STATE OF KANSAS RETIREE HEALTH PLAN FREEDOM (PPO) - …

1 Out-of-Network Providers$0 This is what you pay for Out-of-Network Providers20%20%$020%20%20%$0 One baseline mammogram for members age 35-39; and one annual mammogram for members age 40 & Prostate Cancer Screening Exam$0 For covered males age 50 & over, every 12 RequirementPREVENTIVE CAREThis is what you pay for Network ProvidersAnnual Wellness ExamsOne exam every 12 months.$0 Routine Physical ExamsOne exam every 12 months.$0 Routine Mammograms (Breast Cancer Screening) $0 Routine GYN Care (Cervical and Vaginal Cancer Screenings)$0 One routine GYN visit and pap smear every 24 Covered ImmunizationsPneumococcal, Flu, Hepatitis BThis is the amount you have to pay out of pocket before the plan will pay its share for your covered Medicare Part A and B Maximum Out-of-Pocket AmountNetwork services: The maximum out-of-pocket limit applies to all covered Medicare Part A and B benefits including deductible.

2 $1,000 Not applicablePrimary Care Physician SelectionPLAN DESIGN AND BENEFITSPROVIDED BY COVENTRY HEALTH & LIFE INSURANCE COMPANYPLAN FEATURESN etwork ProvidersBenefits and Premiums are effective January 01, 2018 through December 31, 2018 STATE OF KANSAS RETIREE HEALTH PLANFREEDOM (PPO)Network and out-of-network services combined: $4,100 You are encouraged to select a partcipating PCPA nnual Deductible$0 August 2017 13861_5 Page 1 STATE OF KANSAS RETIREE HEALTH PLANFREEDOM (PPO)20%20%20%20%20%This is what you pay for Out-of-Network Providers20%20%This is what you pay for Out-of-Network Providers20%20%20%20%This is what you pay for Out-of-Network Providers$30$100 This is what you pay for Out-of-Network Providers$150 copay per day, day(s) 1-5$150 The member cost sharing applies to covered benefits incurred during a member's inpatient Surgery$150 Ambulance Services$100 HOSPITAL CAREThis is what you pay for Network ProvidersInpatient Hospital Care$150 copay per day,day(s) 1-5 EMERGENCY MEDICAL CAREThis is what you pay for Network ProvidersUrgently Needed Care; Worldwide$30 Emergency Care.

3 Worldwide (waived if admitted)$80 Outpatient Diagnostic X-ray$0 Outpatient Diagnostic Testing $150 Outpatient Complex Imaging$150 Includes services of an internist, general physician, family practitioner for routine care as well as diagnosis and treatment of an illness or injury and in-office Specialist Visits $25 DIAGNOSTIC PROCEDURESThis is what you pay for Network ProvidersOutpatient Diagnostic Laboratory$0 Routine Hearing ScreeningOne exam every 12 months.$0 PHYSICIAN SERVICESThis is what you pay for Network ProvidersPrimary Care Physician Visits$10 Routine Bone Mass Measurement$0 Additional Medicare Preventive Services*$0 Routine Eye Exams One annual exam every 12 months. $0 Routine Colorectal Cancer ScreeningFor all members age 50 & over.$0$80 August 2017 13861_5 Page 2 STATE OF KANSAS RETIREE HEALTH PLANFREEDOM (PPO)This is what you pay for Out-of-Network Providers20% per stay20%20%This is what you pay for Out-of-Network Providers20% per stay20%20%20%This is what you pay for Out-of-Network Providers 20%$020%Outpatient Rehabilitation Services$0 Limited to 100 days per Medicare Benefit Period**.

4 The member cost sharing applies to covered benefits incurred during a member's inpatient HEALTH Agency Care$0 Hospice CareCovered by Medicare at a Medicare certified member cost sharing applies to covered benefits incurred during a member's inpatient hospitalization$0 OTHER SERVICESThis is what you pay for Network ProvidersSkilled Nursing Facility (SNF) Care$0 copay per day,day(s) 1-20;$ copay per day, day(s) 21-100 Outpatient Substance Abuse (Detox and Rehab)Group therapy visits$15 Inpatient Mental HEALTH Care$150 copay per day,day(s) 1-5 The member cost sharing applies to covered benefits incurred during a member's inpatient therapy visits$30 Outpatient Mental HEALTH CareGroup therapy visits$15 BloodAll components of blood are covered beginning with the first HEALTH SERVICESThis is what you pay for Network ProvidersALCOHOL/DRUG ABUSE SERVICESThis is what you pay for Network ProvidersInpatient Substance Abuse (Detox and Rehab)$150 copay per day,day(s) 1-5 Individual therapy visits$30 August 2017 13861_5 Page 3 STATE OF KANSAS RETIREE HEALTH PLANFREEDOM (PPO)

5 20%20%20%20%20%20%20%20%$020%20%20%Diabe tic Eye Exams & self-management training$0 Outpatient Dialysis Treatments & self-management training$0 Medicare Part B Prescription Drugs20%Radiation Therapy$0 Chiropractic Services$20 Limited to Medicare - covered services for manipulation of the spineDurable Medical Equipment/ Prosthetic Devices20%(Speech, Physical, and Occupational therapy)Cardiac Rehabilitation Services$0 Pulmonary Rehabilitation Services$0 Podiatry ServicesHearing Exams to diagnose and treat hearing and balance issues$0$0 - 20%We exclusively cover blood glucose monitors and diabetic test strips manufactured by OneTouch / LifeScan, such as OneTouch Verio OneTouch Ultra , OneTouch UltraMini systems, test strips and supplies. Higher cost-share applies for non-OneTouch/LifeScan diabetic supplies, even with a medical exception.$0 - 20%$30 Routine Visits (Non-Medicare Covered) Up to two supplemental visits each year.$15 Diabetic SuppliesMedicare Covered Services for foot exams and treatment if you have diabetes-related nerve damage and/or meet certain Covered Services$0 August 2017 13861_5 Page 4 STATE OF KANSAS RETIREE HEALTH PLANFREEDOM (PPO)$0 $3,750 Pharmacy NetworkFormularyInitial Coverage Limit (ICL)To find a network pharmacy, you can visit our website ( ).

6 Your cost for generic drugs is usually lower than your cost for brand drugs. However, aetna in some instances combines higher cost generic drugs on brand drug calendar year deductible must be satisfied before any Medicare Prescription Drug benefits are paid. Covered Medicare Prescription Drug expenses will accumulate toward the pharmacy for LivingPHARMACY - PRESCRIPTION DRUG BENEFITSP rescription drug calendar year deductible**A Medicare Benefit Period begins the day you go into a hospital or skilled nursing facility. The benefit period ends when you haven t received any inpatient hospital care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a skilled nursing facility after one benefit period has ended, a new benefit period begins. There is no limit to the number of benefit For livingsm helps connect you to resources in your community such as senior housing, adult daycare, meal subsidies, community activities and more.

7 $500 once every year. Submit your receipt and itemized bill to us for Aid AllowanceGo online for more information about SilverSneakers You pay a $0 copay for at-home fitness kits in lieu of out of network fitness facility access. Fitness Benefit: Silver SneakersPreventive Care (Non-Medicare Covered)Not coveredADDITIONAL NON-MEDICARE COVERED SERVICES August 2017 13861_5 Page 5 STATE OF KANSAS RETIREE HEALTH PLANFREEDOM (PPO)Retail cost-sharing up to a 90-day supply$2 $0$6 $18$47 $141$100 $30033%Coverage Gap The Initial Coverage Limit includes the applicable plan deductible. Until covered Medicare Prescription Drug expenses reach the Initial Coverage Limit (and after the deductible is satisfied), cost-sharing is as follows:Tier 1 - Preferred GenericGeneric DrugsTier 2 - GenericGeneric DrugsTier 3 - Preferred BrandIncludes some high-cost generic and preferred brand drugsTier 4 - Non-Preferred DrugIncludes some high-cost generic and non-preferred brand drugsTier 5 - SpecialtyIncludes high-cost/unique generic and brand drugs$0$18$141$300 Limited to one-month supplyMail Order cost-sharing up to a 90-day supply 5 Tier PlanRetail cost-sharing up to a 90-day supply August 2017 13861_5 Page 6 STATE OF KANSAS RETIREE HEALTH PLANFREEDOM (PPO)

8 $2 $0$6 $1844% Generic 35% Brand44% Generic 35% Brand44% Generic 35% Brand44% Generic 35% Brand44% Generic 35% BrandTier 1 - Preferred GenericGeneric Drugs$0 Tier 2 - GenericGeneric Drugs$18 Tier 3 - Preferred BrandIncludes some high-cost generic and preferred brand drugs44% Generic 35% BrandTier 4 - Non-Preferred DrugIncludes some high-cost generic and non-preferred brand drugs44% Generic 35% BrandTier 5 - SpecialtyIncludes high-cost/unique generic and brand drugsLimited to one-month supplyOnce covered Medicare Prescription Drug expenses have reached the Initial Coverage Limit, the Coverage Gap begins. Member cost sharing between the Initial Coverage Limit and until $5,000 in true out-of-pocket costs for Covered Part D drugs are incurred is as follows: Catastrophic CoverageGreater of $ or 5% for covered generic (including brand drugs treated as generic) drugs. Greater of $ or 5% for all other covered drugs. Catastrophic Coverage benefits start once $5,000 in true out-of-pocket costs is incurred.

9 August 2017 13861_5 Page 7 STATE OF KANSAS RETIREE HEALTH PLANFREEDOM (PPO) 2017 aetna Medicare Advantage has a network of doctors, hospitals, pharmacies, and other providers. If you use the providers that are not in our network, the plan may not pay for these services. Or you may pay more for these services. Out-of-network/non-contracted providers are under no obligation to treat aetna members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network Medicare is a PDP, HMO, PPO plan with a Medicare contract. Our SNPs also have contracts with STATE Medicaid programs. Enrollment in our plans depends on contract renewal.

10 The Medicare Coverage Gap Discount Program provides a manufacturer discount on brand name drugs to members in a Medicare prescription drug plan. You must have reached the coverage gap and not be receiving Extra Help. Your plan sponsor or former employer provides some additional coverage, during the coverage gap phase, for certain tiers of brand name drugs (depending upon your plan of benefits). For these drugs, you will generally continue to pay the same amount during the coverage gap as you paid in the initial coverage phase. When you obtain other covered brand name drugs that do not qualify for the additional benefit, the pharmacy automatically applies the applicable manufacturer discount when you are billed for your prescription. A 50 percent discount on the negotiated price (excluding a dispensing fee) is available for brand name drugs from manufacturers that have agreed to pay the : Certain drugs have precertification and/or step-therapy requirements.