2019 Allwell Medicare Essentials (HMO) H5590: 005 Maricopa and Pinal counties, AZ

H5590_19_7933SB_005_M_Accepted 09072018

1

This booklet provides you with a summary of what we cover and your cost-sharing responsibilities. It doesn’t list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, please call us at the number listed on the last page, and ask for the “Evidence of Coverage” (EOC), or you may access the EOC on our website at allwell.azcompletehealth.com.

You are eligible to enroll in Allwell Medicare Essentials (HMO) if:

• You are entitled to Medicare Part A and enrolled in Medicare Part B. Members must continue to pay their Medicare Part B premium if not otherwise paid for under Medicaid or by another third party.

• You must be a United States citizen, or are lawfully present in the United States and permanently reside in the service area of the plan (in other words, your permanent residence is within the Allwell Medicare Essentials (HMO) service area counties). Our service area includes the following counties in Arizona: Maricopa and Pinal.

• You do not have end-stage renal disease (ESRD). (Exceptions may apply for individuals who develop ESRD while enrolled in an Allwell commercial or group health plan, or a Medicaid plan.)

The Allwell Medicare Essentials (HMO) plan gives you access to our network of highly skilled medical providers in your area. You can look forward to choosing a primary care provider (PCP) to work with you and coordinate your care. You can ask for a current provider directory or, for an up-to-date list of network providers, visit allwell.azcompletehealth.com. (Please note that, except for emergency care, urgently needed care when you are out of the network, out-of-area dialysis services, and cases in which our plan authorizes use of out-of-network providers, if you obtain medical care from out-of-plan providers, neither Medicare nor Allwell Medicare Essentials (HMO) will be responsible for the costs.)

This Allwell Medicare Essentials (HMO) plan also includes Part D coverage, which provides you with the ease of having both your medical and prescription drug needs coordinated through a single convenient source.

2

Summary of Benefits JANUARY 1, 2019--DECEMBER 31, 2019 ­Benefits Allwell Medicare Essentials (HMO) H5590 - 005

Premiums / Copays / Coinsurance Monthly Plan Premium $0

You must continue to pay your Medicare Part B premium. Deductible • $0 deductible for medical services

• $0 deductible for Part D prescription drugs

Maximum Out-of-Pocket Responsibility (does not include prescription drugs)

$3,400 annually This is the most you will pay in copays and coinsurance for covered medical services for the year.

Inpatient Hospital Coverage*

$190 copay per day, days 1 through 8 $0 copay per day, days 9 through 90

Outpatient Hospital* • Outpatient Hospital (includes observation services): $200 copay per visit

• Ambulatory Surgical Center: $100 copay per visit

Doctor Visits* • Primary Care: $0 copay per visit • Specialist: $15 copay per visit

Preventive Care (e.g. flu vaccine, diabetic screening)

$0 copay Other preventive services are available.

Emergency Care $120 copay per visit You do not have to pay the copay if admitted to the hospital immediately.

Urgently Needed Services

$20 copay per visit

Diagnostic Services/ Labs/Imaging*

• Lab services: $10 - $25 copay • Diagnostic tests and procedures: $0 copay • X-ray services: $10 - $75 copay

Hearing Services • Hearing exam (Medicare-covered): $15 copay • Routine hearing exam: $0 copay (1 every calendar year) • Hearing Aids: $0 - $995 copay (2 hearing aids every year)

Services with an * (asterisk) may require prior authorization and / or a referral from your doctor. 3

Benefits Allwell Medicare Essentials (HMO) H5590 - 005 Premiums / Copays / Coinsurance

Dental Services Dental services (Medicare-covered): $15 copay per visit

Vision Services Vision exam (Medicare-covered): $0 copay per visit

Mental Health Services* Individual and group therapy: $25 copay per visit

Skilled Nursing Facility* For each benefit period, you pay: $0 copay per day, days 1 through 20 $170 copay per day, days 21 through 100

Physical Therapy* $35 copay per visit

Ambulance* $275 copay (per one-way trip)

Transportation Not Covered

Medicare Part B Drugs* • Chemotherapy drugs: 20% coinsurance • Other Part B drugs: 20% coinsurance

Services with an * (asterisk) may require prior authorization and / or a referral from your doctor.

4

Part D Prescription Drugs Deductible Phase This plan does not have a Part D deductible.

Initial Coverage Phase (after you pay your deductible, if applicable)

Preferred Retail Rx 30-day supply

Standard Retail Rx 30-day supply

Mail-Order Rx 90-day supply

Tier 1: Preferred Generic $0 copay $5 copay $0 copay

Tier 2: Generic $15 copay $20 copay $42 copay

Tier 3: Preferred Brand $37 copay $47 copay $101 copay

Tier 4: Non-Preferred Drug

$90 copay $100 copay $260 copay

Tier 5: Specialty 33% coinsurance 33% coinsurance Not available

Tier 6: Select Care Drugs $0 copay $0 copay $0 copay

Important Info: Cost-sharing may change depending on the level of help you receive, the pharmacy you choose (such as Standard Retail, Mail-Order, Long-Term Care or Home Infusion) and when you enter another of the four phases of the Part D benefit.

For more information about the costs for Long-Term Supply, Home Infusion, or additional pharmacy-specific cost-sharing and the phases of the benefit, please call us or access our EOC online.

Low income subsidy (LIS) is extra help you receive from Medicare. To find out if you qualify, visit Medicare.gov or call Member Services at 1-877-935-8020 (TTY: 711).

5

Additional Covered Benefits Benefits Allwell Medicare Essentials (HMO) H5590 - 005

Premiums / Copays / Coinsurance Over-the-Counter (OTC)Items

$0 copay ($20 allowance per month for items available via mail order) Please visit the plan’s website to see the list of covered over-the-counter items.

Meals* The Plan covers up to two home delivered meals per day for up to 14 days following discharge from an inpatient hospital or skilled nursing facility.

Chiropractic Care* Chiropractic services (Medicare-covered): $20 copay per visit

Medical Equipment/ Supplies*

• Durable Medical Equipment (e.g., wheelchairs, oxygen):20% coinsurance

• Prosthetics (e.g., braces, artificial limbs): 20% coinsurance• Diabetic supplies: $0 copay

Foot Care* (Podiatry Services)

Foot exams and treatment (Medicare-covered): $25 copay per visit

Virtual Visit Teladoc offers 24 hours a day/7days a week/365 days a year virtual visit access to board certified doctors to help address a wide variety of health concerns/questions.

Wellness Programs • Fitness program: $0 copay• 24-hour nurse advice line: $0 copay• Supplemental smoking and tobacco use cessation (counseling to

stop smoking or tobacco use): $0 copayFor a detailed list of wellness program benefits offered, please refer to the EOC.

Worldwide Emergency Care

$50,000 plan coverage limit for supplemental urgent/emergent services outside the U.S. and its territories every year.

Routine Annual Exam $0 Copay

Services with an * (asterisk) may require prior authorization and / or a referral from your doctor.

6

7

Section 1557 Non-Discrimination Language Multi-Language Interpreter Services

ENGLISH: ATTENTION: If you speak English, language assistance services, free of charge, are available to you. call the Member Services number listed for your state in the Member Services Telephone Number Chart.

SPANISH: ATENCION: Si habla espaiiol, hay servicios de asistencia de idiomas disponibles para usted sin cargo. Llame al numero del Departamento de Servicios al Afiliado que se enumera para su estado en la Ficha de Numeros de Telefono del Departamento de Servicios al Afiliado.

VIETNAMESE: LliU Y: N~u quyvi n6i ti~ng Vi~t. chung tOi c6 cac djch VI.J h~ trQ' ngOn ngli miAn phf danh cho quy vj. Xin vui long gQi s6 di(:ln tho~i ph1,1c VI.J h()i vien danh cho til!u bang cua quy vi trong Bang s6 di(:ln tho~i djch VI) h()i vien.

CHINESE: lli1a: ~D~1&1flfltf:lx' 1&CJJ..:A~Ii~l1~~ft~t~WJH~~g o ~~~~~~H~J1.i8W~i2i51tfi~~Pfi91Jfrn 1&.Pfi tt ~·1•1 frn 1H~ Hl§~g g~ ~It fi~ o

FRENCH CREOLE (HAITIAN CREOLE): ATANSYON: Si w pale kreyol ayisyen, ou ka resevwa sevis gratis ki la pou ede w nan lang paw. Rele nimewo sevis manm pou eta kate w rete a. w ap jwenn li nan tabla nimewo telefon sevis manm yo.

ARABIC:

~ ~.J~I 4>~ ~I ~t...~ ~Y. J,-:il .~ ~\t. ~~I ~I i~L....JI ~t...~ wJ.i ,~_;all 4.Allll!.l~ w.iS. I~} :~ , .. ~ -·"A'I ~'i .tu WI L.&~l u~ l....i..l1A -' W'i .'HI~ ~ Y. ~ ~ r.J

FRENCH: ATIENTION : Si vous parlez franc;ais. un service d'aide linguistique vous est propose gratuitement. Veuillez appeler le numeko de telephone du Service aux membres specifique a votre Etat qui se trouve dans le tableau de numeros de telephone du Service aux membres.

RUSSIAN: BH~MAH~E! Ecn111 Bbl roeop111Te Ha pyccKOM Sl3b1Ke, Mbl MO>KeM np9A110>KIIITb BaM 6ecnnaTHble ycnyr111 nepeBQA4111Ka. no3BOHIIITe B 0T,Qe.n o6cny>KIIIBaHIIISI y4aCTHIIIKOB no yKa3aHHOMY ,QJlSI Bawero WTaTa HOMepy B Te.neQJOHHOM cnpaB04HIIIKe 0T,Qeila 06Cily>KIIIBaHIIISI Y4aCTHIIIKOB

GERMAN: ACHTUNG: Falls Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur VerfOgung. Rufen Sie bitte die fOr lhren Bundesstaat zustandige Rufnummer des Mitgliederkundendiensts an. die im Telefonverzeichnis des Mitgliederkundendiensts angegeben ist.

TAGALOG: PAUNAWA: Kung nagsasalita ka ng Tagalog, may makukuha kana mga libreng serbisyong pantulong sa wika. Tawagan ang numero ng Mga Serbisyo ng Miyembro na nakalista para sa iyong estado sa Tsart ng Numero ng mga Serbisyo ng Miyembro.

PORTUGUESE: ATEN<;AO: Se falar portugues. estao disponfveis. gratuitamente. servic;os de assistencia lingufstica. Ligue para o numero dos Servic;os aos Membros indicado para o seu estado na Tabela de numeros de telefone destes servic;os.

PENNSYLVANIAN DUTCH: Geb Acht: Wann du Deitsch schwetze kannscht, un Hilfin dei eegni Schprooch brauchst. kannscht dues Koschdefrei griege. Ruf die Glieder Nummer von dei Staat, ass iss uff die Lischt an die Glieder HilfTelefon Nummer Kaart.

GUJARATI: ~lCl~lat.: it cti{ =>J~~lrll CJUC{ctl ~ ctl, Qll~l ~elGI. ~ell~. at.AJC18, ctl-l.l~l l-l.l~ <3'-lc-1.~~ ~- ~~Gt. ~cu ~c-1.~at. ai.~~ ~-ll~cl-I.'L ctl-I.L~L ~LII(Gt. l-l.l~ ~~~~~ ~~Gt. ~cuw ai.~~ 'Ll~ BlC-1. 8~. JAPANESE: d .. : E3*~g{t~~tl.Q~, 11ft~O)§~B:slJI'tf- t:.A{t~~lj}f.ll, 'tcte~t*9 o )i.~J C -'tf-t:.A~~~-7-v- HcsaB~tl"Ll, '.Qt:>.f±*t, 'O)fflO);;i.~J C-'tt- t:.A*C't:>~~ < te~t, '0

8

ITALIAN: ATTENZIONE: se parla italiano, sana disponibili per Lei servizi di assistenza linguistica gratuiti. Consulti la Tabella dei Numeri Telefonici dei Servizi peri Membri e chiami il numero dei Servizi peri Membri del Suo stato.

MARSHALLESE: LALE: Ne kwoj konono Kajin ~ajot, kwomaroii bok jerbal in jipaii ilo kajin eo afTI ilo ejje!c;>k wol)aan iian kwe. KaHQk nofTlba in telpon in Jerbal in Jipaii nan ro uwaan eo ej jeje iian state eo afTI ilo Jaat in NCifTlba in Telpon in Jerbal in Jipaii nan ro uwaan.

LAOTIAN: ce.J<Z~ ~~:, t}.)tll~UcO.)W')~'}:)'}Ch ~::.uu6n">U~OVcmeo.)uw">~'>~Ofl8Vfl.)U6n">Utll~U !ov.u.,c~ve>~. n::~v">Illlm">c::>mru">vu6n">u~::.u.,qntll::>::u2pTu::>oee~tll~u~uccc;,uw.vc::>ntru">v!m::>::~., UU::>fl')U~::.u?qn.

HMONG: CEEV FAJ: Yog koj hais Ius Hmoob, muaj kev pab txhais lus pub dawb rau koj. Hu rau tus xov tooj ntawm Lub Chaw Pab Cuam Tswv Cuab ntawm koj lub xeev ntawm Tus Xov Tooj Ntawm Lub Chaw Pab Cuam Tswv Cuab Hauv Daim Ntawv No.

KOREAN: ~~.1.}.: =fl <5}7} ~~on~ J..}.§--5"}1-J ~ ~4'-. .!f-ii. ~ 01 ;t;J ~ J..-]tlJ.!;:~ ~_Q_{l .::r ~~L-1-ct. 7r~:At "il:Jl.!:: ~~18.:2. .EO!l ~~ =fl-5"t.9l ? 7r~:At "il:Jl.!:: ~1.lll8:2.£ ~~-5"}1} J-1..2...

HINDI:~ t ~ ~ 3il!lqi' ffi" ~ ~. WIT 'fttil4('11 ~. ~ ~. 3q(itiltf ~~ 'ftt\'&4 ~ ~tifllh'IG1 viiR mic ~ ~ * ~ 't{Tflilc;q 'ftt\'&4 ~ *ff tR" ~~I POLISH: UWAGA: Jesli m6wisz po polsku, mozesz skorzystac z bezptatnych ustugttumaczeniowych. Zadzwon pod numer dziatu obstugi klienta odpowiedni dla twojego stanu, dostfilpny w Wypisie numer6w telefonu dziatu obstugi klienta.

THAI: lt.Jnl'fi111J: 111fltJWl3~fll'l!l1iVItl tJWff111THl'\ltll1J1J1fl11'lhvtl1~tl~1llfl1l:l11~vill!irv~11~~1V lmitJv~ 11111 ma'llu1 m1 "N111iniii 1:: 1J i 1"\u i'J'Iltl~tJW l u Hf.I'W fJijl1111 ma'lll 'fllfl'Vl 'ti'n111i'u u1 m1ff111in

AMHARIC: 01fltl'lfi.f: h01fC"i1 ~"''J'tD~ hlf~:r.t}* Mlf MA"lfto-f-"f fl\hfi:f hf\AjP-}:: 0 hllltt MA"lfr>t ~ilAh ;fct "f. lll\lD' Ohlll\t 1\'lt:\"lfr>t ~'l'C ~S'..lD'/t-::

PERSIAN:

w~ ·.:1~ o w u ~u w l.ii:i..l ,, ·tL1 ,_ .u ·u · ~b .. l wl.....l.i. ,.l.US. ~ li ·L · .u t1 ·"-a..:; U"'"' .) • . • ~ .) .. ..r (.) .. _) .)~ . ~ . .) .. ~ . ~.) (.) . .) . y . • ..,... .~_fo. u-ol...:i o.l.!. .fo ~~ wl.....l.i.l-5\A uil:i o_JW J~ y ~ ~P wl\.;1 1..5lY. ~

BURMESE: :lldJu.(i.f: c=>OOG>OJ.>:u§x~tl ~93<lOJCJS :DJ~G>OJ.>:3<l~3<l~ O'~G'Jt'j~: 3;)~~ 'ltcSUl~~~~ 3<l~oto,~G'Jt'j~= oouS~~,:;UloS<!-un:oog ~9u~'uS3<lOJoS aJJ'l_t:~cS:cxn:~~ 3<l~ocSo,~G'Jt'j~:;UloSo? ~'=~~Ulu DUTCH: GRAAG UW AANDACHT: lndien u Nederlands spreekt. zijn taaldiensten gratis voor u beschikbaar. Gelieve de Ledendienstennummer vermeld voor uw staat in de Ledendiensten Telefoonnummer Tabel op te bellen.

PUNJABI:~~: ~3lft~iRre-a-~3"a'il~afNcm:t>f5~~ R~l'fi!3' ~ ~ -ao-1 ~ ~ ~-28l(lo ?5ao tJTaC ~ 3d"iiT R& ~53~ are Hao- 1WW ~ oa-a ~ ~~I - -

SWAHILI: TAHADHARI: Kama unazungumza Kiswahili, hudumaya msaada wa lugha. bure, zinapatikana kwa ajili yako. Piga Nambari ya Hudumaya Mwanachama iliyoorodheshwayajimbo lako kwenye hiyo Chati ya Nambari zaSimu za Hudumaya Mwanachama.

9

URDU:

Y..J->"" y,- ·d ~..:-~~ ~ ~ c?J~ ~T ~t...A w\a... 1)4j ~ UH t:::?lY. u4J ~.;I ~T .}.1 :utJ .....,:i .u;._fi. JtS. fi _>...Jy.o~ ~~ ~.Jt' c?J~ ~.J ~ ~l ~ ~.J~..»-l uJiJ'i;

SERBOCROATIAN: NAPOMENA: Ako govorite hrvatski jezik, dostupne su vam besplatne usluge podrske na vasem jeziku. Pozovite broj za usluge podrske za drZa.ve clan ice naveden u tablici telefonskih brojeva za usluge podrske u drzavama clanicama.

CUSHITE:

~_;.l.a]l ,.~\II ~t...li. rJY-~I~~ .lo!ll ~ti.. ~I~~ ~t.....JI ~t...l.i.. u_li ,~fill~ ujS lj} :~ ... ~\II ~t...li. Uii.JA rti) JJ~ ~ ~'J)

CHOCTAW: Pisa: Chahta anumpa ish anumpuli hokma, anumpa tosholi yvt peh pilla chia pela hinla. Tvli aianumpuli holhtena yvt holisso takanli rna chi state ibaiachvffa i toksvli ya i paya.

UKRAINIAN: YBArAI fl~o BH roeopHTe yKpa'iHCbKOIO, MH MO>K8MO aanponoHyBaTM BaM 683KOWTOBHi nocnyrM nepeKlla,qa'"la. 3arenett>oHyHre AO ei,a.qiny o6cnyroeyeaHHH Y\.ISCHHKiB 3a HOMepoM, aaaHa\.leHL'IM ,o,nH Baworo wmry B ra6nL'IU.i renet1JoHHHX HOMepis si,D,D,inis o6c.nyroeyeaHHH Y\.13CHHKiB.

ROMANIAN: ATENTIE: Daca vorbiti romane~te, va stau Ia dispozitie servicii gratuite de asistenta lingvistica. Sunati numarul departamentului de servicii pentru membri apartinand statului dumneavoastra care se gase~?te in tabelul cu numere de telefon ale departamentelor de servicii pentru membri.

~ON-t<H~ER, CAMgooiAN: 6nmUJmvuw1• ur:is~s.n~unrumflJl~\N MtldfiaWmMtl)WtU'ittnQrui f!ial S t\JflutjS n i llHU'J 9 9"1 rul8 ru11l tutr~fln t3UUUI S nn t\Jfltn~\Jru rtlijSM fJ ~bmnb rul8 ~Jl\JQ 9 ru11l C'\M aMi

ALBANIAN: VINI RE: Ne rast se flisni shqip, dote keni falas ne dispozicionin tuaj sherbimet e ndihmes gjuhesore. Merrni ne telefon numrin e Sherbimeve per Anetarin te shtetit tuaj qe do ta gjeni ne Listen e Numeratorit Telefonik te Sherbimeve per Anetarin.

NAVAJO: BAA' AKoNiNiziN: Bilagaana bizaad bee yanilti'go, saad bee aka'e'eyeed bee aka'ana'awo'l, t'aa jiik'eh bee na'ahoot'i' doole~. Hoyahgo Bahada'dlt'ehlgll Bee Bika'anlda'awo' Beesh Bee Hane'l Naaltsoos Dabika'lgrr biyi' nitsaago nit hahoodzoolgll biyi' Bahada'dlt'ehlgH Bee Aka'anlda'awo' bibeesh bee hane'l bika'lgH bee hodlilnih.

SYRIAC:

.... ~~:! ~ ~~~ ·~ ~~ ~·:! .__~c.~~:! .~~~~ ~~~:! ~ ~ .___aia . .

GREEK: nPOI:OXH: Eav ~..IIMTE EM'lVIKO, OIOTi8EVTOI YIO mac;; owpEOV UTT'lPEOiEc;; yAwoOIK~c;;

~o~9Eia~. KaMarE nw YnnpEaia E~UlTilPETilOil~ MEAwv orov ap181-16 n ou avaypaq>ETOI y1a rnv n oAITEia o ac;; arov nivaKa TllAEq>wvwv E~unrlPtT'lO'lc;; MEAwv.

1~~:~:u . . .. -. -

Allwell is contracted with Medicare for HMO, HMO SN P and PPO plans, and with some state Medicaid programs. Enrollment in Allwell depends on contract renewal.

FLY020520ZKOO (8/1 8)

10

11

For more information, please contact: Allwell Medicare Essentials (HMO) 1870 W. Rio Salado Parkway Tempe, AZ 85281

allwell.azcompletehealth.com

Current members should call: 1-877-935-8020 (TTY: 711)

Prospective members should call: 1-800-333-3930 (TTY: 711)

From October 1 to March 31, you can call us 7 days a week from 8 a.m. to 8 p.m. From April 1 to September 30, you can call us Monday through Friday from 8 a.m. to 8 p.m. A messaging system is used after hours, weekends, and on federal holidays.

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 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.

This information is not a complete description of benefits. Call 1-877-935-8020 (TTY: 711) for more information.

“Coinsurance” is the percentage you pay of the total cost of certain medical services.

The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.

This document is available in other formats such as Braille, large print or audio.

Allwell is contracted with Medicare for HMO, HMO SNP and PPO plans, and with some state Medicaid programs. Enrollment in Allwell depends on contract renewal.

SBS023957EO00 (9/18)

12