AdvantageOptimum Plan (HMO)

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This is an advertisement.

CARE1ST

AdvantageOptimum Plan (HMO)

P

-En ollm n Book 2014

ALAMEDA, SAN FRANCISCO

& SANTA CLARA COUNTIES

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CARE1ST

AdvantageOptimum Plan (HMO)

PRE-EnRollmEnT Book 2014

ALAMEDA, SAN FRANCISCO

& SANTA CLARA COUNTIES

H5928_14_119_MKB Accepted

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Care1st is a Medicare Advantage HMO plan with a Federal Government contract in Texas and California. Enrollment in Care1st Health Plan depends on contract renewal.

www.care1stmedicare.com

Care1st Healt Plan

601 Potrero Grande Dr. #200, Monterey Park, CA 91755

For enrollment inquiries lease all

1-800-847-1222,

8:00 a.m. to 8:00 p.m., 7 days a week

Hearing m aired ssistan e

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Thank you for Your

Interest in Care1st

Dear Medicare Beneficiary:

Thank you for considering one of Care1st Medicare Advantage Health Plans (HMO, HMO SNP) for your healthcare needs. Taking charge of your health is one of the many ways that you can control your health and healthcare options. The information enclosed will help you to explore the benefits of being a Care1st member.

Like most people, we know that you are looking for healthcare coverage that meets your needs and is affordable. With that in mind, we have designed our Medicare Advantage and Special Needs Plans around YOU! You will get more of the benefits you want and need to keep you healthy while maintaining your lifestyle.

By choosing Care1st, you’ll receive the benefits of a great company with proven leadership, integrity, and a dedicated staff that is ready to serve you. And, there’s more!

Care1st was created and is still run today by doctors. We believe our members’ needs come first. We focus on caring for the “whole you” so that you can live a healthier daily life. With over 10,000 physicians and 100 hospitals in our network, we’re certain that you will find the doctor that is right for you and your specific needs.

The information in this folder will help you to explore the benefits of being a Care1st member. As a guide, we encourage you to review the Summary of Benefits as it provides detailed coverage that our plans offer. Are you ready to enroll? Simply complete the Individual Enrollment Form and return it to Care1st.

Choosing healthcare coverage is a big decision and can be confusing. We are happy to help answer any questions you may have. Don’t hesitate to call. No question is too big or too small. “Yes, it is all about you”.

If you’re ready to enroll, simply complete the Individual Enrollment Form and return it to Care1st or you can call us and we can help you enroll telephonically.

Marketing Department

1-800-847-1222 (TTY/TDD users call 711) 8:00 a.m. to 8:00 p.m., seven days a week

We look forward to welcoming you to the Care1st family.

Dawn Maroney

Chief Medicare Officer

Care1st Health Plan • 601 Potrero Grande Drive, Monterey Park, CA 91755

Care1st is a Medicare Advantage HMO plan with a Federal Government contract in Texas and California. Enrollment in Care1st Health Plan depends on contract renewal. H5928_14_042_MK Accepted

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Care1st Medicare Advantage Plan - H5928 CY 2013 Medicare Plan Ratings

The Medicare Program rates all health and prescription drug plans each year, based on a plan’s quality and performance. Medicare Plan Ratings help you know how good a job our plan is doing. You can use this Plan Rating to compare our plan’s performance to other plans. Examples of the areas covered by this rating include:

How our members rate our plan’s services and care;

How well our doctors detect illnesses and keep members healthy;

How well our plan helps our members use recommended and safe prescription medications For 2013, Care1st Medicare Advantage Plan received the following overall Plan Rating from Medicare.



3.5 Stars The number of stars shows how well our plan performs.



excellent



above average



average



below average



poor

Learn more about our plan and how we are different from other plans at www.medicare.gov. You may also contact us Sunday, Monday, Tuesday, Wednesday, Thursday, Friday, Saturday, 8:00 a.m. - 8:00 p.m. Pacific at 800-847-1222 (toll-free) or 800-735-2929 (TTY/TDD). Current members please call 800-544-0088 (toll-free) or 800-735-2929 (TTY/TDD).

H5928_13_039_MK Accepted •

• •

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Service AreAS

HMO & HMO SNP

Alameda (Partial) Los Angeles Orange (Partial) San Bernardino (Partial) San Diego San Francisco Santa Clara

CALiFORNiA

HMO Plan Only

El Paso

TEXAS

Fresno (Partial) Kern (Partial) Riverside (Partial) San Joaquin Stanislaus

Call Member Services for

questions or benefit information:

1-800-544-0088

TTY/TDD users call 711

8:00 a.m. to 8:00 p.m., seven days a week

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Service AreA ZiP codeS

CALIFORNIA

Alameda County

94501; 94502; 94601; 94602; 94603; 94604; 94605; 94606; 94607; 94608; 94609; 94610; 94611; 94612; 94613; 94614; 94617; 94618; 94619; 94620; 94621; 94623; 94624; 94661; 94662; 94701; 94702; 94703; 94704; 94705; 94706; 94707; 94708; 94709; 94710; 94712; 94720

Fresno County

93242; 93606; 93609; 93611; 93612; 93613; 93616; 93619; 93625; 93626; 93630; 93648; 93650; 93652; 93657; 93662; 93667; 93701; 93702; 93703; 93704; 93705; 93706; 93707; 93708; 93709; 93710; 93711; 93712; 93714; 93715; 93716; 93717; 93718; 93720; 93721; 93722; 93723; 93724; 93725; 93726; 93727; 93728; 93729; 93730; 93737; 93740; 93744; 93745; 93747; 93750; 93755; 93761; 93765; 93771; 93772; 93773; 93774; 93775; 93776; 93777; 93778; 93779; 93786; 93790; 93791; 93792; 93793; 93794

Kern County

93203; 93206; 93220; 93241; 93250; 93263; 93276; 93280; 93301; 93302; 93303; 93304; 93305; 93306; 93307; 93308; 93309; 93311; 93312; 93313; 93314; 93380; 93383; 93384; 93385; 93386; 93387; 93388; 93389; 93390

Los Angeles County

All ZIP Codes

Orange County

90620; 90621; 90622; 90623; 90624; 90630; 90631; 90632; 90633; 90638; 90680; 90720; 90740; 90742; 90743; 92609; 92610; 92617; 92619; 92620; 92626; 92637; 92646; 92647; 92648; 92649; 92655; 92657; 92673; 92683; 92685; 92694; 92697; 92698; 92701; 92702; 92703; 92704; 92705; 92706; 92707; 92708; 92725; 92735; 92801; 92802; 92803; 92804; 92805; 92806; 92807; 92808; 92809; 92812; 92814; 92815; 92816; 92817; 92821; 92822; 92823; 92825; 92831; 92832; 92833; 92834; 92835; 92836; 92837; 92838; 92840; 92841; 92842; 92843; 92844; 92845; 92846; 92850; 92868; 92870; 92871; 92885; 92886; 92887; 92899

Riverside

91718, 91719, 91720, 91752, 91760, 92028, 92201, 92202, 92203, 92210, 92211, 92220, 92223, 92230, 92234, 92235, 92236, 92240, 92241, 92247, 92248, 92253, 92254, 92255, 92258, 92260, 92261, 92262, 92263, 92264, 92270, 92274, 92276, 92282, 92292, 92320, 92324, 92373, 92399, 92501, 92502, 92503, 92504, 92505, 92506, 92507, 92508, 92509, 92513, 92514, 92515, 92516, 92517, 92518, 92519, 92521, 92522, 92530, 92531, 92532, 92536, 92539, 92543, 92544, 92545, 92546, 92548, 92549, 92551, 92552, 92553, 92554, 92555, 92556, 92557, 92561, 92562, 92563, 92564, 92567, 92570, 92571, 92572, 92581, 92582, 92583, 92584, 92585, 92586, 92587, 92589, 92590, 92591, 92592, 92593, 92595, 92596, 92599, 92860, 92877, 92878, 92879, 92880, 92881, 92882, 92883

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San Bernardino:

91701, 91708, 91709, 91710, 91730, 91737, 91739, 91761, 91762, 91763, 91764, 91784, 91786, 92301, 92307, 92308, 92313, 92316, 92318, 92324, 92334, 92335, 92336, 92337, 92344, 92345, 92346, 92350, 92354, 92357, 92359, 92368, 92369, 92371, 92373, 92374, 92376, 92377, 92392, 92394, 92395, 92399, 92401, 92402, 92403, 92404, 92405, 92406, 92407, 92408, 92410, 92411, 92412, 92413, 92414, 92415, 92418, 92420, 92423, 92424, 92427

San Diego County

All ZIP Codes

San Francisco County

All ZIP Codes

San Joaquin

County

All ZIP Codes

Santa Clara County

All ZIP Codes

Stanislaus County

All ZIP Codes

TEXAS

El Paso County

All ZIP Codes

Care1st is a Medicare Advantage HMO plan with a Federal Government contract in Texas and California. Enrollment in Care1st Health Plan depends on contract renewal. This information is available for free in other languages. Please contact Member Services: 1-800-544-0088 (TTY: 711), 8:00 a.m. to 8:00 p.m., seven days a week. Esta información está disponible gratuitamente en otros idiomas. Comuníquese con Servicios para los Miembros: 1-800-544-0088 (TTY 711), de 8:00 a.m. a 8:00 p.m., los siete días de la semana.

請聯絡會員服務熱線電話：1-800-544-0088聽障和語障人士可致電 711。我們的辦公時間為每週七天，早上8:00點至晚上

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Do You Have

MeDicare Questions?

Care1st (HMO, HMO sNP) Has aNswers.

What are the different parts of

Medicare A, B, C and D?

Medicare Part A covers inpatient hospital care, skilled nursing facility, home healthcare and hospice care.

Medicare Part B covers outpatient care, such as doctor’s office visits, specialist’s office visits, lab services, durable medical equipment and preventive services. You pay a Part B premium each month.

Medicare Part C are Medicare Advantage plans which are approved by Medicare and offered by private companies. Medicare Advantage Plans provide all of your Part A and Part B coverage. Medicare Advantage plans may offer extra coverage, such as vision, hearing, dental and/or health and wellness programs.

Medicare Part D is your prescription drug coverage. To get prescription drug coverage you must join a plan such as Care1st. Each plan can vary in cost and drugs covered.

How do I join Care1st

Medicare Advantage Plans?

Call Care1st at 1-800-847-1222 and a representative can assist you right over the phone. (TTY) 711. Seven days a week, 8:00 a.m. to 8:00 p.m. PST.

Can I obtain specialty services?

When you need specialty care or additional services your PCP cannot provide, he or she will give you a referral. There are certain services which you can get on your own, without a referral, as long as you get them from a network provider.

What should I do if I’m out of

Care1st’s coverage area and

need emergency services?

Care1st provides worldwide emergency coverage. If you have an emergency when you are not in our service area, you can obtain emergency services at the nearest emergency facility (doctor’s office, clinic or hospital). Emergency services do not require a referral or an okay from your PCP doctor.

Can I obtain care after

normal business hours?

It is important you always carry your Care1st ID card with you. If you think that you have an emergency, call 911 or go to the nearest emergency room. Call your doctor if you need medical care, and he or she can help you arrange care. Care1st also offers a Nurse Advice Line. The call is free and easy. You get advice right away. A nurse will ask about your health problem. You do not have to call the Nurse Advice Line before getting healthcare.

What if I’m a Medicare member

with Care1st and also have

Medicaid benefits elsewhere?

If you are a Medicaid member and eligible for Medicare, then it is important to know that Medicare, not Medicaid is your primary insurance. If you are interested in

combining your benefits, please call Member Services for more information on the additional benefits available.

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How is my private health

information protected?

There are federal and state laws that protect the privacy of your medical records and personal health information. We protect your personal health information under these laws. Any personal health information that you give us when you enroll is protected. We will make sure that unauthorized people don’t see or change your records.

What benefits and services are

not covered?

Care1st plans cover all of the medically-necessary services that are covered by Medicare Part A and Part B. The following items and services aren’t covered under the Original Medicare Plan or by our plans:

Services that aren’t reasonable and necessary, according to the standards of the Original Medicare Plan, unless these services are otherwise listed by our Plan as a covered service

Experimental or investigational medical and surgical procedures, equipment and medications, unless covered by the Original Medicare Plan or unless, for certain services, the procedures are covered under an approved clinical trial

Surgical treatment of morbid obesity unless

medically necessary and covered under the Original Medicare plan

Private room in a hospital, unless medically necessary Private duty nurses

Personal convenience items, such as a telephone or television in your room at a hospital or skilled nursing facility

Nursing care on a full-time basis in your home

Custodial care unless it is provided in conjunction with covered skilled nursing care and/or skilled rehabilitation services. This includes care that helps people with activities of daily living like walking, getting in and out of bed, bathing, dressing, eating and using the bathroom, preparation of special diets, and supervision

of medication that is usually self-administered Homemaker services

Charges imposed by immediate relatives or members of your household

Elective or voluntary enhancement procedures, services, supplies and medications including but not limited to: Weight loss, hair growth, sexual performance, athletic performance, cosmetic purposes, anti-aging and mental performance unless medically necessary

Cosmetic surgery or procedures, unless needed because of accidental injury or to improve the function of a malformed part of the body. All stages of reconstruction are covered for a breast after a mastectomy, as well as for the unaffected breast to produce a symmetrical appearance

Chiropractic care is generally not covered, (with the exception of manual manipulation of the spine), and is limited according to Medicare guidelines

Orthopedic shoes unless they are part of a leg brace and are included in the cost of the brace. Exception: Therapeutic shoes are covered for people with diabetic foot disease

Supportive devices for the feet. Exception: Orthopedic or therapeutic shoes are covered for people with diabetic foot disease

Radial keratotomy, LASIK surgery, vision therapy and other low vision aids and services

Self-administered prescription medication for the treatment of sexual dysfunction, including erectile dysfunction, impotence, and anorgasmy or hyporgasmy Reversal of sterilization procedures, sex change

operations, and non-prescription contraceptive supplies and devices

Naturopath services

Non-emergency services provided to veterans in Veterans Affairs (VA) facilities. However, in the case of emergency services received at a VA hospital, if the VA cost-sharing is more than the cost-sharing required under our Plan, we will reimburse veterans for the difference. Members are still responsible for our Plan cost-sharing amount

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Any of the services listed above that aren’t covered will remain not covered even if received at an emergency facility. For example, non-authorized, routine conditions that do not appear to a reasonable person to be based on a medical emergency are not covered if received at an emergency facility

How can I assign a representative

to act in my behalf?

You have the right to ask someone such as a family member or friend to help you with decisions about your healthcare. If you want to, you can use a special form to give someone the legal authority to make decisions for you if you ever become unable to make decisions for yourself. If you want to have an advance directive, you can get a form from your lawyer, from a social worker or from some office supply stores, or from other sources including the internet and advocacy groups. If you only wish to give the authority to represent you in dealings with Care1st for enrollment, claims and other administrative matters, you can visit our website www.Care1stMedicare.com download and complete the “Appointment of Representative”. Please note that copies of an advance directive, Appointment of Representative, or similar documents must be sent to Care1st to be effective for Care1st purposes.

What can I do if I move out of

your service area?

If you move out of the service area or are away from the service area for more than six months, you cannot remain a member of our Plan. Please call Member Services to find out if the place you are moving to or traveling to is in our Plan’s service area.

A Medicare approved HMO plan

Call Member Services for

questions or benefit information:

1-800-544-0088

TTY/TDD users call 711

8:00 a.m. to 8:00 p.m., seven days a week

www.care1stmedicare.com

facebook/mycare1st

Care1st is a Medicare Advantage HMO plan with a Federal Government contract in Texas and California. Enrollment in Care1st Health Plan depends on contract renewal. The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Benefits and/or co-payments/co-insurance may change on January 1 of each year. Limitations, co-payments, and restrictions may apply. This information is available for free in other languages. Please contact Member Services: 1-800-544-0088 (TTY: 711), 8:00 a.m. to 8:00 p.m., seven days a week. Esta información está disponible gratuitamente en otros idiomas. Comuníquese con Servicios para los Miembros: 1-800-544-0088 (TTY 711), de 8:00 a.m. a 8:00 p.m., los siete días de la

semana. 請聯絡會員服務熱線電話：1-800-544-0088聽障和語障人士可致電 711。我們的辦公時間為每週七天，早

上8:00點至晚上8:00點。

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BENEFIT ALAMEDA/SAN FRANCISCO SANTA CLARA

Premium $28* $0* Primary Care Physician (PCP) $0 copay $0 copay

Physician Specialist $10 copay $5 copay

Inpatient Hospitalization $100 copay days 1 - 5; $50 copay days 1 - 3; $0 copay days 6- 90; $0 copay days 4- 90;

unlimited additional days unlimited additional days

Emergency Care $50 copay $50 copay

(Waived if admitted) (Waived if admitted) Worldwide coverage up to Worldwide coverage up to $25,000 per year $25,000 per year

Ambulance $125 copay $155 copay

(Waived if admitted) (Waived if admitted)

Durable Medical Equipment 20% coinsurance $0 copay Medicare Covered

(DME) item; 20% coinsurance

non-Medicare covered item Health Club / $0 copay / unlimited No benefit

Fitness Classes Membership

Transportation $0 copay $0 copay

48 one-way trips to plan 48 one-way trips to plan approved locations approved locations

2014

BENEFITS

CHART

AdvantageOptimum Plan (HMO)

H5928_14_080_MKB Accepted *Part D Premium Disclaimer: Depending on your level of Medicaid eligibility, you may not have any cost-sharing

responsibility for your part D premium.

Hearing Aid $10 copay Medicare covered $10 copay Medicare covered benefits / $0 copay for (2) benefits / $0 copay for (2)

hearing aids every two years; hearing aids every two years; $500 limit every year $500 limit every year

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2014

BENEFITS

CHART

AdvantageOptimum Plan (HMO)

BENEFIT

Preferred Generic Drugs, T1 $0 copay

Non-Preferred Generic Drugs, T2 $5 copay 1 mo supply; $10 copay 3 mo supply Preferred Brand Drugs, T3 $30 copay 1 mo supply;

$60 copay 3 mo supply Non-Preferred Brand Drugs, T4 $50 copay 1 mo supply;

$100 copay 3 mo supply Specialty Tier Drugs, T5 30% coinsurance Initial Coverage Limit After $2,850 (Tiers 1 & 2)

$0 copay $5 copay 1 mo supply; $10 copay 3 mo supply $30 copay 1 mo supply; $60 copay 3 mo supply $50 copay 1 mo supply; $100 copay 3 mo supply 30% coinsurance After $2,850 (Tiers 1 & 2)

ALAMEDA/SAN FRANCISCO SANTA CLARA

Eye Exam Routine $5 copay routine eye exams $5 copay routine eye exams

(1 every year) (1 every year)

Eyewear $0 copay - $150 limit for glasses $0 copay - $150 limit for glasses every 2 years / refraction test every 2 years / refraction test covered covered

Out-of-Pocket Limit $3400 (In-Network Medicare- $3400 (In-Network Medicare-covered benefits) covered benefits)

Dental Services Covered Covered

Refer to your Summary of Refer to your Summary of Benefits for details Benefits for details

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Care1st is a Medicare Advantage HMO plan with a Federal Government and State Medicaid contract in Arizona and California. Enrollment in Care1st Health Plan depends on contract renewal. The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Benefits, formulary, pharmacy network, premium and/ or co-payments/co-insurance may change on January 1 of each year. Limitations, copayments, and restrictions may apply. You must continue to pay your Medicare Part B premium. This information is available for free in other languages. Please contact Member Services: 1-800-544-0088 (TTY 711), 8am – 8pm, 7 days a week. Esta información está disponible gratuitamente en otros idiomas. Comuníquese con Servicios para los Miembros: 1-800-544-0088 (TTY 711), de 8:00 a.m. a 8:00 p.m., los siete días de la semana. 請聯絡會員服務熱線電話： 1-800-544-0088﹝聽障和語障人士可致電 711﹞。我們的辦公時間為每週七天，早上8:00點至晚上8:00點。Thông tin này cũng được trình bày bằng những ngôn ngữ

khác và cung cấp miễn phí cho hội viên. Vui lòng liên lạc với ban Dịch vụ Hội viên: 1-800-544-0088 (người dùng TTY xin gọi số 1-800-735-2929), 8 giờ sáng–8 giờ tối, 7 ngày trong tuần.

If you have questions about

becoming a Care1st member, call:

1-800-847-1222

TTY/TDD users call 711

www.care1stmedicare.com

/mycare1st

2014

BENEFITS

CHART

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Nurse

Advice

HoTliNe

The Care1st (HMO, HMO SNP) Nurse Advice Line

is a service available to all Care1st members.

The call is free and easy.

A caring nurse will listen

to your health problem.

The nurse can help you decide:

If you need to see the doctor.

If it is safe to wait or if you

need care right away.

What to do if your symptoms

get worse.

What you can start doing at

home to feel better.

For life- or limb-threatening emergencies,

always call 911 or your local emergency

services. You do not have to call the Nurse

Advice Line before getting healthcare.

Call the Care1st Nurse Advice Line at:

1-800-544-0088

TTY/TDD users call 711

8:00 a.m. to 8:00 p.m., seven days a week

www.care1stmedicare.com

facebook/mycare1st

Care1st is a Medicare Advantage HMO plan with a Federal Government contract in Texas and California. Enrollment in Care1st Health Plan depends on contract renewal. The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Benefits and/or co-payments/co-insurance may change on January 1 of each year. Limitations, copayments, and restrictions may apply. This information is available for free in other languages. Please contact Member Services: 1-800-544-0088 (TTY: 711), 8:00 a.m. to 8:00 p.m., seven days a week. Esta información está disponible gratuitamente en otros idiomas. Comuníquese con Servicios para los Miembros: 1-800-544-0088 (TTY 711), de 8:00 a.m. a 8:00 p.m., los siete días de la semana.請聯絡會員服務熱線電話：1-800-544-0088聽障和語障人士可致電 711。我們的辦公時間為每週七天，早上8:00點至晚上 8:00點。

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TransporTaTion

services

$

0

copay for each round trip to

plan-approved locations.*

Care1st (HMO, HMO SNP) is proud to offer transportation

services to our members. Transportation is provided as

needed for non-emergency healthcare visits.

Note: Call Care1st to reserve your ride. Reservations must be made at*

least 24 hours in advance.

Call to reserve your ride:

1-87-RIDEC1ST (1-877-433-2178)

TTY/TDD uSERS Call 711

8:00 a.m. to 8:00 p.m., seven days a week

www.care1stmedicare.com

facebook/mycare1st

Care1st is a Medicare Advantage HMO plan with a Federal Government contract in Texas and California. Enrollment in Care1st Health Plan depends on contract renewal. The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Benefits and/or co-payments/co-insurance may change on January 1 of each year. Limitations, copayments, and restrictions may apply. The number of approved round trips vary by plan and market. Transportation not available in San Diego or San Joaquin counties. This information is available for free in other languages. Please contact Member Services: 1-800-544-0088 (TTY: 711), 8:00 a.m. to 8:00 p.m., seven days a week. Esta información está disponible gratuitamente en otros idiomas. Comuníquese con Servicios para los Miembros: 1-800-544-0088 (TTY 711), de 8:00 a.m. a 8:00 p.m., los siete días de la semana. 請聯絡會員服務熱線電話：1-800-544-0088聽障和語障人士可致電 711。我們的辦公時間為每週七天，早上8:00點至晚上8:00點。

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HealtHways

silversneakers

®

Fitness Program

Get more benefits by being a Care1st

(HMO, HMO SNP) Medicare Member!

Here’s your opportunity to get

fit with the SilverSneakers

®

Fitness Program.

SilverSneakers

®

_includes:

Free membership at a fitness

center in your area.

Group exercise classes designed to

increase strength, flexibility, and energy.

Personalized, friendly service from your

advisor at the fitness center.

For more information, you can visit

SilverSneakers.com. (Please check with your

physician before starting a fitness program.)

For questions about Care1st

Fitness Center Benefit call:

1-800-544-0088

TTY/TDD users call 711

8:00 a.m. to 8:00 p.m., seven days a week

www.care1stmedicare.com

facebook/mycare1st

Care1st is a Medicare Advantage HMO plan with a Federal Government contract in Texas and California. Enrollment in Care1st Health Plan depends on contract renewal. The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Benefits and/or co-payments/co-insurance may change on January 1 of each year. Limitations, copayments, and restrictions may apply. Availability varies by plan and market. Not available in Santa Clara county. Fitness center listing is subject to change and may vary depending on location, change in centers, and geographic service areas served. Additional services outside of the basic fitness center membership, such as personal trainers, special classes, sports participation, massage therapy, etc., are not part of the Care1st benefit and may require additional out-of-pocket costs. This information is available for free in other languages. Please contact Member Services: 1-800-544-0088 (TTY: 711), 8:00 a.m. to 8:00 p.m., seven days a week. Esta información está disponible gratuitamente en otros idiomas. Comuníquese con Servicios para los Miembros: 1-800-544-0088 (TTY 711), de 8:00 a.m. a 8:00 p.m., los siete días de la semana. 請聯絡會員服務熱線電話：1-800-544-0088﹝聽障和語障人士可致電 711﹞。我們的辦公時間為每週七天，早上8:00點至晚上8:00點。 H5928_14_051_MK Accepted

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Understanding Medicare

enrollMent Periods

Annual Election Period Oct 15 - Dec 7

2013

Medicare Advantage Disenrollment Period Jan 1 - Feb 14

2014

Lock-In Period Feb 14 - Oct 14

Special Election Period and Initial Coverage Election Period, for those that qualify, is open all year. Open Enrollment Period for Institutionalized Individuals is open all year.

There are different types of enrollment periods throughout the year

when individuals may enroll or make changes to their Medicare plan.

ANNUAL ELECTION PERIOD

(AEP)

Available October 15th through December 7th

During this time you may join, drop or switch to the Medicare Advantage plan that is best for you.

MEDICARE ADVANTAGE

DISENROLLMENT PERIOD

(MADP)

Available January 1st through February 14th

During this period if you have a Medicare Advantage plan you can leave your plan and return to Original Medicare. If you make the choice to switch to Original Medicare, you have until February 14th to sign up for a prescription drug plan.

During the Disenrollment Period you cannot switch from Original Medicare to a Medicare Advantage plan or switch from one Medicare Advantage plan to another.

H5928_14_047_MK Accepted oct | noV | dec | Jan | FeB | Mar | aPr | MaY | JUn | JUl | aUg | seP | oct

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Understanding Medicare

enrollMent Periods

LOCK IN PERIOD

February 14th through October 14th

During this time you cannot make changes to your Medicare plan unless you meet the requirements for the Special Election Period or Open Enrollment for Institutionalized Individuals.

SPECIAL ELECTION PERIOD

(SEP)

Available all year to qualifying individuals

During this time you may join, drop or switch your Medicare Advantage plan if you move out of the plan’s service area, lose your employer or union coverage, you enroll in a PACE program or have a chronic condition that allows you to enroll in a Special Needs Plan designed to specifically treat individuals with your condition.

INITIAL COVERAGE ELECTION

PERIOD

(ICEP)

This election period revolves around an individual’s 65th birthday or the 25th month of disability. It is associated to one’s entitlement to both Medicare Part A, B and D. This period begins three months before the individual’s first entitlement to both Medicare Part A, B and D and ends on the later of: 1. The last day of the month preceding entitlement to both Part A, B and D, or; 2. The last day of the individual’s Part B initial enrollment period.

OPEN ENROLLMENT PERIOD

FOR INSTITUTIONALIZED

INDIVIDUALS

(OEPI)

If you are institutionalized and need to enroll in or disenroll from a Medicare Advantage Special Needs Plan for institutionalized individuals.

Call Member Services

for questions or benefit information:

1-800-544-0088

(TTY/TDD users call 711)

www.care1stmedicare.com

facebook/mycare1st

Care1st is a Medicare Advantage HMO plan with a Federal Government contract in Texas and California. Enrollment in Care1st Health Plan depends on contract renewal. This information is available for free in other languages. Please contact Member Services: 1-800-544-0088 (TTY: 711), 8:00 a.m. to 8:00 p.m., seven days a week. Esta información está disponible gratuitamente en otros idiomas. Comuníquese con Servicios para los Miembros: 1-800-544-0088 (TTY 711), de 8:00 a.m. a 8:00 p.m., los siete días de la semana. 請聯絡會員服務熱線電話: 1-800-544-0088聽障和語障人士可致電 711。我們的辦公時間為每週七天，早上8:00點至晚上

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Are You reAdY

To enroll?

StepS to take to get

yourSelf ready to enroll

Pick Your PCP

Pick your Primary Care Physician (PCP). Use our Provider Directory, or visit us online at www.Care1stMedicare.com or call us for a list of PCPs near you.

Review Rx Index

Take a moment to review our drug index provided to ensure that your medications are covered. Or visit our website to review our drug formulary or call us for verification of our drug listing.

Locate Medicare ID Card

When you are applying, make sure to have your Medicare ID card available, or some form of proof that you are entitled to Medicare.

How to apply

Apply by Phone

Call Care1st at 1-800-847-1222 (TTY/TDD users call 711) 8:00 a.m. to 8:00 p.m., seven days a week

Apply in Person

Meet with your local Care1st representative.

Apply by Mail

Fill out the enclosed application form completely and mail to:

Care1st Health Plan

ATTN: ENROLLMENT DEPT 601 Potrero Grande Drive Monterey Park, CA 91755

Apply Online

Medicare beneficiaries may also enroll in Care1st through the CMS Medicare Online Enrollment Center located at http://www.medicare.gov

If you have questions about

becoming a Care1st member, call:

1-800-544-0088

(TTY/TDD users call 711)

8:00 a.m. to 8:00 p.m., seven days a week www.care1stmedicare.com

facebook/mycare1st

Care1st is a Medicare Advantage HMO plan with a Federal Government contract in Texas and California. Enrollment in Care1st Health Plan depends on contract renewal. This information is available for free in other languages. Please contact Member Services: 1-800-544-0088 (TTY: 711), 8:00 a.m. to 8:00 p.m., seven days a week. Esta información está disponible gratuitamente en otros idiomas. Comuníquese con Servicios para los Miembros: 1-800-544-0088 (TTY 711), de 8:00 a.m. a 8:00 p.m., los siete días de la semana. 請聯絡會員服務熱線電話: 1-800-544-0088聽障和語障人士可致電 711。我們的辦公時間為每週七天，早上8:00點至晚上

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MEDICARE ADVANTAGE

INDIVIDUAL ENROLLMENT ELECTION FORM

Step 1: Please fill out the application completely.

Use a ballpoint pen and press hard to make two copies. Step 2: Sign and date the last page of the application.

Step 3: Keep the bottom yellow copy for your file.

If you have any questions regarding this application, please call:

Marketing Department: 1-800-847-1222

(TTY 711)

Hours: 8:00 a.m. to 8:00 p.m.

Seven days a week

Care1st Health Plan

P. O. Box 4549

Montebello, CA 90640

www.care1stmedicare.com

Member Services: 1-800-544-0088

(TTY 711)

Hours: 8:00 a.m. to 8:00 p.m.

Seven days a week

WHITE – Enrollment Copy YELLOW – Member’s Copy

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MEDICARE ADVANTAGE INDIVIDUAL

ENROLLMENT ELECTION FORM

Please contact Care1st if you need information in another language or format (Braille).

To Enroll in Care1st, Please Provide the Following Information: Care1st AdvantageOptimum Plan (HMO)

£ Los Angeles/Orange $0/month £ San Joaquin $0/month

£ Stanislaus $0/month

£ San Bernardino/Riverside/ Fresno $0/month

£ San Diego $0/month

£ Santa Clara $0/month

£ El Paso $0/month

£ San Francisco/Alameda $28/month

✔

Care1st TotalDual Plan (HMO SNP)

This plan is designed for people who meet specific enrollment criteria. You may be eligible to join this plan if you receive assistance from the state.

£ San Diego $26.90/month* £ Los Angeles $20.70/month* £ Alameda/San Francisco/

Santa Clara $28.10/month* £ Orange/San Bernardino $21.80/month*

smartHMO Plan

Beneficiaries selecting this plan are exclusively enrolled with the AllCare network of providers.

£ San Joaquin $0/month

Coordinated Choice Plan (HMO)

£ Los Angeles, Orange, San Diego, $26.30/month* San Bernardino, Riverside, Santa Clara,

Stanislaus, Alameda, San Francisco,

Fresno, El Paso *Premiums may vary based on the level of Extra Help you receive. Please contact the plan for further details.

LAST Name: FIRST Name_Doe : Middle Initial: _Joh_n _R. £ Mr. £ Mrs. £ Ms. Birth Date:

03 23 1 9 4 5

( / / )

( M M / D D / Y Y Y Y )

Sex:

£ M £ F _{555 555-5555}Home Phone:( ) _{555 777-7777}Alternate Phone Number:( ) Permanent Residence Street Address (P.O. Box is not allowed): 222 Anywhere St.

City: _{Any Town}

Jane Doe

State:_CA ZIP Code: ₉₃₅₁₀ County: _Stanislaus

Mailing Address (only if different from your Permanent Residence Address):

Street Address: City: State: ZIP Code:

Emergency contact: _____________________________________________________________________________ Phone Number: _________________________ Relationship to You: _555-555-5555 _______________________________________Wife E-mail Address: [email protected]

Please Provide Your Medicare Insurance Information.

Please take out your Medicare card to complete this section.

• Please fill in these blanks so they match your red,

white and blue Medicare card. - OR -

• Attach a copy of your Medicare card or your letter

from Social Security or Railroad Retirement Board. You must have Medicare Part A and Part B to join a Medicare Advantage plan.

H5928_14_088_EN Approved

SAMPLE ONLY Name:John R. Doe

Medicare Claim Number 4 4 4 4 4 4 4 4 4 4

Sex M

Is Entitled To

HOSPITAL (Part A) MM-DD-YYYY MEDICAL (Part B)

Effective Date

✔

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___________________________ ____________________________

✔

_________________________________________________

Paying Your Plan Premium

You can pay your monthly plan premium (including any late enrollment penalty that you currently have or may owe) by mail each month. You can also choose to pay your premium by automatic deduction from your Social Security or Railroad Retirement Board (RRB) benefit check each month. If you are assessed a Part-D-Income related Monthly Adjustment Amount, you will be notified by the Social Security Administration. You will be responsible for paying this extra amount in addition to your plan premium. You will either have the amount withheld from your Social Security benefit check or be billed directly by Medicare or the RRB. DO NOT pay Care1st the Part D-IRMAA.

People with limited incomes may qualify for extra help to pay for their prescription drug costs. If eligible, Medicare could pay for 75% or more of your drug costs including monthly prescription drug premiums, annual deductibles, and co-insurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don’t even know it. For more information about this extra help, contact your local Social Security office, or call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778.

You can also apply for extra help online at www.socialsecurity.gov/prescriptionhelp.

If you qualify for extra help with your Medicare prescription drug coverage costs, Medicare will pay all or part of your plan premium. If Medicare pays only a portion of this premium, we will bill you for the amount that Medicare doesn’t cover.

If you don’t select a payment option, you will get a coupon book.

Please select a premium payment option:

£ Get a coupon book.

£ Automatic deduction from your monthly Social Security or Railroad Retirement Board (RRB) benefit check. (The Social Security/RRB deduction may take two or more months to begin after Social Security or RRB approves the deduction. In most cases, if Social Security or RRB accepts your request for automatic deduction, the first deduction from your Social Security or RRB benefit check will include all premiums due from your enrollment effective date up to the point withholding begins. If Social Security or RRB does not approve your request for automatic deduction, we will send you a paper bill for your monthly premiums.)

Please read and answer these important questions.

1. Do you have End-Stage Renal Disease (ESRD)? £ Yes £ No If you have had a successful kidney transplant and/or you don’t need regular dialysis any more, please attach a note or

records from your doctor showing you have had a successful kidney transplant or you don’t need dialysis, otherwise we may need to contact you to obtain additional information.

✔

___________________________ ________________________ _ ___________________________ ________________________

2. Some individuals may have other medical or drug coverage, including work, other private insurance, TRICARE, Federal employee health benefits coverage, VA benefits, or State pharmaceutical assistance programs.

Will you have other medical or prescription drug coverage in addition to Care1st? £ Yes £ No If “yes”, please list your other coverage and your identification (ID) number(s) for this coverage:

Name of other medical coverage: ID# for this medical coverage: Group# for this medical coverage: Name of other drug coverage: ID# for this drug coverage: Group# for this drug coverage:

_______________________________ 3. Are you a resident in a long-term care facility, such as a nursing home? £ Yes £ No If “yes”, please provide the following information: Name of Institution: Address and Phone Number of Institution (number and street): _____________________________________ 4. Are you enrolled in your State Medicaid program? £ Yes £ No If yes, please provide your Medicaid number:

5. Do you or your spouse work? £ Yes £ No

Please choose the name of a Primary Care Physician (PCP), clinic or health center:

Physician’s Name

Dr. Robert Jones

ID Number

55555

Medical Group / IPA Name

Misc. Medical Group

Are you an existing patient of this doctor? £

✔

Yes £ No WHITE – Enrollment Copy YELLOW – Member’s Copy

H5928_14_088_EN Approved

✔

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Please check one of the boxes below if you would prefer us to send you information in a language other than English or in another format: £ Spanish £ Chinese £ Vietnamese

Contact us if you need a format like Braille, audiotape or large print.

Please contact Care1st at 1-800-544-0088 if you need information in another format or language than what is listed above. Our office hours are from 8:00 a.m. to 8:00 p.m. seven days a week. TTY users should call 711.

Please Read This Important Information

If you currently have health coverage from an employer or union, joining Care1st could affect your employer or union health benefits. You could lose your employer or union health coverage if you join Care1st. Read the communications your

employer or union sends you. If you have questions, visit their website, or contact the office listed in their communications. If there isn’t any information on whom to contact, your benefits administrator or the office that answers questions about your coverage can help.

Please Read and Sign Below

By completing this enrollment application, I agree to the following:

Care1st is a Medicare Advantage plan and has a contract with the Federal government. I will need to keep my Medicare Parts A and B. I can be in only one Medicare Advantage plan at a time, and I understand that my enrollment in this plan will automatically end my enrollment in another Medicare health plan or prescription drug plan. It is my responsibility to inform you of any prescription drug coverage that I have or may get in the future. Enrollment in this plan is generally for the entire year. Once I enroll, I may leave this plan or make changes only at certain times of the year when an enrollment period is available (Example: October 15 - December 7 of every year), or under certain special circumstances.

Care1st serves a specific service area. If I move out of the area that Care1st serves, I need to notify the plan so I can disenroll and find a new plan in my new area. Once I am a member of Care1st, I have the right to appeal plan decisions about payment or services if I disagree. I will read the Evidence of Coverage document from Care1st when I get it to know which rules I must follow to get coverage with this Medicare Advantage plan. I understand that people with Medicare aren’t usually covered under Medicare while out of the country except for limited coverage near the U.S. border.

I understand that beginning on the date Care1st coverage begins, I must get all of my health care from Care1st, except for emergency or urgently needed services or out-of-area dialysis services. Services authorized by Care1st and other services contained in my Care1st Evidence of Coverage document (also known as a member contract or subscriber agreement) will be covered. Without authorization, NEITHER MEDICARE NOR Care1st WILL PAY FOR THE SERVICE.

I understand that if I am getting assistance from a sales agent, broker, or other individual employed by or contracted with Care1st, he/she may be paid based on my enrollment in Care1st.

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Release of Information: By joining this Medicare health plan, I acknowledge that Care1st will release my information to

Medicare and other plans as is necessary for treatment, payment and health care operations. I also acknowledge that Care1st will release my information including my prescription drug event data to Medicare, who may release it for research and other purposes which follow all applicable Federal statutes and regulations. The information on this enrollment form is correct to the best of my knowledge. I understand that if I intentionally provide false information on this form, I will be disenrolled from the plan.

I understand that my signature (or the signature of the person authorized to act on my behalf under the laws of the State where I live) on this application means that I have read and understand the contents of this application. If signed by an authorized individual (as described above), this signature certifies that 1) this person is authorized under State law to complete this enrollment and 2) documentation of this authority is available upon request from Medicare.

Signature:

John R. Doe

Today’s Date:

MM-DD-YYYY

If you are the authorized representative, you must sign above and provide the following information:

Name: _______________________________________________________________________________________ Address: ______________________________________________________________________________________ Phone Number: (_____) ________________ Relationship to Enrollee: ____________________________________

Broker / Sales Use Only

Agent Name: ________________________________ Care1st Agent ID: ___________________________ Form Received On: ____________________________ Agent Phone/Email: _________________________ Agent Signature: ______________________________ Date: ___________________________________ __

Care1st Enrollment Office Use Only

Name of staff member/agent/broker (if assisted in enrollment): ________________________________________ Enrollee ID: ____________________________________ Effective Date of Coverage: ___________________

£ ICEP/IEP £ AEP £ SEP (type): ______________________ £ Not Eligible: ___________________

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SUMMARY OF

BENEFITS

January 1, 2014 - December 31, 2014

CARE1ST HEALTH PLAN

Care1st

AdvantageOptimum Plan (HMO)

California:

Alameda, San Francisco and Santa Clara Counties

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2

Thank you for your interest in Care1st AdvantageOptimum Plan (HMO). Our plan is offered by CARE1ST HEALTH PLAN, a Medicare Advantage Health Maintenance Organization (HMO) that contracts with the Federal government. This Summary of Benefits tells you some features of our plan. It doesn’t list every service that we cover or list every limitation or exclusion. To get a complete list of our benefits, please call Care1st AdvantageOptimum Plan (HMO) and ask for the “Evidence of Coverage.”

you haVe ChoICeS In

your health Care

As a Medicare beneficiary, you can choose from different Medicare options. One option is the Original (Fee-for-Service) Medicare Plan. Another option is a Medicare health plan, like Care1st AdvantageOptimum Plan (HMO). You may have other options too. You make the choice. No matter what you decide, you are still in the Medicare Program.

You may join or leave a plan only at certain times. Please call Care1st AdvantageOptimum Plan (HMO) at the telephone number listed at the end of this introduction or 1-800-MEDICARE (1-800-633-4227) for more information. TTY/TDD users should call 1-877-486-2048. You can call this number 24 hours a day, 7 days a week.

hoW Can I Compare my

optIonS?

You can compare Care1st AdvantageOptimum Plan (HMO) and the Original Medicare Plan using this Summary of Benefits. The charts in this booklet list some important health benefits. For each benefit, you can see what our plan covers and what the Original Medicare Plan covers. Our members receive all of the benefits that the Original Medicare Plan offers. We also offer more benefits, which may change from year to year.

Where IS Care1st

advantageoptimum plan

(hmo) aVaIlaBle?

The service area for this plan includes:

Alameda*, San Francisco, Santa Clara Counties, CA. You must live in one of these areas to join the plan.

* denotes partial county

ALAMEDA 94501, 94502, 94601, 94602, 94603, 94604, 94605, 94606, 94607, 94608, 94609, 94610, 94611, 94612, 94613, 94614, 94617, 94618, 94619, 94620, 94621, 94623, 94624, 94661, 94662, 94701, 94702, 94703, 94704, 94705, 94706, 94707, 94708, 94709, 94710, 94712, 94720

Who IS elIGIBle to JoIn

Care1st advantageoptimum

plan (hmo)?

You can join Care1st AdvantageOptimum Plan (HMO) if you are entitled to Medicare Part A and enrolled in Medicare Part B and live in the service area. However, individuals with End-Stage Renal Disease generally are not eligible to enroll in Care1st AdvantageOptimum Plan (HMO) unless they are members of our organization and have been since their dialysis began.

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3

Can I ChooSe my

DoCtorS?

Care1st AdvantageOptimum Plan (HMO) has formed a network of doctors, specialists, and hospitals. You can only use doctors who are part of our network. The health providers in our network can change at any time.

You can ask for a current provider directory. For an updated list, visit us at http://www. care1stmedicare.com. Our customer service number is listed at the end of this introduction.

What happenS If I Go to

a DoCtor Who’S not In

your netWorK?

If you choose to go to a doctor outside of our network, you must pay for these services yourself. Neither the plan nor the Original Medicare Plan will pay for these services except in limited situations (for example, emergency care).

Where Can I Get my

preSCrIptIonS If I JoIn

thIS plan?

Care1st AdvantageOptimum Plan (HMO) has formed a network of pharmacies. You must use a network pharmacy to receive plan benefits. We may not pay for your prescriptions if you use an out-of-network pharmacy, except in certain cases.

The pharmacies in our network can change at any time. You can ask for a pharmacy directory or visit us at http://www.care1stmedicare.com. Our customer service number is listed at the end of this introduction.

What If my DoCtor

preSCrIBeS leSS than a

month’S Supply?

In consultation with your doctor or pharmacist, you may receive less than a month’s supply of certain drugs. Also, if you live in a long-term care facility, you will receive less than a month’s supply of certain brand [and generic] drugs. Dispensing fewer drugs at a time can help reduce cost and waste in the Medicare Part D program, when this is medically appropriate.

The amount you pay in these circumstances will depend on whether you are responsible for paying coinsurance (a percentage of the cost of the drug) or a copay (a flat dollar amount for the drug). If you are responsible for coinsurance for the drug, you will continue to pay the applicable percentage of the drug cost. If you are responsible for a copay for the drug, a “daily cost-sharing rate” will be applied. If your doctor decides to continue the drug after a trial period, you should not pay more for a month’s supply than you otherwise would have paid. Contact your plan if you have questions about cost-sharing when less than a one-month supply is dispensed.

DoeS my plan CoVer

meDICare part B or part

D DruGS?

Care1st AdvantageOptimum Plan (HMO) does cover both Medicare Part B prescription drugs and Medicare Part D prescription drugs.

What IS a preSCrIptIon

DruG formulary?

Care1st AdvantageOptimum Plan (HMO) uses a formulary. A formulary is a list of drugs covered by your plan to meet patient needs. We may periodically add, remove, or make changes to coverage limitations on certain drugs or change how much you pay for a drug. If we make any formulary change that limits our members’ ability to fill their prescriptions, we will notify the affected members before the change is made. We will send a formulary to you and you can see our complete formulary on our website at http:// www.care1stmedicare.com.

If you are currently taking a drug that is not on our formulary or subject to additional requirements or limits, you may be able to get a temporary supply of the drug. You can contact us to request an exception or switch to an alternative drug listed on our formulary with your physician’s help. Call us to see if you can get a temporary supply of the drug or for more details about our drug transition policy.

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4

hoW Can I Get

eXtra help WIth my

preSCrIptIon DruG

plan

CoStS or Get

eXtra help WIth other

meDICare CoStS?

You may be able to get extra help to pay for your prescription drug premiums and costs as well as get help with other Medicare costs. To see if you qualify for getting extra help, call:

• 1-800-MEDICARE (1-800-633-4227). TTY/ TDD users should call 1-877-486-2048, 24 hours a day/7 days a week; and see http:// www.medicare.gov ‘Programs for People with Limited Income and Resources’ in the publication Medicare & You.

• The Social Security Administration at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY/TDD users should call 1-800-325-0778; or

• Your State Medicaid Office.

What are my

proteCtIonS In thIS

plan?

All Medicare Advantage Plans agree to stay in the program for a full calendar year at a time. Plan benefits and cost-sharing may change from calendar year to calendar year. Each year, plans can decide whether to continue to participate

with Medicare Advantage. A plan may continue in their entire service area (geographic area where the plan accepts members) or choose to continue only in certain areas. Also, Medicare may decide to end a contract with a plan. Even if your Medicare Advantage Plan leaves the program, you will not lose Medicare coverage. If a plan decides not to continue for an additional calendar year, it must send you a letter at least 90 days before your coverage will end. The letter will explain your options for Medicare coverage in your area.

As a member of Care1st AdvantageOptimum Plan (HMO), you have the right to request an organization determination, which includes the right to file an appeal if we deny coverage for an item or service, and the right to file a grievance. You have the right to request an organization determination if you want us to provide or pay for an item or service that you believe should be covered. If we deny coverage for your requested item or service, you have the right to appeal and ask us to review our decision. You may ask us for an expedited (fast) coverage determination or appeal if you believe that waiting for a decision could seriously put your life or health at risk, or affect your ability to regain maximum function. If your doctor makes or supports the expedited request, we must expedite our decision. Finally, you have the right to file a grievance with us if you have any type of problem with us or one of our network providers that does not involve coverage for an item or service. If your problem

involves quality of care, you also have the right to file a grievance with the Quality Improvement Organization (QIO) for your state. Please refer to the Evidence of Coverage (EOC) for the QIO contact information.

As a member of Care1st AdvantageOptimum Plan (HMO), you have the right to request a coverage determination, which includes the right to request an exception, the right to file an appeal if we deny coverage for a prescription drug, and the right to file a grievance. You have the right to request a coverage determination if you want us to cover a Part D drug that you believe should be covered. An exception is a type of coverage determination. You may ask us for an exception if you believe you need a drug that is not on our list of covered drugs or believe you should get a non-preferred drug at a lower out-of-pocket cost. You can also ask for an exception to cost utilization rules, such as a limit on the quantity of a drug. If you think you need an exception, you should contact us before you try to fill your prescription at a pharmacy. Your doctor must provide a statement to support your exception request. If we deny coverage for your prescription drug(s), you have the right to appeal and ask us to review our decision. Finally, you have the right to file a grievance if you have any type of problem with us or one of our network pharmacies that does not involve coverage for a prescription drug. If your problem involves quality of care, you also have the right to file a grievance with the Quality Improvement Organization (QIO) for your state.

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5

Please refer to the Evidence of Coverage (EOC) for the QIO contact information.

What IS a meDICatIon

therapy manaGement

(mtm) proGram?

A Medication Therapy Management (MTM) Program is a free service we offer. You may be invited to participate in a program designed for your specific health and pharmacy needs. You may decide not to participate but it is recommended that you take full advantage of this covered service if you are selected. Contact Care1st AdvantageOptimum Plan (HMO) for more details.

What typeS of DruGS

may Be CoVereD unDer

meDICare part B?

Some outpatient prescription drugs may be covered under Medicare Part B. These may include, but are not limited to, the following types of drugs. Contact Care1st AdvantageOptimum Plan (HMO) for more details.

-- Some Antigens: If they are prepared by a doctor and administered by a properly instructed person (who could be the patient) under doctor supervision.

-- Osteoporosis Drugs: Injectable osteoporosis drugs for some women.

-- Erythropoietin: By injection if you have end-stage renal disease (permanent kidney failure requiring either dialysis or transplantation) and need this drug to treat anemia.

-- Hemophilia Clotting Factors: Self-administered clotting factors if you have hemophilia.

-- Injectable Drugs: Most injectable drugs administered incident to a physicians service. -- Immunosuppressive Drugs: Immunosuppressive drug therapy for transplant patients if the

transplant took place in a Medicare-certified facility and was paid for by Medicare or by a private insurance company that was the primary payer for Medicare Part A coverage.

-- Some Oral Cancer Drugs: If the same drug is available in injectable form.

-- Oral Anti-Nausea Drugs: If you are part of an anti-cancer chemotherapeutic regimen.

-- Inhalation and Infusion Drugs administered through Durable Medical Equipment.

Where Can I fInD

InformatIon on plan

ratInGS?

The Medicare program rates how well plans perform in different categories (for example, detecting and preventing illness, ratings from patients and customer service). If you have access to the web, you can find the plan ratings

information by using the “find health and drug plans” web tool on http://www.medicare.gov to compare the plan ratings for Medicare plans in your area. You can also call us directly to obtain a copy of the plan ratings for this plan. Our customer service number is listed below.

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6

please call Care1st

health plan for more

information about Care1st

advantageoptimum plan

(hmo).

Visit us at http://www.care1stmedicare.com or, call us:

Customer Service Hours for October 1 February 14: Sunday, Monday, Tuesday, Wednesday, Thursday, Friday, Saturday, 8:00 a.m. - 8:00 p.m. Pacific

Customer Service Hours for February 15 September 30: Monday, Tuesday, Wednesday, Thursday, Friday, 8:00 a.m. - 8:00 p.m. Pacific Current members should call toll-free (800)544-0088 for questions related to the Medicare Advantage Program. (TTY/TDD 711) Prospective members should call toll-free (800)847-1222 for questions related to the Medicare Advantage Program. (TTY/TDD 711) Current members should call locally (800)544-0088 for questions related to the Medicare Advantage Program. (TTY/TDD 711)

Prospective members should call locally (800)847-1222 for questions related to the Medicare Advantage Program. (TTY/TDD 711) Current members should call toll-free

(800)544-0088 for questions related to the Medicare Part D Prescription Drug program. (TTY/TDD 711)

Prospective members should call toll-free (800)847-1222 for questions related to the Medicare Part D Prescription Drug program. (TTY/TDD 711)

Current members should call locally (800)544-0088 for questions related to the Medicare Part D Prescription Drug program. (TTY/TDD 711)

Prospective members should call locally (800)847-1222 for questions related to the Medicare Part D Prescription Drug program. (TTY/TDD 711)

For more information about Medicare, please call Medicare at 1-800-MEDICARE (1-800-633-4227).

TTY users should call 1-877-486-2048. You can call 24 hours a day, 7 days a week.

Or, visit http://www.medicare.gov on the web. This document may be available in other formats such as Braille, large print or other alternate formats.

This document may be available in a non-English language. For additional information, call customer service at the phone number listed above.

Este documento puede ser disponible en un idioma que no sea inglés. Para obtener más información, llame al servicio al cliente al número de teléfono indicado arriba.

此文件包括其他語言。若需要獲得更多資訊，請撥打以上所列的電話號碼聯絡我們的會員服務部。

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SUMMARY OF BENEFITS

SECTION 2

7

Summary of BenefItS

– Section 2

-If you have any questions about this plan’s benefits or costs, please contact Care1st Health

Plan for details.

IMPORTANT INFORMATION BENEFIT 1 PreMiuM And OtHer iMPOrtAnt inFOrMAtiOn ORIGINAL MEDICARE

In 2013 the monthly Part B Premium was $104.90 and may change for 2014 and the annual Part B deductible amount was $147 and may change for 2014.

If a doctor or supplier does not accept assignment, their costs are often higher, which means you pay more. Most people will pay the standard monthly Part B premium. However, some people will pay a higher premium because of their yearly income

Care1st

AdvantageOptimum Plan (HMO) Alameda, San Francisco

General

$28 monthly plan premium in addition to your monthly Medicare Part B premium.

Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However, some people will pay higher Part B and Part D premiums because of their yearly income (over $85,000 for singles, $170,000 for married couples). For more information about Part B and Part D premiums based on income, call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may also call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778.

Care1st

AdvantageOptimum Plan (HMO) Santa Clara

General

$0 monthly plan premium in addition to your monthly Medicare Part B premium. Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However, some people will pay higher Part B and Part D premiums because of their yearly income (over $85,000 for singles, $170,000 for married couples). For more information about Part B and Part D premiums based on income, call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may also call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778.

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SUMMARY OF BENEFITS

SECTION 2

8

IMPORTANT INFORMATION (Continued)

BENEFIT ORIGINAL MEDICARE AdvantageOptimum Plan (HMO)Care1st Alameda, San Francisco

Care1st

AdvantageOptimum Plan (HMO) Santa Clara 1 Premium and Other imPOrtant infOrmatiOn (continued)

(over $85,000 for singles, $170,000 for married couples). For more information about Part B premiums based on income, call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may also call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778.

in-network

$3,400 out-of-pocket limit for Medicare-covered services.

in-network

$3,400 out-of-pocket limit for Medicare-covered services.

2

dOctOr and hOsPital c Oh ice

(For more information, see Emergency Care #15 and Urgently Needed Care -#16.)

You may go to any doctor, specialist or

hospital that accepts Medicare. _{You must go to network doctors,}in-network specialists, and hospitals.

Referral required for network hospitals and specialists (for certain benefits).

in-network

You must go to network doctors, specialists, and hospitals.

Referral required for network hospitals and specialists (for certain benefits).

AdvantageOptimum Plan (HMO)

CARE1ST

AdvantageOptimum Plan (HMO)

P

-En ollm n Book 2014

ALAMEDA, SAN FRANCISCO

& SANTA CLARA COUNTIES

RE

R

E T

CARE1ST

AdvantageOptimum Plan (HMO)

PRE-EnRollmEnT Book 2014

ALAMEDA, SAN FRANCISCO

& SANTA CLARA COUNTIES

H

P

C

i P

a

C tt

www.care1stmedicare.com

Care1st Healt Plan

For enrollment inquiries lease all

Hearing m aired ssistan e

Y

Thank you for Your

Interest in Care1st

TABLE OF CONTENTS

Dear Medicare Beneficiary:

We look forward to welcoming you to the Care1st family.

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









Service AreAS

CALiFORNiA

TEXAS

Call Member Services for

questions or benefit information:

1-800-544-0088

TTY/TDD users call 711

Service AreA ZiP codeS

CALIFORNIA

Alameda County

Fresno County

Kern County

Los Angeles County

Orange County

Riverside

San Bernardino:

San Diego County

San Francisco County

San Joaquin

County

Santa Clara County

Stanislaus County

TEXAS

El Paso County

Do You Have

MeDicare Questions?

Care1st (HMO, HMO sNP) Has aNswers.

What are the different parts of

Medicare A, B, C and D?

How do I join Care1st

Medicare Advantage Plans?

Can I obtain specialty services?

What should I do if I’m out of

Care1st’s coverage area and

need emergency services?

Can I obtain care after

normal business hours?

What if I’m a Medicare member

with Care1st and also have

Medicaid benefits elsewhere?

How is my private health

information protected?

What benefits and services are

Note: Call Care1st to reserve your ride. Reservations must be made at*