BENEFITS ASSISTANCE PROGRAMA State Health Insurance Assistance Program (SHIP)A program of the Area Agency on Aging, Region One1366 East Thomas, Suite 108, Phoenix, AZ 85014602 280-1059

This project was supported in part by grant number 15AAAZMSHI, from the U.S. Administration for Community Living, Department of Health and Human Services, Washington, D.C. 20201. Grantees undertaking projects under government sponsorship are encouraged to express freely their findings and conclusions. Points of view or opinions do not, therefore, necessarily represent official Administration for Community Living policy.

2021Medicare Advantage Plans

HMOMaricopa County

Most current revision 10/16/2020

Included in this packet are Medicare Advantage (MA) Health Maintenance Organization (HMO) plans, available to individuals enrolled in Medicare and living in Maricopa County. These plans are available for 2021. Use the enclosed information to compare plans, then select the one that best meets your individual needs.

Joining an MA plan or switching from one to another is only allowed during certain periods, for example when you first are eligible for Medicare, during the annual Open Enrollment Period, and during other Special Enrollment Periods. (Ask SHIP if you have questions about timing.)

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In summary, consider these questions as you make your decision.

What to Consider When Choosing a Plan

Provider networkHMOs have a network of doctors, hospitals, and other health care providers who have contracted with the plan to provide care to that plan’s Medicare beneficiaries. Except for emergency or urgent care, you must generally receive your care from the providers and hospitals in the plan’s network. If you get routine health care outside the plan’s network, you will have to pay the full cost of care for that visit. A referral from your primary care provider is usually required for specialist care.

If you have providers you do not want to lose, check with the doctor’s office or the health plan to determine if the providers are in-network for the plan you are considering. Most insurers offer several plans, and your provider may not be in all of them, so verify the full name and plan number to ensure you have identified the plan correctly.

PrescriptionsAnother major consideration in choosing a health plan is whether the medications you take are on the plan’s formulary. The Medicare.gov website has Plan Finder software to help with that. You enter your medications (drug name, dosage, frequency), and it will provide results showing if all your drugs are covered by the plan and the total cost to you.

Open Enrollment Period (OEP): October 15th – December 7th, with changes taking effect on January 1A plan's costs, benefits, providers, and formulary may change from year to year, so it’s a good habit to re-evaluate your choices each OEP to ensure your needs are still being met. Your medications will be available in the Plan Finder, allowing easy analysis of costs for the upcoming year.

There may be trade-offs when choosing among providers, formularies, and costs (co-pays and premiums) for the best-fit plan. The SHIP team is always happy to assist you with your questions.

Are all my drugs included on the plan’s formulary?

How does the total cost of my drugs compare to other plans?

How do the additional benefits compare with other plans?

Is there a premium and if so, how much?

What is the maximum out of pocket (MOOP) amount for this plan?

How do provider and hospital copays compare to other plans?

Are my doctors in the plan’s network?

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Plan Name Plan # Page

AARP Medicare Complete Plan 1 H0609-026 (United Healthcare) 5

AARP Medicare Complete Plan 2 H0609-027 (United Healthcare) 7

Aetna Medicare Platinum Plan H3931-130 (Aetna) 9

Aetna Medicare Premier Plan H4835-002 (Aetna) 11

Aetna Medicare Prime Plan H3931-092 (Aetna) 13

Aetna Medicare Prime Plus Plan H4835-001 (Aetna) 15

Allwell Medicare Essentials H5590-005 (Allwell) 17Allwell Medicare Premier II H0351-052 (Allwell) 19Banner Medicare Advantage Prime H5843-001 (Banner) 21

Blue Medicare Advantage Classic H0302-006 (Blue Cross Blue Shield) 23

* Blue Medicare Advantage Plus H0302-001 (Blue Cross Blue Shield) 25BluePathway Plan 1 H6936-006 (Blue Cross Blue Shield) 27

BluePathway Plan 2 H6936-003 (Blue Cross Blue Shield) 29

* BluePathway Plan 3 H6939-004 (Blue Cross Blue Shield) 31

Bright Advantage H4853-001 (Bright Health) 33

* Bright Advantage Assist H4853-002 (Bright Health) 35

* Bright Advantage Plus H4853-014 (Bright Health) 37

CIGNA Alliance Medicare H0354-028 (CIGNA) 39

CIGNA Preferred Medicare H0354-001 (CIGNA) 41Devoted Health Core H8173-001 (Devoted Health) 43

* Devoted Health Flex H8173-003 (Devoted Health) 45

* Devoted Health Select H8173-002 (Devoted Health) 47

* Humana Gold Plus 023 H0028-023 (Humana) 49

Humana Gold Plus 027 H0028-027 (Humana) 51

Humana Gold Plus 028 H0028-028 (Humana) 53

Imperial Insurance Co Traditional H2793-003 (Imperial) 55

* Imperial Insurance Traditional Plus H2793-007 (Imperial) 57

* WellCare Compass H6439-003 (WellCare) 59

# WellCare Dividend H6439-004 (WellCare) 61

WellCare Value H6439-002 (WellCare) 63

* Plans with a monthly premium in addition to the Medicare Part B premium# Plans pay part of the Medicare Part B premium.

Health Maintenance Organizations (HMO)Company

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AARP Medicare Advantage (UnitedHealthcare) Plan 1 (HMO) Page 5Plan Number H0609-026 800 555-5757STAR Rating 4.0 out of 5.0 www.AARPMedicarePlans.com

Monthly Plan Premium (in addition to the Medicare Part B Premium) $0Annual Medical Deductible NONEMaximum-out-of-Pocket Limit (MOOP) excluding drug costs $3,900Out-of-Network Services No Coverage

Physician/Provider Services - Copayments (Telehealth may be available)Primary Care Provider $5Specialist $35Mental Health and Outpatient Substance Abuse: Individual / Group $25 / $15Opioid Treatment Services $0PT, OT, Speech Therapy $35Chiropractic (Medicare covered services) $20Podiatry (Medicare covered services) $35

Hospital (Inpatient) Care - CopaymentsHospital inpatient Per Days 1 - 7 $230 Hospital inpatient Per Days 8 and beyond $0Skilled Nursing Facility (SNF) Per Days 1 - 20 $0 Skilled Nursing Facility (SNF) Per Days 21 - 42 $184 Skilled Nursing Facility (SNF) Per Days 43 - 100 $0

Oupatient Care - CopaymentsHospital Surgery Center $0 - $175Ambulatory Surgery Center $125Hospital Observation $0 - $175Renal Dialysis 20%

Emergency/Urgent Care Services - CopaymentsEmergency Room / Urgent Care $90 / $40Ambulance per Trip: Ground / Air $250 / $250

Diagnostic Testing - CopaymentsRadiology Tests and Imaging $0 thru $125Diagnostic & Lab Services $0 - $30

Diabetes & Durable Medical Equipment (DME) - CopaymentsDiabetes Monitoring Supplies and Self-Management Training $0Diabetes therapeutic shoes and inserts 20%Equipment (e.g. wheelchairs, oxygen) and Prosthetics (e.g. braces) 20%

Part B Drugs - CopaymentsPart B Immunizations - Flu, pheumonia, and hepititis B vacinnations $0Chemotherapy, transplant drugs and facility based infusions 20%

Prescription Drugs Part D drugs - Deductible $150 for tiers 4,5INSULIN - call the Plan to determine your estimated drug cost

AARP Medicare Complete Plan 1 (HMO) Page 6Additional Benefits, Physician Network, Preferred Pharmacies and Hospital Networks

Additional Benefits (Non-Medicare covered)Routine eye exam (1 every year) $0 co-payEyewear (lenses/frames and contacts up to $200 every 2 years) $0 co-payHearing Aid Appliance (up to 2 hearing aids every 2 years) $375 - $2,075 copayTransportation to approved locations (36 one-way trips every year) $0 co-payDental (preventive exams, cleanings, x-rays) $0 co-payOver-the-Counter allowance on approved health products $40 per quarter24 hour Nurse Hotline $0 co-payFitness Program $0 co-payMeals after Hospital Stay not covered

Travel Benefit in the United States up to 9 months

Routine chiropractic not covered

Routine footcare (6 visits per year) $35 co-pay

Physician Network** Check with the plan to determine if your physician is in this plan's network.

Preferred pharmacies (check with the plan for the lowest cost pharmacy)If your plan has preferred pharmacies, using those pharmacies may save you money.

Bashas and United Drug CVS Safeway

Cigna Medical Group Pharmacy Fry's Food City

Costco Osco Walgreens

Walmart

Hospital Networks Abrazo Dignity Health BannerArrowhead Arizona General Hospitals Baywood

Central Campus Chandler Regional Boswell

Scottsdale Campus Mercy Gilbert Del Webb

West Campus St Joseph’s Hospital Desert

St Joseph’s Westgate Estrella

HonorHealth Gateway

Deer Valley St Luke’s University Medical Center

John C Lincoln Phoenix Tempe Ironwood

Scottsdale Osborn Thunderbird

Scottsdale Shea

AARP Medicare Advantage (UnitedHealthcare) Plan 2 (HMO) Page 7Plan Number H0609-027 800 555-5757STAR Rating 4.0 out of 5.0 www.AARPMedicarePlans.com

Monthly Plan Premium (in addition to the Medicare Part B Premium) $0Annual Medical Deductible NONEMaximum-out-of-Pocket Limit (MOOP) excluding drug costs $3,000Out-of-Network Services No Coverage

Physician/Provider Services - Copayments (Telehealth may be available)

Primary Care Provider $0Specialist $20Mental Health and Outpatient Substance Abuse: Individual / Group $25 / $15Opioid Treatment Services $0PT, OT, Speech Therapy $20Chiropractic (Medicare covered services) $20Podiatry (Medicare covered services) $20

Hospital (Inpatient) Care - CopaymentsHospital inpatient Per Days 1 - 7 $175 Hospital inpatient Per Days 8 and beyond $0Skilled Nursing Facility (SNF) Per Days 1 - 20 $0 Skilled Nursing Facility (SNF) Per Days 21 - 37 $184 Skilled Nursing Facility (SNF) Per Days 38 - 100 $0

Oupatient Care - CopaymentsHospital Surgery Center $0 - $175Ambulatory Surgery Center $0 - $75Hospital Observation $0 - $175Renal Dialysis 20%

Emergency/Urgent Care Services - CopaymentsEmergency Room / Urgent Care $90 / $40Ambulance per Trip: Ground / Air $250 / $250

Diagnostic Testing - CopaymentsRadiology Tests and Imaging $0 - $125Diagnostic & Lab Services $0 - $30

Diabetes & Durable Medical Equipment (DME) - CopaymentsDiabetes Monitoring Supplies and Self-Management Training $0Diabetes therapeutic shoes and inserts 20%Equipment (e.g. wheelchairs, oxygen) and Prosthetics (e.g. braces) 20%

Part B Drugs - CopaymentsPart B Immunizations - Flu, pheumonia, and hepititis B vacinnations $0Chemotherapy, transplant drugs and facility based infusions 20%

Prescription Drugs Part D drugs - Deductible $0INSULIN - call the Plan to determine your estimated drug cost

AARP Medicare Complete Plan 2 (HMO) Page 8Additional Benefits, Physician Network, Preferred Pharmacies and Hospital Networks

Additional Benefits (Non-Medicare covered)Routine eye exam (1 per year) $0 co-payEyewear (lenses/frames and contacts up to $200 every 2 years) $0 co-payHearing Aid Appliance (up to 2 hearing aids every 2 years) $375 - $2,075 copayTransportation to approved locations not coveredDental (preventive & comprehensive, limit of $500) $0 co-payOver-the-Counter allowance on approved health products $40 per quarter24 hour Nurse Hotline $0 co-payFitness Program $0 co-payMeals after Hospital Stay not coveredTravel Benefit in the United States Up to 9 monthsRoutine chiropractic not coveredRoutine footcare (6 visits per year) $20

Physician Network** Check with the plan to determine if your physician is in this plan's network.

Preferred pharmacies (check with the plan for the lowest cost pharmacy)If your plan has preferred pharmacies, using those pharmacies may save you money.

Bashas and United Drug CVS Safeway

Cigna Medical Group Pharmacy Fry's Food City

Costco Osco Walgreens

Walmart

Hospital NetworksAbrazo Dignity Health BannerArrowhead Arizona General Hospitals Baywood

Central Campus Chandler Regional Boswell

Scottsdale Campus Mercy Gilbert Del Webb

St Joseph’s Hospital Desert

HonorHealth St Joseph’s Westgate Estrella

Deer Valley Gateway

John C Lincoln Phoenix St Luke’s Ironwood

Scottsdale Osborn Tempe Thunderbird

Scottsdale Shea University Medical Center

Scottsdale Thompson Peak

Aetna Medicare Platinum Plan (HMO) Page 9Plan Number H3931-130 833 859-6031STAR Rating 3.5 out of 5.0 www.aetnamedicare.com

Monthly Plan Premium (in addition to the Medicare Part B Premium) $0Annual Medical Deductible NONEMaximum-out-of-Pocket Limit (MOOP) excluding drug costs $7,550Out-of-Network Services No Coverage

Physician/Provider Services - Copayments (Telehealth may be available)

Primary Care Provider $0Specialist $40Mental Health and Outpatient Substance Abuse: Individual / Group $40 / $40Opioid Treatment Services $40PT, OT, Speech Therapy $40Chiropractic (Medicare covered services) $20Podiatry (Medicare covered services) $40

Hospital (Inpatient) Care - CopaymentsHospital inpatient Per Days 1 - 7 $315

Hospital inpatient Per Days 8 and beyond $0Skilled Nursing Facility (SNF) Per Days 1 - 20 $0

Skilled Nursing Facility (SNF) Per Days 21 - 100 $184Oupatient Care - Copayments

Hospital Surgery Center $315Ambulatory Surgery Center $315Hospital Observation $315Renal Dialysis 20%

Emergency/Urgent Care Services - CopaymentsEmergency Room / Urgent Care $90 / $50Ambulance per Trip: Ground / Air $280 / $280

Diagnostic Testing - CopaymentsRadiology Tests and Imaging $40 - $295Diagnostic & Lab Services $0 - $40

Diabetes & Durable Medical Equipment (DME) - CopaymentsDiabetes Monitoring Supplies and Self-Management Training 0% - 20%Diabetes therapeutic shoes and inserts $0Equipment (e.g. wheelchairs, oxygen) and Prosthetics (e.g. braces) 20%

Part B Drugs - CopaymentsPart B Immunizations - Flu, pheumonia, and hepititis B vacinnations $0Chemotherapy, transplant drugs and facility based infusions 20%

Prescription Drugs Part D drugs - Deductible $100 for tiers 3, 4, 5INSULIN - call the Plan to determine your estimated drug cost

Aetna Medicare Platinum Plan (HMO) Page 10Additional Benefits, Physician Network, Preferred Pharmacies and Hospital Networks

Additional Benefits (Non-Medicare covered)Routine eye exam (1 each year) $0 co-payEyewear (lenses/frames and contacts up to $75 per year) $0 co-payHearing Aid Appliance not coveredTransportation to approved locations not coveredDental not coveredOver-the-Counter allowance on approved health products not covered24 hour Nurse Hotline $0 co-payFitness Program $0 co-payMeals after Hospital Stay: 14 meals up to 7 days $0 co-payTravel Benefit in the United States up to 12 monthsRoutine chiropractic not coveredRoutine footcare (with certain medical conditions) $40 co-pay

Physician Network** Check with the plan to determine if your physician is in this plan's network.

Preferred pharmacies (check with the plan for the lowest cost pharmacy)If your plan has preferred pharmacies, using those pharmacies may save you money.

Costco CVS Fry's Walmart Safeway

Hospital NetworksAbrazo Dignity Health BannerWest Campus (Goodyear) Arizona General Baywood

Central Campus Chandler Regional Boswell

Scottsdale (PV-Bell) Mercy Gilbert Del Webb

Arrowhead St Joseph’s Hospital Desert

Mesa St Joseph’s Westgate Estrella

Gateway

HonorHealth Thunderbird

Scottsdale Osborn University Medical Center

Scottsdale Shea

Scottsdale Thompson Peak

Phoenix Deer Valley

Phoenix John C Lincoln

Aetna Medicare Premier Plan (HMO) Page 11Plan Number H4835-002 833 859-6031STAR Rating Plan too new to be measured www.aetnamedicare.com

Monthly Plan Premium (in addition to the Medicare Part B Premium) $0Annual Medical Deductible NONEMaximum-out-of-Pocket Limit (MOOP) excluding drug costs $4,700

Out-of-Network Services No Coverage

Physician/Provider Services - Copayments (Telehealth may be available)Primary Care Provider $0Specialist $30Mental Health and Outpatient Substance Abuse: Individual $40Opioid Treatment Services $40PT, OT, Speech Therapy $30Chiropractic (Medicare covered services) $20Podiatry (Medicare covered services) $30

Hospital (Inpatient) Care - CopaymentsHospital inpatient Per Days 1 - 7 $250 Hospital inpatient Per Days 8 and beyond $0Skilled Nursing Facility (SNF) Per Days 1 - 20 $0 Skilled Nursing Facility (SNF) Per Days 21 - 100 $184

Oupatient Care - CopaymentsHospital Surgery Center $200Ambulatory Surgery Center $150Hospital Observation $200Renal Dialysis $295

Emergency/Urgent Care Services - CopaymentsEmergency Room / Urgent Care $90 / $50Ambulance per Trip: Ground / Air $275 / $275

Diagnostic Testing - CopaymentsRadiology Tests and Imaging $20 - $175Diagnostic & Lab Services $0 - $20

Diabetes & Durable Medical Equipment (DME) - CopaymentsDiabetes Monitoring Supplies and Self-Management Training 0% - 20%Diabetes therapeutic shoes and inserts $0Equipment (e.g. wheelchairs, oxygen) and Prosthetics (e.g. braces) 20%

Part B Drugs - CopaymentsPart B Immunizations - Flu, pheumonia, and hepititis B vacinnations $0Chemotherapy, transplant drugs and facility based infusions 20%

Prescription Drugs Part D drugs - Deductible $0INSULIN - call the Plan to determine your estimated drug cost

Aetna Medicare Premier Plan (HMO) Page 12Additional Benefits, Physician Network, Preferred Pharmacies and Hospital Networks

Additional Benefits (Non-Medicare covered)

Routine eye exam (1 every year) $0 co-payEyewear (lenses/frames and contacts up to $150 per year) $0 co-payHearing Aid Appliance (up to $1,250 per ear per year) $0 co-payTransportation to approved locations not coveredDental (up to $750 for covered services) $0 co-payOver-the-Counter allowance on approved health products $45 per quarter24 hour Nurse Hotline $0 co-payFitness Program $0 co-payMeals after Hospital Stay (14 home delivered) $0 co-payVisitor / Travel Benefit in the United States up to 12 monthsRoutine chiropractic not coveredRoutine footcare $30 co-pay

Physician Network** Check with the plan to determine if your physician is in this plan's network.

Preferred pharmacies (check with the plan for the lowest cost pharmacy)If your plan has preferred pharmacies, using those pharmacies may save you money.

Costco CVS Fry's Osco Safeway Walmart

Hospital NetworksAbrazo Dignity Health BannerWest Campus (Goodyear) Arizona General Baywood

Central Campus Chandler Regional Boswell

Mesa Mercy Gilbert Del Webb

Scottsdale (PV-Bell) St Joseph’s Desert

Arrowhead St Joseph’s Westgate Estrella

Gateway

HonorHealth Thunderbird

Scottsdale Osborn University Medical Center

Scottsdale Shea

Scottsdale Thompson Peak

Deer Valley

Phoenix John C Lincoln

Aetna Medicare Prime Plan (HMO) Page 13Plan Number H3931-092 833 859-6031STAR Rating 3.5 out of 5.0 www.aetnamedicare.com

Monthly Plan Premium (in addition to the Medicare Part B Premium) $0Annual Medical Deductible NONEMaximum-out-of-Pocket Limit (MOOP) excluding drug costs $7,550Out-of-Network Services No Coverage

Physician/Provider Services - Copayments (Telehealth may be available)

Primary Care Provider $0Specialist $40Mental Health and Outpatient Substance Abuse: Individual / Group $40 / $40Opioid Treatment Services $40PT, OT, Speech Therapy $40Chiropractic (Medicare covered services) $20Podiatry (Medicare covered services) $40

Hospital (Inpatient) Care - CopaymentsHospital inpatient Per Days 1 - 7 $315 Hospital inpatient Per Days 8 - 90 $0Skilled Nursing Facility (SNF) Per Days 1 - 20 $0 Skilled Nursing Facility (SNF) Per Days 21 - 100 $184

Oupatient Care - CopaymentsHospital Surgery Center $315Ambulatory Surgery Center $315Hospital Observation $315Renal Dialysis 20%

Emergency/Urgent Care Services - CopaymentsEmergency Room / Urgent Care $90 / $50Ambulance per Trip: Ground / Air $270 / $270

Diagnostic Testing - CopaymentsRadiology Tests and Imaging $30 - $295Diagnostic & Lab Services $0 - $30

Diabetes & Durable Medical Equipment (DME) - CopaymentsDiabetes Monitoring Supplies and Self-Management Training 0% - 20%Diabetes therapeutic shoes and inserts $0Equipment (e.g. wheelchairs, oxygen) and Prosthetics (e.g. braces) 20%

Part B Drugs - CopaymentsPart B Immunizations - Flu, pheumonia, and hepititis B vacinnations $0Chemotherapy, transplant drugs and facility based infusions 20%

Prescription Drugs Part D drugs - Deductible $100 for tiers 3, 4, 5INSULIN - call the Plan to determine your estimated drug cost

Aetna Medicare Prime Plan (HMO) Page 14Additional Benefits, Physician Network, Preferred Pharmacies and Hospital Networks

Additional Benefits (Non-Medicare covered)Routine eye exam (1 every year) $0 co-payEyewear (lenses/frames and contacts up to $75 per year) $0 co-payHearing Aid Appliance not coveredTransportation to approved locations not coveredDental not coveredOver-the-Counter allowance on approved health products not covered24 hour Nurse Hotline $0 co-payFitness Program $0 co-payMeals after Hospital Stay: 14 meals over 7 days $0 co-payTravel Benefit in the United States not coveredRoutine chiropractic not coveredRoutine footcare not covered

Physician Network** Check with the plan to determine if your physician is in this plan's network.

Preferred pharmacies (check with the plan for the lowest cost pharmacy)If your plan has preferred pharmacies, using those pharmacies may save you money.

Costco CVS Fry's Osco Safeway Walmart

Hospital NetworksHonor Health BannerScottsdale Osborn Baywood

Scottsdale Shea Boswell

Scottsdale Thompson Peak Del Webb

Deer Valley Desert

John C Lincoln Phoenix Estrella

Gateway

Thunderbird

University Medical Center

Aetna Medicare Prime Plus Plan (HMO) Page 15Plan Number H4835-001 833 859-6031STAR Rating Plan too new to be measured www.aetnamedicare.com

Monthly Plan Premium (in addition to the Medicare Part B Premium) $0Annual Medical Deductible NONEMaximum-out-of-Pocket Limit (MOOP) excluding drug costs $3,600Out-of-Network Services No Coverage

Physician/Provider Services - Copayments (Telehealth may be available)

Primary Care Provider $0Specialist $25Mental Health and Outpatient Substance Abuse: Individual / Group $40 / $40Opioid Treatment Services $40PT, OT, Speech Therapy $25Chiropractic (Medicare covered services) $20Podiatry (Medicare covered services) $25

Hospital (Inpatient) Care - CopaymentsHospital inpatient Per Days 1 - 7 $195 Hospital inpatient Per Days 8 and beyond $0Skilled Nursing Facility (SNF) Per Days 1 - 20 $0 Skilled Nursing Facility (SNF) Per Days 21 - 100 $184

Oupatient Care - CopaymentsHospital Surgery Center $185Ambulatory Surgery Center $100Hospital Observation $185Renal Dialysis 20%

Emergency/Urgent Care Services - CopaymentsEmergency Room / Urgent Care $90 / $50Ambulance per Trip: Ground / Air $280 / $280

Diagnostic Testing - CopaymentsRadiology Tests and Imaging $10 - $150Diagnostic & Lab Services $0 - $10

Diabetes & Durable Medical Equipment (DME) - CopaymentsDiabetes Monitoring Supplies and Self-Management Training 0% - 20%Diabetes therapeutic shoes and inserts $0Equipment (e.g. wheelchairs, oxygen) and Prosthetics (e.g. braces) 20%

Part B Drugs - CopaymentsPart B Immunizations - Flu, pheumonia, and hepititis B vacinnations $0Chemotherapy, transplant drugs and facility based infusions 20%

Prescription Drugs Part D drugs - Deductible $0INSULIN - call the Plan to determine your estimated drug cost

Aetna Medicare Prime Plus Plan (HMO) Page 16Additional Benefits, Physician Network, Preferred Pharmacies and Hospital Networks

Additional Benefits (Non-Medicare covered)Routine eye exam (1 every year) $0 co-payEyewear (lenses/frames and contacts up to $250 per year) $0 co-payHearing Aid Appliance (up to $1,250 per ear per year) $0 co-payTransportation to approved locations not coveredDental (covered services up to $1,500 per year) $0 co-payOver-the-Counter allowance on approved health products $45 per quarter24 hour Nurse Hotline $0 co-payFitness Program $0 co-payMeals after Hospital Stay: 14 meals $0 co-payTravel Benefit in the United States not coveredRoutine chiropractic not coveredRoutine footcare not covered

Physician Network** Check with the plan to determine if your physician is in this plan's network.

Preferred pharmacies (check with the plan for the lowest cost pharmacy)If your plan has preferred pharmacies, using those pharmacies may save you money.

Costco CVS Fry's Osco Safeway Walmart

Hospital NetworksHonor Health BannerScottsdale Osborn Baywood

Scottsdale Shea Boswell

Scottsdale Thompson Peak Del Webb

John C Lincoln Deer Valley Desert

John C Lincoln Phoenix Estrella

Gateway

Thunderbird

University

Allwell Medicare Essentials (HMO) Page 17Plan Number H5590-005 800 333-3930STAR Rating Not enough data available www.allwellmedicare.com

Monthly Plan Premium (in addition to the Medicare Part B Premium) $0Annual Medical Deductible NONEMaximum-out-of-Pocket Limit (MOOP) excluding drug costs $3,450

Out-of-Network Services No Coverage

Physician/Provider Services - Copayments (Telehealth may be available)Primary Care Provider $0Specialist $15Mental Health and Outpatient Substance Abuse: Individual / Group $25 / $25Opioid Treatment Services: Individual / Group $25 / $25PT, OT, Speech Therapy $35Chiropractic (Medicare covered services) $20Podiatry (Medicare covered services) $15

Hospital (Inpatient) Care - CopaymentsHospital inpatient Per Days 1 - 8 $180 Hospital inpatient Per Days 9 and beyond $0Skilled Nursing Facility (SNF) Per Days 1 - 20 $0 Skilled Nursing Facility (SNF) Per Days 21 - 100 $170

Oupatient Care - CopaymentsHospital Surgery Center $200Ambulatory Surgery Center $100Hospital Observation $200Renal Dialysis 20%

Emergency/Urgent Care Services - CopaymentsEmergency Room / Urgent Care $120 / $20Ambulance per Trip: Ground / Air $275 / $275

Diagnostic Testing - CopaymentsRadiology Tests and Imaging $10 to $200Diagnostic & Lab Services $0 to $25

Diabetes & Durable Medical Equipment (DME) - CopaymentsDiabetes Monitoring Supplies and Self-Management Training $0Diabetes therapeutic shoes and inserts 20%Equipment (e.g. wheelchairs, oxygen) and Prosthetics (e.g. braces) 20%

Part B Drugs - CopaymentsPart B Immunizations - Flu, pheumonia, and hepititis B vacinnations $0Chemotherapy, transplant drugs and facility based infusions 20%

Prescription Drugs Part D drugs - Deductible $0INSULIN - call the Plan to determine your estimated drug cost

Allwell Medicare Essentials (HMO) Page 18Additional Benefits, Physician Network, Preferred Pharmacies and Hospital Networks

Additional Benefits (Non-Medicare covered)Routine eye exam (1 per year) $0 co-payEyewear (lenses/frames and contacts up to $100 per year) $0 co-payHearing Aid Appliance (2 per year) $0 to $1,350 copayTransportation to approved locations not coveredDental not coveredOver-the-Counter allowance on approved health products $50 per quarter24 hour Nurse Hotline $0 co-payFitness Program $0 co-payMeals after Hospital Stay (2 per day for 14 days) $0 co-payTravel Benefit not coveredRoutine chiropractic not coveredRoutine footcare not covered

Physician Network** Check with the plan to determine if your physician is in this plan's network.

Preferred pharmacies (check with the plan for the lowest cost pharmacy)If your plan has preferred pharmacies, using those pharmacies may save you money.

Albertsons Costco CVS Fry's Safeway Walmart Osco Walgreen's Sam's Club Basha's Cigna Medical Group

Hospital NetworksAbrazo St Luke's BannerWest Campus (Goodyear) Tempe BaywoodCentral Campus BoswellMesa Del WebbScottsdale (PV-Bell) HonorHealth DesertArrowhead Scottsdale Osborn Estrella

Scottsdale Shea GatewayScottsdale Thompson Peak Goldfield (Apache Junction)

Valleywise Health Deer Valley UniversityJohn C Lincoln Phoenix Ironwood

Thunderbird

Allwell Medicare Premier II (HMO) Page 19Plan Number H0351-052 800 333-3930STAR Rating 3.0 out of 5.0 www.allwellmedicare.com

Monthly Plan Premium (in addition to the Medicare Part B Premium) $0Annual Medical Deductible NONEMaximum-out-of-Pocket Limit (MOOP) excluding drug costs $3,450Out-of-Network Services No Coverage

Physician/Provider Services - Copayments (Telehealth may be available)Primary Care Provider $0Specialist $15Mental Health and Outpatient Substance Abuse: Individual / Group $25 / $25Opioid Treatment Services $25PT, OT, Speech Therapy $35Chiropractic (Medicare covered services) $20Podiatry (Medicare covered services) $15

Hospital (Inpatient) Care - CopaymentsHospital inpatient Per Days 1 - 8 $180 Hospital inpatient Per Days 9 and beyond $0Skilled Nursing Facility (SNF) Per Days 1 - 20 $0 Skilled Nursing Facility (SNF) Per Days 21 - 100 $184

Oupatient Care - CopaymentsHospital Surgery Center $200Ambulatory Surgery Center $100Hospital Observation $200Renal Dialysis 20%

Emergency/Urgent Care Services - CopaymentsEmergency Room / Urgent Care $120 / $20Ambulance per Trip: Ground / Air $275 / 20%

Diagnostic Testing - CopaymentsRadiology Tests and Imaging $0 to $200Diagnostic & Lab Services $0 - $25

Diabetes & Durable Medical Equipment (DME) - CopaymentsDiabetes Monitoring Supplies and Self-Management Training $0Diabetes therapeutic shoes and inserts 20%Equipment (e.g. wheelchairs, oxygen) and Prosthetics (e.g. braces) 20%

Part B Drugs - CopaymentsPart B Immunizations - Flu, pheumonia, and hepititis B vacinnations $0Chemotherapy, transplant drugs and facility based infusions 20%

Prescription Drugs Part D drugs - Deductible $0

INSULIN - call the Plan to determine your estimated drug cost

Allwell Medicare Premier II (HMO) Page 20Additional Benefits, Physician Network, Preferred Pharmacies and Hospital Networks

Additional Benefits (Non-Medicare covered)Routine eye exam (1 per year) $0 co-payEyewear (lenses/frames and contacts up to $100 per year) $0 co-payHearing Aid Appliance (1 hearing aid per ear per calendar year) $0 to $1,350 copayTransportation to approved locations (up to 16 one-way trips) $0 co-payDental (preventive exams, cleanings, x-rays) $0 co-payOver-the-Counter allowance on approved health products $100 per quarter24 hour Nurse Hotline $0 co-payFitness Program $0 co-payMeals after Hospital Stay (up to 2 meals per day for 14 days) $0 co-payTravel Benefit not coveredRoutine chiropractic not coveredRoutine footcare not covered

Physician Network** Check with the plan to determine if your physician is in this plan's network.

Preferred pharmacies (check with the plan for the lowest cost pharmacy)If your plan has preferred pharmacies, using those pharmacies may save you money.

Albertsons Costco CVS Fry's Safeway Walmart Osco Walgreen's Sam's Club Basha's Cigna Medical Group

Hospital NetworksAbrazo St Luke's BannerWest Campus (Goodyear) Tempe BaywoodCentral Campus BoswellMesa Del WebbScottsdale (PV-Bell) HonorHealth DesertArrowhead Scottsdale Osborn Estrella

Scottsdale Shea GatewayScottsdale Thompson Peak Goldfield (Apache Junction)

Valleywise Health Deer Valley UniversityJohn C Lincoln Phoenix Ironwood

Thunderbird

Banner Medicare Advantage Prime (HMO) Page 21Plan Number H5843-001 844 549-1858STAR Rating Plan too new to be measured www.bannerma.com

Monthly Plan Premium (in addition to the Medicare Part B Premium) $0Annual Medical Deductible NONEMaximum-out-of-Pocket Limit (MOOP) excluding drug costs $4,450Out-of-Network Services No Coverage

Physician/Provider Services - Copayments (Telehealth may be available)Primary Care Provider $0Specialist $30Mental Health and Outpatient Substance Abuse: Individual / Group $25 / $25Opioid Treatment Services $30PT, OT, Speech Therapy $35Chiropractic (Medicare covered services) $35Podiatry (Medicare covered services) $0 - $35

Hospital (Inpatient) Care - CopaymentsHospital inpatient Per Days 1 - 7 $200 Hospital inpatient Per Days 8 - 90 $0Skilled Nursing Facility (SNF) Per Days 1 - 20 $0 Skilled Nursing Facility (SNF) Per Days 21 - 100 $178

Oupatient Care - CopaymentsHospital Surgery Center $225Ambulatory Surgery Center $225Hospital Observation check with planRenal Dialysis 20%

Emergency/Urgent Care Services - CopaymentsEmergency Room / Urgent Care $90 / $40Ambulance per Trip: Ground / Air $265

Diagnostic Testing - CopaymentsRadiology Tests and Imaging check with planDiagnostic & Lab Services $10

Diabetes & Durable Medical Equipment (DME) - CopaymentsDiabetes Monitoring Supplies and Self-Management Training 20%Diabetes therapeutic shoes and inserts check with planEquipment (e.g. wheelchairs, oxygen) and Prosthetics (e.g. braces) 20%

Part B Drugs - CopaymentsPart B Immunizations - Flu, pheumonia, and hepititis B vacinnations $0Chemotherapy, transplant drugs and facility based infusions 20%

Prescription Drugs Part D drugs - Deductible $150 for tiers 3, 4, 5

INSULIN - call the Plan to determine your estimated drug cost

Banner Medicare Advantage Prime (HMO) Page 22Additional Benefits, Physician Network, Preferred Pharmacies and Hospital Networks

Additional Benefits (Non-Medicare covered)Routine eye exam $0 co-payEyewear (lenses/frames and contacts up to $200 for 2 years) $25 co-payHearing Aid Appliance ($1,000 allowance every 2 years) $0 co-payTransportation to approved locations not coveredDental (preventive exams, cleanings, x-rays) $0 co-payOver-the-Counter allowance on approved health products $50 per quarter24 hour Nurse Hotline not coveredFitness Program $0 co-payMeals after Hospital Stay (12 meals over 30 days) $0 co-payTravel Benefit not coveredRoutine chiropractic (up to 6 visits per year) $35 co-payRoutine footcare not covered

Physician Network** Check with the plan to determine if your physician is in this plan's network.

Preferred pharmacies (check with the plan for the lowest cost pharmacy)If your plan has preferred pharmacies, using those pharmacies may save you money.

Cigna Medical Group Costco CVS Fry's Safeway Walmart Osco Basha's Sam's Pharmacy

Hospital NetworksBannerBaywoodBoswellDel WebbDesertEstrellaGatewayGoldfield (Apache Junction)UniversityThunderbird

Blue Medicare Advantage Classic (HMO) Page 23Plan Number H0302-006 800 422-0761STAR Rating Plan too new to be measured azbluemedicare.com

Monthly Plan Premium (in addition to the Medicare Part B Premium) $0Annual Medical Deductible NONEMaximum-out-of-Pocket Limit (MOOP) excluding drug costs $4,250Out-of-Network Services No Coverage

Physician/Provider Services - Copayments (Telehealth may be available)Primary Care Provider $0Specialist $35Mental Health and Outpatient Substance Abuse: Individual / Group $35 / $35Opioid Treatment Services 20%PT, OT, Speech Therapy $35Chiropractic (Medicare covered services) $20Podiatry (Medicare covered services) $35

Hospital (Inpatient) Care - CopaymentsHospital inpatient Per Days 1 - 7 $250 Hospital inpatient Per Days 8 - 90 $0Skilled Nursing Facility (SNF) Per Days 1 - 20 $0 Skilled Nursing Facility (SNF) Per Days 21 - 40 $184 Skilled Nursing Facility (SNF) Per Days 41 - 100 $0

Oupatient Care - CopaymentsHospital Surgery Center $25 - $250Ambulatory Surgery Center $250Hospital Observation $0Renal Dialysis 20%

Emergency/Urgent Care Services - CopaymentsEmergency Room / Urgent Care $90 / $35Ambulance per Trip: Ground / Air $250 / 20%

Diagnostic Testing - CopaymentsRadiology Tests and Imaging 0 - 20%, $0 - $300Diagnostic & Lab Services $0 - $75, 0 - 20%

Diabetes & Durable Medical Equipment (DME) - CopaymentsDiabetes Monitoring Supplies and Self-Management Training 0 - 20%Diabetes therapeutic shoes and inserts $35Equipment (e.g. wheelchairs, oxygen) and Prosthetics (e.g. braces) 20%

Part B Drugs - CopaymentsPart B Immunizations - Flu, pheumonia, and hepititis B vacinnations $0Chemotherapy, transplant drugs and facility based infusions 20%

Prescription Drugs Part D drugs - Deductible $0

INSULIN - call the Plan to determine your estimated drug cost

Blue Medicare Advantage Classic (HMO) Page 24Additional Benefits, Physician Network, Preferred Pharmacies and Hospital Networks

Additional Benefits (Non-Medicare covered)Routine eye exam $0 co-payEyewear ($150 allowance every 2 years) $0 co-payHearing Aid Appliance (1 per ear per year) $699 - $999 co-payTransportation to approved locations not coveredDental not coveredOver-the-Counter allowance on approved health products not covered24 hour Nurse Hotline not coveredFitness Program $0 co-payMeals after Hospital Stay not coveredTravel Benefit in the United States not coveredRoutine chiropractic not coveredRoutine footcare not covered

Physician Network** Check with the plan to determine if your physician is in this plan's network.

Preferred pharmacies (check with the plan for the lowest cost pharmacy)If your plan has preferred pharmacies, using those pharmacies may save you money.

Basha Cigna CVSFry's Osco SafewaySam's Walmart AlbertsonCostco

Hospital Networks HonorHealth Banner Scottsdale Osborn Baywood Scottsdale Shea Boswell Scottsdale Thompson Peak Del Webb Deer Valley Desert John C Lincoln Phoenix Estrella

GatewayGoldfield (Apache Junction)UniversityIronwoodThunderbird

Blue Medicare Advantage Plus (HMO) Page 25Plan Number H0302-001 800 422-0761STAR Rating 3.0 out of 5.0 azbluemedicare.com

Monthly Plan Premium (in addition to the Medicare Part B Premium) $43Annual Medical Deductible NONEMaximum-out-of-Pocket Limit (MOOP) excluding drug costs $4,250Out-of-Network Services No Coverage

Physician/Provider Services - Copayments (Telehealth may be available)Primary Care Provider $0Specialist $20Mental Health and Outpatient Substance Abuse: Individual / Group $20 / $20Opioid Treatment Services 20%PT, OT, Speech Therapy $20Chiropractic (Medicare covered services) $20Podiatry (Medicare covered services) $20

Hospital (Inpatient) Care - CopaymentsHospital inpatient Per Days 1 - 7 $225 Hospital inpatient Per Days 8 - 90 $0Skilled Nursing Facility (SNF) Per Days 1 - 20 $0 Skilled Nursing Facility (SNF) Per Days 21 - 40 $184 Skilled Nursing Facility (SNF) Per Days 41 - 100 $0

Oupatient Care - CopaymentsHospital Surgery Center $225Ambulatory Surgery Center $250Hospital Observation $0Renal Dialysis 20%

Emergency/Urgent Care Services - CopaymentsEmergency Room / Urgent Care $90 / $20Ambulance per Trip: Ground / Air $250 / 20%

Diagnostic Testing - CopaymentsRadiology Tests and Imaging 0 - 20%, $0 - $300Diagnostic & Lab Services $0 - $75, 0 - 20%

Diabetes & Durable Medical Equipment (DME) - CopaymentsDiabetes Monitoring Supplies and Self-Management Training $0 - 20%Diabetes therapeutic shoes and inserts $20Equipment (e.g. wheelchairs, oxygen) and Prosthetics (e.g. braces) 20%

Part B Drugs - CopaymentsPart B Immunizations - Flu, pheumonia, and hepititis B vacinnations $0Chemotherapy, transplant drugs and facility based infusions 20%

Prescription Drugs Part D drugs - Deductible $0INSULIN - call the Plan to determine your estimated drug cost

Blue Medicare Advantage Plus Page 26Additional Benefits, Physician Network, Preferred Pharmacies and Hospital Networks

Additional Benefits (Non-Medicare covered)Routine eye exam $0 co-pay

Eyewear (allowance up to $150 every 2 years) $0 co-payHearing Aid Appliance (1 per ear per year) $699 - $999 co-payTransportation to approved locations not coveredDental (routine preventive exams, x-rays 1 time per yr up to $500) $0 co-payOver-the-Counter allowance on approved health products not covered24 hour Nurse Hotline not coveredFitness Program $0 co-payMeals after Hospital Stay not coveredTravel Benefit in the United States not coveredRoutine chiropractic not coveredRoutine footcare not covered

Physician Network** Check with the plan to determine if your physician is in this plan's network.

Preferred pharmacies (check with the plan for the lowest cost pharmacy)If your plan has preferred pharmacies, using those pharmacies may save you money.

Basha Cigna CVSFry's Osco SafewaySam's Walmart AlbertsonCostco

Hospital Networks HonorHealth Banner Scottsdale Osborn Baywood Scottsdale Shea Boswell Scottsdale Thompson Peak Del Webb Deer Valley Desert John C Lincoln Phoenix Estrella

GatewayGoldfield (Apache Junction)UniversityIronwoodThunderbird

BluePathway Plan 1 (HMO) Page 27Plan Number H6936-006 800 422-0761STAR Rating 3.0 out of 5.0 azbluemedicare.com

Monthly Plan Premium (in addition to the Medicare Part B Premium) $0Annual Medical Deductible NONEMaximum-out-of-Pocket Limit (MOOP) excluding drug costs $2,900Out-of-Network Services No Coverage

Physician/Provider Services - Copayments (Telehealth may be available)Primary Care Provider $0Specialist $20Mental Health and Outpatient Substance Abuse: Individual / Group $20 / $20Opioid Treatment Services 20%PT, OT, Speech Therapy $10Chiropractic (Medicare covered services) $20Podiatry (Medicare covered services) $20

Hospital (Inpatient) Care - CopaymentsHospital inpatient Per Days 1 - 5 $175 Hospital inpatient Per Days 6 - 90 $0Skilled Nursing Facility (SNF) Per Days 1 - 20 $0 Skilled Nursing Facility (SNF) Per Days 21 - 40 $184 Skilled Nursing Facility (SNF) Per Days 41 - 100 $0

Oupatient Care - CopaymentsHospital Surgery Center $175Ambulatory Surgery Center $250Hospital Observation $0Renal Dialysis 20%

Emergency/Urgent Care Services - CopaymentsEmergency Room / Urgent Care $120 / $20Ambulance per Trip: Ground / Air $250 / 20%

Diagnostic Testing - CopaymentsRadiology Tests and Imaging $0 - $200Diagnostic & Lab Services $0 - $75, 20%

Diabetes & Durable Medical Equipment (DME) - CopaymentsDiabetes Monitoring Supplies and Self-Management Training $0 - 20%Diabetes therapeutic shoes and inserts $20Equipment (e.g. wheelchairs, oxygen) and Prosthetics (e.g. braces) 20%

Part B Drugs - CopaymentsPart B Immunizations - Flu, pheumonia, and hepititis B vacinnations $0Chemotherapy, transplant drugs and facility based infusions 20%

Prescription Drugs Part D drugs - Deductible $0INSULIN - call the Plan to determine your estimated drug cost

Blue Pathway Plan 1 (HMO) Page 28Additional Benefits, Physician Network, Preferred Pharmacies and Hospital Networks

Additional Benefits (Non-Medicare covered)Routine eye exam $0 co-payEyewear (lenses/frames and contacts up to $200 every 2 years) $0 co-payHearing Aid Appliance (up to 1 per ear per year limit $699, $999) $0 co-payTransportation to approved locations not coveredDental (preventive exams, cleanings, x-rays up to $1,000) $0 co-payOver-the-Counter allowance on approved health products $50 per quarter24 hour Nurse Hotline not coveredFitness Program $0 co-payMeals after Hospital Stay not coveredRoutine chiropractic $30 co-payRoutine footcare not covered

Physician Network** Check with the plan to determine if your physician is in this plan's network.

Preferred pharmacies (check with the plan for the lowest cost pharmacy)If your plan has preferred pharmacies, using those pharmacies may save you money.

Basha Cigna CVSFry's Osco SafewaySam's Walmart AlbertsonCostco

Hospital Networks HonorHealth St Luke's AbrazoScottsdale Osborn Tempe ArrowheadScottsdale Shea Central CampusScottsdale Thompson Peak Valleywise Health WestDeer Valley Scottsdale (PV-Bell)John C Lincoln Phoenix

Dignity HealthArizona General Hospitals Chandler RegionalMercy GilbertSt Joseph’s HospitalSt Joseph’s Westgate

BluePathway Plan 2 (HMO) Page 29Plan Number H6936-003 800 422-0761STAR Rating Plan too new to be measured azbluemedicare.com

Monthly Plan Premium (in addition to the Medicare Part B Premium) $0Annual Medical Deductible NONEMaximum-out-of-Pocket Limit (MOOP) excluding drug costs $3,400Out-of-Network Services No Coverage

Physician/Provider Services - Copayments (Telehealth may be available)Primary Care Provider $0Specialist $30Mental Health and Outpatient Substance Abuse: Individual / Group $30 / $30Opioid Treatment Services 20%PT, OT, Speech Therapy $10Chiropractic (Medicare covered services) $20Podiatry (Medicare covered services) $30

Hospital (Inpatient) Care - CopaymentsHospital inpatient Per Days 1 - 7 $175 Hospital inpatient Per Days 8 - 90 $0Skilled Nursing Facility (SNF) Per Days 1 - 20 $0 Skilled Nursing Facility (SNF) Per Days 21 - 40 $184 Skilled Nursing Facility (SNF) Per Days 41 - 100 $0

Oupatient Care - CopaymentsHospital Surgery Center $200Ambulatory Surgery Center $250Hospital Observation $0Renal Dialysis 20%

Emergency/Urgent Care Services - CopaymentsEmergency Room / Urgent Care $120 / $30Ambulance per Trip: Ground / Air $250 / 20%

Diagnostic Testing - CopaymentsRadiology Tests and Imaging $0 - $200Diagnostic & Lab Services $0 - $75, 20%

Diabetes & Durable Medical Equipment (DME) - CopaymentsDiabetes Monitoring Supplies and Self-Management Training $0 - 20%Diabetes therapeutic shoes and inserts $30Equipment (e.g. wheelchairs, oxygen) and Prosthetics (e.g. braces) 20%

Part B Drugs - CopaymentsPart B Immunizations - Flu, pheumonia, and hepititis B vacinnations $0Chemotherapy, transplant drugs and facility based infusions 20%

Prescription Drugs Part D drugs - Deductible $0INSULIN - call the Plan to determine your estimated drug cost

Blue Pathway Plan 2 (HMO) Page 30Additional Benefits, Physician Network, Preferred Pharmacies and Hospital Networks

Additional Benefits (Non-Medicare covered)Routine eye exam $0 co-payEyewear (lenses/frames and contacts up to $150 every 2 years) $0 co-payHearing Aid Appliance (up to 1 per ear per year limit $699, $999) $0 co-payTransportation to approved locations not coveredDental (preventive exams, cleanings, x-rays up to $500 per year) $0 co-payOver-the-Counter allowance on approved health products $50 per quarter24 hour Nurse Hotline not coveredFitness Program $0 co-payMeals after Hospital Stay not coveredRoutine chiropractic $30 co-payRoutine footcare not covered

Physician Network** Check with the plan to determine if your physician is in this plan's network.

Preferred pharmacies (check with the plan for the lowest cost pharmacy)If your plan has preferred pharmacies, using those pharmacies may save you money.

Basha Cigna CVSFry's Osco SafewaySam's Walmart Albertson

Hospital Networks HonorHealth St Luke's BannerScottsdale Osborn Tempe BaywoodScottsdale Shea BoswellScottsdale Thompson Peak Abrazo Del WebbDeer Valley Arrowhead DesertJohn C Lincoln Phoenix Central Campus Estrella

West Gateway

Dignity Health Scottsdale (PV-Bell) Goldfield (Apache Junction)Arizona General Mesa UniversityChandler Regional IronwoodMercy Gilbert Valleywise Health ThunderbirdSt Joseph’s HospitalSt Joseph’s Westgate

BluePathway Plan 3 (HMO) Page 31Plan Number H6936-004 800 422-0761STAR Rating Plan too new to be measured azbluemedicare.com

Monthly Plan Premium (in addition to the Medicare Part B Premium) $32Annual Medical Deductible NONEMaximum-out-of-Pocket Limit (MOOP) excluding drug costs $2,900Out-of-Network Services No Coverage

Physician/Provider Services - Copayments (Telehealth may be available)Primary Care Provider $0Specialist $20Mental Health and Outpatient Substance Abuse: Individual / Group $20 / $20Opioid Treatment Services 20%PT, OT, Speech Therapy $10Chiropractic (Medicare covered services) $20Podiatry (Medicare covered services) $20

Hospital (Inpatient) Care - CopaymentsHospital inpatient Per Days 1 - 5 $175 Hospital inpatient Per Days 6 - 90 $0Skilled Nursing Facility (SNF) Per Days 1 - 20 $0 Skilled Nursing Facility (SNF) Per Days 21 - 40 $184 Skilled Nursing Facility (SNF) Per Days 41 - 100 $0

Oupatient Care - CopaymentsHospital Surgery Center $200Ambulatory Surgery Center $250Hospital Observation $0Renal Dialysis 20%

Emergency/Urgent Care Services - CopaymentsEmergency Room / Urgent Care $120 / $20Ambulance per Trip: Ground / Air $250 / 20%

Diagnostic Testing - CopaymentsRadiology Tests and Imaging $0 - $150Diagnostic & Lab Services $0 - $75, 20%

Diabetes & Durable Medical Equipment (DME) - CopaymentsDiabetes Monitoring Supplies and Self-Management Training $0 - 20%Diabetes therapeutic shoes and inserts $20Equipment (e.g. wheelchairs, oxygen) and Prosthetics (e.g. braces) 20%

Part B Drugs - CopaymentsPart B Immunizations - Flu, pheumonia, and hepititis B vacinnations $0Chemotherapy, transplant drugs and facility based infusions 20%

Prescription Drugs Part D drugs - Deductible $0INSULIN - call the Plan to determine your estimated drug cost

BluePathway Plan 3 (HMO) Page 32Additional Benefits, Physician Network, Preferred Pharmacies and Hospital Networks

Additional Benefits (Non-Medicare covered)Routine eye exam $0 co-payEyewear (lenses/frames and contacts up to $200 every 2 years) $0 co-payHearing Aid Appliance (up to 1 per ear per year limit $699, $999) $0 co-payTransportation to approved locations not coveredDental (preventive exams, cleanings, x-rays up to $1,000 year) $0 co-payOver-the-Counter allowance on approved health products $50 per quarter24 hour Nurse Hotline not coveredFitness Program $0 co-payMeals after Hospital Stay not coveredRoutine chiropractic $30 co-payRoutine footcare not covered

Physician Network** Check with the plan to determine if your physician is in this plan's network.

Preferred pharmacies (check with the plan for the lowest cost pharmacy)If your plan has preferred pharmacies, using those pharmacies may save you money.

Basha Cigna CVSFry's Osco SafewaySam's Walmart Albertson

Hospital Networks HonorHealth St Luke's BannerScottsdale Osborn Tempe BaywoodScottsdale Shea BoswellScottsdale Thompson Peak Del WebbDeer Valley Abrazo DesertJohn C Lincoln Phoenix Arrowhead Estrella

Central Campus GatewayDignity Health West Goldfield (Apache Junction)Arizona General Mesa Scottsdale (PV-Bell) UniversityChandler Regional IronwoodMercy Gilbert ThunderbirdSt Joseph’s Hospital Valleywise HealthSt Joseph’s Westgate

Bright Advantage (HMO) Page 33Plan Number H4853-001 844 679-2028STAR Rating 2.5 out of 5.0 www.brighthealthplan.com/medicare

Monthly Plan Premium (in addition to the Medicare Part B Premium) $0Annual Medical Deductible NONEMaximum-out-of-Pocket Limit (MOOP) excluding drug costs $4,900Out-of-Network Services No Coverage

Physician/Provider Services - Copayments (Telehealth may be available)Primary Care Provider $0Specialist $0Mental Health and Outpatient Substance Abuse: Individual / Group $0 / $0Opioid Treatment Services $0PT, OT, Speech Therapy $0Chiropractic (Medicare covered services) check with planPodiatry (Medicare covered services) $0

Hospital (Inpatient) Care - CopaymentsHospital inpatient Per Days 1 - 7 $175 Hospital inpatient Per Days 8 - 90 $0Skilled Nursing Facility (SNF) Per Days 1 - 20 $0 Skilled Nursing Facility (SNF) Per Days 21 - 100 $178

Oupatient Care - CopaymentsHospital Surgery Center $175Ambulatory Surgery Center $100Hospital Observation check with planRenal Dialysis 20%

Emergency/Urgent Care Services - CopaymentsEmergency Room / Urgent Care $90 / $0Ambulance per Trip: Ground / Air $200 / $200

Diagnostic Testing - CopaymentsRadiology Tests and Imaging $0 - $100Diagnostic & Lab Services $0 - $100

Diabetes & Durable Medical Equipment (DME) - CopaymentsDiabetes Monitoring Supplies and Self-Management Training $0Diabetes therapeutic shoes and inserts check with planEquipment (e.g. wheelchairs, oxygen) and Prosthetics (e.g. braces) 20%

Part B Drugs - CopaymentsPart B Immunizations - Flu, pheumonia, and hepititis B vacinnations $0Chemotherapy, transplant drugs and facility based infusions 20%

Prescription Drugs Part D drugs - Deductible $0INSULIN - call the Plan to determine your estimated drug cost

Bright Advantage (HMO) Page 34Additional Benefits, Physician Network, Preferred Pharmacies and Hospital Networks

Additional Benefits (Non-Medicare covered)Routine eye exam $0 co-payEyewear (lenses/frames and contacts up to $130 every 2 years) $0 - $60 co-payHearing Aid Appliance ($750 allowance every year) $0 co-payTransportation (unlimited trips to approved locations) $0 co-payDental (preventive exams, cleanings, x-rays) $0 co-payOver-the-Counter allowance on approved health products $20 per month24 hour Nurse Hotline not coveredFitness Program $0 co-payMeals after Hospital Stay not coveredTravel Benefit in the United States not coveredRoutine chiropractic not coveredRoutine footcare check with plan

Physician Network** Check with the plan to determine if your physician is in this plan's network.

Preferred pharmacies (check with the plan for the lowest cost pharmacy)If your plan has preferred pharmacies, using those pharmacies may save you money.

CVS Fry's WalgreensBasha's Safeway WalmartCostco Osco

Hospital Networks Abrazo Dignity HealthWest Campus (Goodyear) Arizona General LaveenCentral Campus Chandler RegionalScottsdale Mercy GilbertArrowhead St Joseph’s

Arizona General TempeArizona General San TanArizona General Mesa

Bright Advantage Assist (HMO) Page 35Plan Number H4853-002 844 679-2028STAR Rating 2.5 out of 5.0 www.brighthealthplan.com/medicare

Monthly Plan Premium (in addition to the Medicare Part B Premium) $36.10Annual Medical Deductible NONEMaximum-out-of-Pocket Limit (MOOP) excluding drug costs $3,200Out-of-Network Services No Coverage

Physician/Provider Services - Copayments (Telehealth may be available)Primary Care Provider $0Specialist $15Mental Health and Outpatient Substance Abuse: Individual / Group $40 / $10Opioid Treatment Services $0PT, OT, Speech Therapy $20Chiropractic (Medicare covered services) check with planPodiatry (Medicare covered services) $25

Hospital (Inpatient) Care - CopaymentsHospital inpatient Per Days 1 - 5 $170 Hospital inpatient Per Days 6 - 90 $0Skilled Nursing Facility (SNF) Per Days 1 - 20 $0 Skilled Nursing Facility (SNF) Per Days 21 - 100 $178

Oupatient Care - CopaymentsHospital Surgery Center $225Ambulatory Surgery Center $150Hospital Observation check with planRenal Dialysis 20%

Emergency/Urgent Care Services - CopaymentsEmergency Room / Urgent Care $120 / $30Ambulance per Trip: Ground / Air $200 / $200

Diagnostic Testing - CopaymentsRadiology Tests and Imaging $0 - $200Diagnostic & Lab Services $0 - $200

Diabetes & Durable Medical Equipment (DME) - CopaymentsDiabetes Monitoring Supplies and Self-Management Training $0Diabetes therapeutic shoes and inserts check with planEquipment (e.g. wheelchairs, oxygen) and Prosthetics (e.g. braces) 20%

Part B Drugs - CopaymentsPart B Immunizations - Flu, pheumonia, and hepititis B vacinnations $0Chemotherapy, transplant drugs and facility based infusions 20%

Prescription Drugs Part D drugs - Deductible $445 for tiers 2, 3, 4, 5INSULIN - call the Plan to determine your estimated drug cost

Bright Advantage Assist (HMO) Page 36Additional Benefits, Physician Network, Preferred Pharmacies and Hospital Networks

Additional Benefits (Non-Medicare covered)Routine eye exam $0 co-payEyewear (lenses/frames and contacts up to $130 every 2 years) $0 - $60 co-payHearing Aid Appliance ($750 allowance every year) $0 co-payTransportation (unlimited trips to approved locations) $0 co-payDental (preventive / comprehensive) $0 / $0-$775 co-payOver-the-Counter allowance on approved health products $30 per month24 hour Nurse Hotline not coveredFitness Program $0 co-payMeals after Hospital Stay $0 co-payTravel Benefit in the United States not coveredRoutine chiropractic not coveredRoutine footcare check with plan

Physician Network** Check with the plan to determine if your physician is in this plan's network.

Preferred pharmacies (check with the plan for the lowest cost pharmacy)If your plan has preferred pharmacies, using those pharmacies may save you money.

CVS Fry's WalgreensBasha's Safeway WalmartCostco Osco

Hospital Networks Abrazo Dignity HealthWest Campus (Goodyear) Arizona General LaveenCentral Campus Chandler RegionalScottsdale Mercy GilbertArrowhead St Joseph’s

Arizona General TempeArizona General San TanArizona General Mesa

Bright Advantage Plus (HMO) Page 37Plan Number H4853-014 844 679-2028STAR Rating 2.5 out of 5.0 www.brighthealthplan.com/medicare

Monthly Plan Premium (in addition to the Medicare Part B Premium) $54Annual Medical Deductible NONEMaximum-out-of-Pocket Limit (MOOP) excluding drug costs $3,200Out-of-Network Services No Coverage

Physician/Provider Services - Copayments (Telehealth may be available)Primary Care Provider $0Specialist $20Mental Health and Outpatient Substance Abuse: Individual / Group $40 / $10Opioid Treatment Services $0PT, OT, Speech Therapy $20Chiropractic (Medicare covered services) check with planPodiatry (Medicare covered services) $25

Hospital (Inpatient) Care - CopaymentsHospital inpatient Per Days 1 - 5 $170 Hospital inpatient Per Days 6 - 90 $0Skilled Nursing Facility (SNF) Per Days 1 - 20 $0 Skilled Nursing Facility (SNF) Per Days 21 - 100 $178

Oupatient Care - CopaymentsHospital Surgery Center $225Ambulatory Surgery Center $150Hospital Observation check with planRenal Dialysis 20%

Emergency/Urgent Care Services - CopaymentsEmergency Room / Urgent Care $120 / $30Ambulance per Trip: Ground / Air $200 / 20%

Diagnostic Testing - CopaymentsRadiology Tests and Imaging $0 - $125Diagnostic & Lab Services $0 - $125

Diabetes & Durable Medical Equipment (DME) - CopaymentsDiabetes Monitoring Supplies and Self-Management Training $0Diabetes therapeutic shoes and inserts check with planEquipment (e.g. wheelchairs, oxygen) and Prosthetics (e.g. braces) 20%

Part B Drugs - CopaymentsPart B Immunizations - Flu, pheumonia, and hepititis B vacinnations $0Chemotherapy, transplant drugs and facility based infusions 20%

Prescription Drugs Part D drugs - Deductible $0INSULIN - call the Plan to determine your estimated drug cost

Bright Advantage Plus (HMO) Page 38Additional Benefits, Physician Network, Preferred Pharmacies and Hospital Networks

Additional Benefits (Non-Medicare covered)Routine eye exam $0 co-payEyewear (lenses/frames and contacts up to $130 every 2 years) $0 - $60 co-payHearing Aid Appliance ($750 allowance every year) $0 co-payTransportation (unlimited trips to approved locations) $0 co-payDental (preventive / comprehensive) $0 / $0-$775 co-payOver-the-Counter allowance on approved health products $30 per month24 hour Nurse Hotline not coveredFitness Program $0 co-payMeals after Hospital Stay $0 co-payTravel Benefit in the United States not coveredRoutine chiropractic not coveredRoutine footcare check with plan

Physician Network** Check with the plan to determine if your physician is in this plan's network.

Preferred pharmacies (check with the plan for the lowest cost pharmacy)If your plan has preferred pharmacies, using those pharmacies may save you money.

CVS Fry's WalgreensBasha's Safeway WalmartCostco Osco

Hospital Networks Abrazo Dignity HealthWest Campus (Goodyear) Arizona General LaveenCentral Campus Chandler RegionalScottsdale Mercy GilbertArrowhead St Joseph’s

Arizona General TempeArizona General San TanArizona General Mesa

CIGNA Alliance Medicare (HMO) Page 39Plan Name H0354-028 855 561-3811STAR Rating 4.0 out of 5.0 www.cigna.com/medicare

Monthly Plan Premium (in addition to the Medicare Part B Premium) $0Annual Medical Deductible NONEMaximum-out-of-Pocket Limit (MOOP) excluding drug costs $3,200Out-of-Network Services No Coverage

Physician/Provider Services - Copayments (Telehealth may be available)Primary Care Provider $0Specialist $5Mental Health and Outpatient Substance Abuse: Individual / Group $0 / $0, $5 / $5Opioid Treatment Services $5PT, OT, Speech Therapy $5Chiropractic (Medicare covered services) $20Podiatry (Medicare covered services) $5

Hospital (Inpatient) Care - CopaymentsHospital inpatient Per Days 1 - 7 $185 Hospital inpatient Per Days 8 - 90 $0Skilled Nursing Facility (SNF) Per Days 1 - 20 $0 Skilled Nursing Facility (SNF) Per Days 21 - 100 $184

Oupatient Care - CopaymentsHospital Surgery Center $0 - $150Ambulatory Surgery Center $0 - $75Hospital Observation $150Renal Dialysis 20%

Emergency/Urgent Care Services - CopaymentsEmergency Room / Urgent Care $120 / $0Ambulance per Trip: Ground / Air $250 / $250

Diagnostic Testing - CopaymentsRadiology Tests and Imaging $0 - $150, 20%Diagnostic & Lab Services $0

Diabetes & Durable Medical Equipment (DME) - CopaymentsDiabetes Monitoring Supplies and Self-Management Training $0Diabetes therapeutic shoes and inserts $0Equipment (e.g. wheelchairs, oxygen) and Prosthetics (e.g. braces) 20%

Part B Drugs - CopaymentsPart B Immunizations - Flu, pheumonia, and hepititis B vacinnations $0Chemotherapy, transplant drugs and facility based infusions 20%

Prescription Drugs Part D drugs - Deductible $0INSULIN - call the Plan to determine your estimated drug cost

CIGNA Alliance Medicare (HMO) Page 40Additional Benefits, Physician Network, Preferred Pharmacies and Hospital Networks

Additional Benefits (Non-Medicare covered)Routine eye exam $5 co-payEyewear (lenses/frames and contacts up to $200 per year) $0 co-payHearing Aid Appliance (up to $700 per ear per device every 3 years) $0 co-payTransportation to approved locations (unlimited trips) $0 co-payDental preventive / comprehensive $0 - $55 / $0 - $3,336 co-payOver-the-Counter allowance on approved health products $70 per quarter24 hour Nurse Hotline $0 co-payFitness Program $0 co-pay14 meals per Hospital Discharge, up to 3 Discharges per year $0 co-payTravel Benefit in the United States not coveredRoutine chiropractic (up to 12 visits per year) $20 co-payRoutine footcare $5 co-pay

Physician Network** Check with the plan to determine if your physician is in this plan's network.

Preferred pharmacies (check with the plan for the lowest cost pharmacy)If your plan has preferred pharmacies, using those pharmacies may save you money.

Bashas and United Drug Cigna Center Pharmacy Fry'sCVS Costco OscoSafeway Sam's Club Walgreen'sWalmart

Hospital NetworksAbrazo Dignity Health BannerWest Campus (Goodyear) Arizona General BaywoodCentral Campus Chandler Regional BoswellMaryvale Mercy Gilbert Del WebbSottsdale (PV-Bell) St Joseph’s DesertArrowhead St Joseph’s Westgate EstrellaMesa Gateway

St Luke’s ThunderbirdHonorHealth Tempe University Medical CenterScottsdale OsbornScottsdale SheaScottsdale Thompson Peak Valleywise HealthDeer ValleyJohn C Lincoln Phoenix

CIGNA Preferred Medicare (HMO) Page 41Plan Name H0354-001 855 561-3811STAR Rating 4.0 out of 5.0 www.cigna.com/medicare

Monthly Plan Premium (in addition to the Medicare Part B Premium) $0Annual Medical Deductible NONEMaximum-out-of-Pocket Limit (MOOP) excluding drug costs $3,450Out-of-Network Services No Coverage

Physician/Provider Services - Copayments (Telehealth may be available)Primary Care Provider $0Specialist $25Mental Health, Outpatient Substance Abuse: Individual / Group $0 / $0, $25 / $25Opioid Treatment Services $25PT, OT, Speech Therapy $25Chiropractic (Medicare covered services) $20Podiatry (Medicare covered services) $25

Hospital (Inpatient) Care - CopaymentsHospital inpatient Per Days 1 - 7 $225 Hospital inpatient Per Days 8 - 90 $0Skilled Nursing Facility (SNF) Per Days 1 - 20 $0 Skilled Nursing Facility (SNF) Per Days 21 - 100 $184

Oupatient Care - CopaymentsHospital Surgery Center $0 - $250Ambulatory Surgery Center $0 - $75Hospital Observation $150Renal Dialysis 20%

Emergency/Urgent Care Services - CopaymentsEmergency Room / Urgent Care $120 / $15Ambulance per Trip: Ground / Air $250 / $250

Diagnostic Testing - CopaymentsRadiology Tests and Imaging $0 - $150 , 20%Diagnostic & Lab Services $0

Diabetes & Durable Medical Equipment (DME) - CopaymentsDiabetes Monitoring Supplies and Self-Management Training $0Diabetes therapeutic shoes and inserts $0Equipment (e.g. wheelchairs, oxygen) and Prosthetics (e.g. braces) 20%

Part B Drugs - CopaymentsPart B Immunizations - Flu, pheumonia, and hepititis B vacinnations $0Chemotherapy, transplant drugs and facility based infusions 20%

Prescription Drugs Part D drugs - Deductible $0INSULIN - call the Plan to determine your estimated drug cost

CIGNA Preferred Medicare (HMO) Page 42Additional Benefits, Physician Network, Preferred Pharmacies and Hospital Networks

Additional Benefits (Non-Medicare covered)Routine eye exam $25 co-payEyewear (lenses/frames and contacts up to $100) $0 co-payHearing Aid Appliance not coveredTransportation to approved locations - 24 one-way trips every year $0 co-payDental (preventive exams, cleanings, x-rays) $0 - $55 co-payOver-the-Counter allowance on approved health products $40 per quarter24 hour Nurse Hotline $0 co-payFitness Program $0 co-pay14 meals per Hospital Discharge, up to 3 Discharges per year $0 co-payTravel Benefit in the United States not coveredRoutine chiropractic (up to 12 routine visits per year) $20 co-payRoutine footcare $25 co-pay

Physician Network** Check with the plan to determine if your physician is in this plan's network.

Preferred pharmacies (check with the plan for the lowest cost pharmacy)If your plan has preferred pharmacies, using those pharmacies may save you money.

Bashas and United Drug Cigna Center Pharmacy Fry'sCVS Costco OscoSafeway Sam's Club Walgreen'sWalmart

Hospital NetworksAbrazo Dignity Health BannerArrowhead Arizona General BaywoodCentral Campus Chandler Regional BoswellScottsdale Campus (PV - Bell) Mercy Gilbert Del WebbMesa St Joseph’s DesertWest St Joseph’s Westgate Estrella

Gateway

Honor Health St Luke’s UniversityHH Deer Valley Tempe ThunderbirdHH John C Lincoln Phoenix HH Scottsdale Osborn Valleywise HealthHH Scottsdale SheaHH Scottsdale Thompson Peak

Devoted Health Core (HMO) Page 43Plan Number H8173-001 800 376-5889STAR Rating Plan too new to be measured www.devoted.com

Monthly Plan Premium (in addition to the Medicare Part B Premium) $0Annual Medical Deductible NONEMaximum-out-of-Pocket Limit (MOOP) excluding drug costs $3,200Out-of-Network Services No Coverage

Physician/Provider Services - Copayments (Telehealth may be available)Primary Care Provider $0Specialist $20Mental Health and Outpatient Substance Abuse: Individual / Group $20 / $20Opioid Treatment Services $10PT, OT, Speech Therapy $20Chiropractic (Medicare covered services) $20Podiatry (Medicare covered services) $20

Hospital (Inpatient) Care - CopaymentsHospital inpatient Per Days 1 - 7 $175 Hospital inpatient Per Days 8 - 90 $0Skilled Nursing Facility (SNF) Per Days 1 - 20 $0 Skilled Nursing Facility (SNF) Per Days 21 - 40 $184 Skilled Nursing Facility (SNF) Per Days 41 - 100 $0

Oupatient Care - CopaymentsHospital Surgery Center $175Ambulatory Surgery Center $75Hospital Observation $175Renal Dialysis 20%

Emergency/Urgent Care Services - CopaymentsEmergency Room / Urgent Care $120 / $20Ambulance per Trip: Ground / Air $225 / 20%

Diagnostic Testing - CopaymentsRadiology Tests and Imaging $0 to $100, 20%Diagnostic & Lab Services $0 to $50

Diabetes & Durable Medical Equipment (DME) - CopaymentsDiabetes Monitoring Supplies and Self-Management Training $0Diabetes therapeutic shoes and inserts 20%Equipment (e.g. wheelchairs, oxygen) and Prosthetics (e.g. braces) 20%

Part B Drugs - CopaymentsPart B Immunizations - Flu, pheumonia, and hepititis B vacinnations $0Chemotherapy, transplant drugs and facility based infusions 20%

Prescription Drugs Part D drugs - Deductible $0INSULIN - call the Plan to determine your estimated drug cost

Devoted Health Core (HMO) Page 44Additional Benefits, Physician Network, Preferred Pharmacies and Hospital Networks

Additional Benefits (Non-Medicare covered)Routine eye exam $0 co-payEyewear (lenses/frames and contacts up to $180 or $230 per year) $0 co-payHearing Aid Appliance (up to 2 TruHearing hearing aids) $399 - $699 copayTransportation not coveredDental (preventive exams, cleanings, x-rays) $0 co-payOver-the-Counter allowance on approved health products $75 per quarter24 hour Nurse Hotline not coveredFitness Program $0 co-payMeals after Hospital Stay (2 meals per day for 10 days, 4 times/yr) $0 co-payTravel Benefit in the United States not coveredRoutine chiropractic not coveredRoutine footcare (6 visits per year) $0 co-payWellness Bucks ($150 per year) $0 co-pay

Physician Network** Check with the plan to determine if your physician is in this plan's network.

Preferred pharmacies (check with the plan for the lowest cost pharmacy)If your plan has preferred pharmacies, using those pharmacies may save you money.

Basha's Costco CVSFry's Osco SafewayAlbertsons Walgreens Walmart

Hospital NetworksAbrazo Dignity Health HonorHealthCentral Campus Arizona General Phoenix Scottsdale OsbornMesa Chandler Regional Scottsdale SheaScottsdale (PV-Bell) Mercy Gilbert Scottsdale Thompson PeakArrowhead St Joseph’s Deer Valley

St Joseph’s Westgate John C Lincoln Phoenix Arizona General Mesa

Devoted Health Flex (HMO) Page 45Plan Number H8173-003 800 376-5889STAR Rating Plan too new to be measured www.devoted.com

Monthly Plan Premium (in addition to the Medicare Part B Premium) $39Annual Medical Deductible NONEMaximum-out-of-Pocket Limit (MOOP) excluding drug costs $6,700Out-of-Network Services No Coverage

Physician/Provider Services - Copayments (Telehealth may be available)Primary Care Provider $0Specialist $35Mental Health and Outpatient Substance Abuse: Individual / Group $35 / $35Opioid Treatment Services $35PT, OT, Speech Therapy $30Chiropractic (Medicare covered services) $20Podiatry (Medicare covered services) $35

Hospital (Inpatient) Care - CopaymentsHospital inpatient Per Days 1 - 5 $300 Hospital inpatient Per Days 6 and beyond $0Skilled Nursing Facility (SNF) Per Days 1 - 20 $0 Skilled Nursing Facility (SNF) Per Days 21 - 100 $184

Oupatient Care - CopaymentsHospital Surgery Center $250Ambulatory Surgery Center $150Hospital Observation $250Renal Dialysis 20%

Emergency/Urgent Care Services - CopaymentsEmergency Room / Urgent Care $90 / $40Ambulance per Trip: Ground / Air $300 / 20%

Diagnostic Testing - CopaymentsRadiology Tests and Imaging $0 to $250, 20%Diagnostic & Lab Services $0 to $50

Diabetes & Durable Medical Equipment (DME) - CopaymentsDiabetes Monitoring Supplies and Self-Management Training $0Diabetes therapeutic shoes and inserts 20%Equipment (e.g. wheelchairs, oxygen) and Prosthetics (e.g. braces) 20%

Part B Drugs - CopaymentsPart B Immunizations - Flu, pheumonia, and hepititis B vacinnations $0Chemotherapy, transplant drugs and facility based infusions 20%

Prescription Drugs Part D drugs - Deductible $0INSULIN - call the Plan to determine your estimated drug cost

Devoted Health Flex (HMO) Page 46Additional Benefits, Physician Network, Preferred Pharmacies and Hospital Networks

Additional Benefits (Non-Medicare covered)Routine eye exam $0 co-payEyewear myFlex*Hearing Aid Appliance (up to 2 TruHearing hearing aids) $599 - $899 copayTransportation not coveredDental myFlex*Over-the-Counter allowance on approved health products $50 per quarter24 hour Nurse Hotline not coveredFitness Program myFlex*Meals after Hospital Stay not coveredTravel Benefit in the United States not coveredRoutine chiropractic myFlex*Routine footcare not covered

The *myFlex benefit provides up to $3,000 per year to spend on these and other eligible supplemental benefits.

Physician Network** Check with the plan to determine if your physician is in this plan's network.

Preferred pharmacies (check with the plan for the lowest cost pharmacy)If your plan has preferred pharmacies, using those pharmacies may save you money.

Basha's Costco CVSFry's Osco SafewayAlbertson Walgreens Walmart

Hospital NetworksAbrazo Dignity Health HonorHealthCentral Campus Arizona General Phoenix Scottsdale OsbornMesa Chandler Regional Scottsdale SheaScottsdale (PV-Bell) Mercy Gilbert Scottsdale Thompson PeakArrowhead St Joseph’s Deer Valley

St Joseph’s Westgate John C Lincoln Phoenix Arizona General Mesa

Devoted Health Select (HMO) Page 47Plan Number H8173-002 800 376-5889STAR Rating Plan too new to be measured www.devoted.com

Monthly Plan Premium (in addition to the Medicare Part B Premium) $36.10Annual Medical Deductible NONEMaximum-out-of-Pocket Limit (MOOP) excluding drug costs $3,000Out-of-Network Services No Coverage

Physician/Provider Services - Copayments (Telehealth may be available)Primary Care Provider $0Specialist $5Mental Health and Outpatient Substance Abuse: Individual / Group $5 / $5Opioid Treatment Services $5PT, OT, Speech Therapy $0Chiropractic (Medicare covered services) $10Podiatry (Medicare covered services) $5

Hospital (Inpatient) Care - CopaymentsHospital inpatient Per Days 1 - 7 $125 Hospital inpatient Per Days 8 and beyond $0Skilled Nursing Facility (SNF) Per Days 1 - 20 $0 Skilled Nursing Facility (SNF) Per Days 21 - 40 $184 Skilled Nursing Facility (SNF) Per Days 41 - 100 $0

Oupatient Care - CopaymentsHospital Surgery Center $125Ambulatory Surgery Center $25Hospital Observation $125Renal Dialysis 20%

Emergency/Urgent Care Services - CopaymentsEmergency Room / Urgent Care $120 / $5Ambulance per Trip: Ground / Air $175 / 20%

Diagnostic Testing - CopaymentsRadiology Tests and Imaging $0 to $100, 20%Diagnostic & Lab Services $0 to $25

Diabetes & Durable Medical Equipment (DME) - CopaymentsDiabetes Monitoring Supplies and Self-Management Training $0Diabetes therapeutic shoes and inserts 20%Equipment (e.g. wheelchairs, oxygen) and Prosthetics (e.g. braces) $0 to 20%

Part B Drugs - CopaymentsPart B Immunizations - Flu, pheumonia, and hepititis B vacinnations $0Chemotherapy, transplant drugs and facility based infusions 20%

Prescription Drugs Part D drugs - Deductible $0INSULIN - call the Plan to determine your estimated drug cost

Devoted Health Select (HMO) Page 48Additional Benefits, Physician Network, Preferred Pharmacies and Hospital Networks

Additional Benefits (Non-Medicare covered)Routine eye exam $0 co-payEyewear (up to $180 or $230 per year) $0 co-payHearing Aid Appliance (up to 2 TruHearing hearing aids) $199 - $499 copayTransportation (24 one-way trips to approved locations) $0 co-payDental (preventive and comprehensive) $0 co-pay to 50% coinsuranceOver-the-Counter allowance on approved health products $115 per quarter24 hour Nurse Hotline not coveredFitness Program $0 co-payMeals after Hospital Stay (2 meals per day up to 10 days, 4 time/yr) $0 co-payTravel Benefit in the United States not coveredRoutine chiropractic not coveredRoutine footcare (12 visits per year) $5 co-pay

Physician Network** Check with the plan to determine if your physician is in this plan's network.

Preferred pharmacies (check with the plan for the lowest cost pharmacy)If your plan has preferred pharmacies, using those pharmacies may save you money.

Basha's Costco CVSFry's Osco SafewayAlbertson Walgreens Walmart

Hospital NetworksAbrazo Dignity Health HonorHealthCentral Campus Arizona General Phoenix Scottsdale OsbornMesa Chandler Regional Scottsdale SheaScottsdale (PV-Bell) Mercy Gilbert Scottsdale Thompson PeakArrowhead St Joseph’s Deer Valley

St Joseph’s Westgate John C Lincoln Phoenix Arizona General Mesa

Humana Gold Plus 023 (HMO) Page 49Plan Number H0028-023 800 833-2364STAR Rating 4.0 out of 5.0 www.humana.com/medicare

Monthly Plan Premium (in addition to the Medicare Part B Premium) $50Annual Medical Deductible NONEMaximum-out-of-Pocket Limit (MOOP) excluding drug costs $6,700Out-of-Network Services No Coverage

Physician/Provider Services - Copayments (Telehealth may be available)Primary Care Provider $0Specialist $45Mental Health and Outpatient Substance Abuse: Individual / Group $20 / $20Opioid Treatment Services $20PT, OT, Speech Therapy $40Chiropractic (Medicare covered services) $20Podiatry (Medicare covered services) $45

Hospital (Inpatient) Care - CopaymentsHospital inpatient Per Days 1 - 6 $295 Hospital inpatient Per Days 7 - 90 $0Skilled Nursing Facility (SNF) Per Days 1 - 20 $0 Skilled Nursing Facility (SNF) Per Days 21 - 100 $178

Oupatient Care - CopaymentsHospital Surgery Center $295Ambulatory Surgery Center $245Hospital Observation $295Renal Dialysis 20%

Emergency/Urgent Care Services - CopaymentsEmergency Room / Urgent Care $90 / $20Ambulance per Trip: Ground / Air $265 / 20%

Diagnostic Testing - CopaymentsRadiology Tests and Imaging $0 to $295, 20%Diagnostic & Lab Services $0 to $295

Diabetes & Durable Medical Equipment (DME) - CopaymentsDiabetes Monitoring Supplies and Self-Management Training $0 to 20%Diabetes therapeutic shoes and inserts $0Equipment (e.g. wheelchairs, oxygen) and Prosthetics (e.g. braces) 20%

Part B Drugs - CopaymentsPart B Immunizations - Flu, pheumonia, and hepititis B vacinnations $0Chemotherapy, transplant drugs and facility based infusions 20%

Prescription Drugs Part D drugs - Deductible $225 for tiers 3, 4, 5INSULIN - call the Plan to determine your estimated drug cost

Humana Gold Plus 023 (HMO) Page 50Additional Benefits, Physician Network, Preferred Pharmacies and Hospital Networks

Additional Benefits (Non-Medicare covered)Routine eye exam (1 per year) $0 co-payEyewear not coveredHearing Aid Appliance (up to 1 hearing aid per ear per year) $699 - $999 copayTransportation (12 one-way trips to approved locations) $0 co-payDental not coveredOver-the-Counter allowance on approved health products $50 per quarter24 hour Nurse Hotline not coveredFitness Program $0 co-payMeals after Hospital Stay $0 co-payTravel Benefit in the United States not coveredRoutine chiropractic not coveredRoutine footcare (up to 12 visits per year) $0 co-pay

Physician Network** Check with the plan to determine if your physician is in this plan's network.

Preferred pharmacies (check with the plan for the lowest cost pharmacy)If your plan has preferred pharmacies, using those pharmacies may save you money.

Basha's Costco CVSFry's Osco SafewaySam's Pharmacy Walgreens WalmartAlbertsons Cigna Medical Group

Hospital NetworksAbrazo Dignity Health BannerWest Campus (Goodyear) Arizona General BaywoodCentral Campus Chandler Regional BoswellMaryvale Mercy Gilbert Del WebbScottsdale (PV-Bell) St Joseph’s DesertArrowhead St Joseph’s Westgate EstrellaMesa Laveen Gateway

Mesa Goldfield (Apache Junction)HonorHealth UniversityScottsdale Osborn ThunderbirdScottsdale SheaScottsdale Thompson Peak St Luke’s Valleywise HealthDeer Valley TempeJohn C Lincoln Phoenix

Humana Gold Plus 027 (HMO) Page 51Plan Number H0028-027 800 833-2364STAR Rating 4.0 out of 5.0 www.humana.com/medicare

Monthly Plan Premium (in addition to the Medicare Part B Premium) $0Annual Medical Deductible NONEMaximum-out-of-Pocket Limit (MOOP) excluding drug costs $3,400Out-of-Network Services No Coverage

Physician/Provider Services - Copayments (Telehealth may be available)Primary Care Provider $0Specialist $25Mental Health and Outpatient Substance Abuse: Individual / Group $20 / $20Opioid Treatment Services $20PT, OT, Speech Therapy $25Chiropractic (Medicare covered services) $20Podiatry (Medicare covered services) $25

Hospital (Inpatient) Care - CopaymentsHospital inpatient Per Days 1 - 5 $175 Hospital inpatient Per Days 6 - 90 $0Skilled Nursing Facility (SNF) Per Days 1 - 20 $0 Skilled Nursing Facility (SNF) Per Days 21 - 100 $178

Oupatient Care - CopaymentsHospital Surgery Center $175Ambulatory Surgery Center $125Hospital Observation $0Renal Dialysis 20%

Emergency/Urgent Care Services - CopaymentsEmergency Room / Urgent Care $120 / $35Ambulance per Trip: Ground / Air $265 / 20%

Diagnostic Testing - CopaymentsRadiology Tests and Imaging $0 to $175Diagnostic & Lab Services $0 to $100

Diabetes & Durable Medical Equipment (DME) - CopaymentsDiabetes Monitoring Supplies and Self-Management Training $0 to 20%Diabetes therapeutic shoes and inserts $0Equipment (e.g. wheelchairs, oxygen) and Prosthetics (e.g. braces) 20%

Part B Drugs - CopaymentsPart B Immunizations - Flu, pheumonia, and hepititis B vacinnations $0Chemotherapy, transplant drugs and facility based infusions 20%

Prescription Drugs Part D drugs - Deductible $0INSULIN - call the Plan to determine your estimated drug cost

Humana Gold Plus 027 (HMO) Page 52Additional Benefits, Physician Network, Preferred Pharmacies and Hospital Networks

Additional Benefits (Non-Medicare covered)Routine eye exam (1 exam per year) $0 co-payEyewear (ienses/frames and contacts up to $200 per year) $0 co-payHearing Aid Appliance (1 per ear per year) $699 to $999 copayTransportation (up to 12 one-way trips to approved locations) $0 co-payDental (preventive exams, cleanings, x-rays) $0 co-payOver-the-Counter allowance on approved health products $75 per quarter24 hour Nurse Hotline not coveredFitness Program $0 co-payMeals after Hospital Stay $0 co-payTravel Benefit in the United States not coveredRoutine chiropractic not coveredRoutine footcare (up to 12 visits per year) $0 co-pay

Physician Network** Check with the plan to determine if your physician is in this plan's network.

Preferred pharmacies (check with the plan for the lowest cost pharmacy)If your plan has preferred pharmacies, using those pharmacies may save you money.

Basha's Costco CVSFry's Osco SafewaySam's Pharmacy Walgreens WalmartAlbertsons Cigna Medical Group

Hospital NetworksAbrazo Dignity Health BannerWest Campus (Goodyear) Arizona General BaywoodCentral Campus Chandler Regional BoswellMaryvale Mercy Gilbert Del WebbScottsdale (PV-Bell) St Joseph’s DesertArrowhead St Joseph’s Westgate EstrellaMesa Laveen Gateway

Mesa Goldfield (Apache Junction)HonorHealth UniversityScottsdale Osborn ThunderbirdScottsdale SheaScottsdale Thompson Peak St Luke’s Valleywise HealthDeer Valley Tempe

John C Lincoln Phoenix

Humana Gold Plus 028 (HMO) Page 53Plan Number H0028-028 800 833-2364STAR Rating 4.0 out of 5.0 www.humana.com/medicare

Monthly Plan Premium (in addition to the Medicare Part B Premium) $0Annual Medical Deductible NONEMaximum-out-of-Pocket Limit (MOOP) excluding drug costs $5,500Out-of-Network Services No Coverage

Physician/Provider Services - Copayments (Telehealth may be available)Primary Care Provider $0Specialist $40Mental Health and Outpatient Substance Abuse: Individual / Group $20 / $20Opioid Treatment Services $20PT, OT, Speech Therapy $35Chiropractic (Medicare covered services) $20Podiatry (Medicare covered services) $40

Hospital (Inpatient) Care - CopaymentsHospital inpatient Per Days 1 - 7 $225 Hospital inpatient Per Days 8 - 90 $0Skilled Nursing Facility (SNF) Per Days 1 - 20 $0 Skilled Nursing Facility (SNF) Per Days 21 - 100 $178

Oupatient Care - CopaymentsHospital Surgery Center $225Ambulatory Surgery Center $175Hospital Observation $0Renal Dialysis 20%

Emergency/Urgent Care Services - CopaymentsEmergency Room / Urgent Care $90 / $35Ambulance per Trip: Ground / Air $265 / $265

Diagnostic Testing - CopaymentsRadiology Tests and Imaging $0 to $225, 20%Diagnostic & Lab Services $0 to $100

Diabetes & Durable Medical Equipment (DME) - CopaymentsDiabetes Monitoring Supplies and Self-Management Training $0 to 20%Diabetes therapeutic shoes and inserts $0Equipment (e.g. wheelchairs, oxygen) and Prosthetics (e.g. braces) 20%

Part B Drugs - CopaymentsPart B Immunizations - Flu, pheumonia, and hepititis B vacinnations $0Chemotherapy, transplant drugs and facility based infusions 20%

Prescription Drugs Part D drugs - Deductible $225 for tiers 3, 4, 5INSULIN - call the Plan to determine your estimated drug cost

Humana Gold Plus 028 (HMO) Page 54Additional Benefits, Physician Network, Preferred Pharmacies and Hospital Networks

Additional Benefits (Non-Medicare covered)Routine eye exam (1 per year) $0 co-payEyewear (lenses/frames and contacts up to $100 per year) $0 co-payHearing Aid Appliance (up to 1 hearing aid per ear per year) $699 - $999 copayTransportation to approved locations not coveredDental (preventive exams, cleanings, x-rays) $0 co-payOver-the-Counter allowance on approved health products $75 per quarter24 hour Nurse Hotline not coveredFitness Program $0 co-payMeals after Hospital Stay $0 co-payTravel Benefit in the United States not coveredRoutine chiropractic not coveredRoutine footcare (up to 12 visits per year) $0 co-pay

Physician Network** Check with the plan to determine if your physician is in this plan's network.

Preferred pharmacies (check with the plan for the lowest cost pharmacy)If your plan has preferred pharmacies, using those pharmacies may save you money.

Basha's Costco CVSFry's Osco SafewaySam's Pharmacy Walgreens WalmartAlbertsons Cigna Medical Group

Hospital NetworksAbrazo Dignity Health BannerWest Campus (Goodyear) Arizona General BaywoodCentral Campus Chandler Regional BoswellMaryvale Mercy Gilbert Del WebbScottsdale (PV-Bell) St Joseph’s DesertArrowhead St Joseph’s Westgate EstrellaMesa Laveen Gateway

Mesa Goldfield (Apache Junction)

HonorHealth UniversityScottsdale Osborn ThunderbirdScottsdale SheaScottsdale Thompson Peak St Luke’s Valleywise HealthDeer Valley TempeJohn C Lincoln Phoenix

Imperial Insurance Co Traditional (HMO) Page 55Plan Number H2793-003 800 838-8271STAR Rating Plan too new to be rated www.IICTX.com

Monthly Plan Premium (in addition to the Medicare Part B Premium) $0Annual Medical Deductible NONEMaximum-out-of-Pocket Limit (MOOP) excluding drug costs $2,999Out-of-Network Services No Coverage

Physician/Provider Services - Copayments (Telehealth may be available)Primary Care Provider $0Specialist $0Mental Health and Outpatient Substance Abuse: Individual / Group $0, 20% / $0, 20%Opioid Treatment Services $0PT, OT, Speech Therapy $15Chiropractic (Medicare covered services) $0Podiatry (Medicare covered services) $0

Hospital (Inpatient) Care - CopaymentsHospital inpatient Per Days 1 - 5 $125 Hospital inpatient Per Days 6 - 90 $0Skilled Nursing Facility (SNF) Per Days 1 - 20 $0 Skilled Nursing Facility (SNF) Per Days 21 - 100 $164.50

Oupatient Care - CopaymentsHospital Surgery Center $0Ambulatory Surgery Center $0Hospital Observation $0Renal Dialysis 20%

Emergency/Urgent Care Services - CopaymentsEmergency Room / Urgent Care $120 / $0Ambulance per Trip: Ground / Air $125 / 20%

Diagnostic Testing - CopaymentsRadiology Tests and Imaging $0Diagnostic & Lab Services $0

Diabetes & Durable Medical Equipment (DME) - CopaymentsDiabetes Monitoring Supplies and Self-Management Training $0Diabetes therapeutic shoes and inserts $0Equipment (e.g. wheelchairs, oxygen) and Prosthetics (e.g. braces) 20%

Part B DrugsPart B Immunizations - Flu, pheumonia, and hepititis B vacinnations $0Chemotherapy, transplant drugs and facility based infusions 20%

Prescription Drugs Part D drugs - Deductible $0INSULIN - call the Plan to determine your estimated drug cost

Imperial Insurance Co Traditional (HMO) Page 56Additional Benefits, Physician Network, Preferred Pharmacies and Hospital Networks

Additional Benefits (Non-Medicare covered)Routine eye exam $15 co-payEyewear (up to $250 every 2 years) $15 copayHearing Aid Appliance up to $1,250 per calendar year 20%Transportation to approved locations $0 co-payDental (prevent up to $500/yr, restorative up to $500 every 3 months) $0 co-payOver-the-Counter allowance on approved health products $60 per quarter24 hour Nurse Hotline not coveredFitness Program $0Meals after Hospital Stay not coveredTravel Benefit in the United States not coveredRoutine chiropractic not coveredRoutine footcare (6 visits per year) $0

Physician Network** Check with the plan to determine if your physician is in this plan's network.

Preferred pharmacies (check with the plan for the lowest cost pharmacy)If your plan has preferred pharmacies, using those pharmacies may save you money.

Albertson's Basha's CostcoCVS Fry's OscoSafeway Sam's Pharmacy WalgreensWalmart

Hospital NetworksAbrazo HonorHealth BannerCentral Campus Scottsdale Osborn Baywood

Scottsdale Shea BoswellScottsdale Thompson Peak Del WebbDeer Valley IronwoodJohn C Lincoln Phoenix Estrella

UniversityThunderbird

Imperial Insurance Traditional Plus (HMO) Page 57Plan Number H2793-007 800 838-8271STAR Rating Plan too new to be rated www.IICTX.com

Monthly Plan Premium (in addition to the Medicare Part B Premium) $32.40Annual Medical Deductible $198Maximum-out-of-Pocket Limit (MOOP) excluding drug costs $2,999Out-of-Network Services No Coverage

Physician/Provider Services - Copayments (Telehealth may be available)Primary Care Provider 20%Specialist 20%Mental Health and Outpatient Substance Abuse: Individual / Group 20% / 20%Opioid Treatment Services 20%PT, OT, Speech Therapy 20%Chiropractic (Medicare covered services) check with planPodiatry (Medicare covered services) check with plan

Hospital (Inpatient) Care - CopaymentsHospital inpatient Per Days 1 - 60 $0 Hospital inpatient Per Days 61 - 90 $352Skilled Nursing Facility (SNF) Per Days 1 - 20 $0 Skilled Nursing Facility (SNF) Per Days 21 - 100 $176

Oupatient Care - CopaymentsHospital Surgery Center 20%Ambulatory Surgery Center 20%Hospital Observation check with planRenal Dialysis 20%

Emergency/Urgent Care Services - CopaymentsEmergency Room / Urgent Care 20% up to $90/ 20% up to $65Ambulance per Trip: Ground / Air 20% / 20%

Diagnostic Testing - CopaymentsRadiology Tests and Imaging 20%Diagnostic & Lab Services $0 - 20%

Diabetes & Durable Medical Equipment (DME) - CopaymentsDiabetes Monitoring Supplies and Self-Management Training 20%Diabetes therapeutic shoes and inserts check with planEquipment (e.g. wheelchairs, oxygen) and Prosthetics (e.g. braces) 20%

Part B DrugsPart B Immunizations - Flu, pheumonia, and hepititis B vacinnations $0Chemotherapy, transplant drugs and facility based infusions 20%

Prescription Drugs Part D drugs - Deductible $445INSULIN - call the Plan to determine your estimated drug cost

Imperial Insurance Traditional Plus (HMO) Page 58Additional Benefits, Physician Network, Preferred Pharmacies and Hospital Networks

Additional Benefits (Non-Medicare covered)Routine eye exam 20%Eyewear (up to $250 every 2 years) 20%Hearing Aid Appliance (up to $1,250 per calendar year) 20%Transportation (unimited to approved locations) $0 co-payDental (preventive up to $500/yr, restorative up to $500/qtr) $0 co-payOver-the-Counter allowance on approved health products $70 per quarter24 hour Nurse Hotline check with planFitness Program $0 co-payMeals after Hospital Stay not coveredTravel Benefit in the United States check with planRoutine chiropractic not coveredRoutine footcare (6 visits per calendar year) $0 co-pay

Physician Network** Check with the plan to determine if your physician is in this plan's network.

Preferred pharmacies (check with the plan for the lowest cost pharmacy)If your plan has preferred pharmacies, using those pharmacies may save you money.

Albertson's Basha's CostcoCVS Fry's OscoSafeway Sam's Pharmacy WalgreensWalmart

Hospital NetworksAbrazo HonorHealth BannerCentral Campus Scottsdale Osborn Baywood

Scottsdale Shea BoswellScottsdale Thompson Peak Del WebbDeer Valley IronwoodJohn C Lincoln Phoenix Estrella

UniversityThunderbird

Wellcare Compass (HMO) Page 59Plan Number H6439-003 866 527-0056STAR Rating Plan too new to be rated www.wellcare.com/medicare

Monthly Plan Premium (in addition to the Medicare Part B Premium) $15.50Annual Medical Deductible NONEMaximum-out-of-Pocket Limit (MOOP) excluding drug costs $3,400Out-of-Network Services No Coverage

Physician/Provider Services - Copayments (Telehealth may be available)Primary Care Provider $0Specialist $5Mental Health and Outpatient Substance Abuse: Individual / Group $40 / $40Opioid Treatment Services $5PT, OT, Speech Therapy $25Chiropractic (Medicare covered services) $5Podiatry (Medicare covered services) $5

Hospital (Inpatient) Care - CopaymentsHospital inpatient Per Days 1 - 6 $175 Hospital inpatient Per Days 7 - 90 $0Skilled Nursing Facility (SNF) Per Days 1 - 20 $0 Skilled Nursing Facility (SNF) Per Days 21 - 100 $178

Oupatient Care - CopaymentsHospital Surgery Center $250Ambulatory Surgery Center $150Hospital Observation $250Renal Dialysis 20%

Emergency/Urgent Care Services - CopaymentsEmergency Room / Urgent Care $120 / $40Ambulance per Trip: Ground / Air $250 / $250

Diagnostic Testing - CopaymentsRadiology Tests and Imaging $0 - $250, 20%Diagnostic & Lab Services $0 - $20

Diabetes & Durable Medical Equipment (DME) - CopaymentsDiabetes Monitoring Supplies and Self-Management Training $0Diabetes therapeutic shoes and inserts 20%Equipment (e.g. wheelchairs, oxygen) and Prosthetics (e.g. braces) 20%

Part B Drugs - CopaymentsPart B Immunizations - Flu, pheumonia, and hepititis B vacinnations $0Chemotherapy, transplant drugs and facility based infusions 20%

Prescription Drugs Part D drugs - Deductible $445 for tiers 2, 3, 4, 5INSULIN - call the Plan to determine your estimated drug cost

Wellcare Compass (HMO) Page 60Additional Benefits, Physician Network, Preferred Pharmacies and Hospital Networks

Additional Benefits (Non-Medicare covered)Routine eye exam (1 every year) $0 co-payEyewear (lenses/frames and contacts up to $300 per year) $0 co-payHearing Aid Appliance (up to $3,000 for 2 hearing aids per year) $0 co-payTransportation to approved locations (up to 60 one-way trips) $0 co-payDental (preventive & comprehensive up to $2,000) $0 co-payOver-the-Counter allowance on approved health products $880 per year24 hour Nurse Hotline $0 co-payFitness Program $0 co-payMeals after Hospital Stay (3 meals per day up to 14 days) $0 co-payTravel Benefit in the United States not coveredRoutine chiropractic (12 visits per year) $20 co-payRoutine footcare (6 visits per year) $25 co-pay

Physician Network** Check with the plan to determine if your physician is in this plan's network.

Preferred pharmacies (check with the plan for the lowest cost pharmacy)If your plan has preferred pharmacies, using those pharmacies may save you money.

Bashas and United Drug CVS SafewayCigna Medical Group Pharmacy Osco CostcoWalgreens Walmart Albertson

Hospital NetworksAbrazo Dignity Health BannerArrowhead Arizona General BaywoodCentral Campus St Joseph’s Westgate BoswellScottsdale Campus Del WebbWest HonorHealth Desert

Deer Valley EstrellaJohn C Lincoln Phoenix GatewayScottsdale Osborn IronwoodScottsdale Shea ThunderbirdScottsdale Thompson Peak University

Wellcare Dividend (HMO) Page 61Plan Number H6439-004 866 527-0056STAR Rating Plan too new to be rated www.wellcare.com/medicare

Monthly Plan Premium (pays $75 of the Medicare Part B Premium) $0Annual Medical Deductible NONEMaximum-out-of-Pocket Limit (MOOP) excluding drug costs $3,400Out-of-Network Services No Coverage

Physician/Provider Services - Copayments (Telehealth may be available)Primary Care Provider $0Specialist $40Mental Health and Outpatient Substance Abuse: Individual / Group $40 / $40Opioid Treatment Services $40PT, OT, Speech Therapy $40Chiropractic (Medicare covered services) $20Podiatry (Medicare covered services) $40

Hospital (Inpatient) Care - CopaymentsHospital inpatient Per Days 1 - 5 $375 Hospital inpatient Per Days 6 - 90 $0Skilled Nursing Facility (SNF) Per Days 1 - 20 $0 Skilled Nursing Facility (SNF) Per Days 21 - 100 $178

Oupatient Care - CopaymentsHospital Surgery Center $250Ambulatory Surgery Center $200Hospital Observation $250Renal Dialysis 20%

Emergency/Urgent Care Services - CopaymentsEmergency Room / Urgent Care $120 / $40Ambulance per Trip: Ground / Air $250 / $250

Diagnostic Testing - CopaymentsRadiology Tests and Imaging $0 - $250, 20%Diagnostic & Lab Services $0 - $40

Diabetes & Durable Medical Equipment (DME) - CopaymentsDiabetes Monitoring Supplies and Self-Management Training $0Diabetes therapeutic shoes and inserts 20%Equipment (e.g. wheelchairs, oxygen) and Prosthetics (e.g. braces) 20%

Part B Drugs - CopaymentsPart B Immunizations - Flu, pheumonia, and hepititis B vacinnations $0Chemotherapy, transplant drugs and facility based infusions 20%

Prescription Drugs Part D drugs - Deductible $0INSULIN - call the Plan to determine your estimated drug cost

Wellcare Dividend (HMO) Page 62Additional Benefits, Physician Network, Preferred Pharmacies and Hospital Networks

Additional Benefits (Non-Medicare covered)Routine eye exam (1 every year) $0 co-payEyewear (lenses/frames and contacts up to $100 per year) $0 co-payHearing Aid Appliance (up to $1,000 for 2 hearing aids per year) $0 co-payTransportation to approved locations not coveredDental (preventive and some comprehensive up to $750) $0 co-payOver-the-Counter allowance on approved health products $240 per year24 hour Nurse Hotline $0 co-payFitness Program $0 co-payMeals after Hospital Stay (3 meals per day for up to 14 days) $0 co-payTravel Benefit to the United States not coveredRoutine chiropractic (12 visits every year) $20 co-payRoutine footcare (6 visits every year) $40 co-pay

Physician Network** Check with the plan to determine if your physician is in this plan's network.

Preferred pharmacies (check with the plan for the lowest cost pharmacy)If your plan has preferred pharmacies, using those pharmacies may save you money.

Bashas and United Drug CVS SafewayCigna Medical Group Pharmacy Osco CostcoWalgreens Walmart Albertson

Hospital Networks Abrazo Dignity Health BannerScottsdale Campus Arizona General BaywoodWest St Joseph’s Westgate Boswell

Del Webb

HonorHealth DesertDeer Valley EstrellaJohn C Lincoln Phoenix GatewayScottsdale Osborn Goldfield

Scottsdale Shea Ironwood

Scottsdale Thompson Peak Thunderbird

University

Wellcare Value (HMO) Page 63Plan Number H6439-002 866 527-0056STAR Rating Plan too new to be rated www.wellcare.com/medicare

Monthly Plan Premium (in addition to the Medicare Part B Premium) $0Annual Medical Deductible NONEMaximum-out-of-Pocket Limit (MOOP) excluding drug costs $3,400Out-of-Network Services No Coverage

Physician/Provider Services - Copayments (Telehealth may be available)Primary Care Provider $0Specialist $25Mental Health and Outpatient Substance Abuse: Individual / Group $40 / $40Opioid Treatment Services $25PT, OT, Speech Therapy $25Chiropractic (Medicare covered services) $20Podiatry (Medicare covered services) $25

Hospital (Inpatient) Care - CopaymentsHospital inpatient Per Days 1 - 6 $200 Hospital inpatient Per Days 7 - 90 $0Skilled Nursing Facility (SNF) Per Days 1 - 20 $0 Skilled Nursing Facility (SNF) Per Days 21 - 100 $172

Oupatient Care - CopaymentsHospital Surgery Center $250Ambulatory Surgery Center $200Hospital Observation $250Renal Dialysis 20%

Emergency/Urgent Care Services - CopaymentsEmergency Room / Urgent Care $120 / $40Ambulance per Trip: Ground / Air $115 / $115

Diagnostic Testing - CopaymentsRadiology Tests and Imaging $0 - $250, 20%Diagnostic & Lab Services $0 - $50

Diabetes & Durable Medical Equipment (DME) - CopaymentsDiabetes Monitoring Supplies and Self-Management Training $0Diabetes therapeutic shoes and inserts 20%Equipment (e.g. wheelchairs, oxygen) and Prosthetics (e.g. braces) 20%

Part B Drugs - CopaymentsPart B Immunizations - Flu, pheumonia, and hepititis B vacinnations $0Chemotherapy, transplant drugs and facility based infusions 20%

Prescription Drugs Part D drugs - Deductible $0INSULIN - call the Plan to determine your estimated drug cost

Wellcare Value (HMO) Page 64Additional Benefits, Physician Network, Preferred Pharmacies and Hospital Networks

Additional Benefits (Non-Medicare covered)Routine eye exam (1 every year) $0 co-payEyewear (lenses/frames and contacts up to $200 per year) $0 co-payHearing Aid Appliance (up to $1,000 for 2 hearing aids per year) $0 co-payTransportation (to approved locations for 48 one-way trips) $0 co-payDental (preventive & some comprehensive up to $1,000) $0 co-payOver-the-Counter allowance on approved health products $400 per year24 hour Nurse Hotline $0 co-payFitness Program $0 co-payMeals after Hospital Stay (3 meals per day for up to 14 days) $0 co-payTravel Benefit in the United States not coveredRoutine chiropractic (12 visits every year) $20 co-payRoutine footcare (6 visits per year) $25 co-pay

Physician Network** Check with the plan to determine if your physician is in this plan's network.

Preferred pharmaciesIf your plan has preferred pharmacies, using those pharmacies may save you money.

Bashas and United Drug CVS SafewayCigna Medical Group Pharmacy Osco CostcoWalgreens Walmart Albertson

Hospital NetworksAbrazo Dignity Health BannerScottsdale Campus Arizona General BaywoodWest St Joseph’s Westgate Boswell

Del Webb

HonorHealth DesertDeer Valley EstrellaJohn C Lincoln Phoenix GatewayScottsdale Osborn GoldfieldScottsdale Shea IronwoodScottsdale Thompson Peak Thunderbird

University Medical Center