Coordinated Care Plans have the opportunity to terminate their contract with the Centers for Medicare & Medicaid Services (CMS) or reduce their service area annually. Leon Medical Centers Health Plans will give you notice at least 90 days before the effective date of a termination of our contract with CMS or reduction or our service area and include a description of alternatives available for obtaining Medicare services within the service area, including alternative MA plans, Medigap options, original fee-for-service Medicare.

LMC Health Plans Prescription Drug Plan	2012
	Summary of Benefits
Monthly Premiums	$0
Annual Deductible	$0
Initial Coverage: Your plan will pay part of the cots for your covered drugs and you will pay the other part. The amount you pay when you fill a covered prescription is called the co-payment. You pay the following until total yearly drug costs each $6,000.	You pay the following for your covered prescription drugs: Drug Tier Copayment at a Preferred Pharmacy Copayment at a Non-Preferred Pharmacy Generic $0 $5 Brand $0 $10 Specialty 33% Coinsurance 33% Coinsurance
Coverage Gap: After the total yearly drug costs (paid by you and your plan) reach $6,000.	Your plan will continue to provide generic prescription drug coverage until your total out-of-pocket costs reach $4,700. Once your total out-of-pocket costs reach $4,700 you will qualify for catastrophic coverage.
Catastrophic Coverage: After your yearly out-of-pocket drug costs reach $4,700.	You pay the greater of: $2.60 copay for Generics and $6.50 copay for Brand or 5% coinsurance. For Specialty drugs you pay 5% coinsurance.

If you have any questions or need information, please call our Member Services, 7 days a week, from 8:00 am to 8:00 pm, Eastern Standard Time, at 305-559-5366, or toll-free at 1-866-393-5366. TTY users should call 305-220-5752 or toll-free at 1-866-478-9317.

You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or Your Medicaid Office.

Network pharmacies must be used to access your prescription drug benefit, except in non-routine circumstances, and quantity limitations and restrictions may apply.

Monthly Plan Premium for People who get Extra Help from Medicare to Help Pay for their Prescription Drug Costs.

LMC Health Plans premium includes coverage for both medical services and prescription drug coverage

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 form 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 LMC Health Plans
100%	0
75%	0
50%	0
25%	0

You must continue to pay your Medicare Part B premium. This does not include any Medicare Part B premium you may have to pay. Please note that LMC Health Plans does not charge a plan premium.

If you aren’t getting extra help, you can see if you qualify by calling:

• 1-800-Medicare of TTY/TDD 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/TDD users should call
1-800-325-0778 between 7 a.m. and 7 p.m., Monday through Friday.

If you have any questions or need information, please call our Member Services, 7 days a week from 8:00 am to 8:00 pm, Eastern Standard Time, at 305-559-5366, or toll-free at 1-866-393-5366. TTY users should call 305-220-5752 or toll-free at 1-866-478-9317.

You must use plan providers except in emergency or urgent care situations or for out-of-area renal dialysis. If you obtain routine care from out-of-network providers neither Medicare nor Leon Medical Center Health Plans will be responsible for the costs.

You have the right to make a complaint if we end your membership in our Plan.

If we end your membership in our Plan we will tell you our reasons in writing and explain how you may file a complaint against us if you want to.