ChoiceONE Select Plan H Options and Benefits

Basic Core Benefits - Plan H:

The basic core benefits for Plan H, including Medicare (PART A) - Hospital Services - Per Benefit Period , Medicare (PART B) - Medical Services - Per Calendar Year , and Part A&B , shall consist of the following:

The basic core benefits for Plan H shall consist of the following:

A. coverage for Part A Medicare Eligible Expenses for hospitalization to the extent not covered by Medicare from the 61st day through the 90^th day in any Medicare benefit period;

B. coverage for Part A Medicare Eligible Expenses, to the extent not covered by Medicare, incurred as daily hospital charges during use of Medicare lifetime hospital inpatient reserve days;

C. upon exhaustion of all Medicare hospital inpatient coverage including the lifetime reserve days, coverage of the Medicare Part A eligible expenses for hospitalization paid at the diagnostic related group (DRG) day outlier per diem or other appropriate standard of payment, subject to a lifetime maximum benefit of an additional 365 days;

D. coverage under Medicare Parts A and B for the reasonable cost of the first three pints of blood (or equivalent quantities of packed red blood cells, as defined under federal regulation) unless replaced in accordance with federal regulation; and

E. coverage for the coinsurance amount (or in the case of hospital outpatient department services, the copayment amount) of Medicare Eligible Expenses under Part B regardless of hospital confinement, subject to the Medicare Part B deductible.

F. SOME RESTRICTIONS, LIMITATIONS AND EXCLUSIONS apply.

Additional Benefits:

The additional benefits for Plan H shall consist of the following:

A. Medicare Part A Deductible--Coverage for all of the Medicare Part A inpatient hospital deductible amount per benefit period.

B. Skilled Nursing Facility Care--Coverage for the actual billed charges up to the coinsurance amount from the 21st day through the 100th day in a Medicare benefit period for post-hospital skilled nursing facility care eligible under Medicare Part A.

C. Basic Outpatient Prescription Drug Benefit--Coverage for 50% of outpatient prescription drug charges, after a $250 calendar year deductible, to a maximum of $1,250 in benefits received by the Member per calendar year, to the extent not covered by Medicare.

D. Medically Necessary Emergency Care in a Foreign Country--Coverage to the extent not covered by Medicare for 80% of the billed charges for Medicare-Eligible Expenses for Medically Necessary emergency hospital, physician, and medical care received in a foreign country, which care would have been covered by Medicare if provided in the United States and which care began during the first 60 consecutive days of each trip outside the United States, subject to a calendar year deductible of $250, and a lifetime maximum benefit of $50,000. For purposes of this benefit, "emergency care" shall mean care needed immediately because of an injury or an illness of sudden and unexpected onset.

The basic core benefits and additional benefits are summarized in the following table:

PLAN H
MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD *A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
**$0 Indicates your liability for covered charges. You are responsible for all other non-covered charges.
***If you do not use a Network Provider, you are responsible for all charges not paid for by Medicare.

SERVICE TYPE MEDICARE PAYS PLAN PAYS YOU PAY

HOSPITALIZATION*, ***

Semiprivate room and board, general nursing and miscellaneous services and supplies

First 60 days All but $1068 $1068 (Part A Deductible) $0**

61st through 90th day All but $267 a day $267 a day $0**

91st day and after: While using 60 lifetime reserve days All but $512 a day $512 a day $0**

91st day and after: Once lifetime reserve days are used. Additional 365 lifetime days $0 100% of Medicare Eligible Expenses $0**

91st day and after: Once lifetime reserve days are used. Beyond the additional 365 days $0 $0 All costs

SKILLED NURSING FACILITY CARE*, ***

You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital

First 20 days All approved amounts $0 $0**

21st through 100th day All but $133.50 a day $Up to $133.50 a day $0**

101st day and after $0 $0 All costs

BLOOD***

First 3 pints $0 3 pints $0**

Additional amounts 100% $0 $0**

HOSPICE CARE

Available as long as your doctor certifies you are terminally ill and you elect to receive these services All but very limited coinsurance for outpatient drugs and inpatient respite care $0 Balance

PLAN H
MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR *Once you have been billed $131 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.
**$0 Indicates your liability for covered charges. You are responsible for all other non-covered charges.
***If you do not use a Network Provider, you are responsible for all charges not paid for by Medicare.

SERVICE TYPE MEDICARE PAYS PLAN PAYS YOU PAY

MEDICAL EXPENSES-IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT,***

such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic test, durable medical equipment

First $135 of Medicare-Approved Amounts* $0 $0
$135 (Part B Deductible)

Remainder of Medicare-Approved Amounts Generally 80% Generally 20% (or in the case of hospital outpatient department services, applicable copayments) $0**

Part B Excess Charges (Above Medicare-Approved Amounts) $0 $0 All costs

BLOOD***

First 3 pints $0 All costs $0**

Next $135 of Medicare-Approved Amounts* $0 $0 $135 (Part B Deductible)

Remainder of Medicare-Approved Amounts 80% 20% $0**

CLINICAL LABORATORY SERVICES-BLOOD TESTS FOR DIAGNOSTIC SERVICES

N/A 100% $0 $0**

PLAN H
PARTS A & B *Once you have been billed $131 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.
**$0 Indicates your liability for covered charges. You are responsible for all other non-covered charges.
***If you do not use a Network Provider, you are responsible for all charges not paid for by Medicare.

SERVICE TYPE MEDICARE PAYS PLAN PAYS YOU PAY

HOME HEALTH CARE MEDICARE-APPROVED SERVICES:

Medically necessary skilled care services and medical supplies

N/A 100% $0 $0**

DURABLE MEDICAL EQUIPMENT***

First $135 of Medicare-Approved Amounts* $0 $0 $135 (Part B Deductible)

Remainder of Medicare-Approved Amounts 80% 20% $0**

OTHER BENEFITS - NOT COVERED BY MEDICARE

Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA

First $250 each calendar year $0 $0 $250

Remainder of charges $0 80% to a lifetime maximum benefit of $50,000 20% and amounts over the $50,000 lifetime maximum

BASIC OUTPATIENT PRESCRIPTION DRUGS-NOT COVERED BY MEDICARE***

First $250 each calendar year $0 $0 $250

Next $2,500 each calendar year $0 50% of Prescription Drug charges, up to $1,250 each calendar year maximum benefit 50% of Prescription Drug charges

Over $2,500 each calendar year $0 $0 All costs

GENERAL LIMITATIONS AND EXCLUSIONS

This Health Plan does not cover any expenses of the type excluded by Medicare or not covered under the terms of this Health Plan. UTMB HP, INC. will pay full benefits under this Health Plan if you are treated by a Network Provider. If you incur Medicare Eligible Expenses for the services of a Non-network Provider, the Medicare program may provide coverage; however, no coverage will be provided under this Health Plan. Please see Provider Restrictions and Medicare Restrictions for details.

Provider Restrictions:

· The Health Plan does not restrict payment of benefits for Covered Services unless they are provided by a Non-network Provider, with certain exceptions noted below.

· Neither Part A nor Part B benefits under this Health Plan will be paid for either Hospital or Medical Services if those services are provided by a Non-network Provider.

These restrictions will not apply for Medicare Eligible Expenses if:

1. the services are for symptoms requiring Emergency Care or are immediately required for an unforeseen illness, injury, or a condition, and, it is not reasonable to obtain such services through a Network Provider; or

2. the services are not available through Network Providers.

Payment of benefits for Emergency Care or for services immediately required for an unforeseen illness or injury is conditioned on your obtaining Emergency Care or such services through Network Providers if it is reasonable to do so. You must notify UTMB HP, INC. within 48 hours or as soon as reasonably possible after you receive Emergency Care. Unless pre-approved by the Health Plan, the Health Plan does not cover follow-up or post-stabilization care provided by Non-network Providers. Services that are not available through Network Providers must be pre-authorized by the Health Plan before benefits will be paid under this Health Plan. Some Covered Services are subject to utilization management and pre-authorization. Network Providers and their locations are listed in the Provider Directory.

Medicare Restrictions:

Except as provided in the Schedule of Benefits, coverage does not include payment of benefits for any items that are not both Medicare Approved Amounts and Medicare Eligible Expenses. To the extent that Medicare copayments, deductibles, coinsurance, benefit periods, maximum benefits, or other such provisions vary from those specified in this Schedule of Benefits (such as for certain mental health services), Medicare provisions shall govern coverage under this Schedule of Benefits.

BASIC OUTPATIENT PRESCRIPTION DRUG BENEFITS, LIMITATIONS, AND EXCLUSIONS

DEFINITIONS

· Brand Name Drug - a single source, FDA approved drug manufactured by one company for which there is no FDA approved substitute available.

· Covered Drugs - drugs approved under federal law by the FDA for general use, and limited to the following:

Prescription Drugs prescribed by a Network Provider subject to the Coverage and limitations and exclusions listed in this Schedule of Benefits;
Compounded Prescription Drugs containing at least one Drug or Controlled Substance in an amount requiring a Prescription Order; or
Dietary formulas Medically Necessary for the treatment of heritable diseases.

· Drug Formulary - a listing of Prescription Drugs for which the Health Plan provides coverage, approves payment, or encourages or offers incentives for physicians to prescribe.

· Experimental or Investigational Drugs - pharmacological regimens not generally accepted by the American medical community or approved by the FDA.

· FDA -- the federal Food and Drug Administration.

· 50% Member Payment - the 50% of Basic Outpatient Prescription Drugs in the "You Pay" column in the Schedule of Benefits, which is paid by the Member, after the Member has paid the first $250 for Basic Outpatient Prescription Drugs each calendar year, and through a maximum calendar year benefit of $1,250.

· Generic Drug - pharmacological agents approved by the FDA as a bioequivalent substitute and manufactured by a number of different companies as a result of the expiration of the original patent.

· Non-Formulary Drug - a Prescription Drug that is not on Health Plan's approved Drug Formulary.

· Non-Network Pharmacy - a pharmacy which has not entered into a written agreement with UTMB HP, INC. or an agent of UTMB HP, INC. to render Covered Services to Members.

· Off Label Use - a drug prescribed for a non-FDA approved indication.

· Network Pharmacy - any registered, licensed pharmacy with whom UTMB HP, INC. or an agent of UTMB HP, INC. has contracted to dispense Prescription Drugs to Members and to accept as payment in full the UTMB HP, INC. payment plus the 50% Member Payment for Covered Drugs.

· Pharmacist - an individual duly licensed as a Pharmacist by the State Board of Pharmacy or other governing body having jurisdiction and who is employed by or associated with a pharmacy.

· Prescription Drug - a generic or brand drug described in this Schedule of Benefits and subject to the limitations and exclusions listed, which has been approved by the FDA for a specific use and which can, under federal or state law, be dispensed only pursuant to a Prescription Order and only by a licensed Pharmacist.

· Prescription Order or Refill - the authorization for a Prescription Drug, issued by a Physician who is duly licensed to make such an authorization in the ordinary course of that provider's professional practice.

Outpatient Prescription Drug Coverage

The following describes the Basic Outpatient Prescription Drug benefits of Medicare Select Plan H provided by Health Plan.

The Basic Outpatient Prescription Drug benefits shall be available for Covered Drugs dispensed pursuant to a Prescription Order written by a network provider for the out-of-Hospital use of the Member. Following are the benefits provided for Covered Drugs:

· Covered Drugs within the Drug Formulary (except as otherwise provided by law), furnished by a Network Pharmacy without charge to Member except for the 50% Member Payment for each Prescription Order or Refill (after Member has paid the first $250 for Prescription Drugs in each calendar year). Generically equivalent Prescription Drugs will be dispensed whenever applicable.

· Covered Drugs furnished by a Non-Network Pharmacy upon submission to Health Plan of acceptable proof of payment with a direct reimbursement form. Reimbursement for such Covered Drugs will not exceed one hundred percent (100%) of the actual charge less the 50% Member Payment. The Member will be entitled to reimbursement only if such purchase is part of Emergency Care that was rendered to the Member outside the Service Area. All claims for payment must be received by Health Plan or an agent of Health Plan within ninety (90) days of the date of proof of purchase. Direct reimbursement forms may be obtained by contacting 409-797-8064.

The Drug Formulary may change during the Member's Contract Year. Before removing a Prescription Drug from the Drug Formulary, Health Plan shall provide at least 90-days prior written notice to all Members and Network Providers affected by the change. The Heath Plan shall make a Prescription Drug that was approved or covered for a medical condition or mental illness available to each Member at the contracted benefit level until the Member's contract renewal date, regardless of whether the prescribed drug has been removed from the Health Plan's Drug Formulary. This section does not preclude a Physician or other health professional authorized to prescribe a drug from prescribing another drug covered by the Health Plan that is medically appropriate for the Member.

Basic Outpatient Prescription Drug Limitations and Exclusions

The following limitations apply to coverage under the Basic Outpatient Prescription Drug benefits:

1. A pharmacy need not dispense a Prescription Order which, in the Pharmacist's professional judgment, should not be filled without first consulting with the prescribing Physician.

2. The quantity of a Prescription Drug dispensed from a retail pharmacy pursuant to a Prescription Order or Refill is limited to sixty (60) consecutive days, two hundred and forty (240) units, or the maximum allowed dosage as prescribed by law, whichever is less.

3. Prescription Refills will be dispensed only if 50% of the previously dispensed quantity has been consumed based on the dosage prescribed.

4. Impotency drugs are limited to eight (8) unit doses per thirty (30) day supply.

5. Injectable migraine medications including, but not limited to, Imitrex are limited to nine (9) unit doses per thirty (30) day supply.

6. Members must present their Identification Card to the Pharmacist, and the existence of Prescription Drug coverage must be indicated on the card.

7. A Member shall pay to a Network Pharmacy:

One hundred percent (100%) of the cost for a Prescription Drug dispensed when the Member fails to show his or her Identification Card

The 50% Member Payment when the Member shows his or her Identification Card.

The following are excluded from coverage under the Basic Outpatient Prescription Drug benefits:

1. Certain Prescription Drugs and supplies may be subject to coverage under the Schedule of Benefits for Plan H but are not within the Coverage for Basic Outpatient Prescription Drug benefits. Items excluded from Basic Outpatient Prescription Drug benefits include:

· Durable medical equipment, even though such devices may require a Prescription Order, regardless of their intended use;

· Medication for a Member confined to a nursing home, Skilled Nursing Facility, sanitarium, extended care facility, hospital or similar entity;

· Any Prescription Drug which is administered at the time and place of the Prescription Order;

· Any charges for the administration of medications or injectable insulin;

· Fluids, solutions, nutrients, drugs, or medications (including all additives and chemotherapy) used or intended to be used by intravenous or gastrointestinal (internal) infusion or by intravenous injection in the home setting; and

· Drugs prescribed and administered in the Physician's office; including, but not limited to hormonal therapy

2. Drugs and medicines, formulas which do not by law require a Prescription Order (except injectable insulin and dietary formulas necessary for the treatment of heritable diseases).

3. Drugs, insulin, formulas, or covered devices, for which no valid Prescription Order is obtained.

4. Any drugs already covered under a provision of the Schedule of Benefits other than the Basic Outpatient Prescription Drug benefits.

5. Prescription Drugs covered without charge under federal, state or local programs including worker's compensation and occupational disease laws.

6. Medication furnished by any other medical service for which no charge is made to the Member.

7. Drugs dispensed by Non-Network Pharmacies, except as specified above.

8. Prescriptions written by a Non-Network Physician, except where written in conjunction with a non-network Emergency Room visit.

9. Prescription Refills resulting from loss or theft, or any unauthorized Refills.

10.Refills of any prescription in excess of the number of refills specified by the Network Provider or by law, or any drugs or medicines dispensed more than one year following the Prescription Order date.

11.Any services provided or items furnished for which the Network Pharmacy normally does not charge.

12.Drugs and medicine, the use or intended use of which would be illegal, unethical, imprudent, abusive, not Medically Necessary or otherwise improper.

13.Immunization agents, biological sera, blood or plasma and allergy serum.

14.Experimental Drugs or Investigational Drugs not approved by the FDA. Drugs and medicines required by law to be labeled: "Caution - Limited by Federal Law to Investigational Use," or experimental drugs, even though a charge is made for the drugs or medicines.

15.Off Label usage: Drugs and medicines which are not approved by the FDA for a particular indication or when used for a purpose other than the purpose for which FDA approval is given.

16.All newly FDA approved Prescription Drugs will be evaluated for a six (6) month period by UTMB HP, INC. before a determination is made to cover such Prescription Drugs.

17.Drugs and medicine used or intended to be used in the treatment of a condition, sickness, disease, injury, or bodily malfunction which is not covered under this Schedule of Benefits.

18.Injectible Hormonal therapy.

19.Drugs used for cosmetic purposes, including but not limited to, anabolic steroids, minoxidil lotion; Retin A and Accutane for Members over the age of 21.

20.All drugs used for the primary purpose of treating infertility or drugs for fertilization.

21.Vitamins (except those vitamins which by law require a Prescription Order and for which there is no non-prescription alternative).

22.Drugs and medicine prescribed and dispensed for the treatment of obesity or for use in any program of weight reduction, weight loss, or dietary control.

23.Drugs and medicine obtained by unauthorized, fraudulent, abusive, or improper use of a Member's Identification Card.

24.Non-Formulary Drugs except as provided by law.

***If you do not use a Network Provider, you are responsible for all charges not paid for by Medicare.