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MINNESOTA

2018 MEDICARE PLANS

MEDICA PRIME SOLUTION® (COST) Coverage Details

Y0088 4844a CMS Accepted AEP

Talk with an expert consultant you can trust.

Call 1-800-918-2143 (TTY: 711) to speak with a Medicare consultant who can help you evaluate your situation and make the best coverage choice for you and your budget.

PERSONALIZED COVERAGE YOU CAN AFFORD. We know you want affordability and

options. We also know you want to

choose your doctor. Medica Prime

Solution is designed to let you

personalize your coverage to meet

your unique needs and preferences.

Go with the plan that fits you.

Attend a free Get the details online. Medicare Workshop.

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

PRIME SOLUTION HAS ALL THE OPTIONS YOU NEED. It’s your choice.

Choosing the right Medicare coverage is easy with Medica Prime Solution. Select from a range of

plan options - with or without Part D prescription drug coverage. Find the one that is just the right

fit for your needs and budget.

» Premiums as low as $49

» Broad range of coverage levels to choose from

» Option to bundle your medical and Part D drug Get the coverage together in one plan plan features

» $0 medical deductible with most plans that count. » The Prime Solution provider network is broad

and includes major hospitals, clinics and providers in Medica’s four-state service area (Minnesota, North Dakota, South Dakota and

Two Medicare Wisconsin)

» Nationwide travel and “snowbird” coverage plans is too many. from any provider that accepts Medicare

It’s more convenient to bundle » Vision and hearing benefits

your medical and Part D

prescription drug coverage » Free fitness center membership through SilverSneakers® together.

One bundled plan. » More than 64,000 network pharmacies nationwide (for bundled medical and

One combined premium. Part D plans) One less worry.

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Take advantage of the convenience of combining your medical and Part D drug coverage in one plan for 2018. Our Prime Solution Choose one plan for both medical and drug coverage. Cost plan gives you a range of coverage levels to choose from so it’s easy to find a plan that fits your unique needs.

PRIME SOLUTION MEDICAL + PART D BUNDLED PLAN OPTIONS

2017 Original Medicare

Thrift Value Basic Enhanced

with Rx with Rx with Rx2 with Rx with Rx2 with Rx with Rx2

Monthly Premium $134 for Part B $77.40 $94.40 $118.60 $108.30 $131.70 $192.70 $210.70

Medical Deductible $183 for Part B $50 $0 $0 $0 $0 $0 $0

Medical Benefits YOU PAY YOU PAY

Preventive Services $0 $0 $0 $0 $0

Primary Care / Convenience Care 20% 20% $10 $0 $0

Specialist Office Visit 20% 20% $30 $20 $10

Urgent Care 20% $25 $10 - $30 $0 - $20 $0 - $10

Chiropractic* 20% 20% $20 $20 $10

Eye & Hearing Exams - Routine Annual 100% 100% $30 $0 $0

Diagnostic Tests / X-Ray 20% 20% 10% $10 $0

Diagnostic / Therapeutic Radiology 20% 20% 10% $25 $10

Lab Services $0 $0 $0 $0 $0

Diabetes Supplies / Durable Medical Equipment 20% 20% 20% 20% $0

Part B Drugs 20% 20% 20% 20% 20%

Outpatient Surgery 20% 20% $125 $50 $0

Ambulance 20% 20% $50 $25 $0

Emergency Care 20% $50 $50** $50** $50**

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

Days 1-4: $300/day Days 5-90: $0/day

Days 1-8: $150/day Days 9-90: $0/day

Days 1-8: $100/day Days 9-90: $0/day $0 per stay

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

Days 101+: 100%

Days 1-20: $0/day Days 21-100: $164.50/day†

Days 1-20: $0/day Days 21-100: $75/day

Days 1-20: $0/day Days 21-100: $50/day

Days 1-20: $0/day Days 21-100: $25/day

Annual Maximum Out-of-Pocket (medical) n/a $6,700 $4,000 $3,400 $3,000

Part D Prescription Drug Coverage YOU PAY (30-Day Retail)

Part D Deductible n/a $260 $260 $0 $260 $0 $215 $0

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

Tier 1 - Commonly Prescribed Generic 100% Up to $2 Up to $2 Up to $2 Up to $2 Up to $2 Up to $2 Up to $2

Tier 2 - Low-Cost Generic 100% Up to $6 Up to $6 Up to $8 Up to $6 Up to $8 Up to $6 Up to $8

Tier 3 - More Expensive Generic & Brand 100% Up to $28 Up to $31 Up to $35 Up to $27 Up to $35 Up to $25 Up to $35

Tier 4 - Higher-Priced Generic & Brand 100% 50% 50% 50% 50% 50% 50% 50%

Tier 5 - Generic or Brand for Complex Conditions 100% 27% 27% 33% 27% 33% 28% 33%

Level Two - Coverage Gap “Donut Hole” (Member-only drug costs up to $5,000) Generic at 44% and Covered Brand at 35% for all plan options

Level Three - Catastrophic Coverage (Shared drug costs $5,000 and up) Generic at $3.35 or 5%*** and Other Drugs at $8.35 or 5%*** for all plan options

*Medicare-covered visit for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part) / **Worldwide / ***Whichever is greater / † This amount is for 2017 and is subject to change in 2018. You must continue to pay your Medicare Part B premium.

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Want medical coverage only? You have great options. If you want to supplement your Original Medicare with a Prime Solution medical-only plan, you’re on the right track. It’s a great way to keep your doctor and health care costs affordable. Consider your health needs, as well as whether you’ll need help with things like routine vision and hearing exams.

2017 Original Medicare

PRIME SOLUTION MEDICAL-ONLY PLAN OPTIONS

Thrift Value Basic Enhanced

Monthly Medical Only Premium $134 for Part B $49 $67 $79 $157

Medical Deductible $183 for Part B $50 $0 $0 $0

Medical Benefits YOU PAY YOU PAY

Preventive Services $0 $0 $0 $0 $0

Primary Care / Convenience Care 20% 20% $10 $0 $0

Specialist Office Visit 20% 20% $30 $20 $10

Urgent Care 20% $25 $10 - $30 $0 - $20 $0 - $10

Chiropractic* 20% 20% $20 $20 $10

Eye & Hearing Exams - Routine Annual 100% 100% $30 $0 $0

Diagnostic Tests / X-Ray 20% 20% 10% $10 $0

Diagnostic & Therapeutic Radiology 20% 20% 10% $25 $10

Lab Services $0 $0 $0 $0 $0

Diabetes Supplies 20% 20% 20% 20% $0

Durable Medical Equipment 20% 20% 20% 20% $0

Part B Drugs 20% 20% 20% 20% 20%

Outpatient Surgery 20% 20% $125 $50 $0

Ambulance 20% 20% $50 $25 $0

Emergency Care 20% $50 $50** $50** $50**

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

Days 1-4: $300/day Days 5-90: $0/day

Days 1-8: $150/day Days 9-90: $0/day

Days 1-8: $100/day Days 9-90: $0/day $0 per stay

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

Days 101+: 100%

Days 1-20: $0/day Days 21-100: $164.50/day†

Days 1-20: $0/day Days 21-100: $75/day

Days 1-20: $0/day Days 21-100: $50/day

Days 1-20: $0/day Days 21-100: $25/day

Annual Maximum Out-of-Pocket n/a $6,700 $4,000 $3,400 $3,000

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YOUR PLAN TRAVELS WITH YOU. With all Prime Solution plans,

you’ll enjoy nationwide travel

and “snowbird” coverage. So

you can take your coverage

with you when you travel

anywhere within the United

States and enjoy access to

your full in-network benefits

for up to nine consecutive

months. Whether it’s a quick

trip or an extended stay,

you’re covered.

*Medicare-covered visit for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part) **Worldwide † This amount is for 2017 and is subject to change in 2018. You must continue to pay your Medicare Part B premium.

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OUR EXTRAS MAKE A HEALTHY PLAN EVEN

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

SilverSneakers®

makes it easy to stay active.

Prime Solution Value, Basic and Enhanced include a FREE SilverSneakers membership. This program helps people age 65 and over improve their well being through a variety of fitness options.

» More than 13,000 participating fitness locations nationwide

» Enroll at multiple locations any time

» Access to classes, exercise equipment and other amenities

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

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

healthy each and every day.

Your Personal Advocate is ready to help.

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

Our trained Personal Health Advocates can help you tackle health-related questions—from finding the right doctor to resolving claims questions. They can even help you make an appointment with a hard-to-reach doctor.

The service is confidential—and provided to you at no additional cost.

NurseLine™ is available 24/7.

You and your family have a place to turn for trusted advice and information when you need it most. Highly-trained nurses are available to help answer your questions about symptoms, medications and health conditions, and offer self-care tips for non-urgent concerns. The service is included with all Prime Solution plans at no additional cost.

Get reimbursed for eyewear and hearing aids.

If you are enrolled in Basic or Enhanced, you are eligible to receive reimbursement for prescription eyewear and hearing aids.

For prescription eyewear, you are reimbursed up to $125 per year with Enhanced and $75 with Basic.

For hearings aids, receive up to $400 in reimbursement annually for hearing aids and evaluations/fittings with Basic and Enhanced.

The health information you need is in the mail.

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

» Preventive care

» Common health conditions

» Safety tips

» Healthy recipes

» Medicare updates and more!

You can depend on our preventive care support.

Did you know you’re eligible for a variety of immunizations and health screenings as a Medicare member? We can help you stay up-to-date on all the services that are available to you. All new members receive a Quick Reference Guide, that includes a handy list of recommended screenings and immunizations you can review with your doctor and use to track the dates you received applicable services.

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THE ADDED SUPPORT YOU NEED

Convenience and drug savings through mail order.

CVS Caremark Mail Service Pharmacy

YOU PAY

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

» Pay only two copays for a three-month supply of eligible prescription drugs through CVS Caremark Mail Service Pharmacy

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

» Set up handy automatic refills for most maintenance medications

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

Download our handy pharmacy app. If you’re on the go, no problem. As a Medica Part D member, you have access to a mobile app which is powered by CVS Caremark™, the administrator of our pharmacy program.

This app can help you save money and manage your prescriptions wherever you are. It’s free and available for both Android and iOS phones. The app is easy to download and easy to use. Just one more way we meet the changing needs of our members.

LOCAL CUSTOMER SERVICE At Medica, you’ll always receive the caring, personal service you deserve from our local Medicare experts. Our health plan specialists can answer your questions and help you maximize your coverage. It’s another reason to choose the plan that listens to you.

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

Once you enroll, you can register to:

» Track medical or pharmacy claims

» Find a network doctor or pharmacy

» Order a replacement ID card

» Check prescription drug prices

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HOW TO ENROLL IN MEDICA PRIME SOLUTION

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

Call 1-800-918-2143 (TTY: 711) for fast and easy enrollment over the phone.

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

Complete and sign a paper application and submit via mail, fax or web. (You can request a paper application by calling 1-800-918-2143 (TTY: 711).)

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

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

Or fax to: 1-855-250-2166

Or upload securely at: medica.com/EnrollmentUpload

Important Enrollment Periods Initial Enrollment Period (IEP)

This is when you first become

eligible for Medicare at around

age 65. You have a seven-month

window during which you can

sign up for Medicare: three

months before your birthday

month, during your birthday

month and three months after

your birthday month.

Annual Election Period (AEP)

Medicare open enrollment is

October 15–December 7 each

year for January 1 coverage.

All enrollment, disenrollment

or plan change options are

available to you at this time.

Special Enrollment Period

(SEP)

A Special Enrollment Period

allows you to make changes to

your Medicare coverage that

normally you can only make

during your Initial Enrollment

Period or the Annual Election

Period. There are many types of

events that can trigger a Special

Enrollment Period.

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

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

2

3

4

5

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

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

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

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

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

Service area Prime Solution is available to residents of all Minnesota counties.

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IMPORTANT PLAN INFORMATION Prime Solution

Provider Network You can use any provider who is currently part of the Medica Prime Solution network. The providers in network can change at any time. You do not need a referral to use a network provider.

Visit medica.com/PrimeSolutionProviders to search our online directory. Or call us for a printed Provider Directory at 1-800-918-2143 (TTY: 711).

Pharmacy Network We have a broad nationwide pharmacy network of over 64,000 pharmacies, including all major chains and thousands of independent pharmacies. With Medica, there are no preferred pharmacies—you pay the same copay no matter which network pharmacy you choose.

Covered Drugs The Medica Prime Solution formulary is a list of drugs that are covered by your plan if you have selected the optional Part D rider. It includes more than 3,200 prescription drugs. You can check online to see if your drugs are covered at medica.com/Medicare. To request a printed formulary (covered drug list), you can call Medica at 1-800-918-2143 (TTY: 711).

Broad Provider Network Choose any provider currently

part of our extensive network

of doctors, clinics and hospitals.

No referrals needed.

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Call toll free at 1-800-918-2143 (TTY: 711) Hours of operation: October 1–February 14 8 a.m. to 8 p.m. Central, seven days a week MEDICA. February 15–September 30 8 a.m. to 8 p.m. Central, Monday-Friday THE FIRST Visit us online to learn more at medica.com/Medicare. WORD IN Locate a Medicare Workshop near you at medica.com/MedicareWorkshops.

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

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

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

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

This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or co-payments/co-insurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium. The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.

Medica is a Cost plan with a Medicare contract. Enrollment in Medica depends on contract renewal.

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

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

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