21 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 sup- ply 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