Summary of Benefits

Northeast Region

SummaCare Medicare Topaz The SummaCare Medicare Topaz (HMO) plan is available
to residents of the following counties in Ohio: Carroll,
(HMO) (H3660_050) Columbiana, Cuyahoga, Geauga, Lake, Lorain, Mahoning,
Medina, Portage, Stark, Summit, Trumbull and Wayne.
SummaCare Medicare Ruby
(HMO) (H3660_044) The SummaCare Medicare Ruby (HMO) Northeast plan is
available to residents of the following counties in Ohio:
Plan Year January 1, 2019 through Ashland, Ashtabula, Carroll, Columbiana, Cuyahoga,
December 31, 2019 Geauga, Holmes, Lake, Lorain, Mahoning, Medina, Por-
tage, Stark, Summit, Trumbull, Tuscarawas and Wayne.

SummaCare is an HMO and HMO-POS plan with a Medicare

contract. Enrollment in SummaCare depends on contract renewal. H3660_19_63_M Accepted 09042018

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 Summary of Benefits
KEY BENEFITS
• Ambulance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
• Chiropractic Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
• Dental Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15, 21
• Diabetes Supplies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
• Diagnostic Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
• Doctor Visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
• Emergency Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
• Hearing Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
• Home Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
• Home Safety Devices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
• Hospice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
• Hospital – Inpatient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
• Hospital – Outpatient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
• Lab Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
• Medical Equipment / Supplies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
• Mental Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
• Podiatry Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
• Part D Prescription Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17, 18
• Preventive Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
• Prosthetic Devices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
• Radiology Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
• Rehabilitation and Physical Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
• Renal Dialysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
• Skilled Nursing Facility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
• Substance Abuse – Outpatient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
• Telehealth Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
• Transportation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
• Urgent Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
• Vision Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
• X-Rays . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

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 Things to Know About
SummaCare Topaz (HMO) and
SummaCare Ruby (HMO) Northeast:
What do we cover? Want to learn more?
SummaCare Medicare Advantage plans cover Visit www.summacare.com/medicare to
everything Original Medicare covers and more. All find more information about our plans. Or,
of our plans include Medicare (Part D) prescription call us at 888.464.8440 (TTY 800.750.0750).
drugs. You can see the complete plan formulary From October 1 through March 31, a representative
(list of covered drugs) and any restrictions on our is available to take your call from 8:00 a.m. until
website, www.summacare.com/medicare. Or, call 8:00 p.m., seven days a week. From April 1 through
us and we will send you a copy of the formulary. September 30, a representative is available to take
How will I determine my drug costs? your call from 8:00 a.m. until 8:00 p.m., Monday
Our plan groups each medication into one of six through Friday. Outside these hours, you may leave
“tiers.” You will need to use SummaCare’s Medicare us a message and a representative will return your
formulary (list of covered drugs) to locate what call the next business day.
tier your drug is in to determine how much it To enroll in SummaCare, you must be entitled to
will cost you. The amount you pay depends on Medicare Part A, be enrolled in Medicare Part B, and
the drug’s tier and what stage of the benefit you live in our service area.
have reached. Later in this document, we discuss This document is available in other formats such as
the benefit stages that occur: Part D deductible, Braille, large print or audio.
Initial Coverage Stage, Coverage Gap Stage and
This is a summary document. The benefit information
Catastrophic Coverage Stage.
provided does not list every service that we cover or
Which doctors, list every limitation or exclusion. To get a complete
hospitals and pharmacies can I use? list of services we cover, please request the Evidence
SummaCare Medicare Topaz (HMO) and of Coverage (EOC). To request the EOC, please call
SummaCare Medicare Ruby (HMO) Northeast 888.464.8440 (TTY 800.750.0750). If you want to
have a network of doctors, hospitals, pharmacies know more about the coverage and costs of Original
and other providers. If you use providers that Medicare, look in your current “Medicare & You”
are not in our network, the plan may not pay for handbook. View it online at http://www.medicare.gov or
these services - except for emergency, urgent and order a copy by calling 1.800.MEDICARE (1.800.633.4227),
out-of-area renal dialysis services. Out-of-network/ 24 hours a day, 7 days a week. TTY users should
non-contracted providers are under no obligation call 1.877.486.2048.
to treat SummaCare members, except in emergency
situations. Please call our customer service number People with limited incomes may qualify for extra
or request an Evidence of Coverage document for help to pay for their prescription drug costs and medical
more information, including the cost-sharing that expenses. See if you qualify by calling:
applies to out-of-network services. You must • 1.800.MEDICARE (1.800.633.4227), 24 hours per
generally use network pharmacies to fill your day/7 days a week. TTY/TDD users call 1.877.486.2048.
prescriptions for covered Part D drugs. You can • The Social Security Administration at 1.800.772.1213,
see our plan’s provider/pharmacy directory on Monday through Friday, 7 a.m. to 7 p.m. TTY/TDD users
our website, www.summacare.com/medicare. call 1.800.325.0778.
Or, call us and we will send you a copy of the
provider/pharmacy directory.

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 Summary of Benefits
Premiums SummaCare Medicare SummaCare Medicare What you
and Benefits Topaz (HMO) Ruby (HMO) Northeast should know

Monthly Plan You pay $0 You pay $43 You must continue to
Premium pay your Medicare
Part B premium.

Deductible You pay nothing. You pay nothing. These plans do not have
a medical deductible.

Maximum Out-of- $3,800 $3,600 Includes copays and other

Pocket Responsibility costs for medical services
(does not include throughout the year.
prescription drugs)

Hospital – Inpatient $295 copay per day for days $275 copay per day for days Our plan pays for an
1 through 5. 1 through 6. unlimited number of
You pay nothing after day 5. You pay nothing after day 6. days for an inpatient
hospital stay.

Hospital – Outpatient Ambulatory surgical center: Ambulatory surgical center:

$300 copay $250 copay
Outpatient hospital: Outpatient hospital:
$300 copay $250 copay
Observation services: Observation services:
$300 copay $250 copay

Doctor Visits Primary Care Primary Care You are not required to
Physician visit: Physician visit: receive authorization before
You pay nothing. You pay nothing. seeking care from most
Specialist visit: Specialist visit: specialists. Pre-approval
$45 copay $40 copay from SummaCare is needed
before seeing a surgeon for
back pain.

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 Summary of Benefits
Premiums SummaCare Medicare SummaCare Medicare What you
and Benefits Topaz (HMO) Ruby (HMO) Northeast should know

Preventive Care You pay nothing. Our plan You pay nothing. Our plan
(e.g., flu vaccines, covers many preventive covers many preventive
diabetic screenings) services, including: services, including:
•A  bdominal aortic • Abdominal aortic
aneurysm screening aneurysm screening
• Alcohol misuse counseling • Alcohol misuse counseling
• Annual wellness visit • Annual wellness visit
• Bone mass measurement • Bone mass measurement
•B  reast cancer screening • Breast cancer screening
(mammogram) (mammogram)
•C  ardiovascular disease • Cardiovascular disease
risk reduction visit risk reduction visit
• Cardiovascular • Cardiovascular
disease testing disease testing
•C  ervical and vaginal • Cervical and vaginal
cancer screening cancer screening
•C  olorectal cancer • Colorectal cancer
screenings (Colonoscopy, screenings (Colonoscopy,
Fecal occult blood test, Fecal occult blood test,
Flexible sigmoidoscopy) Flexible sigmoidoscopy)
• Depression screening • Depression screening
• Diabetes prevention • Diabetes prevention
• Diabetes screening • Diabetes screening
• HIV screening • HIV screening
• Lung cancer screening • Lung cancer screening
•M  edical nutrition therapy • Medical nutrition therapy
services services
•O  besity screening and • Obesity screening and
counseling counseling
• P rostate cancer and • Prostate cancer and
counseling counseling
• S exually transmitted • Sexually transmitted
infections screening and infections screening and
counseling counseling
• Tobacco use cessation • Tobacco use cessation
counseling (counseling for counseling (counseling for
people with no sign of people with no sign of
tobacco-related disease) tobacco-related disease)
• V accines, including Flu • Vaccines, including Flu
shots, Hepatitis B shots, shots, Hepatitis B shots,
Pneumococcal shots Pneumococcal shots
• “Welcome to Medicare” • “Welcome to Medicare”
preventive visit (one-time) preventive visit (one-time)

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 Summary of Benefits
Premiums SummaCare Medicare SummaCare Medicare What you
and Benefits Topaz (HMO) Ruby (HMO) Northeast should know

Emergency Care $90 copay per visit $90 copay per visit If you are admitted to the
hospital within 24 hours,
you do not have to pay
the copay. Emergency,
urgent care and ambulance
services outside of the
United States are covered
up to a maximum of
$25,000 each year. This
includes emergency
ambulance occurring
immediately before a
covered emergency visit.

Urgently Needed $45 copay per visit $40 copay per visit Emergency, urgent care
Services and ambulance services
outside of the United
States are covered up to
a maximum of $25,000
each year. This includes
emergency ambulance
occurring immediately
before a covered
emergency visit.

Diagnostic Services/ Diagnostic radiology Diagnostic radiology The copay is based on

Labs/Imaging service (e.g., MRI): service (e.g., MRI): where the procedure takes
$175 copay $150 copay place. You pay a lower
Diagnostic tests and Diagnostic tests and copay at a physician’s office
procedures: $0-125 copay, procedures: $0-125 copay, (office visit copay may
depending on the location depending on the location apply). You pay a higher
copay at all other locations.
Lab services: $0-10 copay, Lab services: $0-8 copay,
depending on whether depending on whether
the bloodwork is processed the bloodwork is processed
at a physician’s office or at a physician’s office or
sent to an independent sent to an independent
lab for processing lab for processing
Outpatient X-rays: Outpatient X-rays:
$75-130 copay, depending $0-110 copay, depending on
on the location the location
Therapeutic radiology Therapeutic radiology
services (such as radiation services (such as radiation
treatment for cancer): treatment for cancer):
20% of the cost 20% of the cost

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 Summary of Benefits
Premiums SummaCare Medicare SummaCare Medicare What you
and Benefits Topaz (HMO) Ruby (HMO) Northeast should know

Hearing Services Diagnostic hearing exam: Diagnostic hearing exam: You are covered for an
$20 copay $15 copay annual routine hearing
Supplemental routine Supplemental routine exam every year.
hearing exam: $20 copay hearing exam: $15 copay You receive up to 12 months
Hearing aids: Hearing aids: of hearing aid service visits
$795 copay per hearing aid, $795 copay per hearing aid, from the date of fitting.
for select models of one for select models of one You receive a 60-day trial
hearing aid per ear every hearing aid per ear every period starting with the day
three years three years of fitting during which you
may return your hearing aid
with no restocking fee and/
or choose another hearing
aid model.

Dental Services $10 copay per visit $10 copay per visit Preventive dental covers one
cleaning, one exam, one set
of bitewing X-rays, periapical
X-rays and full-mouth X-rays
(payable once every 5 years)
and palliative treatment per
year through the Delta Dental
of Ohio Medicare Advantage
PPO network. Calendar year
benefit maximum of $500.
See page 21 for Optional
Supplemental Dental benefits.

Vision Services Diagnostic eye exam: Diagnostic eye exam: You are covered for an
$20 copay $15 copay annual supplemental routine
Supplemental routine Supplemental routine eye exam each year.
eye exam: eye exam: Coverage for eyeglasses
$20 copay $15 copay and/or contact lenses
Annual prescription Annual prescription provided after cataract
eyewear allowance: eyewear allowance: surgery limited to
$100 $150 Medicare-allowed amount
for Medicare-covered
Glasses or contacts after Glasses or contacts after lenses and frames.
cataract surgery: cataract surgery:
You pay nothing. You pay nothing. In addition to an annual
routine eye exam and
Yearly glaucoma Yearly glaucoma Medicare-covered eye
screening: screening: exams (for diagnosis and
You pay nothing. You pay nothing. treatment for diseases and
conditions of the eye),
you’ll receive an annual
amount to use toward the
purchase of frames/lenses
or contact lenses – with
the freedom to visit any
vision provider you choose.

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 Summary of Benefits
Premiums SummaCare Medicare SummaCare Medicare What you
and Benefits Topaz (HMO) Ruby (HMO) Northeast should know

Mental Health Inpatient visit: Inpatient visit: There is a 190-day lifetime

Services $295 copay per day for $275 copay per day for limit for inpatient services
days 1 through 4. You pay days 1 through 5. You pay in a psychiatric hospital.
nothing after day 4. nothing after day 5. The 190-day lifetime limit
Outpatient group Outpatient group does not apply to inpatient
therapy visit: therapy visit: mental health services
$40 copay $40 copay provided in a psychiatric
unit of a general hospital.
Outpatient individual Outpatient individual
therapy visit: therapy visit:
$40 copay $40 copay

Skilled Nursing Facility You pay nothing per day You pay nothing per day Our plan covers up to 100
for days 1 through 20. for days 1 through 20. days in a Skilled Nursing
$160 copay per day for $160 copay per day for Facility. No prior hospital
days 21 through 100. days 21 through 100. stay required.

Physical Therapy Cardiac (heart) Cardiac (heart)

rehab services: rehab services:
You pay nothing. You pay nothing.
Occupational therapy visit: Occupational therapy visit:
$40 copay $40 copay
Physical therapy and Physical therapy and
speech and language speech and language
therapy visit: therapy visit:
$40 copay $40 copay

Ambulance Ground Ambulance: Ground Ambulance: Emergency, urgent care and

$200 copay $200 copay ambulance services outside
Air Ambulance: Air Ambulance: of the United States are
$200 copay $200 copay covered up to a maximum
of $25,000 each year.
This includes emergency
ambulance occurring
immediately before a
covered emergency visit.

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 Summary of Benefits
Premiums SummaCare Medicare SummaCare Medicare What you
and Benefits Topaz (HMO) Ruby (HMO) Northeast should know

Transportation You pay nothing for four You pay nothing for four Routine non-emergent
one-way trips. one-way trips. medical transportation
services are covered up
to four one-way trips per
calendar year to in-network
medical appointments or
visits to providers within
the plan service area.
Trips must be scheduled
through SummaCare’s
transportation vendor,
Homelink.
Medicare Part B For Part B-covered For Part B-covered
Drugs chemotherapy drugs and chemotherapy drugs and
other Part B-covered drugs: other Part B-covered drugs:
20% of the cost 20% of the cost

Part D Prescription Drugs

The amount you pay depends on the drug’s tier and what stage of the benefit you have reached.
SummaCare Medicare Ruby (HMO)
SummaCare Medicare Topaz (HMO) Northeast
Deductible There is an annual deductible of There is no deductible.
$150 on the Topaz HMO plan. This
combined deductible only applies to
drug Tiers 3 and 4.

Initial Coverage Stage You pay the following until your total You pay the following until your total
yearly drug costs reach $3,820. Total yearly drug costs reach $3,820. Total
yearly drug costs are the total drug yearly drug costs are the total drug costs
costs paid by both you and our Part paid by both you and our Part D plan.
D plan. You may get your drugs at You may get your drugs at network retail
network retail pharmacies and mail pharmacies and mail order pharmacies.
order pharmacies.

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 Summary of Benefits
Part D Prescription Drugs continued
SummaCare Medicare Ruby (HMO)
SummaCare Medicare Topaz (HMO) Northeast
Retail – One Month
Tier 1 (Preferred Generic) $0 $0
Tier 2 (Generic) $10 $10
Tier 3 (Preferred Brand) $47 $47
Tier 4 (Non-preferred Brand) $100 $100
Tier 5 (Specialty) 30% 33%
Tier 6 (Vaccines) $0 $0
Retail – Three Month
Tier 1 (Preferred Generic) $0 $0
Tier 2 (Generic) $25 $25
Tier 3 (Preferred Brand) $117.50 $117.50
Tier 4 (Non-preferred Brand) $300 $300
Tier 5 (Specialty) N/A - limited to 30-day supply N/A - limited to 30-day supply
Tier 6 (Vaccines) $0 $0
Mail-Order – Three Month
Tier 1 (Preferred Generic) $0 $0
Tier 2 (Generic) $25 $25
Tier 3 (Preferred Brand) $117.50 $117.50
Tier 4 (Non-preferred Brand) $300 $300
Tier 5 (Specialty) 30% – limited to 30-day supply 33% – limited to 30-day supply
Tier 6 (Vaccines) $0 $0
If you reside in a long-term care facility, 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.
Coverage Gap Stage Most Medicare drug plans have a coverage gap (also called the “donut hole”). This means
that there’s a temporary change in what you will pay for your drugs. The coverage gap
begins after the total yearly drug cost (including what our plan has paid and what you
have paid) reaches $3,820.
After you enter the coverage gap, you pay 25% of the plan’s cost for covered brand
name drugs and 37% of the plan’s cost for covered generic drugs until your costs total
$5,100, which is the end of the coverage gap. Not everyone will enter the coverage gap.
Under this plan, you may pay even less for the brand and generic drugs on the formulary.
Your cost varies by tier. You will need to use your formulary to locate your drug’s tier. See
the chart that follows to find out how much it will cost you. All Tier 1 (Preferred Generic)
drugs (retail and mail-order) are covered at a $0 copay if you enter the Coverage Gap. Tier
6 Vaccines are also covered at a $0 copay through the Coverage Gap.
Catastrophic After your yearly out-of-pocket drug costs (including drugs purchased through your
Coverage Stage retail pharmacy and through mail order) reach $5,100 you pay the greater of
• 5% of the cost, or
• $ 3.40 copay for generic (including brand drugs treated as generic) and a
$8.50 copay for all other drugs.
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 Summary of Benefits
Premiums SummaCare Medicare SummaCare Medicare What you
and Benefits Topaz (HMO) Ruby (HMO) Northeast should know

Additional Benefits:

Home Safety Devices $150 allowance per year $150 allowance per year If you have had a diagnosis
of any of the following:
hip replacement, knee
replacement, femur
fractures or a diagnosis
of falls within the past 12
months, as documented
by a provider, you are
eligible for home safety
devices. Covered items
for 2019 include: shower
stools, hand held showers,
bathroom rails, grab bars,
raised toilet seats, toilet
seat frames, hip kits, 30”
security home bed rails and
temporary ramps. Items
must be purchased through
Homelink. Otherwise you
will be responsible for the
full cost of those items and
no payment will be made.

Telehealth Services Primary Care: Primary Care: Visits can be requested 24

$0 copay $0 copay hours a day, 365 days a year
Dermatology: Dermatology: through Teladoc, Inc. by
$45 copay $40 copay web, phone or mobile app.

Chiropractic Care $20 copay $20 copay

Foot Care $45 copay $40 copay

(Podiatry Services)

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 Summary of Benefits
Additional Benefits: continued

SummaCare Medicare Topaz SummaCare Medicare Ruby

(HMO) (HMO) Northeast

Home Health Care You pay nothing. You pay nothing.

Hospice You pay nothing for hospice care from a You pay nothing for hospice care from a
Medicare-certified hospice. You may have Medicare-certified hospice. You may have
to pay part of the costs for drugs and to pay part of the costs for drugs and
respite care. respite care.

Medical Equipment/ Durable Medical Equipment Durable Medical Equipment

Supplies (e.g., wheelchairs, oxygen): (e.g., wheelchairs, oxygen):
20% of the cost 20% of the cost
Prosthetic Devices Prosthetic Devices
(e.g., braces, artificial limbs): (e.g., braces, artificial limbs):
20% of the cost 20% of the cost
Diabetes Monitoring Supplies: Diabetes Monitoring Supplies:
20% of the cost 20% of the cost
Diabetes Self-Management Training: Diabetes Self-Management Training:
You pay nothing. You pay nothing.
Therapeutic Shoes or Inserts: Therapeutic Shoes or Inserts:
20% of the cost 20% of the cost

Outpatient Group therapy visit: Group therapy visit:

Substance Abuse $40 copay $40 copay
Individual therapy visit: Individual therapy visit:
$40 copay $40 copay

Over-the-Counter Select over-the-counter generic Select over-the-counter generic

Items drugs are covered under this plan. drugs are covered under this plan.
Certain smoking cessation products Certain smoking cessation products
are also covered under this plan. are also covered under this plan.

Renal Dialysis 20% of the cost 20% of the cost

Health and Wellness You pay nothing for: You pay nothing for:
Programs and SilverSneakers® SilverSneakers®
Services
Health Coaching Health Coaching
Preventive Health Reminders Preventive Health Reminders
QuitCare QuitCare
Health Manager Powered by WebMD Health Manager Powered by WebMD
Enhanced Disease Management Programs Enhanced Disease Management Programs

20
815177SCG_NE_EnrollGd.indd 20 9/5/18 10:04 AM
 Summary of Benefits
Optional Supplemental Dental

If you elect to enroll Diagnostic and Preventive Services for $0 copay:

in this optional - Exams (including evaluations by a specialist) and Cleanings: One additional exam
supplemental dental and cleaning is added to the preventive dental benefit. If you purchase this optional
plan, you’ll pay an supplemental dental benefit, you will have a total of 2 exams and 2 cleanings per year.
additional $25 per - Bitewing Radiographs: One set of bitewing x-rays per year is covered under your
month. You must preventive dental benefit.
keep paying your
Medicare Part B - Full Mouth X-rays/Panoramic Films: Full mouth x-rays (which include bitewings) or a
premium and your panoramic x-ray once every five years is covered under the preventive dental benefit.
SummaCare Medicare - Periapical X-Rays: Covered under the preventive dental benefit.
plan premium. - Palliative (emergency treatment of dental pain): Covered under the preventive
dental benefit.
Major Restorative Services (Plan pays 50% of allowed amount)
- Crowns, Core Buildup and Pins
- Surgical Periodontics
- Surgical Extractions and Oral Surgery
Minor Restorative Services (Plan pays 50% of allowed amount)
- Fillings and simple extractions
- Periodontal Maintenance and other non-surgical periodontics
- Root Canals to treat teeth with diseased or damaged nerves
- Crown Repair
- Relines and Repairs to complete and partial dentures and fixed or removable bridges
- General Anesthesia or IV Sedation when medically necessary
If you purchase this optional supplemental dental benefit, the plan will pay a total
maximum benefit of $1,500 per benefit year. This includes your preventive and
supplemental dental benefits.
Services must be received through Delta Dental’s Medicare Advantage PPO or Medicare
Advantage Premier network of providers.
Services received from dentists who do NOT participate in Delta Dental’s Medicare
Advantage PPO or Medicare Advantage Premier network are NOT covered benefits.

21
815177SCG_NE_EnrollGd.indd 21 9/5/18 10:04 AM
 SummaCare complies with applicable Federal civil rights laws and does not discriminate on the basis
of race, color, national origin, age, disability, religion, gender identity or sex. SummaCare does not
exclude people or treat them differently because of race, color, national origin, age, disability, religion,
gender identity or sex.
SummaCare:
• 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 SummaCare has failed to provide these services or discriminated in another way
on the basis of race, color, national origin, age, disability, religion, gender identity or sex, you can file a
grievance through Customer Service:

Civil Rights Coordinator

PO Box 1107
Akron, OH 44309-1107
Toll-free: 888-464-8440
TTY: 800-750-0750
Fax: 330-996-8545
Email: appeals@summacare.com

You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, a
Customer Service Representative 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, 800-537-7697 (TDD).
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

SC MDCR 17 1101 11012016 MC_Prospect

22
815177SCG_NE_EnrollGd.indd 22 9/5/18 10:04 AM
  
ATTENTION: Interpreter Services available. Someone who speaks your language can assist you.
Someone who speaks your language   can assist you.
ATENCIÓN: si habla   español, tiene a su disposición servicios gratuitos de asistencia lingüística.
osición servicios ATTENTION:
gratuitos
Llame deInterpreter
asistencia Services
al 1-888-464-8440 lingüística. available. Someone who speaks your language can assist you.
(TTY: 1-800-750-0750).
o speaks your ATTENTION:
language can Interpreter
assist you. Services available. Someone who speaks your language can assist you.
750).
ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos
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 de asistencia lingüística.
1-888-464-8440
cios gratuitos de ATENCIÓN:
asistencia
Llame si habla español, tiene
lingüística. (TTY: 1-800-750-0750).
al1-888-464-8440
1-888-464-8440 a su disposición servicios gratuitos de asistencia lingüística.
語言援助服務。請致電 (TTY：1-800-750-0750)。
Llame al 1-888-464-8440 (TTY: 1-800-750-0750).
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
ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche 1-888-464-8440Hilfsdienstleistungen
務。請致電 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
1-888-464-8440
(TTY：1-800-750-0750)。 1-888-464-8440
hen Ihnen kostenlos sprachliche Hilfsdienstleistungen
zur Verfügung. Rufnummer: 1-888-464-8440 (TTY: 1-800-750-0750).
(TTY：1-800-750-0750)。
(TTY: 1-800-750-0750).
ACHTUNG:
‫االتصال على ھاتف رقم‬Wenn ‫يمكنك‬ Sie Deutsch
.‫لك بالمجان‬sprechen, stehen
‫اللغوية فھي تتوفر‬ Ihnen
‫المساعدة‬ kostenlos
‫خدمات‬ sprachliche
‫الحصول على‬ Hilfsdienstleistungen
‫ فيمكنك‬،‫العربية‬ ‫ إذا كنت تتحدث اللغة‬:‫ملحوظة‬
ostenlos ACHTUNG:
sprachliche
zur Wenn
Hilfsdienstleistungen
Verfügung. Sie Deutsch
Rufnummer: sprechen, stehen
1-888-464-8440 (TTY: Ihnen kostenlos sprachliche Hilfsdienstleistungen
1-800-750-0750).
‫ فيمكنك الحصول على خدمات المساعدة‬،‫ إذا كنت تتحدث اللغة العربية‬:‫ملحوظة‬ .(‫ المخصص للصم والبكم‬1-800-750-0750) ‫( أو‬1-888-464-0440)
750-0750). zur Verfügung. Rufnummer: 1-888-464-8440 (TTY: 1-800-750-0750).
.(‫ المخصص للصم والبكم‬1-800-750-0750) ‫( أو‬1-888-464-0440)
‫ھاتف رقم‬
Wann du‫على‬ ‫ يمكنك االتصال‬kannscht
schwetzscht, .‫تتوفر لك بالمجان‬ ‫اللغوية فھي‬
du mitaus ‫ المساعدة‬ebber
Koschte ‫على خدمات‬ ‫الحصول‬
gricke, ass‫فيمكنك‬
dihr ،‫العربية‬
helft mit ‫اللغة‬die
‫تتحدث‬ ‫ إذا كنت‬:‫ملحوظة‬
englisch
‫على‬ ‫الحصول‬ ‫فيمكنك‬ ‫رقم‬ ‫اللغةھاتف‬
،‫العربية‬ ‫تتحدثعلى‬
‫االتصال‬ ‫كنت‬ ‫يمكنك‬
‫إذا‬ .‫المساعدة اللغوية فھي تتوفر لك بالمجان‬
:‫ملحوظة‬ . (‫والبكم‬ ‫المخصصخدمات‬
‫للصم‬ ‫الحصول على‬
1 - ‫فيمكنك‬
800 - 750،‫العربية‬
- 0750 ‫اللغة‬
) ‫أو‬ ‫تتحدث‬
( 1- 888‫كنت‬ ‫ إذا‬-:‫ملحوظة‬
-464 0440)
oschte ebber gricke, Schprooch.ass dihr Rufhelft
sellimit die englisch
Nummer uff: Call 1-888-464-8440 (TTY: 1-800-750-0750).
‫المخصص‬ 1 - 800 - 750 - 0750 ) ‫أو‬ ( 1 - 888 - 464 - 0440 ) . (‫والبكم‬ ‫للصم‬ ‫المخصص‬ 1 - 800 - 750 - 0750 ) ‫أو‬ ( 1- 888 - 464 -0440)
464-8440 (TTY: 1-800-750-0750).
Wann du schwetzscht,
ВНИМАНИЕ: Если вы kannscht говорите du на mitaus
русском Koschte
языке,ebber то вамgricke, ass dihr
доступны helft mit die
бесплатные englisch
услуги
gricke, ass dihrWann
helft
Schprooch. du
mit schwetzscht,
die
Ruf englisch
selli kannscht
Nummer uff: du mitaus
Call Koschte ebber
1-888-464-8440 gricke,
(TTY: ass dihr helft mit die englisch
1-800-750-0750).
языке, то вамперевода. доступны Звоните бесплатные услуги
1-888-464-8440 (TTY: 1-800-750-0750).
TY: 1-800-750-0750).Schprooch. Ruf selli Nummer uff: Call 1-888-464-8440 (TTY: 1-800-750-0750).
800-750-0750).
ВНИМАНИЕ:
ATTENTION : Если Si vous выparlez
говорите на русском
français, языке,d'aide
des services то вам доступныvous
linguistique бесплатные
sont proposés услуги
ам доступны ВНИМАНИЕ:
бесплатные
перевода. Если вы
услуги
Звоните говорите на русском
1-888-464-8440 (TTY: языке, то вам доступны бесплатные услуги
1-800-750-0750).
rvices d'aide linguistique
gratuitement. vous sont proposés
Appelez le 1-888-464-8440 (ATS : 1-800-750-0750).
50). перевода. Звоните 1-888-464-8440 (TTY: 1-800-750-0750).
S : 1-800-750-0750).
ATTENTION
CHÚ Ý: Nếu bạn : Si vous
nói Tiếng parlez français,
Việt, có cácdes dịchservices
vụ hỗ trợ d'aide
ngônlinguistique
ngữ miễn phí vous sontcho
dành proposés
bạn. Gọi số
linguistique vousATTENTION
sont
gratuitement. proposés:Appelez
Si vous le parlez français, des(ATS
1-888-464-8440 services : d'aide linguistique vous sont proposés
1-800-750-0750).
ụ hỗ trợ ngôn ngữ miễn phí dành
1-888-464-8440 (TTY: cho1-800-750-0750).
bạn. Gọi số
0-0750). gratuitement. Appelez le 1-888-464-8440 (ATS : 1-800-750-0750).
CHÚ Ý: Nếu bạn nóiAfaan
XIYYEEFFANNAA: Tiếngdubbattu
Việt, có các dịch vụ tajaajila
Oroomiffa, hỗ trợ ngôn ngữ miễn
gargaarsa phí dành
afaanii, cho bạn. Gọi
kanfaltiidhaan ala, số
ni
n ngữ miễn phí CHÚ
dành Ý:cho
1-888-464-8440 Nếu bạnGọi
bạn. nóisố
(TTY: Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số
1-800-750-0750).
a, tajaajila gargaarsa argama. afaanii,
Bilbilaakanfaltiidhaan
1-888-464-8440 ala, ni (TTY: 1-800-750-0750).
1-888-464-8440 (TTY: 1-800-750-0750).
-750-0750).
XIYYEEFFANNAA:
주의: 한국어를 사용하시는 Afaan dubbattu
경우, 언어 Oroomiffa,
지원 서비스를 tajaajila무료로gargaarsa
이용하실 afaanii, kanfaltiidhaan ala, ni
수 있습니다.1-888-464-8440
rgaarsa afaanii, XIYYEEFFANNAA:
kanfaltiidhaan ala, Afaan
ni dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni
서비스를 무료로argama. 이용하실
(TTY:
Bilbilaa 1-888-464-8440 (TTY: 1-800-750-0750).
수 있습니다.1-888-464-8440
1-800-750-0750). 번으로 전화해
argama. Bilbilaa 1-888-464-8440 (TTY:주십시오.
1-800-750-0750).
시오. 주의: 한국어를 사용하시는 경우,parlata
언어 지원 서비스를 무료로 이용하실 수 있습니다.1-888-464-8440
ATTENZIONE: In caso la lingua sia 서비스를
l'italiano, sono disponibili
이용하실servizi di assistenza linguistica
로 이용하실 수주의: 한국어를
있습니다.1-888-464-8440
(TTY: 1-800-750-0750). 사용하시는 번으로 경우,전화해 언어 지원 주십시오. 무료로 수 있습니다.1-888-464-8440
taliano, sono disponibili servizi di ilassistenza
gratuiti. Chiamare linguistica
numero 1-888-464-8440 (TTY: 1-800-750-0750).
(TTY: 1-800-750-0750). 번으로 전화해 주십시오.
(TTY: 1-800-750-0750).
ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica
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。1-888-464-8440
disponibili ATTENZIONE:
servizi In
gratuiti. Chiamarelinguistica
di assistenza caso
il numero la lingua parlata sia l'italiano,
1-888-464-8440 sono disponibili servizi di assistenza linguistica
(TTY: 1-800-750-0750).
語支援をご利用いただけます。1-888-464-8440
(TTY: 1-800-750-0750) まで、お電話にてご連絡ください。
750-0750). gratuiti. Chiamare il numero 1-888-464-8440 (TTY: 1-800-750-0750).
連絡ください。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。1-888-464-8440
AANDACHT: Als u nederlands spreekt, kunt u gratis gebruikmaken van de taalkundige diensten. Bel
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。1-888-464-8440
利用いただけます。1-888-464-8440 (TTY: 1-800-750-0750) まで、お電話にてご連絡ください。
u gratis gebruikmaken 1-888-464-8440van de taalkundige diensten. Bel
(TTY: 1-800-750-0750).
。 (TTY: 1-800-750-0750) まで、お電話にてご連絡ください。
AANDACHT:
УВАГА! ЯкщоAls ви uрозмовляєте
nederlands spreekt, українськоюkunt uмовою,
gratis gebruikmaken van de taalkundige
ви можете звернутися до безкоштовної diensten. Bel
uikmaken van AANDACHT:
de taalkundige Als u nederlands spreekt, kunt u gratis gebruikmaken van de taalkundige diensten. Bel
мовою, ви 1-888-464-8440
можете
служби мовноїdiensten.
звернутися (TTY: BelТелефонуйте за номером 1-888-464-8440 (телетайп: 1-800-750-0750).
1-800-750-0750).
до безкоштовної
підтримки.
1-888-464-8440 (TTY: 1-800-750-0750).
номером 1-888-464-8440 (телетайп: 1-800-750-0750).
УВАГА! Якщо
ATENȚIE: Dacă виvorbiți
розмовляєте limba română,українською
vă stauмовою, ви можете
la dispoziție serviciiзвернутися
de asistențăдо безкоштовної
lingvistică, gratuit.
можете звернутися УВАГА!
служби до Якщо ви
безкоштовної
мовної розмовляєте
підтримки. українською
Телефонуйте за мовою,
номером ви можете звернутися
1-888-464-8440 до
(телетайп: безкоштовної
1-800-750-0750).
la dispoziție servicii de asistență lingvistică,
Sunați la 1-888-464-8440 (TTY: 1-800-750-0750). gratuit.
888-464-8440 (телетайп:служби мовної підтримки. Телефонуйте за номером 1-888-464-8440 (телетайп: 1-800-750-0750).
1-800-750-0750).
750).
ATENȚIE:
ध्यान Dacă
िदनुहोस्Dacă vorbiți
: यिद vorbiți
तपाईं नेप limba română,
ाली बोल्नु vă stau laिन:शु
हुन्छ भने dispoziție servicii de asistență lingvistică, gratuit.
servicii de ATENȚIE:
asistență
Sunați lingvistică,
la gratuit.
1-888-464-8440 limba
(TTY:română, văतपाईंले
1-800-750-0750).
ल्�मा भा�ा
stau la dispoziție सहायता
servicii de �ा� गनर् सक्नुlingvistică,
asistență हुन्छ। gratuit.
ले िन:शुल्�मा भा�ाSunați सहायता la �ा� गनर् सक्नुहुन्छ। (TTY: 1-800-750-0750).
1-888-464-8440
1-888-464-8440 (TTY:1-800-750-0750) मा फोन गनुर्होस्।
न गनुर्होस्। ध्यान िदनुहोस्: यिद तपाईं नेपाली बोल्नुहुन्छ भने तपाईंले िन:शुल्�मा भा�ा सहायता �ा� गनर् सक्नुहुन्छ।
ा�ा सहायता �ा� ध्यान िदनु
गनर् सक्न होस्: यिद तपाईं नेपाली बोल्नुहुन्छ भने तपाईंले िन:शुल्�मा भा�ा सहायता �ा� गनर् सक्नुहुन्छ।
ु हुन्छ।
1-888-464-8440 (TTY:1-800-750-0750) मा फोन गनुर्होस्।
1-888-464-8440 (TTY:1-800-750-0750) मा फोन गनुर्होस्।

H3660_17_134 Accepted 11050216  MC_Prospect 
  MC_Prospect 
H3660_17_134 Accepted 11050216 
H3660_17_134 Accepted 11050216 
  MC_Prospect 
MC_Prospect 
MC_Prospect 23
 
815177SCG_NE_EnrollGd.indd 23 9/5/18 10:04 AM
 www.summacare.com/medicare

815177SCG_NE_EnrollGd.indd 40 9/5/18 10:04 AM