Common use of Resources for Living Clause in Contracts

Resources for Living. ® Resources for Living consultants provide research services for members on such topics as caregiver support, household services, eldercare services, activities, and volunteer opportunities. The purpose of the program is to assist members in locating local community services and to provide resource information for a wide variety of eldercare and life‑related issues. Call Resources for Living at 1‑866‑370‑4842. There is no coinsurance, copayment, or deductible for Resources for Living. Screening and counseling to reduce alcohol misuse We cover one alcohol misuse screening for adults with There is no coinsurance, copayment, or deductible for the Medicare‑covered Medicare (including pregnant women) who misuse alcohol but aren’t alcohol dependent. If you screen positive for alcohol misuse, you can get up to 4 brief face‑to‑face counseling sessions per year (if you’re competent and alert during counseling) provided by a qualified primary care doctor or practitioner in a primary care setting. screening and counseling to reduce alcohol misuse preventive benefit. Screening for lung cancer with low dose computed tomography (LDCT) For qualified individuals, a LDCT is covered every 12 months. Eligible members are: people aged 50 – 77 years who have no signs or symptoms of lung cancer, but who have a history of tobacco smoking of at least 20 pack‑years and who currently smoke or have quit smoking within the last 15 years, who receive a written order for LDCT during a lung cancer screening counseling and shared decision‑making visit that meets the Medicare criteria for such visits and be furnished by a physician or qualified non‑physician practitioner. For LDCT lung cancer screenings after the initial LDCT screening: the member must receive a written order for LDCT lung cancer screening, which may be furnished during any appropriate visit with a physician or qualified non‑physician practitioner. If a physician or qualified non‑physician practitioner elects to provide a lung cancer screening counseling and shared decision making visit for subsequent lung cancer screenings with LDCT, the visit must meet the Medicare criteria for such visits. There is no coinsurance, copayment, or deductible for the Medicare‑covered counseling and shared decision making visit or for the LDCT. Screening for sexually transmitted infections (STIs) and counseling to prevent STIs We cover sexually transmitted infection (STI) screenings for chlamydia, gonorrhea, syphilis, and Hepatitis B. These screenings are covered for pregnant women and for certain people who are at increased risk for an STI when the tests are ordered by a primary care provider. We cover these tests once every 12 months or at certain times during pregnancy. We also cover up to 2 individual 20 to 30 minute, face‑to‑face high‑intensity behavioral counseling sessions each year for sexually active adults at increased risk for STIs. We will only cover these counseling sessions There is no coinsurance, copayment, or deductible for the Medicare‑covered screening for STIs and counseling for STIs preventive benefit. as a preventive service if they are provided by a primary care provider and take place in a primary care setting, such as a doctor’s office. Services to treat kidney disease Covered services include: • Kidney disease education services to teach kidney care and help members make informed decisions about their care. For members with stage IV chronic kidney disease when referred by their doctor, we cover up to six sessions of kidney disease education services per lifetime • Outpatient dialysis treatments (including dialysis treatments when temporarily out of the service area, as explained in Chapter 3 of the Evidence of Coverage, or when your provider for this service is temporarily unavailable or inaccessible) • Inpatient dialysis treatments (if you are admitted as an inpatient to a hospital for special care) • Self‑dialysis training (includes training for you and anyone helping you with your home dialysis treatments) • Home dialysis equipment and supplies • Certain home support services (such as, when necessary, visits by trained dialysis workers to check on your home dialysis, to help in emergencies, and check your dialysis equipment and water supply) Certain drugs for dialysis are covered under your Medicare Part B drug benefit. For information about coverage for Part B Drugs, please go to the section, “Medicare Part B prescription drugs.” Prior authorization rules may apply for network services. Your network provider is responsible for requesting prior authorization. Our plan recommends pre‑authorization of the service when provided by an out‑of‑network provider. $0 copay for self‑dialysis training. $0 copay for each Medicare‑covered kidney disease education session. $0 copay for in‑ and out‑of‑area outpatient dialysis. See “Inpatient hospital care” for more information on inpatient services. $0 copay for home dialysis equipment and supplies. $0 copay for Medicare‑covered home support services. Skilled nursing facility (SNF) care (For a definition of “skilled nursing facility care,” see the final chapter (“Definitions of important words”) of the Evidence of Coverage. Skilled nursing facilities are sometimes called “SNFs.”) Days covered: up to 100 days per benefit period. A prior hospital stay is not required. $0 per day, days 1‑100 for each Medicare‑covered SNF stay. A benefit period begins the day you go into a hospital or skilled nursing facility. The benefit period ends when you haven’t received any inpatient hospital care (or skilled care in a SNF) for 60 days in a row, including your day Services that are covered for you What you must pay when you get these services Covered services include but are not limited to: • Semiprivate room (or a private room if medically necessary) • Meals, including special diets • Skilled nursing services • Physical therapy, occupational therapy, and speech therapy • Drugs administered to you as part of your plan of care (This includes substances that are naturally present in the body, such as blood clotting factors.) • Blood – including storage and administration. Coverage of whole blood and packed red cells begins with the first pint of blood that you need. All components of blood are covered beginning with the first pint used. • Medical and surgical supplies ordinarily provided by SNFs • Laboratory tests ordinarily provided by SNFs • X‑rays and other radiology services ordinarily provided by SNFs • Use of appliances such as wheelchairs ordinarily provided by SNFs • Physician/Practitioner services Prior authorization rules may apply for network services. Your network provider is responsible for requesting prior authorization. Our plan recommends pre‑authorization of the service when provided by an out‑of‑network provider. of discharge. If you go into a hospital or a skilled nursing facility after one benefit period has ended, a new benefit period begins. There is no limit to the number of benefit periods you can have. Smoking and tobacco use cessation (counseling to stop smoking or tobacco use) If you use tobacco, but do not have signs or symptoms of tobacco‑related disease: We cover two counseling quit attempts within a 12‑month period as a preventive service with no cost to you. Each counseling attempt includes up to four face‑to‑face visits. If you use tobacco and have been diagnosed with a tobacco‑related disease or are taking medicine that may be affected by tobacco: We cover cessation counseling services. We cover two counseling quit attempts within a 12‑month period, however, you will pay the applicable cost‑sharing. Each counseling attempt includes up to four face‑to‑face visits. There is no coinsurance, copayment, or deductible for the Medicare‑covered smoking and tobacco use cessation preventive benefits. $0 copay for each non‑Medicare covered smoking and tobacco use cessation visit. In addition to Medicare‑covered benefits, we also offer: • Additional individual and group face‑to‑face intermediate and intensive counseling sessions: unlimited visits every year Supervised Exercise Therapy (SET) SET is covered for members who have symptomatic peripheral artery disease (PAD) and a referral for PAD from the physician responsible for PAD treatment. Up to 36 sessions over a 12‑week period are covered if the SET program requirements are met. The SET program must: • Consist of sessions lasting 30‑60 minutes, comprising a therapeutic exercise‑training program for PAD in patients with claudication • Be conducted in a hospital outpatient setting or a physician’s office • Be delivered by qualified auxiliary personnel necessary to ensure benefits exceed xxxxx, and who are trained in exercise therapy for PAD • Be under the direct supervision of a physician, physician assistant, or nurse practitioner/clinical nurse specialist who must be trained in both basic and advanced life support techniques SET may be covered beyond 36 sessions over 12 weeks for an additional 36 sessions over an extended period of time if deemed medically necessary by a health care provider. $0 copay for each Medicare‑covered supervised exercise therapy service. Therapeutic Massage We have partnered with American Specialty Health Group, Inc. (ASH Group) to provide your therapeutic massage coverage. We cover up to fifty visits every year for therapeutic massage.* Services must be medically necessary as determined by ASH Group. To locate an ASH Group network provider, you may contact Aetna® Member Services at the number on the back of your ID card or search our online directory. If you choose to use a provider outside of the ASH Group network, remember to present them with your member ID on your first visit. *Amounts you pay for therapeutic massage do not apply to your out‑of‑pocket maximum. $0 copay for each plan‑approved therapeutic massage visit. Transportation services (non‑emergency transportation) We cover: • 24 one‑way trips to and from plan‑approved locations each year Trips must be within 60 miles of provider location. Coverage includes trips to and from providers or facilities for services that your plan covers. The transportation service will accommodate urgent requests for hospital discharge, dialysis, and trips that your medical provider considers urgent. The service will try to accommodate specific physical limitations or requirements. However, it limits services to wheelchair, taxi, or sedan transportation vehicles. • Transportation services are administered through Access2Care • To arrange for transport, call 1‑855‑814‑1699, Monday through Friday, from 8 AM to 8 PM, in all time zones. (For TTY/TDD assistance please dial 711.) • You must schedule transportation service at least 48 hours before the appointment • You must cancel more than two hours in advance, or Access2Care will deduct the trip from the remaining number of trips available • This program doesn’t support stretcher vans/ambulances $0 copay per trip. Urgently needed services Urgently needed services are provided to treat a non‑emergency, unforeseen medical illness, injury, or condition that requires immediate medical care but given your circumstances, it is not possible, or it is unreasonable, to obtain services from network providers. Examples of urgently needed services that the plan must cover out of network are i) you need immediate care during the weekend, or ii) you are temporarily outside the service area of the plan. Services must be immediately needed and medically necessary. Coverage is available worldwide (i.e., outside of the United States). $0 copay for each urgent care facility visit. $0 copay for each urgent care telehealth service. Vision care $0 copay for exams to diagnose and treat diseases and conditions of the eye. Covered services include: • Outpatient physician services for the diagnosis and treatment of diseases and injuries of the eye, including treatment for age‑related macular degeneration. Original Medicare doesn’t cover routine eye exams (eye refractions) for eyeglasses/contacts • For people who are at high risk of glaucoma, we will cover one glaucoma screening every 12 months. People at high risk of glaucoma include: people with a family history of glaucoma, people with diabetes, African Americans who are age 50 and older, and Hispanic Americans who are 65 or older • For people with diabetes, screening for diabetic retinopathy is covered once per year • One pair of eyeglasses or contact lenses after each cataract surgery that includes insertion of a premium intraocular lens. (If you have two separate cataract operations, you cannot reserve the benefit after the first surgery and purchase two eyeglasses after the second surgery.) In addition to Medicare‑covered benefits, we also offer: • Non‑Medicare covered eye exams: one exam every year • Follow‑up diabetic eye exam $0 copay for each Medicare‑covered glaucoma screening. $0 copay for one diabetic retinopathy screening. $0 copay for each follow‑up diabetic eye exam. $0 copay for one pair of eyeglasses or contact lenses after each cataract surgery. Coverage includes conventional eyeglasses or contact lenses. Excluded is coverage for designer frames and progressive lenses instead of traditional lenses, bifocals, or trifocals. $0 copay for each non‑Medicare covered eye exam. Additional cost‑sharing may apply if you receive additional services during your visit. Vision care – eyewear reimbursement (non‑Medicare covered) Non‑Medicare covered prescription eyewear includes: • Contact lenses • Eyeglass prescription lenses • Eyeglass frames You may see any licensed vision provider in the U.S. You pay the provider for services and submit an itemized billing statement showing proof of payment to our plan. You must submit your documentation within 365 days from the date of service to be eligible for reimbursement. If approved, it can take up to 45 days for you to receive payment. If your request is incomplete, such as no itemization of services, or there is missing information, you will be notified by mail. You will then have to supply the missing information, which will delay the processing time. Our plan will reimburse you up to: $300 once every 24 months towards the cost of eyewear. You may be required to pay for services up front and submit for reimbursement Services that are covered for you What you must pay when you get these services Notes: • If you use a non‑licensed provider you will not receive reimbursement. • You are responsible for any charges above the reimbursement amount. • Eyewear reimbursement excludes eyeglasses or contact lenses after cataract surgery. * Amounts you pay for non‑Medicare covered eyewear do not apply to your Out‑of‑Pocket Maximum.

Resources for Living. ® Resources for Living consultants provide research services for members on such topics as caregiver support, household services, eldercare services, activities, and volunteer opportunities. The purpose of the program is to assist members in locating local community services and to provide resource information for a wide variety of eldercare and life‑related life-related issues. Call Resources for Living at 1‑866‑370‑48420-000-000-0000. There is no coinsurance, copayment, or deductible for Resources for Living. Services that are covered for you What you must pay (after any deductible listed on page 1) when you get these services Screening and counseling to reduce alcohol misuse We cover one alcohol misuse screening for adults with There is no coinsurance, copayment, or deductible for the Medicare‑covered Medicare (including pregnant women) who misuse alcohol alcohol, but aren’t alcohol dependent. If you screen positive for alcohol misuse, you can get up to 4 brief face‑to‑face face-to-face counseling sessions per year (if you’re competent and alert during counseling) provided by a qualified primary care doctor or practitioner in a primary care setting. There is no coinsurance, copayment, or deductible for the Medicare- covered screening and counseling to reduce alcohol misuse preventive benefit. Services that are covered for you What you must pay (after any deductible listed on page 1) when you get these services Screening for lung cancer with low dose computed tomography (LDCT) For qualified individuals, a LDCT is covered every 12 months. Eligible members are: people aged 50 55 – 77 years who have no signs or symptoms of lung cancer, but who have a history of tobacco smoking of at least 20 pack‑years 30 pack-years and who currently smoke or have quit smoking within the last 15 years, who receive a written order for LDCT during a lung cancer screening counseling and shared decision‑making decision making visit that meets the Medicare criteria for such visits and be furnished by a physician or qualified non‑physician non- physician practitioner. For LDCT lung cancer screenings after the initial LDCT screening: the member must receive a written order for LDCT lung cancer screening, which may be furnished during any appropriate visit with a physician or qualified non‑physician non-physician practitioner. If a physician or qualified non‑physician non-physician practitioner elects to provide a lung cancer screening counseling and shared decision making visit for subsequent lung cancer screenings with LDCT, the visit must meet the Medicare criteria for such visits. There is no coinsurance, copayment, or deductible for the Medicare‑covered Medicare- covered counseling and shared decision making visit or for the LDCT. Services that are covered for you What you must pay (after any deductible listed on page 1) when you get these services Screening for sexually transmitted infections (STIs) and counseling to prevent STIs We cover sexually transmitted infection (STI) screenings for chlamydia, gonorrhea, syphilis, and Hepatitis B. These screenings are covered for pregnant women and for certain people who are at increased risk for an STI when the tests are ordered by a primary care provider. We cover these tests once every 12 months or at certain times during pregnancy. We also cover up to 2 individual 20 to 30 minute, face‑to‑face high‑intensity face-to- face high-intensity behavioral counseling sessions each year for sexually active adults at increased risk for STIs. We will only cover these counseling sessions There is no coinsurance, copayment, or deductible for the Medicare‑covered screening for STIs and counseling for STIs preventive benefit. as a preventive service if they are provided by a primary care provider and take place in a primary care setting, such as a doctor’s office. There is no coinsurance, copayment, or deductible for the Medicare- covered screening for STIs and counseling for STIs preventive benefit. Services that are covered for you What you must pay (after any deductible listed on page 1) when you get these services Services to treat kidney disease Covered services include: • Kidney disease education services to teach kidney care and help members make informed decisions about their care. For members with stage IV chronic kidney disease when referred by their doctor, we cover up to six sessions of kidney disease education services per lifetime • Outpatient dialysis treatments (including dialysis treatments when temporarily out of the service area, as explained in Chapter 3 of the Evidence of Coverage, or when your provider for this service is temporarily unavailable or inaccessible) • Inpatient dialysis treatments (if you are admitted as an inpatient to a hospital for special care) • Self‑dialysis Self-dialysis training (includes training for you and anyone helping you with your home dialysis treatments) • Home dialysis equipment and supplies • Certain home support services (such as, when necessary, visits by trained dialysis workers to check on your home dialysis, to help in emergencies, and check your dialysis equipment and water supply) Certain drugs for dialysis are covered under your Medicare Part B drug benefit. For information about coverage for Part B Drugs, please go to the section, “Medicare Part B prescription drugs.” Prior authorization rules may apply for network services. Your network provider is responsible for requesting prior authorization. Our plan recommends pre‑authorization pre-authorization of the service when provided by an out‑of‑network provider. You pay a $0 copay for self‑dialysis self-dialysis training. You pay a $0 copay for each Medicare‑covered kidney disease education sessionservices. You pay a $0 15 copay for in‑ in- and out‑of‑area out- of-area outpatient dialysis. See “Inpatient hospital care” for more information on inpatient services. $0 copay You pay 20% of the total cost for home dialysis equipment and supplies. You pay a $0 copay for Medicare‑covered Medicare- covered home support services. Services that are covered for you What you must pay (after any deductible listed on page 1) when you get these services Skilled nursing facility (SNF) care (For a definition of “skilled nursing facility care,” see the final chapter (“Definitions of important words”) of the Evidence of Coverage. Skilled nursing facilities are sometimes called “SNFs.”) Days covered: up to We cover 100 days per benefit period. A prior hospital stay is not required. $0 per day, days 1‑100 for each Medicare‑covered SNF stay. A benefit period begins the day you go into a hospital or skilled nursing facility. The benefit period ends when you haven’t received any inpatient hospital care (or skilled care in a SNF) for 60 days in a row, including your day Services that are covered for you What you must pay when you get these services Covered services include but are not limited to: • Semiprivate room (or a private room if medically necessary) • Meals, including special diets • Skilled nursing services • Physical therapy, occupational therapy, and speech therapy • Drugs administered to you as part of your plan of care (This includes substances that are naturally present in the body, such as blood clotting factors.) • Blood – including storage and administration. Coverage of whole blood and packed red cells begins with the first pint of blood that you need. All components of blood are covered beginning with the first pint used. • Medical and surgical supplies ordinarily provided by SNFs • Laboratory tests ordinarily provided by SNFs • X‑rays X-rays and other radiology services ordinarily provided by SNFs • Use of appliances such as wheelchairs ordinarily provided by SNFs • Physician/Practitioner services Prior authorization rules may apply for network servicesYou pay $0 per day, days 1-20; $75 per day, days 21-100 for each Medicare-covered SNF stay. Your network provider is responsible A benefit period begins the day you go into a hospital or skilled nursing facility. The benefit period ends when you haven’t received any inpatient hospital care (or skilled care in a SNF) for requesting prior authorization. Our plan recommends pre‑authorization of the service when provided by an out‑of‑network provider. 60 days in a row, including your day of discharge. If you go into a hospital or a skilled nursing facility after one benefit period has ended, a new benefit period begins. There is no limit to the number of benefit periods you can have. Services that are covered for you What you must pay (after any deductible listed on page 1) when you get these services Smoking and tobacco use cessation (counseling to stop smoking or tobacco use) If you use tobacco, but do not have signs or symptoms of tobacco‑related tobacco-related disease: We cover two counseling quit attempts within a 12‑month 12-month period as a preventive service with no cost to you. Each counseling attempt includes up to four face‑to‑face face-to-face visits. If you use tobacco and have been diagnosed with a tobacco‑related tobacco-related disease or are taking medicine that may be affected by tobacco: We cover cessation counseling services. We cover two counseling quit attempts within a 12‑month 12-month period, however, you will pay the applicable cost‑sharinginpatient or outpatient cost-sharing. Each counseling attempt includes up to four face‑to‑face face-to-face visits. In addition to Medicare-covered benefits, we also offer: • Additional individual and group face-to-face intermediate and intensive counseling sessions: unlimited visits every year There is no coinsurance, copayment, or deductible for the Medicare‑covered Medicare- covered smoking and tobacco use cessation preventive benefits. You pay a $0 copay for each non‑Medicare non- Medicare covered smoking and tobacco use cessation visit. In addition to Medicare‑covered benefits, we also offer: • Additional individual and group face‑to‑face intermediate and intensive counseling sessions: unlimited visits every year Services that are covered for you What you must pay (after any deductible listed on page 1) when you get these services Supervised Exercise Therapy exercise therapy (SET) SET is covered for members who have symptomatic peripheral artery disease (PAD) and a referral for PAD from the physician responsible for PAD treatment. Up to 36 sessions over a 12‑week 12-week period are covered if the SET program requirements are met. The SET program must: • Consist of sessions lasting 30‑60 30-60 minutes, comprising a therapeutic exercise‑training exercise-training program for PAD in patients with claudication • Be conducted in a hospital outpatient setting or a physician’s office • Be delivered by qualified auxiliary personnel necessary to ensure benefits exceed xxxxx, and who are trained in exercise therapy for PAD • Be under the direct supervision of a physician, physician assistant, or nurse practitioner/clinical nurse specialist who must be trained in both basic and advanced life support techniques SET may be covered beyond 36 sessions over 12 weeks for an additional 36 sessions over an extended period of time if deemed medically necessary by a health care provider. You pay a $0 15 copay for each Medicare‑covered Medicare-covered supervised exercise therapy service. Therapeutic Massage We have partnered with American Specialty Health Group, Inc. (ASH Group) to provide your therapeutic massage coverage. We cover up to fifty visits every year for therapeutic massage.* Services must be medically necessary as determined by ASH Group. To locate an ASH Group network provider, you may contact Aetna® Member Services at the number on the back of your ID card or search our online directory. If you choose to use a provider outside of the ASH Group network, remember to present them with your member ID on your first visit. *Amounts you pay for therapeutic massage do not apply to your out‑of‑pocket maximum. $0 copay for each plan‑approved therapeutic massage visitsession. Transportation services (non‑emergency non-emergency transportation) We cover: • 24 one‑way one-way trips to and from plan‑approved plan-approved locations each year You pay a $0 copay per trip. Services that are covered for you What you must pay (after any deductible listed on page 1) when you get these services Trips must be within 60 miles of provider location. Coverage includes trips to and from providers or facilities for services that your plan covers. The transportation service will accommodate urgent requests for hospital discharge, dialysis, and trips that your medical provider considers urgent. The service will try to accommodate specific physical limitations or requirements. However, it limits services to wheelchair, taxi, or sedan transportation vehicles. • Transportation services are administered through Access2Care • To arrange for transport, call 1‑855‑814‑16990-000-000-0000, Monday through Friday, from 8 AM to 8 PM, in all time zones. (For TTY/TDD assistance please dial 711.) • You must schedule transportation service at least 48 72 hours before the appointment • You must cancel more than two hours in advance, or Access2Care will deduct the trip from the remaining number of trips available • This program doesn’t support stretcher vans/ambulances $0 copay per trip. • The driver’s role is limited to helping the member in and out of the vehicle Services that are covered for you What you must pay (after any deductible listed on page 1) when you get these services Urgently needed services Urgently needed services are provided to treat a non‑emergencynon- emergency, unforeseen medical illness, injury, or condition that requires immediate medical care but given your circumstances, it is not possible, or it is unreasonable, to obtain services from network providers. Examples of urgently needed services that the plan must cover out of network are i) you need immediate care during the weekend, or ii) you are temporarily outside the service area of the plan. Services must be immediately needed and medically necessarycare. Coverage is available worldwide (i.e., outside of the United States). You pay a $0 35 copay for each urgent care facility visit. Cost-sharing is not waived if you are admitted to the hospital. You pay a $0 35 copay for each urgent care telehealth service. Services that are covered for you What you must pay (after any deductible listed on page 1) when you get these services Vision care $0 copay for exams to diagnose and treat diseases and conditions of the eye. Covered services include: • Outpatient physician services for the diagnosis and treatment of diseases and injuries of the eye, including treatment for age‑related age-related macular degeneration. Original Medicare doesn’t cover routine eye exams (eye refractions) for eyeglasses/contacts • For people who are at high risk of glaucoma, we will cover one glaucoma screening every 12 months. People at high risk of glaucoma include: people with a family history of glaucoma, people with diabetes, African African-Americans who are age 50 and older, and Hispanic Americans who are 65 or older • For people with diabetes, screening for diabetic retinopathy is covered once per year • One pair of eyeglasses or contact lenses after each cataract surgery that includes insertion of a premium an intraocular lens. (If you have two separate cataract operations, you cannot reserve the benefit after the first surgery and purchase two eyeglasses after the second surgery.) In addition to Medicare‑covered Medicare-covered benefits, we also offer: • Non‑Medicare Non-Medicare covered eye exams: one exam every year • Follow‑up Follow up diabetic eye exam You pay a $15 copay for exams to diagnose and treat diseases and conditions of the eye. You pay a $0 copay for each Medicare‑covered Medicare-covered glaucoma screening. You pay a $0 copay for one diabetic retinopathy screening. You pay a $0 copay for each follow‑up follow up diabetic eye exam. You pay a $0 copay for one pair of eyeglasses or contact lenses after each cataract surgery. Coverage includes conventional eyeglasses or contact lenses. Excluded is coverage for designer frames and progressive lenses instead of traditional lenses, bifocals, or trifocals. You pay a $0 copay for each non‑Medicare non- Medicare covered eye exam. Additional cost‑sharing cost-sharing may apply if you receive additional services during your visit. Vision care – eyewear reimbursement (non‑Medicare covered) Non‑Medicare covered prescription eyewear includes: • Contact lenses • Eyeglass prescription lenses • Eyeglass frames You may see any licensed vision provider in the U.S. You pay the provider for services and submit an itemized billing statement showing proof of payment to our plan. You must submit your documentation within 365 days from the date of service to be eligible for reimbursement. If approved, it can take up to 45 days for you to receive payment. If your request is incomplete, such as no itemization of services, or there is missing information, you will be notified by mail. You will then have to supply the missing information, which will delay the processing time. Our plan will reimburse you up to: $300 once every 24 months towards the cost of eyewear. You may be required to pay for services up front and submit for reimbursement Services that are covered for you What you must pay (after any deductible listed on page 1) when you get these services Notes“Welcome to Medicare” preventive visit The plan covers the one-time “Welcome to Medicare” preventive visit. The visit includes a review of your health, as well as education and counseling about the preventive services you need (including certain screenings and shots), and referrals for other care if needed. Important: • If We cover the “Welcome to Medicare” preventive visit only within the first 12 months you use have Medicare Part B. When you make your appointment, let your doctor’s office know you would like to schedule your “Welcome to Medicare” preventive visit. There is no coinsurance, copayment, or deductible for the “Welcome to Medicare” preventive visit. You pay a non‑licensed provider you will not receive reimbursement$0 copay for a Medicare- covered EKG screening following the "Welcome to Medicare" preventive visit. • You are responsible Note: See Chapter 4, Section 2.1 of the Evidence of Coverage for any charges above information on prior authorization rules. Former Employer/Union/Trust Name: Occidental Petroleum Corporation Group Agreement Effective Date: 01/01/2022 Group/Account Number: 0000000 This Prescription Drug Schedule of Cost Sharing is part of the reimbursement amountEvidence of Coverage (EOC) for our plan. • Eyewear reimbursement excludes eyeglasses or contact lenses after cataract surgeryWhen the EOC refers to the document with information on Medicare Part D prescription drug benefits covered under our plan, it is referring to this Prescription Drug Benefits Chart. * Amounts (See Chapter 5, Using the plan’s coverage for your Part D prescription drugs and Chapter 6, What you pay for non‑Medicare covered eyewear do not apply to your Out‑of‑Pocket MaximumPart D prescription drugs.)

Resources for Living. ® Resources for Living consultants provide research services for members on such topics as caregiver support, household services, eldercare services, activities, and volunteer opportunities. The purpose of the program is to assist members in locating local community services and to provide resource information for a wide variety of eldercare and life‑related issues. Call Resources for Living at 1‑866‑370‑4842. There is no coinsurance, copayment, or deductible for Resources for Living. Screening and counseling to reduce alcohol misuse We cover one alcohol misuse screening for adults with There is no coinsurance, copayment, or deductible for the Medicare‑covered Medicare (including pregnant women) who misuse alcohol alcohol, but aren’t alcohol dependent. If you screen positive for alcohol misuse, you can get up to 4 brief face‑to‑face counseling sessions per year (if you’re competent and alert during counseling) provided by a qualified primary care doctor or practitioner in a primary care setting. There is no coinsurance, copayment, or deductible for the Medicare‑covered screening and counseling to reduce alcohol misuse preventive benefit. Screening for lung cancer with low dose computed tomography (LDCT) For qualified individuals, a LDCT is covered every 12 months. Eligible members are: people aged 50 – 77 50–77 years who have no signs or symptoms of lung cancer, but who have a history of tobacco smoking of at least 20 pack‑years and who currently smoke or have quit smoking within the last 15 years, who receive a written order for LDCT during a lung cancer screening counseling and shared decision‑making visit that meets the Medicare criteria for such visits and be furnished by a physician or qualified non‑physician practitioner. For LDCT lung cancer screenings after the initial LDCT screening: the member must receive a written order for LDCT lung cancer screening, which may be furnished during any appropriate visit with a physician or qualified non‑physician practitioner. If a physician or qualified non‑physician practitioner elects to provide a lung cancer screening counseling and shared decision making visit for subsequent lung cancer screenings with LDCT, the visit must meet the Medicare criteria for such visits. There is no coinsurance, copayment, or deductible for the Medicare‑covered counseling and shared decision making visit or for the LDCT. Screening for lung cancer with low dose computed tomography (LDCT) (continued) Screening for sexually transmitted infections (STIs) and counseling to prevent STIs We cover sexually transmitted infection (STI) screenings for chlamydia, gonorrhea, syphilis, and Hepatitis B. These screenings are covered for pregnant women and for certain people who are at increased risk for an STI when the tests are ordered by a primary care provider. We cover these tests once every 12 months or at certain times during pregnancy. We also cover up to 2 two individual 20 20‑ to 30 minute30‑minute, face‑to‑face high‑intensity behavioral counseling sessions each year for sexually active adults at increased risk for STIs. We will only cover these counseling sessions There is no coinsurance, copayment, or deductible for the Medicare‑covered screening for STIs and counseling for STIs preventive benefit. as a preventive service if they are provided by a primary care provider and take place in a primary care setting, such as a doctor’s office. There is no coinsurance, copayment, or deductible for the Medicare‑covered screening for STIs and counseling for STIs preventive benefit. Services to treat kidney disease Covered services include: • Kidney disease education services to teach kidney care and help members make informed decisions about their care. For members with stage IV chronic kidney disease when referred by their doctor, we cover up to six sessions of kidney disease education services per lifetime • Outpatient dialysis treatments (including dialysis treatments when temporarily out of the service area, as explained in Chapter 3 of the Evidence of Coverage, or when your provider for this service is temporarily unavailable or inaccessible) • Inpatient dialysis treatments (if you are admitted as an inpatient to a hospital for special care) • Self‑dialysis training (includes training for you and anyone helping you with your home dialysis treatments) • Home dialysis equipment and supplies • Certain home support services (such as, when $0 copay for self‑dialysis training. $0 copay for each Medicare‑covered kidney disease education session. $0 copay for in‑ and out‑of‑area outpatient dialysis. For each inpatient hospital stay, you pay: $0 per stay. Cost sharing is charged for each medically necessary covered inpatient stay. $0 copay for home dialysis equipment and supplies. $0 copay for Medicare‑covered home support services. Services to treat kidney disease (continued) necessary, visits by trained dialysis workers to check on your home dialysis, to help in emergencies, and check your dialysis equipment and water supply) Certain drugs for dialysis are covered under your Medicare Part B drug benefit. For information about coverage for Part B Drugs, please go to the section, “Medicare Part B prescription drugs.” . Prior authorization rules may apply for network services. Your network provider is responsible for requesting prior authorization. Our plan recommends pre‑authorization of the service when provided by an out‑of‑network provider. $0 copay for self‑dialysis training. $0 copay for each Medicare‑covered kidney disease education session. $0 copay for in‑ and out‑of‑area outpatient dialysis. See “Inpatient hospital care” for more information on inpatient services. $0 copay for home dialysis equipment and supplies. $0 copay for Medicare‑covered home support services. Skilled nursing facility (SNF) care (For a definition of “skilled nursing facility care,” , see the final chapter (“Definitions of important words”) of the Evidence of Coverage. Skilled nursing facilities are sometimes called “SNFs.”) Days covered: up to 100 days per benefit period. A prior hospital stay is not required. $0 per day, days 1‑100 for each Medicare‑covered SNF stay. A benefit period begins the day you go into a hospital or skilled nursing facility. The benefit period ends when you haven’t received any inpatient hospital care (or skilled care in a SNF) for 60 days in a row, including your day Services that are covered for you What you must pay when you get these services Covered services include but are not limited to: • Semiprivate room (or a private room if medically necessary) • Meals, including special diets • Skilled nursing services • Physical therapy, occupational therapy, and speech therapy • Drugs administered to you as part of your plan of care (This includes substances that are naturally present in the body, such as blood clotting factors.) • Blood – including storage and administration. Coverage of whole blood and packed red cells begins with the first pint of blood that you need. All components of blood are covered beginning with the first pint used. • Medical and surgical supplies ordinarily provided by SNFs • Laboratory tests ordinarily provided by SNFs • X‑rays and other radiology services ordinarily provided by SNFs • Use of appliances such as wheelchairs ordinarily $0 per day, days 1‑100 for each Medicare‑covered SNF stay. A benefit period begins the day you go into a hospital or skilled nursing facility. The benefit period ends when you haven’t received any inpatient hospital care (or skilled care in a SNF) for 60 days in a row, including your day of discharge. If you go into a hospital or a skilled nursing facility after one benefit period has ended, a new benefit period begins. There is no limit to the number of benefit periods you can have. Skilled nursing facility (SNF) care (continued) provided by SNFs • Physician/Practitioner services Prior authorization rules may apply for network services. Your network provider is responsible for requesting prior authorization. Our plan recommends pre‑authorization of the service when provided by an out‑of‑network provider. of discharge. If you go into a hospital or a skilled nursing facility after one benefit period has ended, a new benefit period begins. There is no limit to the number of benefit periods you can have. Smoking and tobacco use cessation (counseling to stop smoking or tobacco use) If you use tobacco, but do not have signs or symptoms of tobacco‑related disease: We cover two counseling quit attempts within a 12‑month period as a preventive service with no cost to you. Each counseling attempt includes up to four face‑to‑face visits. If you use tobacco and have been diagnosed with a tobacco‑related disease or are taking medicine that may be affected by tobacco: We cover cessation counseling services. We cover two counseling quit attempts within a 12‑month period, however, you will pay the applicable cost‑sharingcost sharing. Each counseling attempt includes up to four face‑to‑face visits. In addition to Medicare‑covered benefits, we also offer: • Additional individual and group face‑to‑face intermediate and intensive counseling sessions: unlimited visits every year There is no coinsurance, copayment, or deductible for the Medicare‑covered smoking and tobacco use cessation preventive benefits. $0 copay for each non‑Medicare covered smoking and tobacco use cessation visit. In addition to Medicare‑covered benefits, we also offer: • Additional individual and group face‑to‑face intermediate and intensive counseling sessions: unlimited visits every year Supervised Exercise Therapy (SET) SET is covered for members who have symptomatic peripheral artery disease (PAD) and a referral for PAD from the physician responsible for PAD treatment. Up to 36 sessions over a 12‑week period are covered if the SET program requirements are met. The SET program must: • Consist of sessions lasting 30‑60 minutes, comprising a therapeutic exercise‑training program for PAD in patients with claudication • Be conducted in a hospital outpatient setting or a physician’s office • Be delivered by qualified auxiliary personnel necessary to ensure benefits exceed xxxxx, and $0 copay for each Medicare‑covered supervised exercise therapy service. Supervised Exercise Therapy (SET) (continued) who are trained in exercise therapy for PAD • Be under the direct supervision of a physician, physician assistant, or nurse practitioner/clinical nurse specialist who must be trained in both basic and advanced life support techniques SET may be covered beyond 36 sessions over 12 weeks for an additional 36 sessions over an extended period of time if deemed medically necessary by a health care provider. $0 copay for each Medicare‑covered supervised exercise therapy service. Therapeutic Massage We have partnered with American Specialty Health Group, Inc. (ASH Group) to provide your therapeutic massage coverage. We cover up to fifty visits every year for therapeutic massage.* Services must be medically necessary as determined by ASH Group. To locate an ASH Group network provider, you may contact Aetna® Member Services at the number on the back of your ID card or search our online directory. If you choose to use a provider outside of the ASH Group network, remember to present them with your member ID on your first visit. *Amounts you pay for therapeutic massage do not apply to your out‑of‑pocket maximum. $0 copay for each plan‑approved therapeutic massage visit. Transportation services (non‑emergency transportation) We cover: • 24 one‑way trips to and from plan‑approved locations each year Trips must be within 60 miles of provider location. Coverage includes trips to and from providers or facilities for services that your plan covers. The transportation service will accommodate urgent requests for hospital discharge, dialysis, and trips that your medical provider considers urgent. The service will try to accommodate specific physical limitations or requirements. However, it limits services to wheelchair, taxi, or sedan transportation vehicles. • Transportation services are administered through Access2Care • To arrange for transport, call 1‑855‑814‑1699, Monday through Friday, from 8 AM to 8 PM, in all time zones. (For TTY/TDD assistance please dial 711.) • You must schedule transportation service at least 48 hours before the appointment • You must cancel more than two hours in advance, or Access2Care will deduct the trip from the remaining number of trips available • This program doesn’t support stretcher vans/ambulances $0 copay per trip. Urgently needed services Urgently needed services are provided to treat a non‑emergency, unforeseen medical illness, injury, or condition that requires immediate medical care but given your circumstances, it is not possible, or it is unreasonable, to obtain services from network providers. Examples of urgently needed services that the plan must cover out of network are i) you need immediate care during the weekend, or ii) you are temporarily outside the service area of the plan. Services must be immediately needed and medically necessary. Coverage is available worldwide (i.e., outside of the United States). $0 copay for each urgent care facility visit. $0 copay for each urgent care telehealth service. Vision care $0 copay for exams to diagnose and treat diseases and conditions of the eye. Covered services include: • Outpatient physician services for the diagnosis and treatment of diseases and injuries of the eye, including treatment for age‑related macular degeneration. Original Medicare doesn’t cover routine eye exams (eye refractions) for eyeglasses/contacts • For people who are at high risk of glaucoma, we will cover one glaucoma screening every 12 months. People at high risk of glaucoma include: people with a family history of glaucoma, people with diabetes, African Americans who are age 50 and older, and Hispanic Americans who are 65 or older • For people with diabetes, screening for diabetic retinopathy is covered once per year • One pair of eyeglasses or contact lenses after each cataract surgery that includes insertion of a premium intraocular lens. (If you have two separate cataract operations, you cannot reserve the benefit after the first surgery and purchase two eyeglasses after the second surgery.) In addition to Medicare‑covered benefits, we also offer: • Non‑Medicare covered eye exams: one exam every year • Follow‑up diabetic eye exam $0 copay for each Medicare‑covered glaucoma screening. $0 copay for one diabetic retinopathy screening. $0 copay for each follow‑up diabetic eye exam. $0 copay for one pair of eyeglasses or contact lenses after each cataract surgery. Coverage includes conventional eyeglasses or contact lenses. Excluded is coverage for designer frames and progressive lenses instead of traditional lenses, bifocals, or trifocals. $0 copay for each non‑Medicare covered eye exam. Additional cost‑sharing may apply if you receive additional services during your visit. Vision care – eyewear reimbursement (non‑Medicare covered) Non‑Medicare covered prescription eyewear includes: • Contact lenses • Eyeglass prescription lenses • Eyeglass frames You may see any licensed vision provider in the U.S. You pay the provider for services and submit an itemized billing statement showing proof of payment to our plan. You must submit your documentation within 365 days from the date of service to be eligible for reimbursement. If approved, it can take up to 45 days for you to receive payment. If your request is incomplete, such as no itemization of services, or there is missing information, you will be notified by mail. You will then have to supply the missing information, which will delay the processing time. Our plan will reimburse you up to: $300 once every 24 months towards the cost of eyewear. You may be required to pay for services up front and submit for reimbursement Services that are covered for you What you must pay when you get these services Notes: • If you use a non‑licensed provider you will not receive reimbursement. • You are responsible for any charges above the reimbursement amount. • Eyewear reimbursement excludes eyeglasses or contact lenses after cataract surgery. * Amounts you pay for non‑Medicare covered eyewear do not apply to your Out‑of‑Pocket Maximum.

Resources for Living. ® Resources for Living consultants provide research services for members on such topics as caregiver support, household services, eldercare services, activities, and volunteer opportunities. The purpose of the program is to assist members in locating local community services and to provide resource information for a wide variety of eldercare and life‑related life-related issues. Call Resources for Living at 1‑866‑370‑48420-000-000-0000. There is no coinsurance, copayment, or deductible for Resources for Living. Services that are covered for you What you must pay (after any deductible listed on page 1) when you get these services Screening and counseling to reduce alcohol misuse We cover one alcohol misuse screening for adults with There is no coinsurance, copayment, or deductible for the Medicare‑covered Medicare (including pregnant women) who misuse alcohol alcohol, but aren’t alcohol dependent. If you screen positive for alcohol misuse, you can get up to 4 brief face‑to‑face face-to-face counseling sessions per year (if you’re competent and alert during counseling) provided by a qualified primary care doctor or practitioner in a primary care setting. There is no coinsurance, copayment, or deductible for the Medicare- covered screening and counseling to reduce alcohol misuse preventive benefit. Services that are covered for you What you must pay (after any deductible listed on page 1) when you get these services Screening for lung cancer with low dose computed tomography (LDCT) For qualified individuals, a LDCT is covered every 12 months. Eligible members are: people aged 50 55 – 77 years who have no signs or symptoms of lung cancer, but who have a history of tobacco smoking of at least 20 pack‑years 30 pack-years and who currently smoke or have quit smoking within the last 15 years, who receive a written order for LDCT during a lung cancer screening counseling and shared decision‑making decision making visit that meets the Medicare criteria for such visits and be furnished by a physician or qualified non‑physician non- physician practitioner. For LDCT lung cancer screenings after the initial LDCT screening: the member must receive a written order for LDCT lung cancer screening, which may be furnished during any appropriate visit with a physician or qualified non‑physician non-physician practitioner. If a physician or qualified non‑physician non-physician practitioner elects to provide a lung cancer screening counseling and shared decision making visit for subsequent lung cancer screenings with LDCT, the visit must meet the Medicare criteria for such visits. There is no coinsurance, copayment, or deductible for the Medicare‑covered Medicare- covered counseling and shared decision making visit or for the LDCT. Services that are covered for you What you must pay (after any deductible listed on page 1) when you get these services Screening for sexually transmitted infections (STIs) and counseling to prevent STIs We cover sexually transmitted infection (STI) screenings for chlamydia, gonorrhea, syphilis, and Hepatitis B. These screenings are covered for pregnant women and for certain people who are at increased risk for an STI when the tests are ordered by a primary care provider. We cover these tests once every 12 months or at certain times during pregnancy. We also cover up to 2 individual 20 to 30 minute, face‑to‑face high‑intensity face-to- face high-intensity behavioral counseling sessions each year for sexually active adults at increased risk for STIs. We will only cover these counseling sessions There is no coinsurance, copayment, or deductible for the Medicare‑covered screening for STIs and counseling for STIs preventive benefit. as a preventive service if they are provided by a primary care provider and take place in a primary care setting, such as a doctor’s office. There is no coinsurance, copayment, or deductible for the Medicare- covered screening for STIs and counseling for STIs preventive benefit. Services that are covered for you What you must pay (after any deductible listed on page 1) when you get these services Services to treat kidney disease Covered services include: • Kidney disease education services to teach kidney care and help members make informed decisions about their care. For members with stage IV chronic kidney disease when referred by their doctor, we cover up to six sessions of kidney disease education services per lifetime • Outpatient dialysis treatments (including dialysis treatments when temporarily out of the service area, as explained in Chapter 3 of the Evidence of Coverage, or when your provider for this service is temporarily unavailable or inaccessible) • Inpatient dialysis treatments (if you are admitted as an inpatient to a hospital for special care) • Self‑dialysis Self-dialysis training (includes training for you and anyone helping you with your home dialysis treatments) • Home dialysis equipment and supplies • Certain home support services (such as, when necessary, visits by trained dialysis workers to check on your home dialysis, to help in emergencies, and check your dialysis equipment and water supply) Certain drugs for dialysis are covered under your Medicare Part B drug benefit. For information about coverage for Part B Drugs, please go to the section, “Medicare Part B prescription drugs.” Prior authorization rules may apply for network services. Your network provider is responsible for requesting prior authorization. Our plan recommends pre‑authorization pre-authorization of the service when provided by an out‑of‑network provider. You pay a $0 copay for self‑dialysis self-dialysis training. You pay a $0 copay for each Medicare‑covered kidney disease education sessionservices. You pay a $0 copay for in‑ in- and out‑of‑area out- of-area outpatient dialysis. See “Inpatient hospital care” for more information on inpatient services. $0 copay You pay 15% of the total cost for home dialysis equipment and supplies. You pay a $0 copay for Medicare‑covered Medicare- covered home support services. Services that are covered for you What you must pay (after any deductible listed on page 1) when you get these services Skilled nursing facility (SNF) care (For a definition of “skilled nursing facility care,” see the final chapter (“Definitions of important words”) of the Evidence of Coverage. Skilled nursing facilities are sometimes called “SNFs.”) Days covered: up to We cover 100 days per benefit period. A prior hospital stay is not required. $0 per day, days 1‑100 for each Medicare‑covered SNF stay. A benefit period begins the day you go into a hospital or skilled nursing facility. The benefit period ends when you haven’t received any inpatient hospital care (or skilled care in a SNF) for 60 days in a row, including your day Services that are covered for you What you must pay when you get these services Covered services include but are not limited to: • Semiprivate room (or a private room if medically necessary) • Meals, including special diets • Skilled nursing services • Physical therapy, occupational therapy, and speech therapy • Drugs administered to you as part of your plan of care (This includes substances that are naturally present in the body, such as blood clotting factors.) • Blood – including storage and administration. Coverage of whole blood and packed red cells begins with the first pint of blood that you need. All components of blood are covered beginning with the first pint used. • Medical and surgical supplies ordinarily provided by SNFs • Laboratory tests ordinarily provided by SNFs • X‑rays X-rays and other radiology services ordinarily provided by SNFs • Use of appliances such as wheelchairs ordinarily provided by SNFs • Physician/Practitioner services Prior authorization rules may apply for network servicesYou pay $0 per day, days 1-100 for each Medicare-covered SNF stay. Your network provider is responsible A benefit period begins the day you go into a hospital or skilled nursing facility. The benefit period ends when you haven’t received any inpatient hospital care (or skilled care in a SNF) for requesting prior authorization. Our plan recommends pre‑authorization of the service when provided by an out‑of‑network provider. 60 days in a row, including your day of discharge. If you go into a hospital or a skilled nursing facility after one benefit period has ended, a new benefit period begins. There is no limit to the number of benefit periods you can have. Services that are covered for you What you must pay (after any deductible listed on page 1) when you get these services Smoking and tobacco use cessation (counseling to stop smoking or tobacco use) If you use tobacco, but do not have signs or symptoms of tobacco‑related tobacco-related disease: We cover two counseling quit attempts within a 12‑month 12-month period as a preventive service with no cost to you. Each counseling attempt includes up to four face‑to‑face face-to-face visits. If you use tobacco and have been diagnosed with a tobacco‑related tobacco-related disease or are taking medicine that may be affected by tobacco: We cover cessation counseling services. We cover two counseling quit attempts within a 12‑month 12-month period, however, you will pay the applicable cost‑sharinginpatient or outpatient cost-sharing. Each counseling attempt includes up to four face‑to‑face face-to-face visits. In addition to Medicare-covered benefits, we also offer: • Additional individual and group face-to-face intermediate and intensive counseling sessions: unlimited visits every year There is no coinsurance, copayment, or deductible for the Medicare‑covered Medicare- covered smoking and tobacco use cessation preventive benefits. You pay a $0 copay for each non‑Medicare non- Medicare covered smoking and tobacco use cessation visit. In addition to Medicare‑covered benefits, we also offer: • Additional individual and group face‑to‑face intermediate and intensive counseling sessions: unlimited visits every year Services that are covered for you What you must pay (after any deductible listed on page 1) when you get these services Supervised Exercise Therapy exercise therapy (SET) SET is covered for members who have symptomatic peripheral artery disease (PAD) and a referral for PAD from the physician responsible for PAD treatment. Up to 36 sessions over a 12‑week 12-week period are covered if the SET program requirements are met. The SET program must: • Consist of sessions lasting 30‑60 30-60 minutes, comprising a therapeutic exercise‑training exercise-training program for PAD in patients with claudication • Be conducted in a hospital outpatient setting or a physician’s office • Be delivered by qualified auxiliary personnel necessary to ensure benefits exceed xxxxx, and who are trained in exercise therapy for PAD • Be under the direct supervision of a physician, physician assistant, or nurse practitioner/clinical nurse specialist who must be trained in both basic and advanced life support techniques SET may be covered beyond 36 sessions over 12 weeks for an additional 36 sessions over an extended period of time if deemed medically necessary by a health care provider. You pay a $0 copay for each Medicare‑covered Medicare-covered supervised exercise therapy service. Therapeutic Massage We have partnered with American Specialty Health Group, Inc. (ASH Group) to provide your therapeutic massage coverage. We cover up to fifty visits every year for therapeutic massage.* Services must be medically necessary as determined by ASH Group. To locate an ASH Group network provider, you may contact Aetna® Member Services at the number on the back of your ID card or search our online directory. If you choose to use a provider outside of the ASH Group network, remember to present them with your member ID on your first visit. *Amounts you pay for therapeutic massage do not apply to your out‑of‑pocket maximum. $0 copay for each plan‑approved therapeutic massage visitsession. Transportation services (non‑emergency non-emergency transportation) We cover: • 24 one‑way one-way trips to and from plan‑approved plan-approved locations each year You pay a $0 copay per trip. Services that are covered for you What you must pay (after any deductible listed on page 1) when you get these services Trips must be within 60 miles of provider location. Coverage includes trips to and from providers or facilities for services that your plan covers. The transportation service will accommodate urgent requests for hospital discharge, dialysis, and trips that your medical provider considers urgent. The service will try to accommodate specific physical limitations or requirements. However, it limits services to wheelchair, taxi, or sedan transportation vehicles. • Transportation services are administered through Access2Care • To arrange for transport, call 1‑855‑814‑16990-000-000-0000, Monday through Friday, from 8 AM to 8 PM, in all time zones. (For TTY/TDD assistance please dial 711.) • You must schedule transportation service at least 48 72 hours before the appointment • You must cancel more than two hours in advance, or Access2Care will deduct the trip from the remaining number of trips available • This program doesn’t support stretcher vans/ambulances $0 copay per trip. • The driver’s role is limited to helping the member in and out of the vehicle Services that are covered for you What you must pay (after any deductible listed on page 1) when you get these services Urgently needed services Urgently needed services are provided to treat a non‑emergencynon- emergency, unforeseen medical illness, injury, or condition that requires immediate medical care but given your circumstances, it is not possible, or it is unreasonable, to obtain services from network providers. Examples of urgently needed services that the plan must cover out of network are i) you need immediate care during the weekend, or ii) you are temporarily outside the service area of the plan. Services must be immediately needed and medically necessarycare. Coverage is available worldwide (i.e., outside of the United States). You pay a $0 40 copay for each urgent care facility visit. Cost-sharing is not waived if you are admitted to the hospital. You pay a $0 40 copay for each urgent care telehealth service. Services that are covered for you What you must pay (after any deductible listed on page 1) when you get these services Vision care $0 copay for exams to diagnose and treat diseases and conditions of the eye. Covered services include: • Outpatient physician services for the diagnosis and treatment of diseases and injuries of the eye, including treatment for age‑related age-related macular degeneration. Original Medicare doesn’t cover routine eye exams (eye refractions) for eyeglasses/contacts • For people who are at high risk of glaucoma, we will cover one glaucoma screening every 12 months. People at high risk of glaucoma include: people with a family history of glaucoma, people with diabetes, African African-Americans who are age 50 and older, and Hispanic Americans who are 65 or older • For people with diabetes, screening for diabetic retinopathy is covered once per year • One pair of eyeglasses or contact lenses after each cataract surgery that includes insertion of a premium an intraocular lens. (If you have two separate cataract operations, you cannot reserve the benefit after the first surgery and purchase two eyeglasses after the second surgery.) In addition to Medicare‑covered Medicare-covered benefits, we also offer: • Non‑Medicare Non-Medicare covered eye exams: one exam every year • Follow‑up Follow up diabetic eye exam You pay a $15 copay for exams to diagnose and treat diseases and conditions of the eye. You pay a $0 copay for each Medicare‑covered Medicare-covered glaucoma screening. You pay a $0 copay for one diabetic retinopathy screening. You pay a $0 copay for each follow‑up follow up diabetic eye exam. You pay a $0 copay for one pair of eyeglasses or contact lenses after each cataract surgery. Coverage includes conventional eyeglasses or contact lenses. Excluded is coverage for designer frames and progressive lenses instead of traditional lenses, bifocals, or trifocals. You pay a $0 copay for each non‑Medicare non- Medicare covered eye exam. Additional cost‑sharing cost-sharing may apply if you receive additional services during your visit. Vision care – eyewear Eyewear reimbursement (non‑Medicare covered) Non‑Medicare Non-Medicare covered prescription eyewear includes: Our plan will reimburse you up to: $100 once every 12 months towards the cost of eyewear. Services that are covered for you What you must pay (after any deductible listed on page 1) when you get these services • Contact lenses • Eyeglass prescription lenses • Eyeglass frames You may see any licensed vision provider in the U.S. You pay the provider for services and submit an itemized billing statement showing proof of payment to our plan. You must submit your documentation within 365 days from the date of service to be eligible for reimbursement. If approved, it can take up to 45 days for you to receive payment. If your request is incomplete, such as no itemization of services, or there is missing information, you will be notified by mail. You will then have to supply the missing information, which will delay the processing time. Our plan will reimburse you up to: $300 once every 24 months towards the cost of eyewear. You may be required to pay for services up front and submit for reimbursement Services that are covered for you What you must pay when you get these services Notes: • If you use a non‑licensed non-licensed provider you will not receive reimbursement. • You are responsible for any charges above the reimbursement amount. • Eyewear reimbursement excludes eyeglasses or contact lenses after cataract surgery. * Amounts you pay for non‑Medicare non-Medicare covered eyewear do not apply to your Out‑of‑Pocket Out-of-Pocket Maximum. Services that are covered for you What you must pay (after any deductible listed on page 1) when you get these services “Welcome to Medicare” preventive visit The plan covers the one-time “Welcome to Medicare” preventive visit. The visit includes a review of your health, as well as education and counseling about the preventive services you need (including certain screenings and shots), and referrals for other care if needed. Important: We cover the “Welcome to Medicare” preventive visit only within the first 12 months you have Medicare Part B. When you make your appointment, let your doctor’s office know you would like to schedule your “Welcome to Medicare” preventive visit. There is no coinsurance, copayment, or deductible for the “Welcome to Medicare” preventive visit. You pay a $0 copay for a Medicare- covered EKG screening following the "Welcome to Medicare" preventive visit. Note: See Chapter 4, Section 2.1 of the Evidence of Coverage for information on prior authorization rules. Former Employer/Union/Trust Name: Occidental Petroleum Corporation Group Agreement Effective Date: 01/01/2022 Group/Account Number: 0000000 This Prescription Drug Schedule of Cost Sharing is part of the Evidence of Coverage (EOC) for our plan. When the EOC refers to the document with information on Medicare Part D prescription drug benefits covered under our plan, it is referring to this Prescription Drug Benefits Chart. (See Chapter 5, Using the plan’s coverage for your Part D prescription drugs and Chapter 6, What you pay for your Part D prescription drugs.)

Resources for Living. ® Resources for Living consultants provide research services for members on such topics as caregiver support, household services, eldercare services, activities, and volunteer opportunities. The purpose of the program is to assist members in locating local community services and to provide resource information for a wide variety of eldercare and life‑related life-related issues. Call Resources for Living at 1‑866‑370‑48420-000-000-0000. There is no coinsurance, copayment, or deductible for Resources for Living. Services that are covered for you What you must pay (after any deductible listed on page 1) when you get these services Screening and counseling to reduce alcohol misuse We cover one alcohol misuse screening for adults with There is no coinsurance, copayment, or deductible for the Medicare‑covered Medicare (including pregnant women) who misuse alcohol alcohol, but aren’t alcohol dependent. If you screen positive for alcohol misuse, you can get up to 4 brief face‑to‑face face-to-face counseling sessions per year (if you’re competent and alert during counseling) provided by a qualified primary care doctor or practitioner in a primary care setting. There is no coinsurance, copayment, or deductible for the Medicare- covered screening and counseling to reduce alcohol misuse preventive benefit. Services that are covered for you What you must pay (after any deductible listed on page 1) when you get these services Screening for lung cancer with low dose computed tomography (LDCT) For qualified individuals, a LDCT is covered every 12 months. Eligible members are: people aged 50 55 – 77 years who have no signs or symptoms of lung cancer, but who have a history of tobacco smoking of at least 20 pack‑years 30 pack-years and who currently smoke or have quit smoking within the last 15 years, who receive a written order for LDCT during a lung cancer screening counseling and shared decision‑making decision making visit that meets the Medicare criteria for such visits and be furnished by a physician or qualified non‑physician non- physician practitioner. For LDCT lung cancer screenings after the initial LDCT screening: the member must receive a written order for LDCT lung cancer screening, which may be furnished during any appropriate visit with a physician or qualified non‑physician non-physician practitioner. If a physician or qualified non‑physician non-physician practitioner elects to provide a lung cancer screening counseling and shared decision making visit for subsequent lung cancer screenings with LDCT, the visit must meet the Medicare criteria for such visits. There is no coinsurance, copayment, or deductible for the Medicare‑covered Medicare- covered counseling and shared decision making visit or for the LDCT. Services that are covered for you What you must pay (after any deductible listed on page 1) when you get these services Screening for sexually transmitted infections (STIs) and counseling to prevent STIs We cover sexually transmitted infection (STI) screenings for chlamydia, gonorrhea, syphilis, and Hepatitis B. These screenings are covered for pregnant women and for certain people who are at increased risk for an STI when the tests are ordered by a primary care provider. We cover these tests once every 12 months or at certain times during pregnancy. We also cover up to 2 individual 20 to 30 minute, face‑to‑face high‑intensity face-to- face high-intensity behavioral counseling sessions each year for sexually active adults at increased risk for STIs. We will only cover these counseling sessions There is no coinsurance, copayment, or deductible for the Medicare‑covered screening for STIs and counseling for STIs preventive benefit. as a preventive service if they are provided by a primary care provider and take place in a primary care setting, such as a doctor’s office. There is no coinsurance, copayment, or deductible for the Medicare- covered screening for STIs and counseling for STIs preventive benefit. Services that are covered for you What you must pay (after any deductible listed on page 1) when you get these services Services to treat kidney disease Covered services include: • Kidney disease education services to teach kidney care and help members make informed decisions about their care. For members with stage IV chronic kidney disease when referred by their doctor, we cover up to six sessions of kidney disease education services per lifetime • Outpatient dialysis treatments (including dialysis treatments when temporarily out of the service area, as explained in Chapter 3 of the Evidence of Coverage, or when your provider for this service is temporarily unavailable or inaccessible) • Inpatient dialysis treatments (if you are admitted as an inpatient to a hospital for special care) • Self‑dialysis Self-dialysis training (includes training for you and anyone helping you with your home dialysis treatments) • Home dialysis equipment and supplies • Certain home support services (such as, when necessary, visits by trained dialysis workers to check on your home dialysis, to help in emergencies, and check your dialysis equipment and water supply) Certain drugs for dialysis are covered under your Medicare Part B drug benefit. For information about coverage for Part B Drugs, please go to the section, “Medicare Part B prescription drugs.” Prior authorization rules may apply for network services. Your network provider is responsible for requesting prior authorization. Our plan recommends pre‑authorization pre-authorization of the service when provided by an out‑of‑network provider. You pay a $0 copay for self‑dialysis self-dialysis training. You pay a $0 copay for each Medicare‑covered kidney disease education sessionservices. You pay a $0 30 copay for in‑ in- and out‑of‑area out- of-area outpatient dialysis. See “Inpatient hospital care” for more information on inpatient services. $0 copay You pay 20% of the total cost for home dialysis equipment and supplies. You pay a $0 copay for Medicare‑covered Medicare- covered home support services. Services that are covered for you What you must pay (after any deductible listed on page 1) when you get these services Skilled nursing facility (SNF) care (For a definition of “skilled nursing facility care,” see the final chapter (“Definitions of important words”) of the Evidence of Coverage. Skilled nursing facilities are sometimes called “SNFs.”) Days covered: up to We cover 100 days per benefit period. A prior hospital stay is not required. $0 per day, days 1‑100 for each Medicare‑covered SNF stay. A benefit period begins the day you go into a hospital or skilled nursing facility. The benefit period ends when you haven’t received any inpatient hospital care (or skilled care in a SNF) for 60 days in a row, including your day Services that are covered for you What you must pay when you get these services Covered services include but are not limited to: • Semiprivate room (or a private room if medically necessary) • Meals, including special diets • Skilled nursing services • Physical therapy, occupational therapy, and speech therapy • Drugs administered to you as part of your plan of care (This includes substances that are naturally present in the body, such as blood clotting factors.) • Blood – including storage and administration. Coverage of whole blood and packed red cells begins with the first pint of blood that you need. All components of blood are covered beginning with the first pint used. • Medical and surgical supplies ordinarily provided by SNFs • Laboratory tests ordinarily provided by SNFs • X‑rays X-rays and other radiology services ordinarily provided by SNFs • Use of appliances such as wheelchairs ordinarily provided by SNFs • Physician/Practitioner services Prior authorization rules may apply for network servicesYou pay $0 per day, days 1-20; $50 per day, days 21-100 for each Medicare-covered SNF stay. Your network provider is responsible A benefit period begins the day you go into a hospital or skilled nursing facility. The benefit period ends when you haven’t received any inpatient hospital care (or skilled care in a SNF) for requesting prior authorization. Our plan recommends pre‑authorization of the service when provided by an out‑of‑network provider. 60 days in a row, including your day of discharge. If you go into a hospital or a skilled nursing facility after one benefit period has ended, a new benefit period begins. There is no limit to the number of benefit periods you can have. Services that are covered for you What you must pay (after any deductible listed on page 1) when you get these services Smoking and tobacco use cessation (counseling to stop smoking or tobacco use) If you use tobacco, but do not have signs or symptoms of tobacco‑related tobacco-related disease: We cover two counseling quit attempts within a 12‑month 12-month period as a preventive service with no cost to you. Each counseling attempt includes up to four face‑to‑face face-to-face visits. If you use tobacco and have been diagnosed with a tobacco‑related tobacco-related disease or are taking medicine that may be affected by tobacco: We cover cessation counseling services. We cover two counseling quit attempts within a 12‑month 12-month period, however, you will pay the applicable cost‑sharinginpatient or outpatient cost-sharing. Each counseling attempt includes up to four face‑to‑face face-to-face visits. In addition to Medicare-covered benefits, we also offer: • Additional individual and group face-to-face intermediate and intensive counseling sessions: unlimited visits every year There is no coinsurance, copayment, or deductible for the Medicare‑covered Medicare- covered smoking and tobacco use cessation preventive benefits. You pay a $0 copay for each non‑Medicare non- Medicare covered smoking and tobacco use cessation visit. In addition to Medicare‑covered benefits, we also offer: • Additional individual and group face‑to‑face intermediate and intensive counseling sessions: unlimited visits every year Services that are covered for you What you must pay (after any deductible listed on page 1) when you get these services Supervised Exercise Therapy exercise therapy (SET) SET is covered for members who have symptomatic peripheral artery disease (PAD) and a referral for PAD from the physician responsible for PAD treatment. Up to 36 sessions over a 12‑week 12-week period are covered if the SET program requirements are met. The SET program must: • Consist of sessions lasting 30‑60 30-60 minutes, comprising a therapeutic exercise‑training exercise-training program for PAD in patients with claudication • Be conducted in a hospital outpatient setting or a physician’s office • Be delivered by qualified auxiliary personnel necessary to ensure benefits exceed xxxxx, and who are trained in exercise therapy for PAD • Be under the direct supervision of a physician, physician assistant, or nurse practitioner/clinical nurse specialist who must be trained in both basic and advanced life support techniques SET may be covered beyond 36 sessions over 12 weeks for an additional 36 sessions over an extended period of time if deemed medically necessary by a health care provider. You pay a $0 30 copay for each Medicare‑covered Medicare-covered supervised exercise therapy service. Therapeutic Massage We have partnered with American Specialty Health Group, Inc. (ASH Group) to provide your therapeutic massage coverage. We cover up to fifty visits every year for therapeutic massage.* Services must be medically necessary as determined by ASH Group. To locate an ASH Group network provider, you may contact Aetna® Member Services at the number on the back of your ID card or search our online directory. If you choose to use a provider outside of the ASH Group network, remember to present them with your member ID on your first visit. *Amounts you pay for therapeutic massage do not apply to your out‑of‑pocket maximum. $0 copay for each plan‑approved therapeutic massage visitsession. Transportation services (non‑emergency non-emergency transportation) We cover: • 24 one‑way one-way trips to and from plan‑approved plan-approved locations each year You pay a $0 copay per trip. Services that are covered for you What you must pay (after any deductible listed on page 1) when you get these services Trips must be within 60 miles of provider location. Coverage includes trips to and from providers or facilities for services that your plan covers. The transportation service will accommodate urgent requests for hospital discharge, dialysis, and trips that your medical provider considers urgent. The service will try to accommodate specific physical limitations or requirements. However, it limits services to wheelchair, taxi, or sedan transportation vehicles. • Transportation services are administered through Access2Care • To arrange for transport, call 1‑855‑814‑16990-000-000-0000, Monday through Friday, from 8 AM to 8 PM, in all time zones. (For TTY/TDD assistance please dial 711.) • You must schedule transportation service at least 48 72 hours before the appointment • You must cancel more than two hours in advance, or Access2Care will deduct the trip from the remaining number of trips available • This program doesn’t support stretcher vans/ambulances $0 copay per trip. • The driver’s role is limited to helping the member in and out of the vehicle Services that are covered for you What you must pay (after any deductible listed on page 1) when you get these services Urgently needed services Urgently needed services are provided to treat a non‑emergencynon- emergency, unforeseen medical illness, injury, or condition that requires immediate medical care but given your circumstances, it is not possible, or it is unreasonable, to obtain services from network providers. Examples of urgently needed services that the plan must cover out of network are i) you need immediate care during the weekend, or ii) you are temporarily outside the service area of the plan. Services must be immediately needed and medically necessarycare. Coverage is available worldwide (i.e., outside of the United States). You pay a $0 50 copay for each urgent care facility visit. Cost-sharing is not waived if you are admitted to the hospital. You pay a $0 50 copay for each urgent care telehealth service. Services that are covered for you What you must pay (after any deductible listed on page 1) when you get these services Vision care $0 copay for exams to diagnose and treat diseases and conditions of the eye. Covered services include: • Outpatient physician services for the diagnosis and treatment of diseases and injuries of the eye, including treatment for age‑related age-related macular degeneration. Original Medicare doesn’t cover routine eye exams (eye refractions) for eyeglasses/contacts • For people who are at high risk of glaucoma, we will cover one glaucoma screening every 12 months. People at high risk of glaucoma include: people with a family history of glaucoma, people with diabetes, African African-Americans who are age 50 and older, and Hispanic Americans who are 65 or older • For people with diabetes, screening for diabetic retinopathy is covered once per year • One pair of eyeglasses or contact lenses after each cataract surgery that includes insertion of a premium an intraocular lens. (If you have two separate cataract operations, you cannot reserve the benefit after the first surgery and purchase two eyeglasses after the second surgery.) In addition to Medicare‑covered Medicare-covered benefits, we also offer: • Non‑Medicare Non-Medicare covered eye exams: one exam every year • Follow‑up Follow up diabetic eye exam You pay a $40 copay for exams to diagnose and treat diseases and conditions of the eye. You pay a $0 copay for each Medicare‑covered Medicare-covered glaucoma screening. You pay a $0 copay for one diabetic retinopathy screening. You pay a $0 copay for each follow‑up follow up diabetic eye exam. You pay a $0 copay for one pair of eyeglasses or contact lenses after each cataract surgery. Coverage includes conventional eyeglasses or contact lenses. Excluded is coverage for designer frames and progressive lenses instead of traditional lenses, bifocals, or trifocals. You pay a $0 copay for each non‑Medicare non- Medicare covered eye exam. Additional cost‑sharing cost-sharing may apply if you receive additional services during your visit. Vision care – eyewear reimbursement (non‑Medicare covered) Non‑Medicare covered prescription eyewear includes: • Contact lenses • Eyeglass prescription lenses • Eyeglass frames You may see any licensed vision provider in the U.S. You pay the provider for services and submit an itemized billing statement showing proof of payment to our plan. You must submit your documentation within 365 days from the date of service to be eligible for reimbursement. If approved, it can take up to 45 days for you to receive payment. If your request is incomplete, such as no itemization of services, or there is missing information, you will be notified by mail. You will then have to supply the missing information, which will delay the processing time. Our plan will reimburse you up to: $300 once every 24 months towards the cost of eyewear. You may be required to pay for services up front and submit for reimbursement Services that are covered for you What you must pay (after any deductible listed on page 1) when you get these services Notes“Welcome to Medicare” preventive visit The plan covers the one-time “Welcome to Medicare” preventive visit. The visit includes a review of your health, as well as education and counseling about the preventive services you need (including certain screenings and shots), and referrals for other care if needed. Important: • If We cover the “Welcome to Medicare” preventive visit only within the first 12 months you use have Medicare Part B. When you make your appointment, let your doctor’s office know you would like to schedule your “Welcome to Medicare” preventive visit. There is no coinsurance, copayment, or deductible for the “Welcome to Medicare” preventive visit. You pay a non‑licensed provider you will not receive reimbursement$0 copay for a Medicare- covered EKG screening following the "Welcome to Medicare" preventive visit. • You are responsible Note: See Chapter 4, Section 2.1 of the Evidence of Coverage for any charges above information on prior authorization rules. Former Employer/Union/Trust Name: Occidental Petroleum Corporation Group Agreement Effective Date: 01/01/2022 Group/Account Number: 0000000,0000000 This Prescription Drug Schedule of Cost Sharing is part of the reimbursement amountEvidence of Coverage (EOC) for our plan. • Eyewear reimbursement excludes eyeglasses or contact lenses after cataract surgeryWhen the EOC refers to the document with information on Medicare Part D prescription drug benefits covered under our plan, it is referring to this Prescription Drug Benefits Chart. * Amounts (See Chapter 5, Using the plan’s coverage for your Part D prescription drugs and Chapter 6, What you pay for non‑Medicare covered eyewear do not apply to your Out‑of‑Pocket MaximumPart D prescription drugs.)

Resources for Living. ® Resources for Living consultants provide research services for members on such topics as caregiver support, household services, eldercare services, activities, and volunteer opportunities. The purpose of the program is to assist members in locating local community services and to provide resource information for a wide variety of eldercare and life‑related life-related issues. Call Resources for Living at 1‑866‑370‑48420-000-000-0000. There is no coinsurance, copayment, or deductible for Resources for Living. Services that are covered for you What you must pay (after any deductible listed on page 1) when you get these services Screening and counseling to reduce alcohol misuse We cover one alcohol misuse screening for adults with There is no coinsurance, copayment, or deductible for the Medicare‑covered Medicare (including pregnant women) who misuse alcohol alcohol, but aren’t alcohol dependent. If you screen positive for alcohol misuse, you can get up to 4 brief face‑to‑face face-to-face counseling sessions per year (if you’re competent and alert during counseling) provided by a qualified primary care doctor or practitioner in a primary care setting. There is no coinsurance, copayment, or deductible for the Medicare- covered screening and counseling to reduce alcohol misuse preventive benefit. Services that are covered for you What you must pay (after any deductible listed on page 1) when you get these services Screening for lung cancer with low dose computed tomography (LDCT) For qualified individuals, a LDCT is covered every 12 months. Eligible members are: people aged 50 55 – 77 years who have no signs or symptoms of lung cancer, but who have a history of tobacco smoking of at least 20 pack‑years 30 pack-years and who currently smoke or have quit smoking within the last 15 years, who receive a written order for LDCT during a lung cancer screening counseling and shared decision‑making decision making visit that meets the Medicare criteria for such visits and be furnished by a physician or qualified non‑physician non- physician practitioner. For LDCT lung cancer screenings after the initial LDCT screening: the member must receive a written order for LDCT lung cancer screening, which may be furnished during any appropriate visit with a physician or qualified non‑physician non-physician practitioner. If a physician or qualified non‑physician non-physician practitioner elects to provide a lung cancer screening counseling and shared decision making visit for subsequent lung cancer screenings with LDCT, the visit must meet the Medicare criteria for such visits. There is no coinsurance, copayment, or deductible for the Medicare‑covered Medicare- covered counseling and shared decision making visit or for the LDCT. Services that are covered for you What you must pay (after any deductible listed on page 1) when you get these services Screening for sexually transmitted infections (STIs) and counseling to prevent STIs We cover sexually transmitted infection (STI) screenings for chlamydia, gonorrhea, syphilis, and Hepatitis B. These screenings are covered for pregnant women and for certain people who are at increased risk for an STI when the tests are ordered by a primary care provider. We cover these tests once every 12 months or at certain times during pregnancy. We also cover up to 2 individual 20 to 30 minute, face‑to‑face high‑intensity face-to- face high-intensity behavioral counseling sessions each year for sexually active adults at increased risk for STIs. We will only cover these counseling sessions There is no coinsurance, copayment, or deductible for the Medicare‑covered screening for STIs and counseling for STIs preventive benefit. as a preventive service if they are provided by a primary care provider and take place in a primary care setting, such as a doctor’s office. There is no coinsurance, copayment, or deductible for the Medicare- covered screening for STIs and counseling for STIs preventive benefit. Services that are covered for you What you must pay (after any deductible listed on page 1) when you get these services Services to treat kidney disease Covered services include: • Kidney disease education services to teach kidney care and help members make informed decisions about their care. For members with stage IV chronic kidney disease when referred by their doctor, we cover up to six sessions of kidney disease education services per lifetime • Outpatient dialysis treatments (including dialysis treatments when temporarily out of the service area, as explained in Chapter 3 of the Evidence of Coverage, or when your provider for this service is temporarily unavailable or inaccessible) • Inpatient dialysis treatments (if you are admitted as an inpatient to a hospital for special care) • Self‑dialysis Self-dialysis training (includes training for you and anyone helping you with your home dialysis treatments) • Home dialysis equipment and supplies • Certain home support services (such as, when necessary, visits by trained dialysis workers to check on your home dialysis, to help in emergencies, and check your dialysis equipment and water supply) Certain drugs for dialysis are covered under your Medicare Part B drug benefit. For information about coverage for Part B Drugs, please go to the section, “Medicare Part B prescription drugs.” Prior authorization rules may apply for network services. Your network provider is responsible for requesting prior authorization. Our plan recommends pre‑authorization pre-authorization of the service when provided by an out‑of‑network provider. You pay a $0 copay for self‑dialysis self-dialysis training. You pay a $0 copay for each Medicare‑covered kidney disease education sessionservices. You pay a $0 30 copay for in‑ in- and out‑of‑area out- of-area outpatient dialysis. See “Inpatient hospital care” for more information on inpatient services. You pay a $0 copay for home dialysis equipment and supplies. You pay a $0 copay for Medicare‑covered Medicare- covered home support services. Services that are covered for you What you must pay (after any deductible listed on page 1) when you get these services Skilled nursing facility (SNF) care (For a definition of “skilled nursing facility care,” see the final chapter (“Definitions of important words”) of the Evidence of Coverage. Skilled nursing facilities are sometimes called “SNFs.”) Days covered: up to We cover 100 days per benefit period. A prior hospital stay is not required. $0 per day, days 1‑100 for each Medicare‑covered SNF stay. A benefit period begins the day you go into a hospital or skilled nursing facility. The benefit period ends when you haven’t received any inpatient hospital care (or skilled care in a SNF) for 60 days in a row, including your day Services that are covered for you What you must pay when you get these services Covered services include but are not limited to: • Semiprivate room (or a private room if medically necessary) • Meals, including special diets • Skilled nursing services • Physical therapy, occupational therapy, and speech therapy • Drugs administered to you as part of your plan of care (This includes substances that are naturally present in the body, such as blood clotting factors.) • Blood – including storage and administration. Coverage of whole blood and packed red cells begins with the first pint of blood that you need. All components of blood are covered beginning with the first pint used. • Medical and surgical supplies ordinarily provided by SNFs • Laboratory tests ordinarily provided by SNFs • X‑rays X-rays and other radiology services ordinarily provided by SNFs • Use of appliances such as wheelchairs ordinarily provided by SNFs • Physician/Practitioner services Prior authorization rules may apply for network servicesYou pay $0 per day, days 1-100 for each Medicare-covered SNF stay. Your network provider is responsible A benefit period begins the day you go into a hospital or skilled nursing facility. The benefit period ends when you haven’t received any inpatient hospital care (or skilled care in a SNF) for requesting prior authorization. Our plan recommends pre‑authorization of the service when provided by an out‑of‑network provider. 60 days in a row, including your day of discharge. If you go into a hospital or a skilled nursing facility after one benefit period has ended, a new benefit period begins. There is no limit to the number of benefit periods you can have. Services that are covered for you What you must pay (after any deductible listed on page 1) when you get these services Smoking and tobacco use cessation (counseling to stop smoking or tobacco use) If you use tobacco, but do not have signs or symptoms of tobacco‑related tobacco-related disease: We cover two counseling quit attempts within a 12‑month 12-month period as a preventive service with no cost to you. Each counseling attempt includes up to four face‑to‑face face-to-face visits. If you use tobacco and have been diagnosed with a tobacco‑related tobacco-related disease or are taking medicine that may be affected by tobacco: We cover cessation counseling services. We cover two counseling quit attempts within a 12‑month 12-month period, however, you will pay the applicable cost‑sharinginpatient or outpatient cost-sharing. Each counseling attempt includes up to four face‑to‑face face-to-face visits. In addition to Medicare-covered benefits, we also offer: • Additional individual and group face-to-face intermediate and intensive counseling sessions: unlimited visits every year There is no coinsurance, copayment, or deductible for the Medicare‑covered Medicare- covered smoking and tobacco use cessation preventive benefits. You pay a $0 copay for each non‑Medicare non- Medicare covered smoking and tobacco use cessation visit. In addition to Medicare‑covered benefits, we also offer: • Additional individual and group face‑to‑face intermediate and intensive counseling sessions: unlimited visits every year Services that are covered for you What you must pay (after any deductible listed on page 1) when you get these services Supervised Exercise Therapy exercise therapy (SET) SET is covered for members who have symptomatic peripheral artery disease (PAD) and a referral for PAD from the physician responsible for PAD treatment. Up to 36 sessions over a 12‑week 12-week period are covered if the SET program requirements are met. The SET program must: • Consist of sessions lasting 30‑60 30-60 minutes, comprising a therapeutic exercise‑training exercise-training program for PAD in patients with claudication • Be conducted in a hospital outpatient setting or a physician’s office • Be delivered by qualified auxiliary personnel necessary to ensure benefits exceed xxxxx, and who are trained in exercise therapy for PAD • Be under the direct supervision of a physician, physician assistant, or nurse practitioner/clinical nurse specialist who must be trained in both basic and advanced life support techniques SET may be covered beyond 36 sessions over 12 weeks for an additional 36 sessions over an extended period of time if deemed medically necessary by a health care provider. You pay a $0 30 copay for each Medicare‑covered Medicare-covered supervised exercise therapy service. Therapeutic Massage We have partnered with American Specialty Health Group, Inc. (ASH Group) to provide your therapeutic massage coverage. We cover up to fifty visits every year for therapeutic massage.* Services must be medically necessary as determined by ASH Group. To locate an ASH Group network provider, you may contact Aetna® Member Services at the number on the back of your ID card or search our online directory. If you choose to use a provider outside of the ASH Group network, remember to present them with your member ID on your first visit. *Amounts you pay for therapeutic massage do not apply to your out‑of‑pocket maximum. $0 copay for each plan‑approved therapeutic massage visitsession. Transportation services (non‑emergency non-emergency transportation) We cover: • 24 one‑way one-way trips to and from plan‑approved plan-approved locations each year You pay a $0 copay per trip. Services that are covered for you What you must pay (after any deductible listed on page 1) when you get these services Trips must be within 60 miles of provider location. Coverage includes trips to and from providers or facilities for services that your plan covers. The transportation service will accommodate urgent requests for hospital discharge, dialysis, and trips that your medical provider considers urgent. The service will try to accommodate specific physical limitations or requirements. However, it limits services to wheelchair, taxi, or sedan transportation vehicles. • Transportation services are administered through Access2Care • To arrange for transport, call 1‑855‑814‑16990-000-000-0000, Monday through Friday, from 8 AM to 8 PM, in all time zones. (For TTY/TDD assistance please dial 711.) • You must schedule transportation service at least 48 72 hours before the appointment • You must cancel more than two hours in advance, or Access2Care will deduct the trip from the remaining number of trips available • This program doesn’t support stretcher vans/ambulances $0 copay per trip. • The driver’s role is limited to helping the member in and out of the vehicle Services that are covered for you What you must pay (after any deductible listed on page 1) when you get these services Urgently needed services Urgently needed services are provided to treat a non‑emergencynon- emergency, unforeseen medical illness, injury, or condition that requires immediate medical care but given your circumstances, it is not possible, or it is unreasonable, to obtain services from network providers. Examples of urgently needed services that the plan must cover out of network are i) you need immediate care during the weekend, or ii) you are temporarily outside the service area of the plan. Services must be immediately needed and medically necessarycare. Coverage is available worldwide (i.e., outside of the United States). You pay a $0 50 copay for each urgent care facility visit. Cost-sharing is not waived if you are admitted to the hospital. You pay a $0 50 copay for each urgent care telehealth service. Services that are covered for you What you must pay (after any deductible listed on page 1) when you get these services Vision care $0 copay for exams to diagnose and treat diseases and conditions of the eye. Covered services include: • Outpatient physician services for the diagnosis and treatment of diseases and injuries of the eye, including treatment for age‑related age-related macular degeneration. Original Medicare doesn’t cover routine eye exams (eye refractions) for eyeglasses/contacts • For people who are at high risk of glaucoma, we will cover one glaucoma screening every 12 months. People at high risk of glaucoma include: people with a family history of glaucoma, people with diabetes, African African-Americans who are age 50 and older, and Hispanic Americans who are 65 or older • For people with diabetes, screening for diabetic retinopathy is covered once per year • One pair of eyeglasses or contact lenses after each cataract surgery that includes insertion of a premium an intraocular lens. (If you have two separate cataract operations, you cannot reserve the benefit after the first surgery and purchase two eyeglasses after the second surgery.) In addition to Medicare‑covered Medicare-covered benefits, we also offer: • Non‑Medicare Non-Medicare covered eye exams: one exam every year • Follow‑up Follow up diabetic eye exam You pay a $35 copay for exams to diagnose and treat diseases and conditions of the eye. You pay a $0 copay for each Medicare‑covered Medicare-covered glaucoma screening. You pay a $0 copay for one diabetic retinopathy screening. You pay a $0 copay for each follow‑up follow up diabetic eye exam. You pay a $0 copay for one pair of eyeglasses or contact lenses after each cataract surgery. Coverage includes conventional eyeglasses or contact lenses. Excluded is coverage for designer frames and progressive lenses instead of traditional lenses, bifocals, or trifocals. You pay a $0 copay for each non‑Medicare non- Medicare covered eye exam. Additional cost‑sharing cost-sharing may apply if you receive additional services during your visit. Vision care – eyewear reimbursement (non‑Medicare covered) Non‑Medicare covered prescription eyewear includes: • Contact lenses • Eyeglass prescription lenses • Eyeglass frames You may see any licensed vision provider in the U.S. You pay the provider for services and submit an itemized billing statement showing proof of payment to our plan. You must submit your documentation within 365 days from the date of service to be eligible for reimbursement. If approved, it can take up to 45 days for you to receive payment. If your request is incomplete, such as no itemization of services, or there is missing information, you will be notified by mail. You will then have to supply the missing information, which will delay the processing time. Our plan will reimburse you up to: $300 once every 24 months towards the cost of eyewear. You may be required to pay for services up front and submit for reimbursement Services that are covered for you What you must pay (after any deductible listed on page 1) when you get these services Notes“Welcome to Medicare” preventive visit The plan covers the one-time “Welcome to Medicare” preventive visit. The visit includes a review of your health, as well as education and counseling about the preventive services you need (including certain screenings and shots), and referrals for other care if needed. Important: • If We cover the “Welcome to Medicare” preventive visit only within the first 12 months you use have Medicare Part B. When you make your appointment, let your doctor’s office know you would like to schedule your “Welcome to Medicare” preventive visit. There is no coinsurance, copayment, or deductible for the “Welcome to Medicare” preventive visit. You pay a non‑licensed provider you will not receive reimbursement$0 copay for a Medicare- covered EKG screening following the "Welcome to Medicare" preventive visit. • You are responsible Note: See Chapter 4, Section 2.1 of the Evidence of Coverage for any charges above information on prior authorization rules. Former Employer/Union/Trust Name: Xxx County Board of County Commissioners Group Agreement Effective Date: 01/01/2022 Group/Account Number: 0000000 This Prescription Drug Schedule of Cost Sharing is part of the reimbursement amountEvidence of Coverage (EOC) for our plan. • Eyewear reimbursement excludes eyeglasses or contact lenses after cataract surgeryWhen the EOC refers to the document with information on Medicare Part D prescription drug benefits covered under our plan, it is referring to this Prescription Drug Benefits Chart. * Amounts (See Chapter 5, Using the plan’s coverage for your Part D prescription drugs and Chapter 6, What you pay for non‑Medicare covered eyewear do not apply to your Out‑of‑Pocket MaximumPart D prescription drugs.)

Resources for Living. ® Resources for Living consultants provide research services for members on such topics as caregiver support, household services, eldercare services, activities, and volunteer opportunities. The purpose of the program is to assist members in locating local community services and to provide resource information for a wide variety of eldercare and life‑related issues. Call Resources for Living at 1‑866‑370‑4842. There is no coinsurance, copayment, or deductible for Resources for Living. Screening and counseling to reduce alcohol misuse We cover one alcohol misuse screening for adults with There is no coinsurance, copayment, or deductible for the Medicare‑covered Medicare (including pregnant women) who misuse alcohol but aren’t alcohol dependent. If you screen positive for alcohol misuse, you can get up There is no coinsurance, copayment, or deductible for the Medicare‑covered screening and counseling to reduce alcohol misuse preventive benefit. to 4 brief face‑to‑face counseling sessions per year (if you’re competent and alert during counseling) provided by a qualified primary care doctor or practitioner in a primary care setting. screening and counseling to reduce alcohol misuse preventive benefit. Screening for lung cancer with low dose computed tomography (LDCT) For qualified individuals, a LDCT is covered every 12 months. Eligible members are: people aged 50 – 77 years who have no signs or symptoms of lung cancer, but who have a history of tobacco smoking of at least 20 pack‑years and who currently smoke or have quit smoking within the last 15 years, who receive a written order for LDCT during a lung cancer screening counseling and shared decision‑making visit that meets the Medicare criteria for such visits and be furnished by a physician or qualified non‑physician practitioner. For LDCT lung cancer screenings after the initial LDCT screening: the member must receive a written order for LDCT lung cancer screening, which may be furnished during any appropriate visit with a physician or qualified non‑physician practitioner. If a physician or qualified non‑physician practitioner elects to provide a lung cancer screening counseling and shared decision making visit for subsequent lung cancer screenings with LDCT, the visit must meet the Medicare criteria for such visits. There is no coinsurance, copayment, or deductible for the Medicare‑covered counseling and shared decision making visit or for the LDCT. Screening for sexually transmitted infections (STIs) and counseling to prevent STIs We cover sexually transmitted infection (STI) screenings for chlamydia, gonorrhea, syphilis, and Hepatitis B. These screenings are covered for pregnant women and for certain people who are at increased risk for an STI when the tests are ordered by a primary care provider. We cover these tests once every 12 months or at certain times during pregnancy. We also cover up to 2 individual 20 to 30 minute, face‑to‑face high‑intensity behavioral counseling sessions each year for sexually active adults at increased risk for STIs. We will only cover these counseling sessions There is no coinsurance, copayment, or deductible for the Medicare‑covered screening for STIs and counseling for STIs preventive benefit. as a preventive service if they are provided by a primary care provider and take place in a primary care setting, such as a doctor’s office. There is no coinsurance, copayment, or deductible for the Medicare‑covered screening for STIs and counseling for STIs preventive benefit. Services to treat kidney disease $0 copay for self‑dialysis training. Covered services include: • Kidney disease education services to teach kidney care and help members make informed decisions about their care. For members with stage IV chronic kidney disease when referred by their doctor, we cover up to six sessions of kidney disease education services per lifetime • Outpatient dialysis treatments (including dialysis treatments when temporarily out of the service area, as explained in Chapter 3 of the Evidence of Coverage, or when your provider for this service is temporarily unavailable or inaccessible) • Inpatient dialysis treatments (if you are admitted as an inpatient to a hospital for special care) • Self‑dialysis training (includes training for you and anyone helping you with your home dialysis treatments) • Home dialysis equipment and supplies • Certain home support services (such as, when necessary, visits by trained dialysis workers to check on your home dialysis, to help in emergencies, and check your dialysis equipment and water supply) Certain drugs for dialysis are covered under your Medicare Part B drug benefit. For information about coverage for Part B Drugs, please go to the section, “Medicare Part B prescription drugs.” Prior authorization rules may apply for network services. Your network provider is responsible for requesting prior authorization. Our plan recommends pre‑authorization of the service when provided by an out‑of‑network provider. $0 copay for self‑dialysis training. $0 copay for each Medicare‑covered kidney disease education session. $0 copay for in‑ and out‑of‑area outpatient dialysis. See “Inpatient hospital care” for more information on inpatient services. $0 copay for home dialysis equipment and supplies. $0 copay for Medicare‑covered home support services. Skilled nursing facility (SNF) care (For a definition of “skilled nursing facility care,” see the final chapter (“Definitions of important words”) of the Evidence of Coverage. Skilled nursing facilities are sometimes called “SNFs.”) Days covered: up to 100 days per benefit period. A prior hospital stay is not required. Covered services include but are not limited to: • Semiprivate room (or a private room if medically $0 per day, days 1‑100 for each Medicare‑covered SNF stay. A benefit period begins the day you go into a hospital or skilled nursing facility. The benefit period ends when you haven’t received any inpatient hospital care (or skilled care in a SNF) for 60 days in a row, including your day of discharge. If you go into a hospital or a skilled nursing facility after one benefit period has ended, a new benefit period begins. There is no limit to the number of benefit periods you can have. Services that are covered for you What you must pay when you get these services Covered services include but are not limited to: • Semiprivate room (or a private room if medically necessary) • Meals, including special diets • Skilled nursing services • Physical therapy, occupational therapy, and speech therapy • Drugs administered to you as part of your plan of care (This includes substances that are naturally present in the body, such as blood clotting factors.) • Blood – including storage and administration. Coverage of whole blood and packed red cells begins with the first pint of blood that you need. All components of blood are covered beginning with the first pint used. • Medical and surgical supplies ordinarily provided by SNFs • Laboratory tests ordinarily provided by SNFs • X‑rays and other radiology services ordinarily provided by SNFs • Use of appliances such as wheelchairs ordinarily provided by SNFs • Physician/Practitioner services Prior authorization rules may apply for network services. Your network provider is responsible for requesting prior authorization. Our plan recommends pre‑authorization of the service when provided by an out‑of‑network provider. of discharge. If you go into a hospital or a skilled nursing facility after one benefit period has ended, a new benefit period begins. There is no limit to the number of benefit periods you can have. Smoking and tobacco use cessation (counseling to stop smoking or tobacco use) If you use tobacco, but do not have signs or symptoms of tobacco‑related disease: We cover two counseling quit attempts within a 12‑month period as a preventive service with no cost to you. Each counseling attempt includes up to four face‑to‑face visits. If you use tobacco and have been diagnosed with a tobacco‑related disease or are taking medicine that may be affected by tobacco: We cover cessation counseling services. We cover two counseling quit attempts within a 12‑month period, however, you will pay the applicable cost‑sharing. Each counseling attempt includes up to four face‑to‑face visits. In addition to Medicare‑covered benefits, we also offer: There is no coinsurance, copayment, or deductible for the Medicare‑covered smoking and tobacco use cessation preventive benefits. $0 copay for each non‑Medicare covered smoking and tobacco use cessation visit. In addition to Medicare‑covered benefits, we also offer: Services that are covered for you What you must pay when you get these services • Additional individual and group face‑to‑face intermediate and intensive counseling sessions: unlimited visits every year Supervised Exercise Therapy (SET) SET is covered for members who have symptomatic peripheral artery disease (PAD) and a referral for PAD from the physician responsible for PAD treatment. Up to 36 sessions over a 12‑week period are covered if the SET program requirements are met. The SET program must: • Consist of sessions lasting 30‑60 minutes, comprising a therapeutic exercise‑training program for PAD in patients with claudication • Be conducted in a hospital outpatient setting or a physician’s office • Be delivered by qualified auxiliary personnel necessary to ensure benefits exceed xxxxx, and who are trained in exercise therapy for PAD • Be under the direct supervision of a physician, physician assistant, or nurse practitioner/clinical nurse specialist who must be trained in both basic and advanced life support techniques SET may be covered beyond 36 sessions over 12 weeks for an additional 36 sessions over an extended period of time if deemed medically necessary by a health care provider. $0 copay for each Medicare‑covered supervised exercise therapy service. Therapeutic Massage We have partnered with American Specialty Health Group, Inc. (ASH Group) to provide your therapeutic massage coverage. We cover up to fifty visits every year for therapeutic massage.* Services must be medically necessary as determined by ASH Group. To locate an ASH Group network provider, you may contact Aetna® Member Services at the number on the back of your ID card or search our online directory. If you choose to use a provider outside of the ASH Group network, remember to present them with your member ID on your first visit. *Amounts you pay for therapeutic massage do not apply to your out‑of‑pocket maximum. $0 copay for each plan‑approved therapeutic massage visit. Transportation services (non‑emergency transportation) We cover: • 24 one‑way trips to and from plan‑approved locations each year Trips must be within 60 miles of provider location. Coverage includes trips to and from providers or facilities for services that your plan covers. The transportation service will accommodate urgent requests for hospital discharge, dialysis, and trips that your medical provider considers urgent. The service will try to accommodate specific physical limitations or requirements. However, it limits services to wheelchair, taxi, or sedan transportation vehicles. • Transportation services are administered through Access2Care • To arrange for transport, call 1‑855‑814‑1699, Monday through Friday, from 8 AM to 8 PM, in all time zones. (For TTY/TDD assistance please dial 711.) • You must schedule transportation service at least 48 hours before the appointment • You must cancel more than two hours in advance, or Access2Care will deduct the trip from the remaining number of trips available • This program doesn’t support stretcher vans/ambulances $0 copay per trip. Urgently needed services Urgently needed services are provided to treat a non‑emergency, unforeseen medical illness, injury, or condition that requires immediate medical care but given your circumstances, it is not possible, or it is unreasonable, to obtain services from network providers. Examples of urgently needed services that the plan must cover out of network are i) you need immediate care during the weekend, or ii) you are temporarily outside the service area of the plan. Services must be immediately needed and medically necessary. Coverage is available worldwide (i.e., outside of the United States). $0 copay for each urgent care facility visit. $0 copay for each urgent care telehealth service. Vision care $0 copay for exams to diagnose and treat diseases and conditions of the eye. Covered services include: • Outpatient physician services for the diagnosis and treatment of diseases and injuries of the eye, including treatment for age‑related macular degeneration. Original Medicare doesn’t cover routine eye exams (eye refractions) for eyeglasses/contacts • For people who are at high risk of glaucoma, we will cover one glaucoma screening every 12 months. People at high risk of glaucoma include: people with a family history of glaucoma, people with diabetes, African Americans who are age 50 and older, and Hispanic Americans who are 65 or older • For people with diabetes, screening for diabetic retinopathy is covered once per year • One pair of eyeglasses or contact lenses after each cataract surgery that includes insertion of a premium intraocular lens. (If you have two separate cataract operations, you cannot reserve the benefit after the first surgery and purchase two eyeglasses after the second surgery.) In addition to Medicare‑covered benefits, we also offer: • Non‑Medicare covered eye exams: one exam every year • Follow‑up diabetic eye exam $0 copay for each Medicare‑covered glaucoma screening. $0 copay for one diabetic retinopathy screening. $0 copay for each follow‑up diabetic eye exam. $0 copay for one pair of eyeglasses or contact lenses after each cataract surgery. Coverage includes conventional eyeglasses or contact lenses. Excluded is coverage for designer frames and progressive lenses instead of traditional lenses, bifocals, or trifocals. $0 copay for each non‑Medicare covered eye exam. Additional cost‑sharing may apply if you receive additional services during your visit. Vision care – eyewear reimbursement (non‑Medicare covered) Non‑Medicare covered prescription eyewear includes: • Contact lenses • Eyeglass prescription lenses • Eyeglass frames You may see any licensed vision provider in the U.S. You pay the provider for services and submit an itemized billing statement showing proof of payment to our plan. You must submit your documentation within 365 days from the date of service to be eligible for reimbursement. If approved, it can take up to 45 days for you to receive payment. If your request is incomplete, such as no itemization of services, or there is missing information, you will be notified by mail. You will then have to supply the missing information, which will delay the processing time. Our plan will reimburse you up to: $300 once every 24 months towards the cost of eyewear. You may be required to pay for services up front and submit for reimbursement Services that are covered for you What you must pay when you get these services Notes: • If you use a non‑licensed provider you will not receive reimbursement. • You are responsible for any charges above the reimbursement amount. • Eyewear reimbursement excludes eyeglasses or contact lenses after cataract surgery. * Amounts you pay for non‑Medicare covered eyewear do not apply to your Out‑of‑Pocket Maximum.

Resources for Living. ® Resources for Living consultants provide research services for members on such topics as caregiver support, household services, eldercare services, activities, and volunteer opportunities. The purpose of the program is to assist members in locating local community services and to provide resource information for a wide variety of eldercare and life‑related issues. Call Resources for Living at 1‑866‑370‑4842. There is no coinsurance, copayment, or deductible for Resources for Living. Screening and counseling to reduce alcohol misuse There is no coinsurance, copayment, or We cover one alcohol misuse screening for adults with There is no coinsurance, copayment, or deductible for the Medicare‑covered Medicare (including pregnant women) who misuse alcohol but aren’t alcohol dependent. If you screen positive for alcohol misuse, you can get up to 4 brief face‑to‑face counseling sessions per year (if you’re competent and alert during counseling) provided by a qualified primary care doctor or practitioner in a primary care setting. deductible for the Medicare‑covered screening and counseling to reduce alcohol misuse preventive benefit. Screening for lung cancer with low dose computed tomography (LDCT) For qualified individuals, a LDCT is covered every 12 months. Eligible members are: people aged 50 – 77 years who have no signs or symptoms of lung cancer, but who have a history of tobacco smoking of at least 20 pack‑years and who currently smoke or have quit smoking within the last 15 years, who receive a written order for LDCT during a lung cancer screening counseling and shared decision‑making visit that meets the Medicare criteria for such visits and be furnished by a physician or qualified non‑physician practitioner. For LDCT lung cancer screenings after the initial LDCT screening: the member must receive a written order for LDCT lung cancer screening, which may be furnished during any appropriate visit with a physician or qualified non‑physician practitioner. If a physician or qualified non‑physician practitioner elects to provide a lung cancer screening counseling and shared decision making visit for subsequent lung cancer screenings with LDCT, the visit must meet the Medicare criteria for such visits. There is no coinsurance, copayment, or deductible for the Medicare‑covered counseling and shared decision making visit or for the LDCT. Screening for sexually transmitted infections (STIs) and counseling to prevent STIs We cover sexually transmitted infection (STI) screenings for chlamydia, gonorrhea, syphilis, and Hepatitis B. These screenings are covered for pregnant women and for certain people who are at increased risk for an STI when the tests are ordered by a primary care provider. We cover these tests once every 12 months or at certain times during pregnancy. We also cover up to 2 individual 20 to 30 minute, face‑to‑face high‑intensity behavioral counseling sessions each year for sexually active adults at increased risk for STIs. We will only cover these counseling sessions There is no coinsurance, copayment, or deductible for the Medicare‑covered screening for STIs and counseling for STIs preventive benefit. risk for STIs. We will only cover these counseling sessions as a preventive service if they are provided by a primary care provider and take place in a primary care setting, such as a doctor’s office. Services to treat kidney disease Covered services include: • Kidney disease education services to teach kidney care and help members make informed decisions about their care. For members with stage IV chronic kidney disease when referred by their doctor, we cover up to six sessions of kidney disease education services per lifetime • Outpatient dialysis treatments (including dialysis treatments when temporarily out of the service area, as explained in Chapter 3 of the Evidence of Coverage, or when your provider for this service is temporarily unavailable or inaccessible) • Inpatient dialysis treatments (if you are admitted as an inpatient to a hospital for special care) • Self‑dialysis training (includes training for you and anyone helping you with your home dialysis treatments) • Home dialysis equipment and supplies • Certain home support services (such as, when necessary, visits by trained dialysis workers to check on your home dialysis, to help in emergencies, and check your dialysis equipment and water supply) Certain drugs for dialysis are covered under your Medicare Part B drug benefit. For information about coverage for Part B Drugs, please go to the section, “Medicare Part B prescription drugs.” Prior authorization rules may apply for network services. Your network provider is responsible for requesting prior authorization. Our plan recommends pre‑authorization of the service when provided by an out‑of‑network provider. $0 copay for self‑dialysis training. $0 copay for each Medicare‑covered kidney disease education session. $0 30 copay for in‑ and out‑of‑area outpatient dialysis. See “Inpatient hospital care” for more information on inpatient services. $0 copay 20% of the total cost for home dialysis equipment and supplies. $0 copay for Medicare‑covered home support services. Skilled nursing facility (SNF) care (For a definition of “skilled nursing facility care,” see the final chapter (“Definitions of important words”) of the Evidence of Coverage. Skilled nursing facilities are sometimes called “SNFs.”) Days covered: up to 100 days per benefit period. A prior hospital stay is not required. $0 per day, days 1‑100 1‑20; $50 per day, days 21‑100 for each Medicare‑covered SNF stay. A benefit period begins the day you go into a hospital or skilled nursing facility. The benefit period ends when you haven’t received any inpatient hospital care (or skilled care in a SNF) for 60 days in a row, including your day Services that are covered for you What you must pay when you get these services hospital stay is not required. Covered services include but are not limited to: • Semiprivate room (or a private room if medically necessary) • Meals, including special diets • Skilled nursing services • Physical therapy, occupational therapy, and speech therapy • Drugs administered to you as part of your plan of care (This includes substances that are naturally present in the body, such as blood clotting factors.) • Blood – including storage and administration. Coverage of whole blood and packed red cells begins with the first pint of blood that you need. All components of blood are covered beginning with the first pint used. • Medical and surgical supplies ordinarily provided by SNFs • Laboratory tests ordinarily provided by SNFs • X‑rays and other radiology services ordinarily provided by SNFs • Use of appliances such as wheelchairs ordinarily provided by SNFs • Physician/Practitioner services Prior authorization rules may apply for network services. Your network provider is responsible for requesting prior authorization. Our plan recommends pre‑authorization of the service when provided by an out‑of‑network provider. SNF) for 60 days in a row, including your day of discharge. If you go into a hospital or a skilled nursing facility after one benefit period has ended, a new benefit period begins. There is no limit to the number of benefit periods you can have. Smoking and tobacco use cessation (counseling to stop smoking or tobacco use) If you use tobacco, but do not have signs or symptoms of tobacco‑related disease: We cover two counseling quit attempts within a 12‑month period as a preventive service with no cost to you. Each counseling attempt includes up to four face‑to‑face visits. If you use tobacco and have been diagnosed with a tobacco‑related disease or are taking medicine that may be affected by tobacco: We cover cessation counseling services. We cover two counseling quit attempts within a 12‑month period, however, you will pay the applicable cost‑sharing. Each counseling attempt includes up to four face‑to‑face visits. There is no coinsurance, copayment, or deductible for the Medicare‑covered smoking and tobacco use cessation preventive benefits. $0 copay for each non‑Medicare covered smoking and tobacco use cessation visit. Services that are covered for you What you must pay when you get these services In addition to Medicare‑covered benefits, we also offer: • Additional individual and group face‑to‑face intermediate and intensive counseling sessions: unlimited visits every year Supervised Exercise Therapy (SET) SET is covered for members who have symptomatic peripheral artery disease (PAD) and a referral for PAD from the physician responsible for PAD treatment. Up to 36 sessions over a 12‑week period are covered if the SET program requirements are met. The SET program must: • Consist of sessions lasting 30‑60 minutes, comprising a therapeutic exercise‑training program for PAD in patients with claudication • Be conducted in a hospital outpatient setting or a physician’s office • Be delivered by qualified auxiliary personnel necessary to ensure benefits exceed xxxxx, and who are trained in exercise therapy for PAD • Be under the direct supervision of a physician, physician assistant, or nurse practitioner/clinical nurse specialist who must be trained in both basic and advanced life support techniques SET may be covered beyond 36 sessions over 12 weeks for an additional 36 sessions over an extended period of time if deemed medically necessary by a health care provider. $0 20 copay for each Medicare‑covered supervised exercise therapy service. Therapeutic Massage We have partnered with American Specialty Health Group, Inc. (ASH Group) to provide your therapeutic massage coverage. We cover up to fifty visits every year for therapeutic massage.* Services must be medically necessary as determined by ASH Group. To locate an ASH Group network provider, you may contact Aetna® Member Services at the number on the back of your ID card or search our online directory. If you choose to use a provider outside of the ASH Group network, remember to present them with your member ID on your first visit. *Amounts you pay for therapeutic massage do not apply to your out‑of‑pocket maximum. $0 copay for each plan‑approved therapeutic massage visit. Transportation services (non‑emergency transportation) We cover: • 24 one‑way trips to and from plan‑approved locations each year Trips must be within 60 miles of provider location. Coverage includes trips to and from providers or facilities for services that your plan covers. The transportation service will accommodate urgent requests for hospital discharge, dialysis, and trips that your medical provider considers urgent. The service will try to accommodate specific physical limitations or requirements. However, it limits services to wheelchair, taxi, or sedan transportation vehicles. • Transportation services are administered through Access2Care • To arrange for transport, call 1‑855‑814‑1699, Monday through Friday, from 8 AM to 8 PM, in all time zones. (For TTY/TDD assistance please dial 711.) • You must schedule transportation service at least 48 hours before the appointment • You must cancel more than two hours in advance, or Access2Care will deduct the trip from the remaining number of trips available • This program doesn’t support stretcher vans/ambulances $0 copay per trip. Urgently needed services Urgently needed services are provided to treat a non‑emergency, unforeseen medical illness, injury, or condition that requires immediate medical care but given your circumstances, it is not possible, or it is unreasonable, to obtain services from network providers. Examples of urgently needed services that the plan must cover out of network are i) you need immediate care during the weekend, or ii) you are temporarily outside the service area of the plan. Services must be immediately needed and medically necessary. Coverage is available worldwide (i.e., outside of the United States). $0 copay for each urgent care facility visit. $0 copay for each urgent care telehealth service. Vision care $0 copay for exams to diagnose and treat diseases and conditions of the eye. Covered services include: • Outpatient physician services for the diagnosis and treatment of diseases and injuries of the eye, including treatment for age‑related macular degeneration. Original Medicare doesn’t cover routine eye exams (eye refractions) for eyeglasses/contacts • For people who are at high risk of glaucoma, we will cover one glaucoma screening every 12 months. People at high risk of glaucoma include: people with a family history of glaucoma, people with diabetes, African Americans who are age 50 and older, and Hispanic Americans who are 65 or older • For people with diabetes, screening for diabetic retinopathy is covered once per year • One pair of eyeglasses or contact lenses after each cataract surgery that includes insertion of a premium intraocular lens. (If you have two separate cataract operations, you cannot reserve the benefit after the first surgery and purchase two eyeglasses after the second surgery.) In addition to Medicare‑covered benefits, we also offer: • Non‑Medicare covered eye exams: one exam every year • Follow‑up diabetic eye exam $0 copay for each Medicare‑covered glaucoma screening. $0 copay for one diabetic retinopathy screening. $0 copay for each follow‑up diabetic eye exam. $0 copay for one pair of eyeglasses or contact lenses after each cataract surgery. Coverage includes conventional eyeglasses or contact lenses. Excluded is coverage for designer frames and progressive lenses instead of traditional lenses, bifocals, or trifocals. $0 copay for each non‑Medicare covered eye exam. Additional cost‑sharing may apply if you receive additional services during your visit. Vision care – eyewear reimbursement (non‑Medicare covered) Non‑Medicare covered prescription eyewear includes: • Contact lenses • Eyeglass prescription lenses • Eyeglass frames You may see any licensed vision provider in the U.S. You pay the provider for services and submit an itemized billing statement showing proof of payment to our plan. You must submit your documentation within 365 days from the date of service to be eligible for reimbursement. If approved, it can take up to 45 days for you to receive payment. If your request is incomplete, such as no itemization of services, or there is missing information, you will be notified by mail. You will then have to supply the missing information, which will delay the processing time. Our plan will reimburse you up to: $300 once every 24 months towards the cost of eyewear. You may be required to pay for services up front and submit for reimbursement Services that are covered for you What you must pay when you get these services Notes: • If you use a non‑licensed provider you will not receive reimbursement. • You are responsible for any charges above the reimbursement amount. • Eyewear reimbursement excludes eyeglasses or contact lenses after cataract surgery. * Amounts you pay for non‑Medicare covered eyewear do not apply to your Out‑of‑Pocket Maximum.

Resources for Living. ® Resources for Living consultants provide research services for members on such topics as caregiver support, household services, eldercare services, activities, and volunteer opportunities. The purpose of the program is to assist members in locating local community services and to provide resource information for a wide variety of eldercare and life‑related issues. Call Resources for Living at 1‑866‑370‑4842. There is no coinsurance, copayment, or deductible for Resources for Living. Screening and counseling to reduce alcohol misuse We cover one alcohol misuse screening for adults with There is no coinsurance, copayment, or deductible for the Medicare‑covered Medicare (including pregnant women) who misuse alcohol alcohol, but aren’t alcohol dependent. If you screen positive for alcohol misuse, you can get up to 4 brief face‑to‑face counseling sessions per year (if you’re competent and alert during counseling) provided by a qualified primary care doctor or practitioner in a primary care setting. There is no coinsurance, copayment, or deductible for the Medicare‑covered screening and counseling to reduce alcohol misuse preventive benefit. Screening for lung cancer with low dose computed tomography (LDCT) For qualified individuals, a LDCT is covered every 12 months. Eligible members are: people aged 50 – 77 50–77 years who have no signs or symptoms of lung cancer, but who have a history of tobacco smoking of at least 20 pack‑years and who currently smoke or have quit smoking within the There is no coinsurance, copayment, or deductible for the Medicare‑covered counseling and shared decision making visit or for the LDCT. Screening for lung cancer with low dose computed tomography (LDCT) (continued) last 15 years, who receive a written order for LDCT during a lung cancer screening counseling and shared decision‑making visit that meets the Medicare criteria for such visits and be furnished by a physician or qualified non‑physician practitioner. For LDCT lung cancer screenings after the initial LDCT screening: the member must receive a written order for LDCT lung cancer screening, which may be furnished during any appropriate visit with a physician or qualified non‑physician practitioner. If a physician or qualified non‑physician practitioner elects to provide a lung cancer screening counseling and shared decision making decision‑making visit for subsequent lung cancer screenings with LDCT, the visit must meet the Medicare criteria for such visits. There is no coinsurance, copayment, or deductible for the Medicare‑covered counseling and shared decision making visit or for the LDCT. Screening for sexually transmitted infections (STIs) and counseling to prevent STIs We cover sexually transmitted infection (STI) screenings for chlamydia, gonorrhea, syphilis, and Hepatitis B. These screenings are covered for pregnant women and for certain people who are at increased risk for an STI when the tests are ordered by a primary care provider. We cover these tests once every 12 months or at certain times during pregnancy. We also cover up to 2 two individual 20 20‑ to 30 minute30‑minute, face‑to‑face high‑intensity behavioral counseling sessions each year for sexually active adults at increased risk for STIs. We will only cover these counseling sessions There is no coinsurance, copayment, or deductible for the Medicare‑covered screening for STIs and counseling for STIs preventive benefit. as a preventive service if they are provided by a primary care provider and take place in a primary care setting, such as a doctor’s office. There is no coinsurance, copayment, or deductible for the Medicare‑covered screening for STIs and counseling for STIs preventive benefit. Services to treat kidney disease Covered services include: • Kidney disease education services to teach kidney care and help members make informed decisions about their care. For members with stage IV chronic kidney disease when referred by their doctor, we cover up to six sessions of kidney disease education services per lifetime • Outpatient dialysis treatments (including dialysis treatments when temporarily out of the service area, as explained in Chapter 3 of the Evidence of Coverage, or when your provider for this service is temporarily unavailable or inaccessible) • Inpatient dialysis treatments (if you are admitted as $0 copay for self‑dialysis training. $0 copay for each Medicare‑covered kidney disease education session. $0 copay for in‑ and out‑of‑area outpatient dialysis. For each inpatient hospital stay, you pay: $0 per stay. Cost sharing is charged for each medically necessary covered inpatient stay. $0 copay for home dialysis equipment and supplies. Services to treat kidney disease (continued) $0 copay for Medicare‑covered home support services. an inpatient to a hospital for special care) • Self‑dialysis training (includes training for you and anyone helping you with your home dialysis treatments) • Home dialysis equipment and supplies • Certain home support services (such as, when necessary, visits by trained dialysis workers to check on your home dialysis, to help in emergencies, and check your dialysis equipment and water supply) Certain drugs for dialysis are covered under your Medicare Part B drug benefit. For information about coverage for Part B Drugs, please go to the section, “Medicare Part B prescription drugs.” . Prior authorization rules may apply for network services. Your network provider is responsible for requesting prior authorization. Our plan recommends pre‑authorization of the service when provided by an out‑of‑network provider. $0 copay for self‑dialysis training. $0 copay for each Medicare‑covered kidney disease education session. $0 copay for in‑ and out‑of‑area outpatient dialysis. See “Inpatient hospital care” for more information on inpatient services. $0 copay for home dialysis equipment and supplies. $0 copay for Medicare‑covered home support services. Skilled nursing facility (SNF) care (For a definition of “skilled nursing facility care,” , see the final chapter (“Definitions of important words”) of the Evidence of Coverage. Skilled nursing facilities are sometimes called “SNFs.”) Days covered: up to 100 days per benefit period. A prior hospital stay is not required. $0 per day, days 1‑100 for each Medicare‑covered SNF stay. A benefit period begins the day you go into a hospital or skilled nursing facility. The benefit period ends when you haven’t received any inpatient hospital care (or skilled care in a SNF) for 60 days in a row, including your day Services that are covered for you What you must pay when you get these services Covered services include but are not limited to: • Semiprivate room (or a private room if medically necessary) • Meals, including special diets • Skilled nursing services • Physical therapy, occupational therapy, and speech therapy • Drugs administered to you as part of your plan of care (This includes substances that are naturally present in the body, such as blood clotting factors.) • Blood – including storage and administration. Coverage of whole blood and packed red cells begins with the first pint of blood that you need. All components of blood are covered beginning with the first pint used. $0 per day, days 1‑100 for each Medicare‑covered SNF stay. A benefit period begins the day you go into a hospital or skilled nursing facility. The benefit period ends when you haven’t received any inpatient hospital care (or skilled care in a SNF) for 60 days in a row, including your day of discharge. If you go into a hospital or a skilled nursing facility after one benefit period has ended, a new benefit period begins. There is no limit to the number of benefit periods you can have. Skilled nursing facility (SNF) care (continued) • Medical and surgical supplies ordinarily provided by SNFs • Laboratory tests ordinarily provided by SNFs • X‑rays and other radiology services ordinarily provided by SNFs • Use of appliances such as wheelchairs ordinarily provided by SNFs • Physician/Practitioner services Prior authorization rules may apply for network services. Your network provider is responsible for requesting prior authorization. Our plan recommends pre‑authorization of the service when provided by an out‑of‑network provider. of discharge. If you go into a hospital or a skilled nursing facility after one benefit period has ended, a new benefit period begins. There is no limit to the number of benefit periods you can have. Smoking and tobacco use cessation (counseling to stop smoking or tobacco use) If you use tobacco, but do not have signs or symptoms of tobacco‑related disease: We cover two counseling quit attempts within a 12‑month period as a preventive service with no cost to you. Each counseling attempt includes up to four face‑to‑face visits. If you use tobacco and have been diagnosed with a tobacco‑related disease or are taking medicine that may be affected by tobacco: We cover cessation counseling services. We cover two counseling quit attempts within a 12‑month period, however, you will pay the applicable cost‑sharingcost sharing. Each counseling attempt includes up to four face‑to‑face visits. In addition to Medicare‑covered benefits, we also offer: • Additional individual and group face‑to‑face intermediate and intensive counseling sessions: unlimited visits every year There is no coinsurance, copayment, or deductible for the Medicare‑covered smoking and tobacco use cessation preventive benefits. $0 copay for each non‑Medicare covered smoking and tobacco use cessation visit. In addition to Medicare‑covered benefits, we also offer: • Additional individual and group face‑to‑face intermediate and intensive counseling sessions: unlimited visits every year Supervised Exercise Therapy (SET) SET is covered for members who have symptomatic peripheral artery disease (PAD) and a referral for PAD from the physician responsible for PAD treatment. Up to 36 sessions over a 12‑week period are covered if the SET program requirements are met. The SET program must: • Consist of sessions lasting 30‑60 minutes, $0 copay for each Medicare‑covered supervised exercise therapy service. Supervised Exercise Therapy (SET) (continued) comprising a therapeutic exercise‑training program for PAD in patients with claudication • Be conducted in a hospital outpatient setting or a physician’s office • Be delivered by qualified auxiliary personnel necessary to ensure benefits exceed xxxxx, and who are trained in exercise therapy for PAD • Be under the direct supervision of a physician, physician assistant, or nurse practitioner/clinical nurse specialist who must be trained in both basic and advanced life support techniques SET may be covered beyond 36 sessions over 12 weeks for an additional 36 sessions over an extended period of time if deemed medically necessary by a health care provider. $0 copay for each Medicare‑covered supervised exercise therapy service. Therapeutic Massage We have partnered with American Specialty Health Group, Inc. (ASH Group) to provide your therapeutic massage coverage. We cover up to fifty visits every year for therapeutic massage.* Services must be medically necessary as determined by ASH Group. To locate an ASH Group network provider, you may contact Aetna® Member Services at the number on the back of your ID card or search our online directory. If you choose to use a provider outside of the ASH Group network, remember to present them with your member ID on your first visit. *Amounts you pay for therapeutic massage do not apply to your out‑of‑pocket maximum. $0 copay for each plan‑approved therapeutic massage visit. Transportation services (non‑emergency transportation) We cover: • 24 one‑way trips to and from plan‑approved locations each year Trips must be within 60 miles of provider location. Coverage includes trips to and from providers or facilities for services that your plan covers. The transportation service will accommodate urgent requests for hospital discharge, dialysis, and trips that your medical provider considers urgent. The service will try to accommodate specific physical limitations or requirements. However, it limits services to wheelchair, taxi, or sedan transportation vehicles. • Transportation services are administered through Access2Care • To arrange for transport, call 1‑855‑814‑1699, Monday through Friday, from 8 AM to 8 PM, in all time zones. (For TTY/TDD assistance please dial 711.) • You must schedule transportation service at least 48 hours before the appointment • You must cancel more than two hours in advance, or Access2Care will deduct the trip from the remaining number of trips available • This program doesn’t support stretcher vans/ambulances $0 copay per trip. Urgently needed services Urgently needed services are provided to treat a non‑emergency, unforeseen medical illness, injury, or condition that requires immediate medical care but given your circumstances, it is not possible, or it is unreasonable, to obtain services from network providers. Examples of urgently needed services that the plan must cover out of network are i) you need immediate care during the weekend, or ii) you are temporarily outside the service area of the plan. Services must be immediately needed and medically necessary. Coverage is available worldwide (i.e., outside of the United States). $0 copay for each urgent care facility visit. $0 copay for each urgent care telehealth service. Vision care $0 copay for exams to diagnose and treat diseases and conditions of the eye. Covered services include: • Outpatient physician services for the diagnosis and treatment of diseases and injuries of the eye, including treatment for age‑related macular degeneration. Original Medicare doesn’t cover routine eye exams (eye refractions) for eyeglasses/contacts • For people who are at high risk of glaucoma, we will cover one glaucoma screening every 12 months. People at high risk of glaucoma include: people with a family history of glaucoma, people with diabetes, African Americans who are age 50 and older, and Hispanic Americans who are 65 or older • For people with diabetes, screening for diabetic retinopathy is covered once per year • One pair of eyeglasses or contact lenses after each cataract surgery that includes insertion of a premium intraocular lens. (If you have two separate cataract operations, you cannot reserve the benefit after the first surgery and purchase two eyeglasses after the second surgery.) In addition to Medicare‑covered benefits, we also offer: • Non‑Medicare covered eye exams: one exam every year • Follow‑up diabetic eye exam $0 copay for each Medicare‑covered glaucoma screening. $0 copay for one diabetic retinopathy screening. $0 copay for each follow‑up diabetic eye exam. $0 copay for one pair of eyeglasses or contact lenses after each cataract surgery. Coverage includes conventional eyeglasses or contact lenses. Excluded is coverage for designer frames and progressive lenses instead of traditional lenses, bifocals, or trifocals. $0 copay for each non‑Medicare covered eye exam. Additional cost‑sharing may apply if you receive additional services during your visit. Vision care – eyewear reimbursement (non‑Medicare covered) Non‑Medicare covered prescription eyewear includes: • Contact lenses • Eyeglass prescription lenses • Eyeglass frames You may see any licensed vision provider in the U.S. You pay the provider for services and submit an itemized billing statement showing proof of payment to our plan. You must submit your documentation within 365 days from the date of service to be eligible for reimbursement. If approved, it can take up to 45 days for you to receive payment. If your request is incomplete, such as no itemization of services, or there is missing information, you will be notified by mail. You will then have to supply the missing information, which will delay the processing time. Our plan will reimburse you up to: $300 once every 24 months towards the cost of eyewear. You may be required to pay for services up front and submit for reimbursement Services that are covered for you What you must pay when you get these services Notes: • If you use a non‑licensed provider you will not receive reimbursement. • You are responsible for any charges above the reimbursement amount. • Eyewear reimbursement excludes eyeglasses or contact lenses after cataract surgery. * Amounts you pay for non‑Medicare covered eyewear do not apply to your Out‑of‑Pocket Maximum.

Resources for Living. ® Resources for Living consultants provide research services for members on such topics as caregiver support, household services, eldercare services, activities, and volunteer opportunities. The purpose of the program is to assist members in locating local community services and to provide resource information for a wide variety of eldercare and life‑related issues. Call Resources for Living at 1‑866‑370‑4842. There is no coinsurance, copayment, or deductible for Resources for Living. Screening and counseling to reduce alcohol misuse There is no coinsurance, copayment, or We cover one alcohol misuse screening for adults with There is no coinsurance, copayment, or deductible for the Medicare‑covered Medicare (including pregnant women) who misuse alcohol but aren’t alcohol dependent. If you screen positive for alcohol misuse, you can get up to 4 brief face‑to‑face counseling sessions per year (if you’re competent and alert during counseling) provided by a qualified primary care doctor or practitioner in a primary care setting. deductible for the Medicare‑covered screening and counseling to reduce alcohol misuse preventive benefit. Screening for lung cancer with low dose computed tomography (LDCT) For qualified individuals, a LDCT is covered every 12 months. Eligible members are: people aged 50 – 77 years who have no signs or symptoms of lung cancer, but who have a history of tobacco smoking of at least 20 pack‑years and who currently smoke or have quit smoking within the last 15 years, who receive a written order for LDCT during a lung cancer screening counseling and shared decision‑making visit that meets the Medicare criteria for such visits and be furnished by a physician or qualified non‑physician practitioner. For LDCT lung cancer screenings after the initial LDCT screening: the member must receive a written order for LDCT lung cancer screening, which may be furnished during any appropriate visit with a physician or qualified non‑physician practitioner. If a physician or qualified non‑physician practitioner elects to provide a lung cancer screening counseling and shared decision making visit for subsequent lung cancer screenings with LDCT, the visit must meet the Medicare criteria for such visits. There is no coinsurance, copayment, or deductible for the Medicare‑covered counseling and shared decision making visit or for the LDCT. Screening for sexually transmitted infections (STIs) and counseling to prevent STIs We cover sexually transmitted infection (STI) screenings for chlamydia, gonorrhea, syphilis, and Hepatitis B. These screenings are covered for pregnant women and for certain people who are at increased risk for an STI when the tests are ordered by a primary care provider. We cover these tests once every 12 months or at certain times during pregnancy. We also cover up to 2 individual 20 to 30 minute, face‑to‑face high‑intensity behavioral counseling sessions each year for sexually active adults at increased risk for STIs. We will only cover these counseling sessions There is no coinsurance, copayment, or deductible for the Medicare‑covered screening for STIs and counseling for STIs preventive benefit. risk for STIs. We will only cover these counseling sessions as a preventive service if they are provided by a primary care provider and take place in a primary care setting, such as a doctor’s office. Services to treat kidney disease Covered services include: • Kidney disease education services to teach kidney care and help members make informed decisions about their care. For members with stage IV chronic kidney disease when referred by their doctor, we cover up to six sessions of kidney disease education services per lifetime • Outpatient dialysis treatments (including dialysis treatments when temporarily out of the service area, as explained in Chapter 3 of the Evidence of Coverage, or when your provider for this service is temporarily unavailable or inaccessible) • Inpatient dialysis treatments (if you are admitted as an inpatient to a hospital for special care) • Self‑dialysis training (includes training for you and anyone helping you with your home dialysis treatments) • Home dialysis equipment and supplies • Certain home support services (such as, when necessary, visits by trained dialysis workers to check on your home dialysis, to help in emergencies, and check your dialysis equipment and water supply) Certain drugs for dialysis are covered under your Medicare Part B drug benefit. For information about coverage for Part B Drugs, please go to the section, “Medicare Part B prescription drugs.” Prior authorization rules may apply for network services. Your network provider is responsible for requesting prior authorization. Our plan recommends pre‑authorization of the service when provided by an out‑of‑network provider. $0 copay for self‑dialysis training. $0 copay for each Medicare‑covered kidney disease education session. $0 15 copay for in‑ and out‑of‑area outpatient dialysis. See “Inpatient hospital care” for more information on inpatient services. $0 copay 20% of the total cost for home dialysis equipment and supplies. $0 copay for Medicare‑covered home support services. Skilled nursing facility (SNF) care (For a definition of “skilled nursing facility care,” see the final chapter (“Definitions of important words”) of the Evidence of Coverage. Skilled nursing facilities are sometimes called “SNFs.”) Days covered: up to 100 days per benefit period. A prior hospital stay is not required. $0 per day, days 1‑100 1‑20; $75 per day, days 21‑100 for each Medicare‑covered SNF stay. A benefit period begins the day you go into a hospital or skilled nursing facility. The benefit period ends when you haven’t received any inpatient hospital care (or skilled care in a SNF) for 60 days in a row, including your day Services that are covered for you What you must pay when you get these services hospital stay is not required. Covered services include but are not limited to: • Semiprivate room (or a private room if medically necessary) • Meals, including special diets • Skilled nursing services • Physical therapy, occupational therapy, and speech therapy • Drugs administered to you as part of your plan of care (This includes substances that are naturally present in the body, such as blood clotting factors.) • Blood – including storage and administration. Coverage of whole blood and packed red cells begins with the first pint of blood that you need. All components of blood are covered beginning with the first pint used. • Medical and surgical supplies ordinarily provided by SNFs • Laboratory tests ordinarily provided by SNFs • X‑rays and other radiology services ordinarily provided by SNFs • Use of appliances such as wheelchairs ordinarily provided by SNFs • Physician/Practitioner services Prior authorization rules may apply for network services. Your network provider is responsible for requesting prior authorization. Our plan recommends pre‑authorization of the service when provided by an out‑of‑network provider. SNF) for 60 days in a row, including your day of discharge. If you go into a hospital or a skilled nursing facility after one benefit period has ended, a new benefit period begins. There is no limit to the number of benefit periods you can have. Smoking and tobacco use cessation (counseling to stop smoking or tobacco use) If you use tobacco, but do not have signs or symptoms of tobacco‑related disease: We cover two counseling quit attempts within a 12‑month period as a preventive service with no cost to you. Each counseling attempt includes up to four face‑to‑face visits. If you use tobacco and have been diagnosed with a tobacco‑related disease or are taking medicine that may be affected by tobacco: We cover cessation counseling services. We cover two counseling quit attempts within a 12‑month period, however, you will pay the applicable cost‑sharing. Each counseling attempt includes up to four face‑to‑face visits. There is no coinsurance, copayment, or deductible for the Medicare‑covered smoking and tobacco use cessation preventive benefits. $0 copay for each non‑Medicare covered smoking and tobacco use cessation visit. Services that are covered for you What you must pay when you get these services In addition to Medicare‑covered benefits, we also offer: • Additional individual and group face‑to‑face intermediate and intensive counseling sessions: unlimited visits every year Supervised Exercise Therapy (SET) SET is covered for members who have symptomatic peripheral artery disease (PAD) and a referral for PAD from the physician responsible for PAD treatment. Up to 36 sessions over a 12‑week period are covered if the SET program requirements are met. The SET program must: • Consist of sessions lasting 30‑60 minutes, comprising a therapeutic exercise‑training program for PAD in patients with claudication • Be conducted in a hospital outpatient setting or a physician’s office • Be delivered by qualified auxiliary personnel necessary to ensure benefits exceed xxxxx, and who are trained in exercise therapy for PAD • Be under the direct supervision of a physician, physician assistant, or nurse practitioner/clinical nurse specialist who must be trained in both basic and advanced life support techniques SET may be covered beyond 36 sessions over 12 weeks for an additional 36 sessions over an extended period of time if deemed medically necessary by a health care provider. $0 15 copay for each Medicare‑covered supervised exercise therapy service. Therapeutic Massage We have partnered with American Specialty Health Group, Inc. (ASH Group) to provide your therapeutic massage coverage. We cover up to fifty visits every year for therapeutic massage.* Services must be medically necessary as determined by ASH Group. To locate an ASH Group network provider, you may contact Aetna® Member Services at the number on the back of your ID card or search our online directory. If you choose to use a provider outside of the ASH Group network, remember to present them with your member ID on your first visit. *Amounts you pay for therapeutic massage do not apply to your out‑of‑pocket maximum. $0 copay for each plan‑approved therapeutic massage visit. Transportation services (non‑emergency transportation) We cover: • 24 one‑way trips to and from plan‑approved locations each year Trips must be within 60 miles of provider location. Coverage includes trips to and from providers or facilities for services that your plan covers. The transportation service will accommodate urgent requests for hospital discharge, dialysis, and trips that your medical provider considers urgent. The service will try to accommodate specific physical limitations or requirements. However, it limits services to wheelchair, taxi, or sedan transportation vehicles. • Transportation services are administered through Access2Care • To arrange for transport, call 1‑855‑814‑1699, Monday through Friday, from 8 AM to 8 PM, in all time zones. (For TTY/TDD assistance please dial 711.) • You must schedule transportation service at least 48 hours before the appointment • You must cancel more than two hours in advance, or Access2Care will deduct the trip from the remaining number of trips available • This program doesn’t support stretcher vans/ambulances $0 copay per trip. Urgently needed services Urgently needed services are provided to treat a non‑emergency, unforeseen medical illness, injury, or condition that requires immediate medical care but given your circumstances, it is not possible, or it is unreasonable, to obtain services from network providers. Examples of urgently needed services that the plan must cover out of network are i) you need immediate care during the weekend, or ii) you are temporarily outside the service area of the plan. Services must be immediately needed and medically necessary. Coverage is available worldwide (i.e., outside of the United States). $0 copay for each urgent care facility visit. $0 copay for each urgent care telehealth service. Vision care $0 copay for exams to diagnose and treat diseases and conditions of the eye. Covered services include: • Outpatient physician services for the diagnosis and treatment of diseases and injuries of the eye, including treatment for age‑related macular degeneration. Original Medicare doesn’t cover routine eye exams (eye refractions) for eyeglasses/contacts • For people who are at high risk of glaucoma, we will cover one glaucoma screening every 12 months. People at high risk of glaucoma include: people with a family history of glaucoma, people with diabetes, African Americans who are age 50 and older, and Hispanic Americans who are 65 or older • For people with diabetes, screening for diabetic retinopathy is covered once per year • One pair of eyeglasses or contact lenses after each cataract surgery that includes insertion of a premium intraocular lens. (If you have two separate cataract operations, you cannot reserve the benefit after the first surgery and purchase two eyeglasses after the second surgery.) In addition to Medicare‑covered benefits, we also offer: • Non‑Medicare covered eye exams: one exam every year • Follow‑up diabetic eye exam $0 copay for each Medicare‑covered glaucoma screening. $0 copay for one diabetic retinopathy screening. $0 copay for each follow‑up diabetic eye exam. $0 copay for one pair of eyeglasses or contact lenses after each cataract surgery. Coverage includes conventional eyeglasses or contact lenses. Excluded is coverage for designer frames and progressive lenses instead of traditional lenses, bifocals, or trifocals. $0 copay for each non‑Medicare covered eye exam. Additional cost‑sharing may apply if you receive additional services during your visit. Vision care – eyewear reimbursement (non‑Medicare covered) Non‑Medicare covered prescription eyewear includes: • Contact lenses • Eyeglass prescription lenses • Eyeglass frames You may see any licensed vision provider in the U.S. You pay the provider for services and submit an itemized billing statement showing proof of payment to our plan. You must submit your documentation within 365 days from the date of service to be eligible for reimbursement. If approved, it can take up to 45 days for you to receive payment. If your request is incomplete, such as no itemization of services, or there is missing information, you will be notified by mail. You will then have to supply the missing information, which will delay the processing time. Our plan will reimburse you up to: $300 once every 24 months towards the cost of eyewear. You may be required to pay for services up front and submit for reimbursement Services that are covered for you What you must pay when you get these services Notes: • If you use a non‑licensed provider you will not receive reimbursement. • You are responsible for any charges above the reimbursement amount. • Eyewear reimbursement excludes eyeglasses or contact lenses after cataract surgery. * Amounts you pay for non‑Medicare covered eyewear do not apply to your Out‑of‑Pocket Maximum.

Resources for Living. ® Resources for Living consultants provide research services for members on such topics as caregiver support, household services, eldercare services, activities, and volunteer opportunities. The purpose of the program is to assist members in locating local community services and to provide resource information for a wide variety of eldercare and life‑related life-related issues. Call Resources for Living at 1‑866‑370‑48420-000-000-0000. There is no coinsurance, copayment, or deductible for Resources for Living. Services that are covered for you What you must pay (after any deductible listed on page 1) when you get these services Screening and counseling to reduce alcohol misuse We cover one alcohol misuse screening for adults with There is no coinsurance, copayment, or deductible for the Medicare‑covered Medicare (including pregnant women) who misuse alcohol alcohol, but aren’t alcohol dependent. If you screen positive for alcohol misuse, you can get up to 4 brief face‑to‑face face-to-face counseling sessions per year (if you’re competent and alert during counseling) provided by a qualified primary care doctor or practitioner in a primary care setting. There is no coinsurance, copayment, or deductible for the Medicare- covered screening and counseling to reduce alcohol misuse preventive benefit. Services that are covered for you What you must pay (after any deductible listed on page 1) when you get these services Screening for lung cancer with low dose computed tomography (LDCT) For qualified individuals, a LDCT is covered every 12 months. Eligible members are: people aged 50 55 – 77 years who have no signs or symptoms of lung cancer, but who have a history of tobacco smoking of at least 20 pack‑years 30 pack-years and who currently smoke or have quit smoking within the last 15 years, who receive a written order for LDCT during a lung cancer screening counseling and shared decision‑making decision making visit that meets the Medicare criteria for such visits and be furnished by a physician or qualified non‑physician non- physician practitioner. For LDCT lung cancer screenings after the initial LDCT screening: the member must receive a written order for LDCT lung cancer screening, which may be furnished during any appropriate visit with a physician or qualified non‑physician non-physician practitioner. If a physician or qualified non‑physician non-physician practitioner elects to provide a lung cancer screening counseling and shared decision making visit for subsequent lung cancer screenings with LDCT, the visit must meet the Medicare criteria for such visits. There is no coinsurance, copayment, or deductible for the Medicare‑covered Medicare- covered counseling and shared decision making visit or for the LDCT. Services that are covered for you What you must pay (after any deductible listed on page 1) when you get these services Screening for sexually transmitted infections (STIs) and counseling to prevent STIs We cover sexually transmitted infection (STI) screenings for chlamydia, gonorrhea, syphilis, and Hepatitis B. These screenings are covered for pregnant women and for certain people who are at increased risk for an STI when the tests are ordered by a primary care provider. We cover these tests once every 12 months or at certain times during pregnancy. We also cover up to 2 individual 20 to 30 minute, face‑to‑face high‑intensity face-to- face high-intensity behavioral counseling sessions each year for sexually active adults at increased risk for STIs. We will only cover these counseling sessions There is no coinsurance, copayment, or deductible for the Medicare‑covered screening for STIs and counseling for STIs preventive benefit. as a preventive service if they are provided by a primary care provider and take place in a primary care setting, such as a doctor’s office. There is no coinsurance, copayment, or deductible for the Medicare- covered screening for STIs and counseling for STIs preventive benefit. Services that are covered for you What you must pay (after any deductible listed on page 1) when you get these services Services to treat kidney disease Covered services include: • Kidney disease education services to teach kidney care and help members make informed decisions about their care. For members with stage IV chronic kidney disease when referred by their doctor, we cover up to six sessions of kidney disease education services per lifetime • Outpatient dialysis treatments (including dialysis treatments when temporarily out of the service area, as explained in Chapter 3 of the Evidence of Coverage, or when your provider for this service is temporarily unavailable or inaccessible) • Inpatient dialysis treatments (if you are admitted as an inpatient to a hospital for special care) • Self‑dialysis Self-dialysis training (includes training for you and anyone helping you with your home dialysis treatments) • Home dialysis equipment and supplies • Certain home support services (such as, when necessary, visits by trained dialysis workers to check on your home dialysis, to help in emergencies, and check your dialysis equipment and water supply) Certain drugs for dialysis are covered under your Medicare Part B drug benefit. For information about coverage for Part B Drugs, please go to the section, “Medicare Part B prescription drugs.” Prior authorization rules may apply for network services. Your network provider is responsible for requesting prior authorization. Our plan recommends pre‑authorization pre-authorization of the service when provided by an out‑of‑network provider. You pay a $0 copay for self‑dialysis self-dialysis training. You pay a $0 copay for each Medicare‑covered kidney disease education sessionservices. You pay a $0 20 copay for in‑ in- and out‑of‑area out- of-area outpatient dialysis. See “Inpatient hospital care” for more information on inpatient services. $0 copay You pay 20% of the total cost for home dialysis equipment and supplies. You pay a $0 copay for Medicare‑covered Medicare- covered home support services. Services that are covered for you What you must pay (after any deductible listed on page 1) when you get these services Skilled nursing facility (SNF) care (For a definition of “skilled nursing facility care,” see the final chapter (“Definitions of important words”) of the Evidence of Coverage. Skilled nursing facilities are sometimes called “SNFs.”) Days covered: up to We cover 100 days per benefit period. A prior hospital stay is not required. $0 per day, days 1‑100 for each Medicare‑covered SNF stay. A benefit period begins the day you go into a hospital or skilled nursing facility. The benefit period ends when you haven’t received any inpatient hospital care (or skilled care in a SNF) for 60 days in a row, including your day Services that are covered for you What you must pay when you get these services Covered services include but are not limited to: • Semiprivate room (or a private room if medically necessary) • Meals, including special diets • Skilled nursing services • Physical therapy, occupational therapy, and speech therapy • Drugs administered to you as part of your plan of care (This includes substances that are naturally present in the body, such as blood clotting factors.) • Blood – including storage and administration. Coverage of whole blood and packed red cells begins with the first pint of blood that you need. All components of blood are covered beginning with the first pint used. • Medical and surgical supplies ordinarily provided by SNFs • Laboratory tests ordinarily provided by SNFs • X‑rays X-rays and other radiology services ordinarily provided by SNFs • Use of appliances such as wheelchairs ordinarily provided by SNFs • Physician/Practitioner services Prior authorization rules may apply for network servicesYou pay $0 per day, days 1-20; $75 per day, days 21-100 for each Medicare-covered SNF stay. Your network provider is responsible A benefit period begins the day you go into a hospital or skilled nursing facility. The benefit period ends when you haven’t received any inpatient hospital care (or skilled care in a SNF) for requesting prior authorization. Our plan recommends pre‑authorization of the service when provided by an out‑of‑network provider. 60 days in a row, including your day of discharge. If you go into a hospital or a skilled nursing facility after one benefit period has ended, a new benefit period begins. There is no limit to the number of benefit periods you can have. Services that are covered for you What you must pay (after any deductible listed on page 1) when you get these services Smoking and tobacco use cessation (counseling to stop smoking or tobacco use) If you use tobacco, but do not have signs or symptoms of tobacco‑related tobacco-related disease: We cover two counseling quit attempts within a 12‑month 12-month period as a preventive service with no cost to you. Each counseling attempt includes up to four face‑to‑face face-to-face visits. If you use tobacco and have been diagnosed with a tobacco‑related tobacco-related disease or are taking medicine that may be affected by tobacco: We cover cessation counseling services. We cover two counseling quit attempts within a 12‑month 12-month period, however, you will pay the applicable cost‑sharinginpatient or outpatient cost-sharing. Each counseling attempt includes up to four face‑to‑face face-to-face visits. In addition to Medicare-covered benefits, we also offer: • Additional individual and group face-to-face intermediate and intensive counseling sessions: unlimited visits every year There is no coinsurance, copayment, or deductible for the Medicare‑covered Medicare- covered smoking and tobacco use cessation preventive benefits. You pay a $0 copay for each non‑Medicare non- Medicare covered smoking and tobacco use cessation visit. In addition to Medicare‑covered benefits, we also offer: • Additional individual and group face‑to‑face intermediate and intensive counseling sessions: unlimited visits every year Services that are covered for you What you must pay (after any deductible listed on page 1) when you get these services Supervised Exercise Therapy exercise therapy (SET) SET is covered for members who have symptomatic peripheral artery disease (PAD) and a referral for PAD from the physician responsible for PAD treatment. Up to 36 sessions over a 12‑week 12-week period are covered if the SET program requirements are met. The SET program must: • Consist of sessions lasting 30‑60 30-60 minutes, comprising a therapeutic exercise‑training exercise-training program for PAD in patients with claudication • Be conducted in a hospital outpatient setting or a physician’s office • Be delivered by qualified auxiliary personnel necessary to ensure benefits exceed xxxxx, and who are trained in exercise therapy for PAD • Be under the direct supervision of a physician, physician assistant, or nurse practitioner/clinical nurse specialist who must be trained in both basic and advanced life support techniques SET may be covered beyond 36 sessions over 12 weeks for an additional 36 sessions over an extended period of time if deemed medically necessary by a health care provider. You pay a $0 20 copay for each Medicare‑covered Medicare-covered supervised exercise therapy servicesession. Therapeutic Massage We have partnered with American Specialty Health Group, Inc. Services that are covered for you What you must pay (ASH Groupafter any deductible listed on page 1) to provide your therapeutic massage coverage. We cover up to fifty visits every year for therapeutic massage.* Services must be medically necessary as determined by ASH Group. To locate an ASH Group network provider, when you may contact Aetna® Member Services at the number on the back of your ID card or search our online directory. If you choose to use a provider outside of the ASH Group network, remember to present them with your member ID on your first visit. *Amounts you pay for therapeutic massage do not apply to your out‑of‑pocket maximum. $0 copay for each plan‑approved therapeutic massage visit. Transportation get these services (non‑emergency transportation) We cover: • 24 one‑way trips to and from plan‑approved locations each year Trips must be within 60 miles of provider location. Coverage includes trips to and from providers or facilities for services that your plan covers. The transportation service will accommodate urgent requests for hospital discharge, dialysis, and trips that your medical provider considers urgent. The service will try to accommodate specific physical limitations or requirements. However, it limits services to wheelchair, taxi, or sedan transportation vehicles. • Transportation services are administered through Access2Care • To arrange for transport, call 1‑855‑814‑1699, Monday through Friday, from 8 AM to 8 PM, in all time zones. (For TTY/TDD assistance please dial 711.) • You must schedule transportation service at least 48 hours before the appointment • You must cancel more than two hours in advance, or Access2Care will deduct the trip from the remaining number of trips available • This program doesn’t support stretcher vans/ambulances $0 copay per trip. Urgently needed services Urgently needed services are provided to treat a non‑emergencynon- emergency, unforeseen medical illness, injury, or condition that requires immediate medical care but given your circumstances, it is not possible, or it is unreasonable, to obtain services from network providers. Examples of urgently needed services that the plan must cover out of network are i) you need immediate care during the weekend, or ii) you are temporarily outside the service area of the plan. Services must be immediately needed and medically necessarycare. Coverage is available worldwide (i.e., outside of the United States). You pay a $0 20 copay for each urgent care facility visit. Cost-sharing is not waived if you are admitted to the hospital. You pay a $0 20 copay for each urgent care telehealth service. Services that are covered for you What you must pay (after any deductible listed on page 1) when you get these services Vision care $0 copay for exams to diagnose and treat diseases and conditions of the eye. Covered services include: • Outpatient physician services for the diagnosis and treatment of diseases and injuries of the eye, including treatment for age‑related age-related macular degeneration. Original Medicare doesn’t cover routine eye exams (eye refractions) for eyeglasses/contacts • For people who are at high risk of glaucoma, we will cover one glaucoma screening every 12 months. People at high risk of glaucoma include: people with a family history of glaucoma, people with diabetes, African African-Americans who are age 50 and older, and Hispanic Americans who are 65 or older • For people with diabetes, screening for diabetic retinopathy is covered once per year • One pair of eyeglasses or contact lenses after each cataract surgery that includes insertion of a premium an intraocular lens. (If you have two separate cataract operations, you cannot reserve the benefit after the first surgery and purchase two eyeglasses after the second surgery.) In addition to Medicare‑covered Medicare-covered benefits, we also offer: • Non‑Medicare Non-Medicare covered eye exams: one exam every year • Follow‑up Follow up diabetic eye exam You pay a $20 copay for exams to diagnose and treat diseases and conditions of the eye. You pay a $0 copay for each Medicare‑covered Medicare-covered glaucoma screening. You pay a $0 copay for one diabetic retinopathy screening. You pay a $0 copay for each follow‑up follow up diabetic eye exam. You pay a $0 copay for one pair of eyeglasses or contact lenses after each cataract surgery. Coverage includes conventional eyeglasses or contact lenses. Excluded is coverage for designer frames and progressive lenses instead of traditional lenses, bifocals, or trifocals. You pay a $0 copay for each non‑Medicare non- Medicare covered eye exam. Additional cost‑sharing cost-sharing may apply if you receive additional services during your visit. Vision care – eyewear reimbursement (non‑Medicare covered) Non‑Medicare covered prescription eyewear includes: • Contact lenses • Eyeglass prescription lenses • Eyeglass frames You may see any licensed vision provider in the U.S. You pay the provider for services and submit an itemized billing statement showing proof of payment to our plan. You must submit your documentation within 365 days from the date of service to be eligible for reimbursement. If approved, it can take up to 45 days for you to receive payment. If your request is incomplete, such as no itemization of services, or there is missing information, you will be notified by mail. You will then have to supply the missing information, which will delay the processing time. Our plan will reimburse you up to: $300 once every 24 months towards the cost of eyewear. You may be required to pay for services up front and submit for reimbursement Services that are covered for you What you must pay (after any deductible listed on page 1) when you get these services Notes“Welcome to Medicare” preventive visit The plan covers the one-time “Welcome to Medicare” preventive visit. The visit includes a review of your health, as well as education and counseling about the preventive services you need (including certain screenings and shots), and referrals for other care if needed. Important: • If We cover the “Welcome to Medicare” preventive visit only within the first 12 months you use have Medicare Part B. When you make your appointment, let your doctor’s office know you would like to schedule your “Welcome to Medicare” preventive visit. There is no coinsurance, copayment, or deductible for the “Welcome to Medicare” preventive visit. You pay a non‑licensed provider you will not receive reimbursement$0 copay for a Medicare- covered EKG screening following the "Welcome to Medicare" preventive visit. • You are responsible Note: See Chapter 4, Section 2.1 of the Evidence of Coverage for any charges above information on prior authorization rules. Former Employer/Union/Trust Name: THE CITY OF SEATTLE Group Agreement Effective Date: 01/01/2022 Group/Account Number: 0000000 This Prescription Drug Schedule of Cost Sharing is part of the reimbursement amountEvidence of Coverage (EOC) for our plan. • Eyewear reimbursement excludes eyeglasses or contact lenses after cataract surgeryWhen the EOC refers to the document with information on Medicare Part D prescription drug benefits covered under our plan, it is referring to this Prescription Drug Benefits Chart. * Amounts (See Chapter 5, Using the plan’s coverage for your Part D prescription drugs and Chapter 6, What you pay for non‑Medicare covered eyewear do not apply to your Out‑of‑Pocket MaximumPart D prescription drugs.)

Resources for Living. ® Resources for Living consultants provide research services for members on such topics as caregiver support, household services, eldercare services, activities, and volunteer opportunities. The purpose of the program is to assist members in locating local community services and to provide resource information for a wide variety of eldercare and life‑related issues. Call Resources for Living at 1‑866‑370‑4842. There is no coinsurance, copayment, or deductible for Resources for Living. Screening and counseling to reduce alcohol misuse We cover one alcohol misuse screening for adults with There is no coinsurance, copayment, or deductible for the Medicare‑covered Medicare (including pregnant women) who misuse alcohol but aren’t alcohol dependent. If you screen positive for alcohol misuse, you can get up to 4 brief face‑to‑face counseling sessions per year (if you’re competent and alert during counseling) provided by a qualified primary care doctor or practitioner in a primary care setting. There is no coinsurance, copayment, or deductible for the Medicare‑covered screening and counseling to reduce alcohol misuse preventive benefit. Screening for lung cancer with low dose computed tomography (LDCT) For qualified individuals, a LDCT is covered every 12 months. Eligible members are: people aged 50 – 77 years who There is no coinsurance, copayment, or deductible for the Medicare‑covered counseling and shared decision making visit or for the LDCT. have no signs or symptoms of lung cancer, but who have a history of tobacco smoking of at least 20 pack‑years and who currently smoke or have quit smoking within the last 15 years, who receive a written order for LDCT during a lung cancer screening counseling and shared decision‑making visit that meets the Medicare criteria for such visits and be furnished by a physician or qualified non‑physician practitioner. For LDCT lung cancer screenings after the initial LDCT screening: the member must receive a written order for LDCT lung cancer screening, which may be furnished during any appropriate visit with a physician or qualified non‑physician practitioner. If a physician or qualified non‑physician practitioner elects to provide a lung cancer screening counseling and shared decision making visit for subsequent lung cancer screenings with LDCT, the visit must meet the Medicare criteria for such visits. There is no coinsurance, copayment, or deductible for the Medicare‑covered counseling and shared decision making visit or for the LDCT. Screening for sexually transmitted infections (STIs) and counseling to prevent STIs We cover sexually transmitted infection (STI) screenings for chlamydia, gonorrhea, syphilis, and Hepatitis B. These screenings are covered for pregnant women and for certain people who are at increased risk for an STI when the tests are ordered by a primary care provider. We cover these tests once every 12 months or at certain times during pregnancy. We also cover up to 2 individual 20 to 30 minute, face‑to‑face high‑intensity behavioral counseling sessions each year for sexually active adults at increased risk for STIs. We will only cover these counseling sessions There is no coinsurance, copayment, or deductible for the Medicare‑covered screening for STIs and counseling for STIs preventive benefit. as a preventive service if they are provided by a primary care provider and take place in a primary care setting, such as a doctor’s office. There is no coinsurance, copayment, or deductible for the Medicare‑covered screening for STIs and counseling for STIs preventive benefit. Services to treat kidney disease Covered services include: • Kidney disease education services to teach kidney care and help members make informed decisions about their care. For members with stage IV chronic kidney disease when referred by their doctor, we cover up to six sessions of kidney disease education services per lifetime • Outpatient dialysis treatments (including dialysis treatments when temporarily out of the service $0 copay for self‑dialysis training. $0 copay for each Medicare‑covered kidney disease education session. $0 copay for in‑ and out‑of‑area outpatient dialysis. See “Inpatient hospital care” for more information on inpatient services. 15% of the total cost for home dialysis Services that are covered for you What you must pay when you get these services area, as explained in Chapter 3 of the Evidence of Coverage, or when your provider for this service is temporarily unavailable or inaccessible) • Inpatient dialysis treatments (if you are admitted as an inpatient to a hospital for special care) • Self‑dialysis training (includes training for you and anyone helping you with your home dialysis treatments) • Home dialysis equipment and supplies • Certain home support services (such as, when necessary, visits by trained dialysis workers to check on your home dialysis, to help in emergencies, and check your dialysis equipment and water supply) Certain drugs for dialysis are covered under your Medicare Part B drug benefit. For information about coverage for Part B Drugs, please go to the section, “Medicare Part B prescription drugs.” Prior authorization rules may apply for network services. Your network provider is responsible for requesting prior authorization. Our plan recommends pre‑authorization of the service when provided by an out‑of‑network provider. $0 copay for self‑dialysis training. $0 copay for each Medicare‑covered kidney disease education session. $0 copay for in‑ and out‑of‑area outpatient dialysis. See “Inpatient hospital care” for more information on inpatient services. $0 copay for home dialysis equipment and supplies. $0 copay for Medicare‑covered home support services. Skilled nursing facility (SNF) care (For a definition of “skilled nursing facility care,” see the final chapter (“Definitions of important words”) of the Evidence of Coverage. Skilled nursing facilities are sometimes called “SNFs.”) Days covered: up to 100 days per benefit period. A prior hospital stay is not required. $0 per day, days 1‑100 for each Medicare‑covered SNF stay. A benefit period begins the day you go into a hospital or skilled nursing facility. The benefit period ends when you haven’t received any inpatient hospital care (or skilled care in a SNF) for 60 days in a row, including your day Services that are covered for you What you must pay when you get these services Covered services include but are not limited to: • Semiprivate room (or a private room if medically necessary) • Meals, including special diets • Skilled nursing services • Physical therapy, occupational therapy, and speech therapy • Drugs administered to you as part of your plan of care (This includes substances that are naturally present in the body, such as blood clotting factors.) • Blood – including storage and administration. $0 per day, days 1‑100 for each Medicare‑covered SNF stay. A benefit period begins the day you go into a hospital or skilled nursing facility. The benefit period ends when you haven’t received any inpatient hospital care (or skilled care in a SNF) for 60 days in a row, including your day of discharge. If you go into a hospital or a skilled nursing facility after one benefit period has ended, a new benefit period begins. There is no limit to the number of benefit periods you can have. Services that are covered for you What you must pay when you get these services Coverage of whole blood and packed red cells begins with the first pint of blood that you need. All components of blood are covered beginning with the first pint used. • Medical and surgical supplies ordinarily provided by SNFs • Laboratory tests ordinarily provided by SNFs • X‑rays and other radiology services ordinarily provided by SNFs • Use of appliances such as wheelchairs ordinarily provided by SNFs • Physician/Practitioner services Prior authorization rules may apply for network services. Your network provider is responsible for requesting prior authorization. Our plan recommends pre‑authorization of the service when provided by an out‑of‑network provider. of discharge. If you go into a hospital or a skilled nursing facility after one benefit period has ended, a new benefit period begins. There is no limit to the number of benefit periods you can have. Smoking and tobacco use cessation (counseling to stop smoking or tobacco use) If you use tobacco, but do not have signs or symptoms of tobacco‑related disease: We cover two counseling quit attempts within a 12‑month period as a preventive service with no cost to you. Each counseling attempt includes up to four face‑to‑face visits. If you use tobacco and have been diagnosed with a tobacco‑related disease or are taking medicine that may be affected by tobacco: We cover cessation counseling services. We cover two counseling quit attempts within a 12‑month period, however, you will pay the applicable cost‑sharing. Each counseling attempt includes up to four face‑to‑face visits. In addition to Medicare‑covered benefits, we also offer: • Additional individual and group face‑to‑face intermediate and intensive counseling sessions: unlimited visits every year There is no coinsurance, copayment, or deductible for the Medicare‑covered smoking and tobacco use cessation preventive benefits. $0 copay for each non‑Medicare covered smoking and tobacco use cessation visit. In addition to Medicare‑covered benefits, we also offer: • Additional individual and group face‑to‑face intermediate and intensive counseling sessions: unlimited visits every year Supervised Exercise Therapy (SET) SET is covered for members who have symptomatic peripheral artery disease (PAD) and a referral for PAD from the physician responsible for PAD treatment. Up to 36 sessions over a 12‑week period are covered if $0 copay for each Medicare‑covered supervised exercise therapy service. the SET program requirements are met. The SET program must: • Consist of sessions lasting 30‑60 minutes, comprising a therapeutic exercise‑training program for PAD in patients with claudication • Be conducted in a hospital outpatient setting or a physician’s office • Be delivered by qualified auxiliary personnel necessary to ensure benefits exceed xxxxx, and who are trained in exercise therapy for PAD • Be under the direct supervision of a physician, physician assistant, or nurse practitioner/clinical nurse specialist who must be trained in both basic and advanced life support techniques SET may be covered beyond 36 sessions over 12 weeks for an additional 36 sessions over an extended period of time if deemed medically necessary by a health care provider. $0 copay for each Medicare‑covered supervised exercise therapy service. Therapeutic Massage We have partnered with American Specialty Health Group, Inc. (ASH Group) to provide your therapeutic massage coverage. We cover up to fifty visits every year for therapeutic massage.* Services must be medically necessary as determined by ASH Group. To locate an ASH Group network provider, you may contact Aetna® Member Services at the number on the back of your ID card or search our online directory. If you choose to use a provider outside of the ASH Group network, remember to present them with your member ID on your first visit. *Amounts you pay for therapeutic massage do not apply to your out‑of‑pocket maximum. $0 copay for each plan‑approved therapeutic massage visit. Transportation services (non‑emergency transportation) We cover: • 24 one‑way trips to and from plan‑approved locations each year Trips must be within 60 miles of provider location. Coverage includes trips to and from providers or facilities for services that your plan covers. The transportation service will accommodate urgent requests for hospital discharge, dialysis, and trips that your medical provider considers urgent. The service will try to accommodate specific physical limitations or requirements. However, it limits services to wheelchair, taxi, or sedan transportation vehicles. • Transportation services are administered through Access2Care • To arrange for transport, call 1‑855‑814‑1699, Monday through Friday, from 8 AM to 8 PM, in all time zones. (For TTY/TDD assistance please dial 711.) • You must schedule transportation service at least 48 hours before the appointment • You must cancel more than two hours in advance, or Access2Care will deduct the trip from the remaining number of trips available • This program doesn’t support stretcher vans/ambulances $0 copay per trip. Urgently needed services Urgently needed services are provided to treat a non‑emergency, unforeseen medical illness, injury, or condition that requires immediate medical care but given your circumstances, it is not possible, or it is unreasonable, to obtain services from network providers. Examples of urgently needed services that the plan must cover out of network are i) you need immediate care during the weekend, or ii) you are temporarily outside the service area of the plan. Services must be immediately needed and medically necessary. Coverage is available worldwide (i.e., outside of the United States). $0 copay for each urgent care facility visit. $0 copay for each urgent care telehealth service. Vision care $0 copay for exams to diagnose and treat diseases and conditions of the eye. Covered services include: • Outpatient physician services for the diagnosis and treatment of diseases and injuries of the eye, including treatment for age‑related macular degeneration. Original Medicare doesn’t cover routine eye exams (eye refractions) for eyeglasses/contacts • For people who are at high risk of glaucoma, we will cover one glaucoma screening every 12 months. People at high risk of glaucoma include: people with a family history of glaucoma, people with diabetes, African Americans who are age 50 and older, and Hispanic Americans who are 65 or older • For people with diabetes, screening for diabetic retinopathy is covered once per year • One pair of eyeglasses or contact lenses after each cataract surgery that includes insertion of a premium intraocular lens. (If you have two separate cataract operations, you cannot reserve the benefit after the first surgery and purchase two eyeglasses after the second surgery.) In addition to Medicare‑covered benefits, we also offer: • Non‑Medicare covered eye exams: one exam every year • Follow‑up diabetic eye exam $0 copay for each Medicare‑covered glaucoma screening. $0 copay for one diabetic retinopathy screening. $0 copay for each follow‑up diabetic eye exam. $0 copay for one pair of eyeglasses or contact lenses after each cataract surgery. Coverage includes conventional eyeglasses or contact lenses. Excluded is coverage for designer frames and progressive lenses instead of traditional lenses, bifocals, or trifocals. $0 copay for each non‑Medicare covered eye exam. Additional cost‑sharing may apply if you receive additional services during your visit. Vision care – eyewear reimbursement (non‑Medicare covered) Non‑Medicare covered prescription eyewear includes: • Contact lenses • Eyeglass prescription lenses • Eyeglass frames You may see any licensed vision provider in the U.S. You pay the provider for services and submit an itemized billing statement showing proof of payment to our plan. You must submit your documentation within 365 days from the date of service to be eligible for reimbursement. If approved, it can take up to 45 days for you to receive payment. If your request is incomplete, such as no itemization of services, or there is missing information, you will be notified by mail. You will then have to supply the missing information, which will delay the processing time. Our plan will reimburse you up to: $300 once every 24 months towards the cost of eyewear. You may be required to pay for services up front and submit for reimbursement Services that are covered for you What you must pay when you get these services Notes: • If you use a non‑licensed provider you will not receive reimbursement. • You are responsible for any charges above the reimbursement amount. • Eyewear reimbursement excludes eyeglasses or contact lenses after cataract surgery. * Amounts you pay for non‑Medicare covered eyewear do not apply to your Out‑of‑Pocket Maximum.

Resources for Living. ® Resources for Living consultants provide research services for members on such topics as caregiver support, household services, eldercare services, activities, and volunteer opportunities. The purpose of the program is to assist members in locating local community services and to provide resource information for a wide variety of eldercare and life‑related issues. Call Resources for Living at 1‑866‑370‑4842. There is no coinsurance, copayment, or deductible for Resources for Living. Screening and counseling to reduce alcohol misuse We cover one alcohol misuse screening for adults with There is no coinsurance, copayment, or deductible for the Medicare‑covered Medicare (including pregnant women) who misuse alcohol but aren’t alcohol dependent. If you screen positive for alcohol misuse, you can get up to 4 brief face‑to‑face counseling sessions per year (if you’re competent and alert during counseling) provided by a qualified primary care doctor or practitioner in a primary care setting. There is no coinsurance, copayment, or deductible for the Medicare‑covered screening and counseling to reduce alcohol misuse preventive benefit. Screening for lung cancer with low dose computed tomography (LDCT) For qualified individuals, a LDCT is covered every 12 months. Eligible members are: people aged 50 – 77 years who have no signs or symptoms of lung cancer, but who have a history of tobacco smoking of at least 20 pack‑years and who currently smoke or have quit smoking within the last 15 years, who receive a written order for LDCT during a lung cancer screening counseling and shared decision‑making visit that meets the Medicare criteria for such visits and be furnished by a physician or qualified non‑physician practitioner. For LDCT lung cancer screenings after the initial LDCT screening: the member must receive a written order for LDCT lung cancer screening, which may be furnished during any appropriate visit with a physician or qualified non‑physician practitioner. If a physician or qualified non‑physician practitioner elects to provide a lung cancer There is no coinsurance, copayment, or deductible for the Medicare‑covered counseling and shared decision making visit or for the LDCT. screening counseling and shared decision making visit for subsequent lung cancer screenings with LDCT, the visit must meet the Medicare criteria for such visits. There is no coinsurance, copayment, or deductible for the Medicare‑covered counseling and shared decision making visit or for the LDCT. Screening for sexually transmitted infections (STIs) and counseling to prevent STIs We cover sexually transmitted infection (STI) screenings for chlamydia, gonorrhea, syphilis, and Hepatitis B. These screenings are covered for pregnant women and for certain people who are at increased risk for an STI when the tests are ordered by a primary care provider. We cover these tests once every 12 months or at certain times during pregnancy. We also cover up to 2 individual 20 to 30 minute, face‑to‑face high‑intensity behavioral counseling sessions each year for sexually active adults at increased risk for STIs. We will only cover these counseling sessions There is no coinsurance, copayment, or deductible for the Medicare‑covered screening for STIs and counseling for STIs preventive benefit. as a preventive service if they are provided by a primary care provider and take place in a primary care setting, such as a doctor’s office. There is no coinsurance, copayment, or deductible for the Medicare‑covered screening for STIs and counseling for STIs preventive benefit. Services to treat kidney disease Covered services include: • Kidney disease education services to teach kidney care and help members make informed decisions about their care. For members with stage IV chronic kidney disease when referred by their doctor, we cover up to six sessions of kidney disease education services per lifetime • Outpatient dialysis treatments (including dialysis treatments when temporarily out of the service area, as explained in Chapter 3 of the Evidence of Coverage, or when your provider for this service is temporarily unavailable or inaccessible) • Inpatient dialysis treatments (if you are admitted as an inpatient to a hospital for special care) • Self‑dialysis training (includes training for you and anyone helping you with your home dialysis treatments) • Home dialysis equipment and supplies • Certain home support services (such as, when necessary, visits by trained dialysis workers to check on your home dialysis, to help in emergencies, and check your dialysis equipment and water supply) Certain drugs for dialysis are covered under your $0 copay for self‑dialysis training. $0 copay for each Medicare‑covered kidney disease education session. $0 copay for in‑ and out‑of‑area outpatient dialysis. See “Inpatient hospital care” for more information on inpatient services. $0 copay for home dialysis equipment and supplies. $0 copay for Medicare‑covered home support services. Medicare Part B drug benefit. For information about coverage for Part B Drugs, please go to the section, “Medicare Part B prescription drugs.” Prior authorization rules may apply for network services. Your network provider is responsible for requesting prior authorization. Our plan recommends pre‑authorization of the service when provided by an out‑of‑network provider. $0 copay for self‑dialysis training. $0 copay for each Medicare‑covered kidney disease education session. $0 copay for in‑ Providers must be licensed and out‑of‑area outpatient dialysis. See “Inpatient hospital care” for more information on inpatient services. $0 copay for home dialysis equipment eligible to receive payment under the federal Medicare program and supplies. $0 copay for Medicare‑covered home support serviceswilling to accept the plan. Skilled nursing facility (SNF) care (For a definition of “skilled nursing facility care,” see the final chapter (“Definitions of important words”) of the Evidence of Coverage. Skilled nursing facilities are sometimes called “SNFs.”) Days covered: up to 100 days per benefit period. A prior hospital stay is not required. $0 per day, days 1‑100 for each Medicare‑covered SNF stay. A benefit period begins the day you go into a hospital or skilled nursing facility. The benefit period ends when you haven’t received any inpatient hospital care (or skilled care in a SNF) for 60 days in a row, including your day Services that are covered for you What you must pay when you get these services Covered services include but are not limited to: • Semiprivate room (or a private room if medically necessary) • Meals, including special diets • Skilled nursing services • Physical therapy, occupational therapy, and speech therapy • Drugs administered to you as part of your plan of care (This includes substances that are naturally present in the body, such as blood clotting factors.) • Blood – including storage and administration. Coverage of whole blood and packed red cells begins only with the first fourth pint of blood that you needneed – you must either pay the costs for the first 3 pints of blood you get in a calendar year or have the blood donated by you or someone else. All other components of blood are covered beginning with the first pint used. • Medical and surgical supplies ordinarily provided by SNFs • Laboratory tests ordinarily provided by SNFs • X‑rays and other radiology services ordinarily provided by SNFs • Use of appliances such as wheelchairs ordinarily provided by SNFs • Physician/Practitioner services Prior authorization rules may apply $0 per day, days 1‑100 for network serviceseach Medicare‑covered SNF stay. Your network provider is responsible A benefit period begins the day you go into a hospital or skilled nursing facility. The benefit period ends when you haven’t received any inpatient hospital care (or skilled care in a SNF) for requesting prior authorization. Our plan recommends pre‑authorization of the service when provided by an out‑of‑network provider. 60 days in a row, including your day of discharge. If you go into a hospital or a skilled nursing facility after one benefit period has ended, a new benefit period begins. There is no limit to the number of benefit periods you can have. Smoking and tobacco use cessation (counseling to stop smoking or tobacco use) If you use tobacco, but do not have signs or symptoms of tobacco‑related disease: We cover two counseling quit attempts within a 12‑month period as a preventive service with no cost to you. Each counseling attempt includes up to four face‑to‑face visits. If you use tobacco and have been diagnosed with a tobacco‑related disease or are taking medicine that may be affected by tobacco: We cover cessation counseling services. We cover two counseling quit attempts within a 12‑month period, however, you will pay the applicable cost‑sharing. Each counseling attempt includes up to four face‑to‑face visits. In addition to Medicare‑covered benefits, we also offer: • Additional individual and group face‑to‑face intermediate and intensive counseling sessions: unlimited visits every year There is no coinsurance, copayment, or deductible for the Medicare‑covered smoking and tobacco use cessation preventive benefits. $0 copay for each non‑Medicare covered smoking and tobacco use cessation visit. In addition to Medicare‑covered benefits, we also offer: • Additional individual and group face‑to‑face intermediate and intensive counseling sessions: unlimited visits every year Supervised Exercise Therapy (SET) SET is covered for members who have symptomatic peripheral artery disease (PAD) and a referral for PAD from the physician responsible for PAD treatment. Up to 36 sessions over a 12‑week period are covered if the SET program requirements are met. The SET program must: • Consist of sessions lasting 30‑60 minutes, comprising a therapeutic exercise‑training program for PAD in patients with claudication • Be conducted in a hospital outpatient setting or a physician’s office • Be delivered by qualified auxiliary personnel necessary to ensure benefits exceed xxxxx, and $20 copay for each Medicare‑covered supervised exercise therapy service. Services that are covered for you What you must pay when you get these services who are trained in exercise therapy for PAD • Be under the direct supervision of a physician, physician assistant, or nurse practitioner/clinical nurse specialist who must be trained in both basic and advanced life support techniques SET may be covered beyond 36 sessions over 12 weeks for an additional 36 sessions over an extended period of time if deemed medically necessary by a health care provider. $0 copay for each Medicare‑covered supervised exercise therapy service. Therapeutic Massage We have partnered with American Specialty Health Group, Inc. (ASH Group) to provide your therapeutic massage coverage. We cover up to fifty visits every year for therapeutic massage.* Services must be medically necessary as determined by ASH Group. To locate an ASH Group network provider, you may contact Aetna® Member Services at the number on the back of your ID card or search our online directory. If you choose to use a provider outside of the ASH Group network, remember to present them with your member ID on your first visit. *Amounts you pay for therapeutic massage do not apply to your out‑of‑pocket maximum. $0 copay for each plan‑approved therapeutic massage visit. Transportation services (non‑emergency transportation) We cover: • 24 one‑way trips to and from plan‑approved locations each year Trips must be within 60 miles of provider location. Coverage includes trips to and from providers or facilities for services that your plan covers. The transportation service will accommodate urgent requests for hospital discharge, dialysis, and trips that your medical provider considers urgent. The service will try to accommodate specific physical limitations or requirements. However, it limits services to wheelchair, taxi, or sedan transportation vehicles. • Transportation services are administered through Access2Care • To arrange for transport, call 1‑855‑814‑1699, Monday through Friday, from 8 AM to 8 PM, in all time zones. (For TTY/TDD assistance please dial 711.) • You must schedule transportation service at least 48 hours before the appointment • You must cancel more than two hours in advance, or Access2Care will deduct the trip from the remaining number of trips available • This program doesn’t support stretcher vans/ambulances $0 copay per trip. Urgently needed services Urgently needed services are provided to treat a non‑emergency, unforeseen medical illness, injury, or condition that requires immediate medical care but given your circumstances, it is not possible, or it is unreasonable, to obtain services from network providers. Examples of urgently needed services that the plan must cover out of network are i) you need immediate care during the weekend, or ii) you are temporarily outside the service area of the plan. Services must be immediately needed and medically necessary. Coverage is available worldwide (i.e., outside of the United States). $0 copay for each urgent care facility visit. $0 copay for each urgent care telehealth service. Vision care $0 copay for exams to diagnose and treat diseases and conditions of the eye. Covered services include: • Outpatient physician services for the diagnosis and treatment of diseases and injuries of the eye, including treatment for age‑related macular degeneration. Original Medicare doesn’t cover routine eye exams (eye refractions) for eyeglasses/contacts • For people who are at high risk of glaucoma, we will cover one glaucoma screening every 12 months. People at high risk of glaucoma include: people with a family history of glaucoma, people with diabetes, African Americans who are age 50 and older, and Hispanic Americans who are 65 or older • For people with diabetes, screening for diabetic retinopathy is covered once per year • One pair of eyeglasses or contact lenses after each cataract surgery that includes insertion of a premium intraocular lens. (If you have two separate cataract operations, you cannot reserve the benefit after the first surgery and purchase two eyeglasses after the second surgery.) In addition to Medicare‑covered benefits, we also offer: • Non‑Medicare covered eye exams: one exam every year • Follow‑up diabetic eye exam $0 copay for each Medicare‑covered glaucoma screening. $0 copay for one diabetic retinopathy screening. $0 copay for each follow‑up diabetic eye exam. $0 copay for one pair of eyeglasses or contact lenses after each cataract surgery. Coverage includes conventional eyeglasses or contact lenses. Excluded is coverage for designer frames and progressive lenses instead of traditional lenses, bifocals, or trifocals. $0 copay for each non‑Medicare covered eye exam. Additional cost‑sharing may apply if you receive additional services during your visit. Vision care – eyewear reimbursement (non‑Medicare covered) Non‑Medicare covered prescription eyewear includes: • Contact lenses • Eyeglass prescription lenses • Eyeglass frames You may see any licensed vision provider in the U.S. You pay the provider for services and submit an itemized billing statement showing proof of payment to our plan. You must submit your documentation within 365 days from the date of service to be eligible for reimbursement. If approved, it can take up to 45 days for you to receive payment. If your request is incomplete, such as no itemization of services, or there is missing information, you will be notified by mail. You will then have to supply the missing information, which will delay the processing time. Our plan will reimburse you up to: $300 once every 24 months towards the cost of eyewear. You may be required to pay for services up front and submit for reimbursement Services that are covered for you What you must pay when you get these services Notes: • If you use a non‑licensed provider you will not receive reimbursement. • You are responsible for any charges above the reimbursement amount. • Eyewear reimbursement excludes eyeglasses or contact lenses after cataract surgery. * Amounts you pay for non‑Medicare covered eyewear do not apply to your Out‑of‑Pocket Maximum.

Resources for Living. ® Resources for Living consultants provide research services for members on such topics as caregiver support, household services, eldercare services, activities, and volunteer opportunities. The purpose of the program is to assist members in locating local community services and to provide resource information for a wide variety of eldercare and life‑related issues. Call Resources for Living at 1‑866‑370‑4842. There is no coinsurance, copayment, or deductible for Resources for Living. Screening and counseling to reduce alcohol misuse We cover one alcohol misuse screening for adults with There is no coinsurance, copayment, or deductible for the Medicare‑covered Medicare (including pregnant women) who misuse alcohol but aren’t alcohol dependent. If you screen positive for alcohol misuse, you can get up to 4 brief face‑to‑face counseling sessions per year (if you’re competent and alert during counseling) provided There is no coinsurance, copayment, or deductible for the Medicare‑covered screening and counseling to reduce alcohol misuse preventive benefit. by a qualified primary care doctor or practitioner in a primary care setting. screening and counseling to reduce alcohol misuse preventive benefit. Screening for lung cancer with low dose computed tomography (LDCT) For qualified individuals, a LDCT is covered every 12 months. Eligible members are: people aged 50 – 77 years who have no signs or symptoms of lung cancer, but who have a history of tobacco smoking of at least 20 pack‑years and who currently smoke or have quit smoking within the last 15 years, who receive a written order for LDCT during a lung cancer screening counseling and shared decision‑making visit that meets the Medicare criteria for such visits and be furnished by a physician or qualified non‑physician practitioner. For LDCT lung cancer screenings after the initial LDCT screening: the member must receive a written order for LDCT lung cancer screening, which may be furnished during any appropriate visit with a physician or qualified non‑physician practitioner. If a physician or qualified non‑physician practitioner elects to provide a lung cancer screening counseling and shared decision making visit for subsequent lung cancer screenings with LDCT, the visit must meet the Medicare criteria for such visits. There is no coinsurance, copayment, or deductible for the Medicare‑covered counseling and shared decision making visit or for the LDCT. Screening for sexually transmitted infections (STIs) and counseling to prevent STIs We cover sexually transmitted infection (STI) screenings for chlamydia, gonorrhea, syphilis, and Hepatitis B. These screenings are covered for pregnant women and for certain people who are at increased risk for an STI when the tests are ordered by a primary care provider. We cover these tests once every 12 months or at certain times during pregnancy. We also cover up to 2 individual 20 to 30 minute, face‑to‑face high‑intensity behavioral counseling sessions each year for sexually active adults at increased risk for STIs. We will only cover these counseling sessions There is no coinsurance, copayment, or deductible for the Medicare‑covered screening for STIs and counseling for STIs preventive benefit. as a preventive service if they are provided by a primary care provider and take place in a primary care setting, such as a doctor’s office. There is no coinsurance, copayment, or deductible for the Medicare‑covered screening for STIs and counseling for STIs preventive benefit. Services to treat kidney disease Covered services include: $0 copay for self‑dialysis training. $0 copay for each Medicare‑covered kidney Services that are covered for you What you must pay when you get these services • Kidney disease education services to teach kidney care and help members make informed decisions about their care. For members with stage IV chronic kidney disease when referred by their doctor, we cover up to six sessions of kidney disease education services per lifetime • Outpatient dialysis treatments (including dialysis treatments when temporarily out of the service area, as explained in Chapter 3 of the Evidence of Coverage, or when your provider for this service is temporarily unavailable or inaccessible) • Inpatient dialysis treatments (if you are admitted as an inpatient to a hospital for special care) • Self‑dialysis training (includes training for you and anyone helping you with your home dialysis treatments) • Home dialysis equipment and supplies • Certain home support services (such as, when necessary, visits by trained dialysis workers to check on your home dialysis, to help in emergencies, and check your dialysis equipment and water supply) Certain drugs for dialysis are covered under your Medicare Part B drug benefit. For information about coverage for Part B Drugs, please go to the section, “Medicare Part B prescription drugs.” Prior authorization rules may apply for network services. Your network provider is responsible for requesting prior authorization. Our plan recommends pre‑authorization of the service when provided by an out‑of‑network provider. $0 copay for self‑dialysis training. $0 copay for each Medicare‑covered kidney disease education session. $0 copay for in‑ and out‑of‑area outpatient dialysis. See “Inpatient hospital care” for more information on inpatient services. $0 copay for home dialysis equipment and supplies. $0 copay for Medicare‑covered home support services. Skilled nursing facility (SNF) care (For a definition of “skilled nursing facility care,” see the final chapter (“Definitions of important words”) of the Evidence of Coverage. Skilled nursing facilities are sometimes called “SNFs.”) Days covered: up to 100 days per benefit period. A prior hospital stay is not required. Covered services include but are not limited to: • Semiprivate room (or a private room if medically necessary) • Meals, including special diets • Skilled nursing services • Physical therapy, occupational therapy, and speech therapy • Drugs administered to you as part of your plan of care (This includes substances that are naturally $0 per day, days 1‑100 for each Medicare‑covered SNF stay. A benefit period begins the day you go into a hospital or skilled nursing facility. The benefit period ends when you haven’t received any inpatient hospital care (or skilled care in a SNF) for 60 days in a row, including your day of discharge. If you go into a hospital or a skilled nursing facility after one benefit period has ended, a new benefit period begins. There is no limit to the number of benefit periods you can have. Services that are covered for you What you must pay when you get these services Covered services include but are not limited to: • Semiprivate room (or a private room if medically necessary) • Meals, including special diets • Skilled nursing services • Physical therapy, occupational therapy, and speech therapy • Drugs administered to you as part of your plan of care (This includes substances that are naturally present in the body, such as blood clotting factors.) • Blood – including storage and administration. Coverage of whole blood and packed red cells begins with the first pint of blood that you need. All components of blood are covered beginning with the first pint used. • Medical and surgical supplies ordinarily provided by SNFs • Laboratory tests ordinarily provided by SNFs • X‑rays and other radiology services ordinarily provided by SNFs • Use of appliances such as wheelchairs ordinarily provided by SNFs • Physician/Practitioner services Prior authorization rules may apply for network services. Your network provider is responsible for requesting prior authorization. Our plan recommends pre‑authorization of the service when provided by an out‑of‑network provider. of discharge. If you go into a hospital or a skilled nursing facility after one benefit period has ended, a new benefit period begins. There is no limit to the number of benefit periods you can have. Smoking and tobacco use cessation (counseling to stop smoking or tobacco use) If you use tobacco, but do not have signs or symptoms of tobacco‑related disease: We cover two counseling quit attempts within a 12‑month period as a preventive service with no cost to you. Each counseling attempt includes up to four face‑to‑face visits. If you use tobacco and have been diagnosed with a tobacco‑related disease or are taking medicine that may be affected by tobacco: We cover cessation counseling services. We cover two counseling quit attempts within a 12‑month period, however, you will pay the applicable cost‑sharing. Each counseling attempt includes up to four face‑to‑face visits. In addition to Medicare‑covered benefits, we also offer: • Additional individual and group face‑to‑face intermediate and intensive counseling sessions: unlimited visits every year There is no coinsurance, copayment, or deductible for the Medicare‑covered smoking and tobacco use cessation preventive benefits. $0 copay for each non‑Medicare covered smoking and tobacco use cessation visit. In addition to Medicare‑covered benefitsSpecial Supplemental Benefits for the Chronically Ill Landmark providers: If you have been diagnosed by a plan provider with generally six or more of the chronic conditions listed below and you meet certain criteria, we also offeryou There is no coinsurance, copayment, or deductible for this service. may be eligible for in home and/or telehealth physician services offered through Landmark providers: • Additional individual Chronic alcohol and group face‑to‑face intermediate other drug dependence • Autoimmune disorders • Cancer • Cardiovascular disorders • Chronic heart failure • Diabetes • End stage liver disease • End stage renal diseases (ESRD) requiring dialysis • Chronic lung disorders • Chronic and intensive counseling sessions: unlimited visits every year disabling mental health conditions • Neurologic disorders • Stroke • Metabolic • Vascular • Musculoskeletal Aetna and/or Landmark will contact you by phone and/or mail to notify you of your eligibility for this program. You will be provided with additional information to help you better understand the benefits offered by Xxxxxxxx. This is a voluntary program and you can decide if you want to participate. Supervised Exercise Therapy (SET) SET is covered for members who have symptomatic peripheral artery disease (PAD) and a referral for PAD from the physician responsible for PAD treatment. Up to 36 sessions over a 12‑week period are covered if the SET program requirements are met. The SET program must: • Consist of sessions lasting 30‑60 minutes, comprising a therapeutic exercise‑training program for PAD in patients with claudication • Be conducted in a hospital outpatient setting or a physician’s office • Be delivered by qualified auxiliary personnel necessary to ensure benefits exceed xxxxx, and who are trained in exercise therapy for PAD • Be under the direct supervision of a physician, physician assistant, or nurse practitioner/clinical $0 copay for each Medicare‑covered supervised exercise therapy service. Services that are covered for you What you must pay when you get these services nurse specialist who must be trained in both basic and advanced life support techniques SET may be covered beyond 36 sessions over 12 weeks for an additional 36 sessions over an extended period of time if deemed medically necessary by a health care provider. $0 copay for each Medicare‑covered supervised exercise therapy service. Therapeutic Massage We have partnered with American Specialty Health Group, Inc. (ASH Group) to provide your therapeutic massage coverage. We cover up to fifty visits every year for therapeutic massage.* Services must be medically necessary as determined by ASH Group. To locate an ASH Group network provider, you may contact Aetna® Member Services at the number on the back of your ID card or search our online directory. If you choose to use a provider outside of the ASH Group network, remember to present them with your member ID on your first visit. *Amounts you pay for therapeutic massage do not apply to your out‑of‑pocket maximum. $0 copay for each plan‑approved therapeutic massage visit. Transportation services (non‑emergency transportation) We cover: • 24 one‑way trips to and from plan‑approved locations each year Trips must be within 60 miles of provider location. Coverage includes trips to and from providers or facilities for services that your plan covers. The transportation service will accommodate urgent requests for hospital discharge, dialysis, and trips that your medical provider considers urgent. The service will try to accommodate specific physical limitations or requirements. However, it limits services to wheelchair, taxi, or sedan transportation vehicles. • Transportation services are administered through Access2Care • To arrange for transport, call 1‑855‑814‑1699, Monday through Friday, from 8 AM to 8 PM, in all time zones. (For TTY/TDD assistance please dial 711.) • You must schedule transportation service at least 48 hours before the appointment • You must cancel more than two hours in advance, or Access2Care will deduct the trip from the remaining number of trips available • This program doesn’t support stretcher vans/ambulances $0 copay per trip. Urgently needed services Urgently needed services are provided to treat a non‑emergency, unforeseen medical illness, injury, or condition that requires immediate medical care but given your circumstances, it is not possible, or it is unreasonable, to obtain services from network providers. Examples of urgently needed services that the plan must cover out of network are i) you need immediate care during the weekend, or ii) you are temporarily outside the service area of the plan. Services must be immediately needed and medically necessary. Coverage is available worldwide (i.e., outside of the United States). $0 copay for each urgent care facility visit. $0 copay for each urgent care telehealth service. Vision care $0 copay for exams to diagnose and treat diseases and conditions of the eye. Covered services include: • Outpatient physician services for the diagnosis and treatment of diseases and injuries of the eye, including treatment for age‑related macular degeneration. Original Medicare doesn’t cover routine eye exams (eye refractions) for eyeglasses/contacts • For people who are at high risk of glaucoma, we will cover one glaucoma screening every 12 months. People at high risk of glaucoma include: people with a family history of glaucoma, people with diabetes, African Americans who are age 50 and older, and Hispanic Americans who are 65 or older • For people with diabetes, screening for diabetic retinopathy is covered once per year • One pair of eyeglasses or contact lenses after each cataract surgery that includes insertion of a premium intraocular lens. (If you have two separate cataract operations, you cannot reserve the benefit after the first surgery and purchase two eyeglasses after the second surgery.) In addition to Medicare‑covered benefits, we also offer: • Non‑Medicare covered eye exams: one exam every year • Follow‑up diabetic eye exam $0 copay for each Medicare‑covered glaucoma screening. $0 copay for one diabetic retinopathy screening. $0 copay for each follow‑up diabetic eye exam. $0 copay for one pair of eyeglasses or contact lenses after each cataract surgery. Coverage includes conventional eyeglasses or contact lenses. Excluded is coverage for designer frames and progressive lenses instead of traditional lenses, bifocals, or trifocals. $0 copay for each non‑Medicare covered eye exam. Additional cost‑sharing may apply if you receive additional services during your visit. Vision care – eyewear reimbursement (non‑Medicare covered) Non‑Medicare covered prescription eyewear includes: • Contact lenses • Eyeglass prescription lenses • Eyeglass frames You may see any licensed vision provider in the U.S. You pay the provider for services and submit an itemized billing statement showing proof of payment to our plan. You must submit your documentation within 365 days from the date of service to be eligible for reimbursement. If approved, it can take up to 45 days for you to receive payment. If your request is incomplete, such as no itemization of services, or there is missing information, you will be notified by mail. You will then have to supply the missing information, which will delay the processing time. Our plan will reimburse you up to: $300 once every 24 months towards the cost of eyewear. You may be required to pay for services up front and submit for reimbursement Services that are covered for you What you must pay when you get these services Notes: • If you use a non‑licensed provider you will not receive reimbursement. • You are responsible for any charges above the reimbursement amount. • Eyewear reimbursement excludes eyeglasses or contact lenses after cataract surgery. * Amounts you pay for non‑Medicare covered eyewear do not apply to your Out‑of‑Pocket Maximum.