2018 Summary of BenefitsEon Select (HMO) and Eon Choice (PPO)GEORGIA / SOUTH CAROLINA

For more information, call 1-844-895-8643 Y0122_0174 AcceptedMAPD

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This is a summary of drug and health services covered by Eon Health January 1, 2018 - December 31, 2018.

Eon Health has a contract with Medicare to offer HMO and PPO plans. Eon Health also has a contract with the Georgia Medicaid program and a contract with the South Carolina Medicaid program. Enrollment in Eon Health depends on contract renewal.

The benefit information provided is a summary of what we cover and what you pay. It does not list every service that we cover or list ev-ery limitation or exclusion. To get a complete list of services we cover, please request the “Evidence of Coverage.” You can obtain a copy of our Evidence of Coverage by calling us at: Current Members: 1-888-906-3889, Prospective Members: 1-844-895-8643, TTY: 711 or visiting our website at www.eonhealthplan.com

For coverage and cost of Original Medicare look in your current “Medicare and You” Handbook. View it online at www.medicare.gov or get a copy by calling 1-800-Medicare (1-800-663-4227). TTY users should call 1-877-486-2048.

Eon Select: Eon Health has a network of doctors, hospitals, pharmacies, and other providers. If you use the providers that are not in our network, the plan may not pay for these services.

Eon Choice: Eon Health has a network of doctors, hospitals, pharmacies, and other providers. If you use the providers that are not in our network, your costs may be higher, deductibles and coinsurances may apply.

You can see our Provider and Pharmacy Directory on our website at www.eonhealthplan.com

You can see our Formulary (List of Part D prescription drugs) on our website at www.eonhealthplan.com

2018 Summary of BenefitsEon Select (HMO) and Eon Choice (PPO)

IntroductionEon Select

is a Medicare Advantage HMO offered in Georgia and South Carolina.

Eon Choiceis a Medicare Advantage PPO offered in Georgia and South Carolina.

To join Eon Select and Eon Choice, you must be entitled to Medicare Part A, enrolled in Medicare Part B and live in our service area.

Eon Select and Eon Choice Service Areas:

STATE SERVICE AREA

GEORGIA Baker, Baldwin, Banks, Barrow, Bibb, Bleckley, Bryan, Butts, Chatham, Cherokee, Clayton, Clinch, Crawford, Dawson, DeKalb, Dodge, Dooly, Fayette, Forsyth, Franklin, Greene, Hancock, Hart, Heard, Henry, Houston, Jasper, Jones, Lamar, Lumpkin, Macon, Madison, McIntosh, Meriwether, Monroe, Morgan, Newton, Oconee, Oglethorpe, Peach, Pickens, Pike, Pulaski, Putnam, Rabun, Rockdale, Schley, Screven, Stephens, Talbot, Taliaferro, Taylor, Twiggs, Walton, White, Wilcox, Wilkinson counties

SOUTH CAROLINA Beaufort, Chester, Colleton, Fairfield, Greenville, Hampton, Jasper, Lee, Saluda, Spartanburg, Union counties

Eon Select (HMO)SUMMARY OF BENEFITS

Health Maintenance Organization (HMO)

plans – in most HMOs, you can only go to

doctors, other health care providers, or

hospitals in the plan’s network. In an urgent

or emergency situation you can access in-

network and out of network providers.

Eon SelectHMO / Plan Highlights

Monthly Premium:$0

Doctor Visits:$10 PCP / $50 Specialist

Prescription Drugs:Low copayment for generic drugs

Dental Care:Preventative • Comprehensive • Dentures

Vision Care:$175 towards glasses or contact lenses

Hearing Care:Exams and up to $750 for hearing aids

Over-The-Counter (OTC) items:$20 allowance per month

Chiropractic Care:Routine visit $20 copay (4 visits per year)

Meals:Up to 20 meals after inpatient hospital stay

Fitness Program:SilverSneakers®

Benefits Eon Select / Health BenefitsMonthly Plan Premium $0 per month

DeductiblePart C (Medical) $0Part D (Pharmacy) $250 only applies to Tiers 3, 4 and 5

Maximum Out-of-Pocket Responsibility(does not include prescription drugs)

$6,700 annually

Inpatient Hospital Coverage1 $300/day for days 1-5$0/day for days 6-90

Outpatient Hospital Coverage1 $200 copay Ambulatory Surgical Center$225 copay Outpatient Hospital

Doctor Visits(Primary and Specialist)

Primary Care Physician visit: $10 copaySpecialist visit: $50 copay

Preventive Care $0 copay

Emergency Care $80 copay

Urgently Needed Care $50 copay

Diagnostic Services / Labs / Imaging1

Diagnostic radiology services (such as MRIs, CT scans): 20% coinsuranceDiagnostic tests and procedures: 20% coinsuranceLab services: $5 copayOutpatient x-rays: $25 copayTherapeutic radiology services (such as radiation treatment for cancer):20% coinsurance

1May require prior authorization

Eon Select (HMO)SUMMARY OF BENEFITS

Benefits Eon Select / Health Benefits

Hearing Services1

Exam to diagnose and treat hearing and balance issues: $25 copayRoutine hearing exam (for up to 1 every year): $25 copayHearing aid fitting/evaluation (for up to 1 every 3 years): $0 copayOur plan pays up to $750 every three years for hearing aids. Benefit amount applies to bothears combined.

Dental Services1

Preventive dental services:Cleaning (for up to 1 every six months): $0 copayDental x-ray(s) (for up to 1 every six months): $0 copayOral exam (for up to 1 every six months): $0 copay1 dental bitewing x-ray per side every six months: $0 copay1 panoramic x-ray every five years: $0 copay

Comprehensive dental services:Coverage limit is $800 every year.$0 copay for non-Medicare covered services$50 copay for Medicare covered servicesCoverage is limited to fillings, simple extractions, dentures, and denture repair. Additional dental services, such as root canals, crowns, surgical extractions, denture relines and periodontal (gum) treatments, are not covered.1 partial or 1 complete denture per arch every five years. $0 copay

Vision Services

Exam to diagnose and treat diseases and conditions of the eye: $25 copayAnnual Glaucoma screening: $0 copayRoutine eye exam (for up to 1 every year): $0 copayContact lenses: (for up to 1 every year): $0 copayEyeglasses (frames and lenses): (for up to 1 every year): $0 copay Eyeglasses or contact lensesafter cataract surgery: $0 copay$175 every year for contact lenses and or eyeglasses (frames and lenses)

1May require prior authorization

Eon Select (HMO)SUMMARY OF BENEFITS

Benefits Eon Select / Health Benefits

Mental Health Services1

Inpatient:$300/Day for Days 1-5$0/Day for Days 6-90

Outpatient group therapy visit: $40 copayOutpatient individual therapy visit: $40 copay

Skilled Nursing Facility (SNF)1$0 / Day for Days 1-20$167 / Day for Days 21-100

Physical Therapy (Outpatient) 1 Physical therapy visit: $40 copay

Ambulance1 $225 copay

Transportation1 Not covered

Medicare Part B drugs1 20% coinsurance

1May require prior authorization

Eon Select (HMO)SUMMARY OF BENEFITS

Benefits Eon Select / Prescription Drug BenefitsDeductible Part D (Pharmacy) $250 Only applies to Tiers 3, 4, and 5

Initial Coverage Retail (after you pay your deductible, ifapplicable)

Tier 1: Preferred Generic 1 month supply: $4 2 month supply: $8 3 month supply: $12

Tier 2: Non-Preferred Generic 1 month supply: $15 2 month supply: $30 3 month supply: $45

Tier 3: Preferred Brand 1 month supply: $47 2 month supply: $94 3 month supply: $141

Tier 4: Non-Preferred Brand 1 month supply: $100 2 month supply: $200 3 month supply: $300

Tier 5 Specialty 1 month supply: 28% 2 month supply: 28% 3 month supply: 28%

Initial coverage Mail Order

Tier 1: Preferred Generic 3 month: $8

Tier 2: Non-Preferred Generic 3 month: $30

Tier 3: Preferred Brand 3 month: $94

Tier 4: Non-Preferred Brand 3 month: $200

Tier 5 Specialty 3 month: 28%

Coverage GapAfter you enter the coverage gap, you pay 35% of the plan’s cost for covered brand name drugs and 44% of the plan’s cost for covered generic drugs until your costs total $5,000, which is the end of the coverage gap. Not everyone will enter the coverage gap.

Catastrophic CoverageFor generic (including brand drugs treated as generic): 5% of the cost, or $3.35 copay whicheveris greater

For all other drugs: 5% of the cost, or $8.35 copay, whichever is greater

1May require prior authorization

Eon Select (HMO)SUMMARY OF BENEFITS

Benefits Eon Select / Additional Health Benefits

Chiropractic Care

Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): $20 copay Medicare Covered Visit

Routine Visit $20 copay (4 visits per yr.)

Foot Care (Podiatry Services)

Foot exams and treatment if you have diabetes related nerve damage and/or meet certain conditions: $45 copay.

Routine foot care: Not covered.

Diabetic Supplies and Services1Diabetes monitoring supplies: 20% coinsurance

Therapeutic shoes or inserts: 20% coinsurance

Meals1 Up to 20 meals. Plan covers up to 28 days after inpatient hospital stay

Rehabilitation Services (Outpatient)1

Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions for a period of up to 36 weeks): 20% CoinsuranceOccupational therapy visit: $40 copaySpeech and language therapy visit: $40 copay

Medical Equipment and Supplies1

20% CoinsuranceProsthetic devices: 20% coinsuranceRelated medical supplies: 20% coinsurance

Over-the-Counter (OTC) Items Members receive a $20 allowance every month

Fitness Program

Fitness program: SilverSneakers®Basic membership to one Plan approved fitness facility per monthOrientation to the fitness center and instructions about how to use equipmentand servicesOne @Home workout Pak per year

1May require prior authorization

Eon Select (HMO)SUMMARY OF BENEFITS

Eon Choice (PPO)SUMMARY OF BENEFITS

Preferred Provider Organization (PPO) plan:

In a PPO, you pay less if you use doctors,

hospital, and other health care providers

that participate in the plan’s network. With

a PPO you also have access to doctors,

hospital, and other health care providers

that do not participate in the plan’s network.

You will usually pay more if you access

provider(s) outside the plans network.

Eon ChoicePPO / Plan Highlights

Monthly Premium:$15

Doctor Visits:$15 PCP / $50 Specialist

Prescriptions:Low copayment for generic drugs

Dental Care:Preventative Services

Vision Care:$175 towards glasses or contact lenses

Hearing Care:Exams and up to $750 for hearing aids

Over-The-Counter (OTC) items:$20 allowance per month

Chiropractic Care:Routine visit $20 copay (4 visits per year)

Meals:Up to 20 meals after inpatient hospital stay

Fitness Program:SilverSneakers®

1May require prior authorization

Eon Choice (PPO)SUMMARY OF BENEFITS

Benefits Eon Choice / Health BenefitsIN-NETWORK OUT-OF-NETWORK

Monthly Plan Premium

$15 per month

Deductible Part C (Medical) $0 Part C (Medical): $500

Part D (Pharmacy): $250 only applies to Tiers 3, 4, and 5 (In-Network and Out-of-Network)

Maximum Out-of-Pocket Responsibility(does not include pre-scription drugs)

$6,700 annually$10,000 - Services received from in-network providers WILL count toward this limit.

Inpatient Hospital Coverage1

$300 / Day for Days 1-5$0 / Day for Days 6-90

40% Coinsurance

Outpatient Hospital Coverage1

$200 Copay Ambulatory Surgical Center 40% Coinsurance Ambulatory Surgical Center

$225 Copay Outpatient Hospital 40% Coinsurance Outpatient Hospital

Doctor Visits (Primary and Specialist)

Primary care physician visit: $15 copay Primary care physician visit: 40% coinsurance

Specialist visit: $50 copay Specialist visit: 40% coinsurance

Preventive Care $0 copay 0% coinsurance

Emergency Care $80 copay $80 copay

Urgently Needed Care $50 copay $50 copay

Benefits Eon Choice / Health BenefitsIN-NETWORK OUT-OF-NETWORK

Diagnostic Services/Labs/Imaging1

Diagnostic radiology services (such as MRIs, CT scans): 20% coinsurance

Diagnostic radiology services (such as MRIs, CT scans): 40% coinsurance

Diagnostic tests and procedures: 20% coinsurance Diagnostic tests and procedures: 40% coinsurance

Lab services: $5 copay Lab services: 40% coinsurance

Outpatient x-rays: $25 copay Outpatient x-rays: 40% coinsurance

Therapeutic radiology services (such as radiation treatment for cancer): 20% coinsurance

Therapeutic radiology services (such as radiation treatment for cancer): 40% coinsurance

Hearing Services1

Exam to diagnose and treat hearing and balance issues: $25 copay

Exam to diagnose and treat hearing and balance issues: 40% coinsurance

Routine hearing exam (for up to 1 every year): $25 copay

50% coinsurance

Hearing aid fitting/evaluation (for up to 1 every 3 years): $0 copay

50% coinsurance

Our plan pays up to $750 every three years for hearing aids. Benefit amount applies to both ears combined.

50% coinsurance

1May require prior authorization

Eon Choice (PPO)SUMMARY OF BENEFITS

Benefits Eon Choice / Health BenefitsIN-NETWORK OUT-OF-NETWORK

DentalServices1

Preventive dental services:Cleaning (for up to 1 every six months): $0 copayDental x-ray(s) (for up to 1 every six months): $0 copayOral exam (for up to 1 every six months): $0 copayDental bitewing x-ray per side (for up to 1 every six months): $0 copayPanoramic x-ray (for up to 1 every five years): $0 copay

Preventive dental services:Cleaning (for up to 1 every six months): 50% coinsuranceDental x-ray(s) (for up to 1 every six months): 50% coinsuranceOral exam (for up to 1 every six months): 50% coinsuranceDental bitewing x-ray per side (for up to 1 every six months): 50% coinsurancePanoramic x-ray (for up to 1 every five years): 50% coinsurance

Comprehensive dental services:$50 copay for Medicare-covered comprehensive benefits

Comprehensive dental services: 40% coinsurance for Medicare-covered comprehensive benefits

VisionServices

Exam to diagnose and treat diseases and conditions of the eye: $25 copay

Exam to diagnose and treat diseases and conditions of the eye: 40% coinsurance

Glaucoma Screening: $25 copay Glaucoma Screening: 40% coinsurance

Routine eye exam (for up to 1 every year): $0 copay 50% coinsurance

Contact lenses: (for up to 1 every year): $0 copayEyeglasses (frames and lenses): (for up to 1 every year):$0 copayEyeglasses or contact lenses after cataract surgery:$0 copay

50% coinsurance

$175 every year for contact lenses and or eyeglasses (frames and lenses).

50% coinsurance

1May require prior authorization

Eon Choice (PPO)SUMMARY OF BENEFITS

Benefits Eon Choice / Health BenefitsIN-NETWORK OUT-OF-NETWORK

Mental Health Services1

Inpatient:$300 / Day for Days 1-5$0 / Day for days 6 – 90

Inpatient:40% coinsurance

Outpatient:Group therapy visit: $40 copayIndividual therapy visit: $40 copay

Outpatient:Group therapy visit: 40% coinsuranceIndividual therapy visit: 40% coinsurance

Skilled Nursing Facility (SNF)1$0 / Day for Days 1-20$167 / Day for Days 21-100

40% coinsurance

Physical Therapy1 Physical therapy visit:$40 copay

Physical therapy visit:40% coinsurance

Ambulance1 $225 copay $225 copay

Transportation Not covered Not covered

Medicare Part B Drugs1 20% coinsurance 40% coinsurance

1May require prior authorization

Eon Choice (PPO)SUMMARY OF BENEFITS

Benefits Eon Choice / Prescription Drug BenefitsDeductible Part D (Pharmacy) $250 Only applies to Tiers 3, 4, and 5

Initial Coverage Retail(after you pay your deductible, if applicable)

Tier 1: Preferred Generic 1 month supply: $4 2 month supply: $8 3 month supply: $12

Tier 2: Non-Preferred Generic 1 month supply: $15 2 month supply: $30 3 month supply: $45

Tier 3: Preferred Brand 1 month supply: $47 2 month supply: $94 3 month supply: $141

Tier 4: Non-Preferred Brand 1 month supply: $100 2 month supply: $200 3 month supply: $300

Tier 5 Specialty 1 month supply: 28% 2 month supply: 28% 3 month supply: 28%

Initial coverage Mail Order

Tier 1: Preferred Generic 3 month: $8

Tier 2: Non-Preferred Generic 3 month: $30

Tier 3: Preferred Brand 3 month: $94

Tier 4: Non-Preferred Brand 3 month: $200

Tier 5 Specialty 3 month: 28%

Coverage GapAfter you enter the coverage gap, you pay 35% of the plan’s cost for covered brand name drugs and 44% of the plan’s cost for covered generic drugs until your costs total $5,000, which is the end of the coverage gap. Not everyone will enter the coverage gap.

Catastrophic CoverageFor generic (including brand drugs treated as generic): 5% of the cost, or $3.35 copay whichever is greater

For all other drugs: 5% of the cost, or $8.35 copay, whichever is greater

1May require prior authorization

Eon Choice (PPO)SUMMARY OF BENEFITS

Benefits Eon Choice / Additional Health BenefitsIN-NETWORK OUT-OF-NETWORK

Chiropractic Care

Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): $20 copay Medicare Covered Visit

Routine Visit: $20 copay (4 visits per yr.)

Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position):40% coinsurance Medicare Covered Visit

Routine Visit: 50% coinsurance (4 visits per yr.)

Outpatient RehabilitationServices1

Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions over a period of up to 36 weeks):20% Coinsurance

Occupational therapy visit: $40 copaySpeech and language therapy visit:$40 copay

Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions over a period of up to 36 weeks):40% coinsurance

Occupational therapy visit: 40% coinsurance Speech and language therapy visit:40% coinsurance

Diabetic Supplies and Services1Diabetes monitoring supplies: 20% coinsurance

Therapeutic shoes or inserts: 20% coinsurance

Diabetes monitoring supplies: 40% coinsurance

Therapeutic shoes or inserts: 40% coinsurance

Meals1 Up to 20 meals. Plan covers up to 30 days after inpatient hospital stay

Not covered

Foot Care (Podiatry Services)

Foot exams and treatment if you have diabetes related nerve damage and/or meet certain conditions: $45 copayRoutine foot care: Not covered

Foot exams and treatment if you have diabetes related nerve damage and/or meet certain conditions: 40% coinsuranceRoutine foot care: Not covered.

Over-the-Counter (OTC) Items Members receive a $20 allowance every month Not covered

1May require prior authorization

Eon Choice (PPO)SUMMARY OF BENEFITS

Benefits Eon Choice / Additional Health BenefitsIN-NETWORK OUT-OF-NETWORK

Medical Equipment and Supplies1

20% coinsurance 40% coinsurance

Prosthetic devices: 20% coinsuranceRelated medical supplies: 20% coinsurance

Prosthetic devices: 40% coinsuranceRelated medical supplies: 40% coinsurance

Wellness Programs (e.g. Fitness)

Fitness program: SilverSneakers®Basic membership to one Plan approved fitness facility per monthOrientation to the fitness center and instructions about how to use equipment and services One @Home workout Pak per year

1May require prior authorization

Eon Choice (PPO)SUMMARY OF BENEFITS

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This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments and restrictions may apply. Benefits, premiums and/or copayments/coinsurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium – The State pays the Part B premium for full dual members.

Premium, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.

Eon Health complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

Current Members: 1-888-906-3889 TTY: 711

Prospective Members: 1-844-895-8643 TTY: 711

Hours of Operation: October 1 – February 14:Seven days a week, 8:00am – 8:00pm EST

February 15 – September 30: Monday through Friday, 8:00am – 8:00pm EST

(You may leave a voicemail Saturday, Sunday and Federal Holidays)