Summary of Benefits2017

Y0027_16-094_EN CMS Accepted 08/30/2016

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Summary of BenefitsJanuary 1, 2017 – December 31, 2017

This booklet gives you a summary of what we cover and what you pay. It doesn’t list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, call us and ask for the “Evidence of Coverage.”

You have choices about how to get your Medicare benefits

•OnechoiceistogetyourMedicarebenefitsthroughOriginalMedicare(fee-for-service Medicare). Original Medicare is run directly by the Federal government.

•AnotherchoiceistogetyourMedicarebenefitsbyjoiningaMedicarehealthplan(suchas CoxHealth MedicarePlus (HMO)).

Tips for comparing your Medicare choicesThisSummaryofBenefitsbookletgivesyouasummaryofwhatCoxHealth MedicarePlus covers and what you pay.

• If you want to compare our plans with other Medicare health plans, ask the other plans for theirSummaryofBenefitsbooklets.Or,usetheMedicarePlanFinderonhttp://www.medicare.gov.

• If you want to know more about the coverage and costs of Original Medicare, look in your current “Medicare & You” handbook.Viewitonlineathttp://www.medicare.govorgetacopybycalling1-800-MEDICARE(1-800-633-4227),24hoursaday,7daysaweek.TTYusersshouldcall1-877-486-2048.

Sections in this booklet

•Things to Know About CoxHealth MedicarePlus

•Table of Contents

•MonthlyPremium,DeductibleandLimitsonHowMuchYouPayforCoveredServices

•CoveredMedicalandHospitalBenefits

•PrescriptionDrugBenefits

•OtherCoveredBenefits

This document is available in other formats such as Braille and large print. This document may be availableinanon-Englishlanguage.Foradditionalinformation,callusat1-866-597-9560.

Y0027_16-094_ENCMSAccepted08/30/2016

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Things to Know About CoxHealth MedicarePlusHours of Operation

•FromOctober1toFebruary14,youcancallus7daysaweekfrom8:00a.m.to8:00p.m. Central Time.

•FromFebruary15toSeptember30,youcancallusMondaythroughFridayfrom8:00a.m.to8:00p.m. Central Time.

CoxHealth MedicarePlus Phone Numbers and Website• Ifyouhavequestions,calltoll-free1-866-509-5399TTY:711.•Ourwebsite:http://www.essencehealthcare.com

Who can join?Tojoin CoxHealth MedicarePlus, youmustbeentitledtoMedicarePartA,beenrolledinMedicarePartB, and live in our service area.OurserviceareaincludesthefollowingcountiesinMissouri:Christian,Greene,StoneandTaney.

Which doctors, hospitals and pharmacies can I use?CoxHealth MedicarePlus has a network of doctors, hospitals, pharmacies and other providers. If you use the providers that are not in our network, the plan may not pay fortheseservices.Youmustgenerally usenetworkpharmaciestofillyourprescriptionsforcoveredPartDdrugs.Youcanseeourplan’sproviderdirectoryatourwebsite(http://www.essencehealthcare.com). Or, call us and we will send you a copy of the provider directory.

What do we cover?LikeallMedicarehealthplans,wecovereverythingthatOriginalMedicarecovers-andmore.

•Our plan members get all of the benefits covered by Original Medicare. For some of thesebenefits,youmaypaymoreinourplanthanyouwouldinOriginalMedicare.Foroth-ers, you may pay less.

•Our plan members also get more than what is covered by Original Medicare. Some of the extra benefitsareoutlinedinthisbooklet.

What drugs do we cover?WecoverPartDdrugs.Inaddition,wecoverPartBdrugssuchaschemotherapyandsomedrugs administered by your provider.

•Youcanseethecompleteplanformulary(listofPartDprescriptiondrugs)andanyrestrictionson our website, http://www.essencehealthcare.com

•Or, call us and we will send you a copy of the formulary.

How will I determine my drug costs?Ourplangroupseachmedicationintooneoffive“tiers.”Youwillneedtouseyourformularytolocate what tier your drug is on to determine how much it will cost you. The amount you pay depends on the drug’s tier andwhatstageofthebenefityouhavereached.Laterinthisdocumentwediscussthebenefitstagesthatoccur:InitialCoverage,CoverageGapandCatastrophicCoverage.Ifyouhavequestions aboutthedifferentbenefitstages,PleasecontactthePlanformoreinformationoraccesstheEvidence of Coverage on our website.

CoxHealthMedicarePlusisanHMOplanwithaMedicarecontract.EnrollmentinCoxHealthMedicarePlus depends on contract renewal.

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Table of Contents

InpatientHospitalCare ........................................................................................................................................................ 4Doctor’sOfficeVisits ............................................................................................................................................................ 4PreventiveCare ....................................................................................................................................................................... 5Emergency Care...................................................................................................................................................................... 5UrgentlyNeededServices .................................................................................................................................................. 5DiagnosticTests,LabandRadiologyServices,andX-Rays’ .................................................................................. 6HearingServices .................................................................................................................................................................... 6DentalServices ....................................................................................................................................................................... 6Vision Services ........................................................................................................................................................................ 7MentalHealthCare ............................................................................................................................................................... 7InpatientMentalHealthCare ............................................................................................................................................ 7SkilledNursingFacility(SNF)............................................................................................................................................. 7RehabilitationServices ......................................................................................................................................................... 8Ambulance ............................................................................................................................................................................... 8Foot Care ................................................................................................................................................................................... 8DurableMedicalEquipment .............................................................................................................................................. 8WellnessPrograms ................................................................................................................................................................ 8PrescriptionDrugs ................................................................................................................................................................. 8MedicarePartBDrugs ................................................................................................................................................... 8Deductible .......................................................................................................................................................................... 8Initial Coverage ................................................................................................................................................................. 8CoverageGap .................................................................................................................................................................... 9Catastrophic Coverage .................................................................................................................................................. 9

Chiropractic Care ................................................................................................................................................................... 10DiabetesSuppliesandServices ........................................................................................................................................ 10HomeHealthCare ................................................................................................................................................................. 10Outpatient Substance Abuse ............................................................................................................................................ 10Outpatient Surgery ............................................................................................................................................................... 10ProstheticDevices ................................................................................................................................................................. 10RenalDialysis ........................................................................................................................................................................... 10Hospice ...................................................................................................................................................................................... 10

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Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services

CoxHealth MedicarePlus (HMO)

How much is the monthly premium?

$0permonth.Inaddition,youmustkeeppayingyourMedicarePartBpremium.

How much is the deductible?

This plan does not have a deductible.

Is there any limit on how much I will pay for my covered services?

Yes.LikeallMedicarehealthplans,ourplanprotectsyoubyhavingyearlylimitsonyourout-of-pocketcostsformedicalandhospitalcare.

Youryearlylimit(s)inthisplan:• $3,975forservicesyoureceivefromin-networkproviders.

Ifyoureachthelimitonout-of-pocketcosts,youkeepgettingcoveredhospitaland medical services and we will pay the full cost for the rest of the year.

Pleasenotethatyouwillstillneedtopay yourmonthlypremiumsandcost-sharingforyourPartDprescriptiondrugs.

Covered Medical and Hospital BenefitsNote:•Serviceswitha1 may require prior authorization.•Serviceswitha2mayrequireareferralfromyourPCP.

CoxHealth MedicarePlus (HMO)

Inpatient Hospital Care1

Our plan covers an unlimited number of days for an inpatient hospital stay.• $220 copayperdayfordays1through8• Youpaynothingperdayfordays9through90• Youpaynothingperdayfordays91andbeyond

Authorizationrulesapplytoinpatienthospitalbenefits.

Doctor’s Office Visits2

Primarycarephysicianvisit:$5copaySpecialistvisit:$45copay

AreferralisrequiredforPhysicianSpecialistServices.

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CoxHealth MedicarePlus (HMO)

Preventive Care YoupaynothingOurplancoversmanypreventiveservices, including:• Abdominal aortic aneurysm screening• Alcohol misuse counseling• Aortic aneurysm screenings• Bone mass measurement• Breastcancerscreening (mammogram)• Cardiovasculardisease(behavioral therapy)• Cardiovascular screenings• Cervical and vaginal cancer screening• Colorectalcancerscreenings (Colonoscopy,Fecaloccultbloodtest,Flexible

sigmoidoscopy)• Depressionscreening• Diabetesscreenings• Glaucomascreenings• HIVscreening• Medical nutrition therapy services• NutritiontherapyforEndStageRenalDisease• Obesity screening and counseling• Physicalexams• Prostatecancerscreenings(PSA)• Sexually transmitted infections screening and counseling• Tobaccousecessationcounseling(counselingforpeoplewithnosignoftobacco-relateddisease)

• Vaccines,includingFlushots,HepatitisBshots,Pneumococcalshots• “WelcometoMedicare”preventive visit(one-time)• Yearly“Wellness”visit

Any additional preventive services approved by Medicare during the contract year will be covered.

Emergency Care

$75copay

If you are admitted to the hospital within 24hours,youdonothavetopayyourshareofthecostforemergencycare.Seethe“InpatientHospitalCare”sectionofthis booklet for other costs.

Emergency Care is available worldwide.

Urgently Needed Services

$45copay

UrgentlyNeededServicesisavailablenationwide.

$75copayoutsideoftheUnitedStates

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CoxHealth MedicarePlus (HMO)

Diagnostic Tests, Lab and Radiology Services,and X-Rays (Costs for these services may vary based on place of service 1,2

Diagnosticradiologyservices(suchasMRIs,CTscans):20%co-insurance

Diagnostictestsandprocedures:20%co-insurance

Labservices:$5copay

Outpatientx-rays:$20copayTherapeuticradiologyservices(suchasradiationtreatmentforcancer):20%co-insurance

Authorization and referral rules may apply for certain outpatient diagnostic procedures or tests.

There is no copay for abdominal aneurysm screening, diabetes screening or prostate cancer screening when they are ordered as a preventative service.

Hearing Services

Exam to diagnose and treat hearing and balanceissues:$20copay

Routinehearingexam:$20copay

HearingAidsarenotcovered.

Dental Services2

Limiteddentalservices(thisdoesnot includeservicesinconnectionwithcare, treatment,filling,removal,orreplacement ofteeth):$35copay

Dentalservices:$35copayforasingleofficevisitthatincludes:•Cleaning(upto 2everyyear)•Dentalx-ray(s)(upto1everyyear)•Fluoridetreatment(upto1everyyear)•Oralexam(upto 2everyyear)

Thepreventivedentalx-raycoverageis forhorizontalbite-wingx-raysonly.

A referral may be required for some dental services.

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CoxHealth MedicarePlus (HMO)

Vision Services Exam to diagnose and treat diseases and conditionsoftheeye(includingyearlyglaucomascreening): $45 copay

Routineeyeexam(upto 1everyyear):$35copay

Contactlenses(upto1everyyear):$35copay

Ourplanpaysupto$100everyyearforcontactlenses.

Eyeglassframes(upto1everyyear):$35copay

Ourplanpaysupto$100everyyearforeyeglassframes.

Eyeglasslenses(upto1everyyear,thisincludessingle,bifocalandtrifocal): Youpay nothing.

Eyeglasses or contact lenses after cataract surgery:$35copay

Mental Health Care1

Inpatientvisit:Our plan covers an unlimited number of days for an inpatient hospital stay.• $220copayperdayfordays1through7•Youpaynothingperdayfordays8 through90•Youpaynothingperdayfordays91andbeyond

Outpatientgrouptherapyvisit:$35copay

Outpatientindividualtherapyvisit:$40copay

AuthorizationrulesmayapplytoMentalHealthbenefits.

Inpatient Mental Health Care

Forinpatientmentalhealthcare,seethe “MentalHealthCare”sectionofthisbooklet.

Skilled Nursing Facility (SNF)1

Ourplancoversupto100daysinaSNF.• $0copayperdayfordays1through20• $160perdayfordays21through100

Noinpatienthospitalstayisrequiredprior toSNFadmission.Copaymentsare applied per day, per stay.

AuthorizationrulesapplytoSkilledNursingFacilitybenefits.

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CoxHealth MedicarePlus (HMO)

Rehabilitation Services2

Cardiac(heart)rehabservices(foramaximumof2one-hoursessionsperdayupto36sessionsupto36weeks):$30copay

CopaymentforCardiacRehabServicesappliesperday.

Occupationaltherapyvisit:$40copay

A separate copayment for Occupational Therapy will apply if other outpatient therapy services are rendered on the same day.

Physicaltherapyandspeechandlanguagetherapyvisit:$40copay

AreferralisrequiredforCardiacandPulmonaryRehabilitationServices,Occupa-tionaltherapy,PhysicalTherapyandSpeechandLanguagePathologyServices.

Ambulance1 $250copay

AuthorizationrulesmayapplytoAmbulancebenefits.

Foot Care (podiatry services)2

Footexamsandtreatmentifyouhavediabetes-relatednervedamageand/ormeetcertainconditions:$45copay

AreferralisrequiredforPodiatristServices.

Durable Medical Equipment (wheelchairs, oxygen, etc.)1

20%co-insurance

AuthorizationrulesmayapplytoDurableMedicalEquipmentbenefits.

Wellness Programs

HealthClubMembership/FitnessclassesthroughSilverSneakers:$0copay

Prescription Drug Benefits

CoxHealth MedicarePlus (HMO)

Medicare Part B Drugs

ForPartBdrugssuchaschemotherapydrugs1:20%co-insurance

OtherPartBdrugs1:20%co-insurance.

AuthorizationmayberequiredforsomePartBdrugs.

Deductible This plan does not have a deductible.

Initial Coverage

Youpaythefollowinguntilyourtotalyearlydrugcostsreach$3,700.TotalyearlydrugcostsarethetotaldrugcostspaidbybothyouandourPartDplan.Youmaygetyourdrugsatnetworkretailpharmaciesandmailorderpharmacies.

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CoxHealth MedicarePlus (HMO)

Standard Retail Cost-Sharing

Tier One-Month Supply

Two-Month Supply

Three-Month Supply

Tier1 (PreferredGeneric) $3copay $6copay $9copay

Tier2 (Generic) $6copay $12copay $18copay

Tier3 (PreferredBrand) $47copay $94copay $141copay

Tier4 (Non-PreferredBrand) $100copay $200copay $300copay

Tier5 (SpecialtyTier) 33%co- insurance Not Offered Not Offered

Standard Mail Order Cost-Sharing

Tier One-Month Supply

Two-Month Supply

Three-Month Supply

Tier1 (PreferredGeneric) Not Offered Not Offered $9copay

Tier2(Generic) Not Offered Not Offered $18copay

Tier3(PreferredBrand) Not Offered Not Offered $141copay

Tier4(Non-PreferredBrand) Not Offered Not Offered $300copay

Tier5(SpecialtyTier) 33% co- insurance Not Offered Not Offered

Ifyouresideinalong-termcarefacility,youpaythesameasataretailpharmacy.

Youmaygetdrugsfromanout-of-networkpharmacyatthesamecostasanin-networkpharmacy.

Coverage Gap MostMedicaredrugplanshaveacoveragegap(alsocalledthe“donuthole”).This means that there’s a temporary change in what you will pay for your drugs. The coverage gap begins after thetotalyearlydrugcost(includingwhatourplanhas paid and what you havepaid)reaches$3,700

Afteryouenterthecoveragegap,youpay40%oftheplan’scostforcoveredbrandnamedrugsand51%oftheplan’scost forcoveredgenericdrugsuntilyourout-of-pocket coststotal$4,950,whichistheendof thecoveragegap.Noteveryonewillenter the coverage gap.

Catastrophic Coverage

Afteryouryearlyout-of-pocketdrugcosts(includingdrugspurchasedthroughyourretailpharmacyandthroughmailorder)reach$4,950,youpaythegreaterof:• 5%co-insurance,or$3.30copayforgeneric(includingbranddrugstreatedas generic)anda$8.25copayforallotherdrugs.

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Other Covered Benefits

CoxHealth MedicarePlus (HMO)Chiropractic Care2

Manipulationofthespinetocorrecta subluxation(when1ormoreofthebonesofyourspinemoveoutofposition):$20copay

A referral is required for Chiropractic Services.

Diabetes Supplies and Services1

Diabetesmonitoringsupplies (includingglucosemonitors,lancetsandteststrips): 20%co-insurance.

When glucose meters and test strips are obtained at a pharmacy, coverage is limitedtospecificBayer/Ascensiaproducts.

Diabetesself-managementtraining:Youpaynothing

Therapeuticshoesorinserts:20%co-insurance

Authorization is required for diabetic shoes and inserts.

HomeHealth Care2

Youpaynothing

AreferralisrequiredforHomeHealthServices.

Outpatient Substance Abuse1

Grouptherapyvisit:$35copay

Individualtherapyvisit:$40copay

AuthorizationrulesmayapplytoSubstanceAbusebenefits.

Outpatient Surgery1,2

Ambulatorysurgicalcenter:$220copay

Outpatienthospital:$220copayor20%co-insurance,dependingontheservice

Authorization rules may apply for some Ambulatory Surgical Center and OutpatientHospitalSurgeryservices.

Prosthetic Devices (braces, artificiallimbs, etc.)1

Prostheticdevices:20%co-insurance

Relatedmedicalsupplies:20%co-insurance

AuthorizationrulesmayapplyforsomeProsthetics/Medicalsupplies.

Renal Dialysis 20%co-insurance

Hospice YoupaynothingforhospicecarefromaMedicare-certifiedhospice.Youmayhave to pay part of the cost for drugs andrespitecare. Hospiceiscovered outsideofourplan.Pleasecontactusformoredetails.

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Index

Ambulance ................................................................................................................................................................................. 8Chiropractic Care .....................................................................................................................................................................10DentalServices ......................................................................................................................................................................... 6DiabetesSuppliesandServices .........................................................................................................................................10DiagnosticTests,LabandRadiologyServices,andX-Rays’ .................................................................................... 6Doctor’sOfficeVisits .............................................................................................................................................................. 4DurableMedicalEquipment ................................................................................................................................................ 8Emergency Care ....................................................................................................................................................................... 5Foot Care..................................................................................................................................................................................... 8HearingServices ...................................................................................................................................................................... 6HomeHealthCare ...................................................................................................................................................................10Hospice ........................................................................................................................................................................................10InpatientHospitalCare .......................................................................................................................................................... 4InpatientMentalHealthCare .............................................................................................................................................. 7MentalHealthCare ................................................................................................................................................................. 7Outpatient Substance Abuse ..............................................................................................................................................10Outpatient Surgery .................................................................................................................................................................10PreventiveCare ......................................................................................................................................................................... 5PrescriptionDrugs ................................................................................................................................................................... 8

MedicarePartBDrugs ................................................................................................................................................... 8Deductible ........................................................................................................................................................................... 8Initial Coverage ................................................................................................................................................................. 8CoverageGap .................................................................................................................................................................... 9Catastrophic Coverage ................................................................................................................................................... 9

ProstheticDevices ...................................................................................................................................................................10RehabilitationServices .......................................................................................................................................................... 8RenalDialysis .............................................................................................................................................................................10SkilledNursingFacility(SNF) .............................................................................................................................................. 7UrgentlyNeededServices .................................................................................................................................................... 5Vision Services .......................................................................................................................................................................... 7WellnessPrograms .................................................................................................................................................................. 8

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You may receive a messaging service on weekends and holidays from February 15 through September 30. Please leave a message and your call will be returned the next business day. CoxHealth MedicarePlus is an HMO plan with a Medicare contract. Enrollment in CoxHealth MedicarePlus depends on contract renewal.

13900 Riverport DriveMaryland Heights, MO 63043

www.essencehealthcare.com

Toll-free: 1-866-597-9560TTY users dial: 711

8 a.m. to 8 p.m. seven days a week

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