carroll Holmes SummaCare Tuscarawas Medicare Ruby (HMO) Northeast $43 Monthly Premium This plan is available to residents living in the 17 shaded counties on the map to the right. If you live in a county named on the map, you are eligible to enroll in this HMO plan.

10 Summary of Benefits

Premiums SummaCare Medicare SummaCare Medicare SummaCare Medicare and Benefits Topaz (HMO) Garnet 1 (HMO) Ruby (HMO) Northeast

Monthly Plan You pay $0. You pay $29. You pay $43. Premium

Deductible You pay nothing. You pay nothing. You pay nothing.

Maximum Out-of- $3,800 $3,700 $3,600 Pocket Responsibility (does not include prescription drugs) – Include s copays and other costs for medical services throughout the year.

Inpatient Hospital $300 copay per day for $290 copay per day for $275 copay per day for Coverage – our plan days 1 through 5. days 1 through 6. days 1 through 6. pays for an You pay nothing after day 5. You pay nothing after day 6. You pay nothing after day 6. unlimited number of days for an inpatient hospital stay. Outpatient Hospital Ambulatory surgical center: Ambulatory surgical center: Ambulatory surgical center: Coverage $300 copay $275 copay $250 copay Outpatient hospital: Outpatient hospital: Outpatient hospital: $300 copay $275 copay $250 copay Observation services: Observation services: Observation services: $300 copay $275 copay $250 copay

Doctor Visits – Primary Care Primary Care Primary Care You are not Physician visit: Physician visit: Physician visit: required to receive You pay nothing. You pay nothing. You pay nothing. authorization before Specialist visit: Specialist visit: Specialist visit: seeking care from $45 copay $45 copay $40 copay most specialists. Pre-approval from SummaCare is needed before seeing a surgeon for back pain.

11 Summary of Benefits

Premiums SummaCare Medicare SummaCare Medicare SummaCare Medicare and Benefits Topaz (HMO) Garnet 1 (HMO) Ruby (HMO) Northeast

Preventive Care – You pay nothing. You pay nothing. You pay nothing. Our plan covers many preventive services, including: Abdominal aortic aneurysm screening, Alcohol misuse counseling, Annual wellness visit, Bone mass measurement, Breast cancer screening (mammogram), Cardiovascular disease risk reduction, Cardiovascular disease testing, Cervical and vaginal cancer screening, Colorectal cancer screenings (Colonoscopy, Fecal occult blood test, Flexible sigmoidoscopy), Depression screening, Diabetes screening, HIV screening, Medical nutrition therapy services, Obesity screening and counseling, Prostate cancer screening and counseling, Sexually transmitted infections screening and counseling, Tobacco use cessation counseling (counseling for people with no sign of tobacco- related disease), Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots and “Welcome to Medicare” preventive visit (one-time)

12 Summary of Benefits

Premiums SummaCare Medicare SummaCare Medicare SummaCare Medicare and Benefits Topaz (HMO) Garnet 1 (HMO) Ruby (HMO) Northeast

Emergency Care – $90 copay per visit $90 copay per visit $90 copay per visit If you are admitted to the hospital within 24 hours, you do not have to pay the copay. Emergency, urgent care and ambulance services outside of the are covered up to a maximum of $25,000 each year. This includes emergency ambulance occurring immediately before a covered emergency visit.

Urgently $45 copay per visit $45 copay per visit $40 copay per visit Needed Services – Emergency, urgent care and ambulance services outside of the United States are covered up to a maximum of $25,000 each year. This includes emergency ambulance occurring immediately before a covered emergency visit.

Diagnostic Diagnostic radiology Diagnostic radiology Diagnostic radiology Services/Labs/ service (e.g., MRI): service (e.g., MRI): service (e.g., MRI): Imaging – $175 copay $125 copay $150 copay The copay is based on Diagnostic Diagnostic Diagnostic where the procedure tests and procedures: tests and procedures: tests and procedures: takes place. You pay $0-$125 copay, $0-$50 copay, $0-$125 copay, a lower copay at a depending on the location depending on the location depending on the location physician’s office Lab services: Lab services: Lab services: (office visit copay $0-$10 copay, $0-$5 copay, $0-$8 copay, may apply). You pay depending on the location depending on the location depending on the location a higher copay at all Outpatient X-rays: Outpatient X-rays: Outpatient X-rays: other locations. $75-$130 copay, $0-$50 copay, $0-$110 copay, depending on the location depending on the location depending on the location Therapeutic radiology Therapeutic radiology Therapeutic radiology services (such as radiation services (such as radiation services (such as radiation treatment for cancer): treatment for cancer): treatment for cancer): 20% of the cost 20% of the cost 20% of the cost 13 Summary of Benefits

Premiums SummaCare Medicare SummaCare Medicare SummaCare Medicare and Benefits Topaz (HMO) Garnet 1 (HMO) Ruby (HMO) Northeast

Hearing Services – Diagnostic hearing exam: Diagnostic hearing exam: Diagnostic hearing exam: You are covered for an $0-$20 copay $0-$15 copay $0-$15 copay annual routine hearing Supplemental routine Supplemental routine Supplemental routine exam every year. hearing exam: hearing exam: hearing exam: Services for hearing $20 copay $15 copay $15 copay aids must be received Hearing aids: Hearing aids: Hearing aids: through SummaCare's $795 copay per hearing aid, $795 copay per hearing aid, $795 copay per hearing aid, in-network provider, limit 1 per ear every 3 years limit 1 per ear every 3 years limit 1 per ear every 3 years Homelink. You receive up to 12 months of hearing aid service visits from the date of fitting. You receive a 60-day trial period starting the day of fitting during which you may return your hearing aid with no restocking fee and/ or choose another hearing aid model. Costs for hearing aids do not count toward the maximum out- of-pocket amount. There is no copay for a hearing aid fitting/ evaluation.

Dental Services - $0 copay per visit $0 copay per visit $0 copay per visit Preventive dental (The Garnet 1 plan includes covers one cleaning, comprehensive dental one X-ray and one coverage, which includes: exam per year two exams, two cleanings, through the Delta one set of bitewing X-rays, Dental of Ohio periapical X-rays, full-mouth Medicare Advantage X-rays and palliative treatment. PPO network. Plan pays 100% of allowed Calendar year benefit amount for fillings and simple maximum of $500. extractions and root canals. Preventive dental also Maximum of $750 per year includes full mouth for dental services.) X-rays, a panoramic X-ray once every five years, periapical X-rays as needed and emergency treatment of dental pain as needed. 14 Summary of Benefits

Premiums SummaCare Medicare SummaCare Medicare SummaCare Medicare and Benefits Topaz (HMO) Garnet 1 (HMO) Ruby (HMO) Northeast

Vision Services – Diagnostic eye exam: Diagnostic eye exam: Diagnostic eye exam: You are covered for an $0 copay $0 copay $0 copay annual supplemental Supplemental Supplemental Supplemental routine eye exam routine eye exam: routine eye exam: routine eye exam: each year. Coverage $0 copay $0 copay $0 copay for eyeglasses and/ or contact lenses Annual prescription Annual prescription Annual prescription provided after eyewear allowance: eyewear allowance: eyewear allowance: cataract surgery $100 allowance $300 allowance $200 allowance limited to Medicare- Glasses or contacts Glasses or contacts Glasses or contacts allowed amount for after cataract surgery: after cataract surgery: after cataract surgery: Medicare-covered You pay nothing. You pay nothing. You pay nothing. lenses and frames. Yearly glaucoma Yearly glaucoma Yearly glaucoma In addition to an screening: screening: screening: annual routine eye You pay nothing. You pay nothing. You pay nothing. exam and Medicare- covered eye exams (for diagnosis and treatment for diseases and conditions of the eye), you’ll receive an annual amount to use toward the purchase of frames/lenses or contact lenses – with the freedom to visit any vision provider you choose.

Mental Inpatient visit: Inpatient visit: Inpatient visit: Health Services – $300 copay per day for $290 copay per day for $275 copay per day for There is a 190-day days 1 through 4. days 1 through 5. days 1 through 5. lifetime limit for You pay nothing after day 4. You pay nothing after day 5. You pay nothing after day 5. inpatient services in a psychiatric hospital. Outpatient Outpatient Outpatient The 190-day lifetime group therapy visit: group therapy visit: group therapy visit: limit does not apply $40 copay $40 copay $40 copay to inpatient mental Outpatient individual Outpatient individual Outpatient individual health services therapy visit: therapy visit: therapy visit: provided in a $40 copay $40 copay $40 copay psychiatric unit of a general hospital. Skilled Nursing You pay nothing per day You pay nothing per day You pay nothing per day Facility – Our plan for days 1 through 20. for days 1 through 20. for days 1 through 20. covers up to 100 days $178 copay per day for $178 copay per day for $175 copay per day for in a Skilled Nursing days 21 through 100. days 21 through 100. days 21 through 100. Facility. No prior hospital stay required. 15 Summary of Benefits

Premiums SummaCare Medicare SummaCare Medicare SummaCare Medicare and Benefits Topaz (HMO) Garnet 1 (HMO) Ruby (HMO) Northeast

Physical Therapy Cardiac (heart) Cardiac (heart) Cardiac (heart) rehab services: rehab services: rehab services: You pay nothing. You pay nothing. You pay nothing. Occupational therapy visit: Occupational therapy visit: Occupational therapy visit: $40 copay $40 copay $40 copay Physical therapy and speech Physical therapy and speech Physical therapy and speech and language therapy visit: and language therapy visit: and language therapy visit: $40 copay $40 copay $40 copay Ambulance – Ground Ambulance: Ground Ambulance: Ground Ambulance: Emergency, urgent $225 copay $200 copay $200 copay care and ambulance Air Ambulance: Air Ambulance: Air Ambulance: services outside of $225 copay $200 copay $200 copay the United States are covered up to a maximum of $25,000 each year. This includes emergency ambulance occurring immediately before a covered emergency visit. Transportation – You pay nothing for You pay nothing for You pay nothing for Routine non-emergent six one-way trips per eight one-way trips per six one-way trips per medical transportation calendar year. calendar year. calendar year. services are covered for in-network medical appointments or visits to providers within the plan service area. Trips must be scheduled through SummaCare’s transportation vendor, Homelink. Medicare Part B Drugs For Part B-covered For Part B-covered For Part B-covered chemotherapy drugs and chemotherapy drugs and chemotherapy drugs and other Part B-covered drugs: other Part B-covered drugs: other Part B-covered drugs: 20% of the cost 20% of the cost 20% of the cost

16 Summary of Benefits

Part D Prescription Drugs The amount you pay depends on the drug’s tier and what stage of the benefit you have reached.

SummaCare Medicare SummaCare Medicare SummaCare Medicare Topaz (HMO) Northeast Garnet 1 (HMO) Northeast Ruby (HMO) Northeast

Deductible There is an annual deductible There is no deductible. There is no deductible. of $150 on the Topaz HMO plan. This combined deductible only applies to drug Tiers 3 and 4.

Initial You pay the following until your total yearly drug costs reach $4,020. Total yearly drug Coverage Stage costs are the total drug costs paid by both you and our Part D plan. You may get your drugs at network retail pharmacies and mail order pharmacies. Retail – One Month Tier 1 (Preferred Generic) $0 $0 $0 Tier 2 (Generic) $10 $8 $8 Tier 3 $47 $44 $44 (Preferred Brand) Tier 4 $100 $100 $100 (Non-preferred Brand) Tier 5 (Specialty) 30% 33% 33% Tier 6 (Vaccines) $0 $0 $0 Retail – Three Month Tier 1 (Preferred Generic) $0 $0 $0 Tier 2 (Generic) $25 $20 $20 Tier 3 $117.50 $110 $110 (Preferred Brand) Tier 4 $300 $300 $300 (Non-preferred Brand) Tier 5 (Specialty) N/A–limited to 30-day supply N/A–limited to 30-day supply N/A–limited to 30-day supply Tier 6 (Vaccines) N/A N/A N/A Mail-Order – Three Month Tier 1 (Preferred Generic) $0 $0 $0 Tier 2 (Generic) $25 $20 $20 Tier 3 $117.50 $110 $110 (Preferred Brand) Tier 4 $300 $300 $300 (Non-preferred Brand) Tier 5 (Specialty) N/A–limited to 30-day supply N/A–limited to 30-day supply N/A–limited to 30-day supply Tier 6 (Vaccines) N/A N/A N/A

17 Summary of Benefits

Part D Prescription Drugs continued Premiums SummaCare Medicare SummaCare Medicare SummaCare Medicare and Benefits Topaz (HMO) Garnet 1 (HMO) Ruby (HMO) Northeast SummaCare Medicare SummaCare Medicare SummaCare Medicare Topaz (HMO) Northeast Garnet 1 (HMO) Northeast Ruby (HMO) Northeast

If you reside in a long-term care facility, you pay the same as at a retail pharmacy. You may get drugs from an out-of-network pharmacy, but may pay more than you pay at an in-network pharmacy.

Coverage Gap Stage Most Medicare drug plans have a coverage gap (also called the “donut hole”). This means that there’s a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $4,020. After you enter the coverage gap, you pay 25% of the plan’s cost for covered brand name drugs and 25% of the plan’s cost for covered generic drugs until your costs total $6,350, which is the end of the coverage gap. Not everyone will enter the coverage gap. Under this plan, you may pay even less for the brand and generic drugs on the formulary. Your cost varies by tier. You will need to use your formulary to locate your drug’s tier. See the chart that follows to find out how much it will cost you. All Tier 1 (Preferred Generic) drugs (retail and mail-order) are covered at a $0 copay if you enter the Coverage Gap. Tier 6 Vaccines are also covered at a $0 copay through the Coverage Gap.

Catastrophic After your yearly out-of-pocket drug costs (including drugs purchased through your retail Coverage Stage pharmacy and through mail order) reach $6,350, you pay the greater of • 5% of the cost, or • $3.60 copay for generic (including brand drugs treated as generic) and a $8.95 copay for all other drugs

Additional Benefits:

Acupuncture – Up to $20 copay per visit for any $10 copay per visit for any Not covered six visits per calendar combination of acupuncture combination of acupuncture year for any and therapeutic massage and therapeutic massage combination of service visits. This is limited service visits. This is limited general acupuncture to six visits per calendar to six visits per calendar services and year. year. therapeutic massage services performed by in-network providers are covered. The visit limit is combined with the therapeutic massage benefit. Visits must be scheduled through SummaCare’s Acupuncture/ Therapeutic Massage vendor, Homelink.

18 Summary of Benefits

Additional Benefits continued

Premiums SummaCare Medicare SummaCare Medicare SummaCare Medicare and Benefits Topaz (HMO) Garnet 1 (HMO) Ruby (HMO) Northeast

Therapeutic $20 copay per visit for any $10 copay per visit for any Not covered Massage – Up to six combination of acupuncture combination of acupuncture visits per calendar and therapeutic massage and therapeutic massage year for any service visits. This is limited service visits. This is limited combination of to six visits per calendar to six visits per calendar therapeutic massage year. year. services and general acupuncture services performed by in- network providers are covered. The visit limit is combined with the acupuncture benefit. Visits must be scheduled through SummaCare’s Acupuncture/ Therapeutic Massage vendor, Homelink.

Home Safety $150 allowance per year $200 allowance per year $175 allowance per year Devices – If you have had a diagnosis of any of the following: hip replacement, knee replacement, femur fractures or a diagnosis of falls within the past 12 months, as documented by a provider, you are eligible for home safety devices. A list of covered equipment devices is available at www.summacare. com. Items must be purchased through Homelink. Otherwise you will be responsible for the full cost of those items and no payment will be made.

19 Summary of Benefits

Additional Benefits continued

Premiums SummaCare Medicare SummaCare Medicare SummaCare Medicare and Benefits Topaz (HMO) Garnet 1 (HMO) Ruby (HMO) Northeast

Telehealth Services – $0 copay $0 copay $0 copay Talk to a doctor 24/7 by phone or video with Teladoc. Covered services include visits with a mental health provider or a board-certified internal medicine, pediatric or family medicine physician licensed in Ohio via phone or video for non-emergency care. Dermatologists licensed in Ohio are also available remotely for dermatological conditions and can be accessed through the web or mobile app. Upload photos of your condition along with a description of your symptoms and a licensed dermatologist will respond to you with a diagnosis and a prescription if medically necessary within 48 hours.

Chiropractic Care $20 copay $20 copay $20 copay

Foot Care $45 copay $45 copay $40 copay (Podiatry Services)

Home Health Care You pay nothing. You pay nothing. You pay nothing.

Hospice You pay nothing for hospice You pay nothing for hospice You pay nothing for hospice care from a Medicare- care from a Medicare- care from a Medicare- certified hospice. You may certified hospice. You may certified hospice. You may have to pay part of the costs have to pay part of the costs have to pay part of the costs for drugs and respite care. for drugs and respite care. for drugs and respite care. 20 Summary of Benefits

Additional Benefits continued

Premiums SummaCare Medicare SummaCare Medicare SummaCare Medicare and Benefits Topaz (HMO) Garnet 1 (HMO) Ruby (HMO) Northeast

Medical Durable Medical Equipment Durable Medical Equipment Durable Medical Equipment Equipment/Supplies (e.g., wheelchairs, ): (e.g., wheelchairs, oxygen): (e.g., wheelchairs, oxygen): 20% of the cost 20% of the cost 20% of the cost Prosthetic Devices (e.g., Prosthetic Devices (e.g., Prosthetic Devices (e.g., braces, artificial limbs): braces, artificial limbs): braces, artificial limbs): 20% of the cost 20% of the cost 20% of the cost Diabetes Monitoring Supplies: Diabetes Monitoring Supplies: Diabetes Monitoring Supplies: You pay nothing. You pay nothing. You pay nothing. Diabetes Self-Management Diabetes Self-Management Diabetes Self-Management Training: Training: Training: You pay nothing. You pay nothing. You pay nothing. Therapeutic Shoes or Inserts: Therapeutic Shoes or Inserts: Therapeutic Shoes or Inserts: 20% of the cost 20% of the cost 20% of the cost

Outpatient Group therapy visit: Group therapy visit: Group therapy visit: Substance Abuse $40 copay $40 copay $40 copay Individual therapy visit: Individual therapy visit: Individual therapy visit: $40 copay $40 copay $40 copay

Opioid Treatment $40 copay $40 copay $40 copay Program Services – Opioid use disorder treatment services are covered under Part B of Original Medicare. Members of our plan receive coverage for these services through our plan. Covered services include: • FDA-approved opioid agonist and antagonist treatment medications and the dispensing and administration of such medications, if applicable • Substance use counseling • Individual and group therapy • Toxicology testing

21 Summary of Benefits

Additional Benefits continued

Premiums SummaCare Medicare SummaCare Medicare SummaCare Medicare and Benefits Topaz (HMO) Garnet 1 (HMO) Ruby (HMO) Northeast

Partial Hospitalization– $45 copay $45 copay $40 copay “Partial hospitalization” is a structured program of active psychiatric treatment provided as a hospital outpatient service or by a community mental health center, that is more intense than the care received in your doctor’s or therapist’s office and is an alternative to inpatient hospitalization.

Over-the-Counter $15 allowance per quarter $75 allowance per quarter $25 allowance per quarter Items - Coverage includes non-prescription over-the-counter health related items like vitamins, pain relievers, cough and cold medicines and first aid supplies. Refer to your 2020 OTC Product Catalog for a complete list of plan-approved OTC items. If you do not use all of your quarterly OTC benefit amount, the remaining balance will not roll over to the next quarter or calendar year.

Renal Dialysis 20% of the cost 20% of the cost 20% of the cost

Health and Sneakers Fitness Program Silver Sneakers Fitness Program Silver Sneakers Fitness Program Wellness Programs 24-Hour Nurse Line 24-Hour Nurse Line 24-Hour Nurse Line and Services QuitCare QuitCare QuitCare Health Manager Powered Health Manager Powered by Health Manager Powered by by WebMD WebMD WebMD Enhanced Condition Enhanced Condition Enhanced Condition Management Programs Management Programs Management Programs 22 Summary of Benefits

Optional Supplemental Dental

If you elect to enroll Diagnostic and Preventive Services for $0 copay: in this optional - Exams (including evaluations by a specialist) and Cleanings: For Topaz and Ruby: One supplemental dental additional examand cleaning is added to the preventive dental benefit. If you purchase this plan, you’ll pay an optional supplemental dental benefit, you will have a total of 2 exams and 2 cleanings per additional $25 per year. For Garnet 1: Your embedded comprehensive dental benefit already includes 2 cleanings month. You must and 2 exams per year. keep paying your Medicare Part B - Bitewing Radiographs: One set of bitewing X-rays per year is covered under your premium and your preventive dental benefit. SummaCare Medicare - Full Mouth X-rays/Panoramic Films: Full mouth X-rays (which include bitewings) or a plan premium. panoramic X-ray once every five years is covered under the preventive dental benefit. - Periapical X-Rays: Covered under the preventive dental benefit. - Palliative (emergency treatment of dental pain): Covered under the preventive dental benefit. Major Restorative Services (Plan pays 50% of allowed amount) - , Core Buildup and Pins - Surgical Periodontics - Surgical Extractions and Oral Surgery Minor Restorative Services (Plan pays 50% of allowed amount) - Fillings and simple extractions - Periodontal Maintenance and other non-surgical periodontics - Root Canals to treat teeth with diseased or damaged nerves - Repair - Relines and Repairs to complete and partial dentures and fixed or removable bridges - General Anesthesia or IV Sedation when medically necessary If you purchase this optional supplemental dental benefit, the plan will pay a total maximum benefit of $1,500 per benefit year. This includes your preventive and supplemental dental benefits. Services must be received through Delta Dental’s Medicare Advantage PPO or Medicare Advantage Premier network of providers. Services received from dentists who do NOT participate in Delta Dental’s Medicare Advantage PPO or Medicare Advantage Premier network are NOT covered benefits.

23 24 25 www.summacare.com/medicare