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Your Guide to University of Iowa Group Medicare Advantage Plans 1-877-917-8550 Monday through Friday, 8 a.m.–8 p.m. HealthAlliance.org/IA-Retiree Just Seems Right. GROUP MEDICARE PLANS 2017

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Page 1: Just Seems Right

Your Guide to University of Iowa Group Medicare Advantage Plans

1-877-917-8550Monday through Friday,

8 a.m.–8 p.m. HealthAlliance.org/IA-Retiree

Just Seems Right.GROUP MEDICARE PLANS

2017

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mkt-UIAguide-0916 12

HealthAlliance.org/IA-Retiree

University of IowaGroup Medicare Plansby Health Alliance

With our plan you get

We are proud to offer two Medicare Advantage plans to University of Iowa retirees for the 2017 plan year.• Our low-cost HMO Plus Rx Plan• A custom PPO Rx plan to closely match the benefits most familiar to you

Health Alliance is known for our customer service. And with more than 30 years of industry experience, we know what you need and expect from your health plan.

• Fitness center benefits through the Be Fit fitness program• A large provider network• Thousands of pharmacies to choose from• Lots of perks to help you get and stay healthy

.

This book highlights Five Keys to Better Coverage that will help you figure out how to get the most from your Health Alliance plan.

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ID Card: Your Key to Getting CarePresent your Health Alliance ID card whenever you see a doctor or pick up prescriptions from the pharmacy. Your ID card has key information that helps you and your providers access your coverage more easily.

• Copayment information for commonly used services• Customer Service contact information• Anytime Nurse Line phone number• Member number• Where to send medical and pharmacy claims

A Wealth of InformationWhen you become a member, you have access to materials that outline the rules of your plan and help explain your coverage.

Evidence of Coverage The Evidence of Coverage (EOC) is the primary guiding document—just like a policy—for how your health care is covered by Health Alliance.

Summary of BenefitsThe Summary of Benefits tells you deductible, copayment and coinsurance information for various services. It also has information about your service area.

Provider Directory and Pharmacy DirectoryPlease see the enclosed Provider Spotlight flier for some of the most recognized providers in our network. For a complete listing of providers and pharmacies, visit HealthAlliance.org/IA-Retiree. Click “Find a Doctor” to search our provider networks. For hard copies of the directories, call Customer Service.

FormularyThe Formulary is the list of covered drugs for both the Guide HMO Plus Rx and the Custom PPO Rx plans.

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5 Keys to Better Coverage

First.

Tips for UsingYour Coverage

Other MemberMaterials

Medicare HMO RxDate Printed:H1737-802

Member Name:XXXXXXXXXXMember NameXXXXXXXXXXX

Member ID:

Copayments:Primary Visit:Specialty Visit:Emergency:

RxBin: 015789RxPCN: CTRXMEDDRxGroup #:

Issuer (80840): 7659374889

XXXXXXX

Health Alliance Medicare • HealthAllianceMedicare.org

Customer Service: 1-877-917-8550 or TTY: 711For Health Questions: Anytime Nurse Line 1-855-802-4612

Providers: Use YourHealthAlliance.org to check eligibility orclaims status and for any preauthorization assistance.Bill Health Alliance, not Medicare.

Medical Claims: Health Alliance PO Box 6003, Urbana IL 61803EDI Payor ID: 77950

Pharmacy Claims: OptumRxPO Box 968021, Schaumburg IL 60196; 1-844-265-1876

Members: This card is for ID purposes only. It is not a guaranteeof eligibility. See your plan documents for details of coverage.

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Benefits at a Glance

Second.

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HealthAlliance.org/IA-Retiree

Medical Benefits HMO PPOPlus Rx Rx

In-Network

Preferred Pharmacies Include:Walgreens and University of Iowa Health Care Pharmacies

Monthly Premium $52 $279

Annual Out-of-Pocket Max $4,000 $1,700

Deductible $0 $0

PCP $10 $5

Specialist $35 $5

Emergency Room $75 $50, (worldwide coverage) then, 10%

Urgent Care $55 $5(worldwide coverage)

Inpatient Hospital $280 days 1–7 $0 days 8+ 10%

Outpatient Surgery $275 10%

Ambulance $275 10%

Laboratory Services 20% 10%

Diagnostic Radiology 20% 10%

Preventive Services (including wellness No cost to youvisit, Pap smear, cervical cancerscreening and colorectal cancer screening)

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Benefits at a Glance—continued

NOTE: Annual plan deductible must be met before plan benefits apply. Benefit limits are measured on a calendar year. A member’s out-of-pocket expenses by service event cannot exceed the cost-sharing requirements put in place by the federal Centers for Medicare & Medicaid Services (CMS).

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No limit

$400

No

$0

$9

$20

$47

$100

25%

$1,100

$0

Yes

$0

$0

30%

50%

50%

50%

Pharmacy Benefits HMO PPOPlus Rx Rx

90-day supply for 2 x 30-day copayment at preferred cost-sharing pharmacies

90-day supply for 2.5 x 30-day copayment at standard cost-sharing pharmacies

Same copayments apply for mail-order as retail (see above for details)

Annual Out-of-Pocket Max

Deductible: Tier 3, Tier 4 and Tier 5

Pharmacy CoverageThrough the Gap

Initial Coverage Period

Tier 1: Preferred Generic atpreferred pharmacies,30-day supply

Tier 1: Preferred Generic at allother in-network pharmacies,30-day supply Tier 2: Generic, 30-day supply

Tier 3: Preferred Brand

Tier 4: Non-Preferred Brand

Tier 5: Specialty Tier

Retail 90 Bene�t

Mail-Order

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HealthAlliance.org/IA-Retiree

All the Perks You Want and Need

Third.

Get fit with Rally®, our easy-to-use digital health experience with personalized missions, group challenges, support and rewards to help you sleep better, move more, eat healthier and reduce stress.

If you don't have internet access, health surveys, self-management tools and rewards are also available by mail or phone. To participate, call the Member Services number on the back of your ID card.

Assist AmericaAssist America’s services help you get quality emergency care when you are 100 miles or more from home, including:• Medical referrals• Prescription assistance• Interpreter referrals

Health and WellnessTo help you achieve and maintain your best possible health, Health Alliance offers disease management programs for members with asthma, diabetes and high blood pressure.

The case management program serves members who need help managing a chronic or complicated health condition or navigating the healthcare system.

Quit for Life®

Quit for Life is our tobacco cessation program. When you are ready to quit, this program offers:

• One-on-one coaching • A quit plan made for you • Helpful tools, like Text2Quit • Quit Coach, an online learning and support community

Be FitGet fit at the gym of your choice through our Be Fit fitness program.

With Be Fit, your gym memberships and fitness class fees are eligible for monthly, quarterly or yearly reimbursement.

• Up to $30 per month• Up to $360 per year• Freedom to pick your gym

Be Fit applies to standard fitness class and gym membership fees at non-residential commercial or community fitness facilities. Services that require additional fees, like personal trainers or personal equipment, are not eligible.

Restrictions and rules apply.

Dental CoverageOur supplemental dental benefit offers up to $200 in coverage for non-Medicare covered dental services, like oral exams, cleanings, X-rays, fluoride treatments, fillings, dentures, denture adjustments and repairs, crowns, bridge work, root canals and extractions. And with no dental network to stay within, you can see the dentist of your choice.

• $50 for first oral exam, additional exams $0 copayment• Health Alliance will pay up to a maximum of $200 per plan year, you will be responsible for any cost above the $200 maximum.• See any dental provider

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Get More atYourHealthAlliance.org YourHealthAlliance.org is an interactive, secure member website. After logging in, you’ll have all the information you need right at your fingertips.

Customer ServiceSkip the hold line by going online to order ID cards (and print temporary cards while you wait for the new ones to arrive in the mail). You can also ask a question through the website, and a Customer Service rep will respond within one business day.

Claims and Explanation of Benefits (EOB)Check on the status of a claim or view your full EOB, which tells you how much Health Alliance paid and how much you pay for your care. We'll also send you a medical EOB and a pharmacy EOB each month so you can easily keep track of your claims.

Pharmacy CoverageReview your Drug List for covered drugs, use pricing tools to determine your true drug costs and find in-network pharmacies.

Medical and Pharmacy PoliciesLook up policies on specific drugs, treatments or procedures to learn about their coverage rules.

Doctors, Hospitals and ClinicsSearch for in-network doctors and hospitals in our Provider Directory. To change your primary care physician (PCP), go to the Plan & Benefits tab of YourHealthAlliance.org, and under the Covered Members section, choose the Change button by your doctor’s name.

Fourth.

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Connect with UsOn the PhoneWhen you need to speak with one of our Customer Service reps, call 1-877-917-8550. TTY users should call 711. We can help Monday through Friday, 8 a.m.–8 p.m. If you call us after hours, just leave a message and we’ll return your call the next business day.

OnlineHealthAlliance.org/IA-Retiree gives you quick access to materials and other information about your plan. You can also search for a provider and much more. It's available year-round and is packed with lots of helpful resources.

Go to YourHealthAlliance.org for your personal account information and a lot of other helpful features, like claims information and where you are at in meeting your medical out-of-pocket maximum.

Connect with us on Facebook and Twitter and check out our health and wellness blog, blog.HealthAlliance.org.

Fifth.

HealthAlliance.org/IA-Retiree

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Anytime Nurse Line- Your Health Questions Answered, 1-855-802-4612Sometimes you might not feel well, but you aren’t sure if you need medical attention. Or you might wonder if an over-the-counter med might cause issues when taken with your prescription meds. Maybe you just have a question about a diagnosis and need to talk with someone. The Anytime Nurse Line helps with all of that and more. Just like the name implies, it is available anytime you need it, day or night.

Billing OptionsYou will receive a monthly bill from Health Alliance, not the University of Iowa. Health Alliance offers many convenient payment options, including payments by phone, online bill pay, credit card payment or automatic deductions from your checking and savings account or Social Security withhold. To sign up for automatic premium payments, see the form enclosed. Otherwise, you can send us your payment each month.

This information is not a complete description of benefits. Contact the plan for more information.

Limitations, copayments, and restrictions may apply. Benefits, premiums and/or co-payments/co-insurance may change on January 1 of each year.

Benefit limits are measured on a calendar year. A member’s out-of-pocket expenses by service event cannot exceed the cost-sharing requirements put in place by Federal CMS.

Health Alliance Medicare is a Medicare Advantage Organization with a Medicare contract. Enrollment in Health Alliance Medicare depends on contract renewal.

OtherResources

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Please note: As a University of Iowa Retiree, you may choose to return to the UIChoice planduring any future Open Enrollment Period.

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DISCRIMINATION IS AGAINST THE LAW

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

• Provides free aids and services to people with disabilities to communicate effectively with us, such as:

o Qualified sign language interpreters o Written information in other formats (large print audio, accessible electronic formats, other

formats) • Provides free language services to people whose primary language is not English, such as:

o Qualified interpreters o Information written in other languages

If you need these services, contact customer service.

If you believe that Health Alliance 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 with: Health Alliance Medicare, Member Services, 301 S. Vine Street, Urbana, IL 61801, telephone: 1-800-965-4022 TTY: 711 or 1-800-526-0844, fax: 217-337-3425, [email protected]. You can file a grievance in person or by mail, fax or email. If you need help filing a grievance, Member Services is available to help you. 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, DC 20201, 1-800-368-1019, TTY: 1-800-537-7697.

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

HealthAlliance.org/IA-Retiree

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AnytimeNurse Line

1-855-802-4612Available anytime

you need it,day or night.

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Spanish

ATENCIÓN: Si habla Español, servicios de asistencia lingüística, de forma gratuita, están disponibles para usted. Llame 1-800-965-4022 (TTY: 711).

Chinese

注意:如果你講中文,語言協助服務,免費的,都可以給你。呼叫 1-800-965-4022 (TTY: 711)。

Polish

UWAGA: Jeśli mówić Polskie, usługi pomocy języka, bezpłatnie, są dostępne dla Ciebie. Zadzwoń 1-800-965-4022 (TTY: 711).

Vietnamese

Chú ý: Nếu bạn nói Tiếng Việt, các dịch vụ hỗ trợ ngôn ngữ, miễn phí, có sẵn cho bạn. Gọi 1-800-965-4022 (TTY: 711).

Korean

주의 : 당신이한국어, 무료 언어 지원 서비스를 말하는 경우 사용할 수 있습니다. 1-800-965-4022 전화 (TTY: 711).

Russian

ВНИМАНИЕ: Если вы говорите русский, вставки услуги языковой помощи, бесплатно, доступны для вас. Вызов 1-800-965-4022 (TTY: 711).

Tagalog

Pansin: Kung magsalita ka Tagalog, mga serbisyo ng tulong sa wika, nang walang bayad, ay magagamit sa iyo. Tumawag 1-800-965-4022 (TTY: 711).

Arabic

.(TTY: 711) 4022-965-800-1 ، خدمات المساعدة اللغوية ، مجانا ، تتوفر لك . استدعاء العربيةتنبيه: إذا كنت تتحدث اللغة

German

Wenn Sie Deutsch sprechen, Sprachassistenzdienste sind kostenlos, zur Verfügung. Anruf 1-800-965-4022 (TTY: 711). French

ATTENTION: Si vous parlez français, les services d'assistance linguistique, gratuitement, sont à votre disposition. Appelez 1-800-965-4022 (TTY: 711).

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Gujarati

ધ્યા : તમ ેવયત તો � જુરયતી, ભયષય સહય્ વસે યઓ, મફત, તમયરય મયટ� ઉપલબ્ છે. કૉલ 1-800-965-4022

(TTY: 711).

Japanese

注意:あなたは、日本語 、無料で言語支援サービスを、話す場合は、あなたに利用可能です。 1-800-965-4022コール(TTY: 711)。

Pennsylvania Dutch

LET OP: Als je spreekt pennsylvania nederlandse, taalkundige bijstand diensten, gratis voor u beschikbaar zijn. Bel 1-800-965-4022 (TTY: 711).

Ukrainian

УВАГА: Якщо ви говорите український, вставки послуги мовної допомоги, безкоштовно, доступні для вас. Виклик 1-800-965-4022 (TTY: 711).

Italian

ATTENZIONE: Se si parla italiano, servizi di assistenza linguistica, a titolo gratuito, sono a vostra disposizione. Chiamare 1-800-965-4022 (TTY: 711).

GROUP MEDICARE PLANSmkt-UIAguide-0916