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SUMMARYOFBENEFITS

EonDeluxe(HMOSNP)andEonPlus(HMOSNP)

Formoreinformation,call1-844-895-8643

2017SummaryofBenefitsfor

EonDeluxe(HMOSNP) andEonPlus(HMOSNP)

ThisisasummaryofdrugandhealthservicescoveredbyEonHealthJanuary1,2017-December31,2017

EonHealthhasacontractwithMedicaretoofferHMOandPPOplans.EonHealthalsohasacontractwiththeGeorgiaMedicaidProgramandacontractwiththeSouthCarolinaMedicaidprogram.EnrollmentinEonHealthdependsoncontractrenewal.

Thebenefitinformationprovidedisasummaryofwhatwecoverandwhatyoupay.Itdoesnotlistevery servicethatwecoverorlisteverylimitationorexclusion.To getacompletelistofserviceswecover,pleaserequestthe"EvidenceofCoverage."YoucanobtainacopyofourEvidenceofCoveragebycallingusat:CurrentMembers:1-888-906-3889,ProspectiveMembers:1-844-895-8643,TTY:711orvisitingourwebsiteat

Eon Healthhasanetworkof doctors,hospitals,pharmacies,andotherproviders.Ifyouusetheprovidersthatarenotinournetwork,theplanmaynotpayfortheseservices

YoucanseeourProviderand PharmacyDirectoryonourwebsiteat

You seeourFormulary(ListofPartDprescriptiondrugs)on ourwebsiteat

Introduction

EonDeluxeandEonPlusareMedicareAdvantageHMOSpecialNeeds Plans(SNP)offered inGeorgiaandSouthCarolina.Georgia

TojoinEonDeluxe,youmustbeentitledtoMedicarePartA,enrolledinbothMedicarePartBandGeo-rgiaMedicaidProgram,andliveinourservicearea.

TojoinEonPlus,youmustbeentitledtoMedicarePartA,enrolledinMedicarePartB,receiveassistancefromGeorgia Medicaidandliveinourservicearea.

SouthCarolina

TojoinEonDeluxe,youmustbeentitledtoMedicarePartA,enrolledinbothMedicarePartBandSouthCarolinaMedicaidProgram-HealthyConnections,andliveinourservicearea.

TojoinEonPlus,youmustbeentitledtoMedicarePartA,enrolledinMedicarePartB,receiveassistancefromSouthCarolinaMedicaidandliveinourservicearea.

EonDeluxeandEonPlusServiceArea

State / ServiceArea
Georgia / Baker,Baldwin,Banks,Barrow,Bibb,Bleckley,Bryan,Butts,Chatham,Cherokee,Clayton,Clinch,Crawford,Dawson,DeKalb,Dodge,Dooly,Fayette,Forsyth,Franklin,Greene,Hancock,Hart,Heard,Henry,Houston,Jasper,Jones,Lamar,Lumpkin,Macon,Madison,Mcintosh,Meriwether,Monroe,Mor!JID,Newton,Oconee,Oglethorpe,Peach,Pickens,Pike, Pulaski,Putnam,Rabun,Rockdale,Schley,Screven,Stephens,Talbot,Taliaferro,Taylor,Twie:e:s,Walton,White,Wilcox,Wilkinsoncounties
SouthCarolina / Beaufort,Chester,Colleton,Fairfield,Greenville,Hampton,Jasper,Lee,Saluda,Spartanburg,Unioncounties

HMOSummaryofBenefits

HealthMaintenanceOrganization(HMO)plans-InmostHMOs,youcanonlygotodoctors,otherhealthcareproviders,orhospitalsintheplan'snetworkexceptinanurgentoremergencysituation.

HMOSNPPlanHighlights

EonDeluxe
HMOSNP[•.
MonthlyPremium
$0
DoctorVisits
$0PCP
$0Specialist
GenericPrescriptions
Aslowas$0
FitnessProgram
SilverSneak:ers®
DentalCare
Preventative•Comprehensive•Dentures
VisionCare
$100towardsglassesorcontactlenses
HearingCare
Examsandupto$750forhearingaids
Transportation
12one-waytoplan-approvedlocations
Over-the-Counter Medication
$15allowancepermonth
Benefits / EonDeluxe
MonthlyPlanPremium / $0permonth
Deductible / $0
MaximumOut-of-PocketResponsibility
(doesnotincludeprescriptiondrugs) / $3,400annually
InpatientHospitalCoverage1 / $0/DayforDays1-6
$0/DayforDays7-90
DoctorVisits1(PrimaryandSpecialist) / Primarycarephysicianvisit:$0copay
Specialistvisit:$0copay
PreventiveCare / $0copay
EmergencyCare / $0copay
UrgentlyNeededServices / SOcopay
DiagnosticServices/Labs/Imaging1 / Diagnosticradiologyservices(suchasMR.Is,CTscans):0%coinsurance
Di8.2Ilostictestsand procedures:$0copay
Labservices:$0copay
Outpatientx-rays:$0copay
Therapeuticradiologyservices(suchasradiationtreatmentforcancer):0%coinsurance
HearingServices1 / Examtodiagnoseandtreathearingandbalanceissues:$0copay
Routinehearingexam(foruptoleveryyear):$0copay
Hearingaidfitting/evaluation(forupto1every3years):$0copay
Ourplanpaysupto$750everythreeyearsforhearingaids.Benefitamountappliesto
bothearscombined.
Benefits / EonDeluxe
DentalServices1 / Preventivedentalservices:
-Cleaning(forupto1everysixmonths):$0copay
-Dentalx-ray(s)(forupto1everysixmonths):$0copay
-Oralexam(forupto1everysixmonths):$0copay
-1dentalbitewingx-raypersideeverysixmonths:$0copay
-1panoramicx-rayeveryfiveyears:$0copay
Comprehensivedentalservicescoveragelimitis$500everyyear.$0copay
•Coverageislimitedtofillings,simpleextractionsanddenturerepair.Additionaldentalservices,suchasrootcanals,crowns,surgicalextractions,denturerelinesandperiodontal(gum)treatments,arenotcovered.
•1partialor1completedentureperarcheveryfiveyears.$0copay
VisionServices / Examtodiagnoseandtreatdiseasesandconditionsoftheeye(includingyearlyglaucomascreening):$0copay
Routineeyeexam(forupto1everyyear):$0copay
Contact lenses:(forupto1everyyear):$0copay
Eyeglasses(framesandlenses):(forupto1everyyear):$0copayEyeglassesorcontactlensesaftercataractsurgery:$0copay
$100everyyearforcontactlensesandeyeglasses(framesandlenses)
MentalHealthServices1 / Inpatient
$0/DayforDays1-6
$0/DayforDays7-90
Outpatientgrouptherapyvisit:$0copayOutpatientindividualtherapyvisit:$0copay
SkilledNursingFacility(SNF)1 / $0/DayforDays1-20
$0/DayforDays21-100
Benefits / EonDeluxe
RehabilitationServices(Outpatient)1 / Cardiac(heart)rehabservices(foramaximumof2one-hoursessionsperdayforupto36sessionsforaperiodofupto36weeks):0%Coinsurance
Occupationaltherapyvisit:$0copay
Physicaltherapyvisit:$0copay
Speechandlanguagetherapyvisit:$0copay
Ambulance1 / $0copay
Transportation1 / $0copay/12onewaytrips
Foot Care(podiatryservices) / Footexamsandtreatmentifyouhavediabetesrelatednervedamageand/ormeetcertainconditions:$0copay
Routinefootcare:$0copay
MedicalEquipment/Supplies1 / 0%Coinsurance
Prostheticdevices:0%coinsurance
Relatedmedicalsupplies:0%coinsurance
WellnessPrograms(e.g.fitness) / Freehealthclub membership,SilverSneakers•andor
Free@HomePak:(workoutKit)forthosewithlimitedaccesstoanetworkfitnesscenter
MedicarePartBdrugs1 / OOA>coinsurance
Benefits / EonDeluxe
PRESCRIPTIONDRUGBENEFITS
InitialCoverageRetail / Forgenericdrugs(includingbranddrugstreatedasgeneric),either:
$0copay/ $1.20copay/$3.30copay
Forallotherdrugs,either:
$0copay/$3.70copay/$8.25copay
CoverageGap / Forgenericdrugs(includingbranddrugstreatedasgeneric),either:
$0copay/$1.20copay/$3.30copay
Forallotherdrugs,either:
$0copay/$3.70copay/ $8.25copay
CatastrophicCoverage / Forgenericdrugs(includingbranddrugstreatedasgeneric),either:
$0copay
Forallotherdrugs,either:
$0copay
Over-the-Counter Items / Membersreceivea$15allowanceeverymonth

HMOSummaryofBenefits

HealthMaintenanceOrganization(HMO)plans-InmostHMOs,youcanonlygotodoctors,otherhealthcareproviders,orhospitalsintheplan'snetworkexceptinanurgentoremergencysituation.

HMOSNPPlanHighlights

MonthlyPremium
Georgiaresidents$0-$25.80SouthCarolinaResidents$0-$26.00
DoctorVisits
$0or$20PCP
$0or$45Specialist
GenericPrescriptions
Aslowas$0
FitnessProgram
SilverSneakers®
DentalCare
Preventative•Comprehensive•Dentures
VisionCare
$100towardsglassesorcontactlenses
HearingCare
Examsandupto$750forhearingaids
Transportation
12one-waytoplan-approvedlocations
Over-the-Counter Medication
$15allowancepermonth
Benefits
MonthlyPlanPremium / Georgiaresidents$0-$25.80
SouthCarolinaresidents $0-$26.00
Deductible / $0
MaximumOut-of-PocketResponsibility
(doesnotincludeprescriptiondrugs) / $6,700annually
InpatientHospitalCoverage1 / $0or$280/DayforDays1-6
$0/DayforDays7-90
Specialistvisit:$0or$45copay
DoctorVisits1
(PrimaryandSpecialist)
PreventiveCare / $0copay
EmergencyCare / $0or$75copay
UrgentlyNeededServices / $0or$45copay
DiagnosticServices/Labs/lmaging1 / Diagnosticradiologyservices(suchasMRls,CTscans):0%or20%coinsurance
Diagnostictestsandprocedures: $0copay
Labservices:$0copay
Outpatientx-rays:$0or$25copay
Therapeuticradiologyservices(suchasradiationtreatment forcancer):0%or20%coinsurance
HearingServices1 / Examtodiagnoseandtreathearingandbalanceissues:$0or$25copay
Routinehearingexam(forupto1every year):$0or$25copay
Hearingaidfitting/evaluation(forupto1every3years):$0copay
Ourplanpaysupto$750everythreeyearsforhearingaids.Benefitamount
appliestobothearscombined.
Benefits
DentalServices! / Preventivedentalservices:
•Cleaning(forupto1everysixmonths): $0copay
•Dentalx-ray(s)(forupto1everysixmonths):$0copay
•Oral exam(forupto1everysixmonths):$0copay
•1dentalbitewingx-raypersideeverysixmonths:$0copay
•1panoramicx-rayeveryfiveyears:$0copay
Comprehensivedentalservicescoveragelimitis$500everyyear.
$0or$25copay
•Coverageislimitedtofillings,simpleextractionsanddenturerepair.Additionaldentalservices.suchasrootcanals.crowns.surgicalextractions.denturerelinesandperiodontal(gum)treatments,arenotcovered.
•1partial or1completedentureper archeveryfiveyears.$0copay
VisionServices / Examtodiagnoseandtreatdiseasesandconditionsoftheeye(includingyearlyglaucomascreening):$0or$25copay
Routineeyeexam(forupto1everyyear):$0copay
Contactlenses:(forupto1everyyear): $0copay
Eyeglasses(framesandlenses):(forupto1everyyear):$0copayEyeglassesorcontactlensesaftercataractsurgery:$0copay
$100everyyearforcontactlensesandeyeglasses(framesandlenses)
MentalHealthServices1 / Inpatient
$0or$265/DayforDays1-6
$0/Da forDa s7-90
Outpatientgrouptherapyvisit:$0or$40copayOutpatientindividualtherapyvisit:$0or$40copay
SkllledNursingFacllity(SNF)1 / $0/DayforDays1-20
$0or$150/DayforDays21-100
Benefits
RehabilitationServices(Outpatient)1 / Cardiac(heart)rehabservices(foramaximumof2one-hoursessionsperdayforupto36sessionsforaperiodofupto36weeks):0%or20%Coinsurance
Occupationaltherapyvisit:$0or$40copay
Physicaltherapyvisit:$0or$40copay
Speechandlanguagetherapyvisit: $0or$40copay
Ambulance1 / $0or$300copay
Transportation 1 / $0copay/12onewaytrips
FootCare(podiatryservices) / Footexamsandtreatmentifyouhavediabetesrelatednervedamageand/ormeetcertainconditions:$0or$45copay
Routinefootcare:NotCovered
MedicalEquipment/Supplies1 / 0%or200./oCoinsurance
Prostheticdevices:0%or20%coinsuranceRelatedmedicalsupplies:0%or20%coinsurance
WellnessPrograms(e.g.fitness) / Freehealthclubmembership,SilverSneakers•andor
Free@HomePak(workoutKit)forthosewithlimitedaccesstoanetworkfitnesscenter
MedicarePartB drugs1 / 20%coinsurance

StatementofMedicaidBenefitsandCost-SharingProtections

Eligibility

EonDeluxe(HMOSNP)

TheEonDeluxePlanisavailabletoanyonewithbothMedicarePartsAandBandwhoreceivesMedicalAssistance fromthe stateMedicaidprogramtocoverMedicarecost-sharing.

•EonDeluxe(HMOSNP)memberswithFullbenefitMedicaidstatus(FullBenefitDualEligible(FBDE),QualifiedMedicareBeneficiaryPlus(QMB+)andSpecifiedLow-IncomeMedicareBeneficiaryPlus(SLMB+)arecoveredbythestateMedicaidprogramfortheirMedicarecostsharing.

•EonDeluxe(HMOSNP)PlanwithfullMedicaidcoverageareenrolledintheStateMedicaid programthatpaystheirMedicarecostsharing.Thesemembersarealsoeligibletoreceive additionalMedicaidbenefitsdescribebelow.

EonPlus(HMOSNP)

•EonPlus(HMOSNP)memberswithQualifiedMedicareBeneficiaryPlus(QMB), SpecifiedLow-IncomeMedicareBeneficiary(SLMB),QualifiedIndividual(QI)andQualifiedDisabledandWorkingIndividual(QDWI)statusreceivestateassistancefromthestateMedicaidprogramfortheirMedicarecostsharing.

CostSharingandCost-sharingProtectionsforAllMembers

InEonDeluxeplan,thestateMedicaidprogrampaysthecostsharingforMedicare-coveredmedicalservicesyoureceive.YoupaynocostsharingfortheMedicare-coveredbenefitsdescribedintheCoveredMedicalandHospitalBenefitssectionofthisSummaryofBenefits.Youwillpay smallcopaymentsforprescriptionscoveredundertheMedicarePartDprescriptiondrugbenefit.Whenyoureceivehealthservices,theprovidershouldonlybillEonDeluxe(HMOSNP)orthestateMedicaidprogramforthecostofthoseservicesandcost-sharingamounts.Theprovidershouldnotbillyouforservicesorcostsharing.

InEonPlusplan,thestateMedicaidprogram maypaythecostsharingforMedicare-coveredmedicalservicesyoureceivedependentonyourlevelofMedicaideligibility.YouwillpaysmallcopaymentsforprescriptionscoveredundertheMedicarePartDprescriptiondrugbenefit.Whenyoureceivehealthservices,theprovidershouldonlybillEonPlus(HMOSNP)orthestateMedicaidprogramforthecostofthoseservicesandcost­sharingamounts.Theprovidershouldnotbillyouforservicesorcostsharing.

Ifyoureceivecarefromanon-contractedprovider,theprovidermaynotunderstandEonDeluxe,EonPlusorthesebillingrules.IfyoureceiveabillfromaproviderforMedicare-coveredservices,pleasenotifyMemberServicessowecanhelpyou.

Please seeChapter7ofyourEonDeluxeEvidence ofCoverageformoreinformation.

ThebenefitsdescribedbelowarecoveredbyMedicaid.ThebenefitsdescribedintheCoveredMedicalandHospitalBenefitssectionoftheSummaryofBenefitsarecoveredbyMedicare.Foreachbenefitlistedbelow,youcanseewhatyourstateMedicaidcovers andwhatourplancovers.WhatyoupayforcoveredservicesmaydependonyourlevelofMedicaideligibility.

Benefit / GeorgiaMedicaid / EonDeluxe
Ambulance(medicallynecessaryambulanceservices) / Fordual-eligiblemembers,Medicaidpaysforthisserviceifitisnotcoveredby MedicareorwhentheMedicarebenefitisexhausted.
$0pervisitifemergent
$3pervisitwillbeimposediftheconditionisnotanemergentmedicalcondition. / $0copay / $0or$300copay
DentalServices / Preventive,diagnosticandtreatmentservicesprovidedtoMembersunderage21.
EmergencyServicesonlyforMembersage21and older.
Children21:$0pervisit-Servicesincludeexams,cleanings,X-rays,fillings,dentures,oralsurgeryandorthodontictreatment.
Adults21+(emergencyonly):$0co-pay / Preventivedentalservices:
•Cleaning(forupto1everysixmonths):$0copay
•Dental x-ray(s)(forupto1everysixmonths):$0copay
•Oralexam(forupto1everysixmonths):$0copay
1dentalbitewingx-raypersideeverysixmonths:$0copay
•1panoramicx-rayeveryfive ears:$0co a / Preventivedentalservices:
•Cleaning(forupto1everysixmonths):$0copay
•Dentalx-ray(s)(forupto1everysixmonths): $0copay
•Oralexam(forupto1everysixmonths): $0copay1dentalbitewingx-raypersideeverysixmonths:$0 copay
•1panoramicx-rayeveryfiveyears:$0copay

BenefitGeorgiaMedicaidEon DeluxeComprehensivedentalservicescoveragelimitis

$500everyyear.$0copay

•Coverageislimitedtofillings,simpleextractionsanddenturerepair.Additionaldentalservices,suchasrootcanals,crovvns,surgical

extractions,denturerelinesandperiodontal(gum)treatments,are notcovered.

•1partialor1completedentureperarcheveryfiveyears.$0 copay

Comprehensive dentalservicescoveragelimitis

$500 everyyear.

$0or$25copay

•Coverageislimitedtofillings,simpleextractionsanddenturerepair.Additionaldental

services,suchasrootcanals,crowns,surgicalextractions,denturerelinesandperiodontal(gum)treatments,arenotcovered.

•1partialor1completedentureperarcheveryfiveears.$0co a

Diagnostic Tests,X-Rays,LabServices,andRadiologyServices

Fordual-eligiblemembers,DiagnosticradiologyDiagnosticradiologyMedicaidpaysforthisserviceifitservices(suchasMR.Is,CT services(suchasMR.Is,CTisnotcoveredbyMedicare or scans):0%coinsurance scans):

whentheMedicarebenefitis0%or20%coinsuranceexhausted.Diagnostictests andDiagnostictestsand

procedures:procedures:

$3co-payifoutpatientbased$0co a$0co a

*Notcovered:portableX-rayLabservices:$0copayLabservices:$0copayservices;servicesprovidedinOutpatientx-rays: Outpatientx-rays:

facilitiesnotmeetingthedefinition...._o_co...... a...... _s_o_o_r_$_2_5_c_o a..-----1

ofanindependentlaboratoryorX-TherapeuticradiologyTherapeuticradiology

rayfacility; servicesorproceduresservices(suchasradiationservices(suchasradiationreferredtoanothertestingfacility; treatmentforcancer): treatmentforcancer):servicesfurnishedbyaStateor 0%coinsurance 0%or200/ocoinsurancepubliclaboratory;servicesor

proceduresperformedbyafacility

Benefit / GeorgiaMedicaid / EonDeluxe
notcertifiedtoperformthem.
Benefit / GeorgiaMedicaid / EonDeluxe
exhausted.
$0co-payforMedicaid-coveredservices.
*NotcoveredoutsidetheU.S.exceptunderlimitedcircumstances.Contacttheplanformoredetails.
HearingServices / Fordual-eligiblemembers,MedicaidpaysforthisserviceifitisnotcoveredbyMedicareorwhentheMedicarebenefitisexhausted.
*Notcoveredformembersage21andolder.AvailableunderEPSDTaspartofawrittenserviceplan. / Examtodiagnoseandtreat hearingandbalanceissues:
$0coa / Examtodiagnoseandtreat hearingandbalanceissues:
$0or$25coa
Routine hearingexam(for
upto1everyyear):
$0co / Routinehearingexam(forupto1everyyear):
$0or$25coa
Hearingaid fitting/evaluation(forupto1eve3 ears):$0co a / Hearingaidfitting/evaluation(forupto1every3years):
$0copa
Ourplanpays upto $750
everythreeyearsforhearingaids.Benefitamountappliestobothears combined. / Ourplanpaysupto$750everythreeyearsforhearingaids.Benefitamountappliestobothearscombined.
HomeHealthCare / Fordual-eligiblemembers,MedicaidpaysforthisserviceifitisnotcoveredbyMedicareorwhentheMedicarebenefitisexhausted.
*Notcovered:socialservices, / $0copay / $0copay
Benefit / GeorgiaMedicaid / EonDeluxe
choreservices,mealsonwheels,audiologyservices.
Hospice / Fordual-eligiblemembers,Medicaid paysforthisserviceifitisnotcoveredbyMedicareorwhentheMedicarebenefitisexhausted.
$3co-pay
*AvailabletoMemberscertifiedasbeingterminallyilland havingamedicalprognosisoflifeexpectancyofsix(6)monthsorless. / YoupaynothingforhospicecarefromaMedicare-certifiedhospice.
Youmayhavetopaypartofthecostsfordrugsandrespitecare.Hospiceiscoveredoutsideofour plan.Pleasecontactusformoredetails / YoupaynothingforhospicecarefromaMedicare-certifiedhospice.Youmayhavetopaypartofthecostsfordrugsandrespitecare.
Hospiceiscoveredoutsideofourplan.Please contactus
formoredetails
InpatientHospitalCare
(IncludesSubstanceAbuseandRehabilitationServices) / Fordual-eligiblemembers,Medicaid paysforthisserviceifitisnotcoveredbyMedicareorwhentheMedicarebenefitisexhausted.
$12.50peradmissionformembersoverage. / $0/DayforDays1-6
$0/DayforDays7-90 / $0or$280/DayforDays1-6
$0/DayforDays7-90
OutpatientMentalHealthCare / Fordual-eligiblemembers,Medicaid paysforthisserviceifitisnotcoveredbyMedicareorwhentheMedicarebenefitisexhausted.
$3.00memberco-aentis / Outpatientgrouptherapyvisit:
$0copay
Outpatientindividualtherapyvisit:
$0copay / Outpatientgrouptherapyvisit:
$0or $40copay
Outpatientindividualtherapyvisit:
$0or $40copay
Benefit / GeorgiaMedicaid / EonDeluxe
requiredonallnon-emergencyoutpatienthospitalvisits.
*CommunityMentalHealthRehabilitationservicesareonly available aspartofawrittenserviceplan.
Pregnantwomen,membersundertwenty-one(21)yearsofage,nursingfacilitymembers,communitycareparticipants,QualifiedMedicare
Beneficiary(QMB),andhospicecareparticipantsarenotsubjecttotheco-payment.
Whentheoutpatientcost-basedsettlementsaremadeforhospitalservices,theco-paymentplusMedicaidpaymentwillbecomparedtotheallowablecosttodeterminetheamountoffinalsettlement.
Outpatient SubstanceAbuse / Fordual-eligiblemembers,MedicaidpaysforthisserviceifitisnotcoveredbyMedicareorwhentheMedicarebenefitisexhausted.
$3co-pay
*Substanceabusetreatment, / Outpatientgrouptherapyvisit: $0copayOutpatientindividualtherapyvisit:$0copay / Outpatientgrouptherapyvisit: $0or$45copayOutpatientindividualtherapyvisit: $0or$45copay
Benefit / GeorgiaMedicaid / EonDeluxe
Inpatientandrehabilitative,are coveredaspartofawrittenserviceplan.
OutpatientSurgery / Fordual-eligiblemembers,MedicaidpaysforthisserviceifitisnotcoveredbyMedicareorwhentheMedicarebenefit isexhausted. / Ambulatorysurgicalcenter:
$0coa / Ambulatorysurgicalcenter:
$0or$200copay
Outpatienthospital:
$0copay / Outpatienthospital:
$0or$245copay
Over-the-CounterItems / NotCovered / Membersreceive a$15allowanceeverymonth / Membersreceivea$15allowanceeverymonth
PodiatryServices / Fordual-eligiblemembers, / Footexamsandtreatment / Footexamsandtreatmentif
Medicaidpaysforthisserviceifit / ifyouhavediabetesrelated / youhavediabetesrelated
isnotcoveredbyMedicareor / nervedamageand/ormeet / nervedamageand/ormeet
whentheMedicarebenefit is / certainconditions: / certainconditions:
exhausted. / $0copay / $0or$45copay
Cost-based: / Routinefootcare:
$0copay / Routinefootcare:Notcovered
$10.00orless -$0.50
$10.01-$25.00-$1.00
$25.01-$50.00-$2.00
$50.01ormore-$3.00
*Notcovered:servicesforflatfoot;
subluxation;routinefootcare,
supportivedevices;vitaminB-12
injections.
Benefit / GeorgiaMedicaid / Eon Deluxe
ProstheticDevices
(includesbraces,artificiallimbsandeyes, etc.) / Fordual-eligiblemembers,MedicaidpaysforthisserviceifitisnotcoveredbyMedicareorwhentheMedicarebenefitisexhausted.
$3co-pay
*NotcoveredforMembersage21andolder: orthopedicshoesandsupportivedevicesforthefeetwhicharenotanintegralpartofa legbrace;hearingaidsandaccessones. / Prostheticdevices:0%coinsurance
Relatedmedicalsupplies:0%coinsurance / Prostheticdevices:
0%or200/ocoinsurance
Relatedmedicalsupplies:0%or200/ocoinsurance
Benefit / GeorgiaMedicaid
PrescriptionDrugBenefits / Fordual-eligiblemembers,MedicaidpaysforthisserviceifitisnotcoveredbyMedicare.
Cost-based:
$10.00orless-$0.50
$10.01-$25.00-$1.00
$25.01-$50.00-$2.00
$50.01ormore-$3.00
*Notcovered:certainoutpatientdrugspursuanttoSection1927(d)oftheSocial SecurityAct.Additionally,certainoverthecounter(OTC) drugsmustbeincluded,pursuanttotheGeorgia StatePoliciesandProceduresManual.
Benefit / Georgia Medicaid / EonDeluxe
PreventiveCare / Fordual-eligiblemembers,Medicaidpays forthisserviceifitisnotcoveredbyMedicareorwhentheMedicarebenefitisexhausted. / $0copay / $0copay
OutpatientRehabilitation Services / Fordual-eligiblemembers,Medicaidpays forthisserviceifitisnotcoveredbyMedicareorwhentheMedicarebenefitisexhausted.
$3pervisit
*NotcoveredforMembersage21andolder.AvailableunderEPSDTaspartofawrittenserviceplan. / Occupational therapyvisit:
$0copay / Occupationaltherapyvisit:
$0or $40copay
Physicaltherapyvisit:
$0copay / Physicaltherapyvisit:
$0or$40copay
Speechandlanguagetherapyvisit:$0copay / Speechandlanguagetherapyvisit:
$0or $40copay
CardiacandPulmonaryRehabilitationServices / Coveredifmedicallynecessaryfordual-eligiblemembers,Medicaidpays forthisserviceifitisnotcoveredbyMedicareorwhentheMedicarebenefitisexhausted. / Cardiac(heart)rehabservices(foramaximumof2one-hoursessionsper
dayforupto36sessionsupto36weeks):
0%Coinsurance / Cardiac(heart)rehab
services(foramaximumof2one-hoursessionsperdayforupto36sessionsupto36weeks):
00/oor20%Coinsurance
SkilledNursingFacility(SNF)
(InaMedicare-certifiedSkilledNursingFacility) / Fordual-eligiblemembers,MedicaidpaysforthisserviceifitisnotcoveredbyMedicareorwhentheMedicarebenefitisexhausted. / $0/DayforDays1-20
$0/DayforDays21-100 / $0/DayforDays1-20
$0or$150/Day forDays21-100
Benefit / GeorgiaMedicaid / EonDeluxe
Transportation(Routine) / ThefollowingTransportationServicesareabenefitofGeorgiaMedicaid:
Non-emergency transportation
-NETservicesaredefinedasmedicallynecessarytransportationforanymember(andescort,ifrequired,)whohasnoothermeansoftransportationavailabletoanyMedicaidreimbursableserviceforthe
purposeofreceivingtreatment,medicalevaluation,obtainingprescription drugsormedicalequipment.
Fordual-eligiblemembers,Medicaidpays forthisserviceifitisnotcoveredbyMedicareorwhentheMedicarebenefitisexhausted. / $0copay/12oneway / $0copay/12oneway
UrgentlyNeededServices(ThisisNOTemergencycare,andinmostcases,isoutoftheservicearea.) / Fordual-eligiblemembers,Medicaidpays forthisserviceifitisnotcoveredbyMedicareorwhentheMedicarebenefitisexhausted. / $0copay / $0or$45copay

BenefitGeorgiaMedicaidEonDeluxe

VisionServicesMedicallynecessarydiagnosticExamtodiagnoseandtreatExamtodiagnoseandtreatservicesmaybecovered. diseasesandconditionsof diseasesandconditionsofServicesmayonlybecovered theeye(includingyearly theeye(includingyearly

ifperformedformedicalglaucomascreening):glaucomascreening):reasonsandnotforrefractive $0co a $0or$25co a

purposesformemberstwenty-Routineeyeexam(forupRoutineeyeexam(forupto

one(21)yearsofageorolder.to1everyyear):$0copay1everyyear):$0copay

Cost-based:Contactlenses:(forupto1Contactlenses:(forupto1

$10.00orless-$0.50everyyear):$0copayeveryyear):$0copay

Eyeglasses(framesandEyeglasses(framesand

$10.01-$25.00-$1.00lenses):(forupto1everylenses):(forupto1every

$25.01-$50.00-$2.00year):$0copayyear):$0copay

EyeglassesorcontactEyeglassesorcontactlenses

$50.01 ormore-$3.00lensesaftercataractaftercataractsurgery:

s:$0a$0coa

*Notcoveredformembersage$100everyyearforcontact$100everyyearforcontact21andolder:routinerefractive lensesandeyeglasses lensesandeyeglassesservicesandopticaldevices. (framesandlenses) (framesandlenses)

Health/Wellness EducationFordual-eligiblemembers,FreehealthclubFreehealthclub

membership,membership,

•WrittenhealtheducationMedicaidpays forthisserviceSilverSneakers•andorSilverSneakers•andormaterials,including ifitisnotcoveredbyMedicare Free@HomePak(workout Free@HomePak(workoutnewsletters orwhentheMedicarebenefitis Kit)for thosewithlimited Kit)forthosewithlimited

•NutritionalTrainingexhausted.accesstoanetworkfitnessaccessto anetworkfitness

•AdditionalSmokingcentercenterCessation

•OtherWellnessBenefits

Benefit / SouthCarolina / EonDeluxe
Ambulance(medicallynecessaryambulanceservices / Copaymentmayapply / $0copay / $0or$300copay
DentalServices / $3.40copayment / Preventivedentalservices:
•Cleaning(forupto 1everysixmonths):$0copay
•Dentalx-ray(s)(forupto1everysixmonths):SOcopay
•Oralexam(forupto1everysixmonths):$0copay
1dentalbitewingx-raypersideeverysixmonths:$0copay
•1panoramicx-rayeveryfiveyears:$0copay / Preventivedentalservices:
•Cleaning(forupto1everysixmonths): $0copay
•Dentalx-ray(s)(forupto1everysixmonths):$0copay
•Oralexam(forupto1everysixmonths):$0copay 1dentalbitewingx-raypersideeverysixmonths:$0copay
•1panoramicx-ray everyfiveyears:$0copay
Benefit / SouthCarolina / EonDeluxe
Comprehensivedental
servicescoveragelimitis$500everyyear.$0 copay
•Coverageislimitedtofillings,simple
extractionsanddenturerepair.Additionaldentalservices,suchasrootcanals,crowns,surgicalextractions,denturerelinesandperiodontal(gum)treatments,arenotcovered.
•1partialor1completedentureperarcheveryfiveyears.$0copay / Comprehensive dental
services coveragelimitis$500everyyear.$0or$25copay
•Coverageislimitedto
fillings,simple
extractions anddenturerepair.Additionaldentalservices,suchasrootcanals,crowns,surgicalextractions,denturerelinesandperiodontal(gum)treatments,arenotcovered.
•1partialor1completedentureperarcheveryfiveyears.$0copay
DiagnosticTests,X-Rays,LabServices,andRadiologyServices / $3.40copayment / Diagnosticradiology services(suchasMR.Is,CTscans):0%coinsurance / Diagnosticradiologyservices(suchasMRis,CTscans):0%or200/ocoinsurance
Diagnostictestsandprocedures:
$0coa / Diagnostictestsandprocedures:
$0coa
Labservices:$0copay / Labservices: $0copay
Outpatientx-rays:
$0coa / Outpatientx-rays:
$0or$25copay
Therapeuticradiologyservices(suchasradiationtreatment
forcancer):
0%coinsurance / Therapeuticradiologyservices(suchasradiationtreatment
forcancer):
0%or200/ocoinsurance
DoctorVisits / $3.30copayment / Primarycarephysicianvisit:
$0copay / Primarycarephysicianvisit:
$0or$20copay
Specialistvisit:$0copay / Specialistvisit:$0or$45
Benefit / SouthCarolina / EonDeluxe
copay
EmergencyCare / $0copayment / $0copay / $0or$75copay
FootCare(podiatryservices) / $1.15copayment / Footexamsandtreatmentif
youhavediabetesrelatednervedamageand/ormeetcertainconditions:$0copayRoutinefootcare:$0copay / Footexamsandtreatmentifyouhavediabetesrelatednervedamageand/ormeetcertainconditions:
$0or$45copay
Routinefootcare:Notcovered
HearingServices / Copaymentmayapply / Examtodiagnoseandtreathearingandbalanceissues:
$0coa / Examtodiagnoseandtreat
hearingandbalanceissues:
$0or$25co a
Routinehearingexam(forupto1everyyear):
$0coa / Routinehearingexam(forup to1every year):
$0or$25co a
Hearingaidfitting/evaluation(forupto1every3years):
$0coa / Hearingaidfitting/evaluation(forupto1every3years):
$0copa
Ourplanpaysupto$750
everythreeyearsforhearingaids.Benefitamountappliestobothears combined. / Ourplanpaysupto$750everythreeyearsforhearingaids.Benefitamountappliestobothearscombined.
HomeHealthCare / $3.30copayment / $0copay / $0copay
Hospice / $0copayment / YoupaynothingforhospicecarefromaMedicare-certifiedhospice.Youmayhavetopaypartof thecostsfordrugsandrespitecare.Hospiceiscoveredoutsideofourplan.
Pleasecontactusformoredetails / YoupaynothingforhospicecarefromaMedicare-certifiedhospice. Youmayhavetopaypartofthecostsfordrugsandrespitecare.Hospiceiscoveredoutsideofourplan.
Pleasecontactusformoredetails
Benefit / SouthCarolina / EonDeluxe
InpatientHospitalCare
(IncludesSubstanceAbusean / $25copayment
d / $0/DayforDays1-6
$0/DayforDays7-90 / $0or$280/DayforDays1-6
$0/DayforDays7-90

RehabilitationServices)

MedicalEquipment/Supplies / $3.40copayment / 0%Coinsurance / 0%or200/oCoinsurance
Prostheticdevices: / Prostheticdevices:0%or20%
0%coinsurance
Relatedmedicalsupplies:0%coinsurance / coinsurance
Relatedmedicalsupplies:0%or200/ocoinsurance
OutpatientHospitalServices(non-emergency) / $3.40copayment / $0copay / $0or$245copay
OutpatientMentalHealthCare / Copaymentmayapply / Outpatientgrouptherapyvisit:
$0copay
Outpatientindividualtherapyvisit:$0co a / Outpatientgrouptherapyvisit:
$0or$40copay
Outpatientindividualtherapyvisit: $0or$40co a
OutpatientSubstanceAbuse / Copaymentmayapply / Outpatientgrouptherapyvisit:
$0copay / Outpatientgrouptherapyvisit:
$0or$45copay
Outpatientindividual therapyvisit:$0copay / Outpatientindividualtherapyvisit:$0 or$45 co a
OutpatientSurgery / $3.30copayment / Ambulatorysurgicalcenter:
$0copay / Ambulatorysurgicalcenter:
$0or$200copay
Benefit / SouthCarolina / EonDeluxe
PrescriptionDrugBenefits / $3.40copayment / InitialCoverageRetail / InitialCoverageRetail
Forgenericdrugs(includingbranddrugstreatedasgeneric),either:
$0copay/$1.20copay/$3.30copay / Forgenericdrugs(includingbranddrugstreatedasgeneric),either:
$0copay/$1.20copay/$3.30 copay
Forallotherdrugs,either:
$0copay/$3.70copay/$8.25copay / Forallotherdrugs,either:
$0copay/$3.70copay/$8.25copay
CoverageGap / CoverageGap
Forgenericdrugs(includingbranddrugstreatedasgeneric),either:
$0copay/$1.20copay/$3.30copay / Forgenericdrugs(includingbranddrugstreatedasgeneric),either:
$0copay/$1.20copay/$3.30 copay
Forallotherdrugs,either:
$0copay/$3.70copay/$8.25copay / Forallotherdrugs,either:
$0copay/$3.70copay/$8.25copay
CatastrophicCoverage / CatastrophicCoverage
Forgenericdrugs(includingbranddrugstreatedasgeneric),either:
$0copay / Forgenericdrugs(includingbranddrugstreatedasgeneric),either:
$0copay
Forallotherdrugs,either:
$0copay / Forallotherdrugs,either:
$0copay
Benefit / SouthCarolina / Eon Deluxe
PreventiveCare / Copaymentmayapply / $0copay / $0copay
Outpatient RehabilitationServices
(Occupational Therapy,PhysicalTherapy,SpeechandLanguageTherapy) / Copaymentmayapply / Occupationaltherapyvisit:
$0copay / Occupationaltherapyvisit:
$0or$40copay
Physicaltherapyvisit:
$0copay / Physicaltherapyvisit:
$0or$40copay
Speechandlanguagetherapyvisit:
$0copay / Speechandlanguagetherapyvisit:
$0or$40copay
CardiacandPulmonaryRehabilitationServices / Copaymentmayapply / Cardiac(heart)rehabservices(foramaximumof2one-hoursessionsperdayforupto36sessionsforaperiodofupto36weeks:0%Coinsurance / Cardiac(heart)rehabservices(foramaximumof2one-hoursessionsperdayforupto36sessionsforaperiodofupto
36weeks:00/oor20%Coinsurance
SkilledNursingFacility
(SNF) / Copaymentmayapply / $0/DayforDays1-20
$0/DayforDays21-100 / $0/Day forDays1-20
$0or$150/DayforDays21-100
Transportation / Copaymentmayapply / $0copay/12oneway / $0copay/12oneway
VisionServices / $3.30copayment / Examtodiagnoseandtreat diseasesandconditionsoftheeye(includingyearlyglaucomascreening):
$0coa / Examtodiagnoseandtreatdiseasesand conditionsoftheeye(includingyearlyglaucomascreening):
$0or$25coa
Routineeyeexam(forupto 1every year):$0copay / Routineeyeexam(forupto1everyyear):$0copay
Benefit / SouthCarolina / EonDeluxe
Contactlenses:(forupto1everyyear):$0copayEyeglasses(framesandlenses):(forupto1everyyear):$0copay
Eyeglassesorcontactlensesaftercataractsurgery:$0
coa / Contactlenses:(forupto1everyyear):$0copayEyeglasses(framesandlenses):(forupto1everyyear):$0copay
Eyeglassesorcontactlensesaftercataractsurgery:$0
ca
$100everyyearforcontactlensesandeyeglasses(framesandlenses. / $100everyyearforcontactlensesandeyeglasses(framesandlenses.

Thisinformationisnotacompletedescriptionofbenefits.Contacttheplanformoreinformation.Limitations,copaymentsandrestrictionsmayapply.Benefits,premiumsand/orcopayments/coinsurance maychangeonJanuary1ofeachyear.YoumustcontinuetopayyourMedicarePartBpremium-TheStatepaysthePartBpremiumforfulldualmembers.

Premium,co-pays,co-insurance,anddeductiblesmayvarybasedonthelevelofExtraHelpyoureceive.Pleasecontacttheplanforfurtherdetails.

CurrentMembers 1-888-906-3889

TTY:711

ProspectiveMembers 1-844-895-8643

TTY:711

HoursofOperation:

FromOctober15-February14:Sevendaysaweek,8:00am-8:00pmFebruary15-October14:MondaythroughFriday,8:00am-8:00pm(YoumayleaveavoicemailSaturday,SundayandHolidays)