A better Medicare.

A better you
MD MEDICARECHOICE, INC.

MD MedicareChoice Florida Optimum

SUMMARY OF BENEFITS

H5729-005

A Medicare Approved
Coordinated Care Plan

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 Section I - Introduction to the Summary of Benefits
for
MD MedicareChoice Florida Optimum
January 1, 2008 - December 31-2008
Alachua, Brevard, Charlotte, Duval, Escambia, Hernando,
Hillsborough, Lake, Lee, Manatee, Marion, Orange, Osceola,
Palm Beach, Pasco, Pinellas, Polk, Sarasota, Seminole,
Volusia Counties, FL.
The name of the PartnerCare Medicare Maximum FLA plan will now be MD
MedicareChoice Florida Optimum. We have chosen a name that is consistent with the
member population that we serve. All of your member materials will now show the new name
of the plan as MD MedicareChoice Florida Optimum.

SECTION I - INTRODUCTION TO SUMMARY OF BENEFITS

Thank you for your interest in MD MedicareChoice Florida Optimum. Our plan is offered by MD
MedicareChoice, Inc., a Medicare Advantage Health Maintenance Organization (HMO). This
Summary of Benefits tells you some features of our plan. It doesn't list every service that we
cover or list every limitation or exclusion. To get a complete list of our benefits, please call MD
MedicareChoice Florida Optimum and ask for the "Evidence of Coverage".

YOU HAVE CHOICES IN YOUR HEALTH CARE

As a Medicare beneficiary, you can choose from different Medicare options. One option is the
Original (fee-for-service) Medicare Plan. Another option is a Medicare health plan, like MD
MedicareChoice Florida Optimum. You may have other options too. You make the choice. No
matter what you decide, you are still in the Medicare Program.

You may join or leave a plan only at certain times. Please call MD MedicareChoice Florida
Optimum at the telephone number listed at the end of this introduction or 1-800-MEDICARE (1-
800-633-4227) for more information. TTY users should call 1-877-486-2048. You can call this
number 24 hours a day, 7 days a week.

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HOW CAN I COMPARE MY OPTIONS?
You can compare MD MedicareChoice Florida Optimum and the Original Medicare Plan using
this Summary of Benefits. The charts in this booklet list some important health benefits. For each
benefit, you can see what our plan covers and what the Original Medicare Plan covers.

Our members receive all of the benefits that the Original Medicare Plan offers. We also offer
more benefits, which may change from year to year.

WHERE IS MD MedicareChoice Florida Optimum AVAILABLE?

The service area for this plan includes: Alachua, Brevard, Charlotte, Duval, Escambia, Hernando,
Hillsborough, Lake, Lee, Manatee, Marion, Orange, Osceola, Palm Beach, Pasco, Pinellas, Polk,
Sarasota, Seminole, Volusia Counties, FL. You must live in one of these areas to join the plan.

WHO IS ELIGIBLE TO JOIN MD MedicareChoice Florida Optimum?

You can join MD MedicareChoice Florida Optimum if you are entitled to Medicare Part A and
enrolled in Medicare Part B and live in the service area. However, individuals with End Stage
Renal Disease are generally not eligible to enroll in MD MedicareChoice Florida Optimum unless
they are members of our organization and have been since their dialysis began.

CAN I CHOOSE MY DOCTORS?

MD MedicareChoice Florida Optimum has formed a network of doctors, specialists, and
hospitals. You can only use doctors who are part of our network. The health providers in our
network can change at any time. You can ask for a current Provider Directory for an up-to-date
list or visit us at www.mdmedicarechoice.com. Our customer service number is listed at the end
of this introduction.

WHAT HAPPENS IF I GO TO A DOCTOR WHO'S NOT IN YOUR NETWORK?

If you choose to go to a doctor outside of our network, you must pay for these services yourself.
Neither MD MedicareChoice nor the Original Medicare Plan will pay for these services.

DOES MY PLAN COVER MEDICARE PART B OR PART D DRUGS?

MD MedicareChoice Florida Optimum does cover both Medicare Part B prescription drugs and
Medicare Part D prescription drugs.

WHERE CAN I GET MY PRESCRIPTIONS IF I JOIN THIS PLAN?

MD MedicareChoice Florida Optimum has formed a network of pharmacies. You must use a
network pharmacy to receive plan benefits. We may not pay for your prescriptions if you use an
out-of-network pharmacy, except in certain cases. The pharmacies in our network can change at
any time. You can ask for a current Pharmacy Network List or visit us at
www.mdmedicarechoice.com. Our customer service number is listed at the end of this
introduction.

WHAT IS A PRESCRIPTION DRUG FORMULARY?

MD MedicareChoice Florida Optimum uses a formulary. A formulary is a list of drugs covered
by your plan to meet patient needs. We may periodically add, remove, or make changes to
coverage limitations on certain drugs or change how much you pay for a drug. If we make any

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formulary change that limits our members' ability to fill their prescriptions, we will notify the
affected enrollees before the change is made. We will send a formulary to you and you can see
our complete formulary on our Web site at http://www.mdmedicarechoice.com/formulary.pdf.

If you are currently taking a drug that is not on our formulary or subject to additional
requirements or limits, you may be able to get a temporary supply of the drug. You can contact us
to request an exception or switch to an alternative drug listed on our formulary with your
physician's help. Call us to see if you can get a temporary supply of the drug or for more details
about our drug transition policy.

HOW CAN I GET EXTRA HELP WITH PRESCRIPTION DRUG PLAN COSTS?
If you qualify for extra help with your Medicare prescription drug plan costs, your premium and
costs at the pharmacy will be lower. When you join MD MedicareChoice Florida Optimum,
Medicare will tell us how much extra help you are getting. Then we will let you know the amount
you will pay. If you are not getting this extra help you can see if you qualify by calling 1-800-
MEDICARE (1-800-633-4227), TTY users should call 1-877-486-2048. You can call this number
24 hours a day, 7 days a week.

WHAT ARE MY PROTECTIONS IN THIS PLAN?

All Medicare Advantage Plans agree to stay in the program for a full year at a time. Each year, the
plans decide whether to continue for another year. Even if a Medicare Advantage Plan leaves the
program, you will not lose Medicare coverage. If a plan decides not to continue, it must send you
a letter at least 90 days before your coverage will end. The letter will explain your options for
Medicare coverage in your area.

As a member of MD MedicareChoice Florida Optimum, you have the right to request a coverage
determination, which includes the right to request an exception, the right to file an appeal if we
deny coverage for a prescription drug, and the right to file a grievance. You have the right to
request a coverage determination if you want us to cover a Part D drug that you believe should be
covered. An exception is a type of coverage determination. You may ask us for an exception if
you believe you need a drug that is not on our list of covered drugs or believe you should get a
non-preferred drug at a lower out-of-pocket cost. You can also ask for an exception to cost
utilization rules, such as a limit on the quantity of a drug. If you think you need an exception, you
should contact us before you try to fill your prescription at a pharmacy. Your doctor must provide
a statement to support your exception request. If we deny coverage for your prescription drug(s),
you have the right to appeal and ask us to review our decision. Finally, you have the right to file a
grievance if you have any type of problem with us or one of our network pharmacies that does not
involve coverage for a prescription drug.

WHAT IS A MEDICATION THERAPY MANAGEMENT (MTM) PROGRAM?

A Medication Therapy Management (MTM) Program is a free service we may offer. You may be
invited to participate in a program designed for your specific health and pharmacy needs. You
may decide not to participate but it is recommended that you take full advantage of this covered
service if you are selected. Contact MD MedicareChoice Florida Optimum for more details.

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Please call MD MedicareChoice for more information about this plan.
Visit us at www.mdmedicarechoice.com or, call us:
Customer Service Hours:
Monday, Tuesday, Wednesday, Thursday, Friday, 8:00 a.m. - 8:00 p.m. Eastern
Current and Prospective members should call (888)-901-9208 for questions related to the
Medicare Advantage program. (TTY/TDD (866)-268-1800).
Current and Prospective members should call (888)-901-9208 for questions related to the
Medicare Part D Prescription Drug program. (TTY/TDD (866)-268-1800)
For more information about Medicare, please call Medicare at 1-800-MEDICARE
(1-800-633-4227).
TTY users should call 1-877-486-2048. You can call 24 hours a day, 7 days a week.
Or, visit www.medicare.gov on the web.
If you have special needs, this document may be available in other formats.
If you have any questions about this plan's benefits or costs, please contact MD
MedicareChoice for details.

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SECTION II - SUMMARY OF BENEFITS
Benefit Original Medicare MD MedicareChoice Florida Optimum
IMPORTANT INFORMATION
1 - Premium and $96.40 monthly Medicare Part B General
Other Important Premium. $0 monthly plan premium in addition to
Information your $96.40 monthly Medicare Part B
premium.
$135 yearly Medicare Part B In-Network
deductible. $3000 out-of-pocket limit. Contact the
plan for services that apply.
If a doctor or supplier does not Out-of-Network
accept assignment, their costs are Unless otherwise noted, out-of-network
often higher, which means you pay services not covered.
more.
2 - Doctor and You may go to any doctor, In-Network
Hospital Choice specialist or hospital that accepts You must go to network doctors,
Medicare. specialists, and hospitals.
(For more Referral required for network hospitals
information, see and specialists (for certain benefits).
Emergency - #15
and Urgently
Needed Care -
#16.)
SUMMARY OF BENEFITS
INPATIENT CARE
3 - Inpatient For each benefit period: Days 1 - In-Network
Hospital Care 60: $1024 deductible Days 61 - 90: For Medicare-covered hospital stays:
$256 per day Days 91 - 150: $512
per lifetime reserve day
(includes Please call 1-800-MEDICARE (1- Days 1 - 5: $25 copay per day
Substance Abuse 800-633-4227) for information
and about lifetime reserve days.
Rehabilitation
Services)
Lifetime reserve days can only be Days 6 - 90: $0 copay per day
used once.

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 A "benefit period" starts the day $0 copay for additional hospital days
you go into a hospital or skilled
nursing facility. It ends when you
go for 60 days in a row without
hospital or skilled nursing care. If
you go into the hospital after one
benefit period has ended, a new
benefit period begins. You must pay
the inpatient hospital deductible for
each benefit period. There is no
limit to the number of benefit
periods you can have.
No limit to the number of days covered
by the plan each benefit period.
Except in an emergency, your doctor
must tell the plan that you are going to be
admitted to the hospital.
4 - Inpatient Same deductible and copay as In-Network
Mental Health inpatient hospital care (see For hospital stays:
Care "Inpatient Hospital Care" above).
190 day limit in a Psychiatric Days 1 - 5: $25 copay per day
Hospital.
Days 6 - 90: $0 copay per day
You get up to 190 days in a Psychiatric
Hospital in a lifetime.
Except in an emergency, your doctor
must tell the plan that you are going to be
admitted to the hospital.
5 - Skilled For each benefit period after at least General
Nursing Facility a 3-day covered hospital stay: Days Prior authorization is required.
1 - 20: $0 per day Days 21 - 100:
$128 per day
(in a Medicare- 100 days for each benefit period. In-Network
certified skilled For SNF stays:
nursing facility)

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 A "benefit period" starts the day Days 1 - 7: $0 copay per day
you go into a hospital or SNF. It
ends when you go for 60 days in a
row without hospital or skilled
nursing care. If you go into the
hospital after one benefit period has
ended, a new benefit period begins.
You must pay the inpatient hospital
deductible for each benefit period.
There is no limit to the number of
benefit periods you can have.
Days 8 - 100: $25 copay per day
100 days covered for each benefit period
No prior hospital stay is required.
6 - Home Health $0 copay. General
Care Authorization rules may apply.
(includes In-Network
medically $0 copay for Medicare-covered home
necessary health visits.
intermittent
skilled nursing
care, home
health aide
services, and
rehabilitation
services, etc.)
7 - Hospice You pay part of the cost for In-Network
outpatient drugs and inpatient You must get care from a Medicare-
respite care. certified hospice.
You must get care from a Medicare-
certified hospice.
OUTPATIENT CARE
8 - Doctor Office 20% coinsurance General
Visits See "Routine Physical Exams," for more
information.
In-Network
$0 copay for each primary care doctor
visit for Medicare-covered benefits
$5 copay for each specialist visit for
Medicare-covered benefits.
9 - Chiropractic 20% coinsurance In-Network
Services $0 copay for Medicare-covered visits.

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 Routine care not covered Medicare-covered chiropractic visits are
for manual manipulation of the spine to
correct a displacement or misalignment of
a joint or body part.
20% coinsurance for manual
manipulation of the spine to correct
subluxation if you get it from a
chiropractor or other qualified
provider.
10 - Podiatry 20% coinsurance In-Network
Services $0 copay for
Medicare-covered visits
Routine care not covered. up to 6 routine visit(s) every year
20% coinsurance for medically Medicare-covered podiatry benefits are
necessary foot care, including care for medically-necessary foot care.
for medical conditions affecting the
lower limbs.
11 - Outpatient 50% coinsurance for most General
Mental Health outpatient mental health services. Authorization rules may apply.
Care
In-Network
$0 copay for Medicare-covered Mental
Health visits.
12 - Outpatient 20% coinsurance General
Substance Abuse Authorization rules may apply.
Care
In-Network
$0 copay for Medicare-covered visits.
13 - Outpatient 20% coinsurance for the doctor General
Services/Surgery Authorization rules may apply.
20% of outpatient facility In-Network
$0 copay for each Medicare-covered
ambulatory surgical center visit.
$100 copay for each Medicare-covered
outpatient hospital facility visit.
14 - Ambulance 20% coinsurance In-Network
Services $75 copay for Medicare-covered
ambulance benefits.
(medically If you are admitted to the hospital, you
necessary pay $0 for Medicare-covered ambulance
ambulance benefits.
services)

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15 - Emergency 20% coinsurance for the doctor In-Network
Care $50 copay for Medicare-covered
emergency room visits.
(You may go to 20% of facility charge, or a set Out-of-Network
any emergency copay per emergency room visit Not covered outside the U.S. except
room if you under limited circumstances. Contact the
reasonably plan for more details.
believe you need
emergency care.)
You don't have to pay the In and Out-of-Network
emergency room copay if you are If you are admitted to the hospital within
admitted to the hospital for the 48-hour(s) for the same condition, you
same condition within 3 days of the pay $0 for the emergency room visit
emergency room visit.
NOT covered outside the U.S.
except under limited circumstances.
16 - Urgently 20% coinsurance, or a set copay General
Needed Care $0 copay for Medicare-covered urgent-
care visits.
(This is NOT NOT covered outside the U.S.
emergency care, except under limited circumstances.
and in most
cases, is out of
the service area.)
17 - Outpatient 20% coinsurance General
Rehabilitation Authorization rules may apply.
Services
(Occupational In-Network
Therapy, $0 copay for Medicare-covered
Physical Occupational Therapy visits.
Therapy, Speech
and Language
Therapy)
$0 copay for Medicare-covered Physical
and/or Speech/Language Therapy visits.
OUTPATIENT MEDICAL SERVICES AND SUPPLIES
18 - Durable 20% coinsurance General
Medical Authorization rules may apply.
Equipment
(includes In-Network
wheelchairs, $0 copay for Medicare-covered items.
oxygen, etc.)

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19 - Prosthetic 20% coinsurance General
Devices Authorization rules may apply.
(includes braces, In-Network
artificial limbs 10% of the cost for Medicare-covered
and eyes, etc.) items.
20 - Diabetes 20% coinsurance In-Network
Self-Monitoring $0 copay for Diabetes self-monitoring
Training, training.
Nutrition
Therapy, and
Supplies
(includes $0 copay for Nutrition Therapy for
coverage for Diabetes.
glucose
monitors, test
strips, lancets,
screening tests,
and self-
management
training)
$0 copay for Diabetes supplies.
21 - Diagnostic 20% coinsurance for diagnostic General
Tests, X-Rays, tests and x-rays Authorization rules may apply.
and Lab Services
$0 copay for Medicare-covered lab In-Network
services $0 copay for Medicare-covered:
Lab Services: Medicare covers - lab services
medically necessary diagnostic lab
services that are ordered by your
treating doctor when they are
provided by a Clinical Laboratory
Improvement Amendments (CLIA)
certified laboratory that participates
in Medicare. Diagnostic lab services
are done to help your doctor
diagnose or rule out a suspected
illness or condition. Medicare does
not cover most routine screening
tests, like checking your
cholesterol.
- diagnostic procedures and tests
$0 to $25 copay for Medicare-covered X-
rays.
$0 to $25 copay for Medicare-covered

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 diagnostic radiology services.
$20 copay for Medicare-covered
therapeutic radiology services.
PREVENTIVE SERVICES
22 - Bone Mass 20% coinsurance In-Network
Measurement $0 copay for Medicare-covered bone
mass measurement
(for people with Covered once every 24 months
Medicare who (more often if medically necessary)
are at risk) if you meet certain medical
conditions.
23 - Colorectal 20% coinsurance In-Network
Screening $0 copay for Medicare-covered colorectal
Exams screenings.
(for people with Covered when you are high risk or
Medicare age 50 when you are age 50 and older.
and older)
24 - $0 copay for Flu and Pneumonia In-Network
Immunizations vaccines $0 copay for Flu and Pneumonia
vaccines.
(Flu vaccine, 20% coinsurance for Hepatitis B $0 copay for Hepatitis B vaccine.
Hepatitis B vaccine
vaccine - for
people with
Medicare who
are at risk,
Pneumonia
vaccine)
You may only need the Pneumonia No referral needed for Flu and
vaccine once in your lifetime. Call pneumonia vaccines.
your doctor for more information.
25 - 20% coinsurance In-Network
Mammograms $0 copay for Medicare-covered screening
(Annual mammograms.
Screening)
(for women with No referral needed.
Medicare age 40
and older)
Covered once a year for all women
with Medicare age 40 and older.
One baseline mammogram covered
for women with Medicare between
age 35 and 39.

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26 - Pap Smears $0 copay for Pap smears In-Network
and Pelvic $0 copay for Medicare-covered pap
Exams smears and pelvic exams.
(for women with Covered once every 2 years.
Medicare) Covered once a year for women
with Medicare at high risk.
20% coinsurance for Pelvic Exams
27 - Prostate 20% coinsurance for the digital In-Network
Cancer rectal exam. $0 copay for Medicare-covered prostate
Screening cancer screening.
Exams
(for men with $0 for the PSA test; 20%
Medicare age 50 coinsurance for other related
and older) services.
Covered once a year for all men
with Medicare over age 50.
28 - ESRD 20% coinsurance for dialysis General
Authorization rules may apply. Out-of-
area Renal Dialysis services do not
require Authorization.
In-Network
$0 copay for in and out-of-area dialysis
$0 copay for Nutrition Therapy for Renal
Disease
29 - Prescription Most drugs not covered. (You can Drugs covered under Medicare Part B
Drugs add prescription drug coverage to General
Original Medicare by joining a 10% of the cost for Part B-covered drugs
Medicare Prescription Drug Plan.) (not including Part B-covered
chemotherapy drugs).
10% of the cost for Part B-covered
chemotherapy drugs.
Drugs covered under Medicare Part D
General
This plan uses a formulary. The plan will
send you the formulary. You can also see
the formulary at
http://www.mdmedicarechoice.com/form
ulary.pdf on the web.

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 Different out-of-pocket costs may apply
for people who
- have limited incomes,
- live in long term care facilities, or
- have access to Indian/Tribal/Urban
(Indian Health Service).
The plan offers national in-network
prescription coverage. This means that
you will pay the same amount for your
prescription drugs if you get them at an
in-network pharmacy outside of the plan's
service area (for instance when you
travel).
Total yearly drug costs are the total drug
costs paid by both you and the plan.
The plan may require you to first try one
drug to treat your condition before it will
cover another drug for that condition.
Some drugs have quantity limits.
Your provider must get prior
authorization from MD MedicareChoice
Florida Optimum for certain drugs.
The plan will pay for certain over-the-
counter drugs as part of its utilization
management program. Some over-the-
counter drugs are less expensive than
prescription drugs and work just as well.
Contact the plan for details.
If the actual cost of a drug is less than the
normal copay amount for that drug, you
will pay the actual cost, not the higher
copay amount.
You may have to pay more than your
copay if you choose to use a higher cost
drug when a lower cost drug is available.
In-Network
$0 deductible.
Initial Coverage
You pay the following until total yearly
drug costs reach $2850:
Retail Pharmacy
Generic

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 - $0 copay for a one-month (31-day)
supply of drugs
- $0 copay for a three-month (93-day)
supply of drugs
- $0 copay for a 93-day supply of drugs
Preferred Brand
- $15 copay for a one-month (31-day)
supply of drugs
- $45 copay for a three-month (93-day)
supply of drugs
- $45 copay for a 93-day supply of drugs
Non-Preferred Brand
- $30 copay for a one-month (31-day)
supply of drugs
- $90 copay for a three-month (93-day)
supply of drugs
- $90 copay for a 93-day supply of drugs
Specialty Drugs
- 25% coinsurance for a one-month (31-
day) supply of drugs
- 25% coinsurance for a three-month (93-
day) supply of drugs
- 25% coinsurance for a 93-day supply of
drugs
Long Term Care Pharmacy
Generic
- $0 copay for a one-month (31-day)
supply of drugs
Preferred Brand
- $15 copay for a one-month (31-day)
supply of drugs
Non-Preferred Brand
- $30 copay for a one-month (31-day)
supply of drugs
Specialty Drugs
- 25% coinsurance for a one-month (31-
day) supply of drugs
Mail Order
Generic
- $0 copay for a one-month (31-day)
supply of drugs

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 - $0 copay for a three-month (93-day)
supply of drugs
- $0 copay for a 93-day supply of drugs
Preferred Brand
- $15 copay for a one-month (31-day)
supply of drugs
- $45 copay for a three-month (93-day)
supply of drugs
- $45 copay for a 93-day supply of drugs
Non-Preferred Brand
- $30 copay for a one-month (31-day)
supply of drugs
- $90 copay for a three-month (93-day)
supply of drugs
- $90 copay for a 93-day supply of drugs
Specialty Drugs
- 25% coinsurance for a one-month (31-
day) supply of drugs
- 25% coinsurance for a three-month (93-
day) supply of drugs
- 25% coinsurance for a 93-day supply of
drugs
Coverage Gap
You pay the following:
The plan covers All Generics through the
gap.
Retail Pharmacy
Generic
- $0 copay for a one-month (31-day)
supply of drugs
- $0 copay for a three-month (93-day)
supply of drugs
- $0 copay for a 93-day supply of drugs
Long Term Care Pharmacy
Generic
- $0 copay for a one-month (31-day)
supply of drugs
Mail Order
Generic
- $0 copay for a one-month (31-day)
supply of drugs

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 - $0 copay for a three-month (93-day)
supply of drugs
- $0 copay for a 93-day supply of drugs
For all other covered drugs, after your
total yearly drug costs reach $2850, you
pay 100% until your yearly out-of-pocket
drug costs reach $4050.
Catastrophic Coverage
After your yearly out-of-pocket drug
costs reach $ 4050, you pay the greater
of:
- $ 2.25 copay for generic (including
brand drugs treated as generic) and $ 5.60
copay for all other drugs, or
- 5% coinsurance.
Out-of-Network
Plan drugs may be covered in special
circumstances, for instance, illness while
traveling outside of the plan's service area
where there is no network pharmacy. You
may pay more than the copay if you get
your drugs at an out-of-network
pharmacy.
Out-of-Network Initial Coverage
You pay the following until total yearly
drug costs reach $2850:
Out-of-Network Pharmacy
Generic
- $0 copay for a one-month (31-day)
supply of drugs
- $0 copay for a (29-day) supply of drugs
Preferred Brand
- $15 copay for a one-month (31-day)
supply of drugs
- $15 copay for a (29-day) supply of
drugs
Non-Preferred Brand
- $30 copay for a one-month (31-day)
supply of drugs
- $30 copay for a (29-day) supply of
drugs
Specialty Drugs

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 - 25% coinsurance for a one-month (31-
day) supply of drugs
- 25% coinsurance for a (29-day) supply
of drugs
Out-of-Network Coverage Gap
You pay the following:
Generic
- $0 copay for a one-month (31-day)
supply of drugs
- $0 copay for a (29-day) supply of drugs
Out-of-Network Catastrophic Coverage
After your yearly out-of-pocket drug
costs reach $ 4050, you pay the greater
of:
- $ 2.25 copay for generic (including
brand drugs treated as generic) and $ 5.60
copay for all other drugs, or
- 5% coinsurance.
30 - Dental Preventive dental services (such as In-Network
Services cleaning) not covered. $0 copay for Medicare-covered dental
benefits
$0 copay for the following preventive
dental benefits:
- up to 2 oral exam(s) every year
- up to 2 cleaning(s) every year
- fluoride treatments
- up to 1 dental x-ray(s) every year
Plan offers additional comprehensive
dental benefits.
$500 limit for comprehensive dental
benefits every year
31 - Hearing Routine hearing exams and hearing General
Services aids not covered. Authorization rules may apply.
20% coinsurance for diagnostic In-Network
hearing exams. $0 copay for diagnostic hearing exams
- routine hearing tests
- fitting-evaluations for a hearing aid
$0 copay for up to 600 hearing aid(s)
every three years.
32 - Vision 20% coinsurance for diagnosis and General
Services treatment of diseases and conditions Authorization rules may apply.
of the eye.

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 Routine eye exams and glasses not
covered.
Medicare pays for one pair of
eyeglasses or contact lenses after
cataract surgery.
Annual glaucoma screenings
covered for people at risk.
33 - Physical 20% coinsurance for one exam
Exams within the first 6 months of your
new Medicare Part B coverage
When you get Medicare Part B, you Limited to 1 exam(s) every year.
can get a one time physical exam
within the first 6 months of your
new Part B coverage. The coverage
does not include lab tests.
Health/Wellness Not covered.
Education
Transportation Not covered.
(Routine)
19
In-Network
$0 copay for diagnosis and treatment for
diseases and conditions of the eye
and up to 1 routine eye exam(s) every
year
$0 copay for
- one pair of eyeglasses or contact lenses
after each cataract surgery
- up to 1 pair(s) of glasses every year
- up to 1 pair(s) of contacts every year
In-Network
$0 copay for routine exams.
General
Authorization rules may apply.
In-Network
This plan covers health/wellness
education benefits.
-Nutritional benefit
- Health Club Membership/Fitness
Classes
- Nursing Hotline
General
Authorization rules may apply.
In-Network
$0 copay for up to 24 one-way trip(s) to
plan-approved location every year.
H5729 005_03_CO0524 (10/07)