healthpartners freedomplan - carleton college · month are generally effective the first day of the...

HealthPartners® Freedom PlanGroup Summary of Benefits

Emeriti 2007 H2462

Table of ContentsGroup Plan Information . . . . . . . . . . . . . . . . . .5

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . .8

Summary of Benefits . . . . . . . . . . . . . . . . . . .10

- Inpatient Care . . . . . . . . . . . . . . . . . . . . . . . .10

- Outpatient Care . . . . . . . . . . . . . . . . . . . . . . .14

- Outpatient Medical Servicesand Supplies . . . . . . . . . . . . . . . . . . . . . . . . .20

- Preventive Services . . . . . . . . . . . . . . . . . . .22

- Additional Benefits (What OriginalMedicare does NOT cover) . . . . . . . . . . . . .30

HealthPartners is a health plan with a Medicarecontract.

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The HealthPartners® Freedom Group plan is

being offered to you through your employer.

Your employer understands the importance

of having more than just Original Medicare.

This document is designed to provide you

with basic details regarding your coverage. If

you should have any questions that are not

answered within this document, please

contact HealthPartners.

Choice - Control - Affordability

Join the Freedom Frequent Fitness Program at

no additional cost to you

As a HealthPartners® Freedom Group plan Medicare

member, when you enroll and work out at least eight

times a month at one of the participating fitness

clubs, you can enjoy the Freedom Frequent Fitness

Program at no additional cost. HealthPartners pays

the full cost of your monthly membership!

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Great health care coverage The family of HealthPartners® Freedom Groupplan offers all the benefits that are available underOriginal Medicare – and more.

No referral requiredThis plan features an open access network. Thatmeans you can see any network provider withouta referral. The extensive network includes mostMinnesota doctors and hospitals. It’s likely you'llbe able to keep your current doctor.

When you travel, take your health plan withyou at no extra costWith the Extended Absence benefit, you can getyour plan's level of coverage while you are awayfrom Minnesota for up to nine months.

You will need to call HealthPartners each timebefore you receive services outside of Minnesotato activate the coverage. Once activated, coveragebegins immediately. The Extended Absencebenefit coverage is the same as in-networkcoverage. The Extended Absence benefit can onlybe used outside the state of Minnesota and withinthe United States. The out-of-state providers yousee must participate in the Medicare program.They will bill Medicare first for Medicare-eligible services. These providers may requireyou to pay for non-Medicare covered services atthe time they are provided. You may then submita claim to HealthPartners for payment of servicescovered by HealthPartners.

If you do not call to activate the ExtendedAbsence coverage before your trip, you will stillbe able to use your Original Medicare benefitswhen obtaining care outside the plan’s network,but will be responsible for Medicare deductibles,coinsurance and any additional charges notcovered by Medicare. Emergency and urgentlyneeded services are an exception to thisrequirement and are covered anywhere in theworld.

HealthPartners® Freedom Group Plan Information

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Coverage for emergency and urgently-needed care — anywhere in the worldA medical emergency is when you reasonablybelieve that your health is in serious danger –when every second counts. A medical emergencyincludes severe pain, a bad injury, a seriousillness, or a medical condition that is quicklygetting much worse.

Urgently needed services are also coveredwherever you need them. These are the healthcare services which you need and which cannotbe delayed, as a result of unforeseen illness,injury or condition under circumstances thatmake it unreasonable to obtain services in thenetwork. If you need urgent care while you are inthe service area, go to your clinic or any of thenetwork’s urgent care centers.

Emergency services are covered worldwide, whenever you need them. In an emergency call911, or go to the nearest hospital or emergencymedical center.

Attention Persons with Diabetes:

If you have diabetes and enroll in a MedicarePart D Prescription Drug plan, your syringes,oral or injectable insulin, alcohol, swabs andgauze will be covered under your Medicare PartD plan and NOT your Medicare Part B coverage.All other diabetes supplies will remain coveredby your Durable Medical Equipment benefitunder Medicare Part B coverage. See Page 22 for details.

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Completed enrollment forms that are received byHealthPartners by the last working day of themonth are generally effective the first day of thenext calendar month. For example: a completedenrollment form received by HealthPartners onJanuary 30, 2007, is effective February 1, 2007.

HealthPartners’ contract with CMS is renewedannually and the availability of coverage beyondthe end of the current contract year is notguaranteed.

Eligibility for plan membership is based on eligibility for Medicare Parts A and B or Part B only. • It is not based on age, health status, prior or

anticipated use of health services, orpreexisting conditions. There is no healthscreening. Just complete the application formsin this packet and mail them in the enclosedenvelope with a copy of your Medicare card.

• In general, you cannot be a member of twoMedicare HMO plans or Medicare PrescriptionDrug Plans at the same time. You automaticallycancel membership in other Medicare HMO(Medicare Advantage or Cost) plans andMedicare Prescription Drug Plans when youjoin this plan. Automatic cancellation does notapply to Medicare Select/Supplemental plans.

• You must live in Minnesota. • You must not have End Stage Renal Disease

(ESRD) and cannot be in a Medicare hospiceprogram. (The ESRD eligibility condition doesnot apply if you are already a HealthPartnersmember and are within one month of enrollingin Medicare Parts A and B or Part B only.)

If you have Medicare Part B only and areenrolling in this plan, please note that you willonly have coverage for Medicare Part B services.You will not have coverage for hospital, skillednursing facilities, and related services covered byMedicare Part A. You may contact the SocialSecurity Office at 1-800-772-1213 if you wish topurchase Medicare Part A coverage.

Enrollment is easy

Compare the HealthPartners®

Freedom Group plan options in theenclosed Summary of Benefits withthe limitations of Original Medicare.

Mail your completed enrollmentform(s) to HealthPartners in theenclosed postage-paid envelope. Orcall us at the number listed below.

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For questions regarding medical and dental plan options, call 952-883-5601 or 1-800-247-7015,Monday - Friday, 8 a.m. to 6 p.m. TTY users should call 952-883-6060 or 1-800-443-0156. Forquestions about Medicare Part D prescription drug benefits, including copayments, deductibles andnetwork pharmacies, call 952-883-5601 or 1-800-247-7015, 7 days a week, 8 a.m. to 8 p.m. TTYusers should call 952-883-6060 or 1-800-443-0156.

Or visit us at healthpartners.com/medicare.

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YOU HAVE CHOICES IN YOUR HEALTH CAREAs a Medicare beneficiary, you can choose fromdifferent Medicare options. One option is theOriginal (fee-for-service) Medicare Plan. Anotheroption is a Medicare group health plan, likeHealthPartners® Freedom Group plan. You mayhave other options too. You make the choice. Nomatter what you decide, you are still in theMedicare Program.

You may join or leave a plan only at certain times.Please call HealthPartners at the number listed atthe end of this introduction or 1-800-MEDICARE(1-800-633-4227) for more information. TTY usersshould call 1-877-486-2048. You can call thisnumber 24 hours a day, 7 days a week.

HOW CAN I COMPARE MY OPTIONS?You can compare HealthPartners® Freedom Groupplan and the Original Medicare Plan using thisSummary of Benefits. The charts in this booklet listsome important health benefits. For each benefit,you can see what our plan covers and what theOriginal Medicare Plan covers.

Our members receive all of the benefits that theOriginal Medicare Plan offers. We also offer morebenefits, which may change from year to year.

WHERE IS HEALTHPARTNERS® FREEDOMPLAN AVAILABLE?The service area for this plan includes the followingcounties: Aitkin, Anoka, Becker, Beltrami, Benton,Big Stone, Blue Earth, Brown, Carlton, Carver,Cass, Chippewa, Chisago, Clay, Clearwater, Cook,Cottonwood, Crow Wing, Dakota, Dodge, Douglas,Faribault, Fillmore, Freeborn, Goodhue, Grant,Hennepin, Houston, Hubbard, Isanti, Itasca,Jackson, Kanabec, Kandiyohi, Kittson,Koochiching, Lac qui Parle, Lake, Lake of theWoods, Le Sueur, Lincoln, Lyon, Mahnomen,Marshall, Martin, McLeod, Meeker, Mille Lacs,Morrison, Mower, Murray, Nicollet, Nobles,Norman, Olmsted, Otter Tail, Pennington, Pine,Pipestone, Polk, Pope, Ramsey, Red Lake,Redwood, Renville, Rice, Rock, Roseau, Scott,Sherburne, Sibley, St. Louis, Stearns, Steele,Stevens, Swift, Todd, Traverse, Wabasha, Wadena,Waseca, Washington, Watonwan, Wilkin, Winona,Wright, and Yellow Medicine counties. You mustlive in one of these places to join the plan.

WHO IS ELIGIBLE TO JOINHEALTHPARTNERS® FREEDOM PLAN?

You can join HealthPartners® Freedom plan if youare entitled to Medicare Part A and enrolled inMedicare Part B and live in the service area.However, individuals with End Stage Renal Disease(ESRD) are not eligible to enroll in HealthPartners®

Freedom plan.

Introduction to the Summary of Benefits forHealthPartners® Freedom Group Plan

January 1, 2007 - December 31, 2007

Thank you for your interest in HealthPartners® Freedom Group plan. Our plan is offered byHEALTHPARTNERS, a Medicare Cost Managed Care plan. This Summary of Benefits tells you somefeatures of our plan. It doesn't list every service that we cover, every limitation, or every exclusion. Toget a complete list of our benefits, please call HealthPartners and ask for the "Evidence ofCoverage."

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CAN I CHOOSE MY DOCTORS?HealthPartners has formed a network of doctors,specialists, and hospitals. You can use any doctorwho is part of our network. You may also go todoctors outside of our network. The healthproviders in our network can change at any time.You can ask for a current Provider Directory for anup-to-date list or visit us athealthpartners.com/medicare. Our number islisted at the end of this introduction.

WHAT HAPPENS IF I GO TO A DOCTORWHO'S NOT IN YOUR NETWORK?You can always choose to go to a doctor outsideour network. We may not pay for the services youreceive outside of our network, but Medicare willpay for its share of charges it approves. You willbe responsible for Medicare Part B deductible andcoinsurance.

DOES MY PLAN COVER MEDICARE PART BAND MEDICARE PART D DRUGS?HealthPartners® Freedom Group plan covers bothMedicare Part B and Medicare Prescription DrugProgram Part D drugs.

WHAT TYPES OF DRUGS MAY BE COVEREDUNDER MEDICARE PART B?The following outpatient prescription drugs maybe covered under Medicare Part B. This mayinclude, but is not limited to, the following typesof drugs. Contact HealthPartners for more details.

-- Some Antigens: If they are prepared by a doctorand administered by a properly instructedperson (who could be the patient) under doctorsupervision.

-- Osteoporosis Drugs: Injectable drugs forosteoporosis for certain women with Medicare.

-- Erythropoietin (Epoetin alpha or Epogen®): Byinjection if you have end-stage renal disease(permanent kidney failure requiring eitherdialysis or transplantation) and need this drug totreat anemia.

-- Hemophilia Clotting Factors: Self-administeredclotting factors if you have hemophilia.

-- Injectable Drugs: Most injectable drugsadministered incident to a physician’s service.

-- Immunosuppressive Drugs: Immunosuppressivedrug therapy for transplant patients if thetransplant was paid for by Medicare, or paid bya private insurance that paid as a primary payerto your Medicare Part A coverage, in aMedicare-certified facility.

-- Some Oral Cancer Drugs: If the same drug isavailable in injectable form.

-- Oral Anti-Nausea Drugs: If you are part of ananti-cancer chemotherapeutic regimen.Inhalation and infusion drugs provided throughDME.

Please call HealthPartners for more information about this plan.Visit us at healthpartners.com/medicareor call us:

Member Services hours: Sunday, Monday, Tuesday, Wednesday, Thursday, Friday, Saturday, 8:00 a.m. - 8:00 p.m. Central.

Current members should call 1-800-233-9645 ( TTY/TDD 1-800-443-0156). Prospective members shouldcall 1-800-247-7015 (TTY/TDD 1-800-443-0156)

For more information about Medicare, call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users shouldcall 1-877-486-2048. You can call 24 hours a day, 7 days a week. Or, visit www.medicare.gov on the web.

If you have special needs, this document may be available in other formats.

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1 Premium andOther ImportantInformation

Most people will pay the standard monthlyPart B premium of $93.50. However,starting January 1, 2007, some people willhave to pay a higher premium because oftheir yearly income (over $80,000 forsingles, $160,000 for married couples). Formore information on Part B premiumsbased on income, call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778.

You will continue to pay the Medicare PartB premium of $93.50 each month. (This isthe 2007 amount and may change January1, 2008.)There is a $1,500 maximum out-of-pocketlimit every year for all plan services.You pay an additional premium of$218.30 per month.

2 Doctor andHospital Choice(For moreinformation, seeEmergency #15and UrgentlyNeeded Care#16)

You may go to any doctor, specialist orhospital that accepts Medicare

You do NOT need a referral to go tonetwork doctors, specialists and hospitals.

You can use any doctor who is part of ournetwork.

You may also go to doctors outside of ournetwork.

You are covered for U.S. visitor/travelbenefits. Contact plan for details.

3 InpatientHospital Care(IncludesSubstance Abuseand RehabilitationServices)

You pay for each benefit period: (3)

Days 1-60: an initial deductible of $992

Days 61-90: $248 each day

Days 91-150: $496 each lifetime reserveday (4) (These are 2007 amounts and maychange January 1, 2008.)

Please call 1-800-MEDICARE (1-800-633-4227) for information aboutlifetime reserve days (4)

You pay $100 per benefit period.

Except in an emergency, your provider mustobtain authorization from HealthPartners.

Benefit Original Medicare Plan IImportant Information

Inpatient CareSummary of Benefits

(1) Each year, you pay a total of one $131 deductible.(2) If a doctor or supplier chooses not to accept an assignment, their costs are often higher, which means you maypay more.

If you have any questions about this plan’s benefits or costs, please contact HealthPartners.

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(3) A benefit period begins the day you go to the hospital or skilled nursing facility. The benefit period ends when youhave not received hospital or skilled nursing care for 60 days in a row. If you go into the hospital after one benefit periodhas ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There is nolimit to the number of the benefit periods you can have.(4) Lifetime reserve days can only be used once.

You will continue to pay the Medicare Part Bpremium of $93.50 each month. (This is the 2007amount and may change January 1, 2008.)

There is a $3,000 maximum out-of-pocket limitevery year for all plan services.You pay an additional premium of$137.30 per month.

You do NOT need a referral to go to networkdoctors, specialists and hospitals.

You can use any doctor who is part of ournetwork.

You may also go to doctors outside of ournetwork.

You are covered for U.S. visitor/travel benefits.Contact plan for details.


Except in an emergency, your provider must obtainauthorization from HealthPartners.

Plan II

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Benefit Original Medicare Plan I4 Inpatient Mental HealthCare

You pay the same deductibleand copayments as inpatienthospital care (see Page 10)except Medicare beneficiariesmay only receive 190 days ina Psychiatric Hospital in alifetime.


Medicare beneficiaries may only receive 190days in a Psychiatric Hospital in a lifetime.

Except in an emergency, your provider mustobtain authorization from HealthPartners.

5 Skilled Nursing Facility(In a Medicare-certifiedskilled nursing facility)

You pay for each benefitperiod (3), following at least a3-day covered hospital stay:

Days 1-20: $0 for each day.Days 21-100: $124 for eachday

(These are the 2007 amountsand may change January 1,2008.)

There is a limit of 100 daysfor each benefit period. (3)

There is no copayment for services in a SkilledNursing Facility.

Three day prior hospital stay is required.

You are covered for 100 days each benefitperiod.

Authorization rules may apply for services.Contact plan for details.

6 Home Health Care(Includes medicallynecessary intermittentskilled nursing care, homehealth aide services, andrehabilitation services,etc.)

There is no copayment for allcovered home health visits.

There is no copayment for Medicare-coveredhome health visits.


(1) Each year, you pay a total of one $131 deductible.(2) If a doctor or supplier chooses not to accept an assignment, their costs are often higher, which means you paymore.


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Plan IIYou pay $100 per benefit period.

Medicare beneficiaries may only receive 190 daysin a Psychiatric Hospital in a lifetime.


There is no copayment for services in a SkilledNursing Facility.

Three day prior hospital stay is required.

You are covered for 100 days each benefit period.


There is no copayment for Medicare-coveredhome health visits.



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7 Hospice You pay part of the cost for outpatientdrugs and inpatient respite care.

You must receive care from a Medicare-certified hospice.

You must receive care from a Medicare-certified hospice.

8 Doctor OfficeVisits

You pay 20% of Medicare-approvedamounts. (1) (2)

You pay $15 for each primary care orspecialty care office visit for Medicare-covered services.


See 32-Physical Exams for moreinformation.

9 ChiropracticServices

You are covered for manual manipulationof the spine to correct subluxation,provided by chiropractors and otherqualified providers.

You pay 100% for routine care.


You pay $15 for each Medicare-coveredvisit (manual manipulation of the spine tocorrect subluxation).


Benefit Original Medicare Plan IOutpatient Care



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You must receive care from a Medicare-certifiedhospice.

You pay $20 for each primary care or specialtycare office visit for Medicare-covered services.


See 32-Physical Exams for more information.

You pay $20 for each Medicare-covered visit(manual manipulation of the spine to correctsubluxation).


Plan II


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10 Podiatry Services You pay 20% of Medicare-approvedamounts. (1) (2)

You are covered for medically necessaryfoot care, including care for medicalconditions affecting the lower limbs.

You pay 100% for routine care.

You pay $15 for each Medicare-coveredvisit (medically-necessary foot care).

You pay $15 for each routine visit.

Authorization rules may apply forservices. Contact plan for details.

11 Outpatient MentalHealth Care

You pay 50% of Medicare-approvedamounts with the exception of certainsituations and services for which you pay20% of approved charges. (1) (2)

For Medicare-covered Mental Healthservices, you pay $15 for each individualtherapy session and $7.50 for each grouptherapy session.


12 OutpatientSubstance AbuseCare


For Medicare-covered services, you have100% coverage of the cost of eachindividual/group session.

There is a 75-hour limit for treatment percalendar year.

Except in an emergency, your providermust obtain authorization fromHealthPartners.

Benefit Original Medicare Plan I



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You pay $20 for each Medicare-covered visit(medically necessary foot care).

You pay $20 for each routine visit.


For Medicare-covered Mental Health services, youpay $20 for each individual therapy session and$10 for each group therapy session.


For Medicare-covered services, you have 100%coverage of the cost of each individual/groupsession.

There is a 75 hour limit for treatment per calendaryear.


Plan II


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13 OutpatientServices/Surgery

You pay 20% of Medicare-approvedamounts for the doctor. (1) (2)

You pay 20% of outpatient facilitycharges. (1) (2)

100% coverage for each Medicare-coveredvisit to an ambulatory surgical center.

100% coverage for each Medicare-coveredvisit to an outpatient hospital facility.


14 AmbulanceServices (Medicallynecessaryambulance services)

You pay 20% of Medicare-approvedamounts or applicable fee schedulecharges. (1) (2)

100% coverage for Medicare-coveredambulance services.

You pay 20% of the charges incurredoutside the United States.


15 Emergency Care(You may go to anyemergency room ifyou reasonablybelieve you needemergency care.)

You pay 20% of the facility charge orapplicable copayment for each emergencyroom visit; you do NOT pay this amount ifyou are admitted to the hospital for thesame condition within 3 days of theemergency room visit. (1) (2)

You pay 20% of doctor charges. (1) (2)

NOT covered outside the U.S. exceptunder limited circumstances.

You pay $50 for each Medicare-coveredemergency room visit; however, the copayis waived if you are admitted to thehospital within 24 hours with the samecondition.

You pay 20% of the cost for eachemergency room visit outside the UnitedStates.




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100% coverage for each Medicare-covered visit toan ambulatory surgical center.

100% coverage for each Medicare-covered visit toan outpatient hospital facility.


100% coverage for Medicare-covered ambulanceservices.

You pay 20% of the charges incurred outside theUnited States.


You pay $50 for each Medicare-coveredemergency room visit; however, the copay iswaived if you are admitted to the hospital within24 hours with the same condition.

You pay 20% of the cost for each emergency roomvisit outside the United States.

Plan II


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16 UrgentlyNeeded Care (Thisis NOT emergencycare, and in mostcases, is out of theservice area)

You pay 20% of Medicare-approvedamounts or applicable copayment. (1) (2)

NOT covered outside the U.S. exceptunder limited circumstances.

You pay $15 for each Medicare-coveredurgently needed care visit.

You pay 20% of the cost for each urgentlyneeded care visit outside of the UnitedStates.

Worldwide coverage.

17 OutpatientRehabilitationServices(Occupationaltherapy, Physicaltherapy, Speechand Languagetherapy)


Therapy caps include:- Physical and speech therapy at $1,740 percalendar year.- Occupational therapy at $1,740 percalendar year.

100% coverage for each Medicare-coveredOccupational Therapy and/or PhysicalTherapy session.

You pay $15 for each Medicare-coveredSpeech/Language therapy session.


18 Durable MedicalEquipment(Includeswheelchairs,oxygen, etc.)


You pay 10% of the cost for eachMedicare-covered item.


Plan IOriginal MedicareBenefit

Outpatient Medical Services and Supplies



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You pay $20 for each Medicare-covered urgentlyneeded care visit.

You pay 20% of the cost for each urgently neededcare visit outside of the United States.

Worldwide coverage.

You have 100% coverage for each Medicare-covered Occupational Therapy and/or PhysicalTherapy session.

You pay $20 for each Medicare-coveredSpeech/Language therapy session.

Authorization rules may apply for services.Contact plan for details

You pay 10% of the cost for each Medicare-covered item.


Plan II


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19 ProstheticDevices (Includesbraces, artificiallimbs and eyes,etc.)




20 Diabetes Self-MonitoringTraining andSupplies (Includescoverage forglucose monitors,test strips,lancets, screeningtests and self-managementtraining)


You pay $15 of the cost for diabetes self-monitoring training.

You pay 10% of the cost for each Medicare-covered diabetes supply item.


Please refer to page 6 for more informationon diabetes supplies.

21 DiagnosticTests, X-Rays andLab Services

You pay 20% of Medicare-approvedamounts, except for approved lab services.(1) (2)

There is no copayment for Medicare-approved lab services.

You have:- 100% coverage for each Medicare-coveredclinical/diagnostic lab service.- 100% coverage for each Medicare-coveredradiation therapy service.- 100% coverage for each Medicare-coveredX-ray visit.


Benefit Plan IOriginal Medicare



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You pay $20 of the cost for Medicare-coveredDiabetes self-monitoring training.

You pay 10% of the cost for each Medicare-covered Diabetes supply item.


Please refer to page 6 for more information onDiabetes supplies.

You pay:- 100% coverage for each Medicare-coveredclinical/diagnostic lab service.- 100% coverage for each Medicare-coveredradiation therapy service.- 100% coverage for each Medicare-covered X-rayvisit.


See page 34 for additional information about labservices.

Plan II


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22 Bone MassMeasurement (Forpeople with Medicarewho are at risk)


100% coverage for each Medicare-covered Bone Mass measurement.Authorization rules may apply forservices. Contact plan for details.

23 ColorectalScreening Exams(For people withMedicare age 50 andolder)


100% coverage for each Medicare-covered Colorectal screening exam.


24 Immunizations (Fluvaccine, Hepatitis Bvaccine - for people withMedicare who are atrisk, pneumoniavaccine)

There is no copayment for the pneumoniaand flu vaccines.You pay 20% of Medicare-approvedamounts for the Hepatitis B vaccine. (1)(2)You may only need the pneumoniavaccine once in your lifetime. Pleasecontact your doctor for further details.

There is no copayment for the pneumoniaand flu vaccines. No referral necessary forMedicare-covered influenza andpneumonia vaccines.There is no copayment for the Hepatitis Bvaccine.Authorization rules may apply forservices. Contact plan for details.

25 Mammograms(Annual Screening)(For women withMedicare age 40 andolder)

You pay 20% of Medicare-approvedamounts. (2)

No referral necessary for Medicare-covered screenings.

There is no copayment for Medicare-covered screening Mammograms.Authorization rules may apply forservices. Contact plan for details.No referral necessary for Medicare-covered screenings.

26 Pap Smears andPelvic Exams (Forwomen withMedicare)

There is no copayment for a Pap smearonce every 2 years, annually forbeneficiaries at high risk. (2)

You pay 20% of Medicare-approvedamounts for pelvic exams. (2)

There is no copayment for Medicare-covered Pap smears and pelvic exams.


27 Prostate CancerScreening Exams(For men withMedicare age 50 andolder)

There is no copayment for approved labservices and a copayment of 20% ofMedicare-approved amounts for otherrelated services. (1)(2)

There is no copayment for Medicare-covered Prostate Cancer screening exams.





Preventive Services

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100% coverage for each Medicare-covered BoneMass measurement.Authorization rules may apply for services.Contact plan for details.100% coverage for each Medicare-coveredColorectal screening exam.

Authorization rules may apply for services.Contact plan for details.There is no copayment for the pneumonia and fluvaccines.No referral necessary for Medicare-coveredinfluenza and pneumonia vaccines.

There is no copayment for the Hepatitis B vaccine.Authorization rules may apply for services.Contact plan for details.There is no copayment for Medicare-coveredscreening Mammograms.No referral necessary for Medicare-coveredscreenings.Authorization rules may apply for services.Contact plan for details.There is no copayment for Medicare-covered Papsmears and pelvic exams.


There is no copayment for Medicare-coveredProstate Cancer screening exams.


Plan II


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28 PrescriptionDrugs Drugs coveredunder MedicarePart B (OriginalMedicare)

Drugs coveredunder MedicarePart D(Prescription DrugBenefit)

You pay 100% for most prescription drugs,unless you enroll in the MedicarePrescription Drug program.

You pay 20% of the cost for Part B-covereddrugs.

This plan uses a formulary. A formulary is alist of drugs covered by your plan to meetpatient needs. We may periodically add,remove, make changes to coverage limitationson certain drugs or change how much you payfor a drug. If we make any formulary changethat limits our members’ ability to fill theirprescriptions, we will notify the affectedenrollees before the change is made. We willsend a formulary to you and you can see ourcomplete formulary on our website athealthpartners.com/medicare. People who have limited incomes, who live inlong term care facilities, or who have access toIndian/Tribal/Urban (Indian Health Service)facilities may have different out-of-pocket drugcosts. Contact plan for details.

Deductible There is no deductible.

Initial Coverage You pay the following for prescriptiondrugs:

In-Network RetailPharmacy

- $12 for a one month (30-day) supply offormulary generic drugs.- $24 for a one month (30-day) supply forformulary brand name drugs.- 25% coinsurance for a one month (30-day)supply of formulary specialty drugs.




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You pay 20% of the cost for Part B-covered drugs.

This plan uses a formulary. A formulary is a list ofdrugs covered by your plan to meet patient needs. Wemay periodically add, remove, make changes tocoverage limitations on certain drugs or change howmuch you pay for a drug. If we make any formularychange that limits our members’ ability to fill theirprescriptions, we will notify the affected enrolleesbefore the change is made. We will send a formularyto you and you can see our complete formulary onour website at healthpartners.com/medicare. People who have limited incomes, who live in longterm care facilities, or who have access toIndian/Tribal/Urban (Indian Health Service) facilitiesmay have different out-of-pocket drug costs. Contactplan for details.

There is no deductible.

You pay the following for prescription drugs:- $10 for a one month (30-day) supply offormulary generic drugs.- $31 for a one month (30-day) supply forformulary brand name drugs.- 25% coinsurance for a one month (30-day)supply of formulary specialty drugs.- $30 for a three month (90-day) supply offormulary generic drugs.- $93 for a three month (90-day) supply offormulary brand name drugs.

Plan II


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Mail Order

Coverage AfterYou Reach YourInitial CoverageLimit

- $12 for a one month (30-day) supply offormulary generic drugs.- $24 for a one month (30-day) supply offormulary brand name drugs.- 25% coinsurance for a one month (30-day) supply of formulary specialty drugs.- $24 for a three month (90-day) supply offormulary generic drugs.- $48 for a three month (90-day) supply offormulary brand name drug.

Coverage remains the same.

CatastrophicCoverage

After your yearly out-of-pocket drug costsreach $3,850, you pay the greater of:- $2.15 for generic (including brand namedrugs treated as generic) and $5.35 for allother drugs; or- 5% coinsurance.

GeneralInformation

You may incur a cost in addition to thecopay if you select a higher drug when alesser cost drug is available. In some cases,the plan requires you to first try one drugto treat your medical condition before theywill cover another drug for that condition.Certain prescription drugs will havemaximum quantity limits.Your provider must get prior authorizationfrom your plan for certain prescriptiondrugs. Covered Part D drugs are availableat out-of-network pharmacies in specialcircumstances including illness whiletraveling outside the plan’s service areawhere there is no network pharmacy. Youmay also incur an additional cost for drugsreceived at an out-of-network pharmacy.Please contact you plan for details.

Benefit Original Medicare Plan IIf you have any questions about this plan’s benefits or costs, please contact HealthPartners.

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- $10 for a one month (30-day) supply offormulary generic drugs.- $31 for a one month (30-day) supply offormulary brand name drugs.- 25% coinsurance for a one month (30-day)supply of formulary specialty drugs.- $20 for a three month (90-day) supply offormulary generic drugs.- $62 for a three month (90-day) supply offormulary brand name drug.

After the total yearly drug costs (paid by bothyou and your plan) reach $2,400, you pay 100%of your prescription drug costs until your yearlyout-of-pocket drug costs reach $3,850.

After your yearly out-of-pocket drug costs reach$3,850, you pay the greater of:- $2.15 for generic (including brand name drugstreated as generic) and $5.35 for all other drugs; or- 5% coinsurance.

You may incur a cost in addition to the copay ifyou select a higher drug when a lesser cost drugis available. In some cases, the plan requires youto first try one drug to treat your medicalcondition before they will cover another drug forthat condition.

Certain prescription drugs will have maximumquantity limits.

Your provider must get prior authorization fromyour plan for certain prescription drugs. CoveredPart D drugs are available at out-of-networkpharmacies in special circumstances includingillness while traveling outside the plan’s servicearea where there is no network pharmacy. Youmay also incur an additional cost for drugsreceived at an out-of-network pharmacy. Pleasecontact you plan for details.

Plan II

29 Dental Services In general, you pay 100% for preventivedental services.

You pay 100% for preventive dentalservices.


30 Hearing Services You pay 100% for routine hearing examsand hearing aids.

You pay 20% of Medicare-approvedamounts for diagnostic hearing exams. (1)(2)

In general, you have 100% coverage forroutine hearing exams.

You pay 50% of the charges incurred upto $1,000 maximum every two years forhearing aids.


31 Vision Services You are covered for one pair of eyeglassesor contact lenses after each cataractsurgery. (1) (2)

For people with Medicare who are at risk,you are covered for annual glaucomascreenings. (1) (2)

You pay 20% of Medicare-coveredamounts for diagnosis and treatment ofdiseases and conditions of the eye. (1) (2)

You pay 100% for routine eye exams andglasses.

You have 100% coverage for routine eyeexams.There is no copayment for the followingitems:- Eye wear frames or lenses for thepostoperative treatment of cataracts.You pay:- $15 copay for each Medicare-covered eyeexam (diagnosis and treatment for diseasesand conditions of the eye).

30



Additional Benefits (what Original Medicare does not cover)


31

You pay 100% for preventive dental services.


In general, you have 100% coverage for routinehearing exams.

You pay 50% of the charges incurred up to $1,000maximum every two years for hearing aids.


You have 100% coverage for routine eye exams.There is no copayment for the following items:- Eye wear frames or lenses for the postoperativetreatment of cataracts.You pay:- $20 copay for each Medicare-covered eye exam(diagnosis and treatment for diseases and conditionsof the eye).

Plan II


32

32 Physical Exams If your coverage for Medicare Part Bbegins on or after January 1, 2005, youmay receive a one-time physical examwithin the first six months of your newPart B coverage. This will not include laboratory tests.Please contact your plan for furtherdetails.You pay 20% of the Medicare-approvedamount. (1) (2)

If your coverage for Medicare Part Bbegins on or after January 1, 2005, youmay receive a one-time physical examwithin the first six months of your newPart B coverage. This will not include laboratory tests.Please contact your plan for furtherdetails.There is no copayment for routinephysical exams.

33 Health/WellnessEducation

You pay 100%. You are covered for the following:- Written health education materials,including a newsletter.- Smoking cessation.- Health club membership/fitness classes.- Nursing hotline.


34 Acupuncture You pay 100%. You pay $15 for each acupuncture visit.



Plan IOriginal MedicareBenefitIf you have any questions about this plan’s benefits or costs, please contact HealthPartners.

33

If your coverage for Medicare Part B begins onor after January 1, 2005, you may receive a one-time physical exam within the first six months ofyour new Part B coverage. This will not include laboratory tests. Pleasecontact your plan for further details.There is no copayment for routine physicalexams.

You are covered for the following:- Written health education materials, including anewsletter.- Smoking cessation.- Health club membership/fitness classes.- Nursing hotline.


You pay $20 for each acupuncture visit.



Plan II

HealthPartners8170 33rd Avenue SouthP. O. Box 1309Minneapolis, MN 55440-1309

healthpartners.com

© 2006 HealthPartners

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