MINNESOTA

2018 MEDICARE PLANS

MEDICA ADVANTAGE SOLUTION®(HMO-POS) Coverage Details

Y0088_ 4845 CMS Accepted

Talk with an expert consultant you can trust.

Call 1-800-918-2416 (TTY: 711) to speak with a Medicare consultant who can help you evaluate your situation and make the best coverage choice for you and your budget.

ONE LOW PREMIUM. ONE GREAT PLAN. Introducing Medica Advantage

Solution. One low monthly premium

gives you medical and Part D drug

coverage, plus the extras you want.

Advantage Solution is exclusively

available to residents of the 9-county

Twin Cities metro: Anoka, Carver,

Dakota, Hennepin, Ramsey, Scott,

Sherburne, Washington and Wright.

Attend a free Get the details online. Medicare Workshop.

Visit medica.com/Medicare To find a workshop near you, for valuable information and visit medica.com/ resources to help you make the MedicareWorkshops. You’ll best coverage decisions. learn everything you need to know about Medicare and affordable plan options from Medica.

THE MEDICAL AND DRUG COVERAGE YOU NEED IN ONE PLAN Just $65.40 a month Medica Advantage Solution covers medical and Part D drug costs that Medicare does not pay. Plus, it protects you from

unlimited out-of-pocket costs. We offer one plan option for 2018 — Edge — that includes many important plan features:

» Affordable copays/coinsurance for medical and Part D » Worldwide emergency coverage » $0 copay for annual physical exam » Access to more than 64,000 pharmacies nationwide » $25 copay for routine vision and hearing exams » Free fitness center membership through SilverSneakers®

» $5,900 annual out-of-pocket limit » 4.5 Star rating from Medicare* out of five stars for 2017 » Extensive drug formulary with $0 copays for *Medicare evaluates plans based on a 5-star rating system.

Tier 1 drugs (after deductible) Star Ratings are calculated each year and may change from » Broad Twin Cities provider network with no referrals required one year to the next. » Out-of-network coverage for most services when you

travel throughout the United States at any provider that accepts Medicare

Advantage Solution Provider Network Advantage Solution offers a broad provider network in the Twin Cities metro that includes major healthcare systems,* such as:

» Allina Health » CentraCare Health

» Fairview Health Services/HealthEast Care System » Hennepin County Medical Center (HCMC)

» North Memorial Health » Many other facilities, clinics

» Ridgeview Medical Center & Clinics and providers

Search the Advantage Solution provider network at medica.com/AdvantageSolutionProviders *These providers may also contract with other Medicare plans/Part D sponsors.

Advantage Solution is a Medicare Advantage plan. Medicare Advantage plans like Advantage Solution are private plans that administer your Part A and Part B benefits on behalf of Medicare. Advantage Solution also includes Part D drug benefits, giving you the convenience of having one plan for your medical, hospital and prescription drug coverage.

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BENEFIT DETAILS

2017 Original Medicare

ADVANTAGE SOLUTION EDGE

IN-NETWORK OUT-OF-NETWORK

When you use a provider in the Advantage Solution

network

Providers that accept Medicare

With Advantage Solution Edge you will pay your lowest copay/coinsurance amount when you use a network provider. Most medical services are covered out of network too, but you will have higher cost sharing when you use an out-of-network provider – typically 20%. Emergency and urgent care services are covered the same in- and out-of-network. See page 10 for more information on out-of-network coverage.

YOU PAY

PRESCRIPTION DRUG COVERAGE

Advantage Solution has an extensive five-tier formulary (list of covered drugs). The nationwide pharmacy network includes all major chains and thousands of independent pharmacies. Plus, there are no preferred pharmacies - you pay the same copay no matter which network pharmacy you choose!

YOU PAY

Part D Deductible $250

Part D Benefits (30-Day Retail)

Level One – Initial Coverage (Shared drug costs $0 - $3,750)

Tier 1 - Commonly Prescribed Generic $0

Tier 2 – Low-Cost Generic $4

Tier 3 – More Expensive Generic & Brand $40

Tier 4 - Higher Priced Generic & Brand 50%

Tier 5 – Generic or Brand for Complex Conditions 28%

Level Two – Coverage Gap (Member-only drug costs up to $5,000)

Generic 44%

Covered Brand 35%

Level Three – Catastrophic Coverage (Shared drug costs $5,000 and up)

Generic $3.35 or 5%*

Other Drugs $8.35 or 5%*

CVS Caremark Mail Service Pharmacy

YOU PAY

Tier 1 – 3 prescription drugs 2 copays for 3-month supply

Monthly Premium $134 for Part B $65.40

Medical Deductible $183 for Part B $0 $250*

Medical Benefits

Preventive Services $0 $0 $0

Primary Care / Convenience Care 20% $25 20%

virtuwell® eVisits n/a $0 n/a

Specialist Office Visit 20% $50 20%

Urgent Care 20% $40 $40*

Chiropractic** 20% $20 100%

Eye Exam – Routine Annual 100% $25 100%

Hearing Exam – Routine Annual 100% $25 100%

X-Ray /Radiology 20% 20% 20%

Diagnostic Tests 20% 20% 20%

Lab Services $0 $0 20%

Diabetes Supplies 20% 20% 20%

Durable Medical Equipment 20% 20% 100%

Part B Drugs 20% 20% 20%

Outpatient Surgery 20% $250 20%

Ambulance 20% $250 $250*

Emergency Care – U.S. 20% $80 $80*

Emergency Care – Worldwide 20% 20% 20%*

Inpatient Hospital Days 1 – 60: $1,316 total Days 61-90: $329/day Days 91-150: $658/day

Days 1-5: $320/day Days 6-90: $0/day 20%

Skilled Nursing Facility Days 1-20: $0/day Days 21-100: $164.50/day

Days 101+: 100%

Days 1-20: $0/day Days 21-100: $150/day 20%

*Out-of-network deductible does not apply to emergency care, urgent care and ambulance services. **Medicare-covered visit for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part). You must continue to pay your Medicare Part B premium.

*Whichever is greater.

Convenience and drug savings through mail order » Pay only two copays for a three-month supply of

Tier 1 - 3 prescription drugs.

» Order your refills online anytime, anywhere - it is fast and easy.

» Track your order in real time and typically receive in just one to four days.

Covered Drugs » The Advantage Solution formulary is a list of drugs that

are covered by the plan. It includes more than 2,800 prescription drugs.

» You can check online to see if your drugs are covered at medica.com/Medicare.

» To request a printed formulary (covered drug list), you can call Medica at 1-800-918-2416 (TTY: 711).

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OUR EXTRAS MAKE A HEALTHY PLAN EVEN

A great Medicare plan is only one piece of the puzzle when it comes to maintaining your health. So we HEALTHIER. provide you with the extra resources you need to stay

SilverSneakers®

makes it easy to stay active.

Advantage Solution Edge includes a FREE SilverSneakers membership. This program helps people age 65 and over improve their well being through a variety of fitness options.

» More than 13,000 participating fitness locations nationwide

» Enroll at multiple locations any time

» Access to classes, exercise equipment and other amenities

» Track your fitness progress online and find useful health information.

Visit SilverSneakers.com for a complete list of facilities and options.

healthy each and every day.

Personal Advocate and NurseLine™ are ready to help.

HealthAdvocate™ has your back if you have questions about your Medica plan coverage, or need help navigating the medical system.

Our trained Personal Health Advocates can help you tackle health-related questions—from finding the right doctor to resolving claims questions.

NurseLine is available 24/7—highly trained nurses can answer your questions about symptoms, medications and health conditions.

Both services are available at no additional cost.

$0 eVisits through virtuwell®

With Advantage Solution you will have access to quick, convenient online care through virtuwell. Available anytime, anywhere from your computer or mobile device, virtuwell® can treat over 50 common conditions. Get a diagnosis, treatment plan and prescription (if needed), often in less than 30 minutes. The service is available 24/7 with no appointment needed and a $0 copay.

Care coordination when you need it.

Medica provides extra support to members with complex health conditions and social service needs. Based on your specific situation, a Medica Care Coordinator will be made available to you. They can call to see how you are doing, help make doctor appointments, work with your healthcare team, give you community resource information and much more.

Access tools at mymedica.com

mymedica.com is a one-stop member resource that puts your health plan benefits and activity at your fingertips. Take advantage of an array of self-service tools that give you access to your Medica plan information 24/7, 365 days a year.

Once you enroll, you can register to:

» Track medical or pharmacy claims

» Find a network doctor or pharmacy

» Order a replacement ID card

» Check prescription drug prices

The information you need is in the mail.

As a Medica member, you will receive our Focus on Health newsletter three times a year. It is full of practical information to help you maintain or improve your well being.

Shortly after enrolling you will receive a new member kit that includes a Quick Reference Guide to help you understand your coverage and easily access your benefits.

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HOW TO ENROLL IN MEDICA ADVANTAGE SOLUTION

There are three ways to enroll in Advantage Solution. Choose the one that works best for you:

Call 1-800-918-2416 (TTY: 711) for fast and easy enrollment over the phone.

Go to medica.com/Medicare to complete your enrollment online.

Complete and sign a paper application and submit via mail, fax or web. You can request a paper application by calling 1-800-918-2416 (TTY: 711).

Submit your completed paper forms via mail, fax or web.

Mail to: Medica Medicare Solutions PO Box 6300 Eau Claire, WI 54702-9713

Or fax to: 1-855-250-2166

Or upload securely at: medica.com/EnrollmentUpload

Important Enrollment Periods Initial Enrollment Period (IEP) This is when you first become eligible for Medicare at around age 65. You have a seven-month window during which you can sign up for Medicare: three months before your birthday month, during your birthday month and three months after your birthday month.

Annual Election Period (AEP) Medicare open enrollment is October 15–December 7 each year for January 1 coverage. All enrollment, disenrollment or plan change options are available to you at this time. Once you enroll in Medica Advantage Solution, you cannot change plans until the next annual election period.

Special Enrollment Period (SEP) A Special Enrollment Period allows you to make changes to your Medicare coverage that normally you can only make during your Initial Enrollment Period or the Annual Election Period. There are many types of events that can trigger a Special Enrollment Period.

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What to expect after you enroll Once you have submitted your application, you can expect to receive the following communications from us:

1 Acknowledgement Within about a week, you will receive a letter letting you know that your application has been received.

ID Card Within one to two weeks, you will receive your ID card. (NOTE: Your ID card is not included in your member packet—it is sent separately.)

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3

4

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Member Packet Within two weeks, you will receive your member packet, which will contain your Evidence of Coverage, member guide and other important materials that you will want to read and keep for future reference.

Verification Communication Medicare requires that we contact you to verify that you are familiar with the terms of your new plan.

Confirmation Letter This letter confirms Medicare’s approval of your enrollment in Medica Advantage Solution.

Medica Advantage Solution eligibility You are eligible to enroll in Medica Advantage Solution if you have Medicare Part A and Part B, you do not have End-Stage Renal Disease (ESRD) and your permanent residence is in the Advantage Solution service area.

Service area Medica Advantage Solution is available to residents of the following Minnesota counties:

Anoka Carver Dakota Hennepin Ramsey Scott Sherburne Washington Wright

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IMPORTANT PLAN INFORMATION Out-of-Network Coverage (Point of Service)

Emergency Services You pay the same $80 copay for emergency services received out of network within the U.S. and its territories as you do in network. Outside the U.S. and its territories, you pay 20% for emergency care coverage worldwide. The $250 out-of-network deductible does not apply for emergency services.

Non-Emergency Services When you visit an out-of-network provider for non-emergency care, you pay 20% coinsurance for most covered services after your $250 out-of-network deductible is met. You may use any provider that accepts Medicare. Not all services are covered. See the plan Summary of Benefits for more information.

We pay up to $100,000 per year for covered services received from out-of-network providers.

Advantage Solution Provider Network Advantage Solution includes a large network of providers to choose from in the Twin Cities metro and surrounding counties. You pay your lowest cost-sharing when you visit an in-network provider. Emergency services are covered by the plan even if the provider is not in network. Most non-emergency services are also covered, but your cost-sharing will be higher when you use an out-of­network provider.

Visit medica.com/ AdvantageSolutionProviders to search our online directory of network providers. Or call us for a printed provider directory at 1-800-918-2416 (TTY: 711).

Local Customer Service At Medica, you’ll always receive

the caring, personal service you

deserve from our local Medicare

experts, right here in the Twin

Cities. Our health plan specialists

can answer your questions and

help you maximize your coverage.

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Call toll free at 1-800-918-2416 (TTY: 711) Hours of operation: October 1–February 14 8 a.m. to 8 p.m. Central, seven days a week

February 15–September 30 MEDICA. 8 a.m. to 8 p.m. Central, Monday-Friday THE FIRST Visit us online to learn more at medica.com/Medicare.

Locate a Medicare Workshop near you at WORD IN medica.com/MedicareWorkshops.

Find a broker in your community at MEDICARE. medica.com/Medicare

Centers for Medicare & Social Security Follow Medica: Medicaid Services (CMS) Administration

Toll free at 1-800-MEDICARE Toll free at 1-800-772-1213 (1-800-633-4227) (TTY/TTD: 1-800-325-0778) (TTY/TTD: 1-877-486-2048)

Hours of operation: Hours of operation: 7 a.m. to 7 p.m., 24 hours a day, seven days a week Monday-Friday medicare.gov ssa.gov

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/coinsurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium. The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.

Medica is a HMO-POS plan with a Medicare contract. Enrollment in Medica depends on contract renewal.

The SilverSneakers® fitness program is provided by Tivity Health, an independent company. Tivity Health and SilverSneakers are registered trademarks or trademarks of Tivity Health, Inc., and/or its subsidiaries and/or affiliates in the USA and/or other countries.

HealthAdvocate™ is a trademark of Health Advocate, Inc. VIRTUWELL and its logo are the registered trademarks of HealthPartners, Inc.

© 2017 Medica. Medica® and Medica Advantage Solution® are registered service marks of Medica Health Plans. “Medica” refers to the family of health plan businesses that includes Medica Health Plans, Medica Health Plans of Wisconsin, Medica Insurance Company, Medica Self-Insured and Medica Health Management, LLC.

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