Medicare Summary of

BenefitsMIAMI-DADE COUNTY

2 MEDICARE SUMMARY OF BENEFITS H1016_CE395-082014 CMS Accepted

Thank you for your interest in AvMed Medicare Choice.

This booklet gives you a summary of what we cover and what you pay. It doesn't list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, call us and ask for the "Evidence of Coverage."

YOU HAVE CHOICES ABOUT HOW TO GET YOUR MEDICARE BENEFITS

•OnechoiceistogetyourMedicarebenefits throughOriginalMedicare(fee-for-service Medicare).OriginalMedicareisrundirectlyby the Federal government.

•AnotherchoiceistogetyourMedicarebenefits byjoiningaMedicarehealthplan(suchas AvMedMedicareChoice).

TIPS FOR COMPARING YOUR MEDICARE CHOICES

This Summary of Benefits booklet gives you a summaryofwhatAvMedMedicareChoicecoversand what you pay.

•Ifyouwanttocompareourplanwithother Medicarehealthplans,asktheotherplansfor theirSummaryofBenefitsbooklets.Or,usethe MedicarePlanFinderonwww.medicare.gov.

•Ifyouwanttoknowmoreaboutthecoverage andcostsofOriginalMedicare,lookinyour current"Medicare&You"handbook.Viewit online at www.medicare.gov or get a copy by calling 1-800-MEDICARE (1-800-633-4227), 24hoursaday,7daysaweek.TTYusers shouldcall1-877-486-2048.

SECTIONS IN THIS BOOKLET

•ThingstoKnowAboutAvMedMedicare Choice

•MonthlyPremium,Deductible,andLimitson HowMuchYouPayforCoveredServices

•CoveredMedicalandHospitalBenefits

•PrescriptionDrugBenefits

This document is available in other formats such as Braille and large print.

Thisdocumentmaybeavailableinanon-Englishlanguage. For additional information, call us at 1-800-782-8633(TTY/TDD–711or 1-800-955-8771).

Tenemos servicios de intérprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos. Parahablarconunintérprete,porfavorllameal1-800-782-8633(TTY/TDD–711o 1-800-955-8771).Alguienquehableespañollepodrá ayudar. Este es un servicio gratuito.

AVMED MEDICARE CHOICE a Medicare Advantage Health Maintenance Organization

(HMO) by AvMed, Inc. with a Medicare contract January 1, 2015 – December 31, 2015

MIAMI-DADE COUNTY

Summary of Benefits

3H1016_CE395-082014 CMS Accepted

Summary of Benefits

THINGS TO KNOW ABOUT AVMED MEDICARE CHOICE

Hours of Operation:CustomerServiceHoursforOctober1–February14: Sunday,Monday,Tuesday,Wednesday,

Thursday,Friday,Saturday,8:00a.m.–8:00p.m.EasternStandardTime(EST).

CustomerServiceHoursforFebruary15–September30:Monday,Tuesday,Wednesday,

Thursday,Friday,8:00a.m.–8:00p.m.;Saturday9:00a.m.-1:00p.m.EST.

Phone Numbers and Website:•Ifyouareamemberofthisplan,calltoll-free 1-800-782-8633(orlocallyat305-671-5437 x22147).(TTY/TDD–711or1-800-955-8771).

•Ifyouarenotamemberofthisplan,calltoll- free 1-800-535-9355(orlocallyat305-671-5437 x21003).(TTY/TDD–711or1-800-955-8771).

•Ourwebsite:www.avmed.org.

Who can join?TojoinAvMedMedicareChoice,youmustbeentitledtoMedicarePartA,and/orbeenrolledinMedicarePartB,andliveinourservicearea.OurserviceareaincludesMiami-DadeCounty,Florida.

Which doctors, hospitals, and pharmacies can I use?AvMedMedicareChoicehasanetworkofdoctors, hospitals, pharmacies, and other providers. If you use the providers that are not in our network, the plan may not pay for these services.

YoumustgenerallyusenetworkpharmaciestofillyourprescriptionsforcoveredPartDdrugs.

Youcanseeourplan'sproviderandpharmacydirectoryatourwebsite(www.avmed.org).

Or,callusandwewillsendyouacopyoftheprovider and pharmacy directory.

What do we cover?LikeallMedicarehealthplans,wecovereverything thatOriginalMedicarecovers-andmore.

•Ourplanmembersgetallofthebenefits coveredbyOriginalMedicare.Forsomeof these benefits, you may pay more in our plan thanyouwouldinOriginalMedicare.

For others, you may pay less.

•Ourplanmembersalsogetmorethanwhatis coveredbyOriginalMedicare.Someofthe extra benefits are outlined in this booklet.

WecoverPartDdrugs.Inaddition,wecoverPartB drugs such as chemotherapy and some drugs administered by your provider.

•Youcanseethecompleteplanformulary(listof PartDprescriptiondrugs)andanyrestrictions on our website, www.avmed.org.

•Or,callusandwewillsendyouacopyofthe formulary.

How will I determine my drug costs?Ourplangroupseachmedicationintooneoffive"tiers."Youwillneedtouseyourformularyto locate what tier your drug is on to determine how much it will cost you. The amount you pay depends on the drug's tier and what stage of the benefityouhavereached.Laterinthisdocumentwe discuss the benefit stages that occur: Initial Coverage, Coverage Gap, and Catastrophic Coverage.

4 MEDICARE SUMMARY OF BENEFITS H1016_CE395-082014 CMS Accepted

Summary of Benefits

MONTHLY PREMIUM, DEDUCTIBLE, AND LIMITS ONHOW MUCH YOU PAY FOR COVERED SERVICES

AvMed Medicare Choice is an HMO plan with a Medicare contract. Enrollment in AvMed Medicare Choice depends on contract renewal.

How much is the monthly premium?

$0permonth.Inaddition,youmustkeeppayingyourMedicarePartBpremium.

How much is the deductible? This plan does not have a deductible.

Is there any limit on how much I will pay for my covered services?

Yes.LikeallMedicarehealthplans,ourplanprotectsyoubyhavingyearlylimitsonyourout-of-pocketcostsformedicalandhospitalcare.

Youryearlylimit(s)inthisplan:

•$4,000forservicesyoureceivefromin-network providers.

Ifyoureachthelimitonout-of-pocketcosts,you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year.

Pleasenotethatyouwillstillneedtopayyourmonthlypremiumsandcost-sharingforyourPartDprescriptiondrugs.

Is there a limit on how much the plan will pay?

Ourplanhasacoveragelimiteveryyearforcertainin-networkbenefits.Contactusfortheservices that apply.

5H1016_CE395-082014 CMS Accepted

Summary of Benefits

COVERED MEDICAL AND HOSPITAL BENEFITS

Note: • Serviceswitha1 may require prior authorization.

• Serviceswitha2 may require a referral from your doctor.

OUTPATIENT CARE AND SERVICES

Acupuncture and Other Alternative Therapies

Not covered

Ambulance1 $100copay Copay per one way transport.

Chiropractic Care1 Manipulationofthespinetocorrectasubluxation(when1ormoreofthebonesofyourspinemoveoutofposition):$5copay

Dental Services Limiteddentalservices(thisdoesnotincludeservices in connection with care, treatment, filling,removal,orreplacementofteeth): $0-125copay,dependingontheservice

Preventive dental services:

•Cleaning(forupto1everysixmonths): $0-45copay,dependingontheservice

•Dentalx-ray(s)(forupto1):$0-28copay, depending on the service

• Fluoridetreatment:$20copay

•Oralexam(forupto1everysixmonths): $0-10copay,dependingontheservice

BitewingX-rays(2-4films)arelimitedtoonesetin any 12 consecutive month period.

Diabetes Supplies and Services2 Diabetesmonitoringsupplies:20%ofthecost

Diabetesself-managementtraining:Youpaynothing

Therapeuticshoesorinserts:20%ofthecost

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Summary of Benefits

COVERED MEDICAL AND HOSPITAL BENEFITS (CONTINUED)

OUTPATIENT CARE AND SERVICES (CONTINUED)

Diagnostic Tests, Lab and Radiology Services, and X-Rays1,2

Diagnosticradiologyservices(suchasMRIs,CTscans):$50-175copayor20%ofthecost,depending on the service

Diagnostictestsandprocedures:$0-25copay,depending on the service

Labservices:Youpaynothing

Outpatientx-rays:$25copay

Therapeuticradiologyservices(suchasradiationtreatmentforcancer):$35-60copay,dependingon the service

Lowercopaywillapplyforproceduresperformedinnon-hospitalaffiliatedfacilities.

Doctor's Office Visits2 Primarycarephysicianvisit:Youpaynothing

Specialistvisit:$0-25copay,dependingontheservice

LowercopaywillapplywhenutilizingAvMedHighPerformanceNetwork(HPN)providers.

AdditionalinformationcanbefoundintheAvMed2015ProviderandPharmacyDirectory orinthe2015EvidenceofCoverage.

Durable Medical Equipment

(wheelchairs, oxygen, etc.)1

20%ofthecost

7H1016_CE395-082014 CMS Accepted

Summary of Benefits

COVERED MEDICAL AND HOSPITAL BENEFITS (CONTINUED)

OUTPATIENT CARE AND SERVICES (CONTINUED)

Emergency Care $65copay

If you are admitted to the hospital within 24 hours, you do not have to pay your share of the cost for emergency care.

See the "Inpatient Hospital Care" section of this booklet for other costs.

Foot Care (podiatry services) Footexamsandtreatmentifyouhavediabetes-relatednervedamageand/ormeetcertainconditions:$5copay

Routinefootcare(forupto1visit(s)):$5copay

Onevisitevery60daysforroutinefootcareinadditiontoOriginalMedicarebenefits.

Hearing Services2 Exam to diagnose and treat hearing and balance issues:$5copay

Home Health Care1,2 Youpaynothing

Mental Health Care1,2 Inpatient visit:

Ourplancoversupto190daysinalifetimefor inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit applies to inpatient mental services provided in a general hospital.

Ourplancovers90daysforaninpatienthospitalstay.

Ourplanalsocovers60"lifetimereservedays."These are "extra" days that we cover. If your hospital stay islongerthan90days,youcanusetheseextradays.Butonceyouhaveuseduptheseextra60days,yourinpatienthospitalcoveragewillbelimitedto90days.

• $150copayperdayfordays1through9• Youpaynothingperdayfordays10through90

Outpatientgrouptherapyvisit:$15copay

Outpatientindividualtherapyvisit:$15copay

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Summary of Benefits

COVERED MEDICAL AND HOSPITAL BENEFITS (CONTINUED)

OUTPATIENT CARE AND SERVICES (CONTINUED)

Outpatient Rehabilitation1,2 Cardiac(heart)rehabservices(foramaximumof2one-hoursessionsperdayforupto36sessionsupto36weeks):$5copay

Occupationaltherapyvisit:$5copay

Physicaltherapyandspeechandlanguagetherapyvisit:$5copay

Outpatient Substance Abuse1,2 Grouptherapyvisit:$15copay

Individualtherapyvisit:$15copay

Outpatient Surgery1,2 Ambulatorysurgicalcenter:$50-150copay,depending on the service

Outpatienthospital:$50-150copay,dependingon the service

Over-the-Counter Items Not covered

Prosthetic Devices (braces, artificial limbs, etc.)

Prostheticdevices:Youpaynothing

Renal Dialysis1,2 20%ofthecost

Transportation Not covered

Urgent Care $25copay

If you are admitted to the hospital within 24 hours, you do not have to pay your share of the cost for urgent care. See the "Inpatient Hospital Care" section of this booklet for other costs.

Vision Services1,2 Exam to diagnose and treat diseases and conditionsoftheeye(includingyearlyglaucomascreening):$5copay

Routineeyeexam(forupto1everyyear):$5copayContactlenses(forupto1everyyear):Youpaynothing

Eyeglasses(framesandlenses)(forupto1everyyear):Youpaynothing.

9H1016_CE395-082014 CMS Accepted

Summary of Benefits

COVERED MEDICAL AND HOSPITAL BENEFITS (CONTINUED)

Vision Services1,2 (continued) Eyeglasses or contact lenses after cataract surgery:Youpaynothing

Ourplanpaysupto$100everyyearforcontactlensesandeyeglasses(framesandlenses).

AvMedMedicareChoiceprovidesa$100annualallowance toward one pair of eyeglasses with standard frames or contact lenses, in addition to OriginalMedicarecoverage.

Eye exams performed by optometrists do not require a referral. However, referrals are required for eye exams performed by an ophthalmologist.

PREVENTIVE CARE

You pay nothing.

Our plan covers many preventive services, including:

•Abdominalaorticaneurysmscreening

•Alcoholmisusecounseling

•Bonemassmeasurement

•Breastcancerscreening(mammogram)

•Cardiovasculardisease(behavioraltherapy)

•Cardiovascularscreenings

•Cervicalandvaginalcancerscreening

•Colonoscopy

•Colorectalcancerscreenings

•Depressionscreening

•Diabetesscreenings

• Fecaloccultbloodtest

• Flexiblesigmoidoscopy

•HIVscreening

•Medicalnutritiontherapyservices

•Obesityscreeningandcounseling

10 MEDICARE SUMMARY OF BENEFITS H1016_CE395-082014 CMS Accepted

Summary of Benefits

COVERED MEDICAL AND HOSPITAL BENEFITS (CONTINUED)

PREVENTIVE CARE (CONTINUED)

• Prostatecancerscreenings(PSA)

• Sexuallytransmittedinfectionsscreeningand counseling

• Tobaccousecessationcounseling(counseling forpeoplewithnosignoftobacco-related disease)

•Vaccines,includingFlushots,HepatitisBshots, Pneumococcalshots

• "WelcometoMedicare"preventivevisit(one-time)

•Yearly"Wellness"visit

AnyadditionalpreventiveservicesapprovedbyMedicareduringthecontractyearwillbecovered.

HOSPICE

You pay nothing for hospice care from a Medicare-certified hospice. You may have to pay part of the cost for drugs and respite care.

Inpatient Care

Inpatient Hospital Care1 Ourplancoversanunlimitednumberofdaysforan inpatient hospital stay.

•Youpaynothingperdayfordays1through5

•$55copayperdayfordays6through20

• Youpaynothingperdayfordays21through90

• Youpaynothingperdayfordays91andbeyond

Inpatient Mental Health Care Forinpatientmentalhealthcare,seethe"MentalHealth Care" section of this booklet.

Skilled Nursing Facility (SNF)1,2 Ourplancoversupto100daysinaSNF.

•Youpaynothingperdayfordays1through20

•$135copayperdayfordays21through100

11H1016_CE395-082014 CMS Accepted

Summary of Benefits

PRESCRIPTION DRUG BENEFITS

How much do I pay? ForPartBdrugssuchaschemotherapydrugs1: 10-20%ofthecostdependingonthedrug

OtherPartBdrugs1:10-20%ofthecostdepending on the drug

Initial Coverage Youpaythefollowinguntilyourtotalyearlydrugcostsreach$4,000.Totalyearlydrugcostsarethe total drug costs paid by both you and our PartDplan.

Youmaygetyourdrugsatnetworkretailpharmacies and mail order pharmacies.

Standard Retail Cost-Sharing

TIER One-Month Two-Month Three-Month Supply Supply Supply

Tier 1 (Preferred Generic) $0 $0 $0

Tier 2 (Non-Preferred Generic) $0 $0 $0

Tier 3 (Preferred Brand) $25 copay $50 copay $75 copay

Tier 4 (Non-Preferred Brand) $50 copay $100 copay $150 copay

Tier 5 (Specialty Tier) 33% of the cost Not offered Not offered

Standard Mail Order Cost-Sharing

TIER Three-Month Supply

Tier 1 (Preferred Generic) $0

Tier 2 (Non-Preferred Generic) $0

Tier 3 (Preferred Brand) $75 copay

Tier 4 (Non-Preferred Brand) $150 copay

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Summary of Benefits

PRESCRIPTION DRUG BENEFITS (CONTINUED)

Initial Coverage (continued) Ifyouresideinalong-termcarefacility,youpaythe same as at a retail pharmacy.

Youmaygetdrugsfromanout-of-networkpharmacy, but may pay more than you pay at an in-networkpharmacy.

COVERAGE GAP

Most Medicare drug plans have a coverage gap (also called the "donut hole"). This means that there's a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $4,000.

After you enter the coverage gap, you pay 45% of the plan's cost for covered brand name drugs and 65% of the plan's cost for covered generic drugs until your costs total $4,700, which is the end of the coverage gap. Not everyone will enter the coverage gap.

Under this plan, you may pay even less for the brand and generic drugs on the formulary.

Your cost varies by tier. You will need to use your formulary to locate your drug's tier. See the chart that follows to find out how much it will cost you.

Standard Retail Cost-Sharing

TIER Drugs One-Month Two-Month Three-Month Covered Supply Supply Supply

Tier 1 All $0 $0 $0 (Preferred Generic)

Tier 2 (Non-Preferred All $0 $0 $0 Generic)

Standard Mail Order Cost-Sharing

TIER Drugs Covered Three-Month Supply

Tier 1 (Preferred Generic) All $0

Tier 2 (Non-Preferred Generic) All $0

13H1016_CE395-082014 CMS Accepted

Summary of Benefits

PRESCRIPTION DRUG BENEFITS (CONTINUED)

CATASTROPHIC COVERAGE

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4,700, you pay the greater of:

• 5% of the cost, or

• $2.65 copay for generic (including brand drugs treated as generic) and a $6.60 copayment for all other drugs.

Notes

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15H1016_CE395-082014 CMS Accepted

H1016_CE395-082014 CMS Accepted MEDPRF-758(9/14)