PLAN INFORMATION - Benefits

1 Starts INFORMATIONCOUNTY OF RIVERSIDEU nitedHealthcare group medicare advantage (HMO) Effective January 1, 2015 through December 31, 2015 group number: 9000132015 Plan GuideTable of contentsIntroduction ..3 More plan informationRead all about your plan Benefits , including services and supportfor your overall health and well-being. Benefit Highlights ..6 Plan INFORMATION ..8 Summary of Benefits ..17 Required INFORMATION ..33 Drug listFind out which drugs are covered under this plan. The list in this bookis the full list of covered drugs. Drug List ..36 Additional Drug Coverage ..49 Welcome aboardThis section includes additional INFORMATION you may need to becomea member of this plan. Enrollment Instructions ..56 Statements of Understanding ..57 What to expect after you enrollLearn about the materials and follow-up communication you can expect after you become a UnitedHealth group Annual ReportY0066_140627_082134 UHEX15MP3577496_001 SPRJ18923 Dear Retiree,We are pleased and honored that your employer has selected unitedhealthcare to provide health care coverage for all eligible retirees.

2 At unitedhealthcare we believe you deserve more than just a good insurance plan to help maintain your health. We want to work with you so you can live a healthier life. We want to: Help you get access to the care you may need when you need it Give you tools and resources to be in control Try to help you find ways to save money, so you can spend less on health care and more on the things that matter most to you Be there for you whenever and wherever you need usWhat s in this bookIn this book you will find: A description of this plan and how it works INFORMATION on Benefits , programs and services and how much they cost What you can expect after you enrollEnrolling is you want to enroll in this plan, follow your employer s instructions. Working with you to create a positive medicare you have any questions, please give us a call. Our Customer Service team has been specially trained on the details of your plan. They are happy to answer any questions you re with you every step of the 8 8 local time, 7 days a weekLearn more online1-877-714-0178, TTY page intentionally left all about your plan Benefits , including services and support for your overall health and AcceptedUHEX15MP3584413_000 More planINFORMATIONB enefit highlightsCounty of Riverside900013 EffectiveJanuary 1, 2015 toDecember 31, 2015 This is a short description of plan Benefits .

3 For complete INFORMATION , please refer to your Summary ofBenefits or Evidence of Coverage. Limitations, exclusions, and restrictions may CostsIn-NetworkAnnual out-of-pocket maximum$3,400 Medical BenefitsIn-NetworkBenefits covered by Original medicare and your planDoctor s office visitPrimary Care Physician:$10 copaySpecialist:$10 copayPreventive services$0 copay for medicare -covered in-network preventive services. Referto the Summary of Benefits or Evidence of Coverage for hospital care$0 copay per admissionSkilled nursing facility (SNF)$0 copay per day up to100 daysOutpatient surgery$0 copayOutpatient rehabilitation(physical, occupational, orspeech/language therapy)$10 copayDiagnostic radiology services(such as MRIs, CT scans)$0 copayLab services$0 copayOutpatient x-rays$0 copayTherapeutic radiology services(such as radiation treatment forcancer)$0 copayAmbulance$0 copayEmergency care$50 copay (worldwide)Urgent care$50 copayAdditional Benefits and programs not covered by Original MedicareRoutine physical$0 copay.

4 1 per plan yearChiropractic care$10 copay(Up to30 visits per plan year)Foot care - routine$10 copay(Up to6 visits per plan year)Hearing - routine exam$0 copay(1 exam every 12 months)Hearing aidsPlan pays up to$2,500(every3 years)Vision - routine eye exams$0 copay(1 exam every 12 months)6 Medical BenefitsIn-NetworkFitness program throughSilverSneakers Fitness programStay active with a basic membership at a participating location at noextra cost to youNurseLineSMSpeak with a registered nurse (RN) 24 hours a day, 7 days a weekPrescription DrugsYour CostInitial coverage stageNetwork Pharmacy(30-day retail supply)Mail Service Pharmacy(90-day supply)Tier 1: Generic$10 copay$20 copayTier 2: Preferred brand$20 copay$40 copayTier 3: Non-preferred brand$40 copay$80 copayTier 4: Specialty tier$40 copay$80 copayCoverage gap stageAfter your total drug costs reach$2,960 the plan continues to pay itsshare of the cost of your drugs and you pay your share of the costCatastrophic coverage stageAfter your total out-of-pocket costs reach$4,700, you will pay thegreater of$ copay for generic (including brand drugs treated asgeneric),$ copay for all other drugs or,5% of the costYour plan sponsor has elected to offer additional coverage on some prescription drugs that are normallyexcluded from coverage on your Formulary.

5 Please see your Additional Drug Coverage list for are insured through unitedhealthcare Insurance Company or one of its affiliated companies, aMedicare advantage organization with a medicare contract. Enrollment in the plan depends on the plan scontract renewal with plan prospects must meet the eligibility requirements to enroll for group coverage. The benefitinformation provided is a brief summary, not a complete description of Benefits . For more INFORMATION ,contact the plan. Limitations, copayments, and restrictions may , formulary, pharmacy network,provider network,premium and/or co-payments/co-insurance may change each plan Plan InformationOne drug plan at a plan includes prescription drug coverage. You can only have prescription drug coverage under one plan. If you enroll in another stand-alone medicare Part D plan or a medical plan that includes prescription drug coverage, you may be disenrolled from this s start with a quick look at how your plan works.

6 Your plan sponsor has chosen a unitedhealthcare group medicare advantage plan. What is a group medicare advantage plan? The word group means that this is a plan designed just for a plan sponsor, like yours. Only eligible retirees of your plan sponsor can enroll in this plan. You can t get it anywhere else. medicare advantage is also known as medicare Part C. medicare advantage plans are a part of medicare that combine all the Benefits of medicare Part A (hospital coverage) and medicare Part B (doctor and outpatient care) into one convenient plan. Plus, your plan includes programs that go beyond Original medicare Part A and Part sure you are signed up for medicare . You must be enrolled in medicare Part A and purchase medicare Part B to be eligible to enroll in this plan. If you re not sure if you are enrolled in medicare Part A, check with your local Social Security office You must continue paying your medicare Part B premium to keep your coverage under this group -sponsored plan If you stop your payments, you may be disenrolled from this planRemember: If you drop your group -sponsored retiree health coverage, you may not be able to re-enroll.

7 Limitations and restrictions vary by plan group medicare AdvantageMedicare Part AHospitalMedicare Part BDoctor and outpatientMedicare Part DPrescription drugsExtra ProgramsBeyond Original Medicare8 How your HMO plan plan is a Health Maintenance Organization (HMO) plan. That means you must get care through a network of local doctors and hospitals. Your primary care provider (PCP) oversees your care and, in some cases, may refer you to a the doctor or hospital accept my plan?YesNoWhat is my co-pay or co-insurance?Co-pays and co-insurance vary by must pay the full cost for I need to choose a primary care provider (PCP)?YesN/ADo I need a referral to see a specialist?YesN/AAre emergency and urgently needed services covered?YesYesDo I have to pay the full cost for all covered doctor or hospital services?No, you will pay your standard co-pay or co-insurance for the service you there a limit on my total out-of-pocket spending for the year?YesN/AWe will handle the track of bills and payments can be overwhelming.

8 We take care of the payments to doctors and hospitals, so you don t have to. There are no health questions to answer and you don t need a physical to enroll in this plan. Once you re a member, you can register online at to view your account activity, plan details and so much to the Summary of Benefits or Benefit Highlights for more 0 6 6 _14 0722 _153526 UHEX15HM3595695_000 SPRJ20177 Plan basics9 More Plan InformationPrescription Drug CoverageYour drug list covers thousands of brand name and generic prescription drugs. Review the plan drug list to make sure your prescription drugs are price you pay for a covered drug will depend on two factors:TierCostDescriptionTier 1 LowIncludes all generic prescription 2 Includes many common brand name 3 Includes non-preferred brand name 4 (Specialty) HighIncludes unique or very high-cost deductible: If your plan has a deductible, you pay the total cost of your drugs until you reach the deductible amount set by your plan.

9 Then you move to the initial coverage stage. If you don t have a deductible, your coverage begins in the initial coverage stage. Total Drug Costs: The amount you pay (or others pay on your behalf) and the plan pays for prescription drugs. This does not include Costs: The amount you pay (or others pay on your behalf) for prescription drugs. This does not include premiums, or the amount the plan pays for prescription drug payment stage. Your plan has different stages of drug coverage. When you fill a prescription, the amount you pay depends on the stage you re this drug payment stage: You pay a co-pay or co-insurance (percentage of a drug s total cost), the plan pays the rest You stay in this stage until your total drug costs reach $2,960 Your plan sponsor is providing additional coverage through the gap. You continue to pay the same co-pay or co-insurance as you did in the initial coverage stage You stay in this stage until your total out-of-pocket costs reach $4,700 After your total out-of-pocket costs reach $4,700: You pay a small co-pay or co-insurance amount You stay in this stage for the rest of the plan yearThe drug tier for your drug.

10 Each covered drug is assigned to a tier. Generally, the lower the tier, the less you Gap(Donut Hole)Initial CoverageHow your prescription drug coverage works10 Your care begins with your receive your full coverage through your plan, you will need to choose a primary care provider from our large local network. Your doctor may already be in our network. Your primary care provider will help refer you to specialists when needed. With your unitedhealthcare group medicare advantage plan, you re connected to programs, resources, tools and people that can help you live a healthier your prescriptions is has over 65,000 national, regional and local chains, as well as thousands of independent neighborhood pharmacies in its network. Using a unitedhealthcare network pharmacy can help make sure you are getting the lowest cost available through your a doctor is easy. If you need help finding a doctor or a specialist, just give us a call. We can help you find a doctor based on your needs.