2018 Hearing Aids. Apply your benefit and receive two digital Level I hearing aids with $0 copay!

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1 Quality, Affordability. Transparency. Simplicity 2018 Hearing Aids Apply your benefit and receive two digital Level I hearing aids with 0 copay! * All hearing instruments available in all sizes and styles according to manufacturer's production Average Retail per aid Benefit per ear Member copay, 1st instrument 0* Member copay, 2nd instrument 0* Manufacturer Hearing Aids Style Price Arena 2s BTE Free Ria 2 BTE Free Ria 2 CIC Free Ria 2 ITE Free Ria 2 ITC Free Ria 2 OF Free Ria 2 RIC Free Unitron Unitron Widex inox 10 Click-Fit Joy 10 Sterling 10 Targa + Targa 5 Moxi Stride Dream 110 LEVEL III Average Retail per aid 1, Benefit per ear Additional discount on first instrument 450 Member copay, 1st instrument 550 Additional discount on second instrument 450 Member copay, 2nd instrument 550 Manufacturer Hearing Aids Price Beltone Ally 2 Beltone Origin Y0114_18_33239 U CMS ACCEPTED 10/28/2017

2 Joy Sterling Siemens Intuis Unitron Moxi Unitron Stride Widex Unique LEVEL IV Average Retail per aid Benefit per ear Additional discount on first instrument Member copay, 1st instrument Additional discount on second instrument Member copay, 2nd instrument 1, Beltone Ally Beltone Origin Beltone Promise Ria 2 Pro 800 Resound Enya Emerald Joy Sterling Siemens Primax lh Siemens Silk Click Primax Widex Unique LEVEL V Average Retail per aid 2,350 Benefit per ear Additional discount on first instrument 750 Member copay, 1st instrument 1,100 Additional discount on second instrument 750 Member copay, 2nd instrument 1,100 Beltone Bold 3 1,100 Nera 2 Pro 1,100 Emerald 40 6c 1,100 Mosaic 40 6c 1,100 Sterling 40 6c 1,100 inox 40 6c Click Fit 1,100 Siemens Primax 3 1,100 Siemens Silk Click Primax 3 1,100 Starkey Halo 2 i1600 1,100 Starkey Halo iq i1600 1,100 Starkey Muse iq i1600 1,100

3 Starkey Z Series i70 1,100 Unitron Moxi 700 1,100 Unitron Stride 700 1,100 Widex Beyond 220 Fusion 1,100 Widex Super 220 1,100 Widex Unique LEVEL VI Average Retail per aid Benefit per ear Additional discount on first instrument Member copay, 1st instrument Additional discount on second instrument Member copay, 2nd instrument 3,200 1,200 1, 1,200 1, Beltone Promise 17 1,375 Alta 2 Pro 1, Siemens Primax 5 Pure 13 ВТ 1, Siemens Pure Primax 5 1, Starkey Halo iq i2000 1, Starkey Muse iq i2000 1, Starkey Soundlens , Starkey Soundlens Synergy iq , Starkey Z Series i90 1, Unitron Moxi 800 1, Unitron Stride 800 1, Widex Super 400 1, Widex Unique 440 1,375 CareMore Health Plan is an HMO/HMO SNP plan with a Medicare contract. Enrollment in CareMore Health Plan depends on contract renewal. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or copayments/co-insurance may change on January 1 of each year.

4 NOTICE OF NON-DISCRIMINATION We comply with applicable Federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability, or sex. We do not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. We: Provide free aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, other formats) Provide free language services to people whose primary language is not English, such as: o Qualified interpreters o Information written in other languages If you need these services, contact Member Services. If you believe that we have failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Member Services, Appeals & Grievances, Park Plaza Drive, Suite 150, Mailstop 6150, Cerritos, CA 90703, , TTY 711. You can file a grievance in person or by mail, fax, or . If you need help filing a grievance, Member Services Representative is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C , (TDD) Complaint forms are available at index.html. Amharic Arabic Armenian Bengali Chinese English French ATTENTION: If you speak a language other than English, language assistance services, free of charge, are available to you. Call

5 German Hindi Hmong Ilocano Japanese Korean Kru (Bassa) Mon-Khmer, Cambodian Navajo Persian (Farsi) Punjabi Russian Samoan Serbo-Croatian (TTY: 711) Spanish Syriac Tagalog Thai Urdu Vietnamese Y0114_18_32484_I _001 (09/01/2017).(TTY: 711) : NOND_AZ

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