2017 Summary of Benefits

Sunshine Health Medicare Advantage (HMO)

Duval County

H9276, Plan 001

H9276-001_2017_SB_Accepted_09062016

Summary of Benefits

January 1, 2017 – December 31, 2017 This is a summary of drug and health services covered by Sunshine Health Medicare Advantage (HMO).

Sunshine Health Medicare Advantage is contracted with Medicare for HMO and HMO SNP plans, and with the Florida Medicaid program. Enrollment in Sunshine Health Medicare Advantage depends on contract renewal.

The benefit information provided is a summary of what we cover and what you pay. It does not list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, please request the “Evidence of Coverage.”

Who can join? To join Sunshine Health Medicare Advantage (HMO), you must:

have both Medicare A and Medicare Part B

be a United States citizen or are lawfully present in the United States

live in our service area

Our service area includes the following counties in Florida:

Duval County

Which doctors, hospitals and pharmacies can I use? Sunshine Health Medicare Advantage (HMO) has a network of doctors, hospitals, pharmacies, and other providers. If you use the providers that are not in our network, the plan may not pay for these services. You can view our provider & pharmacy directory on our website, https://advantage.sunshinehealth.com.

This plan’s phone numbers and website:

If you are a member of this plan, call toll-free: 1-844-293-2636. (TTY users, please call 711.)

If you are not a member of this plan, call toll-free: 1-877-826-3692. (TTY users, please call 711.)

Our website: https://advantage.sunshinehealth.com

Hours of Operation: From October 1 to February 14, you can call us 7 days a week from 8 a.m. to 8 p.m. From February 15 to September 30, you can call us Monday through Friday from 8 a.m. to 8 p.m. On weekends and holidays, an automated system will handle your call. This document is available in other formats such as Braille, large print or audio. This information is available for free in other languages. Please call our Member Services number at 1-844-293-2636. TTY: 711. October 1 – February 14, 7 days a week, 8 a.m. to 8 p.m.; February 15 – September 30, Monday – Friday, 8 a.m. to 8 p.m. Esta información está disponible gratis en otros idiomas. Por favor llame a nuestro de Servicios al Afiliado al 1-844-293-2636. TTY: 711. 1 de octubre - 14 de febrero, 7 días a la semana, 8 a. m. - 8 p. m.; 15 de febrero – 30 de septiembre, lunes - viernes, 8 a. m. – 8 p. m.

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 co-payments/co-insurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium.

SUMMARY OF BENEFITS January 1, 2017 – December 31, 2017

Premiums and Benefits

Sunshine Health Medicare Advantage (HMO)

What you should know

Monthly Plan Premium

$0 You must continue to pay your Medicare Part B premium.

Deductible $0 per year for Part C benefits $275 per year for Part D prescription drugs

The Part D deductible applies to Tiers 2 – 5 drugs.

Maximum Out-of-Pocket Responsibility

(does not include prescription drugs)

Your yearly limit(s) in this plan:

$5,900 for services you receive from in-network providers

Please note: You will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs.

Inpatient Hospital Coverage

For each benefit period, you pay:

$250 copay per day for days 1 - 6

You pay nothing for days 7 – 90

For more information on “benefit periods” and “lifetime reserve days,” please see the plan’s Evidence of Coverage (EOC).

Prior authorization (approval in advance) may be required. Please contact the plan for details. Our plan covers 90 days for an inpatient hospital stay. Our plan also covers 60 “lifetime reserve days.”

Doctor Visits

o Primary o Specialists

$0 copay for primary care doctor visits

$30 copay for specialist visits

A referral may be required for specialist visits. Please contact the plan for details.

Premiums and Benefits

Sunshine Health Medicare Advantage (HMO)

What you should know

Preventive Care You pay nothing

Please see the plan’s Evidence of Coverage (EOC) for a full list of preventive care services that the plan covers.

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

Emergency Care $75 copay per visit

If you are admitted to the hospital within three days, you do not have to pay your share of the cost for emergency care.

Urgently Needed Services

$40 copay per visit

Diagnostic Services/Labs/ Imaging

Diagnostic tests and procedures: $75 copay Lab services: $35 copay Diagnostic radiological services: $75 copay Therapeutic radiology services (such as radiation treatment for cancer): 20% of the total cost Outpatient x-ray services: $25 copay

Prior authorization (approval in advance) may be required. Please contact the plan for details.

Hearing Services

Routine hearing exam: You pay nothing for up to 1 every calendar year

Medicare-covered services: $30 copay

Medicare-covered services include an exam to diagnose and treat hearing and balance issues.

Dental Services

Medicare-covered dental services: 20% of the total cost

Medicare-covered dental includes limited dental services

Premiums and Benefits

Sunshine Health Medicare Advantage (HMO)

What you should know

Dental Services (cont.)

Preventive dental services: Oral exam (for up to 2 every calendar year): You pay nothing Cleaning (for up to 2 every calendar year): You pay nothing Dental x-ray (for up to 1 every calendar year): You pay nothing

(this does not include services in connection with care, treatment, filling, removal or replacement of teeth. Dental x-rays include bitewing series only.

Vision Services

Routine eye exam (for up to 1 every calendar year): You pay nothing Contact lenses: You pay nothing Eyeglasses (frames and lenses): You pay nothing Medicare-covered services: You pay nothing

Medicare-covered services includes an exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening) and eyeglasses or contact lenses after cataract surgery.

The plan pays for up to $100 for contact lenses and/or eyeglasses (frames and lenses).

Mental Health Services

For each benefit period, you pay:

$250 copay per day for days 1 - 6

You pay nothing for days 7 – 90

For more information on “benefit periods” and “lifetime reserve days,” please see the plan’s Evidence of Coverage (EOC). Outpatient group therapy visit: $30 copay Outpatient individual therapy visit: $30 copay

Prior authorization (approval in advance) may be required. Please contact the plan for details. Our plan covers 90 days for an inpatient hospital stay. Our plan also covers 60 “lifetime reserve days.”

Premiums and Benefits

Sunshine Health Medicare Advantage (HMO)

What you should know

Skilled Nursing Facility (SNF)

For each benefit period, you pay:

You pay nothing for days 1 - 20

$160 copay per day for days 21 - 100

For more information on “benefit periods” and “lifetime reserve days,” please see the plan’s Evidence of Coverage (EOC).

Prior authorization

(approval in advance) may be required.

Please contact the plan for details. Our plan covers up to 100 days in a SNF.

Rehabilitation Services

Cardiac rehab services: $30 copay Occupational therapy visit: $35 copay Physical therapy and speech and language therapy visit: $35 copay

Prior authorization (approval in advance) may be required. Please contact the plan for details. Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks

Ambulance

$250 copay

Prior authorization (approval in advance) is required for non-emergency ambulance services. Please contact the plan for details.

Transportation Not covered

Foot Care (podiatry services)

Medicare-covered podiatry services: $30 copay

Medicare-covered podiatry services include foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions.

Premiums and Benefits

Sunshine Health Medicare Advantage (HMO)

What you should know

Medical Equipment/Supplies

Durable Medical Equipment (DME) (e.g., wheelchairs, oxygen): 20% of the total cost Prosthetics (e.g., braces, artificial limbs): 20% of the total cost Medical supplies: 20% of the total cost Diabetes monitoring supplies: 20% of the total cost Therapeutic shoes or inserts: 20% of the total cost

Prior authorization (approval in advance) may be required. Please contact the plan for details.

Wellness Programs (e.g., fitness)

Fitness program: You pay nothing

24-hour nurse advice line: You pay nothing

The plan covers a basic fitness membership at participating fitness facilities. Members can also request an in-home fitness program. You can call the nursing hotline 24 hours a day, 365 days a year with questions about your health.

Medicare Part B Drugs

Chemotherapy drugs: 20% of the total cost Other Part B drugs: 20% of the total cost

Prior authorization (approval in advance) may be required. Please contact the plan for details.

Outpatient Prescription Drugs

Deductible Phase The plan’s deductible is: $275 per year. You begin in this payment phase when you fill your first prescription of the calendar year. During this phase, you pay the full cost of your Tiers 2 – 5 drugs. You generally stay in this phase until you have paid $275 for your Tiers 2 - 5 drugs. Once you have paid your deductible, you move to the next phase (Initial Coverage).

Initial Coverage Phase

(After you pay your deductible, if applicable)

If you reside in a long-term care facility, you pay the same as at a retail pharmacy.

You may get drugs from an out-of-network pharmacy at the same cost as an in-network pharmacy.

During this phase, the plan pays its share of the cost of your Part D drugs and you pay your share of the cost. After you (or others on your behalf) have met your Part D deductible, the plan pays its share of the costs of your Part D drugs and you pay your share. You generally stay in this phase until your year-to-date “total drug costs” (your payments plus any payments by the plan) reach $3,700. Once your “total drug costs” reach $3,700 you move to the next phase (Coverage Gap).

Retail and Mail-Order Cost Sharing

One-month supply including Mail Order

Two-month supply including Mail Order

Three-month including Mail Order

Tier 1 (Preferred Generic): $0 copay

Tier 1 (Preferred Generic): $0 copay

Tier 1 (Preferred Generic): $0 copay

Tier 2 (Generic): $14 copay

Tier 2 (Generic): $28 copay

Tier 2 (Generic): $42 copay

Tier 3 (Preferred Brand): $47 copay

Tier 3 (Preferred Brand): $94 copay

Tier 3 (Preferred Brand): $141 copay

Tier 4 (Non-Preferred Brand): $100 copay

Tier 4 (Non-Preferred Brand): $200 copay

Tier 4 (Non-Preferred Brand): $300 copay

Tier 5 (Specialty): 25% of the total cost

Tier 5 (Specialty): 25% of the total cost

Tier 5 (Specialty): 25% of the total cost

Tier 6 (Select Care): $0 copay

Tier 6 (Select Care): $0 copay

Tier 6 (Select Care): $0 copay

You can see the complete plan formulary (list of Part D prescription drugs) and any restrictions on our website at https://advantage.sunshinehealth.com. For certain kinds of drugs, you can use the plan’s network mail order services. Generally, the drugs provided through mail order are drugs that you take on a regular basis, for a chronic or long-term medical condition. The drugs available through our plan’s mail order service are marked as “MO” drugs in our Drug List.

Coverage Gap Phase

During this phase, for Tier 6 (Select Care drugs), you continue to pay $0. For Tier 1 (Preferred Generic drugs) and Tier 2 (Generic drugs), you pay your copayment or coinsurance. For generic drugs on all other tiers, you pay 51% of the price. For brand name drugs on all other tiers, you pay 40% of the price (plus a portion of the dispensing fee).

You generally stay in this phase until your year-to-date “out-of-pocket costs” reaches $4,950. Once your “out-of-pocket costs” reach $4,950, you move to the next phase (Catastrophic Coverage).

Catastrophic Phase

During this phase, the plan pays most of the cost for your covered drugs. For each prescription, you pay the greater of:

5% of the cost – OR –

$3.30 copay for a generic drug (or a drug that is treated like a generic)

$8.25 copay for all other drugs.

Multi-language Interpreter Services

English: ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-844-293-2636 (TTY: 711). Spanish: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-844-293-2636 (TTY: 711).

Chinese Mandarin: 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電1-844-293-2636 (TTY: 711)。

Chinese Cantonese:

注意：如果您說英文，您可獲得免費的語言協助服務。請致電1-844-293-2636（聽障專線：711)。

Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-844-293-2636 (TTY: 711).

French: ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-844-293-2636 (ATS : 711).

Vietnamese: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-844-293-2636 (TTY: 711).

German: ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-844-293-2636 (TTY: 711).

Korean:

주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-844-293-2636

(TTY: 711) 번으로 전화해 주십시오.

Russian: ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-844-293-2636 (телетайп: 711).

Y0020_MLI17_R2_Accepted_09052016

Arabic:

)رقم هاتف الصم والبكم: 1-448-392-6362ملحوظة: إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم

711.) Hindi:

ध्यान दें: यदद आप बोलते हैं तो आपके ललए मुफ्त में भाषा सहायता सेवाएं उपलब्ध हैं। 1-844-293-

2636 (TTY: 711) पर कॉल करें। Italian: ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-844-293-2636 (TTY: 711).

Portugués: ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-844-293-2636 (TTY: 711).

French Creole: ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-844-293-2636 (TTY: 711).

Polish: UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-844-293-2636 (TTY: 711). Japanese: 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1-844-293-2636 (TTY: 711)

まで、お電話にてご連絡ください。

Navajo:

Sunshine Health Medicare Advantage complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Sunshine Health Medicare does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Sunshine Health Medicare Advantage:

Provides free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters and written information in other formats (large print, accessible electronic formats, other formats).

Provides free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages.

If you need these services, contact Sunshine Health Medicare Advantage’s Member Services at 1-844-293-2636 (TTY: 711). If you believe that Sunshine Health Medicare Advantage has 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 by calling the number above and telling them you need help filing a grievance; Sunshine Health Medicare Advantage’s Member Services 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 https://ocrportal.hhs.gov/ocr/portal/lobby.jsf or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800–368–1019, (TDD: 1-800–537–7697). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Sunshine Health Medicare Advantage (HMO) Sunshine Health Medicare Advantage 1301 International Parkway, Suite 400 Sunrise, FL 33323 Current members should call 1-844-293-2636 (TTY: 711) Prospective members should call 1-877-826-3692 (TTY: 711) From October 1 to February 14, you can call us 7 days a week from 8 a.m. to 8 p.m. From February 15 to September 30, you can call us Monday through Friday from 8 a.m. to 8 p.m. On weekends and holidays, an automated system will handle your call. You can see our plan’s provider and pharmacy directory at http://advantage.sunshinehealth.com If you want to know more about the coverage and costs of Original Medicare, look in your current ‘‘Medicare & You’’ handbook. View it online at https://www.medicare.gov or get a copy by calling 1‑800‑MEDICARE (1‑800‑633‑4227), 24 hours a day, 7 days a week. TTY users should call 1‑877‑486‑2048.

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