2016 Summary of BenefitsBenefits Effective January 1, 2016

Santa Clara, California

Stanford Health Care Advantage (HMO)

Summary of Benefits for Stanford Health Care Advantage Platinum (HMO)

and Stanford Health Care Advantage Gold (HMO)

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SUMMARY OF BENEFITS FOR JANUARY 1, 2016 – DECEMBER 31, 2016

This booklet gives you a summary of what we cover and what you pay. It doesn’t list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, call us and ask for the “Evidence of Coverage.”

You have choices about how to get your Medicare benefits

• OnechoiceistogetyourMedicarebenefitsthroughOriginalMedicare(fee-for-serviceMedicare).OriginalMedicareisrundirectlybytheFederalgovernment.

• AnotherchoiceistogetyourMedicarebenefitsbyjoiningaMedicarehealthplansuchasStanford Health Care Advantage Platinum (HMO) or Stanford Health Care Advantage Gold (HMO).

Tips for comparing your Medicare choices

This Summary of Benefits booklet gives you a summary of what Stanford Health Care Advantage Platinum (HMO) and Stanford Health Care Advantage Gold (HMO) cover and what you pay.

• IfyouwanttocompareourplanwithotherMedicarehealthplans,asktheotherplansfortheir SummaryofBenefitsbooklets.Or,usetheMedicarePlanFinderonhttp://www.medicare.gov.

• IfyouwanttoknowmoreaboutthecoverageandcostsofOriginalMedicare,lookinyourcurrent “Medicare & You”handbook.Viewitonlineathttp://www.medicare.govorgetacopybycalling1-800-MEDICARE(1-800-633-4227),24hoursaday,7daysaweek.TTYusersshouldcall1-877-486-2048.

Sections in this booklet

Section 1. ThingstoKnowAboutStanford Health Care Advantage Platinum (HMO) and Stanford Health Care Advantage Gold (HMO)

Section 2. MonthlyPremium,Deductible,andLimitsonHowMuchYouPayforCoveredServices

Section 3. CoveredMedicalandHospitalBenefits

Section 4. Prescription Drug Benefits

Section 5. AdditionalInformationAboutStanfordHealthCareAdvantagePlatinum(HMO)andStanfordHealthCareAdvantageGold(HMO).

This document is available in other formats such as Braille and large print. This document may be availableinanon-Englishlanguage.Foradditionalinformation,callusat1-855-996-8422, or by dialing 711forTTYservices.

Este documento se encuentra disponible en otros formatos como braille y letra grande. Este documento puedeestardisponibleenotrosidiomas.Paramásinformaciónllameal1-855-996-8422(TTY711).

Summary of Benefits for Stanford Health Care Advantage Platinum (HMO)

and Stanford Health Care Advantage Gold (HMO)

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Section 1. Things to Know About Stanford Health Care Advantage Plan Platinum (HMO) and Stanford Health Care Advantage Gold (HMO).

Hours of Operation

Youcancallus7daysaweekfrom8amuntil8pmPacificTime.

Stanford Health Care Advantage (HMO) Phone Numbers and Website

• Ifyouareamemberofthisplan,calltoll-free1-855-996-8422,orbydialing711forTTYservices.• Ifyouarenotamemberofthisplan,calltoll-free1-844-205-8422,orbydialing711forTTYservices.• Ourwebsite:http://www.StanfordHealthCareAdvantage.org

Who can join?

TojoinStanford Health Care Advantage Platinum (HMO) or Stanford Health Care Advantage Gold (HMO) youmustbeentitledtoMedicarePartA,beenrolledinMedicarePartB,andliveinourservicearea.OurserviceareaincludesthefollowingcountyinCA:SantaClara.

Which doctors, hospitals, and pharmacies can I use?

Stanford Health Care Advantage Platinum (HMO) and Stanford Health Care Advantage Gold (HMO) has a network of doctors, hospitals, pharmacies, and other providers. If you use the providers that are not in our network,theplanmaynotpayfortheseservices.YoumustgenerallyusenetworkpharmaciestofillyourprescriptionsforcoveredPartDdrugs.Youcanseeourplan’sproviderandpharmacydirectoriesatourwebsitehttp://www.StanfordHealthCareAdvantage.org.Or,callusandwewillsendyouacopyofthe provider and pharmacy directories

What do we cover?

LikeallMedicarehealthplans,wecovereverythingthatOriginalMedicarecovers-andmore.• Our plan members get all of the benefits covered by Original Medicare. For some of these benefits,

you may pay more in our plan than you would in Original Medicare. Forothers,youmaypayless.• Our plan members also get more than what is covered by Original Medicare. Some of the extra ben-

efits are outlined in this booklet.

We cover Part D drugs. In addition, we cover Part B drugs such as chemotherapy and some drugs adminis-tered by your provider.• Youcanseethecompleteplanformulary(listofPartDprescriptiondrugs)andanyrestrictionsonour

website,http://www.StanfordHealthCareAdvantage.org.• Or,callusandwewillsendyouacopyoftheformulary.

How will I determine my drug costs?

Ourplangroupseachmedicationintooneofsix“tiers.”Youwillneedtouseyourformularytolocatewhattier your drug is on to determine how much it will cost you. The amount you pay depends on the drug’s tier and what stage of the benefit you have reached.

Laterinthisdocumentwediscussthebenefitstages:InitialCoverage,CoverageGap,andCatastrophicCoverage.

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Summary of Benefits for Stanford Health Care Advantage Platinum (HMO)

and Stanford Health Care Advantage Gold (HMO)

Section 2. Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services

Stanford Health Care Advantage Gold

Stanford Health Care Advantage Platinum

How much is the monthly premium?

$49In addition, you must keep paying yourMedicarePartBpremium.

$89 In addition, you must keep paying yourMedicarePartBpremium.

How much is the deductible? This plan does not have a deductible.

This plan does not have a deductible.

Is there any limit on how much I will pay for my covered services?

Yes.LikeallMedicarehealthplans,our plan protects you by having yearlylimitsonyourout-of-pocketcosts for medical and hospital care.

Youryearlylimitinthisplan: •$4,900forservicesyoureceivefromin-networkproviders.

Ifyoureachthelimitonout-of-pock-et costs, you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year.

Please note that you will still need to pay your monthly premiums andcost-sharingforyourPartDprescription drugs.

Yes.LikeallMedicarehealthplans,our plan protects you by having yearlylimitsonyourout-of-pocketcosts for medical and hospital care.

Youryearlylimitinthisplan: •$4,400forservicesyoureceivefromin-networkproviders.

Ifyoureachthelimitonout-of-pocketcosts, you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year.

Please note that you will still need to pay your monthly premiums andcost-sharingforyourPartDprescription drugs.

Is there a limit on how much the plan will pay?

No. There are no limits on how much our plan will pay.

Our plan has a coverage limit for certainin-networkbenefits.Contactus for the services that apply.

Summary of Benefits for Stanford Health Care Advantage Platinum (HMO)

and Stanford Health Care Advantage Gold (HMO)

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Section 3. Covered Medical and Hospital Benefits Services with a 1 may require prior authorization.Services with a 2 may require a referral from your doctor.

OUT PATIENT CARE AND SERVICES Stanford Health Care Advantage

GoldStanford Health Care Advantage Platinum

Acupuncture Not covered Forupto15visitseveryyear: $10 copay

Ambulance Services1 $200 copay $200 copayChiropractic Care1 Manipulationofthespinetocorrect

asubluxation(when1ormoreof the bones of your spine move out ofposition):$20copay

Manipulationofthespinetocorrect asubluxation(when1ormoreof the bones of your spine move out ofposition):$20copay

Dental Services1 Limiteddentalservices(thisdoesnot include services in connection with care, treatment, filling, removal, orreplacementofteeth): $10-$30copaydependingon the service.

Limiteddentalservices(thisdoesnot include services in connection with care, treatment, filling, removal, orreplacementofteeth):$10-$20copay, depending on the service.PreventiveDentalServices:•Cleaning(forupto1every sixmonths):Youpaynothing

•Dentalx-ray(s)(forupto1every sixmonths):Youpaynothing

•OralExam(forupto1every sixmonths):Youpaynothing.

PleaseseetheDeltaCareUSAPlanSummaryofBenefitsformorecompleteinformation.

Diabetes Supplies and Services1

Diabetesmonitoringsupplies: Youpaynothing.Diabetesself-managementtraining:Youpaynothing.Therapeuticshoesorinserts: Youpay20%ofthecost.

Diabetesmonitoringsupplies: Youpaynothing.Diabetesself-managementtraining:Youpaynothing.Therapeuticshoesorinserts: Youpay20%ofthecost.

Diagnostic Tests, Lab and Radiology Services, and X-Rays

(Costs for these services may be different if received in an outpatient surgery setting.)1,2

Diagnostictestsandprocedures:$45copayLabservices:$10copayOutpatientx-rays:$45copayTherapeuticRadiologyServices(suchasradiationtreatmentforcancer):Youpay20%ofthecost.

Diagnostictestsandprocedures:$45copayLabservices:$10copayOutpatientx-rays:$25copayTherapeuticRadiologyServices(suchasradiationtreatmentforcancer):Youpay20%ofthecost.

Summary of Benefits for Stanford Health Care Advantage Platinum (HMO)

and Stanford Health Care Advantage Gold (HMO)

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Stanford Health Care Advantage Gold

Stanford Health Care Advantage Platinum

Doctor’s Office Visits1,2 PrimaryCarePhysicianvisit: $10 copay

Specialistvisit:$30copay

PrimaryCarePhysicianvisit: $10 copay

Specialistvisit:$20copay

Durable Medical Equipment (includes wheelchairs, oxygen, etc.) 1

20%ofthecost

If you go to a preferred vendor, your cost may be less. Contact us for a list of preferred vendors.

20%ofthecost

If you go to a preferred vendor, your cost may be less. Contact us for a list of preferred vendors.

Emergency Care $75copay

If you are admitted to the hospital within24hours,youdonothave to pay your share of the cost for emergency care. See the “Inpatient Hospital Care” section of this booklet for other costs.

Worldwideemergencycoverage-Not covered

$75copay

If you are admitted to the hospital within24hours,youdonothave to pay your share of the cost for emergency care. See the “Inpatient Hospital Care” section of this booklet for other costs.

Worldwide emergency coverage – outside the U.S and its territories, emergency care is covered with $0 copayand20%coinsurance,upamaximumof$15,000.

Foot Care (Podiatry Services)1,2

Footexamsandtreatmentifyouhavediabetes-relatednervedamageand/ormeetcertainconditions: $30copay

Footexamsandtreatmentifyouhavediabetes-relatednervedamageand/ormeetcertainconditions: $20 copay

Hearing Services Exam to diagnose and treat hearing andbalanceissues:Youpaynothing.

Exam to diagnose and treat hearing andbalanceissues:Youpaynothing.

Home Health Care1,2 Youpaynothing. Youpaynothing.

Mental Health Care1

(continues on next page)Inpatientvisit:Ourplancoversupto190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital.

The copays for hospital and skilled nursingfacility(SNF)benefits arebasedonbenefitperiods.Abenefit period begins the day you’re admitted as an inpatient and ends

Inpatientvisit:Ourplancoversupto190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital.

The copays for hospital and skilled nursingfacility(SNF)benefits arebasedonbenefitperiods.Abenefit period begins the day you’re admitted as an inpatient and ends

Summary of Benefits for Stanford Health Care Advantage Platinum (HMO)

and Stanford Health Care Advantage Gold (HMO)

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Stanford Health Care Advantage Gold

Stanford Health Care Advantage Platinum

Mental Health Care1

(continued from previous page)when you haven’t received any inpatientcare(orskilledcare inaSNF)for60daysinarow.If yougointoahospitaloraSNF after one benefit period has ended, anewbenefitperiodbegins.Youmust pay the inpatient hospital deductible for each benefit period. There’s no limit to the number of benefit periods.Our plan covers 90 days for an inpatient hospital stay.Our plan also covers 60 “lifetime reserve days.” These are “extra” days that we cover. If your hospital stay is longer than 90 days, you can use these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days.•$250copayperdayfordays

1 through 6•Youpaynothingfordays 7through90.

Outpatientgrouptherapyvisit: $20 copay Outpatientindividualtherapyvisit:$30copay

when you haven’t received any inpatientcare(orskilledcare inaSNF)for60daysinarow.If yougointoahospitaloraSNF after one benefit period has ended, anewbenefitperiodbegins.Youmust pay the inpatient hospital deductible for each benefit period. There’s no limit to the number of benefit periods.Our plan covers 90 days for an inpatient hospital stay.Our plan also covers 60 “lifetime reserve days.” These are “extra” days that we cover. If your hospital stay is longer than 90 days, you can use these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days.•$200copayperday

for days 1 through 6•Youpaynothingfordays 7through90.

Outpatientgrouptherapyvisit: $20 copay Outpatientindividualtherapyvisit:$20 copay

Outpatient Rehabilitation1 Cardiac(heart)rehabservices (foramaximumof2one-hoursessions per day for up to 36sessionsupto36weeks): $30copayOccupationaltherapyvisit: $30copayPhysical therapy and speech andlanguagetherapyvisit: $30copay

Cardiac(heart)rehabservices (foramaximumof2one-hoursessions per day for up to 36sessionsupto36weeks): $25copayOccupationaltherapyvisit: $20 copay Physical therapy and speech andlanguagetherapyvisit: $20 copay

Summary of Benefits for Stanford Health Care Advantage Platinum (HMO)

and Stanford Health Care Advantage Gold (HMO)

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Stanford Health Care Advantage Gold

Stanford Health Care Advantage Platinum

Outpatient Substance Abuse Care1

Grouptherapyvisit:$20copayIndividualtherapyvisit:$30copay

Grouptherapyvisit:$20copayIndividualtherapyvisit:$20copay

Outpatient Surgery1 Ambulatorysurgicalcenter:$200copayOutpatienthospital:$235copay

Ambulatorysurgicalcenter:$200copayOutpatienthospital:$200copay

Over-the-Counter Items Not covered Not coveredProsthetic Devices (braces, artificial limbs, etc.)1

Prostheticdevices:20%ofthecostRelatedmedicalsupplies: 20%ofthecost

Prostheticdevices:20%ofthecostRelatedmedicalsupplies: 20%ofthecost

Renal Dialysis1 10%ofthecost 10%ofthecostTransportation1 Not covered Youpaynothing

Up to 12 round trips per year.Urgently Needed Services $35copay

If you are admitted to the hospital within24hours,youdonothave to pay your share of the cost for urgently needed services. See the “Inpatient Hospital Care” section of this booklet for other costs.

$35copayIf you are admitted to the hospital within24hours,youdonothave to pay your share of the cost for urgently needed services. See the “Inpatient Hospital Care” section of this booklet for other costs.

Vision Services

Exam to diagnose and treat diseases andconditionsoftheeye(includingyearlyglaucomascreening):$10-$30copay, depending on the service.Eyeglasses or contact lenses after cataractsurgery:Youpaynothing.

Exam to diagnose and treat diseases andconditionsoftheeye(includingyearlyglaucomascreening):$10-$20copay, depending on the service.Routineeyeexam(forupto1everyyear):$25copayContactlenses(forupto1everytwoyears):$25copayEyeglasses(framesandlenses) (forupto1everytwoyears): $25copayEyeglassesframes(forupto1everytwoyears):$25copayEyeglasslenses(for up to 1 every twoyears):$25copayEyeglasses or contact lenses after cataractsurgery:Youpaynothing.Ourplanpaysupto$150everytwoyears for eyewear.

Please see the Vision Services Plan Summary of Benefits for more complete information.

Summary of Benefits for Stanford Health Care Advantage Platinum (HMO)

and Stanford Health Care Advantage Gold (HMO)

H2986_PD_119_Summary Of Benefits_English Page | 8

Stanford Health Care Advantage Gold

Stanford Health Care Advantage Platinum

Preventive Care Youpaynothing.Ourplancoversmanypreventiveservices,including:•Abdominalaorticaneurysm

screening•Alcoholmisusecounseling•Bonemassmeasurement•Breastcancerscreening (mammogram)

•Cardiovasculardisease (behavioraltherapy)

•Cardiovascularscreening•Cervicalandvaginal

cancer screening•Colorectalcancerscreenings(ColonoscopyFecaloccultbloodtest,Flexiblesigmoidoscopy)

•Depressionscreenings•Diabetesscreenings•HIVscreening•Medicalnutritiontherapyservices•Obesityscreeningandcounseling•Prostatecancerscreenings(PSA)•Sexuallytransmittedinfections

screening and counseling•Tobaccousecessationcounseling(counselingforpeoplewithnosignoftobacco-relateddisease)

•Vaccines,includingFlushots,Hepatitis B shots, Pneumococcal shots

•“WelcometoMedicare”preventivevisit(one-time)

•Yearly“Wellness”visit

Youpaynothing.Ourplancoversmany preventive services, including:•Abdominalaorticaneurysm

screening•Alcoholmisusecounseling•Bonemassmeasurement•Breastcancerscreening (mammogram)

•Cardiovasculardisease (behavioraltherapy)

•Cardiovascularscreening•Cervicalandvaginal

cancer screening•Colorectalcancerscreenings(ColonoscopyFecaloccultbloodtest,Flexiblesigmoidoscopy)

•Depressionscreenings•Diabetesscreenings•HIVscreening•Medicalnutritiontherapyservices•Obesityscreeningandcounseling•Prostatecancerscreenings(PSA)•Sexuallytransmittedinfections

screening and counseling•Tobaccousecessationcounseling(counselingforpeoplewithnosignoftobacco-relateddisease)

•Vaccines,includingFlushots,Hepatitis B shots, Pneumococcal shots

•“WelcometoMedicare”preventivevisit(one-time)

•Yearly“Wellness”visit

AnyadditionalpreventiveservicesapprovedbyMedicareduringthecontractyearwillbecovered.

Hospice YoupaynothingforhospicecarefromaMedicare-certifiedhospice.Youmayhavetopaypartofthe cost for drugs and respite care.

YoupaynothingforhospicecarefromaMedicare-certifiedhospice.Youmayhavetopaypartofthe cost for drugs and respite care.

Summary of Benefits for Stanford Health Care Advantage Platinum (HMO)

and Stanford Health Care Advantage Gold (HMO)

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Stanford Health Care Advantage Gold

Stanford Health Care Advantage Platinum

INPATIENT CARE

Inpatient Hospital Care1 The copays for hospital and skilled nursingfacility(SNF)benefitsarebasedonbenefitperiods.Abenefitperiod begins the day you’re admitted as an inpatient and ends when you haven’t received any inpatient care (orskilledcareinaSNF)for60daysin a row. If you go into a hospital or aSNFafteronebenefitperiodhasended, a new benefit period begins. Youmustpaytheinpatienthospitaldeductible for each benefit period. There’s no limit to the number of benefit periods.

Our plan covers 90 days for an inpatient hospital stay.

Our plan also covers 60 “lifetime reserve days.” These are “extra” days that we cover. If your hospital stay is longer than 90 days, you can use these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days. •$295copayfordays1through6•Youpaynothingperdayfordays 7through90.

The copays for hospital and skilled nursingfacility(SNF)benefitsarebasedonbenefitperiods.Abenefitperiod begins the day you’re admitted as an inpatient and ends when you haven’t received any inpatient care (orskilledcareinaSNF)for60daysin a row. If you go into a hospital or aSNFafteronebenefitperiodhasended, a new benefit period begins. Youmustpaytheinpatienthospitaldeductible for each benefit period. There’s no limit to the number of benefit periods.

Our plan covers 90 days for an inpatient hospital stay.

Our plan also covers 60 “lifetime reserve days.” These are “extra” days that we cover. If your hospital stay is longer than 90 days, you can use these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days. •$200copayfordays1through6•Youpaynothingperdayfordays 7through90.

Inpatient Mental Health Care

Forinpatientmentalhealthcare,seethe“MentalHealthCare” section of this booklet.

Forinpatientmentalhealthcare,seethe“MentalHealthCare” section of this booklet.

Skilled Nursing Facility (SNF)1 Our plan covers up to 100 days inaSNF.•Youpaynothingfordays

1 through 20.•$150copayperdayfordays

21 through 100

Our plan covers up to 100 days inaSNF.•Youpaynothingfordays

1 through 20.•$100copayperdayfordays

21 through 100

Summary of Benefits for Stanford Health Care Advantage Platinum (HMO)

and Stanford Health Care Advantage Gold (HMO)

H2986_PD_119_Summary Of Benefits_English Page | 10

Section 4. Prescription Drug Benefits

Stanford Health Care Advantage Gold

Stanford Health Care Advantage Platinum

How much do I pay? ForPartBdrugssuchaschemotherapydrugs1:20%ofthecostOther Part B drugs1:20%ofthecost

ForPartBdrugssuchaschemotherapydrugs1:20%ofthecostOther Part B drugs1:20%ofthecost

Initial Coverage Youpaythefollowinguntilyourtotalyearlydrugcostsreach$3,310.Totalyearlydrugcostsarethetotaldrug costs paid by both you and our Part D plan. Youmaygetyourdrugsatnetworkretailpharmaciesandmailorderpharmacies.

Standard Retail Cost-Sharing

Tier Copay for up to a one-month supply

Copay for up to a three-month supply

Tier1(PreferredGeneric) $2 copay $6 copay

Tier2(Generic) $15copay $45copay

Tier3(PreferredBrand) $47copay $141copay

Tier4(Non-PreferredBrand) $100 copay $300copay

Tier5(Specialty) 33%ofcost 33%ofcost

Tier6(SelectDiabeticDrugs) $2 copay $6 copay

Standard Mail Order Cost-Sharing

Tier Copay for up to a one-month supply

Copay for up to a three-month supply

Tier1(Generic) $2 copay $4copay

Tier2(Generic) $15copay $30copay

Tier3(PreferredBrand) $47copay $94copay

Tier4(Non-PreferredBrand) $100 copay $200 copay

Tier5(SpecialtyTier) 33%ofcost 33%ofcost

Tier6(SelectDiabeticDrugs) $2 copay $4copay

Ifyouresideinalong-termcarefacility,youpaythesameasataretailpharmacy.Youmaygetdrugsfromanout-of-networkpharmacy,butmaypaymorethanyoupayatanin-networkpharmacy.

Summary of Benefits for Stanford Health Care Advantage Platinum (HMO)

and Stanford Health Care Advantage Gold (HMO)

H2986_PD_119_Summary Of Benefits_English Page | 11

Coverage Gap MostMedicaredrugplanshaveacoveragegap(alsocalledthe“donuthole”).Thismeansthatthere’satemporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost(includingwhatourplanhaspaidandwhatyouhavepaid)reaches$3,310

Afteryouenterthecoveragegap,youpay45%oftheplan’scostforcoveredbrandnamedrugsand58%oftheplan’scostforcoveredgenericdrugsuntilyourcoststotal$4,850,whichistheendofthecoveragegap.Not everyone will enter the coverage gap.

Underthisplan,youmaypayevenlessforthebrandandgenericdrugsontheformulary.Yourcostvariesbytier.Youwillneedtouseyourformularytolocateyourdrug’stier.Seethechartthatfollowstofindouthowmuch it will cost you.

Standard Retail Cost-Sharing

Tier Drugs covered Copay for up to a one-month supply

Copay for up to a three-month supply

Tier1(PreferredGeneric) All $2 copay $6 copay

Tier2(Generic) All $15copay $45copay

Tier6(SelectDiableticDrugs) All $2 copay $6 copay

Standard Mail Order Cost-Sharing

Tier Drugs covered Copay for up to a one-month supply

Copay for up to a three-month supply

Tier1(PreferredGeneric) All $2 copay $4copay

Tier2(Generic) All $15copay $30copay

Tier6(SelectDiabeticDrugs) All $2 copay $4copay

Catastrophic Coverage Afteryouryearlyout-of-pocketdrugcosts(includingdrugspurchasedthroughyourretailpharmacyandthroughmailorder)reach$4,850,youpaythegreaterof:• 5%ofthecost,or• $2.95copayforgeneric(includingbranddrugstreatedasgeneric)and$7.40copaymentforallotherdrugs.

Summary of Benefits for Stanford Health Care Advantage Platinum (HMO)

and Stanford Health Care Advantage Gold (HMO)

H2986_PD_119_Summary Of Benefits_English Page | 12

Section 5. Additional Information about Stanford Health Care Advantage (HMO)

The Stanford Medicine Vision

To heal humanity, through science and compassion, one patient at a time.

The Stanford Health Care Advantage Value-Proposition

StanfordHealthCareAdvantageistheexclusiveMedicareAdvantageproductbroughttoyoubyStanfordHealthCareandStanfordMedicine.WeofferMedicarebeneficiariesacoordinatedhealthcareexperiencewith programming and resources designed to build upon and foster a community of members engaged in life-longwellness,well-being,andlearning.

Why Choose Stanford Health Care Advantage?

1. WearetheonlyMedicareAdvantageplanofferingaccesstoStanfordMedicinePrimaryCarephysicians.

2. Wecoordinateyourcaresoyoudon’thaveto.You’llhaveaStanfordMedicine,oraffiliatedprimarycaredoctor, and specialists working together for you as a team.

3. WefocusonhealthyagingthroughourSeniorCareClinicandAdultAgingServices.

4. MyHealth*StanfordHealthCare’ssecureonlineportalmakesiteasyforyouto:

• View medical records and test results

• Send messages and schedule appointments

• Manageprescriptionsandmore

5. AccesstoonlinephysicianvisitsfromStanfordMedicineProviders.

6. OurMemberCareSpecialistsarehighlyknowledgeableinMedicareandarereadytohelpguideyouthrough your health care experience.

7. Extensive drug formulary with cost savings throughout the year.

8. ExclusiveCommunityEngagementEvents:YoumayenjoyEducation/Lunch&Learns,HealthEventsand Social Engagements.

*Whereavailble.

Summary of Benefits for Stanford Health Care Advantage Platinum (HMO)

and Stanford Health Care Advantage Gold (HMO)

H2986_PD_119_Summary Of Benefits_English Page | 13

Multi-language Interpreter ServicesWe have free interpreter services to answer any questions you may have about our health or drug plan. To getaninterpreter,justcallusat1-844-996-8422.Someonewhospeaksyourpreferredlanguagecanhelpyou.This is a free service.

Spanish: Tenemos servicios de intérprete sin costo alguno para responder cualquier pregunta que pueda tenersobrenuestroplandesaludomedicamentos.Parahablarconunintérprete,porfavorllameal1-844-996-8422.Alguienquehableespañollepodráayudar.Esteesunserviciogratuito.

Chinese Mandarin: 我们提供免费的翻译服务，帮助您解答关于健康或药物保险的任何疑 问。如果您需要此翻译服务，请致电1-844-996-8422。我们的中文工作人员很乐意帮助您。 这是一项免费服务。

Chinese Cantonese: 您對我們的健康或藥物保險可能存有疑問，為此我們提供免費的翻譯 服務。如需翻譯服務，請致電1-844-996-8422。我們講中文的人員將樂意為您提供幫助。這 是一項免費服務。

Tagalog: Mayroonkaming librengserbisyosapagsasaling-wikaupangmasagotanganumangmgakata-nunganninyohinggilsaamingplanongpangkalusuganopanggamot. Upangmakakuhangtagasaling-wika,tawaganlamangkamisa1-844-996-8422. MaaarikayongtulunganngisangnakakapagsalitangTagalog. Itoay libreng serbisyo.

French: Nous proposons des services gratuits d’interprétation pour répondre à toutes vos questions rela-tivesànotrerégimedesantéoud’assurance-médicaments.Pouraccéderauserviced’interprétation,ilvoussuffitdenousappelerau1-844-996-8422.UninterlocuteurparlantFrançaispourravousaider.Ceserviceestgratuit.

Vietnamese: Chúng tôi có dịch vụ thông dịch miễn phí để trả lời các câu hỏi về chương sức khỏe và chương trìnhthuốcmen.Nếuquívịcầnthôngdịchviênxingọi1-844-996-8422sẽcónhânviênnóitiếngViệtgiúpđỡquí vị. Đây là dịch vụ miễn phí .

German: UnserkostenloserDolmetscherservicebeantwortetIhrenFragenzuunseremGesundheits-undAr-zneimittelplan.UnsereDolmetschererreichenSieunter1-844-996-8422.Manwird IhnendortaufDeutschweiterhelfen. Dieser Service ist kostenlos.

Korean: 당사는 의료 보험 또는 약품 보험에 관한 질문에 답해 드리고자 무료 통역 서비스를 제공하고 있습니다. 통역 서비스를 이용하려면 전화1-844-996-8422번으로 문의해 주십시오. 한국어를 하는 담당자가 도와 드릴 것입니다. 이 서비스는 무료로 운영됩니다.

Russian: Если у вас возникнут вопросы относительно страхового или медикаментного плана, вы можете воспользоваться нашими бесплатными услугами переводчиков. Чтобы воспользоваться услугами переводчика, позвоните нам по телефону1-844-996-8422.Вам окажет помощь сотрудник, который говорит по-pусски. Данная услуга бесплатная.

Arabic: لوصحلل .انيدل ةيودألا لودج وأ ةحصلاب قلعتت ةلئسأ يأ نع ةباجإلل ةيناجملا يروفلا مجرتملا تامدخ مدقن اننإ

ةيبرعلا ثدحتي ام صخش موقيس .2248-699-448-1 ىلع انب لاصتالا ىوس كيلع سيل ،يروف مجرتم ىلع.ةيناجم ةمدخ هذه .كتدعاسمب

Hindi: हमारे स्वास्थ्य या दवा की योजना के बार ेमें आपके किसी भी प्रश्न के जवाब देने के लिए हमारे पास मुफ्त दुभाषिया सेवाए ँउपलब्ध हैं. एक दुभाषिया प्राप्त करने के लिए, बस हमें 1-844-996-8422पर फोन करें. कोई व्यक्ति जो हिन्दी बोलता है आपकी मदद कर सकता है. यह एक मुफ्त सेवा है.

Summary of Benefits for Stanford Health Care Advantage Platinum (HMO)

and Stanford Health Care Advantage Gold (HMO)

H2986_PD_119_Summary Of Benefits_English Page | 14

Italian: È disponibile un servizio di interpretariato gratuito per rispondere a eventuali domande sul nostro piano sanitario e farmaceutico. Per un interprete, contattare il numero 1-844-996-8422. Un nostro incaricato che parla Italianovi fornirà l’assistenza necessaria. È un servizio gratuito.

Portugués: Dispomosdeserviçosdeinterpretaçãogratuitospararesponderaqualquerquestãoquetenhaacercadonossoplanodesaúdeoudemedicação.Paraobterumintérprete,contacte-nosatravésdonúmero1-844-996-8422.IráencontraralguémquefaleoidiomaPortuguêsparaoajudar.Esteserviçoégratuito.

French Creole: Nou genyen sèvis entèprèt gratis pou reponn tout kesyon ou ta genyen konsènan plan medikaloswadwògnouan. Pou jwennyonentèprèt, jis relenounan1-844-996-8422. YonmounkipaleKreyòl kapab ede w. Sa a se yon sèvis ki gratis.

Polish: Umożliwiamy bezpłatne skorzystanie z usług tłumacza ustnego, który pomoże w uzyskaniu odpowiedzi na temat planu zdrowotnego lub dawkowania leków.  Aby skorzystać z pomocy tłumaczaznającegojęzykpolski,należyzadzwonićpodnumer1-844-996-8422. Tausługajestbezpłatna.

Japanese: 当社の健康 健康保険と薬品 処方薬プランに関するご質問にお答えするため に、無料の通訳サービスがありますございます。通訳をご用命になるには、1-844-996-8422にお電話ください。日本語を話す人 者 が支援いたします。これは無料のサー ビスです。

Stanford Health Care Advantage (HMO) has a contract with Medicare to offer an HMO plan. You must reside in Santa Clara County, CA to enroll. Enrollment in the Stanford Health Care Advantage (HMO) 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.

Limitations, copayments and restrictions may apply. Benefits, formulary, pharmacy network, provider network, premium and/or copayments/coinsurance may change on January 1 of each year. The actual complete terms and conditions of the health plan are set forth in the applicable Evidence of Coverage (EOC) document.

For additional information, please contact our Member Services at 1-855-996-8422, or by dialing 711 for TTY services. Hours are 8:00 a.m. to 8:00 p.m., 7 days a week.

This information is available for free in other languages. Please call our Member Services number at 1-855-996-8422, 8:00 a.m. to 8:00 p.m., Pacific Time, 7 days a week. TTY users call 711.

Esta información está disponible gratuitamente en otros idiomas. Llame a nuestro número de servicio al cliente 1-855-996-8422, 8:00 a.m. a 8:00 p.m., hora pacífico, siete días a la semana. Los usuarios de TTY deben llamar al 711.

H2986_PD_119_Summary Of Benefits_English Page | 15

Summary of Benefits for Stanford Health Care Advantage Platinum (HMO)

and Stanford Health Care Advantage Gold (HMO)

Notes:

H2986_PD_119_Summary Of Benefits_English Page | 16

Summary of Benefits for Stanford Health Care Advantage Platinum (HMO)

and Stanford Health Care Advantage Gold (HMO)

Notes:

StanfordHealthCareAdvantageP.O.Box72530Oakland,CA94612 www.StanfordHealthCareAdvantage.org H2986_PD_119_Summary Of Benefits_English_Accepted 2015