AdvantageOptimum Plan (HMO)

Transcription

1 CARE1ST AdvantageOptimum Plan (HMO) PRE-EnRollmEnT Book 2014 San diego & los angeles counties H5928_14_117_MKB Accepted

2 Thank you for Your Interest in Care1st TABLE OF CONTENTS 1. Thank you for Your Interest in Care1st / Table of Contents 2. Welcome Letter 3. Medicare Plan Rating 4. Care1st Health Plan 2014 Service Area Map 5. Frequently Asked Questions and Answers about Medicare Advantage Plans Care1st Benefit Chart - a condensed list of some of the benefits you will receive as a Care1st member. 7. Nurse Advice Line 8. Understanding Enrollment Periods - explanation of the different times of year when you can enroll or make changes to your plan. 9. Ready to Enroll - guidelines and instructions to help you through the enrollment process. 11. Summary of Benefits 12. Drug List - a comprehensive list of the drugs covered by Care1st and their tier levels. 13. Delta Dental Flyer - important information about the Care1st dental program and provider. 14. Outbound Education & Verification (OEV) Call 15. What to Expect After Enrollment - providing details about the enrollment process and timelines. 16. Visit Us Online - information about our website at Multi Language Information - if you require enrollment information in another language, please follow the instructions provided. 10. Sample Enrollment Form - demonstrates the information you need to include on your application. SDLA

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4 Dear Medicare Beneficiary: Care1st Health Plan P.O. Box 4239, Montebello, CA Thank you for considering one of Care1st Medicare Advantage Health Plans (HMO, HMO SNP) for your healthcare needs. Taking charge of your health is one of the many ways that you can control your health and healthcare options. The information enclosed will help you to explore the benefits of being a Care1st member. Like most people, we know that you are looking for healthcare coverage that meets your needs and is affordable. With that in mind, we have designed our Medicare Advantage and Special Needs Plans around YOU! You will get more of the benefits you want and need to keep you healthy while maintaining your lifestyle. By choosing Care1st, you ll receive the benefits of a great company with proven leadership, integrity, and a dedicated staff that is ready to serve you. And, there s more! Care1st was created and is still run today by doctors. We believe our members needs come first. We focus on caring for the whole you so that you can live a healthier daily life. With over 10,000 physicians and 100 hospitals in our network, we re certain that you will find the doctor that is right for you and your specific needs. The information in this folder will help you to explore the benefits of being a Care1st member. As a guide, we encourage you to review the Summary of Benefits as it provides detailed coverage that our plans offer. Are you ready to enroll? Simply complete the Individual Enrollment Form and return it to Care1st. Choosing healthcare coverage is a big decision and can be confusing. We are happy to help answer any questions you may have. Don t hesitate to call. No question is too big or too small. Yes, it is all about you. If you re ready to enroll, simply complete the Individual Enrollment Form and return it to Care1st or you can call us and we can help you enroll telephonically. Marketing Department (TTY/TDD users call 711) 8:00 a.m. to 8:00 p.m., seven days a week We look forward to welcoming you to the Care1st family. Dawn Maroney Chief Medicare Officer Care1st Health Plan 601 Potrero Grande Drive, Monterey Park, CA Care1st is a Medicare Advantage HMO plan with a Federal Government contract in Texas and California. Enrollment in Care1st Health Plan depends on contract renewal. H5928_14_042_MK Accepted

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6 Care1st Medicare Advantage Plan - H5928 CY 2013 Medicare Plan Ratings The Medicare Program rates all health and prescription drug plans each year, based on a plan s quality and performance. Medicare Plan Ratings help you know how good a job our plan is doing. You can use this Plan Rating to compare our plan s performance to other plans. Examples of the areas covered by this rating include: How our members rate our plan s services and care; How well our doctors detect illnesses and keep members healthy; How well our plan helps our members use recommended and safe prescription medications For 2013, Care1st Medicare Advantage Plan received the following overall Plan Rating from Medicare. 3.5 Stars The number of stars shows how well our plan performs. excellent above average average below average poor Learn more about our plan and how we are different from other plans at You may also contact us Sunday, Monday, Tuesday, Wednesday, Thursday, Friday, Saturday, 8:00 a.m. - 8:00 p.m. Pacific at (toll-free) or (TTY/TDD). Current members please call (toll-free) or (TTY/TDD). H5928_13_039_MK Accepted

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8 Service AreAS El Paso San Joaquin Alameda (Partial) Stanislaus San Francisco Fresno Santa Clara (Partial) TEXAS CALiFORNiA HMO & HMO SNP Kern (Partial) HMO Plan Only Los Angeles Orange (Partial) Call Member Services for questions or benefit information: San Bernardino (Partial) Riverside (Partial) San Diego TTY/TDD users call 711 8:00 a.m. to 8:00 p.m., seven days a week facebook/mycare1st H5928_14_043_MK Accepted

9 Service AreA ZiP codes CALIFORNIA Alameda County 94501; 94502; 94601; 94602; 94603; 94604; 94605; 94606; 94607; 94608; 94609; 94610; 94611; 94612; 94613; 94614; 94617; 94618; 94619; 94620; 94621; 94623; 94624; 94661; 94662; 94701; 94702; 94703; 94704; 94705; 94706; 94707; 94708; 94709; 94710; 94712; Fresno County 93242; 93606; 93609; 93611; 93612; 93613; 93616; 93619; 93625; 93626; 93630; 93648; 93650; 93652; 93657; 93662; 93667; 93701; 93702; 93703; 93704; 93705; 93706; 93707; 93708; 93709; 93710; 93711; 93712; 93714; 93715; 93716; 93717; 93718; 93720; 93721; 93722; 93723; 93724; 93725; 93726; 93727; 93728; 93729; 93730; 93737; 93740; 93744; 93745; 93747; 93750; 93755; 93761; 93765; 93771; 93772; 93773; 93774; 93775; 93776; 93777; 93778; 93779; 93786; 93790; 93791; 93792; 93793; Kern County 93203; 93206; 93220; 93241; 93250; 93263; 93276; 93280; 93301; 93302; 93303; 93304; 93305; 93306; 93307; 93308; 93309; 93311; 93312; 93313; 93314; 93380; 93383; 93384; 93385; 93386; 93387; 93388; 93389; Los Angeles County All ZIP Codes Orange County 90620; 90621; 90622; 90623; 90624; 90630; 90631; 90632; 90633; 90638; 90680; 90720; 90740; 90742; 90743; 92609; 92610; 92617; 92619; 92620; 92626; 92637; 92646; 92647; 92648; 92649; 92655; 92657; 92673; 92683; 92685; 92694; 92697; 92698; 92701; 92702; 92703; 92704; 92705; 92706; 92707; 92708; 92725; 92735; 92801; 92802; 92803; 92804; 92805; 92806; 92807; 92808; 92809; 92812; 92814; 92815; 92816; 92817; 92821; 92822; 92823; 92825; 92831; 92832; 92833; 92834; 92835; 92836; 92837; 92838; 92840; 92841; 92842; 92843; 92844; 92845; 92846; 92850; 92868; 92870; 92871; 92885; 92886; 92887; Riverside 91718, 91719, 91720, 91752, 91760, 92028, 92201, 92202, 92203, 92210, 92211, 92220, 92223, 92230, 92234, 92235, 92236, 92240, 92241, 92247, 92248, 92253, 92254, 92255, 92258, 92260, 92261, 92262, 92263, 92264, 92270, 92274, 92276, 92282, 92292, 92320, 92324, 92373, 92399, 92501, 92502, 92503, 92504, 92505, 92506, 92507, 92508, 92509, 92513, 92514, 92515, 92516, 92517, 92518, 92519, 92521, 92522, 92530, 92531, 92532, 92536, 92539, 92543, 92544, 92545, 92546, 92548, 92549, 92551, 92552, 92553, 92554, 92555, 92556, 92557, 92561, 92562, 92563, 92564, 92567, 92570, 92571, 92572, 92581, 92582, 92583, 92584, 92585, 92586, 92587, 92589, 92590, 92591, 92592, 92593, 92595, 92596, 92599, 92860, 92877, 92878, 92879, 92880, 92881, 92882, 92883

10 San Bernardino: 91701, 91708, 91709, 91710, 91730, 91737, 91739, 91761, 91762, 91763, 91764, 91784, 91786, 92301, 92307, 92308, 92313, 92316, 92318, 92324, 92334, 92335, 92336, 92337, 92344, 92345, 92346, 92350, 92354, 92357, 92359, 92368, 92369, 92371, 92373, 92374, 92376, 92377, 92392, 92394, 92395, 92399, 92401, 92402, 92403, 92404, 92405, 92406, 92407, 92408, 92410, 92411, 92412, 92413, 92414, 92415, 92418, 92420, 92423, 92424, San Diego County All ZIP Codes San Francisco County All ZIP Codes San Joaquin County All ZIP Codes Santa Clara County All ZIP Codes Stanislaus County All ZIP Codes TEXAS El Paso County All ZIP Codes Care1st is a Medicare Advantage HMO plan with a Federal Government contract in Texas and California. Enrollment in Care1st Health Plan depends on contract renewal. This information is available for free in other languages. Please contact Member Services: (TTY: 711), 8:00 a.m. to 8:00 p.m., seven days a week. Esta información está disponible gratuitamente en otros idiomas. Comuníquese con Servicios para los Miembros: (TTY 711), de 8:00 a.m. a 8:00 p.m., los siete días de la semana. 請聯絡 會員服務熱線電話 聽障和語障人士可致電 711 我們的辦公時間為每週七天 早上8:00點至晚上 8:00點 H5928_14_043_MK Accepted

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12 Do You Have MeDicare Questions? Care1st (HMO, HMO snp) Has answers. What are the different parts of Medicare A, B, C and D? Medicare Part A covers inpatient hospital care, skilled nursing facility, home healthcare and hospice care. Medicare Part B covers outpatient care, such as doctor s office visits, specialist s office visits, lab services, durable medical equipment and preventive services. You pay a Part B premium each month. Medicare Part C are Medicare Advantage plans which are approved by Medicare and offered by private companies. Medicare Advantage Plans provide all of your Part A and Part B coverage. Medicare Advantage plans may offer extra coverage, such as vision, hearing, dental and/or health and wellness programs. Medicare Part D is your prescription drug coverage. To get prescription drug coverage you must join a plan such as Care1st. Each plan can vary in cost and drugs covered. How do I join Care1st Medicare Advantage Plans? Call Care1st at and a representative can assist you right over the phone. (TTY) 711. Seven days a week, 8:00 a.m. to 8:00 p.m. PST. Can I obtain specialty services? When you need specialty care or additional services your PCP cannot provide, he or she will give you a referral. There are certain services which you can get on your own, without a referral, as long as you get them from a network provider. What should I do if I m out of Care1st s coverage area and need emergency services? Care1st provides worldwide emergency coverage. If you have an emergency when you are not in our service area, you can obtain emergency services at the nearest emergency facility (doctor s office, clinic or hospital). Emergency services do not require a referral or an okay from your PCP doctor. Can I obtain care after normal business hours? It is important you always carry your Care1st ID card with you. If you think that you have an emergency, call 911 or go to the nearest emergency room. Call your doctor if you need medical care, and he or she can help you arrange care. Care1st also offers a Nurse Advice Line. The call is free and easy. You get advice right away. A nurse will ask about your health problem. You do not have to call the Nurse Advice Line before getting healthcare. What if I m a Medicare member with Care1st and also have Medicaid benefits elsewhere? If you are a Medicaid member and eligible for Medicare, then it is important to know that Medicare, not Medicaid is your primary insurance. If you are interested in combining your benefits, please call Member Services for more information on the additional benefits available. H5928_14_049_MKB Accepted

13 How is my private health information protected? There are federal and state laws that protect the privacy of your medical records and personal health information. We protect your personal health information under these laws. Any personal health information that you give us when you enroll is protected. We will make sure that unauthorized people don t see or change your records. What benefits and services are not covered? Care1st plans cover all of the medically-necessary services that are covered by Medicare Part A and Part B. The following items and services aren t covered under the Original Medicare Plan or by our plans: Services that aren t reasonable and necessary, according to the standards of the Original Medicare Plan, unless these services are otherwise listed by our Plan as a covered service Experimental or investigational medical and surgical procedures, equipment and medications, unless covered by the Original Medicare Plan or unless, for certain services, the procedures are covered under an approved clinical trial Surgical treatment of morbid obesity unless medically necessary and covered under the Original Medicare plan Private room in a hospital, unless medically necessary Private duty nurses Personal convenience items, such as a telephone or television in your room at a hospital or skilled nursing facility Nursing care on a full-time basis in your home Custodial care unless it is provided in conjunction with covered skilled nursing care and/or skilled rehabilitation services. This includes care that helps people with activities of daily living like walking, getting in and out of bed, bathing, dressing, eating and using the bathroom, preparation of special diets, and supervision of medication that is usually self-administered Homemaker services Charges imposed by immediate relatives or members of your household Elective or voluntary enhancement procedures, services, supplies and medications including but not limited to: Weight loss, hair growth, sexual performance, athletic performance, cosmetic purposes, anti-aging and mental performance unless medically necessary Cosmetic surgery or procedures, unless needed because of accidental injury or to improve the function of a malformed part of the body. All stages of reconstruction are covered for a breast after a mastectomy, as well as for the unaffected breast to produce a symmetrical appearance Chiropractic care is generally not covered, (with the exception of manual manipulation of the spine), and is limited according to Medicare guidelines Orthopedic shoes unless they are part of a leg brace and are included in the cost of the brace. Exception: Therapeutic shoes are covered for people with diabetic foot disease Supportive devices for the feet. Exception: Orthopedic or therapeutic shoes are covered for people with diabetic foot disease Radial keratotomy, LASIK surgery, vision therapy and other low vision aids and services Self-administered prescription medication for the treatment of sexual dysfunction, including erectile dysfunction, impotence, and anorgasmy or hyporgasmy Reversal of sterilization procedures, sex change operations, and non-prescription contraceptive supplies and devices Naturopath services Non-emergency services provided to veterans in Veterans Affairs (VA) facilities. However, in the case of emergency services received at a VA hospital, if the VA cost-sharing is more than the cost-sharing required under our Plan, we will reimburse veterans for the difference. Members are still responsible for our Plan cost-sharing amount

14 Any of the services listed above that aren t covered will remain not covered even if received at an emergency facility. For example, non-authorized, routine conditions that do not appear to a reasonable person to be based on a medical emergency are not covered if received at an emergency facility How can I assign a representative to act in my behalf? You have the right to ask someone such as a family member or friend to help you with decisions about your healthcare. If you want to, you can use a special form to give someone the legal authority to make decisions for you if you ever become unable to make decisions for yourself. If you want to have an advance directive, you can get a form from your lawyer, from a social worker or from some office supply stores, or from other sources including the internet and advocacy groups. If you only wish to give the authority to represent you in dealings with Care1st for enrollment, claims and other administrative matters, you can visit our website download and complete the Appointment of Representative. Please note that copies of an advance directive, Appointment of Representative, or similar documents must be sent to Care1st to be effective for Care1st purposes. What can I do if I move out of your service area? If you move out of the service area or are away from the service area for more than six months, you cannot remain a member of our Plan. Please call Member Services to find out if the place you are moving to or traveling to is in our Plan s service area. A Medicare approved HMO plan Call Member Services for questions or benefit information: TTY/TDD users call 711 8:00 a.m. to 8:00 p.m., seven days a week facebook/mycare1st Care1st is a Medicare Advantage HMO plan with a Federal Government contract in Texas and California. Enrollment in Care1st Health Plan depends on contract renewal. The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Benefits and/or co-payments/co-insurance may change on January 1 of each year. Limitations, co-payments, and restrictions may apply. This information is available for free in other languages. Please contact Member Services: (TTY: 711), 8:00 a.m. to 8:00 p.m., seven days a week. Esta información está disponible gratuitamente en otros idiomas. Comuníquese con Servicios para los Miembros: (TTY 711), de 8:00 a.m. a 8:00 p.m., los siete días de la semana. 請聯絡會員服務熱線電話 : 聽障和語障人士可致電 711 我們的辦公時間為每週七天, 早上 8:00 點至晚上 8:00 點 H5928_14_049_MKB Accepted

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16 2014 Benefits chart san DieGO / LOs angeles counties Benefit advantageoptimum Plan (hmo) Premium $0* Primary Care Physician (PCP) $0 copay Physician Specialist Hearing Aid $15 copay $0 copay for (2) hearing aids every two years; $500 limit every year Inpatient Hospitalization $150 copay days 1-5; $0 copay days 6-90; unlimited additional days Emergency Care $50 copay (Waived if admitted) Worldwide coverage up to $25,000 per year Ambulance Durable Medical Equipment (DME) Dental Services Eye Exam Routine Eyewear $180 copay (Waived if admitted) $0 copay standard Medicare Covered item; 20% coinsurance non-standard Medicare covered item Covered Refer to your Summary of Benefits for details $10 copay routine eye exams (1 every year) $0 copay - $150 limit for glasses every 2 years / refraction test covered *Part D Premium Disclaimer: Depending on your level of Medicaid eligibility, you may not have any cost-sharing responsibility for your part D premium. H5928_14_085_MK Accepted

17 2014 Benefits chart san DieGO / LOs angeles counties Benefit advantageoptimum Plan (hmo) Preferred Generic Drugs, T1 $0 copay Non-Preferred Generic Drugs, T2 $7 copay 1 mo supply; $14 copay 3 mo supply Preferred Brand Drugs, T3 $35 copay 1 mo supply; $70 copay 3 mo supply Non-Preferred Brand Drugs, T4 $60 copay 1 mo supply; $120 copay 3 mo supply Specialty Tier Drugs, T5 30% coinsurance Initial Coverage Limit After $2,850 (Tiers 1 & 2) Out-of-Pocket Limit $3400 (In-Network Medicare-covered benefits) if you have questions about becoming a care1st member, call: tty/tdd users call 711 8:00 a.m. to 8:00 p.m., seven days a week /mycare1st Care1st is a Medicare Advantage HMO plan with a Federal Government and State Medicaid contract in Arizona and California. Enrollment in Care1st Health Plan depends on contract renewal. The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Benefits, formulary, pharmacy network, premium and/ or co-payments/co-insurance may change on January 1 of each year. Limitations, copayments, and restrictions may apply. You must continue to pay your Medicare Part B premium. This information is available for free in other languages. Please contact Member Services: (TTY 711), 8am 8pm, 7 days a week. Esta información está disponible gratuitamente en otros idiomas. Comuníquese con Servicios para los Miembros: (TTY 711), de 8:00 a.m. a 8:00 p.m., los siete días de la semana.

18 Nurse Advice HoTliNe A Medicare approved HMO plan The Care1st (HMO, HMO SNP) Nurse Advice Line is a service available to all Care1st members. The call is free and easy. A caring nurse will listen to your health problem. The nurse can help you decide: If you need to see the doctor. If it is safe to wait or if you need care right away. What to do if your symptoms get worse. What you can start doing at home to feel better. For life- or limb-threatening emergencies, always call 911 or your local emergency services. You do not have to call the Nurse Advice Line before getting healthcare. Call the Care1st Nurse Advice Line at: TTY/TDD users call 711 8:00 a.m. to 8:00 p.m., seven days a week facebook/mycare1st Care1st is a Medicare Advantage HMO plan with a Federal Government contract in Texas and California. Enrollment in Care1st Health Plan depends on contract renewal. The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Benefits and/or co-payments/co-insurance may change on January 1 of each year. Limitations, copayments, and restrictions may apply. This information is available for free in other languages. Please contact Member Services: (TTY: 711), 8:00 a.m. to 8:00 p.m., seven days a week. Esta información está disponible gratuitamente en otros idiomas. Comuníquese con Servicios para los Miembros: (TTY 711), de 8:00 a.m. a 8:00 p.m., los siete días de la semana. 請聯絡會員服務熱線電話 : 聽障和語障人士可致電 711 我們的辦公時間為每週七天, 早上 8:00 點至晚上 8:00 點 H5928_14_010_MK Accepted

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20 Understanding Medicare enrollment Periods oct nov dec Jan FeB Mar apr MaY JUn JUl aug sep oct Annual Election Period Oct 15 - Dec 7 Medicare Advantage Disenrollment Period Jan 1 - Feb 14 Lock-In Period Feb 14 - Oct 14 Special Election Period and Initial Coverage Election Period, for those that qualify, is open all year. Open Enrollment Period for Institutionalized Individuals is open all year. There are different types of enrollment periods throughout the year when individuals may enroll or make changes to their Medicare plan. ANNUAL ELECTION PERIOD (AEP) Available October 15th through December 7th During this time you may join, drop or switch to the Medicare Advantage plan that is best for you. MEDICARE ADVANTAGE DISENROLLMENT PERIOD (MADP) Available January 1st through February 14th During this period if you have a Medicare Advantage plan you can leave your plan and return to Original Medicare. If you make the choice to switch to Original Medicare, you have until February 14th to sign up for a prescription drug plan. During the Disenrollment Period you cannot switch from Original Medicare to a Medicare Advantage plan or switch from one Medicare Advantage plan to another. H5928_14_047_MK Accepted

21 Understanding Medicare enrollment Periods LOCK IN PERIOD February 14th through October 14th During this time you cannot make changes to your Medicare plan unless you meet the requirements for the Special Election Period or Open Enrollment for Institutionalized Individuals. SPECIAL ELECTION PERIOD (SEP) Available all year to qualifying individuals During this time you may join, drop or switch your Medicare Advantage plan if you move out of the plan s service area, lose your employer or union coverage, you enroll in a PACE program or have a chronic condition that allows you to enroll in a Special Needs Plan designed to specifically treat individuals with your condition. INITIAL COVERAGE ELECTION PERIOD (ICEP) Available all year to qualifying individuals This election period revolves around an individual s 65th birthday or the 25th month of disability. It is associated to one s entitlement to both Medicare Part A, B and D. This period begins three months before the individual s first entitlement to both Medicare Part A, B and D and ends on the later of: 1. The last day of the month preceding entitlement to both Part A, B and D, or; 2. The last day of the individual s Part B initial enrollment period. OPEN ENROLLMENT PERIOD FOR INSTITUTIONALIZED INDIVIDUALS (OEPI) Available all year to qualifying individuals If you are institutionalized and need to enroll in or disenroll from a Medicare Advantage Special Needs Plan for institutionalized individuals. Call Member Services for questions or benefit information: (TTY/TDD users call 711) 8:00 a.m. to 8:00 p.m., seven days a week facebook/mycare1st Care1st is a Medicare Advantage HMO plan with a Federal Government contract in Texas and California. Enrollment in Care1st Health Plan depends on contract renewal. This information is available for free in other languages. Please contact Member Services: (TTY: 711), 8:00 a.m. to 8:00 p.m., seven days a week. Esta información está disponible gratuitamente en otros idiomas. Comuníquese con Servicios para los Miembros: (TTY 711), de 8:00 a.m. a 8:00 p.m., los siete días de la semana. 請聯絡會員服務熱線電話 : 聽障和語障人士可致電 711 我們的辦公時間為每週七天, 早上 8:00 點至晚上 8:00 點 H5928_14_047_MK Accepted

22 Are You ready To enroll? StepS to take to get yourself ready to enroll How to apply A Medicare approved HMO plan Pick Your PCP Pick your Primary Care Physician (PCP). Use our Provider Directory, or visit us online at or call us for a list of PCPs near you. Apply by Phone Call Care1st at (TTY/TDD users call 711) 8:00 a.m. to 8:00 p.m., seven days a week Review Rx Index Take a moment to review our drug index provided to ensure that your medications are covered. Or visit our website to review our drug formulary or call us for verification of our drug listing. Apply in Person Meet with your local Care1st representative. Locate Medicare ID Card When you are applying, make sure to have your Medicare ID card available, or some form of proof that you are entitled to Medicare. If you have questions about becoming a Care1st member, call: (TTY/TDD users call 711) 8:00 a.m. to 8:00 p.m., seven days a week facebook/mycare1st Apply by Mail Fill out the enclosed application form completely and mail to: Care1st Health Plan ATTN: ENROLLMENT DEPT 601 Potrero Grande Drive Monterey Park, CA Apply Online Medicare beneficiaries may also enroll in Care1st through the CMS Medicare Online Enrollment Center located at Care1st is a Medicare Advantage HMO plan with a Federal Government contract in Texas and California. Enrollment in Care1st Health Plan depends on contract renewal. This information is available for free in other languages. Please contact Member Services: (TTY: 711), 8:00 a.m. to 8:00 p.m., seven days a week. Esta información está disponible gratuitamente en otros idiomas. Comuníquese con Servicios para los Miembros: (TTY 711), de 8:00 a.m. a 8:00 p.m., los siete días de la semana. 請聯絡會員服務熱線電話 : 聽障和語障人士可致電 711 我們的辦公時間為每週七天, 早上 8:00 點至晚上 8:00 點 H5928_14_036_MK Accepted

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24 MEDICARE ADVANTAGE INDIVIDUAL ENROLLMENT ELECTION FORM Step 1: Please fill out the application completely. Use a ballpoint pen and press hard to make two copies. Step 2: Sign and date the last page of the application. Step 3: Keep the bottom yellow copy for your file. If you have any questions regarding this application, please call: Marketing Department: (TTY 711) Hours: 8:00 a.m. to 8:00 p.m. Seven days a week Care1st Health Plan P. O. Box 4549 Montebello, CA Member Services: (TTY 711) Hours: 8:00 a.m. to 8:00 p.m. Seven days a week WHITE Enrollment Copy YELLOW Member s Copy H5928_14_088_EN Approved

25 MEDICARE ADVANTAGE INDIVIDUAL ENROLLMENT ELECTION FORM Please contact Care1st if you need information in another language or format (Braille). To Enroll in Care1st, Please Provide the Following Information: Care1st AdvantageOptimum Plan (HMO) Los Angeles/Orange $0/month San Joaquin $0/month Stanislaus $0/month San Bernardino/Riverside/ Fresno $0/month San Diego $0/month Santa Clara $0/month El Paso $0/month San Francisco/Alameda $28/month smarthmo Plan Beneficiaries selecting this plan are exclusively enrolled with the AllCare network of providers. San Joaquin $0/month Coordinated Choice Plan (HMO) Los Angeles, Orange, San Diego, $26.30/month* San Bernardino, Riverside, Santa Clara, Stanislaus, Alameda, San Francisco, Fresno, El Paso Care1st TotalDual Plan (HMO SNP) This plan is designed for people who meet specific enrollment criteria. You may be eligible to join this plan if you receive assistance from the state. San Diego $26.90/month* Los Angeles $20.70/month* Alameda/San Francisco/ $28.10/month* Santa Clara Orange/San Bernardino $21.80/month* *Premiums may vary based on the level of Extra Help you receive. Please contact the plan for further details. LAST Name : Doe FIRST Name: Joh n Middle Initial: R. Mr. Mrs. Ms. Birth Date: Sex: Home Phone: Alternate Phone Number: ( 03 / 23 / ) (MM/DD/YYYY) M F ( 555 ) ( 555 ) Permanent Residence Street Address (P.O. Box is not allowed): 222 Anywhere St. City: Any Town State: CA ZIP Code: County: Stanislaus Mailing Address (only if different from your Permanent Residence Address): Street Address: City: State: ZIP Code: Emergency contact: Jane Doe Phone Number: Relationship to You: Wife Address: johnrdoe@website.com Please Provide Your Medicare Insurance Information. Please take out your Medicare card to complete this section. Please fill in these blanks so they match your red, white and blue Medicare card. - OR - Attach a copy of your Medicare card or your letter from Social Security or Railroad Retirement Board. You must have Medicare Part A and Part B to join a Medicare Advantage plan. SAMPLE ONLY Name: John R. Doe Medicare Claim Number Sex M Is Entitled To HOSPITAL (Part A) MEDICAL (Part B) Effective Date MM-DD-YYYY WHITE Enrollment Copy YELLOW Member s Copy H5928_14_088_EN Approved

26 Paying Your Plan Premium You can pay your monthly plan premium (including any late enrollment penalty that you currently have or may owe) by mail each month. You can also choose to pay your premium by automatic deduction from your Social Security or Railroad Retirement Board (RRB) benefit check each month. If you are assessed a Part-D- Income related Monthly Adjustment Amount, you will be notified by the Social Security Administration. You will be responsible for paying this extra amount in addition to your plan premium. You will either have the amount withheld from your Social Security benefit check or be billed directly by Medicare or the RRB. DO NOT pay Care1st the Part D-IRMAA. People with limited incomes may qualify for extra help to pay for their prescription drug costs. If eligible, Medicare could pay for 75% or more of your drug costs including monthly prescription drug premiums, annual deductibles, and co-insurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don t even know it. For more information about this extra help, contact your local Social Security office, or call Social Security at TTY users should call You can also apply for extra help online at If you qualify for extra help with your Medicare prescription drug coverage costs, Medicare will pay all or part of your plan premium. If Medicare pays only a portion of this premium, we will bill you for the amount that Medicare doesn t cover. If you don t select a payment option, you will get a coupon book. Please select a premium payment option: Get a coupon book. Automatic deduction from your monthly Social Security or Railroad Retirement Board (RRB) benefit check. (The Social Security/RRB deduction may take two or more months to begin after Social Security or RRB approves the deduction. In most cases, if Social Security or RRB accepts your request for automatic deduction, the first deduction from your Social Security or RRB benefit check will include all premiums due from your enrollment effective date up to the point withholding begins. If Social Security or RRB does not approve your request for automatic deduction, we will send you a paper bill for your monthly premiums.) Please read and answer these important questions. 1. Do you have End-Stage Renal Disease (ESRD)? Yes No If you have had a successful kidney transplant and/or you don t need regular dialysis any more, please attach a note or records from your doctor showing you have had a successful kidney transplant or you don t need dialysis, otherwise we may need to contact you to obtain additional information. 2. Some individuals may have other medical or drug coverage, including work, other private insurance, TRICARE, Federal employee health benefits coverage, VA benefits, or State pharmaceutical assistance programs. Will you have other medical or prescription drug coverage in addition to Care1st? Yes No If yes, please list your other coverage and your identification (ID) number(s) for this coverage: Name of other medical coverage: ID# for this medical coverage: Group# for this medical coverage: Name of other drug coverage: ID# for this drug coverage: Group# for this drug coverage: 3. Are you a resident in a long-term care facility, such as a nursing home? Yes No If yes, please provide the following information: Name of Institution: Address and Phone Number of Institution (number and street): 4. Are you enrolled in your State Medicaid program? Yes No If yes, please provide your Medicaid number: 5. Do you or your spouse work? Yes No Please choose the name of a Primary Care Physician (PCP), clinic or health center: Physician s Name Dr. Robert Jones ID Number Medical Group / IPA Name Misc. Medical Group Are you an existing patient of this doctor? Yes No WHITE Enrollment Copy YELLOW Member s Copy H5928_14_088_EN Approved

27 Please check one of the boxes below if you would prefer us to send you information in a language other than English or in another format: Spanish Chinese Vietnamese Contact us if you need a format like Braille, audiotape or large print. Please contact Care1st at if you need information in another format or language than what is listed above. Our office hours are from 8:00 a.m. to 8:00 p.m. seven days a week. TTY users should call 711. Please Read This Important Information If you currently have health coverage from an employer or union, joining Care1st could affect your employer or union health benefits. You could lose your employer or union health coverage if you join Care1st. Read the communications your employer or union sends you. If you have questions, visit their website, or contact the office listed in their communications. If there isn t any information on whom to contact, your benefits administrator or the office that answers questions about your coverage can help. Please Read and Sign Below By completing this enrollment application, I agree to the following: Care1st is a Medicare Advantage plan and has a contract with the Federal government. I will need to keep my Medicare Parts A and B. I can be in only one Medicare Advantage plan at a time, and I understand that my enrollment in this plan will automatically end my enrollment in another Medicare health plan or prescription drug plan. It is my responsibility to inform you of any prescription drug coverage that I have or may get in the future. Enrollment in this plan is generally for the entire year. Once I enroll, I may leave this plan or make changes only at certain times of the year when an enrollment period is available (Example: October 15 - December 7 of every year), or under certain special circumstances. Care1st serves a specific service area. If I move out of the area that Care1st serves, I need to notify the plan so I can disenroll and find a new plan in my new area. Once I am a member of Care1st, I have the right to appeal plan decisions about payment or services if I disagree. I will read the Evidence of Coverage document from Care1st when I get it to know which rules I must follow to get coverage with this Medicare Advantage plan. I understand that people with Medicare aren t usually covered under Medicare while out of the country except for limited coverage near the U.S. border. I understand that beginning on the date Care1st coverage begins, I must get all of my health care from Care1st, except for emergency or urgently needed services or out-of-area dialysis services. Services authorized by Care1st and other services contained in my Care1st Evidence of Coverage document (also known as a member contract or subscriber agreement) will be covered. Without authorization, NEITHER MEDICARE NOR Care1st WILL PAY FOR THE SERVICE. I understand that if I am getting assistance from a sales agent, broker, or other individual employed by or contracted with Care1st, he/she may be paid based on my enrollment in Care1st. WHITE Enrollment Copy YELLOW Member s Copy H5928_14_088_EN Approved

28 Release of Information: By joining this Medicare health plan, I acknowledge that Care1st will release my information to Medicare and other plans as is necessary for treatment, payment and health care operations. I also acknowledge that Care1st will release my information including my prescription drug event data to Medicare, who may release it for research and other purposes which follow all applicable Federal statutes and regulations. The information on this enrollment form is correct to the best of my knowledge. I understand that if I intentionally provide false information on this form, I will be disenrolled from the plan. I understand that my signature (or the signature of the person authorized to act on my behalf under the laws of the State where I live) on this application means that I have read and understand the contents of this application. If signed by an authorized individual (as described above), this signature certifies that 1) this person is authorized under State law to complete this enrollment and 2) documentation of this authority is available upon request from Medicare. Signature: John R. Doe Today s Date: MM-DD-YYYY If you are the authorized representative, you must sign above and provide the following information: Name: Address: Phone Number: ( ) Relationship to Enrollee: Broker / Sales Use Only Agent Name: Care1st Agent ID: Form Received On: Agent Phone/ Agent Signature: Date: Care1st Enrollment Office Use Only Name of staff member/agent/broker (if assisted in enrollment): Enrollee ID: Effective Date of Coverage: ICEP/IEP AEP SEP (type): Not Eligible: WHITE Enrollment Copy YELLOW Member s Copy H5928_14_088_EN Approved

29

30 SUMMARY OF BENEFITS January 1, December 31, 2014 CARE1ST HEALTH PLAN Care1st AdvantageOptimum Plan (HMO) California: San Diego, Los Angeles Counties H5928_14_130_AOSB_SDLA Accepted

31 INTRODUCTION TO SUMMARY OF BENEFITS SECTION 1 Thank you for your interest in Care1st AdvantageOptimum (HMO). Our plan is offered by CARE1ST HEALTH PLAN, a Medicare Advantage Health Maintenance Organization (HMO) that contracts with the federal government. This Summary of Benefits tells you some features of our plan. It doesn t list every service that we cover or list every limitation or exclusion. To get a complete list of our benefits, please call AdvantageOptimum Plan (HMO) and ask for the Evidence of Coverage. YOU HAVE CHOICES IN YOUR HEALTH CARE As a Medicare beneficiary, you can choose from different Medicare options. One option is the Original (Fee-for-Service) Medicare Plan. Another option is a Medicare health plan, like Care1st AdvantageOptimum Plan (HMO). You may have other options too. You make the choice. No matter what you decide, you are still in the Medicare Program. You may join or leave a plan only at certain times. Please call Care1st AdvantageOptimum Plan (HMO) at the telephone number listed at the end of this introduction or MEDICARE ( ) for more information. TTY/TDD users should call You can call this number 24 hours a day, 7 days a week. HOW CAN I COMPARE MY OPTIONS? You can compare Care1st AdvantageOptimum Plan (HMO) and the Original Medicare Plan using this Summary of Benefits. The charts in this booklet list some important health benefits. For each benefit, you can see what our plan covers and what the Original Medicare Plan covers. Our members receive all of the benefits that the Original Medicare Plan offers. We also offer more benefits, which may change from year to year. WHERE IS Care1st AdvantageOptimum Plan (HMO) AVAILABLE? The service area for this plan includes: Los Angeles, San Diego Counties, CA. You must live in one of these areas to join the plan. WHO IS ELIGIBLE TO JOIN Care1st AdvantageOptimum Plan (HMO)? You can join Care1st AdvantageOptimum Plan (HMO) if you are entitled to Medicare Part A and enrolled in Medicare Part B and live in the service area. However, individuals with End-Stage Renal Disease generally are not eligible to enroll in Care1st AdvantageOptimum Plan (HMO) unless they are members of our organization and have been since their dialysis began. CAN I CHOOSE MY DOCTORS? Care1st AdvantageOptimum Plan (HMO) has formed a network of doctors, specialists, and hospitals. You can only use doctors who are part of our network. The health providers in our network can change at any time. You can ask for a current provider directory. For an updated list, visit us at care1stmedicare.com. Our customer service number is listed at the end of this introduction. 2

32 INTRODUCTION TO SUMMARY OF BENEFITS SECTION 1 WHAT HAPPENS IF I GO TO A DOCTOR WHO S NOT IN YOUR NETWORK? If you choose to go to a doctor outside of our network, you must pay for these services yourself. Neither the plan nor the Original Medicare Plan will pay for these services except in limited situations (for example, emergency care). WHERE CAN I GET MY PRESCRIPTIONS IF I JOIN THIS PLAN? Care1st AdvantageOptimum Plan (HMO) has formed a network of pharmacies. You must use a network pharmacy to receive plan benefits. We may not pay for your prescriptions if you use an out-of-network pharmacy, except in certain cases. The pharmacies in our network can change at any time. You can ask for a pharmacy directory or visit us at Our customer service number is listed at the end of this introduction. WHAT IF MY DOCTOR PRESCRIBES LESS THAN A MONTH S SUPPLY? In consultation with your doctor or pharmacist, you may receive less than a month s supply of certain drugs. Also, if you live in a long-term care facility, you will receive less than a month s supply of certain brand [and generic] drugs. Dispensing fewer drugs at a time can help reduce cost and waste in the Medicare Part D program, when this is medically appropriate. The amount you pay in these circumstances will depend on whether you are responsible for paying coinsurance (a percentage of the cost of the drug) or a copay (a flat dollar amount for the drug). If you are responsible for coinsurance for the drug, you will continue to pay the applicable percentage of the drug cost. If you are responsible for a copay for the drug, a daily cost-sharing rate will be applied. If your doctor decides to continue the drug after a trial period, you should not pay more for a month s supply than you otherwise would have paid. Contact your plan if you have questions about costsharing when less than a one-month supply is dispensed. DOES MY PLAN COVER MEDICARE PART B OR PART D DRUGS? Care1st AdvantageOptimum Plan (HMO) does cover both Medicare Part B prescription drugs and Medicare Part D prescription drugs. 3 WHAT IS A PRESCRIPTION DRUG FORMULARY? Care1st AdvantageOptimum Plan (HMO) uses a formulary. A formulary is a list of drugs covered by your plan to meet patient needs. We may periodically add, remove, or make changes to coverage limitations on certain drugs or change how much you pay for a drug. If we make any formulary change that limits our members ability to fill their prescriptions, we will notify the affected members before the change is made. We will send a formulary to you and you can see our complete formulary on our website at If you are currently taking a drug that is not on our formulary or subject to additional requirements or limits, you may be able to get a temporary supply of the drug. You can contact us to request an exception or switch to an alternative drug listed on our formulary with your physician s help. Call us to see if you can get a temporary supply of the drug or for more details about our drug transition policy.

33 INTRODUCTION TO SUMMARY OF BENEFITS SECTION 1 HOW CAN I GET EXTRA HELP WITH MY PRESCRIPTION DRUG PLAN COSTS OR GET EXTRA HELP WITH OTHER MEDICARE COSTS? You may be able to get extra help to pay for your prescription drug premiums and costs as well as get help with other Medicare costs. To see if you qualify for getting extra help, call: MEDICARE ( ). TTY/ TDD users should call , 24 hours a day/7 days a week; and see Programs for People with Limited Income and Resources in the publication Medicare & You. The Social Security Administration at between 7 a.m. and 7 p.m., Monday through Friday. TTY/TDD users should call ; or Your State Medicaid Office. WHAT ARE MY PROTECTIONS IN THIS PLAN? All Medicare Advantage Plans agree to stay in the program for a full calendar year at a time. Plan benefits and cost-sharing may change from calendar year to calendar year. Each year, plans can decide whether to continue to participate with Medicare Advantage. A plan may continue in their entire service area (geographic area where the plan accepts members) or choose to continue only in certain areas. Also, Medicare may decide to end a contract with a plan. Even if your Medicare Advantage Plan leaves the program, you will not lose Medicare coverage. If a plan decides not to continue for an additional calendar year, it must send you a letter at least 90 days before your coverage will end. The letter will explain your options for Medicare coverage in your area. As a member of Care1st AdvantageOptimum Plan (HMO), you have the right to request an organization determination, which includes the right to file an appeal if we deny coverage for an item or service, and the right to file a grievance. You have the right to request an organization determination if you want us to provide or pay for an item or service that you believe should be covered. If we deny coverage for your requested item or service, you have the right to appeal and ask us to review our decision. You may ask us for an expedited (fast) coverage determination or appeal if you believe that waiting for a decision could seriously put your life or health at risk, or affect your ability to regain maximum function. If your doctor makes or supports the expedited request, we must expedite our decision. Finally, you have the right to file a grievance with us if you have any type of problem with us or one of our network providers that does not involve coverage for an item or service. If your problem 4 involves quality of care, you also have the right to file a grievance with the Quality Improvement Organization (QIO) for your state. Please refer to the Evidence of Coverage (EOC) for the QIO contact information. As a member of Care1st AdvantageOptimum Plan (HMO), you have the right to request a coverage determination, which includes the right to request an exception, the right to file an appeal if we deny coverage for a prescription drug, and the right to file a grievance. You have the right to request a coverage determination if you want us to cover a Part D drug that you believe should be covered. An exception is a type of coverage determination. You may ask us for an exception if you believe you need a drug that is not on our list of covered drugs or believe you should get a non-preferred drug at a lower out-of-pocket cost. You can also ask for an exception to cost utilization rules, such as a limit on the quantity of a drug. If you think you need an exception, you should contact us before you try to fill your prescription at a pharmacy. Your doctor must provide a statement to support your exception request. If we deny coverage for your prescription drug(s), you have the right to appeal and ask us to review our decision. Finally, you have the right to file a grievance if you have any type of problem with us or one of our network pharmacies that does not involve coverage for a prescription drug. If your problem involves quality of care, you also have the right to file a grievance with the Quality Improvement Organization (QIO) for your state.

34 INTRODUCTION TO SUMMARY OF BENEFITS SECTION 1 Please refer to the Evidence of Coverage (EOC) for the QIO contact information. WHAT IS A MEDICATION THERAPY MANAGEMENT (MTM) PROGRAM? A Medication Therapy Management (MTM) Program is a free service we offer. You may be invited to participate in a program designed for your specific health and pharmacy needs. You may decide not to participate but it is recommended that you take full advantage of this covered service if you are selected. Contact Care1st AdvantageOptimum Plan (HMO) for more details. WHAT TYPES OF DRUGS MAY BE COVERED UNDER MEDICARE PART B? Some outpatient prescription drugs may be covered under Medicare Part B. These may include, but are not limited to, the following types of drugs. Contact Care1st AdvantageOptimum Plan (HMO) for more details. -- Some Antigens: If they are prepared by a doctor and administered by a properly instructed person (who could be the patient) under doctor supervision. -- Osteoporosis Drugs: Injectable osteoporosis drugs for some women. -- Erythropoietin: By injection if you have endstage renal disease (permanent kidney failure requiring either dialysis or transplantation) and need this drug to treat anemia. -- Hemophilia Clotting Factors: Self-administered clotting factors if you have hemophilia. -- Injectable Drugs: Most injectable drugs administered incident to a physicians service. -- Immunosuppressive Drugs: Immunosuppressive drug therapy for transplant patients if the transplant took place in a Medicare-certified facility and was paid for by Medicare or by a private insurance company that was the primary payer for Medicare Part A coverage. -- Some Oral Cancer Drugs: If the same drug is available in injectable form. -- Oral Anti-Nausea Drugs: If you are part of an anti-cancer chemotherapeutic regimen. -- Inhalation and Infusion Drugs administered through Durable Medical Equipment. WHERE CAN I FIND INFORMATION ON PLAN RATINGS? The Medicare program rates how well plans perform in different categories (for example, detecting and preventing illness, ratings from patients and customer service). If you have access to the web, you can find the plan ratings information by using the find health and drug plans web tool on to compare the plan ratings for Medicare plans in your area. You can also call us directly to obtain a copy of the plan ratings for this plan. Our customer service number is listed below. 5

35 INTRODUCTION TO SUMMARY OF BENEFITS SECTION 1 Please call Care1st Health Plan for more information about AdvantageOptimum Plan (HMO). Visit us at or, call us: Customer Service Hours for October 1 February 14: Sunday, Monday, Tuesday, Wednesday, Thursday, Friday, Saturday, 8:00 a.m. - 8:00 p.m. Pacific Customer Service Hours for February 15 September 30: Monday, Tuesday, Wednesday, Thursday, Friday, 8:00 a.m. - 8:00 p.m. Pacific Current members should call toll-free (800) for questions related to the Medicare Advantage Program. (TTY/TDD 711) Prospective members should call toll-free (800) for questions related to the Medicare Advantage Program. (TTY/TDD 711) Current members should call locally (800) for questions related to the Medicare Advantage Program. (TTY/TDD 711) Prospective members should call locally (800) for questions related to the Medicare Advantage Program. (TTY/TDD 711) Current members should call toll-free (800) for questions related to the Medicare Part D Prescription Drug program. (TTY/TDD 711) Prospective members should call toll-free (800) for questions related to the Medicare Part D Prescription Drug program. (TTY/TDD 711) Current members should call locally (800) for questions related to the Medicare Part D Prescription Drug program. (TTY/TDD 711) Prospective members should call locally (800) for questions related to the Medicare Part D Prescription Drug program. (TTY/TDD 711) For more information about Medicare, please call Medicare at MEDICARE ( ). TTY users should call You can call 24 hours a day, 7 days a week. Or, visit on the web. This document may be available in other formats such as Braille, large print or other alternate formats. This document may be available in a non- English language. For additional information, call customer service at the phone number listed above. Este documento puede ser disponible en un idioma que no sea inglés. Para obtener más información, llame al servicio al cliente al número de teléfono indicado arriba. 此文件包括其他語言 若需要獲得更多資訊, 請撥打以上所列的電話號碼聯絡我們的會員服務部 6

36 SUMMARY OF BENEFITS SECTION 2 SUMMARY OF BENEFITS Section 2 - If you have any questions about this plan s benefits or costs, please contact Care1st Health Plan for details. BENEFIT ORIGINAL MEDICARE Care1st AdvantageOptimum Plan (HMO) IMPORTANT INFORMATION 1 PREMIUM AND OTHER IMPORTANT INFORMATION In 2013 the monthly Part B Premium was $ and may change for 2014 and the annual Part B deductible amount was $147 and may change for Most people will pay the standard monthly Part B premium. However, some people will pay a higher premium because of their yearly income (over $85,000 for singles, $170,000 for married couples). For more information about Part B premiums based on income, call Medicare at MEDICARE ( ). TTY users should call You may also call Social Security at TTY users should call General $0 monthly plan premium in addition to your monthly Medicare Part B premium. Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However, some people will pay higher Part B and Part D premiums because of their yearly income (over $85,000 for singles, $170,000 for married couples). For more information about Part B and Part D premiums based on income, call Medicare at MEDICARE ( ). TTY users should call You may also call Social Security at TTY users should call In-Network $3,400 out-of-pocket limit for Medicare-covered services. 7

37 SUMMARY OF BENEFITS SECTION 2 BENEFIT ORIGINAL MEDICARE Care1st AdvantageOptimum Plan (HMO) IMPORTANT INFORMATION (Continued) 2 DOCTOR AND HOSPITAL CHOICE (For more information, see Emergency Care #15 and Urgently Needed Care -#16.) 3 INPATIENT CARE INPATIENT HOSPITAL CARE (includes Substance Abuse and Rehabilitation Services) You may go to any doctor, specialist or hospital that accepts Medicare. In 2013 the amounts for each benefit period were: Days 1-60: $1,184 deductible Days 61-90: $296 per day Days : $592 per lifetime reserve day These amounts may change for Call MEDICARE ( ) for information about lifetime reserve days. Lifetime reserve days can only be used once. In-Network You must go to network doctors, specialists, and hospitals. Referral required for network hospitals and specialists (for certain benefits). In-Network No limit to the number of days covered by the plan each hospital stay. For Medicare-covered hospital stays: - Days 1-5: $150 copay per day - Days 6-90: $0 copay per day $0 copay for additional non-medicare-covered hosptial days Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital. 8

38 SUMMARY OF BENEFITS SECTION 2 BENEFIT ORIGINAL MEDICARE Care1st AdvantageOptimum Plan (HMO) INPATIENT CARE (Continued) 3 INPATIENT HOSPITAL CARE (includes Substance Abuse and Rehabilitation Services) (continued) A benefit period starts the day you go into a hospital or skilled nursing facility. It ends when you go for 60 days in a row without hospital or skilled nursing care. If you go into the hospital after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods you can have. 4 INPATIENT MENTAL HEALTH CARE In 2013 the amounts for each benefit period were: Days 1-60: $1,184 deductible Days 61-90: $296 per day Days : $592 per lifetime reserve day These amounts may change for You get up to 190 days of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital. In-Network You get up to 190 days of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital. $800 out-of-pocket limit every benefit period. For Medicare-covered hospital stays: -Days 1-8: $100 copay per day -Days 9-90: $0 copay per day Plan covers 60 lifetime reserve days. $0 copay per lifetime reserve day. Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital. 9

39 SUMMARY OF BENEFITS SECTION 2 BENEFIT ORIGINAL MEDICARE Care1st AdvantageOptimum Plan (HMO) INPATIENT CARE (Continued) 5 SKILLED NURSING FACILITY (SNF) (in a Medicare-certified skilled nursing facility) In 2013 the amounts for each benefit period after at least a 3-day Medicare-covered hospital stay were: Days 1-20: $0 per day Days : $148 per day These amounts may change for days for each benefit period. A benefit period starts the day you go into a hospital or SNF. It ends when you go for 60 days in a row without hospital or skilled nursing care. If you go into the hospital after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods you can have. General Authorization rules may apply. In-Network Plan covers up to 100 days each benefit period No prior hospital stay is required. For SNF stays: - Days 1-20: $25 copay per day - Days : $75 copay per day 10

40 SUMMARY OF BENEFITS SECTION 2 BENEFIT ORIGINAL MEDICARE Care1st AdvantageOptimum Plan (HMO) INPATIENT CARE (Continued) 6 HOME HEALTH CARE (includes medically necessary intermittent skilled nursing care, home health aide services, and rehabilitation services, etc.) $0 copay. General Authorization rules may apply. In-Network $0 copay for Medicare-covered home health visits 7 HOSPICE You pay part of the cost for outpatient drugs and inpatient respite care. You must get care from a Medicare-certified hospice. General You must get care from a Medicare-certified hospice. You must consult with your plan before you select hospice. OUTPATIENT CARE 8 DOCTOR OFFICE VISITS 20% coinsurance General Authorization rules may apply. In-Network $0 copay for each Medicare-covered primary care doctor visit. $15 copay for each Medicare-covered specialist visit. 11

41 SUMMARY OF BENEFITS SECTION 2 BENEFIT ORIGINAL MEDICARE Care1st AdvantageOptimum Plan (HMO) OUTPATIENT CARE (Continued) 9 CHIROPRACTIC SERVICES Supplemental routine care not covered 20% coinsurance for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part). General Authorization rules may apply. In-Network $5 copay for each Medicare-covered chiropractic visit Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part). 10 PODIATRY SERVICES 11 OUTPATIENT MENTAL HEALTH CARE Supplemental routine care not covered 20% coinsurance for medically necessary foot care, including care for medical conditions affecting the lower limbs. 20% coinsurance for most outpatient mental health services Specified copayment for outpatient partial hospitalization program services furnished by a hospital or community mental health center (CMHC). Copay cannot exceed the Part A inpatient hospital deductible. General Authorization rules may apply. In-Network $5 copay for each Medicare-covered podiatry visit $5 copay for each supplemental routine podiatry visit Medicare-covered podiatry visits are for medically necessary foot care. General Authorization rules may apply. In-Network $10 copay for each Medicare-covered individual therapy visit $10 copay for each Medicare-covered group therapy visit 12

42 SUMMARY OF BENEFITS SECTION 2 BENEFIT ORIGINAL MEDICARE Care1st AdvantageOptimum Plan (HMO) OUTPATIENT CARE (Continued) 11 OUTPATIENT MENTAL HEALTH CARE (continued) Partial hospitalization program is a structured program of active outpatient psychiatric treatment that is more intense than the care received in your doctor s or therapist s office and is an alternative to inpatient hospitalization. In-Network $10 copay for each Medicare-covered individual therapy visit with a psychiatrist $10 copay for each Medicare-covered group therapy visit with a psychiatrist $0 copay for Medicare-covered partial hospitalization program services 12 OUTPATIENT SUBSTANCE ABUSE CARE 20% coinsurance General Authorization rules may apply. In-Network $10 copay for Medicare-covered individual substance abuse outpatient treatment visits $10 copay for Medicare-covered group substance abuse outpatient treatment visits 13 OUTPATIENT SERVICES 20% coinsurance for the doctor s services Specified copayment for outpatient hospital facility services Copay cannot exceed the Part A inpatient hospital deductible. 20% coinsurance for ambulatory surgical center facility services General Authorization rules may apply. In-Network $150 copay for each Medicare-covered ambulatory surgical center visit $150 copay for each Medicare-covered outpatient hospital facility visit 13

43 SUMMARY OF BENEFITS SECTION 2 BENEFIT ORIGINAL MEDICARE Care1st AdvantageOptimum Plan (HMO) OUTPATIENT CARE (Continued) 14 AMBULANCE SERVICES (medically necessary ambulance services) 20% coinsurance General Authorization rules may apply. In-Network $180 copay for Medicare-covered ambulance benefits. If you are admitted to the hosptial, you pay $0 for Medicarecovered ambulance benefits. 15 EMERGENCY CARE (you may go to any emergency room if you reasonably believe you need emergency care) 16 URGENTLY-NEEDED CARE (This is NOT emergency care, and in most cases, is out of the service area) 20% coinsurance for the doctor s services Specified copayment for outpatient hospital facility emergency services. Emergency services copay cannot exceed Part A inpatient hospital deductible for each service provided by the hospital. You don t have to pay the emergency room copay if you are admitted to the hospital as an inpatient for the same condition within 3 days of the emergency room visit. Not covered outside the U.S. except under limited circumstances. 20% coinsurance, or a set copay If you are admitted to the hospital within 3 days for the same condition, you pay $0 for the urgently-needed care visit. NOT covered outside the U.S. except under limited circumstances. General $50 copay for Medicare-covered emergency room visits $25,000 plan coverage limit for supplemental emergency services outside the U.S. and its territories every year. If you are admitted to the hospital within 1-day for the same condition, you pay $0 for the emergency room visit. General $15 to $25 copay for Medicare-covered urgently-needed-care visits. If you are admitted to the hospital within 1-day for the same condition, you pay $0 for the urgently-needed-care visit. 14

44 SUMMARY OF BENEFITS SECTION 2 BENEFIT ORIGINAL MEDICARE Care1st AdvantageOptimum Plan (HMO) OUTPATIENT CARE (Continued) 17 OUTPATIENT REHABILITATION SERVICES (Occupational Therapy, Physical Therapy, Speech and Language Therapy) 20% coinsurance Medically necessary physical therapy, occupational therapy, and speech and language pathology services are covered. General Authorization rules may apply. Medically necessary physical therapy, occupational therapy, and speech and language pathology services are covered. In-Network $10 copay for Medicare-covered Occupational Therapy visits $10 copay for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits OUTPATIENT MEDICAL SERVICES AND SUPPLIES 18 DURABLE MEDICAL EQUIPMENT (includes wheelchairs, oxygen, etc.) 20% coinsurance General Authorization rules may apply. In-Network 0% to 20% of the cost for Medicare-covered durable medical equipment You may pay less if you purchase these items from the plan s preferred manufacturers/vendors. Contact the plan for a list of non-preferred and preferred manufacturers/vendors. 15

45 SUMMARY OF BENEFITS SECTION 2 BENEFIT ORIGINAL MEDICARE Care1st AdvantageOptimum Plan (HMO) OUTPATIENT MEDICAL SERVICES AND SUPPLIES (Continued) 19 PROSTHETIC DEVICES (includes braces, artificial limbs and eyes, etc.) 20% coinsurance 20% coinsurance for Medicare-covered medical supplies related to prosthetics, splints, and other devices. General Authorization rules may apply. In-Network 20% of the cost for Medicare-covered prosthetic devices 20% of the cost for Medicare-covered medical supplies related to prosthetics, splints, and other devices 20 DIABETES PROGRAMS AND SUPPLIES 20% coinsurance for diabetes self-management training 20% coinsurance for diabetes supplies 20% coinsurance for diabetic therapeutic shoes or inserts General Authorization rules may apply. In-Network $0 copay for Medicare-covered Diabetes self-management training $0 copay for Medicare-covered: - Diabetes monitoring supplies. 20% of the cost for Medicare-coveredTherapeutic shoes or inserts Diabetic Supplies and Services are limited to specific manufacturers, products and/or brands. Contact the plan for a list of covered supplies. If the doctor provides you services in addition to Diabetes selfmanagement training, separate cost sharing of $0 to $15 may apply 16

46 SUMMARY OF BENEFITS SECTION 2 BENEFIT ORIGINAL MEDICARE Care1st AdvantageOptimum Plan (HMO) OUTPATIENT MEDICAL SERVICES AND SUPPLIES (Continued) 21 DIAGNOSTIC TESTS, XRAYS, LAB SERVICES, AND RADIOLOGY SERVICES 20% coinsurance for diagnostic tests and x-rays $0 copay for Medicare-covered lab services Lab Services: Medicare covers medically necessary diagnostic lab services that are ordered by your treating doctor when they are provided by a Clinical Laboratory Improvement Amendments (CLIA) certified laboratory that participates in Medicare. Diagnostic lab services are done to help your doctor diagnose or rule out a suspected illness or condition. Medicare does not cover most supplemental routine screening tests, like checking your cholesterol. General Authorization rules may apply. In-Network $0 copay for Medicare-covered: - X-rays - diagnostic radiology services (not including X-rays). 10% of the cost for Medicare-covered lab services 10% of the cost for Medicare-covered diagnostic procedures and tests 10% of the cost for Medicare-covered therapeutic radiology services. 22 CARDIAC AND PULMONARY REHABILITATION SERVICES 20% coinsurance for Cardiac Rehabilitation services 20% coinsurance for Pulmonary Rehabilitation services 20% coinsurance for Intensive Cardiac Rehabilitation services General Authorization rules may apply. In-Network $10 copay for Medicare-covered Cardiac Rehabilitation Services $10 copay for Medicare-covered Intensive Cardiac Rehabilitation Services $10 copay for Medicare-covered Pulmonary Rehabilitation Services 17

47 SUMMARY OF BENEFITS SECTION 2 BENEFIT ORIGINAL MEDICARE Care1st AdvantageOptimum Plan (HMO) PREVENTIVE SERVICES 23 PREVENTIVE SERVICES No coinsurance, copayment or deductible for the following: - Abdominal Aortic Aneurysm Screening - Bone Mass Measurement. Covered once every 24 months (more often if medically necessary) if you meet certain medical conditions. - Cardiovascular Screening - Cervical and Vaginal Cancer Screening. Covered once every 2 years. Covered once a year for women with Medicare at high risk. - Colorectal Cancer Screening - Diabetes Screening - Influenza Vaccine - Hepatitis B Vaccine for people with Medicare who are at risk - HIV Screening. $0 copay for the HIV screening, but you generally pay 20% of the Medicare-approved amount for the doctors visit. HIV screening is covered for people with Medicare who are pregnant and people at increased risk for the infection, including anyone who asks for the test. Medicare covers this test once every 12 months or up to three times during a pregnancy. General Authorization rules may apply. In-Network $0 copay for all preventive services covered under Original Medicare at zero cost sharing. Any additional preventive services approved by Medicare midyear will be covered by the plan or by Original Medicare. 18

48 SUMMARY OF BENEFITS SECTION 2 BENEFIT ORIGINAL MEDICARE Care1st AdvantageOptimum Plan (HMO) PREVENTIVE SERVICES (Continued) 23 PREVENTIVE SERVICES (continued) - Breast Cancer Screening (Mammogram). Medicare covers screening mammograms once every 12 months for all women with Medicare age 40 and older. Medicare covers one baseline mammogram for women between ages Medical Nutrition Therapy Services Nutrition therapy is for people who have diabetes or kidney disease (but arent on dialysis or havent had a kidney transplant) when referred by a doctor. These services can be given by a registered dietitian and may include a nutritional assessment and counseling to help you manage your diabetes or kidney disease - Personalized Prevention Plan Services (Annual Wellness Visits) - Pneumococcal Vaccine. You may only need the Pneumonia vaccine once in your lifetime. Call your doctor for more information. - Prostate Cancer Screening - Prostate Specific Antigen (PSA) test only. Covered once a year for all men with Medicare over age Smoking and Tobacco Use Cessation (counseling to stop smoking and tobacco use). Covered if ordered by your doctor. Includes two counseling attempts within a 12-month period. Each counseling attempt includes up to four face-to-face visits. 19

49 SUMMARY OF BENEFITS SECTION 2 BENEFIT ORIGINAL MEDICARE Care1st AdvantageOptimum Plan (HMO) PREVENTIVE SERVICES (Continued) 23 PREVENTIVE SERVICES (continued) - Screening and behavioral counseling interventions in primary care to reduce alcohol misuse - Screening for depression in adults - Screening for sexually transmitted infections (STI) and high-intensity behavioral counseling to prevent STIs - Intensive behavioral counseling for Cardiovascular Disease (bi-annual) - Intensive behavioral therapy for obesity - Welcome to Medicare Preventive Visits (initial preventive physical exam) When you join Medicare Part B, then you are eligible as follows. During the first 12 months of your new Part B coverage, you can get either a Welcome to Medicare Preventive Visits or an Annual Wellness Visit. After your first 12 months, you can get one Annual Wellness Visit every 12 months. 24 KIDNEY DISEASE AND CONDITIONS 20% coinsurance for renal dialysis 20% coinsurance for kidney disease education services General Authorization rules may apply. In-Network $10 copay for Medicare-covered renal dialysis $0 copay for Medicare-covered kidney disease education services 20

50 SUMMARY OF BENEFITS SECTION 2 BENEFIT ORIGINAL MEDICARE Care1st AdvantageOptimum Plan (HMO) PRESCRIPTION DRUG BENEFITS 25 OUTPATIENT PRESCRIPTION DRUGS (continued) Most drugs are not covered under Original Medicare. You can add prescription drug coverage to Original Medicare by joining a Medicare Prescription Drug Plan, or you can get all your Medicare coverage, including prescription drug coverage, by joining a Medicare Advantage Plan or a Medicare Cost Plan that offers prescription drug coverage. Drugs covered under Medicare Part B General 20% of the cost for Medicare Part B chemotherapy drugs and other Part B drugs. Drugs covered under Medicare Part D General This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at on the web. Different out-of-pocket costs may apply for people who - have limited incomes, - live in long term care facilities, or - have access to Indian/Tribal/Urban (Indian Health Service) providers. The plan offers national in-network prescription coverage (i.e., this would include 50 states and the District of Columbia). This means that you will pay the same costsharing amount for your prescription drugs if you get them at an in-network pharmacy outside of the plan s service area (for instance when you travel). Total yearly drug costs are the total drug costs paid by both you and a Part D plan. 21

51 SUMMARY OF BENEFITS SECTION 2 BENEFIT ORIGINAL MEDICARE Care1st AdvantageOptimum Plan (HMO) PRESCRIPTION DRUG BENEFITS (Continued) 25 OUTPATIENT PRESCRIPTION DRUGS (continued) The plan may require you to first try one drug to treat your condition before it will cover another drug for that condition. Some drugs have quantity limits. Your provider must get prior authorization from Care1st AdvantageOptimum Plan (HMO) for certain drugs. The plan will pay for certain over-the-counter drugs as part of its utilization management program. Some over-the-counter drugs are less expensive than prescription drugs and work just as well. Contact the plan for details. You must go to certain pharmacies for a very limited number of drugs, due to special handling, provider coordination, or patient education requirements that cannot be met by most pharmacies in your network. These drugs are listed on the plan s website, formulary, printed materials, as well as on the Medicare Prescription Drug Plan Finder on Medicare.gov. If the actual cost of a drug is less than the normal cost-sharing amount for that drug, you will pay the actual cost, not the higher cost-sharing amount. If you request a formulary exception for a drug and Care1st AdvantageOptimum Plan (HMO) approves the exception, you will pay Tier 4: Non-Preferred Brand cost sharing for that drug. 22

52 SUMMARY OF BENEFITS SECTION 2 BENEFIT ORIGINAL MEDICARE Care1st AdvantageOptimum Plan (HMO) PRESCRIPTION DRUG BENEFITS (Continued) 25 OUTPATIENT PRESCRIPTION DRUGS (continued) In-Network $0 deductible. Initial Coverage After you pay your yearly deductible, you pay the following until total yearly drug costs reach $2,850: Retail Pharmacy Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed. You can get drugs the following way(s): Tier 1: Preferred Generic - $0 copay for a one-month (30-day) supply of drugs in this tier - $0 copay for a three-month (90-day) supply of drugs in this tier Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. Tier 2: Non-Preferred Generic - $7 copay for a one-month (30-day) supply of drugs in this tier - $14 copay for a three-month (90-day) supply of drugs in this tier Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. 23

53 SUMMARY OF BENEFITS SECTION 2 BENEFIT ORIGINAL MEDICARE Care1st AdvantageOptimum Plan (HMO) PRESCRIPTION DRUG BENEFITS (Continued) 25 OUTPATIENT PRESCRIPTION DRUGS (continued) Tier 3: Preferred Brand - $35 copay for a one-month (30-day) supply of drugs in this tier - $70 copay for a three-month (90-day) supply of drugs in this tier Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. Tier 4: Non-Preferred Brand - $60 copay for a one-month (30-day) supply of drugs in this tier - $120 copay for a three-month (90-day) supply of drugs in this tier Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. Tier 5: Specialty Tier - 30% coinsurance for a one-month (30-day) supply of drugs in this tier - 30% coinsurance for a three-month (90-day) supply of drugs in this tier Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. 24

54 SUMMARY OF BENEFITS SECTION 2 BENEFIT ORIGINAL MEDICARE Care1st AdvantageOptimum Plan (HMO) PRESCRIPTION DRUG BENEFITS (Continued) 25 OUTPATIENT PRESCRIPTION DRUGS (continued) Long Term Care Pharmacy Long term care pharmacies must dispense brand name drugs in amounts less than a 14 days supply at a time. They may also dispense less than a month s supply of generic drugs at a time. Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed. You can get drugs the following way(s): Tier 1: Preferred Generic - $0 copay for a one-month (31-day) supply of drugs in this tier Tier 2: Non-Preferred Generic - $7 copay for a one-month (31-day) supply of drugs in this tier Tier 3: Preferred Brand - $35 copay for a one-month (31-day) supply of drugs in this tier Tier 4: Non-Preferred Brand - $60 copay for a one-month (31-day) supply of drugs in this tier Tier 5: Specialty Tier - 30% coinsurance for a one-month (31-day) supply of drugs in this tier 25

55 SUMMARY OF BENEFITS SECTION 2 BENEFIT ORIGINAL MEDICARE Care1st AdvantageOptimum Plan (HMO) PRESCRIPTION DRUG BENEFITS (Continued) 25 OUTPATIENT PRESCRIPTION DRUGS (continued) Mail Order Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed. You can get drugs the following way(s): Tier 1: Preferred Generic - $0 copay for a three-month (90-day) supply of drugs in this tier Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. Tier 2: Non-Preferred Generic - $14 copay for a three-month (90-day) supply of drugs in this tier Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. Tier 3: Preferred Brand - $70 copay for a three-month (90-day) supply of drugs in this tier Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. Tier 4: Non-Preferred Brand - $120 copay for a three-month (90-day) supply of drugs in this tier Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. 26

56 SUMMARY OF BENEFITS SECTION 2 BENEFIT ORIGINAL MEDICARE Care1st AdvantageOptimum Plan (HMO) PRESCRIPTION DRUG BENEFITS (Continued) 25 OUTPATIENT PRESCRIPTION DRUGS (continued) Tier 5: Specialty Tier - 30% coinsurance for a three-month (90-day) supply of drugs in this tier Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. Coverage Gap After your total yearly drug costs reach $2,850, you receive limited coverage by the plan on certain drugs. You will also receive a discount on brand name drugs and generally pay no more than 47.5% for the plan s costs for brand drugs and 72% of the plan s costs for generic drugs until your yearly out-of-pocket drug costs reach $4,550. Additional Coverage Gap The plan covers many formulary generics (65%-99% of formulary generic drugs) through the coverage gap. 27

57 SUMMARY OF BENEFITS SECTION 2 BENEFIT ORIGINAL MEDICARE Care1st AdvantageOptimum Plan (HMO) PRESCRIPTION DRUG BENEFITS (Continued) 25 OUTPATIENT PRESCRIPTION DRUGS (continued) The plan offers additional coverage in the gap for the following tiers. You pay the following: Retail Pharmacy Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed. Tier 1: Preferred Generic - $0 copay for a one-month (30-day) supply of all drugs covered within this tier - $0 copay for a three-month (90-day) supply of all drugs covered within this tier Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. Tier 2: Non-Preferred Generic - $7 copay for a one-month (30-day) supply of drugs in this tier - $14 copay for a three-month (90-day) supply of drugs in this tier Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. 28

58 SUMMARY OF BENEFITS SECTION 2 BENEFIT ORIGINAL MEDICARE Care1st AdvantageOptimum Plan (HMO) PRESCRIPTION DRUG BENEFITS (Continued) 25 OUTPATIENT PRESCRIPTION DRUGS (continued) Long Term Care Pharmacy Long term care pharmacies must dispense brand name drugs in amounts less than a 14 days supply at a time. They may also dispense less than a month s supply of generic drugs at a time. Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed. Tier 1: Preferred Generic - $0 copay for a one-month (31-day) supply of all drugs covered within this tier Tier 2: Non-Preferred Generic - $7 copay for a one-month (31-day) supply of all drugs in this tier Mail Order Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed. Tier 1: Preferred Generic - $0 copay for a three-month (90-day) supply of all drugs covered within this tier Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. Tier 2: Non-Preferred Generic - $14 copay for a three-month (90-day) supply of all drugs in this tier Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. 29

59 SUMMARY OF BENEFITS SECTION 2 BENEFIT ORIGINAL MEDICARE Care1st AdvantageOptimum Plan (HMO) PRESCRIPTION DRUG BENEFITS (Continued) 25 OUTPATIENT PRESCRIPTION DRUGS (continued) Catastrophic Coverage After your yearly out-of-pocket drug costs reach $4,550, you pay the greater of: - 5% coinsurance, or - $2.55 copay for generic (including brand drugs treated as generic) and a $6.35 copay for all other drugs. Out-of-Network Plan drugs may be covered in special circumstances, for instance, illness while traveling outside of the plan s service area where there is no network pharmacy. You may have to pay more than your normal cost-sharing amount if you get your drugs at an outof-network pharmacy. In addition, you will likely have to pay the pharmacy s full charge for the drug and submit documentation to receive reimbursement from AdvantageOptimum Plan (HMO). You can get out-of-network drugs the following way: Out-of-Network You will be reimbursed up to the plan s cost of the drug minus the following for drugs purchased out-of-network until your total yearly drug costs reach $2,850: Tier 1: Preferred Generic - $0 copay for a one-month (30-day) supply of drugs in this tier 30

60 SUMMARY OF BENEFITS SECTION 2 BENEFIT ORIGINAL MEDICARE Care1st AdvantageOptimum Plan (HMO) PRESCRIPTION DRUG BENEFITS (Continued) 25 OUTPATIENT PRESCRIPTION DRUGS (continued) Tier 2: Non-Preferred Generic - $7 copay for a one-month (30-day) supply of drugs in this tier Tier 3: Preferred Brand - $35 copay for a one-month (30-day) supply of drugs in this tier Tier 4: Non-Preferred Brand - $60 copay for a one-month (30-day) supply of drugs in this tier Tier 5: Specialty Tier - 30% coinsurance for a one-month (30-day) supply of drugs in this tier You will not be reimbursed for the difference between the Out-of- Network Pharmacy charge and the plan s In-Network allowable amount. Out-of-Network Coverage Gap You will be reimbursed up to 28% of the plan allowable cost for generic drugs purchased out-of-network until total yearly outof-pocket drug costs reach $4,550. Please note that the plan allowable cost may be less than the out-ofnetwork pharmacy price paid for your drug(s). You will be reimbursed up to 52.5% of the plan allowable cost for brand name drugs purchased out-of-network until your total yearly out-of-pocket drug costs reach $4,550. Please note that the plan allowable cost may be less than the out-of-network pharmacy price paid for your drug(s). 31

61 SUMMARY OF BENEFITS SECTION 2 BENEFIT ORIGINAL MEDICARE Care1st AdvantageOptimum Plan (HMO) PRESCRIPTION DRUG BENEFITS (Continued) 25 OUTPATIENT PRESCRIPTION DRUGS (continued) Additional Out-of-Network Coverage Gap You will be reimbursed for these drugs purchased out-of-network up to the plan s cost of the drug minus the following: Tier 1: Preferred Generic - $0 copay for a one-month (30-day) supply of all drugs covered within this tier Tier 2: Non-Preferred Generic - $7 copay for a one-month (30-day) supply of drugs in this tier Out-of-Network Catastrophic Coverage After your yearly out-of-pocket drug costs reach $4,550, you will be reimbursed for drugs purchased out-of-network up to the plan s cost of the drug minus your cost share, which is the greater of: - 5% coinsurance, or - $2.55 copay for generic (including brand drugs treated as generic) and a $6.35 copay for all other drugs. You will not be reimbursed for the difference between the Out-of- Network Pharmacy charge and the plan s In-Network allowable amount. 32

62 SUMMARY OF BENEFITS SECTION 2 BENEFIT ORIGINAL MEDICARE Care1st AdvantageOptimum Plan (HMO) OUTPATIENT MEDICAL SERVICES AND SUPPLIES 26 DENTAL SERVICES Preventive dental services (such as cleaning) not covered. In-Network $8 to $570 copay for Medicare-covered dental benefits $8 copay for supplemental oral exams $8 copay for up to 1 supplemental cleaning(s) every six months $13 copay for up to 1 supplemental fluoride treatment(s) every six months $8 copay for up to 1 supplemental dental x-ray(s) every two years Plan offers additional supplemental comprehensive dental benefits. See page 36 for additional information about Dental Services. 27 HEARING SERVICES Supplemental routine hearing exams and hearing aids not covered. 20% coinsurance for diagnostic hearing exams. General Authorization rules may apply. In-Network $0 copay each for up to 2 supplemental hearing aid(s) every two years $10 copay each for Medicare-covered diagnostic hearing exams $10 copay each for up to 1 supplemental routine hearing exam(s) every year $0 copay each for up to 1 supplemental hearing aid fittingevaluation(s) every year $500 plan coverage limit for supplemental hearing aids every year. 33

63 SUMMARY OF BENEFITS SECTION 2 BENEFIT ORIGINAL MEDICARE Care1st AdvantageOptimum Plan (HMO) OUTPATIENT MEDICAL SERVICES AND SUPPLIES (Continued) 28 VISION SERVICES 20% coinsurance for diagnosis and treatment of diseases and conditions of the eye, including an annual glaucoma screening for people at risk Supplemental routine eye exams and eyeglasses (lenses and frames) not covered. Medicare pays for one pair of eyeglasses or contact lenses after cataract surgery. In-Network $0 copay for Medicare-covered exams to diagnose and treat diseases and conditions of the eye, including an annual glaucoma screening for people at risk $10 copay for up to 1 supplemental routine eye exam(s)every year $0 copay for - one pair of Medicare-covered eyeglasses (lenses and frames) or contact lenses after cataract surgery - up to 1 pair(s) of eyeglasses (lenses and frames) every two years $150 plan coverage limit for supplemental eyewear every two years See page 36 for additional information about Vision Services. WELLNESS/ EDUCATION AND OTHER SUPPLEMENTAL BENEFITS & SERVICES Not covered. In-Network The plan covers the following supplemental education/wellness programs: - Health Education - Nursing Hotline See page 36 for additional information about Wellness/Education and other Supplemental Benefits & Services. 34

64 SUMMARY OF BENEFITS SECTION 2 BENEFIT ORIGINAL MEDICARE Care1st AdvantageOptimum Plan (HMO) OUTPATIENT MEDICAL SERVICES AND SUPPLIES (Continued) OVER-THE-COUNTER ITEMS Not covered. General The plan does not cover Over-the-Counter items. TRANSPORTATION (Routine) Not covered. In-Network This plan does not cover supplemental routine transportation. See page 48 for additional information about Transportation. ACUPUNCTURE AND OTHER ALTERNATIVE THERAPIES Not covered. In-Network This plan does not cover Acupuncture and other alternative therapies. 35

65 SUMMARY OF BENEFITS SECTION 3 ADDITIONAL PLAN INFORMATION This section provides additional details on some of the benefits listed in Section 2. The numbered items below correspond to the same numbers in Section 2. For more information, please call Care1st AdvantageOptimum Plan (HMO) at the phone numbers listed on page 6, or visit 26 Dental Services (see page 33) Routine Dental Benefits Co-payment of $8 applies to each office visit in addition to co-payments for the services provided in accordance to the dental schedule of benefits. Please refer to your dental handbook for details. $8 copay for oral exams, cleaning and x-rays apply to services received from a general dentist. $13 copay for fluoride treatments apply to services received from a general dentist. Additional copays may apply for full set of dental x-rays received more often than every two years, and/or specialized diagnostic x-rays such as multiple vertical bitewing views. Refer to the current Dental Member Handbook for details. Comprehensive Dental Benefits Plan authorization/referral applies only to Medicare-covered Dental Services. No plan authorization/referral is required for all other Comprehensive Dental Services. Prior benefit authorization may be required from your dental benefit provider for certain dental services. Refer to the current Dental Member Handbook for details Vision Services (see page 34) Care1st covers the refraction test once every two years when the eye doctor has determined that the member may need prescription glasses. Member has the option to pay for additional upgrade items such as progressive lenses, lens coating or tinting, and frames not classified as standard. Wellness/Education and other Supplemental Benefit Programs (see page 34) No authorization required for health educational classes offered by Care1st Health Plan. There is no copay for educational classes provided by plan-approved locations. There is no limit to the number of educational classes for the plan year. Authorization rules apply to health educational classes not sponsored by Care1st Health Plan. 36

66 2014 DRUG LISTING A Medicare approved HMO plan 8-MOP Caps, T3 A A-Hydrocort Inject, T2 A-Methapred Inject, T2 Abacavir Tabs, T2 ABELCET Inject IV, T3 ABILIFY DISCMELT Tabs, T5 ABILIFY Inject, T3 ABILIFY MAINTENA Inject, T5 ABILIFY Soln, T3 ABILIFY Tabs, T5 Acarbose Tabs, T2 Acebutolol HCL Caps, T2 Acetaminophen-Codeine Soln, T2 Acetaminophen-Codeine Tabs, T2 Acetasol Hc Ear Drops, T2 ACETAZOLAMIDE Caps, T4 Acetazolamide Tabs, T2 ACTHIB Inject, T3 ACTIMMUNE Inject, T5 ACTONEL Tabs, T4 Acyclovir Caps, T2 ACYCLOVIR Oint, T3 Acyclovir Sodium Inject IV, T2 Acyclovir Suspension, T2 Acyclovir Tabs, T2 ADACEL Inject Syr, T3 # ADACEL Inject, T3 ADAGEN Inject, T5 Adapalene Cr, T2 Adapalene Gel, T2 ADCETRIS Inject IV, T5 ADCIRCA Tabs, T5 ADVAIR DISKUS Inhaler, T3 ADVAIR HFA Inhaler, T3 Afeditab Cr Tabs, T2 AFINITOR Tabs, T5 AGGRENOX Caps, T4 Ala-Cort Cr, T2 Ala-Scalp Lotion, T2 ALBENZA Tabs, T3 Albuterol Sulfate Inhale Soln, T2 Albuterol Sulfate Syrup, T2 Albuterol Sulfate Tabs, T2 Alcaine Eye Drops, T2 Alclometasone Dipropionate Cr, T2 Alclometasone Dipropionate Oint, T2 ALDURAZYME Inject IV, T5 Alendronate Sodium Tabs, T1 Alfuzosin HCL Tabs, T2 ALIMTA Inject IV, T5 ALINIA Tabs, T4 Allopurinol Tabs, T2 ALORA Patch, T3 ALPHAGAN P Eye Drops, T3 Alprazolam Tabs, T2 Altavera Tabs, T2 Alyacen Tabs, T2 Amantadine Caps, T2 Amantadine Syrup, T2 Amantadine Tabs, T2 AMBISOME Inject IV, T3 Amcinonide Cr, T2 Amcinonide Lotion, T2 Amcinonide Oint, T2 AMIFOSTINE Inject IV, T5 Amikacin Sulfate Inject, T2 Amiloride HCL Tabs, T2 Amiloride-Hydrochlorothiazide Tabs, T2 Aminocaproic Acid Inject IV, T2 Aminocaproic Acid Soln, T2 Aminocaproic Acid Tabs, T2 Aminophylline Soln, T2 Aminosyn Ii Inject IV, T2 AMINOSYN II Inject IV, T3 AMINOSYN Inject IV, T3 AMINOSYN-HBC Inject IV, T3 AMINOSYN-PF Inject IV, T3 Amiodarone HCL Tabs, T2 AMITIZA Caps, T3 Amitriptyline HCL Tabs, T2 Amlodipine Besylate Tabs, T1 Brand-name drugs are listed in upper case. Generic drugs are listed in lower case. Pharmacy Benefits are subject to a covered list which is subject to change. Limitations, copayments, and restrictions may apply. Refer to the Care1st Comprehensive formulary and Evidence of Coverage for more information. T1 = Tier 1 T2 = Tier 2 T3 = Tier 3 T4 = Tier 4 T5 = Tier 5 H5928_14_139_MK Accepted 1

67 Amlodipine Besylate-Benazepril Caps, T1 Ammonium Lactate Cr, T2 Ammonium Lactate Lotion, T2 AMNESTEEM Caps, T4 Amox Tr-Potassium Clavulanate Suspension, T2 Amox Tr-Potassium Clavulanate Tabs Chew, T2 Amox Tr-Potassium Clavulanate Tabs, T2 Amoxapine Tabs, T2 Amoxicillin Caps, T2 Amoxicillin Suspension, T2 Amoxicillin Tabs Chew, T2 Amoxicillin Tabs, T2 Amphetamine Salt Combo Tabs, T2 Amphotericin B Inject, T2 AMPICILLIN SODIUM Inject, T3 Ampicillin Trihydrate Caps, T2 Ampicillin Trihydrate Suspension, T2 Ampicillin-Sulbactam Inject IV, T2 Ampicillin-Sulbactam Inject, T2 AMPYRA Tabs, T5 Anacaine Oint, T2 ANADROL-50 Tabs, T5 Anagrelide HCL Caps, T2 Anastrozole Tabs, T2 ANDRODERM Patch, T3 Android Caps, T2 Androxy Tabs, T2 Anergan 50 Inject, T2 ANTIVENIN LATRODECTUS MACTANS Inject, T5 ANTIVENIN MICRURUS FULVIUS Inject, T5 Anusol-Hc Rectal Cr, T2 Apexicon E Cr, T2 APOKYN Inject, T5 2 Apri Tabs, T2 APTIVUS Caps, T5 APTIVUS Soln, T5 Aranelle Tabs, T2 ARANESP 150MCG/0.3, 200MCG/0.4, 300MCG/0.6, 500MCG/ML Inject Syr, T5 ARANESP 200MCG/ML. 300MCG/ML Inject, T5 ARANESP 25MCG/0.45, 40MCG/0.4, 60MCG/0.3,100MCG/0.5 Inject Syr, T3 ARANESP 25MCG/ML, 40MCG/ML, 60MCG/ML,100MCG/ML Inject, T3 ARCALYST Inject, T5 ARICEPT Tabs, T3 ARZERRA Inject IV, T5 Ascomp With Codeine Caps, T2 ASMANEX Inhaler, T4 ASTRAMORPH-PF 0.5MG Inject, T3 Astramorph-PF 1MG Inject, T2 ATELVIA Tabs, T4 Atenolol Tabs, T1 Atenolol-Chlorthalidone Tabs, T1 ATGAM Inject IV, T3 Atorvastatin Calcium Tabs, T1 ATOVAQUONE-PROGUANIL HCL Tabs, T3 ATRIPLA Tabs, T5 ATROVENT HFA Inhaler, T3 AUBAGIO Tabs, T5 AUVI-Q Auto Inj, T3 AVANDIA Tabs, T3 AVASTIN Inject IV, T5 AVELOX ABC PACK Tabs, T4 AVELOX Tabs, T4 Aviane Tabs, T2 Avita Gel, T2 AVODART Caps, T4 AVONEX ADMINISTRATION PACK Inject Kit, T5 AVONEX Inject Kit, T5 Azathioprine Tabs, T2 Azelastine HCL Eye Drops, T2 Azelastine HCL Nasal Spray, T2 AZILECT 0.5MG Tabs, T4 AZILECT Tabs, T4 Azithromycin Inject IV, T2 Azithromycin Oral Pwd, T2 Azithromycin Suspension, T2 Azithromycin Tabs, T2 AZOPT Eye Susp, T3 Aztreonam Inject, T2 Azurette Tabs, T2 B Bacitracin Eye Ointment, T2 Bacitracin-Polymyxin Eye Ointment, T2 Baclofen Tabs, T2 BALSALAZIDE DISODIUM Caps, T4 Balziva Tabs, T2 BANZEL 200MG Tabs, T4 BANZEL 400MG Tabs, T5 BANZEL Suspension, T4 BARACLUDE Soln, T3 BARACLUDE Tabs, T5 Baycadron Soln, T2 BCG VACCINE (TICE STRAIN) Inject, T3 Benazepril HCL Tabs, T1 Benazepril-Hydrochlorothiazide Tabs, T1 Benztropine Mesylate Tabs, T2 Betamethasone Dipropionate Cr, T2 Betamethasone Dipropionate Gel, T2 Betamethasone Dipropionate Lotion, T2 Betamethasone Dipropionate Oint, T2 Betamethasone Valerate Cr, T2

68 Betamethasone Valerate Lotion, T2 Betamethasone Valerate Oint, T2 BETASERON Inject Kit, T5 Betaxolol HCL Eye Drops, T2 Betaxolol HCL Tabs, T2 Bethanechol Chloride Tabs, T2 Bicalutamide Tabs, T2 BICILLIN C-R Inject Syr, T3 BICILLIN L-A Inject Syr, T3 BILTRICIDE Tabs, T3 Bisoprolol Fumarate Tabs, T2 Bisoprolol-Hydrochlorothiazide Tabs, T2 BIVIGAM Inject IV, T5 Bleomycin Sulfate Inject, T2 Bleph-10 Eye Drops, T2 BOOSTRIX Inject Syr, T3 BOOSTRIX Inject, T3 BOSULIF Tabs, T5 BREVIBLOC Inject IV, T3 Briellyn Tabs, T2 Brimonidine Tartrate Eye Drops, T2 BROMFENAC SODIUM Eye Drops, T4 Bromocriptine Mesylate Caps, T2 Bromocriptine Mesylate Tabs, T2 Budeprion Sr Tabs, T2 BUDESONIDE EC Caps, T5 Bumetanide Inject, T2 Bumetanide Tabs, T2 BUPHENYL Tabs, T3 BUPRENORPHINE HCL Tabs Subl, T4 BUPRENORPHINE-NALOXONE Tabs Subl, T4 Buproban Tabs, T2 Bupropion HCL Sr Tabs, T2 Bupropion HCL Tabs, T2 Bupropion XL Tabs, T2 Bupropion XL 150MG Tabs, T2 Buspirone HCL Tabs, T2 Butalb-Caff-Acetaminoph-Codein Caps, T2 Butalbital Compound-Codeine Caps, T2 BYDUREON Inject, T4 BYETTA Inject Pen, T4 C Cabergoline Tabs, T2 Calcipotriene Cr, T2 Calcipotriene Topical Soln, T2 CALCITONIN-SALMON Nasal Spray, T4 Calcitriol Caps, T2 Calcium Acetate Caps, T2 Calcium Acetate Tabs, T2 Camila Tabs, T2 CAMPRAL Tabs, T4 CANASA Rectal Supp, T3 CANCIDAS Inject IV, T5 CAPASTAT SULFATE Inject, T3 CAPRELSA Tabs, T5 Captopril Tabs, T1 Captopril-Hydrochlorothiazide Tabs, T1 Carbamazepine Caps, T2 Carbamazepine Suspension, T2 Carbamazepine Tabs Chew, T2 Carbamazepine Tabs, T2 Carbamazepine XR Tabs, T2 Carbidopa-Levodopa Tabs, T2 CARBIDOPA-LEVODOPA-ENTACAPONE Tabs, T3 CARIMUNE NF NANOFILTERED Inject IV, T5 Carisoprodol Tabs, T2 Carteolol HCL Eye Drops, T2 Cartia Xt Caps, T2 Carvedilol Tabs, T1 CAYSTON Inhale Soln, T5 Caziant Tabs, T2 CEENU Caps, T3 Cefaclor Caps, T2 Cefaclor ER Tabs, T2 Cefaclor Suspension, T2 Cefadroxil Caps, T2 Cefadroxil Suspension, T2 Cefadroxil Tabs, T2 Cefazolin Inject IV, T2 Cefazolin Sodium Inject, T2 Cefdinir Caps, T2 Cefepime HCL Inject, T2 Cefotaxime Sodium Inject, T2 Cefpodoxime Proxetil Suspension, T2 Cefpodoxime Proxetil Tabs, T2 Cefprozil Suspension, T2 Cefprozil Tabs, T2 CEFTAZIDIME Inject IV, T3 Ceftazidime Inject, T2 Ceftriaxone Inject IV, T2 Ceftriaxone Inject, T2 Ceftriaxone IV-Froz Piggy, T2 Brand-name drugs are listed in upper case. Generic drugs are listed in lower case. Pharmacy Benefits are subject to a covered list which is subject to change. Limitations, copayments, and restrictions may apply. Refer to the Care1st Comprehensive formulary and Evidence of Coverage for more information. T1 = Tier 1 T2 = Tier 2 T3 = Tier 3 T4 = Tier 4 T5 = Tier 5 3

69 Cefuroxime Sodium Inject IV, T2 Cefuroxime Sodium Inject, T2 Cefuroxime Tabs, T2 CELEBREX Caps, T4 CELESTONE Soln, T3 CELLCEPT Suspension, T5 CELONTIN Caps, T3 CENESTIN Tabs, T3 Cephalexin Caps, T2 Cephalexin Suspension, T2 Cephalexin Tabs, T2 CEREZYME Inject IV, T5 CERVARIX Inject Syr, T3 CHANTIX Tabs, T4 CHLORAMPHENICOL SOD SUCCINATE Inject IV, T4 Chlordiazepoxide-Amitriptyline Tabs, T2 Chlorhexidine Gluconate Soln, T2 Chloroquine Phosphate Tabs, T2 Chlorothiazide Tabs, T2 Chlorpromazine HCL Inject, T2 Chlorpromazine HCL Oral Conc, T2 Chlorpromazine HCL Tabs, T2 Chlorthalidone Tabs, T2 Chlorzoxazone Tabs, T2 Cholestyramine Oral Pwd, T2 Choline Mag Trisalicylate Soln, T2 Chorionic Gonadotropin Inject, T2 Ciclopirox Cr, T2 Ciclopirox Gel, T2 Ciclopirox Topical Soln, T2 Ciclopirox Topical Susp, T2 Cilostazol Tabs, T2 Cimetidine HCL Soln, T2 Cimetidine Inject, T2 Cimetidine Tabs, T2 Ciprofloxacin ER Tabs, T2 4 Ciprofloxacin HCL Ear Drops, T2 Ciprofloxacin HCL Eye Drops, T2 Ciprofloxacin HCL Tabs, T2 Ciprofloxacin Inject IV, T2 Citalopram Hbr Soln, T2 Citalopram Hbr Tabs, T2 CLARAVIS Caps, T4 Clarithromycin ER Tabs, T2 Clarithromycin Suspension, T2 Clarithromycin Tabs, T2 Clemastine Fumarate Syrup, T2 Clemastine Fumarate Tabs, T2 Clindamax Gel, T2 Clindamax Lotion, T2 Clindamycin HCL Caps, T2 Clindamycin Phosphate Gel, T2 Clindamycin Phosphate Inject IV, T2 Clindamycin Phosphate Lotion, T2 Clindamycin Phosphate Swabs, T2 Clindamycin Phosphate Topical Soln, T2 Clindamycin Phosphate Vaginal Cr, T2 Clobetasol Propionate Cr, T2 Clobetasol Propionate Foam, T2 Clobetasol Propionate Gel, T2 Clobetasol Propionate Oint, T2 Clobetasol Propionate Topical Soln, T2 Clomipramine HCL Caps, T2 Clonazepam Tabs, T2 Clonidine HCL Tabs, T1 Clopidogrel Tabs, T1 Clorazepate Dipotassium Tabs, T2 Clotrimazole Cr, T2 Clotrimazole Topical Soln, T2 Clotrimazole Trouche, T2 Clotrimazole-Betamethasone Cr, T2 Clotrimazole-Betamethasone Lotion, T2 CLOZAPINE ODT Tabs, T3 Clozapine Tabs, T2 Co-Gesic Tabs, T2 Codeine Sulfate Tabs, T2 COLCRYS Tabs, T3 Colestipol HCL Oral Pwd, T2 Colestipol HCL Tabs, T2 Colistimethate Sodium Inject, T2 Colocort Enema, T2 COMBIPATCH Patch, T3 COMBIVENT Inhaler, T3 COMBIVENT RESPIMAT Inhaler, T3 COMETRIQ Caps, T5 COMPLERA Tabs, T5 Compro Rectal Supp, T2 COMVAX Inject, T3 Constulose Soln, T2 COPAXONE Inject Kit, T5 Cormax Topical Soln, T2 Cortisone Acetate Tabs, T2 COUMADIN Tabs, T3 CREON Caps, T3 CRIXIVAN Caps, T3 CROFAB Inject, T5 Cromolyn Sodium Eye Drops, T2 Cromolyn Sodium Inhale Soln, T2 CROMOLYN SODIUM Soln, T3 Cryselle Tabs, T2 CUBICIN Inject IV, T5 CUPRIMINE Caps, T3 Cyclafem Tabs, T2 Cyclobenzaprine HCL Tabs, T2 Cyclopentolate HCL Eye Drops, T2 Cyclophosphamide Tabs, T2 CYCLOSET Tabs, T4 Cyclosporine Caps, T2 Cyclosporine Modified Caps, T2 Cyclosporine Soln, T2

70 CYMBALTA Caps, T4 Cyproheptadine HCL Tabs, T2 CYSTADANE Oral Pwd, T3 CYSTAGON Caps, T3 CYTOGAM Inject IV, T5 Cytra-2 Soln, T2 Cytra-3 Soln, T2 Cytra-K Oral Pwd, T2 D DACOGEN Inject IV, T5 DALIRESP Tabs, T4 Danazol Caps, T2 Dantrolene Sodium Caps, T2 DAPSONE Tabs, T3 DAPTACEL Inject, T3 DARAPRIM Tabs, T3 Dasetta Tabs, T2 Deferoxamine Mesylate Inject, T2 DELZICOL Caps, T3 Demeclocycline HCL Tabs, T2 DENAVIR Cr, T3 Denta 5000 Plus Dental Cr, T2 Dentagel Dental Cr, T2 Depade Tabs, T2 DEPEN Tabs, T3 DEPO-MEDROL Inject, T4 DEPO-PROVERA Inject, T3 Desipramine HCL Tabs, T2 Desloratadine Tabs, T2 Desmopressin Acetate Nasal Soln, T2 Desmopressin Acetate Nasal Spray, T2 Desmopressin Acetate Tabs, T2 DESONATE Gel, T4 Desonide Cr, T2 Desonide Lotion, T2 Desonide Oint, T2 Desoximetasone Cr, T2 Desoximetasone Gel, T2 Desoximetasone Oint, T2 DESVENLAFAXINE ER Tabs, T4 DETROL LA Caps, T3 Dexamethasone Acetate Inject, T2 Dexamethasone Sodium Phosphate Eye Drops, T2 Dexamethasone Sodium Phosphate Inject, T2 Dexamethasone Soln, T2 Dexamethasone Tabs, T2 Dexmethylphenidate HCL Tabs, T2 Dextroamphetamine Sulfate Caps, T2 Dextroamphetamine Sulfate Tabs, T2 Dextroamphetamine-Amphetamine Caps, T2 Dextrose 5%-1/2Ns-Kcl Inject IV, T2 Dextrose 5%-1/3Ns-Kcl Inject IV, T2 Dextrose 5%-1/4Ns-Kcl Inject IV, T2 Dextrose 5%-Ns-Kcl Inject IV, T2 Dextrose 5%-Potassium Chloride Inject IV, T2 Dextrose In Lactated Ringers Inject IV, T2 Dextrose In Ringers Injection Inject IV, T2 Dextrose In Water Inject IV, T2 Dextrose In Water IV- Syr, T2 Dextrose With Sodium Chloride Inject IV, T2 Diazepam Rectal Kit, T2 Diazepam Soln, T2 Diazepam Tabs, T2 Diclofenac Potassium Tabs, T2 Diclofenac Sodium Eye Drops, T2 Diclofenac Sodium Tabs, T2 Dicloxacillin Sodium Caps, T2 Dicyclomine HCL Caps, T2 Dicyclomine HCL Tabs, T2 Didanosine Caps, T2 DIFFERIN Gel, T3 DIFFERIN Lotion, T3 DIFFERIN Swabs, T3 Diflorasone Diacetate Cr, T2 Diflorasone Diacetate Oint, T2 Diflunisal Tabs, T2 DIGIFAB Inject IV, T5 Digitek 125MCG Tabs, T1 Digitek 250MCG Tabs, T1 Digoxin 125MCG Tabs, T1 Digoxin 250MCG Tabs, T1 Digoxin Inject, T2 DIGOXIN Soln, T3 Dihydroergotamine Mesylate Inject, T2 DILANTIN Caps, T3 DILANTIN Tabs Chew, T3 DILANTIN-125 Suspension, T3 Dilt-Cd Caps, T2 Dilt-Xr Caps, T2 Diltia Xt Caps, T2 Diltiazem 24Hr Cd Caps, T2 Brand-name drugs are listed in upper case. Generic drugs are listed in lower case. Pharmacy Benefits are subject to a covered list which is subject to change. Limitations, copayments, and restrictions may apply. Refer to the Care1st Comprehensive formulary and Evidence of Coverage for more information. T1 = Tier 1 T2 = Tier 2 T3 = Tier 3 T4 = Tier 4 T5 = Tier 5 5

71 Diltiazem 24Hr ER Caps, T2 Diltiazem ER Caps, T2 Diltiazem HCL Tabs, T2 Diltzac ER Caps, T2 DIOVAN Tabs, T3 DIPENTUM Caps, T3 Diphenhydramine HCL Caps, T2 Diphenhydramine HCL Inject, T2 Diphenoxylate-Atropine Soln, T2 Diphenoxylate-Atropine Tabs, T2 DIPHTHERIA-TETANUS TOXOIDS-PED Inject, T3 Dipyridamole Tabs, T2 Disopyramide Phosphate Caps, T2 Disulfiram Tabs, T2 Divalproex Sodium Caps, T2 Divalproex Sodium ER Tabs, T2 Divalproex Sodium Tabs, T2 DOCETAXEL Inject IV, T5 Donepezil HCL Tabs, T2 Dorzolamide HCL Eye Drops, T2 Dorzolamide-Timolol Eye Drops, T2 Doxazosin Mesylate Tabs, T1 Doxepin HCL Caps, T2 Doxepin HCL Oral Conc, T2 Doxy-Lemmon Caps, T2 Doxy-Lemmon Tabs, T2 Doxycycline Hyclate Caps, T2 Doxycycline Hyclate Inject IV, T2 Doxycycline Hyclate Tabs, T2 Doxycycline Monohydrate Tabs, T2 DRONABINOL Caps, T4 Drospirenone-Ethinyl Estradiol Tabs, T2 DROXIA Caps, T3 6 E E.E.S. 400 Tabs, T2 Econazole Nitrate Cr, T2 Ed Doxy-Caps Caps, T2 Ed K+10 Tabs, T2 EDURANT Tabs, T5 Effer-K Tabs Eff, T2 ELAPRASE Inject IV, T5 ELELYSO Inject IV, T5 ELIDEL Cr, T3 ELIGARD Inject Syr, T3 Eliphos Tabs, T2 ELIQUIS Tabs, T4 ELITEK Inject IV, T5 Elixophyllin Soln, T2 EMCYT Caps, T3 EMEND Caps, T3 EMEND Inject IV, T3 Emoquette Tabs, T2 EMSAM Patch, T4 EMTRIVA Caps, T3 EMTRIVA Soln, T3 Enalapril Maleate Tabs, T1 Enalapril-Hydrochlorothiazide Tabs, T1 ENBREL Inject Pen, T5 ENBREL Inject Syr, T5 ENBREL Inject, T5 Endocet Tabs, T2 Endodan Tabs, T2 ENGERIX-B Inject Syr, T3 ENGERIX-B Inject, T3 ENOXAPARIN SODIUM 30MG/0.3ML, 40MG/0.4ML, 60MG/0.6ML Inject Syr, T3 ENOXAPARIN SODIUM 80MG/0.8ML, 100MG/ML, 120MG/0.8ML, 150MG/ ML Inject Syr, T5 ENOXAPARIN SODIUM Inject, T3 Enpresse Tabs, T2 Enskyce Tabs, T2 ENTACAPONE Tabs, T3 Epinephrine Inject Pen, T2 Epinephrine Inject Syr, T2 EPIPEN 2-PAK Inject Pen, T3 Epitol Tabs, T2 EPIVIR HBV Soln, T3 EPIVIR HBV Tabs, T3 EPIVIR Soln, T3 EPLERENONE Tabs, T4 EPOGEN 20000/ML Inject, T5 EPOGEN ALL OTHER STRENGTHS Inject, T3 EPOPROSTENOL SODIUM Inject IV, T5 EPZICOM Tabs, T5 ERAXIS (ALCOHOL DILUENT) Inject IV, T5 ERGOMAR Tabs Subl, T3 Ergotamine-Caffeine Tabs, T2 ERIVEDGE Caps, T5 Errin Tabs, T2 ERWINAZE Inject, T5 Ery Swabs, T2 Erythrocin Stearate Tabs, T2 Erythromycin Caps, T2 Erythromycin Ethylsuccinate Tabs, T2 Erythromycin Eye Ointment, T2 Erythromycin Gel, T2 Erythromycin Swabs, T2 Erythromycin Tabs, T2 Erythromycin Topical Soln, T2 Erythromycin-Benzoyl Peroxide Gel, T2 Erythromycin-Sulfisoxazole Suspension, T2 Escitalopram Oxalate Soln, T2 Escitalopram Oxalate Tabs, T2 Esmolol HCL IV- Syr, T2 Estradiol Patch, T2 Estradiol Tabs, T2

72 Estradiol-Norethindrone Acetat Tabs, T2 Estropipate Tabs, T2 Ethambutol HCL Tabs, T2 Ethosuximide Caps, T2 Ethosuximide Soln, T2 Etidronate Disodium Tabs, T2 Etodolac Caps, T2 Etodolac Tabs, T2 EVISTA Tabs, T3 EXELON Patch, T4 EXELON Soln, T3 Exemestane Tabs, T2 EXJADE 125MG Tabs, T3 EXJADE 250MG, 500MG Tabs, T5 EXTAVIA Inject Kit, T5 F FABRAZYME Inject IV, T5 Falmina Tabs, T2 Famotidine Inject IV, T2 Famotidine Tabs, T2 FANAPT Tabs, T4 FARESTON Tabs, T3 FASLODEX Inject Syr, T4 FAZACLO Tabs, T3 FELBAMATE Suspension, T4 FELBAMATE Tabs, T4 Felodipine ER Tabs, T2 Fenofibrate Caps, T2 Fenofibrate Tabs, T2 Fenoprofen Calcium Tabs, T2 FENTANYL CITRATE Loz, T4 Fentanyl Patch, T2 Finasteride Tabs, T2 FIRMAGON 120MG Inject, T5 FIRMAGON 80MG Inject, T4 Flecainide Acetate Tabs, T2 FLOVENT HFA Inhaler, T3 Fluconazole In Saline Inject IV, T2 Fluconazole Suspension, T2 Fluconazole Tabs, T2 Flucytosine Caps, T2 Fludrocortisone Acetate Tabs, T2 Flunisolide Nasal Spray, T2 Fluocinolone Acetonide Cr, T2 FLUOCINOLONE ACETONIDE OIL Ear Drops, T3 Fluocinolone Acetonide Oint, T2 Fluocinolone Acetonide Topical Soln, T2 Fluocinonide Cr, T2 Fluocinonide Gel, T2 Fluocinonide Oint, T2 Fluocinonide Topical Soln, T2 FLUOROMETHOLONE Eye Susp, T3 Fluorouracil Cr, T2 Fluorouracil Topical Soln, T2 Fluoxetine Dr Caps, T2 Fluoxetine HCL Caps, T2 Fluoxetine HCL Soln, T2 Fluoxetine HCL Tabs, T2 Fluphenazine Decanoate Inject, T2 Fluphenazine HCL Inject, T2 Fluphenazine HCL Oral Conc, T2 Fluphenazine HCL Soln, T2 Fluphenazine HCL Tabs, T2 Flurbiprofen Sodium Eye Drops, T2 Flurbiprofen Tabs, T2 Flutamide Caps, T2 Fluticasone Propionate Cr, T2 Fluticasone Propionate Nasal Spray, T2 Fluticasone Propionate Oint, T2 Fluvoxamine Maleate Tabs, T2 FOCALIN XR Caps, T4 FOLOTYN Inject IV, T5 FOMEPIZOLE Inject IV, T5 FONDAPARINUX SODIUM Inject Syr, T3 FORTAZ IN ISO-OSMOTIC DEXTROSE IV-Froz Piggy, T3 FORTEO Inject Pen, T5 FORTICAL Nasal Spray, T4 Fosinopril Sodium Tabs, T2 Fosinopril-Hydrochlorothiazide Tabs, T2 FRAGMIN Inject Syr, T4 FRAGMIN Inject, T4 FREAMINE HBC Inject IV, T3 FRUCTOSE Inject IV, T3 FULVICIN U/F Tabs, T3 Furosemide Inject Syr, T2 Furosemide Inject, T2 Furosemide Soln, T1 Furosemide Tabs, T1 FUZEON Inject, T5 Brand-name drugs are listed in upper case. Generic drugs are listed in lower case. Pharmacy Benefits are subject to a covered list which is subject to change. Limitations, copayments, and restrictions may apply. Refer to the Care1st Comprehensive formulary and Evidence of Coverage for more information. T1 = Tier 1 T2 = Tier 2 T3 = Tier 3 T4 = Tier 4 T5 = Tier 5 7

73 G Gabapentin Caps, T2 Gabapentin Soln, T2 Gabapentin Tabs, T2 GABITRIL Tabs, T4 GAMUNEX-C Inject, T3 GANCICLOVIR SODIUM Inject IV, T3 GARDASIL Inject Syr, T3 GARDASIL Inject, T3 GASTROCROM Soln, T3 Gavilyte-C Soln, T2 Gavilyte-N Soln, T2 GEMCITABINE HCL Inject IV, T5 Gemfibrozil Tabs, T2 Generlac Soln, T2 Gengraf Caps, T2 Gengraf Soln, T2 GENOTROPIN 0.2MG/0.25 Inject Syr, T3 GENOTROPIN ALL OTHER STRENGTHS Inject Syr, T5 GENOTROPIN Inject, T5 Gentak Eye Drops, T2 Gentak Eye Ointment, T2 Gentamicin Sulfate Eye Drops, T2 Gentamicin Sulfate Eye Ointment, T2 Gentamicin Sulfate Inject, T2 GEODON Inject, T3 Gildagia Tabs, T2 Gildess Fe Tabs, T2 Gildess Tabs, T2 GILENYA Caps, T5 GLEEVEC Tabs, T5 Glimepiride Tabs, T1 Glipizide ER Tabs, T1 Glipizide Tabs, T1 Glipizide-Metformin Tabs, T1 GLUCAGEN Inject Kit, T3 8 GLUCAGON EMERGENCY KIT Inject Kit, T3 Glyburide Micronized Tabs, T1 Glyburide Tabs, T1 Glyburide-Metformin HCL Tabs, T1 Glycopyrrolate Tabs, T2 GLYSET Tabs, T3 Granisetron HCL Inject IV, T2 GRANISETRON HCL Inject IV, T4 Granisetron HCL Tabs, T2 Griseofulvin Suspension, T2 Griseofulvin Tabs, T2 Griseofulvin Ultramicrosize Tabs, T2 Guanfacine HCL Tabs, T2 Guanidine HCL Tabs, T2 H HALAVEN Inject IV, T5 Halobetasol Propionate Cr, T2 Halobetasol Propionate Oint, T2 Haloperidol Decanoate Inject, T2 Haloperidol Lactate Inject, T2 Haloperidol Lactate Oral Conc, T2 Haloperidol Tabs, T2 HAVRIX Inject Syr, T3 HAVRIX Inject, T3 Hctz/Reserpine/Hydralazine Tabs, T2 Heather Tabs, T2 HECTOROL 0.5MCG, 1MCG Caps, T3 HECTOROL 2.5MCG Caps, T3 HECTOROL Inject IV, T3 HEPAGAM B Inject, T5 Heparin Sodium In 0.45% Nacl Inject IV, T2 Heparin Sodium Inject Syr, T2 Heparin Sodium Inject, T2 Heparin Sodium-D5W Inject IV, T2 Heparin Sodium-Ns Inject IV, T2 Hepatasol Inject IV, T2 HEPSERA Tabs, T5 HEXALEN Caps, T5 Homatropaire Eye Drops, T2 HUMALOG Inject, T3 HUMALOG Insulin Pen, T3 HUMALOG MIX Inject, T3 HUMALOG MIX Insulin Pen, T3 HUMALOG MIX Inject, T3 HUMALOG MIX Insulin Pen, T3 HUMATROPE 5MG, 12MG, 24MG Inject, T5 HUMATROPE 6MG Inject, T3 HUMIRA Inject Kit, T5 HUMORSOL Eye Drops, T3 HUMULIN Inject, T3 HUMULIN Insulin Pen, T3 HUMULIN N Inject, T3 HUMULIN N Insulin Pen, T3 HUMULIN R 500/ML Inject, T5 HUMULIN R Inject, T3 HUMULIN R Insulin Pen, T3 Hycort Oint, T2 Hydralazine HCL Tabs, T2 Hydralazine W/Hctz Caps, T2 Hydrochlorothiazide Caps, T1 Hydrochlorothiazide Tabs, T1 Hydrochlorothiazide/Reserpine Tabs, T2 Hydrocodone Bit-Ibuprofen Tabs, T2 Hydrocodone-Acetaminophen Soln, T2 Hydrocodone-Acetaminophen Tabs, T2 Hydrocodone-Ibuprofen Tabs, T2 Hydrocortisone Butyrate Cr, T2 Hydrocortisone Butyrate Oint, T2 Hydrocortisone Butyrate Topical Soln, T2 Hydrocortisone Cr, T2 Hydrocortisone Enema, T2

74 Hydrocortisone Lotion, T2 Hydrocortisone Oint, T2 Hydrocortisone Plus Cr, T2 Hydrocortisone Tabs, T2 Hydrocortisone Valerate Cr, T2 Hydrocortisone Valerate Oint, T2 Hydromorphone HCL Inject, T2 Hydromorphone HCL Tabs, T2 Hydroxychloroquine Sulfate Tabs, T2 Hydroxyurea Caps, T2 Hydroxyzine HCL Syrup, T2 Hydroxyzine HCL Tabs, T2 HYPERHEP B S-D Inject Syr, T5 HYPERHEP B S-D Inject, T5 HYPERLYTE CR Inject IV, T3 HYPERLYTE R Inject IV, T3 HYPERRAB S-D Inject Syr, T5 HYPERRHO S-D Inject Syr, T4 HYPERRHO S-D Inject Syr, T5 HYPERTET S-D Inject Syr, T5 I IBANDRONATE SODIUM Tabs, T4 Ibuprofen Tabs, T2 Ibuprohm Tabs, T2 ICLUSIG Tabs, T5 Imipenem-Cilastatin Sodium Inject IV, T2 Imipramine HCL Tabs, T2 Imipramine Pamoate Caps, T2 Imiquimod Cr, T2 IMOGAM RABIES-HT Inject, T5 IMOVAX RABIES VACCINE Inject, T3 INCIVEK Tabs, T5 INCRELEX Inject, T5 Indapamide Tabs, T2 Indomethacin Caps, T2 INFANRIX Inject, T3 INFANRIX PF Inject Syr, T3 INFERGEN Inject, T5 INLYTA Tabs, T5 Insulin Syringe Syringes, T2 INTELENCE Tabs, T5 INTRALIPID IV- Emulsion, T3 INTRON A 50MMU Inject, T5 INTRON A ALL OTHER STRENGTHS Inject, T3 INTRON A Inject Kit, T3 Introvale Tabs, T2 INTUNIV Tabs, T3 INVEGA 1.5MG, 3MG Tabs, T4 INVEGA 6MG, 9MG Tabs, T5 INVEGA SUSTENNA 117MG/0.75, 156MG/ML, 234MG/1.5ML Inject Syr, T5 INVEGA SUSTENNA 39MG/0.25ML, 78MG/0.5ML Inject Syr, T4 INVIRASE Caps, T3 INVIRASE Tabs, T5 INVOKANA Tabs, T4 IPOL Inject, T3 Ipratropium Bromide Inhale Soln, T2 Ipratropium Bromide Nasal Spray, T2 Ipratropium-Albuterol Inhale Soln, T2 ISENTRESS Tabs Chew, T3 ISENTRESS Tabs, T5 Isoniazid Soln, T2 Isoniazid Tabs, T2 Isopto Homatropine Eye Drops, T2 Isosorbide Dinitrate Tabs Subl, T1 Isosorbide Dinitrate Tabs, T1 Isosorbide Mononitrate ER Tabs, T2 Isosorbide Mononitrate Tabs, T2 Isradipine Caps, T2 ISTODAX Inject IV, T5 Itraconazole Caps, T2 IXIARO Inject Syr, T4 J JAKAFI Tabs, T5 Jantoven Tabs, T1 JANUMET Tabs, T3 JANUMET XR Tabs, T3 JANUVIA Tabs, T3 JE-VAX Inject, T3 JENTADUETO Tabs, T3 JEVTANA Inject IV, T5 Jolessa Tabs, T2 Jolivette Tabs, T2 Junel Fe Tabs, T2 Junel Tabs, T2 JUVISYNC Tabs, T3 K K Effervescent Tabs Eff, T2 KADCYLA Inject IV, T5 KALETRA 100MG-25MG Tabs, T3 KALETRA 200MG-50MG Tabs, T5 KALETRA Soln, T5 KAPVAY Tabs, T3 Brand-name drugs are listed in upper case. Generic drugs are listed in lower case. Pharmacy Benefits are subject to a covered list which is subject to change. Limitations, copayments, and restrictions may apply. Refer to the Care1st Comprehensive formulary and Evidence of Coverage for more information. T1 = Tier 1 T2 = Tier 2 T3 = Tier 3 T4 = Tier 4 T5 = Tier 5 9

75 Kariva Tabs, T2 Kelnor 1-35 Tabs, T2 KEPIVANCE Inject IV, T5 KETEK Tabs, T4 Ketoconazole Cr, T2 Ketoconazole Shampoo, T2 Ketoconazole Tabs, T2 Ketoprofen Caps, T2 Ketorolac Tromethamine Eye Drops, T2 Ketorolac Tromethamine Inject, T2 Ketorolac Tromethamine Tabs, T2 KINERET Inject Syr, T5 KINRIX Inject Syr, T3 KINRIX Inject, T3 Kionex Suspension, T2 Klor-Con 10 Tabs, T2 Klor-Con 8 Tabs, T2 Klor-Con M15 Tabs, T2 Klor-Con M20 Tabs, T2 Klor-Con Oral Pwd, T2 Klor-Con-EF Tabs Eff, T2 Kurvelo Tabs, T2 KUVAN Tabs, T5 KYPROLIS Inject IV, T5 L Labetalol HCL Tabs, T2 LACRISERT eye Insert, T3 LACTATED RINGERS Inject IV, T4 Lactulose Soln, T2 Lactulose Syrup, T2 LAMICTAL (BLUE) Tabs, T3 Lamivudine Tabs, T2 LAMIVUDINE-ZIDOVUDINE Tabs, T5 Lamotrigine Tabs, T2 LANOXIN PEDIATRIC Inject, T3 Lansoprazole Caps, T2 LANTUS Inject, T3 10 LANTUS SOLOSTAR Insulin Pen, T3 Latanoprost Eye Drops, T2 LATUDA Tabs, T4 LAZANDA Nasal Spray, T5 Leena Tabs, T2 Leflunomide Tabs, T2 Lessina Tabs, T2 LETAIRIS Tabs, T5 Letrozole Tabs, T2 Leucovorin Calcium Inject, T2 Leucovorin Calcium Tabs, T2 LEUKERAN Tabs, T3 LEUKINE Inject, T5 LEUPROLIDE ACETATE Inject Kit, T3 Levetiracetam Inject IV, T2 Levetiracetam Soln, T2 Levetiracetam Tabs, T2 Levetiracetam-Nacl Inject IV, T2 Levlen 28 Tabs, T2 Levobunolol HCL 0.25% Eye Drops, T1 Levobunolol HCL 0.5% Eye Drops, T1 Levofloxacin Soln, T2 Levofloxacin Tabs, T2 Levofloxacin-D5W Inject IV, T2 Levonest Tabs, T2 Levonorgestrel Tabs, T2 Levonorgestrel-Eth Estradiol Tabs, T2 Levora-28 Tabs, T2 LEVOTHROID Tabs, T3 Levothyroxine Sodium Tabs, T2 LEVOXYL Tabs, T3 LEVULAN Topical Soln, T3 LEXIVA Suspension, T3 LEXIVA Tabs, T5 Lidocaine HCL In 5% Dextrose Inject IV, T2 Lidocaine HCL Inject IV, T2 Lidocaine HCL Inject Syr, T2 Lidocaine HCL Inject, T2 Lidocaine HCL Oral Jel, T2 Lidocaine HCL Soln, T2 Lidocaine HCL Viscous Soln, T2 Lidocaine Oint, T2 Lidocaine-Prilocaine Cr, T2 LIDODERM Patch, T4 Lindane Lotion, T2 Lindane Shampoo, T2 Liothyronine Sodium Tabs, T2 LIPODOX Inject IV, T5 Lisinopril Tabs, T1 Lisinopril-Hydrochlorothiazide Tabs, T1 Lithium Carbonate Caps, T2 Lithium Carbonate Tabs, T2 Lithium Soln, T2 Lokara Lotion, T2 Loperamide Caps, T2 Lorazepam Tabs, T2 Losartan Potassium Tabs, T1 Losartan-Hydrochlorothiazide Tabs, T1 LOTEMAX Eye Susp, T3 LOTRONEX Tabs, T5 Lovastatin Tabs, T1 LOVAZA Caps, T4 Low-Ogestrel Tabs, T2 Loxapine Caps, T2 LUPRON DEPOT 3.75MG Inject Kit, T3 LUPRON DEPOT ALL OTHER STRENGTHS Inject Kit, T5 LUPRON DEPOT-PED Inject Kit, T5 Lutera Tabs, T2 LYRICA Caps, T4 LYRICA Soln, T4 LYSODREN Tabs, T3

76 M M-M-R II VACCINE Inject, T3 Maprotiline HCL Tabs, T2 Marlissa Tabs, T2 MARPLAN Tabs, T3 MATULANE Caps, T5 MAXIDEX Eye Susp, T3 Meclizine HCL Tabs, T2 Meclofenamate Sodium Caps, T2 Medroxyprogesterone Acetate Inject Syr, T2 Medroxyprogesterone Acetate Inject, T2 Medroxyprogesterone Acetate Tabs, T2 Mefloquine HCL Tabs, T2 Megestrol Acetate Suspension, T2 Megestrol Acetate Tabs, T2 MEKINIST Tabs, T5 Meloxicam Tabs, T2 MELPHALAN HCL Inject IV, T5 MENACTRA Inject, T3 MENEST Tabs, T3 MENOMUNE-A-C-Y-W-135 Inject, T3 MENVEO A-C-Y-W-135-DIP Inject Kit, T3 Meperidine HCL Soln, T2 Meperidine HCL Tabs, T2 MEPRON Suspension, T5 Mercaptopurine Tabs, T2 Mesalamine Rectal Kit, T2 MESNEX Tabs, T3 Metaproterenol Sulfate Syrup, T2 Metaproterenol Sulfate Tabs, T2 Metformin HCL ER Tabs, T1 Metformin HCL Tabs, T1 Methadone HCL Inject, T2 Methadone HCL Soln, T2 Methadone HCL Tabs, T2 Methadone Intensol Oral Conc, T2 Methadose Tabs, T2 Methazolamide Tabs, T2 Methimazole Tabs, T2 Methocarbamol Tabs, T2 Methotrexate Tabs, T2 Methyclothiazide Tabs, T2 Methyldopa Tabs, T2 Methyldopa-Hydrochlorothiazide Tabs, T2 Methylphenidate ER Tabs, T2 METHYLPHENIDATE ER Tabs, T3 Methylphenidate HCL Tabs, T2 Methylprednisolone Acetate Inject, T2 Methylprednisolone Sod Succ Inject IV, T2 Methylprednisolone Sod Succ Inject, T2 Methylprednisolone Tabs, T2 Metipranolol Eye Drops, T2 Metoclopramide HCL Inject, T2 Metoclopramide HCL Soln, T2 Metoclopramide HCL Tabs, T2 Metolazone Tabs, T2 Metoprolol Succinate Tabs, T2 Metoprolol Tartrate Tabs, T1 Metoprolol-Hydrochlorothiazide Tabs, T1 Metronidazole Cr, T2 Metronidazole Gel, T2 Metronidazole Inject IV, T2 Metronidazole Lotion, T2 Metronidazole Tabs, T2 Metronidazole Vaginal Gel, T2 Metryl Tabs, T2 Mexiletine HCL Caps, T2 Miconazole 3 Vaginal Supp, T2 MICRHOGAM PLUS Inject Syr, T3 Microgestin Fe Tabs, T2 Microgestin Tabs, T2 Midodrine HCL Tabs, T2 MIFEPREX Tabs, T3 Migergot Rectal Supp, T2 Milrinone In 5% Dextrose Inject IV, T2 Mimvey Tabs, T2 Minitran Patch, T2 Minocycline HCL Caps, T2 Minocycline HCL Tabs, T2 Minoxidil Tabs, T2 Mirtazapine Tabs, T2 Misoprostol Tabs, T2 Mitoxantrone HCL Inject IV, T2 MODAFINIL Tabs, T3 Moexipril HCL Tabs, T2 Mometasone Furoate Cr, T2 Mometasone Furoate Oint, T2 Mometasone Furoate Topical Soln, T2 Mono-Linyah Tabs, T2 Mononessa Tabs, T2 Montelukast Sodium Tabs Chew, T2 Montelukast Sodium Tabs, T2 Brand-name drugs are listed in upper case. Generic drugs are listed in lower case. Pharmacy Benefits are subject to a covered list which is subject to change. Limitations, copayments, and restrictions may apply. Refer to the Care1st Comprehensive formulary and Evidence of Coverage for more information. T1 = Tier 1 T2 = Tier 2 T3 = Tier 3 T4 = Tier 4 T5 = Tier 5 11

77 Morphine Sulfate ER All Other Strengths Tabs, T2 Morphine Sulfate Inject, T2 Morphine Sulfate Rectal Supp, T2 Morphine Sulfate Soln, T2 Morphine Sulfate Tabs, T2 MULTAQ Tabs, T4 Mupirocin Oint, T2 MYCOBUTIN Caps, T3 Myconel Cr, T2 Mycophenolate Mofetil Caps, T2 Mycophenolate Mofetil Tabs, T2 MYFORTIC 180MG Tabs, T3 MYFORTIC 360MG Tabs, T5 MYRBETRIQ Tabs, T4 MYTELASE Tabs, T3 Myzilra Tabs, T2 N NABI-HB Inject, T5 Nabumetone Tabs, T2 Nadolol Tabs, T1 Nafcillin Sodium Inject IV, T2 Nafcillin Sodium Inject, T2 NAGLAZYME Inject IV, T5 Nalidixic Acid Tabs, T2 Nallpen-Iso-Osmotic Dextrose IV-Froz Piggy, T2 NALOXONE HCL Inject Syr, T3 NALOXONE HCL Inject, T3 Naltrexone HCL Tabs, T2 NAMENDA Soln, T3 NAMENDA Tabs, T3 Naphazoline HCL Eye Drops, T2 Naphazoline HCL W/Antazoline Eye Drops, T2 Naproxen Sodium Tabs, T2 Naproxen Suspension, T2 Naproxen Tabs, T2 12 Nateglinide Tabs, T2 NEBUPENT Inhale Soln, T3 Necon Tabs, T2 Nefazodone HCL Tabs, T2 NEGGRAM Tabs, T3 Neomycin Sulfate Tabs, T2 Neomycin W/Dexamethasone Eye Drops, T2 Neomycin-Bacitracin-Poly-Hc Eye Ointment, T2 Neomycin-Bacitracin-Polymyxin Eye Ointment, T2 Neomycin-Polymyxin-Dexameth Eye Ointment, T2 Neomycin-Polymyxin-Dexameth Eye Susp, T2 Neomycin-Polymyxin-Gramicidin Eye Drops, T2 Neomycin-Polymyxin-Hc Ear Susp, T2 Neomycin-Polymyxin-Hc Eye Susp, T2 Neomycin-Polymyxin-Hydrocort Ear Soln, T2 NEPHRAMINE Inject IV, T3 NEULASTA Inject Syr, T5 NEUMEGA Inject, T5 NEUPOGEN Inject Syr, T5 NEUPOGEN Inject, T5 Nevirapine Suspension, T2 Nevirapine Tabs, T2 NEXAVAR Tabs, T5 Next Choice One Dose Tabs, T2 NIASPAN Tabs, T4 Nicardipine HCL Caps, T2 NICOTROL Inhaler, T3 NICOTROL NS Nasal Spray, T3 Nifediac Cc Tabs, T2 Nifedical Xl Tabs, T2 Nifedipine ER Tabs, T2 NILANDRON Tabs, T3 Nitrofurantoin Caps, T2 Nitroglycerin Patch Patch, T2 NITROSTAT Tabs Subl, T3 Nizatidine Caps, T2 Nora-Be Tabs, T2 NORDITROPIN FLEXPRO Inject Pen, T5 NORDITROPIN Inject, T5 NORDITROPIN NORDIFLEX Inject Pen, T5 Norethindrone Acetate Tabs, T2 Norethindrone Tabs, T2 Norgestimate-Ethinyl Estradiol Tabs, T2 Nortrel Tabs, T2 Nortriptyline HCL Caps, T2 Nortriptyline HCL Soln, T2 NORVIR Caps, T3 NORVIR Soln, T3 NORVIR Tabs, T3 NOVOLIN Inject, T3 NOVOLIN INNOLET Insulin Pen, T3 NOVOLIN N Inject, T3 NOVOLIN N INNOLET Insulin Pen, T3 NOVOLIN R Inject, T3 NOVOLIN R Insulin Pen, T3 NOVOLOG FLEXPEN Insulin Pen, T3 NOVOLOG Inject, T3 NOVOLOG MIX FLEXPEN Insulin Pen, T3 NOVOLOG MIX Inject, T3 NUEDEXTA Caps, T3 NULOJIX Inject IV, T5 NUTRILYTE II Inject IV, T3 NUTROPIN AQ Inject, T5 NUTROPIN AQ NUSPIN Inject, T5 NUTROPIN Inject, T5 Nyamyc Powder, T2 Nystatin Cr, T2

78 Nystatin Oint, T2 Nystatin Oral Pwd, T2 Nystatin Powder, T2 Nystatin Tabs, T2 Nystatin-Triamcinolone Cr, T2 Nystatin-Triamcinolone Oint, T2 Nystop Powder, T2 O Ofloxacin Ear Drops, T2 Ofloxacin Eye Drops, T2 Ofloxacin Tabs, T2 Ogestrel Tabs, T2 OLANZAPINE 20MG Tabs, T3 Olanzapine All Other Strengths Tabs, T2 Olanzapine Inject, T2 Olanzapine Odt Tabs, T2 Omeprazole Caps, T2 Ondansetron HCL Soln, T2 Ondansetron HCL Tabs, T2 Ondansetron Odt Tabs, T2 ONFI Tabs, T4 ONTAK Inject IV, T3 Oralone Dental Paste, T2 ORAP Tabs, T4 ORENCIA Inject IV, T5 ORFADIN Caps, T3 Orsythia Tabs, T2 Otimar Ear Soln, T2 Otimar Ear Susp, T2 Otomycet-Hc Ear Drops, T2 OXALIPLATIN Inject IV, T5 Oxandrolone Tabs, T2 Oxaprozin Tabs, T2 Oxcarbazepine Suspension, T2 Oxcarbazepine Tabs, T2 OXSORALEN Lotion, T3 OXSORALEN-ULTRA Caps, T3 Oxybutynin Chloride ER Tabs, T2 Oxybutynin Chloride Syrup, T2 Oxybutynin Chloride Tabs, T2 Oxycodone Concentrate Oral Conc, T2 Oxycodone HCL Caps, T2 Oxycodone HCL Soln, T2 Oxycodone HCL Tabs, T2 Oxycodone HCL-Acetaminophen Tabs, T2 Oxycodone HCL-Aspirin Tabs, T2 Oxycodone-Acetaminophen Caps, T2 Oxycodone-Acetaminophen Tabs, T2 OXYCONTIN Tabs, T4 P Pacerone Tabs, T2 Pamidronate Disodium Inject IV, T2 PANCREAZE Caps, T3 PANCRELIPASE 5,000 Caps, T3 PANRETIN Gel, T5 Pantoprazole Sodium Tabs, T2 Parcaine Eye Drops, T2 Paromomycin Sulfate Caps, T2 Paroxetine HCL Tabs, T2 PASER Oral Pwd, T4 PATANOL Eye Drops, T3 PAXIL Suspension, T3 Pedi-Dri Powder, T2 PEDIARIX Inject Syr, T3 PEDVAXHIB Inject, T3 Peg 3350-Electrolyte Soln, T2 Peg-3350 And Electrolytes Soln, T2 Peg-3350 With Flavor Packs Soln, T2 PEGANONE Tabs, T3 PEGASYS Inject Syr, T5 PEGASYS Inject, T5 PEGASYS PROCLICK Inject Pen, T5 PEGINTRON Inject Kit, T5 PEGINTRON REDIPEN Inject Kit, T5 Pen Needle Syringes, T2 Penicillin G Potassium Inject, T2 Penicillin G Sodium Inject, T2 Penicillin Gk-Iso-Osm Dextrose IV-Froz Piggy, T2 Penicillin V Potassium Soln, T2 Penicillin V Potassium Tabs, T2 PENTAM 300 Inject, T4 PENTAMIDINE ISETHIONATE Inject, T4 PENTASA Caps, T4 PENTAZOCINE-ACETAMINOPHEN Tabs, T4 Pentoxifylline Tabs, T2 Periogard Soln, T2 PERJETA Inject IV, T5 Permethrin Cr, T2 Perphenazine Tabs, T2 Perphenazine-Amitriptyline Tabs, T2 PFizerpen Inject, T2 Phenadoz Rectal Supp, T2 Phenelzine Sulfate Tabs, T2 Brand-name drugs are listed in upper case. Generic drugs are listed in lower case. Pharmacy Benefits are subject to a covered list which is subject to change. Limitations, copayments, and restrictions may apply. Refer to the Care1st Comprehensive formulary and Evidence of Coverage for more information. T1 = Tier 1 T2 = Tier 2 T3 = Tier 3 T4 = Tier 4 T5 = Tier 5 13

79 Phenobarbital Soln, T2 Phenobarbital Tabs, T2 Phenylephrine HCL Eye Drops, T2 PHENYTEK Caps, T3 Phenytoin Sodium Extended Caps, T2 Phenytoin Sodium Inject IV, T2 Phenytoin Sodium IV- Syr, T2 Phenytoin Suspension, T2 Phenytoin Tabs Chew, T2 Philith Tabs, T2 Phospha 250 Neutral Tabs, T2 PHOSPHOLINE IODIDE Eye Drops, T3 PICATO Gel, T5 Pilocarpine HCL Eye Drops, T2 Pilocarpine HCL Tabs, T2 PILOPINE HS Eye Gel, T3 Pindolol Tabs, T1 Pioglitazone HCL Tabs, T2 Pirmella Tabs, T2 Piroxicam Caps, T2 PODOCON-25 Liq, T3 Podofilox Topical Soln, T2 Polyethylene Glycol 3350 Oral Pwd, T2 Polymyxin B Sul-Trimethoprim Eye Drops, T2 POMALYST Caps, T5 Portia Tabs, T2 Potassium Bicarbonate Tabs Eff, T2 Potassium Chl-Normal Saline Inject IV, T2 Potassium Chloride Caps, T2 Potassium Chloride In D5Lr Inject IV, T2 Potassium Chloride Soln, T2 Potassium Chloride Tabs Eff, T2 Potassium Chloride Tabs, T2 Potassium Citrate Tabs, T2 POTIGA 200MG, 400MG Tabs, T5 POTIGA 300MG Tabs, T4 14 POTIGA 50MG Tabs, T4 PRADAXA Caps, T4 Pramipexole Dihydrochloride Tabs, T2 PRANDIN Tabs, T3 Pravastatin Sodium Tabs, T2 Prazosin HCL Caps, T2 Prednisolone Acetate Eye Susp, T2 Prednisolone Sodium Phosphate Eye Drops, T2 Prednisolone Sodium Phosphate Soln, T2 Prednisone Tabs, T2 PREMARIN Tabs, T3 PREMARIN Vaginal Cr, T3 Premasol Inject IV, T2 PREMPHASE Tabs, T3 PREMPRO Tabs, T3 Prenatal Plus Tabs, T2 Prevalite Oral Pwd, T2 Previfem Tabs, T2 PREZISTA 150MG Tabs, T3 PREZISTA 400MG, 60MG, 800MG Tabs, T5 PREZISTA 75MG Tabs, T3 PREZISTA Suspension, T3 PRIFTIN Tabs, T3 PRIMAQUINE Tabs, T3 PRIMAXIN I.M. Inject, T3 Primidone Tabs, T2 PRISTIQ ER Tabs, T4 PROAIR HFA Inhaler, T3 Probenecid Tabs, T2 Probenecid-Colchicine Tabs, T2 Procainamide HCL Caps, T2 Procainamide HCL Tabs, T2 Prochlorperazine Edisylate Inject, T2 Prochlorperazine Maleate Rectal Supp, T2 Prochlorperazine Maleate Tabs, T2 PROCRIT 10000/ML, 20000/ML, 40000/ML Inject, T5 PROCRIT 2000/ML, 3000/ML, 4000/ ML Inject, T3 Procto-Pak Rectal Cr, T2 Proctosol-Hc Rectal Cr, T2 Proctozone-Hc Rectal Cr, T2 Progesterone Caps, T2 PROGLYCEM Suspension, T3 PROGRAF Inject IV, T3 PROLEUKIN Inject IV, T5 PROLIA Inject Syr, T4 PROMACTA Tabs, T5 Promethazine HCL Inject, T2 Promethazine HCL Rectal Supp, T2 Promethazine HCL Syrup, T2 Promethazine HCL Tabs, T2 Promethegan Rectal Supp, T2 PRONESTYL Caps, T3 Propafenone HCL Tabs, T2 Proparacaine HCL Eye Drops, T2 Propranolol HCL Caps, T2 Propranolol HCL Tabs, T2 Propranolol-Hydrochlorothiazid Tabs, T2 Propylthiouracil Tabs, T2 PROQUAD Inject, T3 PROSTIGMIN Tabs, T3 PROTONIX IV Inject IV, T3 Protriptyline HCL Tabs, T2 PULMICORT FLEXHALER Inhaler, T4 PULMOZYME Inhale Soln, T5 Pyrazinamide Tabs, T2 Pyridostigmine Bromide Tabs, T2 Q Quasense Tabs, T2 Quetiapine Fumarate Tabs, T2 Quinapril HCL Tabs, T2

80 Quinapril-Hydrochlorothiazide Tabs, T2 Quinidine Gluconate Tabs, T2 Quinidine Sulfate Tabs, T2 QVAR Inhaler, T3 R RABAVERT Inject Kit, T3 Ramipril Caps, T2 RANEXA Tabs, T3 Ranitidine HCL Caps, T2 Ranitidine HCL Inject, T2 Ranitidine HCL Syrup, T2 Ranitidine HCL Tabs, T2 RAPAMUNE 0.5MG Tabs, T3 RAPAMUNE 1MG, 2MG Tabs, T5 RAPAMUNE Soln, T3 REBIF Inject Syr, T5 REBIF REBIDOSE Inject Pen, T5 Reclipsen Tabs, T2 RECOMBIVAX HB Inject Syr, T3 RECOMBIVAX HB Inject, T3 Rectasol-Hc Rectal Supp, T2 RELENZA Inhaler, T4 RELISTOR Inject Syr, T4 REMICADE Inject IV, T5 REMODULIN Inject, T5 RENAGEL Tabs, T4 RENVELA Tabs, T4 Reprexain Tabs, T2 RESCRIPTOR Tabs, T3 Reserpine 0.1MG Tabs, T2 Reserpine 0.25MG Tabs, T2 RESTASIS Eye Drops, T4 RETROVIR Inject IV, T3 REVATIO Inject IV, T5 REVLIMID Caps, T5 REYATAZ 100MG Caps, T3 REYATAZ 150MG, 200MG, 300MG Caps, T5 RHOGAM PLUS Inject Syr, T3 RHOPHYLAC Inject Syr, T4 Ribasphere Caps, T2 Ribasphere Tabs, T2 Ribavirin Caps, T2 Ribavirin Tabs, T2 RIDAURA Caps, T3 Rifampin Caps, T2 RIFAMPIN Inject IV, T4 RIFATER Tabs, T3 Riluzole Tabs, T2 Rimantadine HCL Tabs, T2 Ringers Injection Inject IV, T2 RISPERDAL CONSTA Inject Syr, T3 Risperidone M-Tab Tabs, T2 Risperidone Odt Tabs, T2 Risperidone Soln, T2 Risperidone Tabs, T2 RITUXAN Inject IV, T5 Rivastigmine Caps, T2 Rizatriptan Tabs, T2 Ropinirole HCL Tabs, T2 ROTATEQ Suspension, T3 Roxicet Tabs, T2 S SABRIL Oral Pwd, T5 SABRIL Tabs, T5 SAIZEN Inject, T5 Salsalate Tabs, T2 SANDOSTATIN LAR Inject Kit, T5 SANTYL Oint, T3 SAPHRIS Tabs Subl, T4 SAVELLA Tabs, T3 Selegiline HCL Caps, T2 Selegiline HCL Tabs, T2 Selenium Sulfide Topical Susp, T2 Selenos Shampoo, T2 SELZENTRY Tabs, T5 SENSIPAR 30MG Tabs, T3 SENSIPAR 60MG, 90MG Tabs, T5 SEREVENT DISKUS Inhaler, T3 SEROMYCIN Caps, T3 SEROSTIM Inject, T5 Sertraline HCL Oral Conc, T2 Sertraline HCL Tabs, T2 SF 5000 Plus Dental Gel, T2 Sildenafil Tabs, T2 Silver Sulfadiazine Cr, T2 SIMULECT Inject IV, T4 Simvastatin Tabs, T1 Single Use Swab Pads, T2 Sodium Bicarbonate Inject IV, T2 Sodium Bicarbonate IV- Syr, T2 Sodium Chloride Inject IV, T2 Sodium Chloride Irrigation, T2 Sodium Citrate & Citric Acid Soln, T2 Sodium Fluoride Dental Soln, T2 Brand-name drugs are listed in upper case. Generic drugs are listed in lower case. Pharmacy Benefits are subject to a covered list which is subject to change. Limitations, copayments, and restrictions may apply. Refer to the Care1st Comprehensive formulary and Evidence of Coverage for more information. T1 = Tier 1 T2 = Tier 2 T3 = Tier 3 T4 = Tier 4 T5 = Tier 5 15

81 SODIUM PHENYLBUTYRATE Oral Pwd, T3 SOLARAZE Gel, T5 SOLTAMOX Soln, T4 SOMATULINE DEPOT Inject Syr, T5 SOMAVERT Inject, T5 SORIATANE Caps, T5 Sorine Tabs, T2 Sotalol Af Tabs, T2 Sotalol Tabs, T2 SOTRET Caps, T4 SPIRIVA Inhaler, T3 Spironolactone Tabs, T2 Spironolactone-HCTZ Tabs, T2 Sprintec Tabs, T2 SPRYCEL Tabs, T5 Sps Suspension, T2 Sronyx Tabs, T2 SSD Cr, T2 Stagesic Caps, T2 STALEVO 100 Tabs, T3 STALEVO 125 Tabs, T3 STALEVO 150 Tabs, T3 STALEVO 200 Tabs, T3 STALEVO 50 Tabs, T3 STALEVO 75 Tabs, T3 Stannous Fluoride Dental Soln, T2 Stavudine Caps, T2 Stavudine Soln, T2 Sterile Pads Bandage, T2 STIVARGA Tabs, T5 STRATTERA Caps, T3 Streptomycin Sulfate Inject, T2 STRIBILD Tabs, T5 STROMECTOL Tabs, T3 SUBOXONE SL Film Tab, T4 SUCRAID Soln, T3 Sucralfate Suspension, T2 16 Sucralfate Tabs, T2 Sulfacetamide Sodium Eye Drops, T2 Sulfacetamide Sodium Eye Ointment, T2 Sulfacetamide-Prednisolone Eye Drops, T2 Sulfadiazine Tabs, T2 Sulfamethoxazole-Trimethoprim Inject IV, T2 Sulfamethoxazole-Trimethoprim Suspension, T2 Sulfamethoxazole-Trimethoprim Tabs, T2 Sulfasalazine DR Tabs, T2 Sulfasalazine Tabs, T2 Sulfazine Tabs, T2 Sulindac Tabs, T2 Sumatriptan Nasal Spray, T2 Sumatriptan Succinate Inject, T2 Sumatriptan Succinate Tabs, T2 SUPRAX Tabs, T3 Sure Comfort Syringes, T2 SUSTIVA Caps, T3 SUSTIVA Tabs, T3 SUTENT Caps, T5 SYLATRON 4-PACK Inject Kit, T5 SYMLIN Inject, T4 SYMLINPEN 120 Inject Pen, T4 SYMLINPEN 60 Inject Pen, T4 SYNAREL Nasal Spray, T5 SYNRIBO Inject, T5 SYNTHROID Tabs, T3 T TABLOID Tabs, T3 Tacrolimus 0.5MG, 1MG Caps, T2 TACROLIMUS 5MG Caps, T5 TAFINLAR Caps, T5 TAMIFLU Caps, T4 TAMIFLU Suspension, T4 Tamoxifen Citrate Tabs, T2 Tamsulosin HCL Caps, T2 TARCEVA Tabs, T5 TARGRETIN Caps, T5 TARGRETIN Gel, T5 TASIGNA Caps, T5 TASMAR Tabs, T3 Tazicef In Dextrose IV-Froz Piggy, T2 Tazicef Inject IV, T2 Tazicef Inject, T2 TAZORAC Cr, T4 TAZORAC Gel, T4 Taztia Xt Caps, T2 TE ANATOXAL BERNA Inject Syr, T3 TECFIDERA Caps, T5 TEGRETOL XR Tabs, T3 TEKTURNA HCT Tabs, T3 TEKTURNA Tabs, T3 Temazepam Caps, T2 TEMODAR Inject IV, T5 TENIVAC Inject Syr, T3 Terazosin HCL Caps, T2 Terbinafine HCL Tabs, T2 Terbutaline Sulfate Inject, T2 Terbutaline Sulfate Tabs, T2 Terconazole Vaginal Cr, T2 Terconazole Vaginal Supp, T2 TETANUS DIPHTHERIA TOXOIDS Inject, T3 Tetanus Toxoid Adsorbed Inject, T2 Tetcaine Eye Drops, T2 Tetracaine HCL Eye Drops, T2 Tetracycline HCL Caps, T2 THALOMID Caps, T5 THEO-24 Caps, T3 Theochron Tabs, T2 Theophylline Anhydrous Tabs, T2

82 Theophylline In 5% Dextrose Inject IV, T2 Theophylline Soln, T2 Theophylline Tabs, T2 THERACYS Inject, T3 Thermazene Cr, T2 THIOLA Tabs, T3 Thioridazine HCL Oral Conc, T2 Thioridazine HCL Tabs, T2 Thiothixene Caps, T2 THYROLAR-1 Tabs, T3 THYROLAR-1/2 Tabs, T3 THYROLAR-1/4 Tabs, T3 THYROLAR-2 Tabs, T3 THYROLAR-3 Tabs, T3 TIAGABINE HCL Tabs, T4 TICAR IN DEXTROSE Inject IV, T3 TICAR Inject IV, T3 TICAR Inject, T3 Ticlopidine HCL Tabs, T2 TIKOSYN Caps, T4 Tilia Fe Tabs, T2 TIMENTIN Inject IV, T3 Timolol Maleate Eye Drops, T1 Timolol Maleate Eye Gel, T2 Timolol Maleate Tabs, T2 TIROSINT Caps, T4 Tizanidine HCL Tabs, T2 TOBI Inhale Soln, T5 Tobramycin Eye Drops, T2 Tobramycin Sulfate Inject, T2 Tobramycin-Dexamethasone Eye Susp, T2 Tolazamide Tabs, T2 Tolbutamide Tabs, T2 Tolmetin Sodium Caps, T2 Tolmetin Sodium Tabs, T2 TOLTERODINE TARTRATE Tabs, T3 Topiragen Tabs, T2 Topiramate Caps, T2 Topiramate Tabs, T2 TOPOTECAN HCL Inject IV, T3 Torsemide Tabs, T2 TPN ELECTROLYTES Inject IV, T3 TRACLEER Tabs, T5 TRADJENTA Tabs, T3 Tramadol HCL Tabs, T2 Tramadol HCL-Acetaminophen Tabs, T2 Trandolapril Tabs, T2 TRANEXAMIC ACID Inject IV, T3 TRANEXAMIC ACID Tabs, T4 Tranylcypromine Sulfate Tabs, T2 TRAVAMULSION IV- Emulsion, T3 Travasol Inject IV, T2 TRAVATAN Z Eye Drops, T3 TRAVOPROST Eye Drops, T3 Trazodone HCL Tabs, T2 TRECATOR Tabs, T3 TRELSTAR Inject Syr, T5 TRELSTAR Inject, T5 TRETINOIN Caps, T5 Tretinoin Cr, T2 Tretinoin Gel, T2 Tri-Legest Fe Tabs, T2 Tri-Linyah Tabs, T2 Tri-Previfem Tabs, T2 Tri-Sprintec Tabs, T2 Triamcinolone 1% Cream Cr, T2 Triamcinolone Acetonide Cr, T2 Triamcinolone Acetonide Dental Paste, T2 Triamcinolone Acetonide Lotion, T2 Triamcinolone Acetonide Oint, T2 Triamterene-HCTZ Caps, T1 Triamterene-HCTZ Tabs, T1 Triamterene-Hydrochlorothiazid Tabs, T1 Triazolam Tabs, T2 Tricitrates Soln, T2 Triderm Cr, T2 Trifluoperazine HCL Tabs, T2 Trifluridine Eye Drops, T2 Trihexyphenidyl HCL Soln, T2 Trihexyphenidyl HCL Tabs, T2 TRILEPTAL Suspension, T3 Trilyte With Flavor Packets Soln, T2 Trimethoprim Tabs, T2 Trimipramine Maleate Caps, T2 Trinessa Tabs, T2 TRISENOX Inject IV, T3 Trivora-28 Tabs, T2 TRIZIVIR Tabs, T5 Trophamine Inject IV, T2 Tropicamide Eye Drops, T2 TRUVADA Tabs, T5 TUDORZA PRESSAIR Inhaler, T4 TWINRIX Inject, T3 TYGACIL Inject IV, T3 Brand-name drugs are listed in upper case. Generic drugs are listed in lower case. Pharmacy Benefits are subject to a covered list which is subject to change. Limitations, copayments, and restrictions may apply. Refer to the Care1st Comprehensive formulary and Evidence of Coverage for more information. T1 = Tier 1 T2 = Tier 2 T3 = Tier 3 T4 = Tier 4 T5 = Tier 5 17

83 TYKERB Tabs, T5 TYPHIM VI Inject, T3 TYSABRI Inject IV, T5 TYZEKA Tabs, T5 TYZINE Nasal Drops, T3 TYZINE Nasal Spray, T3 U U-Cort Cr, T2 UNITHROID Tabs, T3 Ursodiol Caps, T2 V Valacyclovir Tabs, T2 VALCYTE Tabs, T5 Valproate Sodium Inject IV, T2 Valproic Acid Caps, T2 Valproic Acid Soln, T2 Valsartan-Hydrochlorothiazide Tabs, T2 VANCOMYCIN HCL Caps, T5 Vancomycin HCL Inject IV, T2 VAQTA Inject Syr, T3 VAQTA Inject, T3 VARIVAX VACCINE Inject, T3 VASCEPA Caps, T4 VELCADE Inject, T5 VELETRI Inject IV, T5 Velivet Tabs, T2 Venlafaxine HCL ER Caps, T2 VENLAFAXINE HCL ER Tabs, T4 Venlafaxine HCL Tabs, T2 VENTOLIN Inhaler, T3 Verapamil ER Caps, T2 Verapamil ER Pm Caps, T2 Verapamil ER Tabs, T2 Verapamil HCL Caps, T2 Verapamil HCL Tabs, T2 VERDESO Foam, T4 Veripred 20 Soln, T2 VICTOZA 3-PAK Inject Pen, T4 VICTRELIS Caps, T5 VIDAZA Inject, T5 VIDEX Soln, T3 VIGAMOX Eye Drops, T4 VIIBRYD Tabs, T4 VIMPAT Inject IV, T4 VIMPAT Soln, T4 VIMPAT Tabs, T4 Viorele Tabs, T2 VIRACEPT Tabs, T5 VIRAMUNE Suspension, T3 VIRAMUNE XR Tabs, T3 VIREAD Oral Pwd, T5 VIREAD Tabs, T5 VIVOTIF BERNA Caps, T3 VORAXAZE Inject IV, T5 VORICONAZOLE Tabs, T5 VOTRIENT Tabs, T5 VPRIV Inject IV, T5 W Warfarin Sodium Tabs, T1 Water Irrigation, T2 WELCHOL Oral Pwd, T4 WELCHOL Tabs, T4 Wera Tabs, T2 WINRHO SDF Inject, T5 X XALKORI Caps, T5 XARELTO Tabs, T4 XELJANZ Tabs, T5 XENAZINE Tabs, T5 XGEVA Inject, T5 XOLAIR Inject, T5 XTANDI Caps, T5 XYREM Soln, T5 Y YERVOY Inject IV, T5 YF-VAX Inject, T3 Yodoxin Tabs, T2 Z Zafirlukast Tabs, T2 Zaleplon Caps, T2 ZALTRAP Inject IV, T5 ZAVESCA Caps, T5 Zazole Vaginal Cr, T2 ZELBORAF Tabs, T5 ZEMAIRA Inject IV, T5 ZEMPLAR Caps, T3 ZEMPLAR Inject IV, T3 Zenchent Fe Tabs Chew, T2 Zenchent Tabs, T2 ZENPEP Caps, T3 ZETIA Tabs, T3 ZIAGEN Soln, T3 Zidovudine Caps, T2 Zidovudine Syrup, T2 Zidovudine Tabs, T2 Ziprasidone HCL Caps, T2 ZMAX Suspension, T3 ZOLADEX Implant, T5 ZOLEDRONIC ACID Inject IV, T4 ZOLEDRONIC ACID IV-Infusion, T4 ZOLINZA Caps, T5 Zolpidem Tartrate Tabs, T2 ZOMETA IV-Infusion, T5 ZONALON Cr, T3 Zonisamide Caps, T2 ZORBTIVE Inject, T5 ZORTRESS 0.25MG Tabs, T4 ZORTRESS 0.5MG, 0.75MG Tabs, T5 18

84 ZOSTAVAX Inject, T3 Zovia 1-35E Tabs, T2 Zovia 1-50E Tabs, T2 ZOVIRAX Cr, T3 ZYTIGA Tabs, T5 ZYVOX Inject IV, T5 ZYVOX Suspension, T5 ZYVOX Tabs, T (TTY/TDD users call 711) 8:00 a.m. to 8:00 p.m., seven days a week facebook/mycare1st Care1st is a Medicare Advantage HMO plan with a Federal Government contract in Texas and California. Enrollment in Care1st Health Plan depends on contract renewal. The benefit information provided is a brief summary, not a complete description of benefits. Benefits and/or co-payments/co-insurance may change on January 1 of each year. Limitations, copayments, and restrictions may apply For more information contact the plan. This information is available for free in other languages. Please contact Member Services: (TTY: 711), 8:00 a.m. to 8:00 p.m., seven days a week. Esta información está disponible gratuitamente en otros idiomas. Comuníquese con Servicios para los Miembros: (TTY 711), de 8:00 a.m. a 8:00 p.m., los siete días de la semana. 請聯絡會員服務熱線電話 : 聽障和語障人士可致電 711 我們的辦公時間為每週七天, 早上 8:00 點至晚上 8:00 點 H5928_14_139_MK Accepted 19

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86 DeltaCare USA provided by Delta Dental of California We ll do whatever it takes and then some. Find a DeltaCare USA dentist Select from among the many conveniently located DeltaCare USA contracted general dentists. To find the most current listing of DeltaCare USA dental offices you can: Visit our website at deltadentalins.com/ enrollees Click on Find a Dentist on our home page Select DeltaCare USA as your plan network Or call Customer Service at (TTY/TDD users call 711 for help in finding a DeltaCare USA dentist Plan CAD27 Care1st AdvantageOptimum Plan (HMO) - Los Angeles, Orange, San Diego, San Bernardino, Riverside, Fresno, Santa Clara, San Joaquin, Stanislaus, Alameda, San Francisco Counties. Care1st TotalDual Plan (HMO) - San Diego County smarthmo Plan San Joaquin County Welcome to DeltaCare USA quality, convenience, predictable costs DeltaCare USA (administered by Delta Dental Insurance Company) provides you with quality dental benefits at an affordable cost. DeltaCare USA is designed to encourage you to visit the dentist regularly to maintain your dental health. When you enroll, you select a contract dentist to provide services. The DeltaCare USA network consists of private practice dental facilities that have been carefully screened for quality and have agreed to participate in this program. With DeltaCare USA you ll enjoy these features: Quality Extensive benefits for you No restrictions on pre-existing conditions covered, except for work in progress Large, stable network of dentists, so you can enjoy a long-term relationship with your dentist Convenience No claim forms to complete Easy access to specialty care Expanded business hours for toll-free customer service, from 5 a.m. to 6 p.m., Pacific time Predictable costs No deductibles Out of pocket costs are clearly defined Out of area dental emergency coverage up to $100 per emergency No annual or lifetime dollar maximums Administered by Delta Dental Insurance Company H5928_14_097_DENTAL Accepted HL_DCU_CAD27_6719-1_V14_

87 Highlights of your DeltaCare USA Program How your DeltaCare USA program works What if I have questions about my DeltaCare USA Program? Your selected contract dentist will take care of your dental care needs. If you require treatment from a specialist, your contract dentist will handle the referral for you. After you have enrolled, you will receive a Delta Dental membership packet that includes an identification card and a Benefit Booklet that fully describes the benefits of your dental program. Also included in this packet are the name, address and phone number of your contract dentist. Simply call the dental facility to make an appointment. Under the DeltaCare USA program, many services are covered at no cost, while others have copayments (amount you pay your contract dentist) for certain benefits. See the Description of Benefits and Copayments for a list of your benefits. Please note: Dental services that are not performed by your selected contract dentist, or are not covered under provisions for emergency care below, must be preauthorized by Delta Dental to be covered by your DeltaCare USA program. Provisions for emergency care Under your DeltaCare USA program, you are covered for out-ofnetwork dental emergencies. Your program pays up to $100 for out-of-network emergency dental expenses per emergency. My dentist is a Delta Dental dentist but is not on the list of DeltaCare USA dentists. Can I still receive treatment from this dentist? You must receive treatment from your selected DeltaCare USA contract dentist. Please note that Delta Dental dentists are not necessarily DeltaCare USA dentists. With more than 3,800 general and specialist dentists, the DeltaCare USA network is one of the largest dental networks in California. Can I change my contract dentist? You may change contract dentists by notifying us either by phone or in writing, or by visiting our website (deltadentalins.com). If you contact us by the 21st of the month, the change will become effective the first of the following month

88 Highlights of your DeltaCare USA Program How long does it take to get an appointment with a DeltaCare USA dentist? Two to four weeks is a reasonable amount of time to wait for a routine, non-urgent appointment. If you require a specific time, you may have to wait longer. Most DeltaCare USA dentists are in private group practices, which means greater appointment availability and extended office hours. Are pre existing dental conditions and work in progress covered? Treatment for pre-existing conditions, such as extracted teeth, is covered under the DeltaCare USA program. However, benefits are not provided for any dental treatment started before joining the program (that is, work in progress, such as preparations for crowns, root canals and impressions for dentures). How does the DeltaCare USA program encourage preventive care? Your DeltaCare USA program is designed to encourage regular visits to the dentist by having no copayments (fees you pay to the contract dentist) on most diagnostic and preventive benefits. See the enclosed Description of Benefits and Copayments. Does my DeltaCare USA program cover specialists services? Your contract dentist will coordinate your specialty care needs for oral surgery, endodontics or periodontics with an approved contract specialist. If there is no contract specialist within your service area, a referral to an out-of-network specialist will be authorized at no extra cost, other than the applicable copayment. If you are assigned to a dental school clinic for specialty services, those services may be provided by a dentist, a dental student, a clinician or a dental instructor. What if I have questions about my DeltaCare USA program? Call Delta Dental Customer Service at (TTY/TDD users call 711). We have multilingual representatives available from 5 a.m. to 6 p.m. Pacific time, Monday through Friday. Our Customer Service representatives can answer benefits questions, as well as arrange facility transfers and urgent care referrals. Co pay of $8 applies to each office visit. Our Customer Service representatives can answer benefits questions, as well as arrange facility transfers and urgent care referrals

89 Plan CAD27 Description of Benefits and Co-payments SCHEDULE A Description of Benefits and Copayments The benefits shown below are performed as deemed appropriate by the attending Contract Dentist subject to the limitations and exclusions of the program. Please refer to the DeltaCare USA Limitations and Exclusions section for further clarification of benefits. Enrollees should discuss all treatment options with their Contract Dentist prior to services being rendered. Text that appears in italics below is specifically intended to clarify the delivery of benefits under the DeltaCare USA program and is not to be interpreted as CDT 2014 procedure codes, descriptors or nomenclature that are under copyright by the American Dental Association. The American Dental Association may periodically change CDT codes or definitions. Such updated codes, descriptors and nomenclature may be used to describe these covered procedures in compliance with federal legislation. CODE DESCRIPTION ENROLLEE PAYS D0100 D0999 I. DIAGNOSTIC D0120 Periodic oral evaluation - established patient...no Cost D0140 Limited oral evaluation - problem focused...no Cost D0150 Comprehensive oral evaluation - new or established patient...no Cost D0160 Detailed and extensive oral evaluation - problem focused, by report...no Cost D0170 Re-evaluation - limited, problem focused (established patient; not post-operative visit)...no Cost D0180 Comprehensive periodontal evaluation - new or established patient...no Cost D0190 Screening of a patient...no Cost D0191 Assessment of a patient...no Cost D0210 Intraoral - complete series of radiographic images - limited to 1 series every 24 months...no Cost D0220 Intraoral - periapical first radiographic image...no Cost D0230 Intraoral - periapical each additional radiographic image...no Cost D0240 Intraoral - occlusal radiographic image...no Cost D0250 Extraoral - first radiographic image...no Cost D0260 Extraoral - each additional radiographic image...no Cost D0270 Bitewing - single radiographic image...no Cost D0272 Bitewings - two radiographic images...no Cost D0273 Bitewings three radiographic images...no Cost D0274 Bitewings - four radiographic images - limited to 1 series every 6 months...no Cost D0277 Vertical bitewings - 7 to 8 radiographic images... $5.00 D0330 Panoramic radiographic image...no Cost D0460 Pulp vitality tests...no Cost D0470 Diagnostic casts...no Cost D0999 Unspecified diagnostic procedure, by report - includes office visit, per visit (in addition to other services)... $8.00 D1000 D1999 II. PREVENTIVE D1110 Prophylaxis cleaning - adult - 1 per 6 month period...no Cost D1208 Topical application of fluoride - 1 per 6 month period... $

90 Plan CAD27 Description of Benefits and Co-payments D1510 D1515 D1520 D1525 D1550 D1555 Space maintainer - fixed - unilateral...no Cost Space maintainer - fixed - bilateral...no Cost Space maintainer - removable - unilateral...no Cost Space maintainer - removable - bilateral...no Cost Re-cementation of space maintainer...no Cost Removal of fixed space maintainer...no Cost D2000 D2999 III. RESTORATIVE - Includes polishing, all adhesives and bonding agents, indirect pulp capping, bases, liners and acid etch procedures. - When there are more than six crowns in the same treatment plan, an Enrollee may be charged an additional $ per crown, beyond the 6th unit. - Replacement of crowns, inlays and onlays requires the existing restoration to be 5+ years old. * The provider may charge an additional fee up to $ for noble or high noble metal. D2140 Amalgam - one surface, primary or permanent... $24.00 D2150 Amalgam - two surfaces, primary or permanent... $26.00 D2160 Amalgam - three surfaces, primary or permanent... $28.00 D2161 Amalgam - four or more surfaces, primary or permanent... $30.00 D2330 Resin-based composite - one surface, anterior... $25.00 D2331 Resin-based composite - two surfaces, anterior... $31.00 D2332 Resin-based composite - three surfaces, anterior... $35.00 D2335 Resin-based composite - four or more surfaces or involving incisal angle (anterior)... $47.00 D2391 Resin-based composite - one surface, posterior... $75.00 D2392 Resin-based composite - two surfaces, posterior... $85.00 D2393 Resin-based composite - three surfaces, posterior... $95.00 D2394 Resin-based composite - four or more surfaces, posterior... $ D2510 Inlay - metallic - one surface*... $ D2520 Inlay - metallic - two surfaces*... $ D2530 Inlay - metallic - three or more surfaces*... $ D2542 Onlay - metallic - two surfaces*... $ D2543 Onlay - metallic - three surfaces*... $ D2544 Onlay - metallic - four or more surfaces*... $ D2610 Inlay - porcelain/ceramic - one surface... $ D2620 Inlay - porcelain/ceramic - two surfaces... $ D2630 Inlay - porcelain/ceramic - three or more surfaces... $ D2642 Onlay - porcelain/ceramic - two surfaces... $ D2643 Onlay - porcelain/ceramic - three surfaces... $ D2644 Onlay - porcelain/ceramic - four or more surfaces... $ D2650 Inlay - resin-based composite - one surface... $ D2651 Inlay - resin-based composite - two surfaces... $ D2652 Inlay - resin-based composite - three or more surfaces... $ D2662 Onlay - resin-based composite - two surfaces... $ D2663 Onlay - resin-based composite - three surfaces... $ D2664 Onlay - resin-based composite - four or more surfaces... $ D2710 Crown - resin-based composite (indirect)... $

91 Plan CAD27 Description of Benefits and Co-payments D2712 Crown - ¾ resin-based composite (indirect)... $ D2720 Crown - resin with high noble metal*... $ D2721 Crown - resin with predominantly base metal... $ D2722 Crown - resin with noble metal*... $ D2740 Crown - porcelain/ceramic substrate... $ D2750 Crown - porcelain fused to high noble metal*... $ D2751 Crown - porcelain fused to predominantly base metal... $ D2752 Crown - porcelain fused to noble metal*... $ D2780 Crown - ¾ cast high noble metal*... $ D2781 Crown - ¾ cast predominantly base metal... $ D2782 Crown - ¾ cast noble metal*... $ D2790 Crown - full cast high noble metal*... $ D2791 Crown - full cast predominantly base metal... $ D2792 Crown - full cast noble metal*... $ D2794 Crown - titanium*... $ D2910 Recement inlay, onlay or partial coverage restoration... $20.00 D2915 Recement cast or prefabricated post and core... $20.00 D2920 Recement crown... $25.00 D2921 Reattachment of tooth fragment, incisal edge or cusp (anterior)... $47.00 D2931 Prefabricated stainless steel crown - permanent tooth... $75.00 D2940 Protective restoration... $16.00 D2941 Interim therapeutic restoration - primary dentition... $16.00 D2949 Restorative foundation for an indirect restoration... $50.00 D2950 Core buildup, including any pins when required... $50.00 D2951 Pin retention - per tooth, in addition to restoration... $40.00 D2952 Post and core in addition to crown, indirectly fabricated - includes canal preparation... $85.00 D2953 Each additional indirectly fabricated post - same tooth - includes canal preparation... $85.00 D2954 Prefabricated post and core in addition to crown - base metal post; includes canal preparation... $75.00 D2957 Each additional prefabricated post - same tooth - base metal post; includes canal preparation... $75.00 D2970 Temporary crown (fractured tooth) - palliative treatment only... $35.00 D2980 Crown repair necessitated by restorative material failure... $45.00 D2981 Inlay repair necessitated by restorative material failure... $45.00 D2982 Onlay repair necessitated by restorative material failure... $45.00 D3000 D3999 IV. ENDODONTICS D3110 Pulp cap - direct (excluding final restoration)... $15.00 D3120 Pulp cap - indirect (excluding final restoration)... $15.00 D3220 Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament... $35.00 D3221 Pulpal debridement, primary and permanent teeth... $55.00 D3222 Partial pulpotomy for apexogenesis - permanent tooth with incomplete root development... $35.00 D3310 Root canal - endodontic therapy, anterior tooth (excluding final restoration)... $

92 Plan CAD27 Description of Benefits and Co-payments D3320 Root canal - endodontic therapy, bicuspid tooth (excluding final restoration)... $ D3330 Root canal - endodontic therapy, molar (excluding final restoration)... $ D3346 Retreatment of previous root canal therapy - anterior... $ D3347 Retreatment of previous root canal therapy - bicuspid... $ D3348 Retreatment of previous root canal therapy - molar... $ D3351 Apexification/recalcification - initial visit (apical closure/calcific repair of perforations, root resorption, pulp space disinfection, etc.)... $90.00 D3352 Apexification/recalcification - interim medication replacement (apical closure/calcific repair of perforations, root resorption, pulp space disinfection, etc.)... $75.00 D3353 Apexification/recalcification - final visit (includes completed root canal therapy - apical closure/calcific repair of perforations, root resorption, etc.)... $ D3410 Apicoectomy - anterior... $ D3421 Apicoectomy - bicuspid (first root)... $ D3425 Apicoectomy - molar (first root)... $ D3426 Apicoectomy (each additional root)... $ D3427 Periradicular surgery without apicoectomy... $ D3430 Retrograde filling - per root... $50.00 D3450 Root amputation, per root... $85.00 D4000 D4999 V. PERIODONTICS - Includes preoperative and postoperative evaluations and treatment under a local anesthetic. D4210 Gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant... $ D4211 Gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant... $60.00 D4212 Gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth... $60.00 D4240 Gingival flap procedure, including root planing - four or more contiguous teeth or tooth bounded spaces per quadrant... $ D4241 Gingival flap procedure, including root planing - one to three contiguous teeth or tooth bounded spaces per quadrant... $ D4260 Osseous surgery (including flap entry and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant... $ D4261 Osseous surgery (including flap entry and closure) - one to three contiguous teeth or tooth bounded spaces per quadrant... $ D4341 Periodontal scaling and root planing - four or more teeth per quadrant - limited to 4 quadrants during any 12 consecutive months... $85.00 D4342 Periodontal scaling and root planing - one to three teeth per quadrant - limited to 4 quadrants during any 12 consecutive months... $85.00 D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis - limited to 1 treatment in any 12 consecutive months... $85.00 D4910 Periodontal maintenance - limited to 1 treatment each 6 month period... $65.00 D4921 Gingival irrigation - per quadrant...no Cost - 6 -

93 Plan CAD27 Description of Benefits and Co-payments D5000 D5899 VI. PROSTHODONTICS (removable) - For all listed dentures and partial dentures, Copayment includes after delivery adjustments and tissue conditioning, if needed, for the first six months after placement. The Enrollee must continue to be eligible, and the service must be provided at the Contract Dentist s facility where the denture was originally delivered. - Rebases, relines and tissue conditioning are limited to 1 per denture during any 12 consecutive months. - Replacement of a denture or a partial denture requires the existing denture to be 5+ years old. D5110 Complete denture - maxillary... $ D5120 Complete denture - mandibular... $ D5130 Immediate denture - maxillary... $ D5140 Immediate denture - mandibular... $ D5211 Maxillary partial denture - resin base (including any conventional clasps, rests and teeth)... $ D5212 Mandibular partial denture - resin base (including any conventional clasps, rests and teeth)... $ D5213 Maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth)... $ D5214 Mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth)... $ D5225 Maxillary partial denture - flexible base (including any clasps, rests and teeth)... $ D5226 Mandibular partial denture - flexible base (including any clasps, rests and teeth)... $ D5410 D5411 Adjust complete denture - maxillary... $15.00 Adjust complete denture - mandibular... $15.00 D5421 D5422 D5510 Adjust partial denture - maxillary... $15.00 Adjust partial denture - mandibular... $15.00 Repair broken complete denture base... $35.00 D5520 Replace missing or broken teeth - complete denture (each tooth)... $35.00 D5610 Repair resin denture base... $35.00 D5620 D5630 D5640 Repair cast framework... $35.00 Repair or replace broken clasp... $35.00 Replace broken teeth - per tooth... $35.00 D5650 Add tooth to existing partial denture... $20.00 D5660 Add clasp to existing partial denture... $20.00 D5710 Rebase complete maxillary denture... $ D5711 Rebase complete mandibular denture... $ D5720 Rebase maxillary partial denture... $ D5721 Rebase mandibular partial denture... $ D5730 Reline complete maxillary denture (chairside)... $85.00 D5731 Reline complete mandibular denture (chairside)... $85.00 D5740 Reline maxillary partial denture (chairside)... $85.00 D5741 Reline mandibular partial denture (chairside)... $85.00 D5750 Reline complete maxillary denture (laboratory)... $ D5751 Reline complete mandibular denture (laboratory)... $ D5760 Reline maxillary partial denture (laboratory)... $ D5761 Reline mandibular partial denture (laboratory)... $ D5820 Interim partial denture (maxillary) - limited to 1 in any 12 consecutive months... $

94 Plan CAD27 Description of Benefits and Co-payments D5821 Interim partial denture (mandibular) - limited to 1 in any 12 consecutive months... $ D5850 Tissue conditioning, maxillary... $35.00 D5851 Tissue conditioning, mandibular... $35.00 D5900 D5999 VII. MAXILLOFACIAL PROSTHETICS Not Covered D6000 D6199 VIII. IMPLANT SERVICES Not Covered D6200 D6999 IX. PROSTHODONTICS, fixed (each retainer and each pontic constitutes a unit in a fixed partial denture [bridge]) - When a crown and/or pontic exceeds six units in the same treatment plan, an Enrollee may be charged an additional $ per unit, beyond the 6th unit. - Replacement of a crown, pontic, inlay, onlay or stress breaker requires the existing bridge to be 5+ years old. D6210 Pontic - cast high noble metal... $ D6211 Pontic - cast predominantly base metal... $ D6212 D6214 Pontic - cast noble metal... $ Pontic - titanium... $ D6240 Pontic - porcelain fused to high noble metal... $ D6241 Pontic - porcelain fused to predominantly base metal... $ D6242 Pontic - porcelain fused to noble metal... $ D6245 Pontic - porcelain/ceramic... $ D6250 Pontic - resin with high noble metal... $ D6251 Pontic - resin with predominantly base metal... $ D6252 Pontic - resin with noble metal... $ D6600 Inlay - porcelain/ceramic, two surfaces... $ D6601 Inlay - porcelain/ceramic, three or more surfaces... $ D6602 Inlay - cast high noble metal, two surfaces... $ D6603 Inlay - cast high noble metal, three or more surfaces... $ D6604 Inlay - cast predominantly base metal, two surfaces... $ D6605 Inlay - cast predominantly base metal, three or more surfaces... $ D6606 Inlay - cast noble metal, two surfaces... $ D6607 Inlay - cast noble metal, three or more surfaces... $ D6608 Onlay - porcelain/ceramic, two surfaces... $ D6609 Onlay - porcelain/ceramic, three or more surfaces... $ D6610 Onlay - cast high noble metal, two surfaces... $ D6611 Onlay - cast high noble metal, three or more surfaces... $ D6612 Onlay - cast predominantly base metal, two surfaces... $ D6613 Onlay - cast predominantly base metal, three or more surfaces... $ D6614 Onlay - cast noble metal, two surfaces... $ D6615 Onlay - cast noble metal, three or more surfaces... $ D6720 Crown - resin with high noble metal... $ D6721 Crown - resin with predominantly base metal... $ D6722 Crown - resin with noble metal... $ D6740 Crown - porcelain/ceramic... $ D6750 Crown - porcelain fused to high noble metal... $

95 Plan CAD27 Description of Benefits and Co-payments D6751 Crown - porcelain fused to predominantly base metal... $ D6752 Crown - porcelain fused to noble metal... $ D6780 Crown - ¾ cast high noble metal... $ D6781 Crown - ¾ cast predominantly base metal... $ D6782 Crown - ¾ cast noble metal... $ D6790 Crown - full cast high noble metal... $ D6791 Crown - full cast predominantly base metal... $ D6792 Crown - full cast noble metal... $ D6794 Crown - titanium... $ D6930 Recement fixed partial denture... $45.00 D6940 Stress breaker... $ D6980 Fixed partial denture repair necessitated by restorative material failure... $85.00 D7000 D7999 X. ORAL AND MAXILLOFACIAL SURGERY - Includes preoperative and postoperative evaluations and treatment under a local anesthetic. D7111 Extraction, coronal remnants - deciduous tooth... $20.00 D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal)... $20.00 D7210 Surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated... $75.00 D7220 Removal of impacted tooth - soft tissue... $75.00 D7230 Removal of impacted tooth - partially bony... $ D7240 Removal of impacted tooth - completely bony... $ D7241 Removal of impacted tooth - completely bony, with unusual surgical complications... $ D7250 Surgical removal of residual tooth roots (cutting procedure)... $65.00 D7286 Biopsy of oral tissue - soft - does not include pathology laboratory procedures... $45.00 D7310 Alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant... $ D7311 Alveoloplasty in conjunction with extractions - one to three teeth or tooth spaces, per quadrant... $ D7320 Alveoloplasty not in conjunction with extractions - four or more teeth or tooth spaces, per quadrant... $ D7321 Alveoloplasty not in conjunction with extractions - one to three teeth or tooth spaces, per quadrant... $ D7471 Removal of lateral exostosis (maxilla or mandible)... $ D7510 Incision and drainage of abscess - intraoral soft tissue... $45.00 D7960 Frenulectomy - also known as frenectomy or frenotomy - separate procedure not incidental to another procedure...no Cost D7970 Excision of hyperplastic tissue - per arch... $ D7971 Excision of pericoronal gingiva... $

96 Plan CAD27 Description of Benefits and Co-payments D8000 D8999 XI. ORTHODONTICS - The listed Copayment for each phase of orthodontic treatment (limited, interceptive or comprehensive) covers up to 24 months of active treatment. Beyond 24 months, an additional monthly fee, not to exceed $125.00, may apply. - The retention copayment includes adjustments and/or office visits up to 24 months. The benefit for pre-treatment records and diagnostic services includes: D8040 Limited orthodontic treatment of the adult dentition - adults, including covered dependent adult children... $1, D8090 Comprehensive orthodontic treatment of the adult dentition - adults, including covered dependent adult children... $1, D8660 Pre-orthodontic treatment visit... $25.00 D8670 Periodic orthodontic treatment visit (as part of contract)... No Cost D8680 Orthodontic retention (removal of appliances, construction and placement of removable retainers)... No Cost D8999 Unspecified orthodontic procedure, by report - includes treatment planning session... $ D9000 D9999 XII. ADJUNCTIVE GENERAL SERVICES D9110 Palliative (emergency) treatment of dental pain - minor procedure... $35.00 D9211 Regional block anesthesia... No Cost D9212 Trigeminal division block anesthesia... No Cost D9215 Local anesthesia in conjunction with operative or surgical procedures... No Cost D9310 Consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician... $65.00 D9430 Office visit for observation (during regularly scheduled hours) - no other services performed... $8.00 D9440 Office visit - after regularly scheduled hours... $50.00 D9450 Case presentation, detailed and extensive treatment planning... No Cost D9951 D9952 Occlusal adjustment, limited... $55.00 Occlusal adjustment, complete... $ D9999 Unspecified adjunctive procedure, by report - includes failed appointment without 24 hour notice - per 15 minutes of appointment time... $15.00 If services for a listed procedure are performed by the assigned Contract Dentist, the Enrollee pays the specified Copayment. Listed procedures which require a Dentist to provide Specialist Services, and are referred by the assigned Contract Dentist, must be authorized by the Plan. The Enrollee pays the Copayment specified for such services. Procedures not listed above are not covered, however, may be available at the Contract Dentist s filed fees. Filed fees means the Contract Dentist s fees on file with Delta Dental. Questions regarding these fees should be directed to Delta Dental s Customer Service department at (TTY/TDD users call 711)

97 Plan CAD27 Limitations and Exclusions of Benefits SCHEDULE B Limitations of Benefits 1. The frequency of certain Benefits is limited. All frequency limitations are listed in Schedule A, Description of Benefits and Copayments. 2. If the Enrollee accepts a treatment plan from the Contract Dentist that includes any combination of more than six crowns, bridge pontics and/or bridge retainers, the Enrollee may be charged an additional $ above the listed Copayment for each of these services after the sixth unit has been provided. 3. The cost to an Enrollee receiving orthodontic treatment whose coverage is cancelled or terminated for any reason will be based on the Contract Orthodontist s usual fee for the treatment plan. The Contract Orthodontist will prorate the amount for the number of months remaining to complete treatment. The Enrollee makes payment directly to the Contract Orthodontist as arranged. Exclusions of Benefits 1. Any procedure that is not specifically listed under Schedule A, Description of Benefits and Copayments. 2. Any procedure that in the professional opinion of the Contract Dentist: a. has poor prognosis for a successful result and reasonable longevity based on the condition of the tooth or teeth and/or surrounding structures, or b. is inconsistent with generally accepted standards for dentistry. 3. Services solely for cosmetic purposes or for conditions that are a result of hereditary or developmental defects, such as cleft palate, upper and lower jaw malformations, congenitally missing teeth and teeth that are discolored or lacking enamel. 4. Lost or stolen appliances including, but not limited to, full or partial dentures, crowns and fixed partial dentures (bridges). 5. Procedures, appliances or restoration if the purpose is to change vertical dimension, or to diagnose or treat abnormal conditions of the temporomandibular joint (TMJ). 6. Precious metal for removable appliances, metallic or permanent soft bases for complete dentures, porcelain denture teeth, precision abutments for removable partials or fixed partial dentures (overlays, implants, and appliances associated therewith) and personalization and characterization of complete and partial dentures. 7. Implant-supported dental appliances and attachments, implant placement, maintenance, removal and all other services associated with a dental implant. 8. Consultations for non-covered benefits. 9. Dental services received from any dental facility other than the assigned Contract Dentist, a preauthorized dental specialist, or a Contract Orthodontist except for Emergency Services as described in the Contract and/or Benefit booklet

98 Plan CAD27 Limitations and Exclusions of Benefits 10. All related fees for admission, use, or stays in a hospital, out-patient surgery center, extended care facility, or other similar care facility. 11. Prescription drugs. 12. Dental expenses incurred in connection with any dental or orthodontic procedure started before the Enrollee s eligibility with the DeltaCare USA program. Examples include: teeth prepared for crowns, root canals in progress, full or partial dentures for which an impression has been taken and orthodontics. 13. Changes in orthodontic treatment necessitated by accident of any kind. 14. Myofunctional and parafunctional appliances and/or therapies. 15. Composite or ceramic brackets, lingual adaptation of orthodontic bands and other specialized or cosmetic alternatives to standard fixed and removable orthodontic appliances. 16. Extraction of teeth, when teeth are asymptomatic/non-pathologic (no signs or symptoms of pathology or infection), including but not limited to the removal of third molars and orthodontic extractions. 17. Interim partial dentures (stayplates), in conjunction with fixed or removable appliances, are limited to the replacement of extracted anterior teeth for adults during a healing period when the teeth cannot be added to an existing partial denture. 18. Benefits for a soft tissue management program are limited to those parts, which are listed covered services listed on Schedule A. If an Enrollee declines non-covered services within a soft tissue management program, it does not eliminate or alter other covered benefits. 19. Treatment or appliances that are provided by a Dentist whose practice specializes in prosthodontic services

99 SmileWay Wellness Program Find all of our dental health resources, including risk assessment quizzes, articles, videos and a free e-newsletter subscription, at: mysmileway.com. Connect with us! facebook.com/deltadentalins twitter.com/deltadentalins youtube.com/deltadentalins DeltaCare USA Customer Service (TTY/TDD users call 711). Care1st Health Plan is an HMO plan with a Medicare contract and a contract with the California Medicaid program. Enrollment in Care1st Health Plan depends on contract renewal. The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Benefits and/or co-payments/ co-insurance may change on January 1 of each year. Limitations, copayments, and restrictions may apply. Care1st Health Plan Member Services: (TTY/TDD users call 711), 8am 8pm, 7 days a week. NOTE: THIS IS ONLY A BRIEF SUMMARY OF THE PLAN. The Group Dental Service Contract must be consulted to determine the exact terms and conditions of coverage. A Delta Dental Evidence of Coverage will be sent to you upon enrollment. If you wish to review a Delta Dental Evidence of Coverage prior to enrollment, you may request a copy by calling the Customer Service department at (TTY/TDD users call 711). In California, DeltaCare USA is underwritten by Delta Dental of California and administered by Delta Dental Insurance Company. These companies are financially responsible for their own products. Customer Service (TTY/TDD users call 711) Monday through Friday 5 a.m. to 6 p.m., Pacific time Provided by: Delta Dental of California Park Plaza Drive, Suite 200 Cerritos, CA Administered by: Delta Dental Insurance Company P.O. Box 1803 Alpharetta, GA deltadentalins.com/enrollees A REGISTERED MARK OF DELTA DENTAL PLANS ASSOCIATION

100 A Medicare approved HMO plan OutbOund EducatiOn & VErificatiOn (OEV) call After receiving your application, a Care1st (HMO, HMO SNP) Health Plan representative will call you to review your application and answer any questions you may have. They will also explain Care1st guidelines and procedures. This call is required by Medicare and will not affect the status of your application. Your sales agent will not be present during the time of the call. Topics that will be discussed include: Care1st Health Plan is an HMO Plan. What does this mean for our members? Care1st is a Medicare Advantage Prescription Drug Plan. Care1st is not Original Medicare and it is not a Medigap or Medicare supplemental insurance plan. Use your Care1st member ID card for receiving services. Do not use your red, white and blue Medicare card. Care1st offers a list of services and their cost sharing amounts. We will make sure you have this list. Care1st offers a network of doctors, specialists, hospitals, and other providers that provide healthcare services to plan members. Familiarize yourself with these approved providers because you must use our in network providers to get your healthcare services. These healthcare providers in the plan s network can change at any time, so check our website at: or call Member services for the most up-to-date list. Care1st has a network of pharmacies. In most situations, we ll only pay for your prescriptions if you use a pharmacy in our network. We will explain Care1st s membership enrollment cancellation policy. H5928_14_040_MK Accepted

101 Your guide for enrollment confirmation or verification Please review your personal checklist for reference around submitting your enrollment When submitting an enrollment or enrolling by the phone you re confirming that you understand the type of plan you re enrolling in. I will receive an outbound enrollment verification (0EV) call within the next 15 days to confirm my understanding and intent to enroll in the plan. Once my enrollment is approved by Medicare, Care1st will provide my Medicare health and/or prescription drug coverage. I understand that the plan I have chosen is NOT a Medicare supplement (Medigap) plan. Once my enrollment is approved by Medicare, I will receive a member ID card. I understand that I must use this member ID card instead of my Original Medicare card when I receive healthcare services or visit the pharmacy. I have reviewed the all the information available in this enrollment guide. I understand the plan s premium, deductible, covered benefits, copays and coinsurance amounts, if applicable. For additional information I can refer to the Evidence of Coverage, which I will receive in my Welcome Kit. I understand that I must continue to pay my Medicare Part B premium, if not otherwise paid for under Medicaid or by another third party. If a power of attorney (or any other person who assists in my healthcare decisions) should have been included with this enrollment process, they were present or contacted. I understand that my plan will only cover healthcare and services provided by physicians and hospitals in the plan s network. Except for emergencies, these plans do not cover care received outside the network. The agent verified whether any of my doctors are in the plan s network. For plans with prescription drug coverage I have reviewed all of my current prescription medications and have verified if they are covered within the plan s formulary. For my medications that are not listed in the plan s formulary, I understand they are not covered by the plan, unless an exception is granted. If I reach the coverage gap, I understand my cost and coverage may change, depending on my level of state assistance, if applicable. I understand that a late-enrollment penalty (LEP) will be added to my monthly Part D premium if I did not join a Medicare plan when I was first eligible. Care1st is a Medicare Advantage HMO plan with a Federal Government contract in Texas and California. Enrollment in Care1st Health Plan depends on contract renewal. The benefit information provided is a brief summary, not a complete description of benefits. Benefits and/or co-payments/co-insurance may change on January 1 of each year. Limitations, copayments, and restrictions may apply For more information contact the plan. This information is available for free in other languages. Please contact Member Services: (TTY: 711), 8:00 a.m. to 8:00 p.m., seven days a week. Esta información está disponible gratuitamente en otros idiomas. Comuníquese con Servicios para los Miembros: (TTY 711), de 8:00 a.m. a 8:00 p.m., los siete días de la semana. 請聯絡會員服務熱線電話 : 聽障和語障人士可致電 711 我們的辦公時間為每週七天, 早上 8:00 點至晚上 8:00 點 H5928_14_040_MK Accepted

102 What to ExpEct after EnrollmEnt 1 Enrollment Forms Received Your enrollment is sent to Care1st (HMO, HMO SNP) by phone, mail, fax, agent or via the Internet. 2 Confirmation Within 10 days of enrollment, you will receive a confirmation of enrollment letter in the mail. This letter will also serve as confirmation that Medicare has approved your enrollment forms. 3 Verification Call Within 10 days of enrollment you will receive a phone call to confirm that your Medicare Advantage Plan was explained completely by your sales agent. During this call you will be asked to confirm that it was your intent to enroll in the plan. 4 Member ID Card Within 10 days of your confirmed enrollment you will receive your Member ID card. You need to bring your new Member ID card with you to all doctor, hospital and pharmacy visits. 5 Welcome Package You will receive a package containing important plan documents. They include the Evidence of Coverage, Drug Formulary and Provider Directory. 6 Premium Assistance If you qualify for the state s Extra Help, you will receive a LIS (Low Income Subsidy) letter within 10 days of verified enrollment. A Medicare approved HMO plan If you have questions about enrollment, call: (TTY/TDD users call 711) 8:00 a.m. to 8:00 p.m., seven days a week facebook/mycare1st Care1st is a Medicare Advantage HMO plan with a Federal Government contract in Texas and California. Enrollment in Care1st Health Plan depends on contract renewal. This information is available for free in other languages. Please contact Member Services: (TTY: 711), 8:00 a.m. to 8:00 p.m., seven days a week. Esta información está disponible gratuitamente en otros idiomas. Comuníquese con Servicios para los Miembros: (TTY 711), de 8:00 a.m. a 8:00 p.m., los siete días de la semana. 請聯絡會員服務熱線電話 : 聽障和語障人士可致電 711 我們的辦公時間為每週七天, 早上 8:00 點至晚上 8:00 點 H5928_14_045_MK Accepted

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104 Visit Us Online! Your Care1st (HMO, HMO SNP) Resource Site: A Medicare approved HMO plan Our website is your resource for the most up-to-date information. You ll find Provider listings for specialists and primary care physicians Retail Pharmacy list Drugs and formulary information Service area Member materials including Statement of Benefits, Evidence of Coverage and Annual Notice of Changes Out-of-Network Coverage information and much more... Bookmark our page or add us to your favorites for quick and easy access. For questions about our website, call: (TTY/TDD users call 711) 8:00 a.m. to 8:00 p.m., seven days a week facebook/mycare1st Care1st is a Medicare Advantage HMO plan with a Federal Government contract in Texas and California. Enrollment in Care1st Health Plan depends on contract renewal. This information is available for free in other languages. Please contact Member Services: (TTY: 711), 8:00 a.m. to 8:00 p.m., seven days a week. Esta información está disponible gratuitamente en otros idiomas. Comuníquese con Servicios para los Miembros: (TTY 711), de 8:00 a.m. a 8:00 p.m., los siete días de la semana. 請聯絡會員服務熱線電話 : 聽障和語障人士可致電 711 我們的辦公時間為每週七天, 早上 8:00 點至晚上 8:00 點 H5928_14_048_MKB Accepted

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106 Multi-language interpreter ServiceS English French We have free interpreter services to answer any questions you may have about our health or drug plan. To get an interpreter, just call us at Someone who speaks English can help you. This is a free service. Nous proposons des services gratuits d interprétation pour répondre à toutes vos questions relatives à notre régime de santé ou d assurance-médicaments. Pour accéder au service d interprétation, il vous suffit de nous appeler au Un interlocuteur parlant Français pourra vous aider. Ce service est gratuit. Spanish Tenemos servicios de intérprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos. Para hablar con un intérprete, por favor llame al Alguien que hable español le podrá ayudar. Este es un servicio gratuito. Simplified Chinese 我们提供免费的翻译服务 帮助您解答关于健康或药 物保险的任何疑问 如果您需要此翻译服务 请致电 我们的中文工作人员很乐意帮助 您 这是一项免费服务 Traditional Chinese 您對我們的健康或藥物保險可能存有疑問 為此我們 提供免費的翻譯 服務 如需翻譯服務 請致電 我們講中文的人員將樂意為您提供幫助 這 是一項免費服務 Tagalog Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot. Upang makakuha ng tagasaling-wika, tawagan lamang kami sa Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog. Ito ay libreng serbisyo. Vietnamese Chúng tôi có dịch vụ thông dịch miễn phí để trả lời các câu hỏi về chương sức khỏe và chương trình thuốc men. Nếu quí vị cần thông dịch viên xin gọi sẽ có nhân viên nói tiếng Việt giúp đỡ quí vị. Đây là dịch vụ miễn phí. German Unser kostenloser Dolmetscherservice beantwortet Ihren Fragen zu unserem Gesundheits- und Arzneimittelplan. Unsere Dolmetscher erreichen Sie unter Man wird Ihnen dort auf Deutsch weiterhelfen. Dieser Service ist kostenlos. Korean 당사는 의료 보험 또는 약품 보험에 관한 질문에 답해 드리고자 무료 통역 서비스를 제공하고 있습니다. 통역 서비스를 이용하려면 전화 번으로 문의해 주십시오. 한국어를 하는 담당자가 도와 드릴 것입니다. 이 서비스는 무료로 운영됩니다. H5928_13_003_GEN File & Use

107 Multi-language interpreter ServiceS Russian French Creole Если у вас возникнут вопросы относительно страхового или медикаментного плана, вы можете воспользоваться нашими бесплатными услугами переводчиков. Чтобы воспользоваться услугами переводчика, позвоните нам по телефону Вам окажет помощь сотрудник, который говорит по pусски. Данная услуга бесплатная. Nou genyen sèvis entèprèt gratis pou reponn tout kesyon ou ta genyen konsènan plan medikal oswa dwòg nou an. Pou jwenn yon entèprèt, jis rele nou nan Yon moun ki pale Kreyòl kapab ede w. Sa a se yon sèvis ki gratis. Arabic أي عن لإلجابة يةالمجان الفوري المترجم خدمات نقدم إننا لدينا األدوية جدول أو بالصحة تتعلق أسئلة. على للحصول مترجم على بنا االتصال سوى عليك ليس فوري العربية يتحدث ما شخص سيقوم بمساعدتك. مجانية خدمة هذه. Italian È disponibile un servizio di interpretariato gratuito per rispondere a eventuali domande sul nostro piano sanitario e farmaceutico. Per un interprete, contattare il numero Un nostro incaricato che parla Italianovi fornirà l assistenza necessaria. È un servizio gratuito. Portugués Dispomos de serviços de interpretação gratuitos para responder a qualquer questão que tenha acerca do nosso plano de saúde ou de medicação. Para obter um intérprete, contacte-nos através do número Irá encontrar alguém que fale o idioma Português para o ajudar. Este serviço é gratuito. Polish Umożliwiamy bezpłatne skorzystanie z usług tłumacza ustnego, który pomoże w uzyskaniu odpowiedzi na temat planu zdrowotnego lub dawkowania leków. Aby skorzystać z pomocy tłumacza znającego język polski, należy zadzwonić pod numer Ta usługa jest bezpłatna. Hindi हम र व थ य य दव क य जन क ब र म आपक कस भ श न क जव ब द न क लए हम र प स म फ त द भ षय स व ए उपलब ध ह. एक द भ षय प त करन क लए, बस हम पर फ न कर. क ई व य क त ज हन द ब लत ह आपक मदद कर सकत ह. यह एक म फ त स व ह. Japanese 当社の健康 健康保険と薬品 処方薬プランに 関するご質問にお答えするために 無料の通 訳サービスがありますございます 通訳をご用 命になるには にお電話 ください 日本語を話す人 者 が支援いたしま す これは無料のサービスです H5928_13_003_GEN File & Use

108 Multi-language interpreter ServiceS Armenian Hmong Մեր առողջապահական կամ դեղերի ծրագրի վերաբերյալ ձեր ունեցած ցանկացած հարցի պատասխանելու համար ունենք անվճար թարգմանչական ծառայություններ: Թարգմանիչ ձեռք բերելու համար պարզապես զանգահարեք մեզ` համարով: Հայերեն խոսող մի անձ կարող է ձեզ օգնել: Այս ծառայությունն անվճար է: Peb muaj kev pab txhais lus pub dawb los pab teb cov nqe lus nug uas tej zaum koj yuax muaj nyob rau ntawm peb txoj kev npaj saib xyuas kev noj qab haus huv lossis kev npaj saib xyuas txog yeeb tshuaj. Yuav tau ib tug kws txhais lus ces cia li hu rau peb ntawm tus xov tooj (Los Angeles) lossis (San Diego). Tus neeg uas hais Lus Hmoob tuaj yeem pab koj tau. Qhov no yog ib qho kev pab dawb. Khmer eyigmanesvabig~kbke beday²tkit«fâ edimºieqâiysmnyr GÃImYyEdlG~kman GMBIKMeragsuxPaB É{sfrbs eyig. edimºi[vng~kbke b Kan EtTUrs&BæmkeyIg tamelx eyigmanmnus EdlniyayPasaExµr GacCYyG~kVn. esvaenh KW²tecj«fÂeT. Farsi ییوگخساپ یارب ار ناگیار یهافش همجرت تامدخ ام ینامرد همیب دروم رد تسا نکمم هک یلاؤس هنوگره هب میراد رایتخا رد دیشاب هتشاد ام یئوراد ای. یارب یهافش همجرت تامدخ تفایرد هب ام اب تسیفاک هرامش دییامن لصاح سامت. یصخش امش هب دناوت یم دنک یم تبحص یسراف هب هک دنک کمک. دنشاب یم ناگیار تامدخ نیا. H5928_13_003_GEN File & Use