Welcome to EssentiaCare!

Your health coverage and health care in one.

2018

EssentiaCare

TABLE OF CONTENTS

Welcome to EssentiaCare Member Letter ........................................................1

Getting Started ................................................................................................................2

Plan Highlights .................................................................................................................4

Maximize Your Membership ......................................................................................7

Have Fun and Stay Active ...........................................................................................8

Go Online ........................................................................................................................10

Contact Information ...................................................................................................11

Your Rights ..............................................................................................................12-13

Welcome to EssentiaCare —where your health matters most, and is at the heart of all we do. Thank you for choosing us as your health plan; we’re glad to have you as a member and we’ll help you get the care and coverage you need, when you need it.

This booklet will help you explore the many benefits and features of your plan. Read it carefully, keep it handy and refer to it as you make healthy choices in your life. Consider this your guide to good health as you choose well and live well every day.

Few other health plans offer you opportunities to improve your health the way EssentiaCare does. You can take advantage of great health and wellness benefits to keep you healthy with the unique advantage of coordinated care through Essentia Health.

Welcome to the EssentiaCare family, and thank you for trusting us with your care.

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One phone call does it all: Whether you’re calling us to discuss your benefits, pay your bill, speak to a nurse or schedule an appointment, EssentiaCare Customer Service handles it all. We’re here to take your call 24/7 at 218-722-4915 and 1-855-432-7025 toll free, or TTY 1-800-688-2534 toll free.

Access coverage information online — anytime, anywhere! Go to EssentiaCare.org/member for convenience and ease whenever and wherever you are, 24/7.

• Print and reorder your member ID card

• Check the provider directory• Look up claims, track your

health care spending and access billing information

• Download a copy of your plan coverage

• Review your formulary (list of covered drugs/medications)

• Keep your contact information up-to-date

Access care online, too. It’s online, it’s easy, it’s confidential. Set up a connection to Essentia MyHealth – and your online health records. Essentia MyHealth safely stores online health records, your notes, test results, appointment scheduling, prescription refills and secure email access to your doctor — all available for you at essentiamyhealth.org. In addition to Essentia MyHealth, you also have convenient access to a 24/7 nurse line (same phone number as Customer Services) and virtuwell® for virtual visits round-the-clock. Get started at essentiamyhealth.org.

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Welcome to EssentiaCare!At EssentiaCare, you are at the center of all we do. Your health and well-being are our priority. We’re focused on providing opportunities to improve your health. Picture it… you, making healthy choices and living well.

Now that you’re an EssentiaCare member, let’s get started. Here are three ways to contact us or access our services.

We look forward to helping you access the health care you need!

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VISIT ESSENTIACARE.ORG TO REGISTER TODAY.

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Issuer: 80840ID: 12345678900Name: JOHN Q DOERxBIN: 003858 RxPCN: MD RxGrp: MNUARxID: 12345678900SVC Type: Medical/DentalGroup Number: xxxxxxCare Type: EssentiaCare SecureH0735 001Medicare Limiting Charges Apply Coverage Year 2016 Issued: 11/15/2015

essentiacare.org

• Review your ID card carefully and make sure the information is correct.

• Carry your ID card with you at all times.• Present your current ID card when you

seek care.

• Keep your ID card handy when you call Customer Services.

• If you lose or misplace your ID card, order a new card through the secure member site or by calling Customer Services.

MEMBER ID NUMBER Secure member ID number unique to you.

PLAN NAME The name of the specific plan you have.

SILVERSNEAKERS® FITNESS PROGRAM This SilverSneakers fitness icon verifies your program eligibility.

HEALTH CLUB SAVINGS This Health Club Savings icon shows your program eligibility.

ESSENTIACARE.ORG WEBSITE Access the member site and helpful information.

CONTACT INFORMATION Important information, including Customer Services and 24/7 nurse line phone numbers.

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Issuer: 80840ID: 12345678900Name: JOHN Q DOERxBIN: 003858 RxPCN: MD RxGrp: MNUARxID: 12345678900SVC Type: Medical/DentalGroup Number: xxxxxxCare Type: EssentiaCare SecureH0735 001Medicare Limiting Charges Apply Coverage Year 2016 Issued: 11/15/2015

essentiacare.org FOR MEMBER USE – Emergency Care: For emergency situations, go to the nearest hospital or call 911.Customer Services, including 24/7 nurse line: 218-722-4915 or 1-855-432-7025, TTY 1-800-688-2534Complaints, Appeals and Grievances: 218-722-4316 or 1-855-432-7026, TTY 1-800-688-2534FOR PROVIDER USE – Notify UCare within 24 hours of admission: 1-612-676-6705 or 1-877-447-4384, Fax 1-612-884-2499 or 1-866-610-7215Provider submit claims to:All Medical: UCare, P.O. Box 70, Minneapolis, MN 55440-0070Pharmacy: Express Scripts, Inc., Attn: Med D Accts. P.O. Box 2858, Clinton, IA 52733-2858Chiropractic: Chiropractic Care of Minnesota, Inc., c/o Landmark Healthcare, Inc., P.O. Box 13977, Sacramento, CA 95853-3977Dental: Delta Dental of Minnesota, P.O. Box 330, Minneapolis, MN 55440-0330Provider Assistance Center: 612-676-3300 or 1-888-531-1493 Pharmacy Help Desk: 1-800-824-0898

Issuer: 80840ID: 12345678900Name: JOHN Q DOERxBIN: 003858 RxPCN: MD RxGrp: MNUARxID: 12345678900SVC Type: Medical/DentalGroup Number: xxxxxxCare Type: EssentiaCare SecureH0735 001Medicare Limiting Charges Apply Coverage Year 2016 Issued: 11/15/2015

essentiacare.org

Issuer: 80840ID: 12345678900Name: JOHN Q DOERxBIN: 003858 RxPCN: MD RxGrp: MNUARxID: 12345678900SVC Type: Medical/DentalGroup Number: xxxxxxCare Type: EssentiaCare SecureH0735 001Medicare Limiting Charges Apply Coverage Year 2016 Issued: 11/15/2015

essentiacare.org FOR MEMBER USE – Emergency Care: For emergency situations, go to the nearest hospital or call 911.Customer Services, including 24/7 nurse line: 218-722-4915 or 1-855-432-7025, TTY 1-800-688-2534Complaints, Appeals and Grievances: 218-722-4316 or 1-855-432-7026, TTY 1-800-688-2534FOR PROVIDER USE – Notify UCare within 24 hours of admission: 1-612-676-6705 or 1-877-447-4384, Fax 1-612-884-2499 or 1-866-610-7215Provider submit claims to:All Medical: UCare, P.O. Box 70, Minneapolis, MN 55440-0070Pharmacy: Express Scripts, Inc., Attn: Med D Accts. P.O. Box 2858, Clinton, IA 52733-2858Chiropractic: Chiropractic Care of Minnesota, Inc., c/o Landmark Healthcare, Inc., P.O. Box 13977, Sacramento, CA 95853-3977Dental: Delta Dental of Minnesota, P.O. Box 330, Minneapolis, MN 55440-0330Provider Assistance Center: 612-676-3300 or 1-888-531-1493 Pharmacy Help Desk: 1-800-824-0898

What’s on your card?Your member ID card is the key to helping you access the care you need. It’s also an important tool that helps providers better understand your health care coverage. Keep in mind these important tips:

FOR MEMBER USE – Emergency Care: For emergency situations, go to the nearest hospital or call 911.Customer Services, including 24/7 nurse line: 218-722-4915 or 1-855-432-7025, TTY 1-800-688-2534Complaints, Appeals and Grievances: 218-722-4316 or 1-855-432-7026, TTY 1-800-688-2534FOR PROVIDER USE – Notify UCare within 24 hours of admission: 1-612-676-6705 or 1-877-447-4384, Fax 1-612-884-2499 or 1-866-610-7215Provider submit claims to:All Medical: UCare, P.O. Box 70, Minneapolis, MN 55440-0070Pharmacy: Express Scripts, Inc., Attn: Med D Accts. P.O. Box 2858, Clinton, IA 52733-2858Chiropractic: Chiropractic Care of Minnesota, Inc., c/o Landmark Healthcare, Inc., P.O. Box 13977, Sacramento, CA 95853-3977Dental: Delta Dental of Minnesota, P.O. Box 330, Minneapolis, MN 55440-0330Provider Assistance Center: 612-676-3300 or 1-888-531-1493 Pharmacy Help Desk: 1-800-824-0898

FOR MEMBER USE – Emergency Care: For emergency situations, go to the nearest hospital or call 911.Customer Services, including 24/7 nurse line: 218-722-4915 or 1-855-432-7025, TTY 1-800-688-2534Complaints, Appeals and Grievances: 218-722-4316 or 1-855-432-7026, TTY 1-800-688-2534FOR PROVIDER USE – Notify UCare within 24 hours of admission: 1-612-676-6705 or 1-877-447-4384, Fax 1-612-884-2499 or 1-866-610-7215Provider submit claims to:All Medical: UCare, P.O. Box 70, Minneapolis, MN 55440-0070Pharmacy: Express Scripts, Inc., Attn: Med D Accts. P.O. Box 2858, Clinton, IA 52733-2858Chiropractic: Chiropractic Care of Minnesota, Inc., c/o Landmark Healthcare, Inc., P.O. Box 13977, Sacramento, CA 95853-3977Dental: Delta Dental of Minnesota, P.O. Box 330, Minneapolis, MN 55440-0330Provider Assistance Center: 612-676-3300 or 1-888-531-1493 Pharmacy Help Desk: 1-800-824-0898

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Plan HighlightsDRUG BENEFITS

As an EssentiaCare member, we know that your prescription drug benefits are an important part of your health care coverage. So be sure to read through the prescription drug coverage details in your Evidence of Coverage book, found in your new member packet and available online at EssentiaCare.org/member. See your Provider Directory for a list of plan pharmacies.

FILLING PRESCRIPTIONS

You have options. When your doctor prescribes a medication, you have three ways to have your prescription filled.

• Your provider sends your prescription to the pharmacy you select

• You take the prescription orders in person to your pharmacy of choice

• You enroll in the convenient and cost-saving mail-order program through Express Scripts

MAIL-ORDER PHARMACY

The Express Scripts mail-order program allows you to receive a 90-day supply of many medications for two copays. Interested in signing up? Here’s how:

1. Call Express Scripts at 1-877-567-6320 from 7:45 a.m. to 5 p.m., Monday through Friday.

2. Log in 24/7 to Express-Scripts.com and follow the prompts to enroll. Remember to call Customer Services with any questions at 218-722-4915 or 1-855-432-7025 toll free. TTY users call 1-800-688-2534 toll free.

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See page 11 for information on how to get a list of plan pharmacies and covered medications

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DENTAL COVERAGE

You have basic preventive dental coverage as part of your plan. Need more dental coverage? You may add EssentiaCare Choice Dental to enhance the preventive coverage included with EssentiaCare. You can add this optional coverage up to 30 days from your effective date or during the Annual Enrollment Period each year. Call Customer Services to learn more and enroll. UCare’s Dental network is the CivicSmiles Senior through Delta Dental. Check out “Find a Dentist” on essentiacare.org

VISION

A routine eye exam and up to two refractions are included annually (used to determine your prescription strength). Refer to the Vision Care section of your Evidence of Coverage to learn about all your vision benefits.

SAVE AT ESSENTIAHEALTH

When purchasing eyewear (other than post-cataract) you get a 20% discount off the retail price of frames and lenses at Essentia Health Optical Shops.

Choice Dental

Premium $20

Deductible $75

Annual Maximum $1000

Preventive/Diagnostic 1 exam, 1 cleaning, X-rays

Covered services: endodontics, periodontics, oral surgery, major restorative service, prosthetics, implant services

30-60%

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• Essentia Health – Duluth Clinic 2nd Street Building

• Essentia Health – Virginia Clinic• Essentia Health St. Mary’s –

Detroit Lakes Clinic

• Essentia Health – Wahpeton Clinic• Essentia Health – South University

Clinic (Fargo)

MOBILE DENTAL CLINIC

Our Mobile Dental Clinic offers dental check-ups, cleanings and simple restorative care to members who have limited access to quality dental care. All care is provided by faculty-supervised dental, dental hygiene and dental therapy students from the University of Minnesota School of Dentistry. To make an appointment, call 1-866-451-1555 toll free TTY: 1-800-627-3529 toll free 8 a.m. to 4:30 p.m., Monday-Friday.

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HEARING SERVICES

When ordering a new hearing aid, you’ll receive a 20% discount at these locations:

• Essentia Health – Duluth Clinic 2nd Street Building

• Essentia Health – Superior Clinic• Essentia Health – Virginia Clinic

• Essentia Health – South University Clinic (Fargo),

• Essentia Health St. Joseph’s – Brainerd Clinic

You may also use the EPIC Hearing Healthcare Network, which provides access to credentialed ear, nose and throat physicians and licensed audiologists, plus up to 35% off most discount offers on brand-name hearing aids.

EPIC’s prices may be as much as 60% below manufacturer’s suggested retail price, and up to 35% lower than most discount offers. To access the EPIC Hearing Healthcare Network, call 1-866-956-5400 toll free (TTY 711) prior to making any appointments and/or purchases.

PREVENTIVE SERVICES

Your coverage includes an annual wellness visit and routine physical. Many important preventive screenings and vaccines are also available at no cost to you.

SCREENINGS

Be sure to take advantage of these preventive screenings. Ask your health care professional which ones are important for you:

• Bone density • Diabetes exams • Cholesterol

• Mammograms • Colon cancer • Vision

VACCINES

Flu and pneumonia vaccines have no copay and are covered under your EssentiaCare medical benefits. Other preventive vaccines — including shingles vaccines, tetanus and Hepatitis A — are covered under Medicare Part D, so your prescription drug copays apply. We recommend getting Part D vaccines at your pharmacy. Call your pharmacy to see if getting a vaccination requires an appointment.

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Maximize your membership WHOLE HEALTH LIVING

Online access to WholeHealth Living® offers:

• Access to more than 40,000 practitioners• Discounts on name brand health products• No referrals, pre-authorizations or

claims to file• Diverse network includes acupuncture,

Tai Chi, massage, nutritionists and more• Simple access: just print discount

certificate from websiteAlways check your Plan for covered services. These discounts are for non-Medicare covered benefits.

SKIN PRODUCTS AND SERVICES

You will receive a 20% discount at EssentiaHealth Skin Renewal Services on skin products and services offered at the Essentia Health – Duluth Clinic 3rd Street Building. From treatment for blemishes to concerns about signs of aging skin, experienced skin renewal specialists offer a full selection of treatment options.

TAKE A CLASS, GET A DISCOUNT

Sign up for a community education class and receive up to a $15 discount (limits apply). Choose from cooking, fitness, social activities, painting or another class that interests you. To find out what’s available in your community, check with your local school district.

GET FREE HELP QUITTING TOBACCO

EssentiaCare members get free help to quit smoking or chewing tobacco. Call the tobacco quit line at 1-855-260-9713 toll free to get started today. Hearing impaired dial TTY 711 toll free.

• Speak to a counselor about habit-changing strategies

• Request nicotine patches, gum, or lozenges, available at no charge

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To find discounts and print certificates, access your member account at EssentiaCare.org > Member > Access My Benefits

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Have fun and stay activeTrim your budget and your waistline with EssentiaCare fitness benefits. Choose between SilverSneakers® Fitness or Health Club Savings – depending on which program is available at your preferred club.

SILVERSNEAKERS FITNESS PROGRAM

Free basic fitness membership at more than 13,000 locations nationwide with 500 clubs in Minnesota, like the YMCA and most community centers, including locations close to you.

• SilverSneakers FlexTM offers classes at convenient locations like parks and recreation centers

• Online tools to help you reach your fitness goals

• Fitness kit to use at home or when traveling

Present your SilverSneakers card when you visit a participating location. For more information, or to print your SilverSneakers card, visit silversneakers.com or call SilverSneakers at 1-888-423-4632 toll free (TTY 711), Monday through Friday, 7 a.m. to 7 p.m.

HEALTH CLUB SAVINGS

• Receive up to a $20 monthly reimbursement from a participating club outside the SilverSneakers network. Visit EssentiaCare.org for a club list.

• Enrollment is easy. Simply show your EssentiaCare member ID card at a participating location. Typically you will begin receiving your credit two months after you sign up.

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Tivity Health, WholeHealth Living, SilverSneakers Flex and SilverSneakers are registered trademarks or trademarks of Tivity Health, Inc., and/or its subsidiaries and/or affiliates in the USA and/or other countries. ©2017 Tivity Health, Inc. All rights reserved.

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EDGet engaged!Your opinion matters. Our online member communities provide valuable feedback when it comes to building strong and competitive Medicare Advantage plans for all Minnesotans. Please consider joining the following member communities by contacting Customer Service through dialing the phone number on the back of your Member ID card to Get Engaged!

GET ENGAGED!

Champions

GET ENGAGED!

Ambassadors

GET ENGAGED!

Member FeedbackCommunity

Stay abreast of the latest Congressional actions that may affect your Medicare Advantage plan. Attend Minnesota Congressional face-to-face meetings for EssentiaCare Champions and share your story or insight with influential leaders.

Show your support for EssentiaCare by participating in EssentiaCare sponsored community events or activities and earn rewards for your participation. Share your positive member experiences with others on social media and in your community. Stay connected to EssentiaCare activities through exclusive email communications.

EssentiaCare is always interested in hearing from members like you! We may email you up to 10 surveys per year to gather your opinions or ask you to participate in a focus group. Participation is optional and you can opt out at any time.

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Go online!The EssentiaCare.org member site is your secure, online health resource. The member site gives you the tools you need to stay organized and to manage your health care – online, anytime! Register for a member account at EssentiaCare.org.

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Provider/Pharmacy Directory Information and Formulary(drug list)For the most current provider and pharmacy directory, Formulary (drug list), visit EssentiaCare.org

Select “Network,” then “Find a Medical Professional, Clinic or Hospital” to:

• Find a doctor (in the Essentia Health network)

• Find a pharmacy

To request a printed directory or formulary (updated monthly) email a request to DirectoryRequest@ucare.org or call Customer Services at the numbers below.

Have questions?EssentiaCare’s Customer Services Team is available 24/7 at 218-722-4915 or 1-855-432-7025 toll free. TTY users call 24/7 at 612-676-6810 or 1-800-688-2534 toll free.

Medicare is available 24/7 at 1-800-MEDICARE (1-800-633-4227) (TTY 1-877-486-2048)

• Find a dentist• Find a chiropractor

EssentiaCare is a PPO plan with a Medicare contract. Enrollment in EssentiaCare depends on contract renewal. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments and restrictions may apply. Benefits, premiums and/or copayments/coinsurance may change on January 1 of each year. The formulary, pharmacy network and/or provider network may change at any time. You will receive notice when necessary. You must continue to pay your Medicare Part B premium.

VISIT US ONLINE ANYTIME AT ESSENTIACARE.ORG

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TS Notice of NondiscriminationUCare complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. UCare does not exclude people or treat them differently because of race, color, national origin, age, disability or sex.

We provide aids and services at no charge to people with disabilities to communicate effectively with us, such as TTY line, or written information in other formats, such as large print.

If you need these services, contact us at 612-676-6500 (voice) or toll free at 1-866-457-7144 (voice), 612-676-6810 (TTY), or 1-800-688-2534 (TTY).

We provide language services at no charge to people whose primary language is not English, such as qualified interpreters or information written in other languages.

If you need these services, contact us at the number on the back of your membership card or 612-676-6500 or toll free at 1-866-457-7144 (voice); 612-676-6810 or toll free at 1-800-688 2534 (TTY).

If you believe that UCare has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you can file an oral or written grievance.

ORAL GRIEVANCE

If you are a current UCare member, please call the number on the back of your membership card. Otherwise please call 612-676-6500 or toll free at 1-866-457-7144 (voice); 612-676-6810 or toll free at 1-800-688-2534 (TTY). You can also use these numbers if you need assistance filing a grievance.

WRITTEN GRIEVANCE

Mailing Address UCare Attn: Complaints, Appeals and Grievances PO Box 52 Minneapolis, MN 55440-0052 Email: cag@ucare.org Fax: 612-884-2021

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/smartscreen/main.jsf, or by mail or phone at:

U.S. Department of Health and Human Services 200 Independence Avenue SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 1-800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/filing-with-ocr/index.html.

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U6582 (09/17)Y0120_0735_081817 CMS Approved (09222017)