Page 1 Page 2 Page 3 Page 4 Page 5 Page 6 Page 7 Page 8 Page 9 Page 10 Page 11 Page 12 Page 13 Page 14 Page 15 Page 16 Page 17 Page 18 Page 19 Page 20 Page 21 Page 22 Page 23 Page 24 Page 25 Page 26 Page 27 Page 28 Page 29 Page 30 Page 31 Page 32 Page 33 Page 34 Page 35 Page 36 Page 37 Page 3821 Plan Benefits UnitedHealthcare PPO Kaiser Permanente Medicare Supplement Medicare Plus Doctor and Hospital Choice Annual Physical Inpatient Hospital Care Doctor’s Office Visits Diagnostic Tests, X-rays & Lab Services Emergency Room Services Prescriptions Durable Medical Equipment Vision Services Primary Insurance Secondary Insurance You may choose any doctor or hospital that accepts Medicare Covered at 100% Plan pays 100% of covered charges remaining after Medicare Plan pays 100% of covered charges remaining after Medicare Plan pays 100% of covered charges remaining after Medicare Plan pays 100% of covered charges remaining after Medicare See Caremark on page 11. Copays for SilverScript are the same as the CVS/ caremark commercial plan Plan pays 100% of covered charges remaining after Medicare. Prior notification required Plan pays 100% (after $25 copay) for a refractive eye examination every calendar year at participating providers; discounts on frames and lenses at participating providers Medicare: Parts A & B UnitedHealthcare You may choose any Kaiser Permanente network doctor, specialist, and participating hospital. Specialty care may require a referral from your Primary Care Physician Covered at 100% Unlimited days for a Medicare covered stay in a network hospital are covered in full after $100 copay $15 copay $15 copay for radiation therapy; no charge for XRays, lab services, or diagnostic tests $50 copay (copay waived if admitted) $10 copay for up to a 90 day supply of mail order medicine (brand or generic), $15 copay for up to a 60 day supply (brand or generic) at Kaiser Permanente center pharmacy, $25 copay for up to a 60 day supply (brand or generic) at participating network pharmacy Covered in full through participating providers $15 copay for eye exam; discounts on frames, lenses and contact lenses Kaiser Permanente Medicare: Parts A, B & D This is a summary of health care benefits. In the event of a difference between this summary and the plan brochure, the plan brochure will govern. All WSSC sponsored health plans provide supplemental coverage for retirees with Medicare Part A and Part B. Benefits under the UnitedHealthcare and Kaiser Medicare Supplements differ from non-Medicare benefit plans and are described below. Medicare-eligible Summary of Services