2020 imperial health plan of california (hmo)...2020/05/18 · imperial health plan of california...

IR_180 H5496 Pre-Enrollment Kit TOC 2020_C ENG

2020 Imperial Health Plan of California (HMO) (HMO SNP) Pre-Enrollment Kit Table of Contents

INTRODUCTION LETTER AND CONTACT PHONE NUMBERS ................................................

BENEFIT HIGHLIGHTS ......................................................................................................................

SUMMARY OF BENEFITS (005, 007 AND 009) ...........................................................................

HOW TO ENROLL AND WHAT HAPPENS NEXT...........................................................................

SCOPE OF APPOINTMENT ................................................................................................................

PRE-ENROLLMENT CHECKLIST.......................................................................................................

ENROLLMENT ELIGIBILITY ATTESTATION..................................................................................

ENROLLMENT APPLICATION.........................................................................................................

DRUG MAIL ORDER FORM ..............................................................................................................

OVER THE COUNTER ORDER FORM .............................................................................................

CSNP ASSESSMENT..............................................................................................................................

WITNESS TRANSLATOR FORM.........................................................................................................

DENTAL BENEFIT DIRECTORY......................................................................................................

IR_180 H5496 Pre-Enrollment Kit TOC 2020_C ENG

2020 Imperial Health Plan of California (HMO)(HMO SNP) Pre-Enrollment Kit Table of Contents

INTRODUCTION LETTER AND CONTACT PHONE NUMBERS ................................................

BENEFIT HIGHLIGHTS ......................................................................................................................

SUMMARY OF BENEFITS (005, 007 AND 009) ...........................................................................

HOW TO ENROLL AND WHAT HAPPENS NEXT...........................................................................

SCOPE OF APPOINTMENT ................................................................................................................

PRE-ENROLLMENT CHECKLIST.......................................................................................................

ENROLLMENT ELIGIBILITY ATTESTATION..................................................................................

ENROLLMENT APPLICATION.........................................................................................................

DRUG MAIL ORDER FORM ..............................................................................................................

OVER THE COUNTER ORDER FORM .............................................................................................

CSNP ASSESSMENT..............................................................................................................................

WITNESS TRANSLATOR FORM.........................................................................................................

DENTAL BENEFIT DIRECTORY......................................................................................................

LOW INCOME SUBSIDY PREMIUM ................................................................................................

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87LOW INCOME SUBSIDY PREMIUM ..........................................................................................97

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IR_182 H5496 Intro Ltr_C ENG 09/06/19

Dear Imperial Health Plan of California (HMO) (HMO SNP) Prospective Member,

Thank you for reviewing Imperial as your Medicare Health Plan. Imperial Health Plan is a Medicare Advantage Plan ready to provide you with detailed professional medical services. For 2020, we are pleased to introduce Imperial Health Plan in the following 12 California Counties:

Sacramento Fresno

Los Angeles Alameda

Kern Orange

San Francisco San Bernardino

San Mateo Riverside

Santa Clara San Diego

Imperial Health Plan provides personalized, comprehensive health care focusing on wellness and prevention. As your Medicare Health Plan of choice, we work collaboratively with our contracted medical groups, hospitals and physicians (primary and specialists) to coordinate all aspects of your patient care including inpatient hospitalization and specialty consultation care, as needed. We have a vast number of providers and our extensive specialty roster ensures you see a provider timely and within your community.

For 2020, you will have access to many supplemental benefits such as; comprehensive dental care, vision, hearing, transportation, health club membership, routine foot care and more. We are certain once you compare your benefits, you will make Imperial Health Plan your Medicare Advantage plan.

If you should have any questions during the next few days regarding your enrollment please contact our Member Services Department at 1-800-838-8271, TTY/TDD: 711, Monday through Sunday, 8:00 am to 8:00 pm except holidays during October 1 through March 31 and Monday through Friday 8:00 am to 8:00 pm April 1 through September 30 except holidays. We look forward to working with you.

Important Contact #s: Imperial Health Plan of California 800-708-8273 Potential members call: 800-838-5914 or [email protected] Member Services: 800-838-8271 or [email protected] Imperial web site: www.Imperialhealthplan.com Medicare 800-633-4227 Medicare web page www.medicare.gov CMS web Page www.cms.gov Pavelijit S. Bindra, M.D. CEO

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2020 Benefit Highlights Chart

2020 Benefit Imperial Traditional

(HMO) 007 Imperial Traditional Plus

(HMO) 009 Imperial Senior Value (HMO C-SNP) 005

Premium $0 $0 $0

Physician Services Doctor: $0 Specialist1,2: $0

Doctor: 20% co-insurance Specialist1,2: 20% coinsurance

Doctor: $0 Specialist1,2: $0

Inpatient Hospital Care1,2

$100 per day for days 1 through 5 and $0 for days 6 through 90

$0 $100 per day for days 1 through 5 and $0 for days 6 through 90

Emergency Care $90 (waived if admitted within 48 hours)

20% co-insurance (waived if admitted within 48 hours)

$90 (waived if admitted within 48 hours)

Urgent Care $0 20% co-insurance $0

Worldwide Emergency Care

$90 co-payment Maximum of $50,000 for qualifying expenses

20% co-insurance Maximum of $50,000 for qualifying expenses

$90 co-payment Maximum of $50,000 for qualifying expenses

Ambulance Services1 $100 20% co-insurance $100

Transportation1,2 $0 co-payment

Round trip to plan approved health-related location

Durable Medical Equipment1,2 20% co-insurance

Services with a ¹ may require prior authorization. Services with a 2 may require a referral from your doctor. Allowance will vary based on plan. Co-insurance and co-payments vary by plan. H5496_171 CA Benefit Highlights 2020_M ENG Accepted 08/24/19

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2020 Benefit Imperial Traditional

(HMO) 007 Imperial Traditional Plus

(HMO) 009 Imperial Senior Value (HMO C-SNP) 005

Health and Wellness $0 for fitness center membership or up to two home fitness kits per calendar year

Vision Care

$15 for annual routine eye exam, $255 maximum for contacts, lenses and frames (every two years)

20% co-insurance for annual routine eye exam, $500 maximum for contacts, lenses and frames (every two years)

$15 for annual routine eye exam, $250 maximum for contacts, lenses and frames (every two years)

Dental Services $0 Preventive Care Services, $0 comprehensive dental services.

0% for Preventive Care Services,

$0 for comprehensive dental services

Hearing Services 20% co-insurance for routine hearing exams fitting/evaluation $250 maximum. 20% co-insurance for Hearing Aid $1,250 maximum for both ears per year.

Over-the-Counter (OTC) $0 You have a $35 maximum every month

Podiatry Services1,2

$0 for 6 routine foot care visits per calendar year

20% co-insurance for 6 routine foot care visits per calendar year

$0 for 6 routine foot care visits per calendar year

Part D Drugs Covered. Refer to your Evidence of Coverage for detailed information.

Acupuncture1,2

$15 per treatment. You are allowed 12 treatments per calendar year.

$0 per treatment. You are allowed 12 treatments per calendar year

$15 per treatment. You are allowed 12 treatments per calendar year

Services with a ¹ may require prior authorization. Services with a 2 may require a referral from your doctor. Allowance will vary based on plan. Co-insurance and co-payments vary by plan. Imperial Health Plan is an (HMO) (HMO SNP) with a Medicare Contract. Enrollment in Imperial Health Plan depends on contract renewal. This information is not a complete description of benefits. Contact 1-800-838-8271 (TTY: 711) for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/ or copayments/co-insurance may change on January 1 of each year. Imperial Health Plan of California (HMO) (HMO SNP) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-800-838-8271 (TTY: 711). ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-838-8271 (TTY: 711). 注意：如果您使

用繁體中文，您可以免費獲得語言援助服務。請致電 1-800-708-5976 (TTY: 711). 5

2020 Summary of BenefitsAlameda, Fresno, Kern, Los Angeles, Orange, Riverside, Sacramento, San Bernardino, San Diego, San Francisco, San Mateo, Santa Clara

2020 Summary of BenefitsAlameda, Fresno, Kern, Los Angeles, Orange, Riverside, Sacramento, San Bernardino, San Diego, San Francisco, San Mateo, Santa Clara

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Imperial Health Plan of California (HMO) (HMO SNP)

Who can join?

To join any of our Plan Benefit Packages (PBP’s), you must meet all of the following requirements:

• You live in our service area• You have both Medicare Part A and Medicare

Part B• You are a United States Citizen• You do not have End-Stage Renal Disease

(ESRD), with limited exceptions

network, the plan may not pay for these services, except in emergency situations. You can view our directories on our website:www.Imperialhealthplan.com.

This document is available for free in Spanish. This document is available in other formats such as Braille, large print or audio.

For more information, please call us at 1-800-838- 8271 (TTY 711) October 1 – March 31: Monday – Sunday, from 8:00 a.m. – 8:00 p.m. April 1 – September 30: Monday – Friday, from 8:00 a.m. – 8:00 p.m., or visit us at www.imperialhealthplan.com.

How do I determine my Part D prescription drug costs?

The Part D drugs we cover are grouped into five and six different tiers, depending on the plan benefit package you enroll with. You will need a copy of our drug list or “formulary” to find out which tier your drug is on. The amount you pay depends on the drug’s tier, the number of day supplies, the benefit stage you have reached, whether you are using a network pharmacy, and the type of pharmacy you use (e.g., retail, mail order, long term care, home infusion, etc.

To join Imperial Senior Value (HMO C-SNP) you must also have been diagnosed with Diabetes, Chronic Heart Failure (CHF), and/or Cardiovascular Disorder(s).

Which doctors, hospitals, and pharmacies can I use?

Imperial Health Plan of California (HMO) (HMO SNP) has a network of doctors, hospitals, pharmacies, and other providers who are available to provide you with medical and supplemental benefit care. When you join our health plan, you must select a primary care physician (PCP). Your PCP will work with us to coordinate your medical and specialty care when you need to see other providers. If you use any provider that is not in our

H5496_178 SB 2020_M ENG �� 09�07�19 7

Where can I find more information? Our Member Services staff is available to answer your questions in regards to eligibility and benefits. Please call 1-800-838-8271, (TTY: 711), Monday through Sunday, 8:00 am to 8:00 pm except holidays during October 1 through March 31 and Monday through Friday 8:00 am to 8:00 pm April 1 through September 30 except holidays.

This Summary of Benefits is a summary of what we cover and what you pay. It does not list every service

that we cover or list every limitation or exclusion. To get a complete list of services we cover, please refer to the "Evidence of coverage". You can find this book on our website at www.Imperialhealthplan.com listed under member benefits.

If you want to know more about the coverage and costs of Original Medicare, please refer to the “Medicare & You” handbook. You can find this handbook at www.Medicare.gov or call 1-800-Medicare (1-800-633-4227). TTY usersshould call 1-877-486-2048.

Service Area

Alameda: 94501, 94502, 94536, 94537, 94538, 94539, 94540, 94541, 94542, 94543, 94544, 94545, 94546, 94550, 94551, 94552, 94555, 94557, 94560, 94566, 94568, 94577, 94578, 94579, 94580, 94586, 94587, 94588, 94601, 94602, 94603, 94604, 94605, 94606, 94607, 94608, 94609, 94610, 94611, 94612, 94613, 94614, 94615, 94617, 94618, 94619, 94620, 94621, 94622, 94623, 94624, 94625, 94626, 94627, 94643, 94649, 94659, 94660, 94661, 94662, 94666, 94701, 94702, 94703, 94704, 94705, 94706, 94707, 94708, 94709, 94710, 94712, 94720, 94505, 94514, 95377, 95391 Fresno: 93210, 93234, 93242, 93602, 93605, 93606, 93607, 93608, 93609, 93611, 93612, 93613, 93616, 93619, 93621, 93622, 93624, 93625, 93626, 93627, 93628, 93629, 93630, 93631, 93634, 93640, 93641,

93642, 93646, 93648, 93649, 93650, 93651, 93652, 93654, 93656, 93657, 93660, 93662, 93664, 93667, 93668, 93675, 93701, 93702, 93703, 93704, 93705, 93706, 93707, 93708, 93709, 93710, 93711, 93712, 93714, 93715, 93716, 93717, 93718, 93720, 93721, 93722, 93723, 93724, 93725, 93726, 93727, 93728, 93729, 93730, 93737, 93740, 93741, 93744, 93745, 93747, 93750, 93755, 93759, 93760, 93761, 93762, 93764, 93765, 93771, 93772, 93773, 93774, 93775, 93776, 93777, 93778, 93779, 93780, 93782, 93784, 93786, 93790, 93791, 93792, 93793, 93794, 93844, 93888, 93245, 93618, 93620 Kern: 93203, 93205, 93206, 93215, 93216, 93220, 93222, 93224, 93225, 93226, 93238, 93240, 93241, 93243, 93249, 93250, 93251, 93252, 93255, 93263, 93268, 93276, 93280, 93283, 93285, 93287, 93301,

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93302, 93303, 93304, 93305, 93306, 93307, 93308, 93309, 93311, 93312, 93313, 93314, 93380, 93381, 93382, 93383, 93384, 93385, 93386, 93387, 93388, 93389, 93390, 93501, 93502, 93504, 93505, 93516, 93518, 93519, 93523, 93524, 93527, 93528, 93531, 93554, 93555, 93556, 93558, 93560, 93561, 93581, 93596, 93536 Los Angeles: 90001, 90002, 90003, 90004, 90005, 90006, 90007, 90008, 90009, 90010, 90011, 90012, 90013, 90014, 90015, 90016, 90017, 90018, 90019, 90020, 90021, 90022, 90023, 90024, 90025, 90026, 90027, 90028, 90029, 90030, 90031, 90032, 90033, 90034, 90035, 90036, 90037, 90038, 90039, 90040, 90041, 90042, 90043, 90045, 90046, 90047, 90048, 90049, 90050, 90052, 90053, 90054, 90055, 90056, 90057, 90058, 90060, 90062, 90063, 90064, 90065, 90066, 90067, 90068, 90069, 90070, 90071, 90072, 90073, 90074, 90075, 90076, 90077, 90078, 90079, 90080, 90081, 90082, 90083, 90084, 90086, 90087, 90088, 90089, 90090, 90091, 90093, 90094, 90095, 90096, 90097, 90099, 90101, 90102, 90103, 90134, 90174, 90185, 90189, 90198, 90201, 90202, 90209, 90210, 90211, 90212, 90213, 90220, 90221, 90222, 90223, 90224, 90230, 90231, 90232, 90233, 90234, 90239, 90240, 90241, 90242, 90245, 90247, 90248, 90249, 90250, 90251, 90254, 90255, 90260, 90261, 90262, 90263, 90264, 90265, 90266, 90267, 90270, 90272, 90274, 90275, 90277, 90278, 90280, 90290, 90291, 90292, 90293, 90294, 90295, 90296, 90301, 90302, 90303, 90304, 90305, 90306, 90307, 90308, 90309, 90310, 90311, 90312, 90313, 90397, 90398, 90401, 90402, 90403, 90404, 90405, 90406, 90407, 90408, 90409, 90410, 90411, 90501, 90502, 90503, 90504, 90505, 90506, 90507, 90508, 90509, 90510, 90601, 90602, 90603, 90604, 90605, 90606, 90607, 90608, 90609, 90610, 90612, 90637, 90638, 90639, 90640, 90650, 90651, 90652, 90659, 90660, 90661, 90662, 90665, 90670, 90671, 90701, 90702, 90703, 90704, 90706, 90707, 90710, 90711, 90712, 90713, 90714, 90715, 90716, 90717, 90723, 90731, 90732, 90733, 90734, 90744, 90745, 90746, 90747, 90748, 90749, 90755, 90801, 90802, 90803, 90804, 90805, 90806, 90807, 90808, 90809, 90810, 90813, 90814, 90815, 90822, 90831, 90832, 90833, 90834, 90835, 90840, 90842, 90844, 90845, 90846, 90847, 90848, 90853, 90888, 90895, 90899, 91001, 91003, 91006, 91007, 91008, 91009, 91010, 91011, 91012, 91016, 91017, 91020, 91021, 91023, 91024, 91025, 91030, 91031, 91040, 91041, 91042, 91043, 91046, 91050, 91051, 91066, 91077, 91101, 91102, 91103, 91104, 91105, 91106, 91107, 91108, 91109, 91110, 91114,

91115, 91116, 91117, 91118, 91121, 91123, 91124, 91125, 91126, 91129, 91131, 91175, 91182, 91184, 91185, 91186, 91187, 91188, 91189, 91191, 91199, 91201, 91202, 91203, 91204, 91205, 91206, 91207, 91208, 91209, 91210, 91214, 91221, 91222, 91224, 91225, 91226, 91301, 91302, 91303, 91304, 91305, 91306, 91307, 91308, 91309, 91310, 91311, 91312, 91313, 91316, 91321, 91322, 91324, 91325, 91326, 91327, 91328, 91329, 91330, 91331, 91333, 91334, 91335, 91337, 91340, 91341, 91342, 91343, 91344, 91345, 91346, 91350, 91351, 91352, 91353, 91354, 91355, 91356, 91357, 91363, 91364, 91365, 91367, 91371, 91372, 91376, 91380, 91381, 91382, 91383, 91384, 91385, 91386, 91387, 91388, 91390, 91392, 91393, 91394, 91395, 91396, 91399, 91401, 91402, 91403, 91404, 91405, 91406, 91407, 91408, 91409, 91410, 91411, 91412, 91413, 91416, 91423, 91426, 91436, 91470, 91482, 91495, 91496, 91497, 91499, 91501, 91502, 91503, 91504, 91505, 91506, 91507, 91508, 91510, 91521, 91522, 91523, 91526, 91601, 91602, 91603, 91604, 91605, 91606, 91607, 91608, 91609, 91610, 91611, 91612, 91614, 91615, 91616, 91617, 91618, 91702, 91706, 91711, 91714, 91715, 91716, 91722, 91723, 91724, 91731, 91732, 91733, 91734, 91735, 91740, 91741, 91744, 91745, 91746, 91747, 91748, 91749, 91750, 91754, 91755, 91756, 91765, 91766, 91767, 91768, 91769, 91770, 91771, 91772, 91773, 91775, 91776, 91778, 91780, 91788, 91789, 91790, 91791, 91792, 91793, 91795, 91797, 91799, 91801, 91802, 91803, 91804, 91841, 91896, 91899, 93510, 93532, 93534, 93535, 93536, 93539, 93543, 93544, 93550, 93551, 93552, 93553, 93563, 93584, 93586, 93590, 93591, 93599, 90623, 90630, 90631, 91361, 91362, 91759, 93243, 93560, 90044, 90051, 90059, 90061 Orange: 90620, 90621, 90622, 90623, 90624, 90630, 90631, 90632, 90633, 90680, 90720, 90721, 90740, 90742, 90743, 92602, 92603, 92604, 92605, 92606, 92607, 92609, 92610, 92612, 92614, 92615, 92616, 92617, 92618, 92619, 92620, 92623, 92624, 92625, 92626, 92627, 92628, 92629, 92630, 92637, 92646, 92647, 92648, 92649, 92650, 92651, 92652, 92653, 92654, 92655, 92656, 92657, 92658, 92659, 92660, 92661, 92662, 92663, 92672, 92673, 92674, 92675, 92676, 92677, 92678, 92679, 92683, 92684, 92685, 92688, 92690, 92691, 92692, 92693, 92694, 92697, 92698, 92701, 92702, 92703, 92704, 92705, 92706, 92707, 92708, 92709, 92710, 92711, 92712, 92725, 92728, 92735, 92780, 92781, 92782, 92799, 92801, 92802, 92803, 92804, 92805, 92806, 92807, 92808, 92809, 92811, 92812, 92814, 92815, 92816,

9

92817, 92821, 92822, 92823, 92825, 92831, 92832, 92833, 92834, 92835, 92836, 92837, 92838, 92840, 92841, 92842, 92843, 92844, 92845, 92846, 92850, 92856, 92857, 92859, 92861, 92862, 92863, 92864, 92865, 92866, 92867, 92868, 92869, 92870, 92871, 92885, 92886, 92887, 92899, 90638 Riverside: 91718, 91719, 91720, 91752, 91760, 92201, 92202, 92203, 92210, 92211, 92220, 92223, 92225, 92226, 92230, 92234, 92235, 92236, 92239, 92240, 92241, 92247, 92248, 92253, 92254, 92255, 92258, 92260, 92261, 92262, 92263, 92264, 92270, 92274, 92276, 92282, 92292, 92320, 92501, 92502, 92503, 92504, 92505, 92506, 92507, 92508, 92509, 92513, 92514, 92515, 92516, 92517, 92518, 92519, 92521, 92522, 92530, 92531, 92532, 92536, 92539, 92543, 92544, 92545, 92546, 92548, 92549, 92551, 92552, 92553, 92554, 92555, 92556, 92557, 92561, 92562, 92563, 92564, 92567, 92570, 92571, 92572, 92581, 92582, 92583, 92584, 92585, 92586, 92587, 92589, 92590, 92591, 92592, 92593, 92595, 92596, 92599, 92860, 92877, 92878, 92879, 92880, 92881, 92882, 92883, 92028, 92324, 92373, 92399 Sacramento: 94203, 94204, 94205, 94206, 94207, 94208, 94209, 94211, 94229, 94230, 94232, 94234, 94235, 94236, 94237, 94239, 94240, 94243, 94244, 94245, 94246, 94247, 94248, 94249, 94250, 94252, 94253, 94254, 94256, 94257, 94258, 94259, 94261, 94262, 94263, 94267, 94268, 94269, 94271, 94273, 94274, 94277, 94278, 94279, 94280, 94282, 94283, 94284, 94285, 94286, 94287, 94288, 94289, 94290, 94291, 94293, 94294, 94295, 94296, 94297, 94298, 94299, 95608, 95609, 95610, 95611, 95615, 95621, 95624, 95626, 95628, 95630, 95632, 95638, 95639, 95641, 95652, 95655, 95660, 95662, 95670, 95671, 95673, 95680, 95683, 95690, 95693, 95741, 95743, 95757, 95758, 95759, 95763, 95811, 95812, 95813, 95814, 95815, 95816, 95817, 95818, 95819, 95820, 95821, 95822, 95823, 95824, 95825, 95826, 95827, 95828, 95829, 95830, 95831, 95832, 95833, 95834, 95835, 95836, 95837, 95838, 95840, 95841, 95842, 95843, 95851, 95852, 95853, 95857, 95860, 95864, 95865, 95866, 95867, 95873, 95887, 95894, 95899, 94571, 95678 San Bernardino: 91701, 91708, 91709, 91710, 91729, 91730, 91737, 91739, 91743, 91758, 91759, 91761, 91762, 91763, 91764, 91784, 91785, 91786, 91798, 92242, 92252, 92256, 92267, 92268, 92277, 92278, 92280, 92284, 92285, 92286, 92301, 92304, 92305, 92307, 92308, 92309, 92310, 92311, 92312, 92313, 92314, 92315, 92316, 92317, 92318, 92321, 92322, 92323, 92324, 92325, 92326, 92327, 92329,

92331, 92332, 92333, 92334, 92335, 92336, 92337, 92338, 92339, 92340, 92341, 92342, 92344, 92345, 92346, 92347, 92350, 92352, 92354, 92356, 92357, 92358, 92359, 92363, 92364, 92365, 92366, 92368, 92369, 92371, 92372, 92373, 92374, 92375, 92376, 92377, 92378, 92382, 92385, 92386, 92391, 92392, 92393, 92394, 92395, 92397, 92398, 92399, 92401, 92402, 92403, 92404, 92405, 92406, 92407, 92408, 92410, 92411, 92412, 92413, 92414, 92415, 92416, 92418, 92420, 92423, 92424, 92427, 93562, 93592, 91766, 92880, 93516, 93555 San Diego: 91901, 91902, 91903, 91905, 91906, 91908, 91909, 91910, 91911, 91912, 91913, 91914, 91915, 91916, 91917, 91921, 91931, 91932, 91933, 91934, 91935, 91941, 91942, 91943, 91944, 91945, 91946, 91947, 91948, 91950, 91951, 91962, 91963, 91976, 91977, 91978, 91979, 91980, 91987, 91990, 92003, 92004, 92007, 92008, 92009, 92010, 92011, 92013, 92014, 92018, 92019, 92020, 92021, 92022, 92023, 92024, 92025, 92026, 92027, 92028, 92029, 92030, 92033, 92036, 92037, 92038, 92039, 92040, 92046, 92049, 92051, 92052, 92054, 92055, 92056, 92057, 92058, 92059, 92060, 92061, 92064, 92065, 92066, 92067, 92068, 92069, 92070, 92071, 92072, 92074, 92075, 92078, 92079, 92081, 92082, 92083, 92084, 92085, 92086, 92088, 92090, 92091, 92092, 92093, 92096, 92101, 92102, 92103, 92104, 92105, 92106, 92107, 92108, 92109, 92110, 92111, 92112, 92113, 92114, 92115, 92116, 92117, 92118, 92119, 92120, 92121, 92122, 92123, 92124, 92126, 92127, 92128, 92129, 92130, 92131, 92132, 92133, 92134, 92135, 92136, 92137, 92138, 92139, 92140, 92142, 92143, 92145, 92147, 92149, 92150, 92152, 92153, 92154, 92155, 92158, 92159, 92160, 92161, 92162, 92163, 92164, 92165, 92166, 92167, 92168, 92169, 92170, 92171, 92172, 92173, 92174, 92175, 92176, 92177, 92178, 92179, 92182, 92184, 92186, 92187, 92190, 92191, 92192, 92193, 92194, 92195, 92196, 92197, 92198, 92199 San Francisco: 94101, 94102, 94103, 94104, 94105, 94106, 94107, 94108, 94109, 94110, 94111, 94112, 94114, 94115, 94116, 94117, 94118, 94119, 94120, 94121, 94122, 94123, 94124, 94125, 94126, 94127, 94129, 94130, 94131, 94132, 94133, 94134, 94135, 94136, 94137, 94138, 94139, 94140, 94141, 94142, 94143, 94144, 94145, 94146, 94147, 94150, 94151, 94152, 94153, 94154, 94155, 94156, 94157, 94158, 94159, 94160, 94161, 94162, 94163, 94164, 94165, 94166, 94167, 94168, 94169, 94170, 94171, 94172, 94175, 94177, 94188, 94199, 94128 San Mateo: 94002, 94003, 94005, 94010, 94011,

10

94012, 94013, 94014, 94015, 94016, 94017, 94018, 94019, 94020, 94021, 94025, 94026, 94027, 94028, 94029, 94030, 94031, 94037, 94038, 94044, 94045, 94059, 94060, 94061, 94062, 94063, 94064, 94065, 94066, 94067, 94070, 94071, 94074, 94080, 94083, 94096, 94098, 94099, 94128, 94307, 94308, 94401, 94402, 94403, 94404, 94405, 94406, 94407, 94408, 94409, 94497, 94303 Santa Clara Counties: 94022, 94023, 94024, 94035, 94030¸ 94040, 94041, 94042, 94043, 94085, 94086, 94087, 94088, 94089, 94090, 94301, 94302, 94303, 94304, 94305, 94306, 94309, 94310, 95002, 95008,

95009, 95011, 95013, 95014, 95015, 95020, 95021, 95026, 95030, 95031, 95032, 95035, 95036, 95037, 95038, 95042, 95044, 95046, 95050, 95051, 95052, 95053, 95054, 95055, 95056, 95070, 95071, 95101, 95102, 95103, 95106, 95108, 95109, 95110, 95111, 95112, 95113, 95114, 95115, 95116, 95117, 95118, 95119, 95120, 95121, 95122, 95123, 95124, 95125, 95126, 95127, 95128, 95129, 95130, 95131, 95132, 95133, 95134, 95135, 95136, 95137, 95138, 95139, 95140, 95141, 95142, 95148, 95150, 95151, 95152, 95153, 95154, 95155, 95156, 95157, 95158, 95159, 95160, 95161, 95164, 95170, 95171, 95172, 95173, 95190, 95191, 95192, 95193, 95194, 95196, 94550, 95023, 95033, 95076

11

Premiums and Benefits Imperial Traditional (HMO) 007

Premium How much do I need to pay monthly?

• You pay $0 per month • You must continue to pay your Medicare Part B

premium

Deductible How much do I need to pay before the plan pays?

• This plan does not have a deductible

Maximum Out-of-Pocket costs What’s the limit on how much I will pay?

• Your yearly limit(s) in this plan is $4000

Inpatient Hospital Coverage1,2

How long will my plan cover? How much do I pay?

• You pay $100 for days 1 through 5 • You pay $0 for days 6 through 90 • Our plan provides a maximum of 60 Lifetime

Reserve days. You pay $670 copayment per day, Days 1 – 60.

Outpatient Hospital Coverage1,2 • You pay $0

Doctor visits How much do I pay to visit primary care physician or specialist?

• Primary care physician visit: You pay $0 • Specialist visit1,2:

You pay $0

Preventive Care How much do I pay for Preventive Care?

• You pay $0 for covered services

Ambulatory Surgery Center1,2 How much do I pay for ambulatory surgery center visits?

• You pay $0 copayment for each Medicare-covered ambulatory surgical center visit.

Imperial Traditional (HMO) 007

Services with a ¹ may require prior authorization. Services with a 2 may require a referral from your doctor.

12


Emergency Care How much do I pay for Emergency Care?

• You pay $90 copayment • If you are admitted to the hospital within 48

hours, you don’t have to pay your share of the cost for emergency care

Urgently Needed Services How much do I pay for Urgently Needed Services?

• You pay $0

Diagnostic Services / Labs / Imaging1,2

How much do I pay for Diagnostic Services?

• Diagnostic radiology services (e.g., MRI): You pay $0

• Lab services: You pay $0 • Diagnostic tests (such as MRI): You pay $0 • Therapeutic radiology services: You pay $0

• Outpatient x-rays: You pay $0

Hearing Services1,2

How much do I pay for Hearing Services or Hearing Aids?

• Medicare-covered Diagnostic exams: You pay 20% coinsurance

• Routine hearing exam: You pay 20% coinsurance. The plan covers up to $250 per calendar year

• Hearing aid allowance: You pay 20% coinsurance. The plan covers up to $1,250 per calendar year

Dental Services

How much do I pay for dental services?

• Medicare-covered Dental services: You pay $0 • Preventive dental services: You pay $0 for

routine office visits. Office visits includes exam, cleaning, fluoride treatment and dental X-ray. Your plan covers up to $500 in routine dental services per year

• You pay $0 for restorative services; prosthodontics, other oral/ maxillofacial surgery, other services. Your plan covers up to $1000 per year.

Dental care brought to you by Liberty Dental Plan


13

Vision Services

How much do I pay for Vision Services? What’s my Eyewear Allowance per year?

• Medicare-covered Vision services: You pay $0 • You pay $15 for routine eye exams • You pay $15 for contact lenses or eyeglasses

(frames and lenses). The plan covers up to $255.00 every two years

Vision care brought to you by March Vision


14


Mental Health Services1,2

How much do I pay for inpatient or outpatient services?

• Inpatient Visit: You pay $200 for days 1-7 • You pay $0 for days 8 through 90 • Our plan provides a maximum of 60 Lifetime

Reserve days. You pay $670 copayment per day, Days 1 – 60.

• Outpatient services: You pay 20% coinsurance for each Medicare-covered individual or group therapy outpatient mental health visit (non-physician).

• You pay $0 copay for each Medicare-covered psychiatric individual or group therapy session.

Skilled Nursing Facility1,2

How much do I pay for Skilled Nursing Facility stay?

We cover up to 100 days in a SNF per benefit period: • You pay $0 for days 1 – 20 • You pay $164.50 copayment per day for days 21

– 100

Physical Therapy1,2

How much do I pay for Outpatient Rehab?

• Cardiac (heart) rehab services: You pay 20% coinsurance

• Occupational therapy visit: You pay $10 copayment

• Physical therapy and speech and language therapy visit: You pay 20% coinsurance

Ambulance1

How much do I pay for Ambulance?

• You pay $100 copayment per one-way trip

Transportation1,2

How much do I pay for Transportation services?

• You pay $0 for unlimited round-trip transportation to plan approved locations

Medicare Part B Drugs1

How much do I pay for Part B Drugs?

• You pay $0 for Part B drugs such as chemotherapy drugs

• You pay $0 for all other Part B drugs


15

Part D Prescription Drugs Imperial Traditional (HMO) 007

Deductible Stage No deductible (Your coverage begins on the effective date of your enrollment)

Initial Coverage Stage

You pay the following costs until your total yearly drug costs reach $4,020

Retail 30 Day Supply Mail Order 90 Day Supply

Tier 1 - Preferred Generic Drugs $0.00 $0.00

Tier 2 - Generic Drugs $5.00 $10.00

Tier 3 - Preferred Brand Drugs $45.00 $90.00

Tier 4 – Non-Preferred Drugs $90.00 $180.00

Tier 5 – Specialty Tier Drugs 33% Long term supply not available for Tier 5

Coverage Gap Stage

You pay the following costs until your yearly out-of- pocket drug costs reach $6,350




Tier 3 - Preferred Brand Drugs Generic: You pay 25% of the cost Brand: You pay 25% of the cost

and a portion of the dispensing fee Tier 4 – Non-Preferred Drugs

Tier 5 – Specialty Tier Drugs Long term supply not available for Tier 5

Catastrophic Coverage Stage

Once your yearly out-of-pocket drug costs reach $6,350, you pay

The greater of: 5% of the cost or 3.60 for generic (including brand drugs treated as generic) and $8.95 for all other drugs


16


Medical Equipment / Supplies1,2

How much do I pay for Medical Equipment/Supplies?

• You pay 20% coinsurance per item for Durable Medical Equipment (DME), such as oxygen or a wheelchair. You pay 20% coinsurance per item on prosthetics such as braces, artificial limbs

• You pay $0 for diabetic monitoring supplies

Home Health Services1,2

How much do I pay for Home Health Services?

• You pay $0 for Home Health Services.

Outpatient Substance Abuse1,2

How much do I pay for Outpatient Substance Abuse?

• You pay 20% coinsurance for each Outpatient Substance Abuse visit.

Supplemental Benefits Imperial Traditional (HMO) 007

Routine Foot Care1,2

How much do I pay for Foot Care services?

• You pay $0 for Medicare-covered foot care. • You pay $0 for 6 routine foot care visits per

calendar year

Over-the-Counter (OTC) What is my OTC monthly benefit?

• $35 monthly allowance every month through our OTC mail order catalog.

• Cash, checks, credit cards or money orders are not accepted under this OTC benefit

• No roll over

Worldwide Coverage How much is my Worldwide Coverage reimbursement?

• Reimbursement up to $50,000 for qualifying expenses with a $90 co-payment

• Urgently needed or Emergency services only

Acupuncture1,2

How much do I pay for Acupuncture Services?

• You pay $15 for 12 routine treatments per calendar year


17

Supplemental Benefits Imperial Traditional (HMO) 007

Wellness Programs

What is my Fitness Center Membership/ Fitness benefit?

You pay $0 for fitness center membership or up to two home fitness kits. The Home Fitness Program and participating fitness centers are offered through the Silver&Fit® Program, with unlimited visits to any of their participating fitness centers

The Silver&Fit Program is provided by American Specialty Health Fitness, Inc. (ASH Fitness), a subsidiary of American Specialty Health Incorporated (ASH). Silver&Fit is a trademark of ASH and used with permission herein.


18

Premiums and Benefits Imperial Traditional Plus (HMO) 009

Premium How much do I need to pay monthly?


premium

Deductible How much do I need to pay before the plan pays?

• This plan does not have a deductible for medical services and items.

• For Part D prescription drugs on tiers 2-5 there is a $435 deductible.

Maximum Out-of-Pocket costs What’s the limit on how much I will pay?




• Medicare defined cost shares apply

Outpatient Hospital Coverage1,2 • You pay 20% co-insurance

Doctor visits How much do I pay to visit primary care physician or specialist?

• Primary care physician visit: You pay $20% coinsurance

• Specialist visit1,2: You pay $20% coinsurance

Preventive Care How much do I pay for Preventive Care?

• You pay $0 for Medicare-covered services


• You pay 20% coinsurance for each Medicare-covered ambulatory surgical center visit.

Emergency Care How much do I pay for Emergency Care?

• You pay $20% coinsurance with a maximum per visit of $90

Urgently Needed Services How much do I pay for Urgently Needed Services?

• You pay $20% coinsurance with a maximum per visit of $65

Imperial Traditional Plus (HMO) 009


19




• Diagnostic radiology services (e.g., MRI): You pay 20% coinsurance

• Lab services: You pay $0 • Diagnostic tests (such as MRI): You pay 20%

coinsurance • Therapeutic radiology services: You pay 20%

coinsurance • Outpatient x-rays: You pay 20% coinsurance

Hearing Services1,2



• Routine hearing exam: You pay 20% coinsurance. The plan covers up to $250 per calendar year

• Hearing aid allowance: You pay 20% coinsurance. The plan covers up to $1,250 per calendar year

Dental Services


• Medicare-covered Dental services: You pay $0 • Preventive dental services: You pay $0

copayment for office visit. Office visit includes exam, cleaning, fluoride treatment and dental X-ray. The plan covers up to $500 per year in routine dental.

• You Pay $0 copayment for restorative services; prosthodontics, other oral/ maxillofacial surgery, other services. The plan covers up to $1000 per year.


Vision Services

How much do I pay for Vision Services?

What’s my Eyewear Allowance per year?

• Medicare-covered Vision services: You pay 20% coinsurance

• You pay 20% coinsurance for routine eye exam • You pay 20% coinsurance for contact lenses or

eyeglasses (frames and lenses) • Eyewear allowance: Up to $500.00 every two

years Vision care brought to you by March Vision


20



How much do I pay for inpatient for outpatient services?

• Inpatient Visit: Medicare defined cost shares apply

• You pay 20% coinsurance for each Medicare-covered individual or group therapy outpatient mental health visit (non-physician).

• You pay 20% coinsurance for each Medicare-covered psychiatric individual or group therapy session.



• Medicare defined cost shares apply

Physical Therapy1,2



• Occupational therapy visit: You pay 20% coinsurance

• Physical therapy and speech and language therapy visit: You pay 20% coinsurance

Ambulance1


• You pay 20% coinsurance per one-way trip

Transportation1,2





• You pay 20% coinsurance for Part B drugs such as chemotherapy drugs

• You pay 20% coinsurance for all other Part B drugs


21

Part D Prescription Drugs Imperial Traditional Plus (HMO) 009

Deductible Stage $435 deductible. Does not apply to drugs in Tier 1. (Your coverage begins on the effective date of your enrollment)




Tier 1 - Preferred Generic Drugs 0% 0%

Tier 2 - Generic Drugs 25% 25%

Tier 3 - Preferred Brand Drugs 25% 25%

Tier 4 – Non-Preferred Drugs 25% 25%


Coverage Gap Stage

You pay the following costs until your yearly out-of- pocket drug costs reach $6,350











22



How much do I pay for Medical Equipment/ Supplies?


• You pay 20% coinsurance for diabetic monitoring supplies







Supplemental Benefits Imperial Traditional Plus HMO 009


How much do I pay for Foot Care services?

• You Pay 20% coinsurance for Medicare-covered foot care.

• You pay $0 for 6 routine foot care visits per calendar year




• No roll over


• Reimbursement up to $50,000 for qualifying expenses with a 20% coinsurance


Acupuncture1,2

How much do I pay for Acupuncture Services?

• You pay $0 for 12 routine treatments per calendar year

Wellness Programs


• You pay $0 for fitness center membership or up to two home fitness kits. The Home Fitness Program and participating fitness centers are offered through the Silver&Fit® Program, with unlimited visits to any of their participating fitness centers


23

Supplemental Benefits Imperial Traditional Plus HMO 009

The Silver&Fit Program is provided by American Specialty Health Fitness, Inc., (ASH Fitness), a subsidiary of American Specialty Health Incorporated (ASH). Silver&Fit is a trademark of ASH and used with permission herein.


24

Premiums and Benefits Senior Value (HMO C-SNP) 005

Premium

How much do I need to pay monthly?


premium

Deductible

How much do I need to pay before the plan pays?

• This plan does not have a deductible

Maximum Out-of-Pocket costs

What’s the limit on how much I will pay?




• You pay $100 for days 1 through 5 • You pay $0 for days 6 though 90 • Our plan provides a maximum of 60 Lifetime

Reserve days. You pay $670 copayment per day, Days 1-60.

Outpatient Hospital Coverage1,2 • You pay $0

Doctor visits

How much do I pay to visit primary care physician or specialist?

• Primary care physician visit: You pay $0 • Specialist visit1,2: You pay $0

Preventive Care

How much do I pay for Preventive Care?

• You pay $0 for Medicare-covered services


• You pay $0 copayment for each Medicare-covered ambulatory surgical center visit.

Emergency Care

How much do I pay for Emergency Care?

• You pay $90 copayment • If you are admitted to the hospital within 48

hours, you don’t have to pay your share of the cost for emergency care

Imperial Senior Value (HMO C-SNP) 005


25


Urgently Needed Services

How much do I pay for Urgently Needed Services?

• You pay $0 copayment



• Diagnostic radiology services (e.g., MRI): You pay $0

• Lab services: You pay $0 • Diagnostic tests (such as MRI): You pay $0 • Therapeutic radiology services: You pay $0 • Outpatient x-rays: You pay $0

Hearing Services1,2



• Routine hearing exam: You pay 20% coinsurance. The plan covers up to $250 per calendar year.

• Hearing aids: You pay 20% coinsurance. The plan covers up to $1,250 per calendar year

Dental Services


• Medicare-covered Dental services: You pay $0 • Preventive dental services: You pay $0

copayment for office visits. Office visits includes exam, cleaning, fluoride treatment and dental X-ray. The plan covers up to $500 per year.

• You Pay $0 copayment for restorative services; prosthodontics, other oral/ maxillofacial surgery, other services. The plan covers up to $1,000 per year.


Vision Services

How much do I pay for Vision Services?

What’s my Eyewear Allowance per year?

• Medicare-covered Vision services: You pay $0 • You pay $15 for routine eye exams • You pay $15 for contact lenses or eyeglasses

(frames and lenses) • Eyewear allowance: Up to $250 every two

years Vision care brought to you by March Vision


26



How much do I pay for inpatient or outpatient services?

• Inpatient Visit: You pay Medicare defined cost share apply

• You pay 20% coinsurance for each Medicare-covered individual or group therapy outpatient mental health visit (non-physician).

• You pay $0 copay for each Medicare-covered psychiatric individual or group therapy session.



We cover up to 100 days in a SNF per benefit period: • You pay $0 for days 1 – 20 • You pay $164.50 copayment per day for days

21 – 100

Physical Therapy1,2



• Occupational therapy visit: You pay $10 copayment

• Physical therapy and speech and language therapy visit: You pay $0

Ambulance1


• You pay $100 copayment per one-way trip

Transportation1,2





• You pay $0 for Part B drugs such as chemotherapy drugs

• You pay $0 for all other Part B drugs


27

Part D Prescription Drugs Senior Value (HMO C-SNP) 005

Deductible Stage No deductible (Your coverage begins on the effective date of your enrollment)






Tier 3 - Preferred Brand Drugs $45.00 $90.00

Tier 4 – Non-Preferred Drugs $90.00 $180.00


Tier 6 – Select Care Drugs $3.00 $0.00

Coverage Gap Stage

You pay the following costs until your yearly out-of-pocket drug costs reach $6,350











28



How much do I pay for Medical Equipment/ Supplies?


• You pay $0 for diabetic monitoring supplies







Supplemental Benefits Senior Value (HMO C-SNP) 005


How much do I pay for Foot Care services? • You pay $0 for Medicare covered foot care. • You pay $0 for 6 routine foot care visits per

calendar year




• No roll over


• Reimbursement up to $50,000 for qualifying expenses with a $90 co-payment


Acupuncture1,2

How much do I pay for Acupuncture Services? • You pay $15 for 12 treatments per calendar

year

Wellness Programs


You pay $0 for fitness center membership or up to two home fitness kits. The Home Fitness Program and participating fitness centers are offered through the Silver&Fit® Program, with unlimited visits to any of their participating fitness centers


29

Supplemental Benefits Senior Value (HMO C-SNP) 005

The Silver&Fit Program is provided by American Specialty Health Fitness, Inc. (ASH Fitness), a subsidiary of American Specialty Health Incorporated (ASH). Silver&Fit is a trademark of ASH and used with permission herein.


30

Imperial Health Plan is an (HMO) (HMO SNP) with a Medicare Contract. Enrollment in Imperial Health Plan depends on contract renewal.

This information is not a complete description of benefits. Call 1-800-838-8271 (TTY: 711) for more information Limitations, copayments, and restrictions may apply. Benefits, premiums and/or copayments/co-insurance may change on January 1 of each year.

Imperial Health Plan of California (HMO) (HMO SNP) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-800- 838-8271 (TTY: 711).

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-838-8271 (TTY: 711).

31

IR_169 H5496 How to Enroll 2020_C ENG 09/06/19

How to Enroll and What Happens After Enrollment

Enrollment into one of Imperial Health Plan of California (HMO) (HMO SNP) MAPD plans is easy. Please use one of the enrollment methods below:

Fax Complete the enrollment application and fax it to 1-626-380-9066 Mail Complete the enrollment application and mail it:

Imperial Health Plan Attention: Membership Department

PO Box 60874 Pasadena, CA 91116

Email Complete the enrollment application and email it to [email protected] Phone Call us at 1-800-838-5914 and we will complete the application with you over the phone.

What Happens After Enrollment Application Is Completed? After you have completed and submitted the enrollment application for Imperial, what happens next? 1. Enrollment Confirmation: We will confirm your enrollment based on enrollment criteria

2. Acknowledgement/Confirmation Letter: When enrollment is confirmed we will send you an

Acknowledgement/Confirmation letter that confirms your enrollment. This letter will contain the plan you selected and your Member ID number. If, for any reason, your application is not accepted, we will notify you, including the reason(s) why.

3. Evidence of Coverage (EOC) & ID Card: The EOC will include your plan ID Card, Provider/Pharmacy Directory and Drug Formulary. These books have all the information needed to use your plan benefits. Please keep your ID Card with you all times. Your ID Card is used for all medical services including Dr. visits, hospital stays, emergencies and pharmacy.

4. Phone Call: Member Services will call you within 7-10 business days of your confirmed enrollment. The Member Services Representative will inform you that you can start receiving services and will be happy to help set-up your first PCP visit and answer any additional questions you may have.

33

IR_181 H5496 SOA 2020_C ENG 09/06/19

SCOPE OF APPOINTMENT CONFIRMATION (SOA) First Name ___________________________ Last Name _____________________________ MI______________ Phone #_______________________ Mobile #______________________ MBI Number _____________________ The Centers for Medicare and Medicaid Services requires agents to document the scope of a marketing appointment prior to any face-to-face or telephonic sales meeting to ensure understanding of what will be discussed between the Agent and the Medicare Beneficiary (or their authorized representative). Imperial Health Plan of California (HMO) (HMO SNP) requires agents to submit a signed and complete copy of this form with your enrollment application. Please select which type of product you want the agent to discuss with you during your appointment: Alameda, Fresno, Kern, Los Angeles, Orange, Riverside, Sacramento, San Bernardino, San Diego, San Francisco, San Mateo, Santa Clara

Imperial Senior Value (HMO C-SNP) 005 Imperial Traditional (HMO) 007 Imperial Traditional Plus (HMO) 009

Medicare Health Maintenance Organization (HMO) is a Medicare Advantage Plan that provides all Original Medicare Part A and Part B health coverage and sometimes covers Part D prescription drug coverage. In most HMO’s, you can get your care from doctors or hospitals in the plan’s network except in emergency situations.

Beneficiary or Authorized Representative Name, Signature and Signature Date:

Name________________________________ Signature___________________________ Date_______________

Beneficiaries are not obligated to enroll in the plan. Current or future Medicare enrollment status will not be impacted, and you will not automatically be enrolled in the plan(s) discussed.

TO BE COMPLETED BY AGENT: Date of Application ___________ Agent Name __________________________ Phone #____________________ Initial Method of Contact_______________________________________________________________________ Agent’s Signature _____________________________________________________________________________ Plan(s) the agent represented during this meeting: Alameda, Fresno, Kern, Los Angeles, Orange, Riverside, Sacramento, San Bernardino, San Diego, San Francisco, San Mateo, Santa Clara


**SCOPE OF APPOINTMENT DOCUMENTATION IS SUBJECT TO CMS RECORD RETENTION REQUIREMENTS**

IR_181 H5496 SOA 2020_C ENG 09/06/19










35

IR_181 H5496 SOA 2020_C ENG 09/06/19










IR_181 H5496 SOA 2020_C ENG 09/06/19










37

IR_188 H5496 PreEnroll Cklist Ch3 Appendix 3 2020_C ENG 09/19/19

Imperial Health Plan (HMO) (HMO SNP) Pre-Enrollment Checklist Before making an enrollment decision, it is important that you fully understand our benefits and rules. If you have any questions, you can call and speak to a Member Service representative at 1-800-838-8271 (TTY users should call 711). Understanding the Benefits ☐ Review the full list of benefits found in the Evidence of Coverage (EOC), especially for

those services for which you routinely see a doctor. Visit www.imperialhealthplan.com or call 1-800-838-8271 to view a copy of the EOC.

☐ Review the provider directory (or ask your doctor) to make sure the doctors you see now

are in the network. If they are not listed, it means you will likely have to select a new doctor.

☐ Review the pharmacy directory to make sure the pharmacy you use for any prescription

medicines is in the network. If the pharmacy is not listed, you will likely have to select a new pharmacy for your prescriptions.

Understanding Important Rules ☐ In addition to your monthly plan premium, you must continue to pay your Medicare Part

B premium. This premium is normally taken out of your Social Security check each month.

☐ Benefits, premiums and/or copayments/co-insurance may change on January 1, 2020. ☐ Except in emergency or urgent situations, we do not cover services by out-of-network

providers (doctors who are not listed in the provider directory). ☐ This plan is a chronic condition special needs plan (C-SNP). Your ability to enroll will be

based on verification that you have a qualifying specific severe or disabling chronic condition.

39

IR_188 H5496 PreEnroll Cklist Ch3 Appendix 3 2020_C ENG 09/19/19

Imperial Health Plan (HMO) (HMO SNP) Pre-Enrollment Checklist Before making an enrollment decision, it is important that you fully understand our benefits and rules. If you have any questions, you can call and speak to a Member Service representative at 1-800-838-8271 (TTY users should call 711). Understanding the Benefits ☐ Review the full list of benefits found in the Evidence of Coverage (EOC), especially for

those services for which you routinely see a doctor. Visit www.imperialhealthplan.com or call 1-800-838-8271 to view a copy of the EOC.

☐ Review the provider directory (or ask your doctor) to make sure the doctors you see now

are in the network. If they are not listed, it means you will likely have to select a new doctor.

☐ Review the pharmacy directory to make sure the pharmacy you use for any prescription

medicines is in the network. If the pharmacy is not listed, you will likely have to select a new pharmacy for your prescriptions.

Understanding Important Rules ☐ In addition to your monthly plan premium, you must continue to pay your Medicare Part

B premium. This premium is normally taken out of your Social Security check each month.

☐ Benefits, premiums and/or copayments/co-insurance may change on January 1, 2020. ☐ Except in emergency or urgent situations, we do not cover services by out-of-network

providers (doctors who are not listed in the provider directory). ☐ This plan is a chronic condition special needs plan (C-SNP). Your ability to enroll will be

based on verification that you have a qualifying specific severe or disabling chronic condition.

41

IR_058 CA Enroll Elig Attestation 2019_C ENG 08/29/18

Attestation of Eligibility for an Enrollment Period

Typically, you may enroll in a Medicare Advantage plan only during the annual enrollment period from October 15 through December 7 of each year. There are exceptions that may allow you to enroll in a Medicare Advantage plan outside of this period. Please read the following statements carefully and check the box if the statement applies to you. By checking any of the following boxes you are certifying that, to the best of your knowledge, you are eligible for an Enrollment Period. If we later determine that this information is incorrect, you may be disenrolled. I am new to Medicare. I am enrolled in a Medicare Advantage plan and want to make a change during the Medicare

Advantage Open Enrollment Period (MA OEP). I recently moved outside of the service area for my current plan or I recently moved, and this plan is

a new option for me. I moved on (insert date) _______________________. I recently was released from incarceration. I was released on (insert date) _____________________. I recently returned to the United States after living permanently outside of the U.S. I returned to the

U.S. on (insert date) ________________________. I recently obtained lawful presence status in the United States. I got this status on (insert date)

_____________________. I recently had a change in my Medicaid (newly got Medicaid, had a change in level of Medicaid

assistance, or lost Medicaid) on (insert date) ___________________________. I recently had a change in my Extra Help paying for Medicare prescription drug coverage (newly got

Extra Help, had a change in the level of Extra Help, or lost Extra Help) on (insert date) __________. I have both Medicare and Medicaid (or my state helps pay for my Medicare premiums) or I get Extra

Help paying for my Medicare prescription drug coverage, but I haven’t had a change. I am moving into, live in, or recently moved out of a Long-Term Care Facility (for example, a

nursing home or long-term care facility). I moved/will move into/out of the facility on (insert date) ________________________.

I recently left a PACE program on (insert date) ___________________________. I recently involuntarily lost my creditable prescription drug coverage (coverage as good as

Medicare’s). I lost my drug coverage on (insert date) _________________________. I am leaving employer or union coverage on (insert date) _______________________. I belong to a pharmacy assistance program provided by my state. My plan is ending its contract with Medicare, or Medicare is ending its contract with my plan. I was enrolled in a plan by Medicare (or my state) and I want to choose a different plan. My

enrollment in that plan started on (insert date) ______________________________. I was enrolled in a Special Needs Plan (SNP) but I have lost the special needs qualification required

to be in that plan. I was disenrolled from the SNP on (insert date) ___________________________. I was affected by a weather-related emergency or major disaster (as declared by the Federal

Emergency Management Agency (FEMA). One of the other statements here applied to me, but I was unable to make my enrollment because of the natural disaster.

If none of these statements applies to you or you’re not sure, please contact Imperial Health Plan of California (HMO) (HMO SNP) at 1-800-838-5914, TTY/TDD:711, to see if you are eligible to enroll. We are open Monday through Sunday, 8:00 am to 8:00 pm except holidays during October 1 through March 31 and Monday through Friday 8:00 am to 8:00 pm April 1 through September 30 except holidays.

43

IR_058 CA Enroll Elig Attestation 2019_C ENG 08/29/18

Attestation of Eligibility for an Enrollment Period

Typically, you may enroll in a Medicare Advantage plan only during the annual enrollment period from October 15 through December 7 of each year. There are exceptions that may allow you to enroll in a Medicare Advantage plan outside of this period. Please read the following statements carefully and check the box if the statement applies to you. By checking any of the following boxes you are certifying that, to the best of your knowledge, you are eligible for an Enrollment Period. If we later determine that this information is incorrect, you may be disenrolled. I am new to Medicare. I am enrolled in a Medicare Advantage plan and want to make a change during the Medicare

Advantage Open Enrollment Period (MA OEP). I recently moved outside of the service area for my current plan or I recently moved, and this plan is

a new option for me. I moved on (insert date) _______________________. I recently was released from incarceration. I was released on (insert date) _____________________. I recently returned to the United States after living permanently outside of the U.S. I returned to the

U.S. on (insert date) ________________________. I recently obtained lawful presence status in the United States. I got this status on (insert date)

_____________________. I recently had a change in my Medicaid (newly got Medicaid, had a change in level of Medicaid

assistance, or lost Medicaid) on (insert date) ___________________________. I recently had a change in my Extra Help paying for Medicare prescription drug coverage (newly got

Extra Help, had a change in the level of Extra Help, or lost Extra Help) on (insert date) __________. I have both Medicare and Medicaid (or my state helps pay for my Medicare premiums) or I get Extra

Help paying for my Medicare prescription drug coverage, but I haven’t had a change. I am moving into, live in, or recently moved out of a Long-Term Care Facility (for example, a

nursing home or long-term care facility). I moved/will move into/out of the facility on (insert date) ________________________.

I recently left a PACE program on (insert date) ___________________________. I recently involuntarily lost my creditable prescription drug coverage (coverage as good as

Medicare’s). I lost my drug coverage on (insert date) _________________________. I am leaving employer or union coverage on (insert date) _______________________. I belong to a pharmacy assistance program provided by my state. My plan is ending its contract with Medicare, or Medicare is ending its contract with my plan. I was enrolled in a plan by Medicare (or my state) and I want to choose a different plan. My

enrollment in that plan started on (insert date) ______________________________. I was enrolled in a Special Needs Plan (SNP) but I have lost the special needs qualification required

to be in that plan. I was disenrolled from the SNP on (insert date) ___________________________. I was affected by a weather-related emergency or major disaster (as declared by the Federal

Emergency Management Agency (FEMA). One of the other statements here applied to me, but I was unable to make my enrollment because of the natural disaster.

If none of these statements applies to you or you’re not sure, please contact Imperial Health Plan of California (HMO) (HMO SNP) at 1-800-838-5914, TTY/TDD:711, to see if you are eligible to enroll. We are open Monday through Sunday, 8:00 am to 8:00 pm except holidays during October 1 through March 31 and Monday through Friday 8:00 am to 8:00 pm April 1 through September 30 except holidays.

45

Enrollment Application

LAST NAME: FIRST NAME: Middle Initial:

q Mr. q Mrs. q Ms. Email Address: (optional)q M q F

Home Telephone Number Birth Date: (MM/DD/YY) Alternate Phone Number: (optional)

Permanent Residence Street Address (P.O. Box is not allowed): City: State: Zip Code

Mailing Address (If different from above): City: State: Zip Code

Emergency contact: Telephone Number: Relationship to you:

To enroll in Imperial Health Plan (HMO) (HMO SNP), please provide the following information: (please print)

Please check which plan you want to enroll in: q 005 Senior Value (HMO SNP)

q 007 Imperial Traditional (HMO)

q 009 Imperial Traditional Plus (HMO)

Page 1 of 4

Please contact Imperial Health Plan of California (HMO) and (HMO SNP) if you need information in

another language or format (braille).

H5496_001 CA Enroll App 2019_M ENG Accepted 08/20/18

Please provide your Medicare insurance information:

Please take out your red, white and blue Medicare card to complete this section.

• Fill out this information as it appears on yourMedicare card.

- OR -

• Attach a copy of your Medicare card or yourletter from Social Security or the RailroadRetirement Board.

Name (as it appears on your Medicare card):

Medicare Number:

Is Entitled to: Effective Date:

HOSPITAL (Part A)

MEDICAL (Part B)

You must have Medicare Part A and Part B to join a Medicare Advantage plan.

47

Paying Your Plan Premium:

For plans with no premium (plans 005, and 007): If we determine that you owe a late enrollment penalty (or if you currently have a late enrollment penalty), we need to know how you would prefer to pay it. You can pay by mail each month. You can also choose to pay your premium by automatic deduction from your Social Security or Railroad Retirement Board (RRB) benefit check each month. If you are assessed a Part D-Income Related Monthly Adjustment Amount, you will be notified by the Social Security Administration. You will be responsible for paying this extra amount in addition to your plan premium. You will either have the amount withheld from your Social Security benefit check or be billed directly by Medicare or the RRB. DO NOT pay Imperial Health Plan the Part D -IRMAA.For plans with premium (plan 009): You can pay your monthly plan premium (including any late enrollment penalty that you currently have or may owe) by mail each month. You can also choose to pay your premium by automatic deduction from your Social Security or Railroad Retirement Board (RRB) benefit check each month.If you are assessed a Part D-Income Related Monthly Adjustment Amount, you will be notified by the Social Security Administration. You will be responsible for paying this extra amount in addition to your plan premium. You will either have the amount withheld from your Social Security benefit check or be billed directly by Medicare or RRB. DO NOT pay Imperial Health Plan the Part D-IRMAA.People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If eligible, Medicare could pay for 75% or more of your drug costs including monthly prescription drug premiums, annual deductibles, and co-insurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don’t even know it. For more information about this Extra Help, contact your local Social Security office, or call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. You can also apply for Extra Help online at www.socialsecurity.gov/prescriptionhelp.If you qualify for Extra Help with your Medicare prescription drug coverage costs, Medicare will pay all or part of your plan premium. If Medicare pays only a portion of this premium, we will bill you for the amount that Medicare doesn’t cover;If you don’t select a payment option, you will get a bill each month;Please select a premium payment option:q Get a monthly billq Automatic deductions from your monthly Social Security or Railroad Retirement Board (RRB) benefit check. I get monthly benefits from: q Social Security q RRB (The Social Security/RRB deduction may take two or more months to begin after Social Security or RRB approves the deduction. In most cases, if Social Security or RRB accepts your request for automatic deduction, the first deduction from your Social Security or RRB benefit check will include all premiums due from your enrollment effective date up to the point withholding begins. If Social Security or RRB does not approve your request for automatic deduction, we will send you a paper bill for your monthly premiums.)

Please read and answer these important questions:1. Do you have End Stage Renal Disease (ESRD)? .............................................................................. q Yes q No

If you have had a successful kidney transplant and/or you don’t need regular dialysis any more, please attach a note or records from your doctor showing you have had a successful kidney transplant or you don’t need dialysis, otherwise we may need to contact you to obtain additional information.

2. Some individuals may have other drug coverage, including other private insurance, TRICARE, Federal employee health benefits coverage, VA benefits or State pharmaceuticals assistance programs. Will you have other prescription drug coverage in addition to Imperial Health Plan?....................... q Yes q NoIf “yes”, please list your other coverage and your identification (ID) number(s) for this coverage:

Page 2 of 4 49

Name of other coverage:_________________________

ID# for this coverage:_________________________

Group # for this coverage:_________________________

3. Are you a resident in a long-term care facility, such as a nursing home? ........................................... q Yes q NoIf yes, Name of Institution: Address & Phone Number of Institution (number and street):

4. Are you enrolled in your State Medicaid program? ............................................................................ q Yes q NoIf yes, please provide your Medicaid number:

5. Do you or your spouse work? ............................................................................................................. q Yes q No

6. Do you have Cardiovascular Disorder, Chronic Heart Failure and/or Diabetes? ............................... q Yes q NoPlease choose the name of a Primary Care Physician (PCP) and Physician Group:PCP First Name: M.I.: Last

Physician Group (spell out completely): PCP ID#:

Please check one of the boxes below if you would prefer us to send you information in a language other than English or in an accessible format:q Spanish q Chinese Other:q Braille q Audio Tape q Large PrintPlease contact Imperial Health Plan at 800-838-8271 if you need information in an accessible format or language other than what is listed above. Our offi ce hours are Monday through Sunday 8:00 am to 8:00 pm except holidays during October 1 through March 31 and Monday through Friday 8:00 am to 8:00 pm April 1 through September 30 except holidays.

Please Read This Important InformationIf you currently have health coverage from an employer or union, joining Imperial Health Plan could affect your employer or union health benefi ts. You could lose your employer or union health coverage if you join Imperial Health Plan. Read the communications your employer or union sends you. If you have questions, visit their website, or contact the offi ce listed in their communications. If there isn’t any information on whom to contact, your benefi ts administrator or the offi ce that answers questions about your coverage can help.

Please Read and Sign BelowBy completing this enrollment application, I agree to the following:Imperial Health Plan is a Medicare Advantage plan and has a contract with the Federal government. I will need to keep my Medicare Parts A and B. I can be in only one Medicare Advantage plan at a time, and I understand that my enrollment in this plan will automatically end my enrollment in another Medicare health plan or prescription drug plan. It is my responsibility to inform you of any prescription drug coverage that I have or may get in the future. I understand that if I don’t have Medicare prescription drug coverage, or creditable prescription drug coverage (as good as Medicare’s), I may have to pay a late enrollment penalty if I enroll in Medicare prescription drug coverage in the future. Enrollment in this plan is generally for the entire year. Once I enroll, I may leave this plan or make changes only at certain times of the year when an enrollment period is available (Example: October 15 – December 7 of every year), or under certain special circumstances.

Page 3 of 4 51

Imperial Health Plan serves a specific service area. If I move out of the area that Imperial Health Plan serves, I need to notify the plan so I can disenroll and find a new plan in my new area. Once I am a member of Imperial Health Plan, I have the right to appeal plan decisions about payment or services if I disagree. I will read the Evidence of Coverage document from Imperial Health Plan when I get it to know which rules I must follow to get coverage with this Medicare Advantage plan. I understand that people with Medicare aren’t usually not covered under Medicare while out of the country except for limited coverage near the U.S. border.I understand that beginning on the date Imperial Health Plan coverage begins, I must get all of my health care from Imperial Health Plan, except for emergency or urgently needed services or out-of-area dialysis services. Services authorized by Imperial Health Plan and other services contained in my Imperial Health Plan Evidence of Coverage document (also known as a member contract or subscriber agreement) will be covered. Without authorization, NEITHER MEDICARE NOR IMPERIAL HEALTH PLAN WILL PAY FOR THE SERVICES. I understand that if I am getting assistance from a sales agent, broker or other individual employed by or contracted with Imperial Health Plan, he/she may be paid based on my enrollment in Imperial Health Plan.Release of Information: By joining this Medicare health plan, I acknowledge that Imperial Health Plan will release my information to Medicare and other plans as is necessary for treatment, payment and health care operations. I also acknowledge that Imperial Health Plan will release my information, including my prescription drug event data to Medicare, who may release it for research and other purposes which follow all applicable Federal statutes and regulations. The information on this enrollment form is correct to the best of my knowledge. I understand that if I intentionally provide false information on this form, I will be disenrolled from the plan.I understand that my signature (or the signature of the person authorized to act on my behalf under the laws of the State where I live) on this application means that I have read and understand the contents of this application. If signed by an authorized individual (as described above), this signature certifies that: 1) this person is authorized under State law to complete this enrollment and 2) documentation of this authority is available upon request from Medicare.Signature: Today’s Date:

If you are the authorized representative, you must sign above and provide the following information:

Name: Phone Number:

Address: Relationship to Enrollee:

Office Use Only

Name of Agent (if assisted in enrollment): Date

Plan ID#:

Effective Date of Coverage:

q ICEP/IEP q AEP q SEP (TYPE) q Not eligible

Page 4 of 4

Imperial Health Plan is an (HMO) (HMO SNP) with a Medicare Contract. Enrollment in Imperial Health Plan depends on contract renewal. Imperial Health Plan of California (HMO) (HMO SNP) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-800-838-8271 (TTY: 711). ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-838-8271 (TTY: 711). 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-800-838-8271 (TTY: 711).

53

Enrollment Application

LAST NAME: FIRST NAME: Middle Initial:

q Mr. q Mrs. q Ms. Email Address: (optional)q M q F

Home Telephone Number Birth Date: (MM/DD/YY) Alternate Phone Number: (optional)

Permanent Residence Street Address (P.O. Box is not allowed): City: State: Zip Code

Mailing Address (If different from above): City: State: Zip Code

Emergency contact: Telephone Number: Relationship to you:

To enroll in Imperial Health Plan (HMO) (HMO SNP), please provide the following information: (please print)

Please check which plan you want to enroll in: q 005 Senior Value (HMO SNP)

q 007 Imperial Traditional (HMO)

q 009 Imperial Traditional Plus (HMO)

Page 1 of 4

Please contact Imperial Health Plan of California (HMO) and (HMO SNP) if you need information in

another language or format (braille).

H5496_001 CA Enroll App 2019_M ENG Accepted 08/20/18

Please provide your Medicare insurance information:

Please take out your red, white and blue Medicare card to complete this section.

• Fill out this information as it appears on yourMedicare card.

- OR -

• Attach a copy of your Medicare card or yourletter from Social Security or the RailroadRetirement Board.

Name (as it appears on your Medicare card):

Medicare Number:

Is Entitled to: Effective Date:

HOSPITAL (Part A)

MEDICAL (Part B)

You must have Medicare Part A and Part B to join a Medicare Advantage plan.

55

Paying Your Plan Premium:

For plans with no premium (plans 005, and 007): If we determine that you owe a late enrollment penalty (or if you currently have a late enrollment penalty), we need to know how you would prefer to pay it. You can pay by mail each month. You can also choose to pay your premium by automatic deduction from your Social Security or Railroad Retirement Board (RRB) benefit check each month. If you are assessed a Part D-Income Related Monthly Adjustment Amount, you will be notified by the Social Security Administration. You will be responsible for paying this extra amount in addition to your plan premium. You will either have the amount withheld from your Social Security benefit check or be billed directly by Medicare or the RRB. DO NOT pay Imperial Health Plan the Part D -IRMAA.For plans with premium (plan 009): You can pay your monthly plan premium (including any late enrollment penalty that you currently have or may owe) by mail each month. You can also choose to pay your premium by automatic deduction from your Social Security or Railroad Retirement Board (RRB) benefit check each month.If you are assessed a Part D-Income Related Monthly Adjustment Amount, you will be notified by the Social Security Administration. You will be responsible for paying this extra amount in addition to your plan premium. You will either have the amount withheld from your Social Security benefit check or be billed directly by Medicare or RRB. DO NOT pay Imperial Health Plan the Part D-IRMAA.People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If eligible, Medicare could pay for 75% or more of your drug costs including monthly prescription drug premiums, annual deductibles, and co-insurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don’t even know it. For more information about this Extra Help, contact your local Social Security office, or call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. You can also apply for Extra Help online at www.socialsecurity.gov/prescriptionhelp.If you qualify for Extra Help with your Medicare prescription drug coverage costs, Medicare will pay all or part of your plan premium. If Medicare pays only a portion of this premium, we will bill you for the amount that Medicare doesn’t cover;If you don’t select a payment option, you will get a bill each month;Please select a premium payment option:q Get a monthly billq Automatic deductions from your monthly Social Security or Railroad Retirement Board (RRB) benefit check. I get monthly benefits from: q Social Security q RRB (The Social Security/RRB deduction may take two or more months to begin after Social Security or RRB approves the deduction. In most cases, if Social Security or RRB accepts your request for automatic deduction, the first deduction from your Social Security or RRB benefit check will include all premiums due from your enrollment effective date up to the point withholding begins. If Social Security or RRB does not approve your request for automatic deduction, we will send you a paper bill for your monthly premiums.)

Please read and answer these important questions:1. Do you have End Stage Renal Disease (ESRD)? .............................................................................. q Yes q No

If you have had a successful kidney transplant and/or you don’t need regular dialysis any more, please attach a note or records from your doctor showing you have had a successful kidney transplant or you don’t need dialysis, otherwise we may need to contact you to obtain additional information.

2. Some individuals may have other drug coverage, including other private insurance, TRICARE, Federal employee health benefits coverage, VA benefits or State pharmaceuticals assistance programs. Will you have other prescription drug coverage in addition to Imperial Health Plan?....................... q Yes q NoIf “yes”, please list your other coverage and your identification (ID) number(s) for this coverage:

Page 2 of 4 57

Name of other coverage:_________________________

ID# for this coverage:_________________________

Group # for this coverage:_________________________

3. Are you a resident in a long-term care facility, such as a nursing home? ........................................... q Yes q NoIf yes, Name of Institution: Address & Phone Number of Institution (number and street):

4. Are you enrolled in your State Medicaid program? ............................................................................ q Yes q NoIf yes, please provide your Medicaid number:

5. Do you or your spouse work? ............................................................................................................. q Yes q No

6. Do you have Cardiovascular Disorder, Chronic Heart Failure and/or Diabetes? ............................... q Yes q NoPlease choose the name of a Primary Care Physician (PCP) and Physician Group:PCP First Name: M.I.: Last

Physician Group (spell out completely): PCP ID#:

Please check one of the boxes below if you would prefer us to send you information in a language other than English or in an accessible format:q Spanish q Chinese Other:q Braille q Audio Tape q Large PrintPlease contact Imperial Health Plan at 800-838-8271 if you need information in an accessible format or language other than what is listed above. Our offi ce hours are Monday through Sunday 8:00 am to 8:00 pm except holidays during October 1 through March 31 and Monday through Friday 8:00 am to 8:00 pm April 1 through September 30 except holidays.

Please Read This Important InformationIf you currently have health coverage from an employer or union, joining Imperial Health Plan could affect your employer or union health benefi ts. You could lose your employer or union health coverage if you join Imperial Health Plan. Read the communications your employer or union sends you. If you have questions, visit their website, or contact the offi ce listed in their communications. If there isn’t any information on whom to contact, your benefi ts administrator or the offi ce that answers questions about your coverage can help.

Please Read and Sign BelowBy completing this enrollment application, I agree to the following:Imperial Health Plan is a Medicare Advantage plan and has a contract with the Federal government. I will need to keep my Medicare Parts A and B. I can be in only one Medicare Advantage plan at a time, and I understand that my enrollment in this plan will automatically end my enrollment in another Medicare health plan or prescription drug plan. It is my responsibility to inform you of any prescription drug coverage that I have or may get in the future. I understand that if I don’t have Medicare prescription drug coverage, or creditable prescription drug coverage (as good as Medicare’s), I may have to pay a late enrollment penalty if I enroll in Medicare prescription drug coverage in the future. Enrollment in this plan is generally for the entire year. Once I enroll, I may leave this plan or make changes only at certain times of the year when an enrollment period is available (Example: October 15 – December 7 of every year), or under certain special circumstances.

Page 3 of 4 59

Imperial Health Plan serves a specific service area. If I move out of the area that Imperial Health Plan serves, I need to notify the plan so I can disenroll and find a new plan in my new area. Once I am a member of Imperial Health Plan, I have the right to appeal plan decisions about payment or services if I disagree. I will read the Evidence of Coverage document from Imperial Health Plan when I get it to know which rules I must follow to get coverage with this Medicare Advantage plan. I understand that people with Medicare aren’t usually not covered under Medicare while out of the country except for limited coverage near the U.S. border.I understand that beginning on the date Imperial Health Plan coverage begins, I must get all of my health care from Imperial Health Plan, except for emergency or urgently needed services or out-of-area dialysis services. Services authorized by Imperial Health Plan and other services contained in my Imperial Health Plan Evidence of Coverage document (also known as a member contract or subscriber agreement) will be covered. Without authorization, NEITHER MEDICARE NOR IMPERIAL HEALTH PLAN WILL PAY FOR THE SERVICES. I understand that if I am getting assistance from a sales agent, broker or other individual employed by or contracted with Imperial Health Plan, he/she may be paid based on my enrollment in Imperial Health Plan.Release of Information: By joining this Medicare health plan, I acknowledge that Imperial Health Plan will release my information to Medicare and other plans as is necessary for treatment, payment and health care operations. I also acknowledge that Imperial Health Plan will release my information, including my prescription drug event data to Medicare, who may release it for research and other purposes which follow all applicable Federal statutes and regulations. The information on this enrollment form is correct to the best of my knowledge. I understand that if I intentionally provide false information on this form, I will be disenrolled from the plan.I understand that my signature (or the signature of the person authorized to act on my behalf under the laws of the State where I live) on this application means that I have read and understand the contents of this application. If signed by an authorized individual (as described above), this signature certifies that: 1) this person is authorized under State law to complete this enrollment and 2) documentation of this authority is available upon request from Medicare.Signature: Today’s Date:

If you are the authorized representative, you must sign above and provide the following information:

Name: Phone Number:

Address: Relationship to Enrollee:

Office Use Only

Name of Agent (if assisted in enrollment): Date

Plan ID#:

Effective Date of Coverage:

q ICEP/IEP q AEP q SEP (TYPE) q Not eligible

Page 4 of 4

Imperial Health Plan is an (HMO) (HMO SNP) with a Medicare Contract. Enrollment in Imperial Health Plan depends on contract renewal. Imperial Health Plan of California (HMO) (HMO SNP) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-800-838-8271 (TTY: 711). ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-838-8271 (TTY: 711). 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-800-838-8271 (TTY: 711).

61

To help make your experience easier, register with EnvisionPharmacies using one of the three available options below. Please note, you will need your Member ID number from your prescription card to complete registration using any of these methods.

3. MEMBER INFORMATION

First Name: __________________________________ Last Name: _____________________________ Middle Initial: ______

Address: ___________________________________ City: _____________________ State: _____ Zip Code: __________

Phone Number: ( )__________________________ Email: _____________________________________________________

Member Identification Number: ________________________________________ Date of Birth: ___________ Sex: M F

Drug Allergies: None Aspirin Codeine Erythromycin Penicillin Sulfa Other: _________________

Medical Conditions: Arthritis Asthma Cancer Diabetes Glaucoma Heart Condition High Blood Pressure High Cholesterol Migraine Thyroid Disease Other: ___________________________

Current Over-the-Counter or Herbal Medications Taken Regularly: ________________________________________________

4. HEALTH INFORMATION

PRESCRIPTION HOME DELIVERY REGISTRATIONEnvisionPharmacies provides convenient home delivery for traditional maintenance medications and specialty drugs. Our pharmacy care model focuses on the individual needs of our patients, better coordinating care and improving outcomes. For more information visit envisionpharmacies.com.

1. REGISTRATION INFORMATION

To register by mail: Send this form to EnvisionPharmacies, 7835 Freedom Ave. NW, North Canton, OH 44720

To register by phone: Call EnvisionPharmacies at 866-909-5170 (TTY:711)

To register via the online portal: Visit envisionpharmacies.com/mail and select “Enroll Now.”

It’s easy to fill a prescription with EnvisionPharmacies. Ask your physician for a 90-day prescription of your medication. Your doctor can send the new prescription to EnvisionPharmacies using any of the following secure and easy methods:

Electronic: Have your doctor send the prescription to EnvisionPharmacies using NCPDP 36-77361.

Fax: Have your doctor fax the prescription to EnvisionPharmacies at 866-909-5171.

Mail: If you have a written prescription, you or your doctor can include it with this completed form or, if you’ve already registered online or via the phone, mail it to: EnvisionPharmacies, 7835 Freedom Ave., NW, North Canton, OH 44720.

You can also transfer any current prescriptions that are with another pharmacy to EnvisionPharmacies by going to envisionpharmacies.com/mail, signing in and selecting “Transfer Now” from the homepage or “Transfer A Prescription” under “My Prescriptions.”

If you need any assistance with this process or help contacting your doctor, call EnvisionPharmacies at 866-909-5170 (TTY: 711) for maintenance medications or 877-437-9012 (TTY: 711) for specialty medications. Please have your prescription bottle handy.

2. FILLING PRESCRIPTIONS

IR_158 CA Drug Mail Order Form 2020_C ENG 08/30/19 63

© 2019 EnvisionPharmacies All Rights Reserved. 19-3286

Drug Name Doctor’s Name Doctor’s Phone # * Autorefill * *Fill when Rx Received

1.

2.

3.

4.

5.

6.

7.

I do not want child-proof caps. If you check this box, we will include snap caps or easy off lids with your medications.

Generics: EnvisionMail will automatically dispense the generic drug unless your prescriber writes “DAW” (dispense as written) on the prescription and the brand name drug is medically necessary. Brand name drugs typically require you to pay a higher copayment.

Please note, to be eligible for automatic refills, your plan must allow participation. If you have given us a credit card to keep on file, we will charge your card for copays up to $500 and will contact you for authorization over that amount. No refrigerated or controlled substances can be filled automatically due to deliveries needing to be pre-scheduled and other restrictions. EnvisionPharmacies will send you a notice when your prescriptions are out of refills or expire, recommending you contact your physician’s office or EnvisionPharmacies to request a refill.

*Check box if you would like this option. * *Check box if you would like us to fill your prescription when we receive it.

5. PRESCRIPTION INFORMATION

How would you like to pay for this order? (Please do not send cash. If your copay is $0, you do not need to provide payment information.)

Expedited Shipping: Add $10 for ground, $25 for 2-day and $50 for priority overnight to total order amount. Note: Expedited shipping cannot be sent to a P.O. Box.

For new prescription orders and maintenance refills, this credit card will be billed for copay/coinsurance and other such expenses related to prescription orders. By supplying my credit card number, I authorize EnvisionPharmacies to maintain my credit card on file as payment method for any future charges. To modify payment selection, contact customer service at any time.

EnvisionPharmacies complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Español (Spanish): ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-866-909-5170 (TTY: 711).注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-866-909-5170 (TTY: 711).

6. PAYMENT AND SHIPPING

Charge my credit card: Visa MC Discover Amex Diners

Credit Card Number:

Expiration date:

X I authorize EnvisionPharmacies to charge this M M Y Y Cardholder signature card for all orders from any person in this membership.

65

IR_159 CA OTC Form 2020_C ENG 08/08/19 1

As an Imperial Health Plan of California (HMO) (HMO SNP) member, you are eligible to get over the counter (OTC) items delivered to your home at no cost.

• You do not need a prescription to receive products in this program. • You may spend up to $35 per month and you can place multiple orders per month. • Unused balances DO NOT carry over from month to month.

Items usually arrive within seven (7) to ten (10) business days from the date your order is received and verified.

Ways to place your order: 1. Visit shopping.drugsourceinc.com/imperial

Your web portal is available 24/7 and is the best way to see all available items (including new products). You can place your order, track your shipments and view your available benefit amount by logging in with your member ID number located on your Imperial Health Plan member ID Card and your date of birth.

2. Order by phone a) Review the items located is this catalog and select what you want. b) Call 1 (877) 777-9470 TTY 711, to place your order. Our customer service representatives are available to take

your order Monday through Friday, 8:30am to 10pm Central Time. 3. Order by mail or fax

a) Review the items located is this catalog and complete the order form. When you are finished, you may fax completed form to 1 (847) 258-1913 or mail to:

DrugSource, Inc. PO Box 1366

Elk Grove Village, IL 60009-1366

If you have questions about your OTC benefit or OTC orders, call 1 (877) 777-9470. If you have other questions regarding other plan benefits, call 1 (800) 838-8271, TTY 711. October 1 through March 31 Monday through Sunday, from 8:00 am to 8:00 pm and April 1 through September 30 Monday through Friday, from 8:00 am to 8:00 pm.

Your Over-the-Counter Benefit



























67



About OTC Products The products located on this order form are eligible for coverage. Products such as Anti-Diarrheal, Cold & Allergy medicines, Dental and Oral Care, Diabetes care, Digestive Health, Ear and Eye care, Foot Treatments, Incontinence products are all examples of eligible categories.

Dual-Purpose items If a product can be used either to treat a medical condition or for a general health purpose, it is considered a dual-purpose item. For example, vitamins are considered dual-purpose items. We recommend you talk to your doctor before ordering or using a dual-purpose product. Do not order a dual-purpose product if your doctor doesn’t recommend it.

On this order form, dual-purpose products are marked with plus sign (+).

Some items may be covered under Medicare Part B or Part D. For example, rolled gauze may be covered under Part B when used as prescribed for covering or dressing a surgical wound. On the order form, these items are marked with two plus signs (++). When an item is covered by Part B or Part D due to particular circumstances, you would not use your OTC benefit to obtain the item because it is Medicare-covered in those circumstances, and not part of the supplemental OTC benefit. (For instance, you should make sure that any OTC listed items are covered by Part B or Part D, then you would not use your OTC benefits.)

Items that are not eligible Items that are not eligible for your OTC benefit include but are not limited to:

• Deodorants and antiperspirants • Foods or meal replacement items • Birth control medications and contraceptives • Herbal supplements and alternative medications • Lotions, facial creams and other cosmetic items • Household items including hand soaps, razors, etc. • Baby diapers, formulas and other childcare products




















69


Over-the-Counter Order Form

Member Name

Phone Member ID#

Shipping Address City State Zip Code

Month for Delivery (Circle one; can be up to two months in advance) Jan | Feb | Mar Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec | Signature Date

Monthly Allowance: $35.00

Item # Product Price Qty Anti-Diarrheal 2326001 Anti-Diarrheal Cap 2mg 12ct 3.60 1246001 Imodium A-D Liquid Cool Mint 4oz 8.15 1247001 Kaopectate Liq Regular Flavor 8oz 6.65 Anti-Fungal 3966001 Athletes Antifungal Cream 0.5oz 12.10 0987004 Clotrimazole 1% Cream 1oz 7.20 1828001 Fungi Nail Tincture 30ml 19.50 2730001 Miconazole Nitrate 2% Cream 1oz 6.70 1723001 Tolnaftate 1% Powder 1.5oz 4.65 Anti-Infective 2104004 Bacitracin Oint 1oz 6.20 0982004 Triple Antibiotic Oint 1oz 7.75 4655001 Triple Antibiotic Plus Oint 1oz 6.08 Anti-Itch

2695001 Aveeno Soothing Oatmeal Bath Treatment 8pk 8.73

1984001 Bactine Max Liquid 4oz 6.07 1796002 Calamine Lotion 6oz 4.10 0979004 Hydrocortisone 1% Cream 1oz 5.15 2163001 Hydrocortisone 1% Oint 1oz 5.65 1715001 Hydrocortisone Cream + Aloe 1%

Max Strength 1oz 4.50

Bath Safety 2687003 Bathtub Mat, 15” X 27” 15.95 Cold & Allergy 1050002 Cetirizine 10mg Tab 30ct 11.85

1809001 Chloraseptic Sore Throat Spray Cherry 6oz Sugar Free 7.30

1852001 Chloraseptic Sore Throat Spray Menthol 6oz Sugar Free 7.30

3950001 Coricidin HBP Cough & Cold Tab 16ct 8.45

4277006 Diphenhydramine Cap 25mg 24ct 4.50 2746005 Effervescent Cold Relief Tab 20ct 7.50

Item # Product Price Qty 4657005 Fexofenadine Allergy Tab 12hr 12ct 11.72 1056001 Loratadine 10mg Tablet 30ct 4.10 3953001 Mucinex DM Max Str Tab 14ct 18.82 4024002 Nasacort Allergy 24hr Spray 0.5oz 27.75 1061001 Saline Nasal Spray 1.5oz 3.60 4658005 Sore Throat Spray Cherry 6oz 4.49 2997002 Sudogest PE Tab 10mg 36ct 6.20 1070001 Tussin DM Sugar Free Liquid 4oz 4.10 1843005 Tussin Formula 4oz 4.50 1844005 Tussin Formula DM 4oz 5.50 3313001 Vicks Vaporub 3.53oz 11.55

Diabetic 4951008 Diasox Crew White Large 1 Pair 9.79 4948008 Diasox Crew White XL 1 Pair 9.79 4667005 Glucose Tab 4gm 10ct 3.95

Diagnostics

4746003 Digital Blood Pressure Monitor, Automatic Wrist 25.99

Ear Care 4665005 Ear Wax Drop Removal Kit 0.5oz 5.15

Eye Care

4884008 Artificial Tears 0.5oz W/ Polyvinyl Alcohol 0.5%, Povidone 0.6% 8.25

1347001 Clear Eyes Itchy Eye Relief Drops 0.5oz 5.35

1348001 Clear Eyes Maximum Redness Relief Drops 0.5oz 5.50

4673005 Contact Lens Solution 12oz (Hydrogen Peroxide) 9.79

4674008 Eye Drops Moisture 0.5oz 2.95

1353001 Systane Lubricant Eye Drops 15ml 16.30 3341001 Thera Tears Lid Scrub 1.62oz 20.03

Fiber Supplements 2115005 Fiber Laxative Cplt 100ct 10.80


Over-the-Counter Order Form

Member Name

Phone Member ID#

Shipping Address City State Zip Code

Month for Delivery (Circle one; can be up to two months in advance) Jan | Feb | Mar Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec | Signature Date

Monthly Allowance: $35.00

Item # Product Price Qty Anti-Diarrheal 2326001 Anti-Diarrheal Cap 2mg 12ct 3.60 1246001 Imodium A-D Liquid Cool Mint 4oz 8.15 1247001 Kaopectate Liq Regular Flavor 8oz 6.65 Anti-Fungal 3966001 Athletes Antifungal Cream 0.5oz 12.10 0987004 Clotrimazole 1% Cream 1oz 7.20 1828001 Fungi Nail Tincture 30ml 19.50 2730001 Miconazole Nitrate 2% Cream 1oz 6.70 1723001 Tolnaftate 1% Powder 1.5oz 4.65 Anti-Infective 2104004 Bacitracin Oint 1oz 6.20 0982004 Triple Antibiotic Oint 1oz 7.75 4655001 Triple Antibiotic Plus Oint 1oz 6.08 Anti-Itch

2695001 Aveeno Soothing Oatmeal Bath Treatment 8pk 8.73

1984001 Bactine Max Liquid 4oz 6.07 1796002 Calamine Lotion 6oz 4.10 0979004 Hydrocortisone 1% Cream 1oz 5.15 2163001 Hydrocortisone 1% Oint 1oz 5.65 1715001 Hydrocortisone Cream + Aloe 1%

Max Strength 1oz 4.50

Bath Safety 2687003 Bathtub Mat, 15” X 27” 15.95 Cold & Allergy 1050002 Cetirizine 10mg Tab 30ct 11.85

1809001 Chloraseptic Sore Throat Spray Cherry 6oz Sugar Free 7.30

1852001 Chloraseptic Sore Throat Spray Menthol 6oz Sugar Free 7.30

3950001 Coricidin HBP Cough & Cold Tab 16ct 8.45

4277006 Diphenhydramine Cap 25mg 24ct 4.50 2746005 Effervescent Cold Relief Tab 20ct 7.50

Item # Product Price Qty 4657005 Fexofenadine Allergy Tab 12hr 12ct 11.72 1056001 Loratadine 10mg Tablet 30ct 4.10 3953001 Mucinex DM Max Str Tab 14ct 18.82 4024002 Nasacort Allergy 24hr Spray 0.5oz 27.75 1061001 Saline Nasal Spray 1.5oz 3.60 4658005 Sore Throat Spray Cherry 6oz 4.49 2997002 Sudogest PE Tab 10mg 36ct 6.20 1070001 Tussin DM Sugar Free Liquid 4oz 4.10 1843005 Tussin Formula 4oz 4.50 1844005 Tussin Formula DM 4oz 5.50 3313001 Vicks Vaporub 3.53oz 11.55

Diabetic 4951008 Diasox Crew White Large 1 Pair 9.79 4948008 Diasox Crew White XL 1 Pair 9.79 4667005 Glucose Tab 4gm 10ct 3.95

Diagnostics

4746003 Digital Blood Pressure Monitor, Automatic Wrist 25.99

Ear Care 4665005 Ear Wax Drop Removal Kit 0.5oz 5.15

Eye Care

4884008 Artificial Tears 0.5oz W/ Polyvinyl Alcohol 0.5%, Povidone 0.6% 8.25

1347001 Clear Eyes Itchy Eye Relief Drops 0.5oz 5.35

1348001 Clear Eyes Maximum Redness Relief Drops 0.5oz 5.50

4673005 Contact Lens Solution 12oz (Hydrogen Peroxide) 9.79

4674008 Eye Drops Moisture 0.5oz 2.95

1353001 Systane Lubricant Eye Drops 15ml 16.30 3341001 Thera Tears Lid Scrub 1.62oz 20.03

Fiber Supplements 2115005 Fiber Laxative Cplt 100ct 10.80














71


Over-the-Counter Order Form Item # Product Price Qty

Fiber Supplements, cont. 4683005 Fiber Laxative Cap Psyllium 160ct 10.79 3945001 Natural Fiber Powder 13oz 9.80 3946001 Natural Fiber Powder Orange 13oz 9.25

First Aid Supplies 2529001 Ace Cold Compress Reusable 7.50 0973005 Adhesive Fabric Strips Asst 30ct 3.60

0972005 Adhesive Pads Non-Stick Large 3x4in 10ct 3.60

0975005 Adhesive Sheer Strips Asst 60ct 3.50

3996001 Adhesive Waterproof Tape ½” x 10yd 3.10

3981001 Alcohol Prep Pads 100ct 3.10 0235001 Band-aid Flex Fabric ¾” 30ct 4.63 0998003 Basic Thermometer Digital 5.15 1361001 BD Alcohol Swabs 100ct 3.60 3915001 Cotton Balls 100ct 2.50 2548005 Cotton Swabs 300ct 4.65 4676001 Elastic Bandage 2in 4.29 4677001 Elastic Bandage 3in 5.79 4680003 Hand Sanitizer 8oz 4.02 2553006 Hydrogen Peroxide 3% 8oz 3.50 0968006 Hydrogen Peroxide 3% 16oz 3.60 1691001 Ice Bag 6inches 8.67 4702001 J&J First Aid Kit Mini 2.59 4546015 J&J First Aid Kit 140 Pieces 20.10 1876001 J&J Tape Waterproof ½” X 10yd 5.15 1301001 New-Skin Liquid Bandage 1oz 7.20 2559004 Petroleum Jelly 13oz 5.00 0967006 Rubbing Alcohol 70% 16oz 4.50 1841003 Thermometer Digital Flexible Tip 8.25 4463001 Thermometer Forehead Strip 5.10 1424001 Vaseline Petroleum Jelly 13oz 6.50

Foot Care 4682005 Corn Cushions 9ct 1.99 4335001 Dr Scholl Corn Remover Pads 9ct 3.85

Gastrointestinals 1078002 Antacid Assorted Tab 150ct 4.20 2263001 Antacid Chewable Ex/Str 96ct 5.20 2459002 Antacid Reg Strength Liquid 12oz 5.85 1822001 Anti-gas 80mg Tab 100ct 4.50 2303002 Azo Standard Tab 95mg 30ct 11.35 1819005 Effervescent Pain Relief Tab 36ct 6.45 2942010 Famotidine Tab 10mg 30ct 6.20 4280001 Lansoprazole 15mg Cap 14ct 12.03 2744005 Milk of Magnesia 12oz 4.10 4281010 Omeprazole 20mg OTC 14ct 16.57 2724005 Pink Bismuth Liquid 8oz 4.32

Item # Product Price Qty 1091001 Pink Bismuth Tab – Chew 30ct 5.03 2121001 Ranitidine 75mg Tab 30ct 5.15

Gloves 4103002 Latex Gloves PF Large 100ct 9.00 4102002 Latex Gloves PF Medium 100ct 9.00 4101002 Latex Gloves PF Small 100ct 9.00 4104002 Latex Gloves PF X-Large 100ct 9.00 4368002 Nitrile Gloves Latex Free PF 50ct 11.42

Heating Pads 4668003 Deluxe Heating Pad Moist/Dry 24.95 2788003 Heating Pad Econo Dry 12 X 15 20.90

Hemorrhoidal 2962001 Antiseptic Cleansing Pads 100ct 6.85 4684005 Hemorrhoidal Oint 2oz 5.79 1832001 Hemorrhoidal Suppositories 12ct 5.15

Hot/Cold Packs 2541001 Bed Buddy Hot/Cold Pack 12.15 4700003 Hot Cold Compress Gel Reusable 4.29

Incontinence 1744004 A & D Oint 4oz 6.30 4771006

Adult Pullup Underwear Large 18ct Heavy Absorbency 14.00

4773006 Adult Pullup Underwear Medium 20ct Heavy Absorbency 14.00

4772006 Adult Pullup Underwear X-Large 14ct Heavy Absorbency 14.00

4468006 Attends Brief *Diapers* Medium 24ct 23.63

4516006 Perineum Wash 8oz 7.20

4748006 Prevail Bladder Control Pads, Ultimate Absorbency 33ct 15.00

4452006 Prevail Underpad 30x36 10ct 10.30 4615006 Underpad Reusable 32x36 1ct 16.80

Lactose Intolerant 2167001 Lactaid Cplt 120ct 20.10

Laxatives 1093002 Stool Softener Softgels 100ct 5.00

Lice Treatment

1900002 Nix Lice Treatment Creme Rinse 2oz Single 14.95

Medicated Lip Products 1305001 Abreva Cold Sore Cream 2gm 26.20 2019001 Blistex Lip Balm Reg SPF 0.15oz 2.15 1902005 Lip Balm Regular Twin Pack SPF4 2.05

Motion Sickness 2172002 Motion Sickness Tab 12ct 2.60

Oral Care 4251001 Aim Anti-Tartar Toothpaste 5.5oz 1.60


























Lice Treatment






























Lice Treatment





73



Oral Care, cont. 2629015 Colgate Extra Toothbrush Soft 3.10 2964004 Dental Floss 100yd 2.95 1015004 Denture Cleaner Tablet 90ct 7.80 4666004 Denture Tablets Mint 40ct 3.95

3319001 Fixodent Denture Adhesive Cream Original 2.5oz 7.65

2634001 Oral Denture Brush 4.00 4660008 Oral Pain Relief Gel 0.5oz 5.79 3955001 Polident Overnight Cleanser 120ct 11.25

2352001 Super Poligrip Denture Adhesive Cream Zinc Free Formula 2.4oz 8.25

2965004 Toothbrush Full Head Soft 1.55 4462001 Toothpaste Colgate Regular 8oz 5.15

4662004 Toothpaste Complete Care Original 5.5oz 2.99

Pain Relievers 1170004 Acetaminophen 325mg Tab 100ct 4.65 1514004 Acetaminophen 500mg Tab 100ct 5.15 3146002 Ibuprofen 200mg Cplt 50ct 3.10 3148005 Migraine Formula Cplt 24ct 4.10 4289005 Naproxen Sodium 220mg Cplt 50ct 6.50

1190004 Pain Reliever PM Extra Strength Caplet 50ct 4.10

Pill Boxes 2266001 Pill Organizer 7 Day XXL 5.65

Scales 4620003 Smartheart Digital Weight Scale 26.95

Sleep Aids 3973001 Melatonin Tab 3mg 60ct 6.20

Smoking Deterrents 1042010 Nicotine Gum 2mg Sugar Free 50ct 26.00 1043010 Nicotine Gum 4mg Sugar Free 50ct 26.32

Sunscreen 4230005 Sunscreen Lotion SPF 30 8oz 8.75 4231005 Sunscreen Lotion SPF 50 8oz 8.75

Support Items 4698001 Wrist Support - Sport, Adjustable 6.47

Topical Pain Relief 4293001 Arthritis Cream 3oz 5.44 4614003 Cold Hot Medicated Patch 5ct 5.99 0283001 Flexall Gel Maximum Strength 3oz 7.85 5127003 Heat Wrap Back-Hip 2ct 5.00 5126003 Heat Wrap Neck-Shoulder 3ct 5.00 4295002 Muscle Rub Cream 3oz 4.50 4709001 Salonpas Patch Large 6ct 8.00

Vaginal 4654005 Miconazole 3 Day w/ Applicator 3ct 16.65

1725002 Miconazole 7 Vaginal Cream 45gm 10.80 Item # Product Price Qty

2705002 Monistat 7 Cream with Disposable Applicator 1.59oz 14.80

Vitamins + 4819002 Co-Q-10 100mg Cap 30ct + 16.59 1952002 Ferrous Sulfate Tab 325mg 100ct + 6.20 3979001 Fish Oil 1000mg Softgels 100ct + 7.75

4751010 Magnesium Oxide 400mg Tab 120ct + 9.00

4110001 Milk Thistle 140 Mg Cap 60ct + 11.00

4357001 Oyster Shell Calcium + D Tab 500mg 60ct + 4.10

1771002 Vitamin B-1 100mg 100ct + 6.50 4036010 Vitamin B-12 500mcg Tab 100ct + 5.65 2220001 Vitamin C 500mg Tab 100ct + 6.70 1964001 Vitamin D 400iu Tab 100ct + 5.15 2950002 Vitamin D3 1000iu Tab 100ct + 7.73 2718010 Vitamin D3 2000iu Softgels 100ct + 6.70

Wart Removal 2017001 Compound W Gel 0.25oz 10.90

Monthly Benefit Allowance: $35.00 Order Total $



Oral Care, cont. 2629015 Colgate Extra Toothbrush Soft 3.10 2964004 Dental Floss 100yd 2.95 1015004 Denture Cleaner Tablet 90ct 7.80 4666004 Denture Tablets Mint 40ct 3.95

3319001 Fixodent Denture Adhesive Cream Original 2.5oz 7.65

2634001 Oral Denture Brush 4.00 4660008 Oral Pain Relief Gel 0.5oz 5.79 3955001 Polident Overnight Cleanser 120ct 11.25

2352001 Super Poligrip Denture Adhesive Cream Zinc Free Formula 2.4oz 8.25

2965004 Toothbrush Full Head Soft 1.55 4462001 Toothpaste Colgate Regular 8oz 5.15

4662004 Toothpaste Complete Care Original 5.5oz 2.99

Pain Relievers 1170004 Acetaminophen 325mg Tab 100ct 4.65 1514004 Acetaminophen 500mg Tab 100ct 5.15 3146002 Ibuprofen 200mg Cplt 50ct 3.10 3148005 Migraine Formula Cplt 24ct 4.10 4289005 Naproxen Sodium 220mg Cplt 50ct 6.50

1190004 Pain Reliever PM Extra Strength Caplet 50ct 4.10

Pill Boxes 2266001 Pill Organizer 7 Day XXL 5.65

Scales 4620003 Smartheart Digital Weight Scale 26.95

Sleep Aids 3973001 Melatonin Tab 3mg 60ct 6.20

Smoking Deterrents 1042010 Nicotine Gum 2mg Sugar Free 50ct 26.00 1043010 Nicotine Gum 4mg Sugar Free 50ct 26.32

Sunscreen 4230005 Sunscreen Lotion SPF 30 8oz 8.75 4231005 Sunscreen Lotion SPF 50 8oz 8.75

Support Items 4698001 Wrist Support - Sport, Adjustable 6.47

Topical Pain Relief 4293001 Arthritis Cream 3oz 5.44 4614003 Cold Hot Medicated Patch 5ct 5.99 0283001 Flexall Gel Maximum Strength 3oz 7.85 5127003 Heat Wrap Back-Hip 2ct 5.00 5126003 Heat Wrap Neck-Shoulder 3ct 5.00 4295002 Muscle Rub Cream 3oz 4.50 4709001 Salonpas Patch Large 6ct 8.00

Vaginal 4654005 Miconazole 3 Day w/ Applicator 3ct 16.65

1725002 Miconazole 7 Vaginal Cream 45gm 10.80 Item # Product Price Qty

2705002 Monistat 7 Cream with Disposable Applicator 1.59oz 14.80

Vitamins + 4819002 Co-Q-10 100mg Cap 30ct + 16.59 1952002 Ferrous Sulfate Tab 325mg 100ct + 6.20 3979001 Fish Oil 1000mg Softgels 100ct + 7.75

4751010 Magnesium Oxide 400mg Tab 120ct + 9.00

4110001 Milk Thistle 140 Mg Cap 60ct + 11.00

4357001 Oyster Shell Calcium + D Tab 500mg 60ct + 4.10

1771002 Vitamin B-1 100mg 100ct + 6.50 4036010 Vitamin B-12 500mcg Tab 100ct + 5.65 2220001 Vitamin C 500mg Tab 100ct + 6.70 1964001 Vitamin D 400iu Tab 100ct + 5.15 2950002 Vitamin D3 1000iu Tab 100ct + 7.73 2718010 Vitamin D3 2000iu Softgels 100ct + 6.70

Wart Removal 2017001 Compound W Gel 0.25oz 10.90

Monthly Benefit Allowance: $35.00 Order Total $

75

Imperial Health Plan of California (HMO SNP) Pre-Enrollment Qualification Assessment Tool

IR_033.3 H5496 CSNP Assessment_C ENG 05/18/20

This form must be submitted with the enrollment application for Imperial Health Plan of California (IHP) (HMO SNP) Senior Value plan 005.

Applicant to Complete First Name: MI: Last Name:

Gender: Male Female DOB: Phone Number:

Address: City: State: Zip

Clinical Qualifying Questions If you have any of the following, you may be eligible to join IHP plan 005. Prior to the end of the first month of enrollment, IHP will confirm with your assigned licensed practitioner that you have a qualifying condition necessary for enrollment in IHP Chronic SNP plan 005. If at any time, or at some subsequent time, it is determined you do not have a qualifying condition, you will no longer be eligible for IHP Chronic SNP plan 005 and IHP will be required to disenroll you from plan 005. Check off the boxes for conditions your doctor has said you may have:

Diabetes Mellitus (high blood sugar) Chronic Heart Failure

Hypertension (high blood pressure) Cardiovascular Disorder

Cardiac arrhythmias (palpitations, extra heart beats, atrial fibrillation, atrial flutter, fast or slow heart rate, pacemaker, defibrillator, fainting)

Coronary artery disease (heart attacks, stents, heart surgery) Peripheral vascular disease (poor circulation) Chronic venous thromboembolic disorder (blood clots) History of stroke Hyperlipidemia (High cholesterol level)

Medication Questions 1. Are you now or have you ever taken medications for an illness listed above? Yes No 2. Have you ever been taken insulin Injections? Yes No 3. Have you ever taken Metformin? Yes No 4. What medications are you currently taking? _______________________________________________________

Physician Name: Phone Number: Fax Number: Physician Address:

Applicant’s Authorization to Disclosure Health Information I hereby authorize the disclosure of my health information by the provider listed above to IHP to verify I have been diagnosed with a chronic condition which qualifies me for enrollment in IHP. This authorization applies to all health information maintained by the provider concerning my medical history for the chronic condition(s) indicated above.

Print Name of Applicant Signature of Applicant Date

77



Applicant Information First Name: Last Name: DOB:

Licensed Practitioner to Complete Physician Name: Phone Number: Fax Number: Physician Address: I hereby confirm the above applicant has the qualifying chronic condition(s) indicated below. Applicant has:





______________________ ______________________ __________________________ Print Name of Physician Signature: Date Applicant Seen:

Fax Assessment Tool to IHP at 1-626-380-9066 attention Membership Department

If you should have any questions please contact our Member Services Department at 1-800-838-8271, (TTY/TDD: 711), Monday through Sunday, 8:00 am to 8:00 pm except holidays during October 1 through March 31 and Monday through Friday 8:00 am to 8:00 pm April 1 through September 30 except holidays. Imperial Health Plan is an (HMO) (HMO SNP) with a Medicare Contract. Enrollment in Imperial Health Plan depends on contract renewal. Imperial Health Plan of California (HMO) (HMO SNP) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-800-838-8271 (TTY: 711). ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-838-8271 (TTY: 711).

1-800-708-5976 (TTY: 711).

79



This form must be submitted with the enrollment application for Imperial Health Plan of California (IHP) (HMO SNP) Senior Value plan 005.

Applicant to Complete First Name: MI: Last Name:

Gender: Male Female DOB: Phone Number:

Address: City: State: Zip

Clinical Qualifying Questions If you have any of the following, you may be eligible to join IHP plan 005. Prior to the end of the first month of enrollment, IHP will confirm with your assigned licensed practitioner that you have a qualifying condition necessary for enrollment in IHP Chronic SNP plan 005. If at any time, or at some subsequent time, it is determined you do not have a qualifying condition, you will no longer be eligible for IHP Chronic SNP plan 005 and IHP will be required to disenroll you from plan 005. Check off the boxes for conditions your doctor has said you may have:





Medication Questions 1. Are you now or have you ever taken medications for an illness listed above? Yes No 2. Have you ever been taken insulin Injections? Yes No 3. Have you ever taken Metformin? Yes No 4. What medications are you currently taking? _______________________________________________________

Physician Name: Phone Number: Fax Number: Physician Address:

Applicant’s Authorization to Disclosure Health Information I hereby authorize the disclosure of my health information by the provider listed above to IHP to verify I have been diagnosed with a chronic condition which qualifies me for enrollment in IHP. This authorization applies to all health information maintained by the provider concerning my medical history for the chronic condition(s) indicated above.

Print Name of Applicant Signature of Applicant Date

81



Applicant Information First Name: Last Name: DOB:

Licensed Practitioner to Complete Physician Name: Phone Number: Fax Number: Physician Address: I hereby confirm the above applicant has the qualifying chronic condition(s) indicated below. Applicant has:





______________________ ______________________ __________________________ Print Name of Physician Signature: Date Applicant Seen:

Fax Assessment Tool to IHP at 1-626-380-9066 attention Membership Department

If you should have any questions please contact our Member Services Department at 1-800-838-8271, (TTY/TDD: 711), Monday through Sunday, 8:00 am to 8:00 pm except holidays during October 1 through March 31 and Monday through Friday 8:00 am to 8:00 pm April 1 through September 30 except holidays. Imperial Health Plan is an (HMO) (HMO SNP) with a Medicare Contract. Enrollment in Imperial Health Plan depends on contract renewal. Imperial Health Plan of California (HMO) (HMO SNP) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-800-838-8271 (TTY: 711). ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-838-8271 (TTY: 711).

1-800-708-5976 (TTY: 711).

83

Translator/ Witness Statement

I, _________________________________, have witnessed the verification process for(Translator/Witness Name)

___________________________________. As a neutral party involved in this process, I verify that(Enrollee’s Name)

the enrollee mentioned above has answered the required questions for enrollment. In my opinion, the

prospective member has given affirmative responses indicating a thorough understanding of program

requirements, responsibilities and benefits.

Check One:q Non-Speaking English q Hearing Impaired q Blind q Other

Translator/Witness (Print Name)

Relationship to member

Address

Telephone Number

Enrollee (Print Name)

Date

Translator/Witness (Signature)

Date

City State Zip Code

Language (if non-English speaking)

Enrollee Signature

Imperial Health Plan is an (HMO) (HMO SNP) with a Medicare Contract. Enrollment in Imperial Health Plan depends on contract renewal. Imperial Health Plan of California (HMO) (HMO SNP) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-800-838-8271 (TTY: 711). ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-838-8271 (TTY: 711). 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-800-838-8271 (TTY: 711).IR_014 CA Witness Trans 2019_C ENG 08/23/18 85

IR_161.1 H5496 Dental Benefit Directory 2020_C ENG 05/07/20

Imperial Health Plan of California (HMO) (HMO SNP)

2020 Dental Benefit

Dental care provided by

87


IMPERIAL TRADITIONAL PLUS (HMO) PBP 009 ALAMEDA, FRESNO, KERN, LOS ANGELES, ORANGE, RIVERSIDE, SACRAMENTO, SAN BERNARDINO, SAN DIEGO, SAN FRANCISCO, SAN MATEO, SANTA CLARA IMPERIAL SENIOR VALUE (HMO C-SNP) PBP 005 ALAMEDA, FRESNO, KERN, LOS ANGELES, ORANGE, RIVERSIDE, SACRAMENTO, SAN BERNARDINO, SAN DIEGO, SAN FRANCISCO, SAN MATEO, SANTA CLARA DIAGNOSTIC AND PREVENTIVE CALENDAR YEAR MAXIMUM: $500 COMPREHENSIVE CALENDAR YEAR MAXIMUM: $1,000

The following is a complete list of the dental procedures for which benefits are payable under this Plan. Non-listed procedures are not covered. This Plan does not allow alternate benefits. Members must visit a contracted provider to utilize covered

benefits. If elected, Member is responsible for all non-covered procedures.

CDT Code Description Member

Coinsurance Limitations

Diagnostic Services D0120 Periodic oral evaluation 0%

1 of (D0120-D0180) every 6 months

D0140 Limited oral evaluation 0% D0150 Comprehensive oral evaluation 0% D0160 Oral evaluation, problem focused 0% D0170 Re-evaluation, limited, problem focused 0% D0171 Re-evaluation, post-operative office visit 0% D0180 Comprehensive periodontal evaluation 0% D0210 Intraoral, complete series of radiographic images 0% 1 of (D0210, D0330) every 12 months D0220 Intraoral, periapical, first radiographic image 0% D0230 Intraoral, periapical, each add 'l radiographic image 0% D0240 Intraoral, occlusal radiographic image 0% 2 (D0240) every 36 months D0270 Bitewing, single radiographic image 0%

1 of (D0270-D0274) every 6 months D0272 Bitewings, two radiographic images 0% D0273 Bitewings, three radiographic images 0% D0274 Bitewings, four radiographic images 0% D0277 Vertical bitewings, 7 to 8 radiographic images 0% D0330 Panoramic radiographic image 0% 1 of (D0210, D0330) every 12 months

D0414 Laboratory process of microbial specimen, culture, sensitivity, prep, report

0%

D0415 Collection of microorganisms for culture 0% D0460 Pulp vitality tests 0% D0470 Diagnostic casts 0% 1 (D0470) every 12 months Preventive Services D1110 Prophylaxis, adult 0% 1 of (D1110, D4346) every 6 months D1206 Topical application of fluoride varnish 0%

1 of (D1206, D1208) every 6 months D1208 Topical application of fluoride, excluding varnish 0% Restorative Services D2140 Amalgam, one surface, primary or permanent 0%

D2150 Amalgam, two surfaces, primary or permanent 0%

D2160 Amalgam, three surfaces, primary or permanent 0%

D2161 Amalgam, four or more surfaces, primary or permanent 0%

D2330 Resin-based composite, one surface, anterior 0%

D2331 Resin-based composite, two surfaces, anterior 0%

D2332 Resin-based composite, three surfaces, anterior 0%

D2335 Resin-based composite, four or more surfaces, involving incisal angle

0%

88


D2390 Resin-based composite crown, anterior 0%

D2391 Resin-based composite, one surface, posterior 0%

D2392 Resin-based composite, two surfaces, posterior 0%

D2393 Resin-based composite, three surfaces, posterior 0%

D2394 Resin-based composite, four or more surfaces, posterior 0%

D2710 Crown, resin-based composite (indirect) 0%

D2712 Crown, ¾ resin-based composite (indirect) 0%

D2720 Crown, resin with high noble metal 0%

D2721 Crown, resin with predominantly base metal 0%

D2722 Crown, resin with noble metal 0%

D2740 Crown, porcelain/ceramic substrate 0%

D2750 Crown, porcelain fused to high noble metal 0%

D2751 Crown, porcelain fused to predominantly base metal 0%

D2752 Crown, porcelain fused to noble metal 0%

D2780 Crown, ¾ cast high noble metal 0%

D2781 Crown, ¾ cast predominantly base metal 0%

D2782 Crown, ¾ cast noble metal 0%

D2783 Crown, ¾ porcelain/ceramic 0%

D2790 Crown, full cast high noble metal 0%

D2791 Crown, full cast predominantly base metal 0%

D2792 Crown, full cast noble metal 0%

D2910 Re-cement or re-bond inlay, onlay, veneer, or partial coverage 0%

D2915 Re-cement or re-bond indirectly fabricated/prefabricated post & core

0%

D2920 Re-cement or re-bond crown 0% D2940 Protective restoration 0% D2950 Core buildup, including any pins when required 0% D2951 Pin retention, per tooth, in addition to restoration 0% D2952 Post and core in addition to crown, indirectly fabricated 0% D2953 Each additional indirectly fabricated post, same tooth 0% D2954 Prefabricated post and core in addition to crown 0% D2955 Post removal 0% D2957 Each additional prefabricated post, same tooth 0% Restorative Services (continued)

D2971 Additional procedure to construct new crown, existing partial denture frame

0%

D2980 Crown repair necessitated by restorative material failure 0% Endodontic Services D3110 Pulp cap, direct (excluding final restoration) 0% D3120 Pulp cap, indirect (excluding final restoration) 0% D3221 Pulpal debridement, primary and permanent teeth 0%

D3230 Pulpal therapy, anterior, primary tooth (excluding final restoration)

0%

D3240 Pulpal therapy, posterior, primary tooth (excluding finale restoration)

0%

D3331 Treatment of root canal obstruction; non-surgical access 0% 1 (D3331) per tooth per lifetime

D3332 Incomplete endodontic therapy; inoperable, unrestorable, fractured tooth

0% 1 (D3332) per tooth per lifetime

D3333 Internal root repair of perforation defects 0% 1 (D3333) per tooth per lifetime D3346 Retreatment of previous root canal therapy, anterior 0%

1 of (D3346, D3347) per tooth per lifetime D3347 Retreatment of previous root canal therapy, bicuspid 0% D3351 Apexification/recalcification, initial visit 0% 1 (D3351) per tooth per lifetime D3352 Apexification/recalcification, interim medication replacement 0% 1 (D3352) per tooth per lifetime D3353 Apexification/recalcification, final visit 0% 1 (D3353) per tooth per lifetime D3410 Apicoectomy, anterior 0%

1 of (D3410-D3425) per tooth per lifetime D3421 Apicoectomy, bicuspid (first root) 0%

89


D3425 Apicoectomy, molar (first root) 0% D3426 Apicoectomy, (each additional root) 0% 1 (D3426) per tooth per lifetime D3430 Retrograde filling, per root 0% 1 (D3430) per tooth per lifetime D3450 Root amputation, per root 0% D3910 Surgical procedure for isolation of tooth with rubber dam 0% D3920 Hemisection, not including root canal therapy 0% Periodontal Services D4210 Gingivectomy or gingivoplasty, four or more teeth per quadrant 0%

1 of (D4210-D4285) per site/quad every 24 months

D4211 Gingivectomy or gingivoplasty, one to three teeth per quadrant 0% D4212 Gingivectomy or gingivoplasty, restorative procedure, per tooth 0% D4240 Gingival flap procedure, four or more teeth per quadrant 0% D4241 Gingival flap procedure, one to three teeth per quadrant 0% D4245 Apically positioned flap 0% D4260 Osseous surgery, four or more teeth per quadrant 0% D4261 Osseous surgery, one to three teeth per quadrant 0% D4270 Pedicle soft tissue graft procedure 0% D4273 Autogenous connective tissue graft procedure, first tooth 0% D4274 Mesial/distal wedge procedure, single tooth 0% D4275 Non-autogenous connective tissue graft, first tooth 0% D4277 Free soft tissue graft, first tooth 0% D4278 Free soft tissue graft, each additional tooth 0%

D4283 Autogenous connective tissue graft procedure, each additional tooth, per site

0%

D4285 Non-autogenous connective tissue graft procedure, each additional tooth, per site

0%

D4346 Scaling in presence of moderate or severe inflammation, full mouth after evaluation

0% 1 of (D1110, D4346) every 6 months

D4355 Full mouth debridement 0% 1 (D4355) every 24 months Removable Prosthodontic Services D5110 Complete denture, maxillary 0%

D5120 Complete denture, mandibular 0%

D5130 Immediate denture, maxillary 0%

D5140 Immediate denture, mandibular 0%

D5211 Maxillary partial denture, resin base 0%

D5212 Mandibular partial denture, resin base 0%

D5213 Maxillary partial denture, cast metal, resin base 0%

D5214 Mandibular partial denture, cast metal, resin base 0%

D5221 Immediate maxillary partial denture, resin base 0%

D5222 Immediate mandibular partial denture, resin base 0%

D5223 Immediate maxillary partial denture, cast metal framework, resin denture base

0%

D5224 Immediate mandibular partial denture, cast metal framework, resin denture base

0%

D5281 Removable unilateral partial denture, one piece cast metal 0%

D5410 Adjust complete denture, maxillary 0%

D5411 Adjust complete denture, mandibular 0%

D5421 Adjust partial denture, maxillary 0%

D5422 Adjust partial denture, mandibular 0%

D5510 Repair broken complete denture base 0%

D5520 Replace missing or broken teeth, complete denture 0%

Removable Prosthodontic Services (continued) D5610 Repair resin denture base 0% D5620 Repair cast framework 0% D5630 Repair or replace broken clasp, per tooth 0% D5640 Replace broken teeth, per tooth 0%

90


D5650 Add tooth to existing partial denture 0% D5660 Add clasp to existing partial denture, per tooth 0% D5670 Replace all teeth & acrylic on cast metal frame, maxillary 0% D5671 Replace all teeth & acrylic on cast metal frame, mandibular 0% D5710 Rebase complete maxillary denture 0%

D5711 Rebase complete mandibular denture 0%

D5720 Rebase maxillary partial denture 0%

D5721 Rebase mandibular partial denture 0%

D5730 Reline complete maxillary denture, chairside 0%

D5731 Reline complete mandibular denture, chairside 0%

D5740 Reline maxillary partial denture, chairside 0%

D5741 Reline mandibular partial denture, chairside 0%

D5750 Reline complete maxillary denture, laboratory 0%

D5751 Reline complete mandibular denture, laboratory 0%

D5760 Reline maxillary partial denture, laboratory 0%

D5761 Reline mandibular partial denture, laboratory 0%

D5810 Interim complete denture, maxillary 0%

D5811 Interim complete denture, mandibular 0%

D5820 Interim partial denture, maxillary 0%

D5821 Interim partial denture, mandibular 0%

D5850 Tissue conditioning, maxillary 0%

D5851 Tissue conditioning, mandibular 0%

Fixed Prosthodontic Services D6210 Pontic, cast high noble metal 0%

D6211 Pontic, cast predominantly base metal 0%

D6212 Pontic, cast noble metal 0%

D6240 Pontic, porcelain fused to high noble metal 0%

D6241 Pontic, porcelain fused to predominantly base metal 0%

D6242 Pontic, porcelain fused to noble metal 0%

D6245 Pontic, porcelain/ceramic 0%

D6250 Pontic, resin with high noble metal 0%

D6251 Pontic, resin with predominantly base metal 0%

D6252 Pontic, resin with noble metal 0%

D6545 Retainer, cast metal for resin bonded fixed prosthesis 0%

D6548 Retainer, porcelain/ceramic, resin bonded fixed prosthesis 0%

D6549 Resin retainer, for resin bonded fixed prosthesis 0%

D6720 Retainer crown, resin with high noble metal 0%

D6721 Retainer crown, resin with predominantly base metal 0%

D6722 Retainer crown, resin with noble metal 0%

D6740 Retainer crown, porcelain/ceramic 0%

D6750 Retainer crown, porcelain fused to high noble metal 0%

D6751 Retainer crown, porcelain fused to predominantly base metal 0%

D6752 Retainer crown, porcelain fused to noble metal 0%

D6780 Retainer crown, ¾ cast high noble metal 0%

D6781 Retainer crown, ¾ cast predominantly base metal 0%

D6782 Retainer crown, ¾ cast noble metal 0%

D6783 Retainer crown, ¾ porcelain/ceramic 0%

D6790 Retainer crown, full cast high noble metal 0%

D6791 Retainer crown, full cast predominantly base metal 0%

D6792 Retainer crown, full cast noble metal 0%

D6930 Re-cement or re-bond fixed partial denture 0% D6980 Fixed partial denture repair, restorative material failure 0%

Oral and Maxillofacial Services D7111 Extraction, coronal remnants, deciduous tooth 0%

91


D7220 Removal of impacted tooth, soft tissue 0% D7230 Removal of impacted tooth, partially bony 0% D7241 Removal impacted tooth, complete bony, complication 0% D7250 Removal of residual tooth roots (cutting procedure) 0% D7261 Primary closure of a sinus perforation 0% D7270 Tooth reimplantation and/or stabilization, accident 0%

D7272 Tooth transplantation 0%

D7280 Exposure of an unerupted tooth 0%

D7283 Placement, device to facilitate eruption, impaction 0% D7285 Incisional biopsy of oral tissue, hard (bone, tooth) 0%

D7286 Incisional biopsy of oral tissue, soft 0%

Oral and Maxillofacial Services (continued) D7310 Alveoloplasty with extractions, four or more teeth per quadrant 0%

D7311 Alveoloplasty with extractions, one to three teeth per quadrant 0%

D7320 Alveoloplasty, w/o extractions, four or more teeth per quadrant 0%

D7321 Alveoloplasty, w/o extractions, one to three teeth per quadrant 0%

D7340 Vestibuloplasty, ridge extension (2nd epithelialization) 0%

D7350 Vestibuloplasty, ridge extension 0%

D7450 Removal, benign odontogenic cyst/tumor, up to 1.25 cm 0% D7451 Removal, benign odontogenic cyst/tumor, greater than 1.25 cm 0% D7460 Removal, benign nonodontogenic cyst/tumor, up to 1.25 cm 0%

D7461 Removal, benign nonodontogenic cyst/tumor, greater than 1.25 cm

0%

D7471 Removal of lateral exostosis, maxilla or mandible 0%

D7472 Removal of torus palatinus 0%

D7473 Removal of torus mandibularis 0%

D7485 Reduction of osseous tuberosity 0% D7510 Incision & drainage of abscess, intraoral soft tissue 0% D7511 Incision & drainage of abscess, intraoral soft tissue, complicated 0% D7520 Incision & drainage of abscess, extraoral soft tissue 0% D7521 Incision & drainage of abscess, extraoral soft tissue, complicated 0% D7530 Remove foreign body, mucosa, skin, tissue 0%

D7560 Maxillary sinusotomy for removal of tooth fragment or foreign body

0%

D7960 Frenulectomy (frenectomy or frenotomy), separate procedure 0% D7963 Frenuloplasty 0% D7970 Excision of hyperplastic tissue, per arch 0% D7971 Excision of pericoronal gingiva 0%

D7972 Surgical reduction of fibrous tuberosity 0%

Adjunctive General Services D9110 Palliative (emergency) treatment, minor procedure 0%

D9120 Fixed partial denture sectioning 0%

D9210 Local anesthesia not in conjunction, operative or surgical procedures

0%

D9211 Regional block anesthesia 0% D9212 Trigeminal division block anesthesia 0%

D9215 Local anesthesia in conjunction with operative or surgical procedures

0%

D9219 Evaluation for deep sedation or general anesthesia 0% D9223 Deep sedation/general anesthesia, each 15 minute increment 0% D9230 Inhalation of nitrous oxide/analgesia, anxiolysis 0%

D9243 Intravenous moderate (conscious) sedation/analgesia, each 15 minute increment

0%

D9310 Consultation, other than requesting dentist 0%

D9311 Consultation with a medical health care professional 0%

92


D9430 Office visit, observation, regular hours, no other services 0% D9440 Office visit, after regularly scheduled hours 0% D9610 Therapeutic parenteral drug, single administration 0%

D9940 Occlusal guard, by report 0%

D9942 Repair and/or reline of occlusal guard 0% D9950 Occlusion analysis, mounted case 0% D9951 Occlusal adjustment, limited 0% D9952 Occlusal adjustment, complete 0% D9971 Odontoplasty 1-2 teeth; includes removal of enamel projections 0%

D9991 Dental case management, addressing appointment compliance barriers

0%

D9992 Dental case management, care coordination 0% D9993 Dental case management, motivational interviewing 0%

D9994 Dental case management, patient education to improve oral health literacy

0%

93


IMPERIAL TRADITIONAL (HMO) PBP 007 ALAMEDA, FRESNO, KERN, LOS ANGELES, ORANGE, RIVERSIDE, SACRAMENTO, SAN BERNARDINO, SAN DIEGO, SAN FRANCISCO, SAN MATEO, SANTA CLARA PREVENTIVE CALENDAR YEAR MAXIMUM: $500 COMPREHENSIVE CALENDAR YEAR MAXIMUM: $1,000

The following is a complete list of the dental procedures for which benefits are payable under this Plan. Non-listed procedures are not covered. This Plan does not allow alternate benefits. Members must visit a contracted provider to utilize

covered benefits. If elected, Member is responsible for all non-covered procedures.

CDT Code Description Member

Coinsurance Limitations

Diagnostic Services D0120 Periodic oral evaluation 0%

1 of (D0120-D0180) every 6 months D0140 Limited oral evaluation 0% D0150 Comprehensive oral evaluation 0% D0160 Oral evaluation, problem focused 0% D0180 Comprehensive periodontal evaluation 0% D0210 Intraoral, complete series of radiographic images 0% 1 of (D0210, D0330) every 12 months D0220 Intraoral, periapical, first radiographic image 0% D0230 Intraoral, periapical, each add 'l radiographic image 0% D0270 Bitewing, single radiographic image 0%

1 of (D0270-D0274) per 12 months D0272 Bitewings, two radiographic images 0% D0274 Bitewings, four radiographic images 0% D0330 Panoramic radiographic image 0% 1 of (D0210, D0330) every 12 months D0470 Diagnostic casts 0% 1 (D0470) every 12 months Preventive Services D1110 Prophylaxis, adult 0% 1 of (D1110, D4346) every 6 months D1206 Topical application of fluoride varnish 0%

1 of (D1206, D1208) per 6 months D1208 Topical application of fluoride, excluding varnish 0% Restorative Services D2140 Amalgam, one surface, primary or permanent 0%

D2150 Amalgam, two surfaces, primary or permanent 0%

D2160 Amalgam, three surfaces, primary or permanent 0%

D2161 Amalgam, four or more surfaces, primary or permanent 0%

D2330 Resin-based composite, one surface, anterior 0%

D2331 Resin-based composite, two surfaces, anterior 0%

D2332 Resin-based composite, three surfaces, anterior 0%

D2335 Resin-based composite, four or more surfaces, involving incisal angle

0%

Endodontic Services D3410 Apicoectomy, anterior 0%

1 of (D3410-D3425) per tooth per lifetime D3421 Apicoectomy, bicuspid (first root) 0% D3425 Apicoectomy, molar (first root) 0% D3426 Apicoectomy, (each additional root) 0% 1 (D3426) per tooth per lifetime Periodontal Services

D4346 Scaling in presence of moderate or severe inflammation, full mouth after evaluation

0% 1 of (D1110, D4346) every 6 months

Removable Prosthodontic Services D5110 Complete denture, maxillary 0%

D5120 Complete denture, mandibular 0%

D5211 Maxillary partial denture, resin base 0%

94


D5212 Mandibular partial denture, resin base 0%

D5213 Maxillary partial denture, cast metal, resin base 0%

D5214 Mandibular partial denture, cast metal, resin base 0%

D5410 Adjust complete denture, maxillary 0%

D5411 Adjust complete denture, mandibular 0%

D5421 Adjust partial denture, maxillary 0%

D5422 Adjust partial denture, mandibular 0%

D5510 Repair broken complete denture base 0%

D5520 Replace missing or broken teeth, complete denture 0%

D5610 Repair resin denture base 0% D5620 Repair cast framework 0% D5630 Repair or replace broken clasp, per tooth 0% D5640 Replace broken teeth, per tooth 0% D5650 Add tooth to existing partial denture 0% D5660 Add clasp to existing partial denture, per tooth 0% D5710 Rebase complete maxillary denture 0%

D5711 Rebase complete mandibular denture 0%

D5720 Rebase maxillary partial denture 0%

D5721 Rebase mandibular partial denture 0%

D5730 Reline complete maxillary denture, chairside 0%

D5731 Reline complete mandibular denture, chairside 0%

D5740 Reline maxillary partial denture, chairside 0%

D5741 Reline mandibular partial denture, chairside 0%

D5750 Reline complete maxillary denture, laboratory 0%

D5751 Reline complete mandibular denture, laboratory 0%

Removable Prosthodontic Services (continued) D5760 Reline maxillary partial denture, laboratory 0%

D5761 Reline mandibular partial denture, laboratory 0%

D5850 Tissue conditioning, maxillary 0%

D5851 Tissue conditioning, mandibular 0%

Oral and Maxillofacial Services D7111 Extraction, coronal remnants, deciduous tooth 0% D7220 Removal of impacted tooth, soft tissue 0% D7230 Removal of impacted tooth, partially bony 0% D7241 Removal impacted tooth, complete bony, complication 0% D7250 Removal of residual tooth roots (cutting procedure) 0% D7251 Coronectomy, intentional partial tooth removal 0% D7270 Tooth reimplantation and/or stabilization, accident 0% D7272 Tooth transplantation 0% D7285 Incisional biopsy of oral tissue, hard (bone, tooth) 0%

D7286 Incisional biopsy of oral tissue, soft 0%

D7310 Alveoloplasty with extractions, four or more teeth per quadrant

0%

D7311 Alveoloplasty with extractions, one to three teeth per quadrant

0%

D7320 Alveoloplasty, w/o extractions, four or more teeth per quadrant

0%

D7321 Alveoloplasty, w/o extractions, one to three teeth per quadrant

0%

D7410 Excision of benign lesion, up to 1.25 cm 0% D7411 Excision of benign lesion, greater than 1.25 cm 0% D7412 Excision of benign lesion, complicated 0% D7413 Excision of malignant lesion, up to 1.25 cm 0% D7414 Excision of malignant lesion, greater than 1.25 cm 0% D7415 Excision of malignant lesion, complicated 0%

95


D7440 Excision of malignant tumor, up to 1.25 cm 0% D7441 Excision of malignant tumor, greater than 1.25 cm 0% D7450 Removal, benign odontogenic cyst/tumor, up to 1.25 cm 0%

D7451 Removal, benign odontogenic cyst/tumor, greater than 1.25 cm

0%

D7460 Removal, benign nonodontogenic cyst/tumor, up to 1.25 cm 0% D7510 Incision & drainage of abscess, intraoral soft tissue 0%

D7511 Incision & drainage of abscess, intraoral soft tissue, complicated

0%

D7520 Incision & drainage of abscess, extraoral soft tissue 0%

D7521 Incision & drainage of abscess, extraoral soft tissue, complicated

0%

D7960 Frenulectomy (frenectomy or frenotomy), separate procedure

0%

D7970 Excision of hyperplastic tissue, per arch 0%

D7971 Excision of pericoronal gingiva 0%

D7972 Surgical reduction of fibrous tuberosity 0%

Adjunctive General Services D9110 Palliative (emergency) treatment, minor procedure 0% D9310 Consultation, other than requesting dentist 0% D9311 Consultation with a medical health care professional 0% D9430 Office visit, observation, regular hours, no other services 0% D9440 Office visit, after regularly scheduled hours 0%

D9991 Dental case management, addressing appointment compliance barriers

0%

D9992 Dental case management, care coordination 0% D9993 Dental case management, motivational interviewing 0%

D9994 Dental case management, patient education to improve oral health literacy

0%

96

1 IR_155 CA LIS Premium 2020_C ENG 08/08/19

Imperial Health Plan of California (HMO) (HMO SNP) Monthly Plan Premium for People who get Extra Help from Medicare

to Help Pay for their Prescription Drug Costs If you get extra help from Medicare to help pay for your Medicare prescription drug plan costs, your monthly plan premium will be lower than what it would be if you did not get extra help from Medicare. The amount of extra help you get will determine your total monthly plan premium as a member of our Plan. This table shows you what your monthly plan premium will be if you get extra help.

Your level of extra help

Monthly Premium for Imperial Senior Value (HMO SNP) PBP 005

Monthly Premium for Imperial Traditional (HMO) PBP 007

Monthly Premium for -Imperial Traditional Plus (HMO) PBP 009

100% $0 $0 $0 75% $0 $0 $0 50% $0 $0 $0 25% $0 $0 $0

*This does not include any Medicare Part B premium you may have to pay. Imperial Health Plan’s premium includes coverage for both medical services and prescription drug coverage. If you aren’t getting extra help, you can see if you qualify by calling: • 1-800-Medicare. TTY users call 1-877-486-2048 (24 hours a day/7 days a week), • Your State Medicaid Office, or • The Social Security Administration at 1-800-772-1213. TTY users should call 1-800-325-0778

between 7 a.m. and 7 p.m., Monday through Friday. If you have any questions, please call Member Services at 1-800-838-8271, (TTY: 711) from 8:00 a.m. to 8:00 p.m. Monday through Sunday., October 1st through March 31st (except holidays) and April 1st through September 30th 8:00 a.m. to 8:00 p.m. Monday through Friday (except holidays).

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2020 imperial health plan of california (hmo)...2020/05/18 · imperial health plan of california...

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