It’s Personal.

Benefit Highlights Value Preferred Choice (HMO)2018

H0545_FUY2018_016 Accepted

Antoinette Wolfard

Service To Seniors (HMO)

Member for seven years.

Inter Valley Health Plan Value Preferred Choice (HMO) is a Medicare Advantage HMO plan with a Medicare contract. Enrollment in the Plan depends on contract renewal.

The benefit information provided is a summary of what we cover and what you pay. It does not list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, please request the “Evidence of Coverage.”

To join Inter Valley Health Plan Value Preferred Choice (HMO), you must be entitled to Medicare Part A, be enrolled in Medicare Part B, and live in our service area. Our service area includes portions of the following counties in California: Los Angeles, Orange and San Bernardino.

Inter Valley Health Plan Value Preferred Choice (HMO) has a network of doctors, hospitals, pharmacies, and other providers. If you use the providers that are not in our network, the Plan may not pay for these services.

BENEFITS Monthly Plan Premium $0 $35.50

Primary Care Physician Visit $0 20%

Specialist Physician Visit $0 20%

Urgent Care Visit (using a network provider) $0 $65

Physical / Occupational Therapy $0 20%

Lab Services $0 20%

Outpatient Mental Health Care $0 20%

X-Rays • Standard Radiology Services $0 20% • Diagnostic Radiology Services (specialized equipment x-rays) $0 20%

Radiation Therapy $0 20%

Medicare Part B Drugs $0 20%

Diabetic Supplies (glucose monitors, test strips, lancets) $0 20%

Diabetic Therapeutic Shoes or Inserts $0 20%

Durable Medical Equipment / Prosthetic Devices $0 20%

Preventive Screenings (Medicare covered screenings) $0 $0

Flu & Pneumonia Vaccine $0 $0

Annual Maximum Out-of-Pocket $5,900 $5,900

HOSPITAL & EMERGENCY CARE

Inpatient Hospital Care $0 Medicare fee- for-service costs

Skilled Nursing Facility $0 Medicare fee- for-service costs

Outpatient Surgery/Ambulatory Surgery Center $0 20%

Ambulance Services (each one-way trip) $0 20%

Emergency Room Visit $0 $80 (copay waived if admitted to hospital within US & its territories)

Worldwide Emergency Care • Emergency Room Visit $100 $100 • Limit per year outside US & its territories $20,000 $20,000

ADDITIONAL BENEFITS Basic Dental Plan • Routine Cleanings (once every 6 months) $0 $0 • Oral Exams (once every 6 months) $0 $0 • Fluoride Treatment (once every 6 months) $0 $0 • Dental x-rays (once every 3 years) $0 $0Additional dental services available including diagnostic, preven tive and restorative procedures. Copayments for Basic Dental Plan vary based upon the procedure performed by a general dentist.

Routine Foot Care $0 (4 visits per yr) $0 (4 visits per yr)

Value Preferred Choice (with Medicare & Full-

Medi-Cal Eligibility)

Value Preferred Choice (with Medicare only)VALUE PREFERRED CHOICE (HMO) BENEFIT HIGHLIGHTS

ADDITIONAL BENEFITS…CONTINUED

Routine Transportation $0 (60 one-way trips per year) $0 (60 one-way trips per year)

Accupuncture & Routine Chiropractic Services $0 (20 visits per year combined) $0 (20 visits per year combined)

Over-the-Counter Items Up to $35 each month Up to $35 each month towards selected items towards selected items

Personal Emergency Response System $0 (criteria & limitations apply) $0 (criteria & limitations apply)

Home Delivered Meals $0 (criteria & limitations apply) $0 (criteria & limitations apply)

Annual Routine Vision Exam (VSP) $0 $0 • Eyewear $0 $0 (eyewear coverage limit every 2 years) $175 coverage limit $175 coverage limit

Health Club Membership through Silver & Fit $0 $0

Routine Hearing Exam $0 $0 • Routine Hearing Aids (hearing aid coverage limit every 2 yrs) $1,500 $1,500

Value Preferred Choice (with Medicare &

Full- Medi-Cal Eligibility)

Value Preferred Choice (with Medicare only)

PRESCRIPTION COVERAGE Premiums & Benefits Value Preferred Choice (HMO) Value Preferred Choice (HMO) (with Medicare & Part D extra help) (with Medicare only)

VALUE PREFERRED CHOICE (HMO) BENEFIT HIGHLIGHTS

Cost sharing may change depending on the pharmacy you choose and when you enter another phase of the Part D benefit. For more information, please call the Sales Department at the number provided on the back of this document or access our Evidence of Coverage online.If you reside in a long-term care facitlity, you pay the same as at a retail pharmacy.You may get drugs from an out-of-network pharmacy, but may pay more than you pay at an in-network pharmacy.For more information about the costs for additional days' supplies that are available to you, please visit our Evidence of Coverage online.This document may be available in other formats such as large print.

Depend ing on your income & institutional status; you pay:

Generic drugs: $0 or $1.25 or $3.35

All other drugs: $0 or $3.70 or $8.35

Depend ing on your income & institutional status; you pay:

Generic drugs: $0 or $1.25 or $3.35

All other drugs: $0 or $3.70 or $8.35

Depend ing on your income & institutional status; you pay:

$0 for generic drugs $0 for all other drugs:

30-day supply retail

You pay 25%

You pay 25%

You pay no more than 44% of the Plan’s cost for generic drugs You recieve a discount on brand name drugs & generally pay no more than 35% of the Plan’s cost.

5% of the cost or, $3.35 copay for generic drugs and $8.35 for all other drugs.

Phase 1: INITIAL COVERAGE (After you pay your deductible, if applicable)

Generic drugs

All other drugs

Phase 2: COVERAGE GAP Begins after the total yearly drug costs (including what our Plan has paid & what you have paid) reaches $3,750.

Phase 3: CATASTOPHIC COVERAGE After your yearly out-of-pocket drug costs reach $5,000 you pay the greater of:

Inter Valley Health Plan complies with applicable federal civil rights laws and does not discriminate, exclude people, or treat them differently on the basis of, or because of, race, color, national origin, age, disability, or sex.

Inter Valley Health Plan provides free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters, and written information in other formats (large print, audio, accessible electronic formats, other formats).

Inter Valley Health Plan provides free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages. If you need these services, contact Inter Valley Health Plan Member Services.

If you believe that Inter Valley Health Plan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance in person, by phone, mail, or fax, at:

Inter Valley Health Plan Attention: Robin Davis Manager, Grievance and Appeals Department 300 S. Park Avenue, Suite 300, Pomona, CA 91769-6002 800-251-8191 Ext. 469, (TTY: 711) FAX: 909-620-6413

If you need help filing a grievance, Inter Valley Health Plan Member Services is available to help you.

Or by filling out the “File a Grievance” form on our website at: www.ivhp.com/AppealsGrievance.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019 (TTY: 1-800-537-7697)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Inter Valley Health Plan is a not-for-profit HMO with a Medicare contract. Enrollment in Inter Valley Health Plan depends on contract renewal.

General Notice About Nondiscrimination & Accessibility Requirements

Multi-language Interpreter Services

ENGLISH: ATTENTION: If you speak a language other than English, language assistance services, free of charge, are available to you. Call 1-800-251-8191. (TTY: 711).

SPANISH: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-251-8191. (TTY: 711).

CHINESE TRADITIONAL: 注意：如果您使用中文，您可以免費獲得語言援助服務。請致電 1-800-251-8191。(TTY: 711)。

CHINESE SIMPLIFIED: 注意：如果您使用中文，您可以免费获得语言援助服务，请致电 1-800-251-8191。(TTY: 711)。

VIETNAMESE: CHÚ Ý: Nếu quý vị nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho quý vị. Xin vui lòng gọi số 1-800-251-8191. (TTY: 711).

TAGALOG: PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-800-251-8191. (TTY: 711).

KOREAN: 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-800-251-8191 번으로 연락해 주십시오. (TTY: 711).

ARMENIAN: ՈՒՇԱԴՐՈՒԹՅՈՒՆ՝ Եթե խոսում եք հայերեն, ապա Ձեզ անվճար կարող են տրամադրվել լեզվական աջակցության ծառայություններ: Զանգահարե’ք 1-800-251-8191 հեռախոսահամարով: Հեռատիպի համարն է՝ 711:

PERSIAN (FARSI): ینابز تالیهست ،دینک یم وگتفگ یسراف نابز هب رگا :هجوت .(TTY: 711) .دیریگب سامت 8191-251-800-1 هرامش اب .دشاب یم مهارف امش یارب ناگیار تروصبRUSSIAN: ВНИМАНИЕ! Если вы говорите по-русски, вы можете бесплатно получить услуги перевод;а. Звоните по телефону 1-800-251-8191 (TTY: 711).

JAPANESE: 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。お問合せ先 1-800-251-8191. (TTY: 711).

ARABIC: كل رفاوتت ةيوغللا ةدعاسملا تامدخ نإف ،ةيبرعلا ثدحتت تنك اذإ :ةظوحلم .(711 :يصنلا فتاهلا) .8191-251-800-1 مقرب لصتا .ناجملابPUNJABI: ਧਿਆਨ ਦਿਓ: ਜੇ ਤੁਸੀਂ ਪੰਜਾਬੀ ਬੋਲਦੇ ਹੋ, ਤਾਂ ਭਾਸ਼ਾ ਵਿੱਚ ਸਹਾਇਤਾ ਸੇਵਾ ਤੁਹਾਡੇ ਲਈ ਮੁਫਤ ਉਪਲਬਧ ਹੈ। 1-800-251-8191 ਉੱਤੇ ਕਾਲ ਕਰੋ। (TTY: 711)।

MON-KHMER, CAMBODIAN: សូមយកចិត្តទុកដាក់៖ បើសិនជាអ្នកនិយាយភាសាខ្មែរ សេវាជំនួយផ្នែកភាសា ដោយមិនគិតថ្លៃ អាចមានសំរាប់បំរើអ្នក។ សូមទូរស័ព្ទទៅលេខ 1-800-251-8191 ។ (TTY: 711) ។

HMONG: LUS CEEV: Yog tias koj hais lus Hmoob (Ntawv Suav - Hmoob), muaj kev pab txhais lus pub dawb rau koj. Hu rau 1-800-251-8191. (TTY: 711).

HINDI: ध्यान दें: यदि आप हिंदी बोलते हैं तो आपके लिए मुफ्त में भाषा सहायता सेवाएं उपलब्ध हैं। कॉल करें 1-800-251-8191, (TTY: 711)।

THAI: โปรดทราบ: ถ้าคุณพูดภาษาไทย คุณสามารถใช้บริการช่วยเหลือทางภาษาได้ฟรี โทร 1-800-251-8191 (TTY: 711).

It’s Personal.

800-500-7018 or TTY 711, 8 am to 8 pm, 7 days a week. 300 S. Park AvenueP.O. Box 6002, Pomona, CA 91769-6002www.ivhp.com • www.facebook.com/intervalley

Inter Valley Health Plan is an HMO with a Medicare contract. Enrollment in Inter Valley Health Plan depends on contract renewal. Individuals must have both Medicare Part A, and Medicare Part B to enroll. You must continue to pay your Medicare Part B premium. Members may enroll in the Plan only during specific times of the year.

The benefit information provided herein is a brief summary, not a complete description of benefits. For more information contact the Plan. Inter Valley Health Plan’s benefits, formulary, pharmacy network, provider network, premium, co-payments and/or co-insurance may change on January 1 of each year.

You must use Plan providers, except in emergency or urgent care situations or for out-of-area renal dialysis. If you obtain routine care from out-of-network providers neither Medicare nor Inter Valley Health Plan will be responsible for the costs.

Eligible beneficiaries must use network pharmacies to access their prescription drug benefit, except under non-routine circumstances. Limitations, copayments, and restrictions may apply.

For beneficiaries who qualify for “Extra Help:” Premiums, Co-pays, Co-insurance and Deductibles may vary based on the level of Extra Help that you receive. Please contact the Plan for further details.

You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for extra help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day / 7 days a week; The Social Security Office at 1-800-772-1213 between 7 am and 7 pm, Monday through Friday. TTY users should call, 1-800-325-0778; or Your State Medicaid Office.

Inter Valley Health Plan complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Inter Valley Health Plan cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo. ATTENTION: This information and language assistance services are available to you free of charge. Call 1-800-251-8191 (TTY: 711). ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-251-8191 (TTY: 711). 注意：如果您使用繁體中文， 您可以免費獲得語言援助服務。請致電 1-800-251-8191 (TTY: 711) 。 For more information please call the number below or visit us at www.ivhp.com. Current Members call toll free: 1-800-251-8191, TTY users should call 711.Prospective Members call toll free: 1-800-500-7018, TTY users should call 711.From October 1 to February 14, you can call us 7 days a week from 8 am to 8 pm Pacific Time.From February 15 to September 30, you can call us Monday through Friday from 8 am to 8 pm Pacific Time.After hours and holidays, please leave a message and a representative will call on the next business day.You can see our plan’s provider/pharmacy directory on our website at www.ivhp.com.

We cover Part D drugs. In addition, we cover Part B drugs such as chemotherapy and some drugs administered by your provider.

You can see the complete Plan formulary (list of Part D prescription drugs) and restrictions on our website at www.ivhp.com

MED300SUM VPC 9/17