2015 Plan Information Medtronic Inc Group # Medical Benefits ▼ Primary Care Office Visit Specialist Office Visit Urgent Care Inpatient Hospital Outpatient Hospital 70515 $15 copay $15 copay $15 copay $0 copay $0 copay Ambulance $0 copay Worldwide Emergency Room* Preventive Care Eyewear Hearing Aids $0 copay Up to $150 Up to $500 Chiropractic $15 copay Durable Medical Equipment $0 copay $50 copay 20% coinsurance Part D Prescription Drug Coverage ▼ Part B Drugs Plan Benefit Summary Visits to doctor’s office No referral required Non-emergencies with no appointment Hospital stay more than 23 hours Hospital stay less than 23 hours Coverage of medically necessary ambulance services No copay required if admitted as inpatient within 48 hours Includes annual physical exam This is a reimbursement benefit This is a reimbursement benefit Covers manual manipulation of the spine to correct a displacement or misalignment Medical equipment such as walkers, wheelchairs, etc., ordered by your doctor Drugs covered under Part B per CMS Approved by the FDA as having the same active ingredient as the brand name drug $20 copay Has cheaper generic equivalent available Tier 2 (Non-preferred Generic) $25 copay No generic available Tier 3 (Preferred Brand) Tier 4 (Non-preferred Brand) Has a generic equivalent available $50 copay Compounded medication created at a specialty Tier 5 (Specialty) $75 copay pharmacy Yes Gap Coverage 50% MFR discount on covered brand name drugs Deductibles and Maximum Out-of-Pocket Limits ▼ Medical Deductible $0 The amount you pay prior to plan payment for eligible services Pharmacy Deductible $0 Medical Out-of-Pocket Max. $1,500 Maximum amount of money paid out-of-pocket in a Rx Out-of-Pocket Max. Medicare Limits calendar year for eligible charges *Yearly $20,000 plan coverage limit outside the U.S. and its territories. **Per calendar year Tier 1 ( Preferred Generic) $10 copay Eligibility Must be enrolled in Medicare Parts A & B, or Part B only – If enrolled in Medicare Part B only, there is no coverage for Medicare Part A services Must continue to pay Medicare Part B premium Must reside within the Medica Prime Solution service area – see other side Must not have End Stage Renal Disease (ESRD) unless currently enrolled in a Medica Commercial Plan The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Limitations, copayments and restrictions may apply. Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Medica is a Cost plan with a Medicare contract. Enrollment in Medica depends on contract renewal. Additional Plan Features Large Provider Network Open access to all participating Medica providers with no referrals needed – visit www.medica.com/Medicare for a list of network providers. Silver&Fit® Program Low $25 annual fee for membership at a participating fitness facility – visit www.SilverandFit.com to view the facilities list. Or instead of a fitness center membership you can select the Silver&Fit Home Exercise option that includes two fitness kits of your choice for only $10 per year. Nationwide Travel and “Snowbird” Coverage Whether you are going away for a vacation or spend part of the year in another area of the country, our Extended Absence Option allows you to receive in-network benefits when you are temporarily away (for up to 9 consecutive months). Member must call Medica to activate this option. HealthAdvocateTM 24-Hour NurseLine and Personal Health Advocate A 24/7 NurseLine and access to a Personal Health Advocate who can help you navigate the often complex healthcare system in unique ways such as arranging appointments with hard-to-reach specialists, finding doctors taking new patients, explaining your doctor’s instructions and much more. Novu Well-being Program Novu is a free web tool designed to make living a healthy lifestyle easier, more interesting and FUN! Through Novu you can create a personalized well-being program that reflects your goals and preferences. You can track your progress and receive support from a Novu coach, online communities, and healthy events in your town. Medica Customer Service Toll-free at 1-800-575-2330 or locally at 952-992-2330 TTY users, please call the National Relay Center at 1-800-855-2880 Hours of Operation: October 1 - February 14 8 a.m. to 8 p.m. CT, 7 days a week. February 15 - September 30 8 a.m. to 8 p.m. CT, Monday - Friday You will speak to a live representative if you call during our business hours unless we are closed for a holiday. If you call when we are not open for business, you can leave a voicemail message and we will return your call within one business day. www.medica.com/Medicare Service Area Counties Minnesota – All counties North Dakota – Adams, Barnes, Bowman, Burleigh, Cass, Cavalier, Dickey, Dunn, Eddy, Emmons, Foster, Grand Forks, Grant, Griggs, Hettinger, Kidder, LaMoure, Logan, McHenry, McIntosh, McLean, Mercer, Morton, Oliver, Pembina, Pierce, Ransom, Richland, Sargent, Sheridan, Sioux, Stark, Steele, Stutsman, Traill, Walsh, Ward South Dakota – Aurora, Beadle, Bennett, Bon Homme, Brookings, Brown, Brule, Buffalo, Butte, Campbell, Charles Mix, Clark, Clay, Codington, Custer, Davison, Day, Deuel, Dewey, Douglas, Edmunds, Fall River, Grant, Gregory, Haakon, Hamlin, Hand, Hanson, Harding, Hughes, Hutchinson, Jackson, Jerauld, Jones, Kingsbury, Lake, Lawrence, Lincoln, Lyman, Marshall, McCook, McPherson, Meade, Mellette, Miner, Minnehaha, Moody, Pennington, Perkins, Roberts, Sanborn, Shannon, Spink, Stanley, Todd, Tripp, Turner, Union, Yankton, Ziebach Wisconsin – Ashland, Barron, Bayfield, Burnett, Chippewa, Douglas, Dunn, Eau Claire, Pierce, Polk, Sawyer, St Croix, Washburn. Medicare 1-800-MEDICARE (1-800-633-4227). TTY: 1-877-486-2048. www.medicare.gov Social Security 1-800-772-1213. TTY: 1-800-325-0778. www.ssa.gov © 2014 Medica <CHA50173-100813A>