Generations By GlobalHealth 2021 Summary Of Benefits

Generations by GlobalHealth2021 Summary of BenefitsJanuary 1 – December 31, 2021Generations State ofOklahoma GroupRetirees (HMO)1-844-280-5555 (TTY: 711)8 a.m. to 8 p.m.7 days a week (October 1 - March 31)Monday - Friday (April 1 - September 30)www.GlobalHealth.com/osrH3706 OSRSB 2021 M

GlobalHealth is an HMO plan with a Medicare contract. Enrollment in GlobalHealth dependson contract renewal.The benefit information provided does not list every service that we cover or list every limitationor exclusion. To get a complete list of services we cover, please see the “Evidence of Coverage.”The Evidence of Coverage can be found online at www.GlobalHealth.com, or you can request acopy from Customer Care at 1-844-280-5555 (TTY users should call 711).To join GlobalHealth, you must be entitled to Medicare Part A, be enrolled in Medicare Part B,and live in our service area. Our service area includes the following counties in ept in emergency situations, if you use the providers that are not in our network, we maynot pay for these services.For coverage and costs of Original Medicare, look in your current “Medicare & You” handbook.View it online at www.medicare.gov or get a copy by calling 1-800-MEDICARE (1-800-633-4227' .TTY users should call 1-877-486-2048.This document is available in other formats such as large print.For more information, please call us at 1-844-280-5555 (TTY users should call 711),or visit us at www.GlobalHealth.com.2

2021Medicare AdvantagePrescription Drug (MA-PD) Plans3

January 1, 2021 – December 31, 2021Generations State of Oklahoma Group Retirees (MA-PD)Summary of BenefitsPlans may offer supplemental benefits in addition to Part C benefits and Part D benefits.PREMIUMS AND BENEFITSGENERATIONS STATEOF OKLAHOMA GROUPRETIREESWHAT YOU SHOULD KNOWMonthly Plan Premium, includingPart C and Part D premiumYou pay 206You must continue to pay yourMedicare Part B premium.DeductibleYou pay nothingThis plan does not have adeductible.Maximum Out-of-PocketResponsibility (does notinclude prescription drugs) 3,450 annuallyThe most you pay for copays,coinsurance and other costs formedical services for the year.Inpatient Hospital Coverage1,2You pay 250 copay pervist; you pay nothing forCOVID-19 treatmentOutpatient Hospital Services 1,2 Observation servicesSurgeryDoctor Visits Primary SpecialistsPreventive Care1 Prior Authorization Required2 Referral Required You pay 150copay per visit; youpay nothing forCOVID-19 treatmentYou pay 200copay per visitIf you are admitted to thehospital as an inpatient afteroutpatient surgery or outpatientobservation, the outpatientcost-share is waived and theinpatient cost-share applies.You pay nothingYou pay 20 copayper visit; youpay nothing forCOVID-19 treatmentYou pay nothing forMedicare-coveredpreventive services.4Any additional preventive services approved by Medicareduring the contract year willbe covered.

PREMIUMS AND BENEFITSGENERATIONS STATEOF OKLAHOMA GROUPRETIREESEmergency CareYou pay 75 copay pervisit; you pay nothingfor COVID-19 treatmentUrgently Needed ServicesYou pay 15 copay pervisit; you pay nothingfor COVID-19 treatmentAmbulatory Surgery Center1, 2You pay nothingDiagnostic Services/Labs/Imaging Diagnostic radiology service(e.g., MRI)1,2 Lab services Diagnostic tests andprocedures Therapeutic Radiology1,2 Outpatient x-rays Hearing Services PCP diagnostic evaluation Specialist exam Routine exam Hearing aidsDental Services Medicare-covered services1,21 Prior Authorization Required2 Referral Required WHAT YOU SHOULD KNOWIf you are admitted toobservation, the hospital within24 hours, or outpatient surgicalservices are needed within 24hours, you do not have to payyour copay for emergency care.You pay 150copay per visitYou pay nothingYou pay 100for sleep studiesin an outpatientfacility; all otherdiagnostic tests andprocedures, you paynothingYou pay 40copay per visitYou pay nothingPrior authorization is requiredfor some services. Pleasecontact the plan for moreinformation.You pay nothingYou pay 20copay per visitYou pay nothingNo cost-share. Youare responsible forthe cost over yourbenefit allowance.Routine exam is for theevaluation for hearing aidsand limited to 1 per year. Ourplan pays up to a total of 500 for hearing aids peryear.You pay based onsetting (doctor’s office,emergency room, etc.)5

PREMIUMS AND BENEFITSVision Services Medicare-covered eye exam Supplemental eye exam Eyeglasses or contact lensesafter cataract surgery Supplemental eyeglasses orcontact lensesMental Health Services Inpatient visit1,2 Outpatient mental health visit Outpatient psychiatric visitSkilled Nursing Facility1,2Rehabilitation Services1,2 Occupational therapy visit Physical therapy and speechand language therapy visitGENERATIONS STATEOF OKLAHOMA GROUPRETIREES You pay nothingYou pay nothingYou pay nothingNo cost-share. Youare responsible forthe cost over yourbenefit allowance. Supplemental eye exam limitedto 1 per year.Choice of 1 pair of supplementaleyeglasses or contacts.Our plan pays up to 200 forsupplemental eye wear per year.You pay nothingYou pay nothingYou pay nothingYou pay nothing per dayfor days 1 through 20;You pay 184 copay perday for days 21 through100; you pay nothingfor COVID-19 treatment WHAT YOU SHOULD KNOWYou pay 20copay per visitYou pay 20copay per visitOur plan covers up to 100 daysin a SNF.Prior hospital stay is not required.If these services are provided inyour home, then the home healthcost-sharing applies instead.One-way trip.AmbulanceTransportationYou pay 50 copay peroccurrenceNot covered1 Prior Authorization Required2 Referral Required6If you are admitted to thehospital, you do not have topay your share of the cost forambulance services.See “Help with Certain ChronicConditions” in the Evidence ofCoverage for transportationservices provided for beneficiarieswith certain chronic illnesses.

PREMIUMS AND BENEFITSGENERATIONS STATEOF OKLAHOMA GROUPRETIREESMedicare Part B Drugs1,2, 3Home Health Services1,2Medical Equipment/Supplies Durable Medical Equipment(e.g., wheelchairs, oxygen)1 Prosthetics and relatedsupplies (e.g., braces,artificial limbs)1 Standard diabetic testingsuppliesYou pay 20% of thecost; you pay nothingfor COVID-19 treatmentYou pay nothing You pay 20% of thecostYou pay nothing forsurgically implanteddevices and medicalsupplies; you pay20% of the cost forexternal devices andmedical suppliesYou pay nothingChiropractic ServicesYou pay 20 copayper visitFoot Care (podiatry services) Foot exams and treatment Routine foot careWHAT YOU SHOULD KNOWYou pay 20 copayper visitYou pay 20 copayper visit1 Prior Authorization Required2 Referral Required3 May be subject to Part B step therapy.7You pay regular cost-sharingfor services or equipmentnot provided through a homehealth agency.Continuous Glucose Monitors(CGM) are considered DurableMedical Equipment. Please seeDurable Medical Equipment forCGM cost-share information.Routine foot care is limitedto members with certainmedical conditions affectingthe lower limbs.

PREMIUMS ANDBENEFITSGENERATIONS STATE OF OKLAHOMAGROUP RETIREESWHAT YOU SHOULDKNOWOUTPATIENT PRESCRIPTION DRUGSPhase 2: InitialCoverage (You don’thave a deductible)PreferredRetail Rx30-day supplyStandardRetail Rx30-day supplyPreferredRetail andMail Order90-day supply*Tier 1: PreferredGenericYou pay 5copay per fillYou pay 10copay per fillTier 2: GenericYou pay 15copay per fillYou pay 20copay per fillTier 3: PreferredBrandYou pay 42copay per fillYou pay 47copay per fillTier 4: NonPreferred DrugYou pay 40% of You pay 50% ofthe cost per fill the cost per fillTier 5: Specialty TierYou pay 33% of You pay 33% ofthe cost per fill the cost per fillCost-sharing mayYou pay nothing differ depending on thepharmacy’s status (e.g.,preferred, non-preferred,You pay nothing mail-order, Long-Term Care(LTC), or home infusion)You pay 84or the supply (e.g., 30- orcopay per fill90-days supply). Formore information on theYou pay 40% of additional pharmaciesthe cost per fill specific cost-sharing andthe phases of the benefit,please call us or accessN/Aour Evidence of Coverageonline.Phase 3: Coverage Gap StageAfter your prescription costs reach 4,130For generic drugs in Tiers 1 and 2,you pay either the same copaymentas in the Initial Coverage Stageor 25% of the costs, whichever islower. For brand name drugs inTiers 1 and 2, you pay either thesame copayment as the initialcoverage stage or 25% of the price(plus a portion of the dispensingfee), whichever is lower. For insulin,syringes, and oral anti-diabeticsin Tier 3, you pay either the samecopayment as in the Initial CoverageStage or 25% of the costs (plusa portion of the dispensing fee),whichever is lower. For all othergeneric drugs, you pay 25% of thecosts. For all other brand namedrugs, you pay 25% of the costs(plus a portion of the dispensing fee).You stay in this stageuntil your year-to-date“out-of-pocket costs” (yourpayments) reach a total of 6,550. This amount andrules for counting coststoward this amount havebeen set by Medicare.Phase 4: Catastrophic Coverage Stage You pay the greater of 5% ofAfter you have paid 6,550 out-ofthe cost of the drug or 3.70 forpocketgenerics/ 9.20 for brand names.PLEASE NOTE: Please visit our website for the most up-to-date drug Formulary. The formulary and/orpharmacy network may change at any time. You will receive notice when necessary.*Costs for 90-day supply are higher at a Standard Pharmacy.8

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Customer Care: 1-844-280-5555 (TTY: 711)8 a.m. to 8 p.m.7 days a week (October 1 - March 31)Monday - Friday (April 1 - September 30)www.GlobalHealth.com/osrProvider Directory and Pharmacy Directory:www.GlobalHealth.com/searchYou can see the complete plan formulary (list of Part D prescription drugs) and anyrestrictions on our website at www.GlobalHealth.com.GlobalHealth is an HMO plan with a Medicare contract. Enrollment in GlobalHealth dependson contract renewal.Fraud, Waste and Abuse: GlobalHealth iscommitted to fighting healthcare fraud, waste and abuse. If you suspectMedicare fraud, waste or abuse, call our hotline — 1-877-280-5852.GlobalHealth complies with applicable Federal civil rights laws and does notdiscriminate on the basis of race, color, national origin, age, disability, or sex.ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencialingüística. Llame al 1-844-280-5555 (TTY: 711).CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành chobạn. Gọi số 1-844-280-5555 (TTY: 711).

Generations State of Oklahoma Group Retirees (HMO). Generations by GlobalHealth 1-844-280-5555 (TTY: 7