BENEFITS WITHIN REACH George K. Member since 2017 Summary of Benefits Northeast Core Region SummaCare Medicare Topaz 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 Garnet 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 Ruby 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 January 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) – Includes 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