<p> Group UCare for Seniors Bloomington Schools Retirees</p><p>Effective January 1, 2016 through December 31, 2016</p><p>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.</p><p>Comprehensive Dental $24/month $24/month $24/month</p><p>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.</p><p>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</p><p>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.</p><p>SilverSneakers® SilverSneakers® SilverSneakers® Fitness Programs Health Club Savings Health Club Savings Health Club Savings </p><p> Service area includes the entire state of Minnesota & 26 counties in western Wisconsin.</p><p> Enrollees must carry both Parts A and B of Medicare; automatic enrollment in Part D.</p><p> Worldwide emergency coverage for up to 6 months out-of-area.</p><p> See Group UCare for Seniors Summary of Benefits for full plan description.</p><p> Website: www.ucare.org.</p><p>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.</p><p>H2459 H4270 Group_100714 IA (10072014) </p>