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2019 Summary of BenefitsMCS Classicare InteliCare (HMO)H5577, Plan 005This is a summary of drug and health services covered by MCS ClassicareInteliCare (HMO)January 1, 2019 - December 31, 2019MCS Classicare is a product subscribed by MCS Advantage, Inc. MCS Classicare is an HMOplan with a Medicare contract. Enrollment in MCS Classicare depends on contract renewal.This information is not a complete description of benefits. Call 787-620-2530 (Metro Area) or1-866-627-8183 (toll free). TTY users (hearing impaired) may call 1-866-627-8182 for moreinformation.The benefit information provided is a summary of what we cover and what you pay. It does notlist every service that we cover or list every limitation or exclusion. To get a complete list ofservices we cover, you may visit our website at www.mcsclassicare.com to view your 2019Evidence of Coverage.To join MCS Classicare InteliCare (HMO), you must be entitled to Medicare Part A, beenrolled in Medicare Part B, and live in our service area. You are also eligible for membership inour plan as long as you are a United States citizen or are lawfully present in the United States;and you do not have End-Stage Renal Disease (ESRD), with limited exceptions, such as if youdevelop ESRD when you are already a member of a plan that we offer, or you were a memberof a different plan that was terminated. Our service area includes the following counties inPuerto Rico: Adjuntas, Aguada, Aguadilla, Aguas Buenas, Aibonito, Añasco, Arecibo, Arroyo,Barceloneta, Barranquitas, Bayamón, Cabo Rojo, Caguas, Camuy, Canóvanas, Carolina, Cataño,Cayey, Ceiba, Ciales, Cidra, Coamo, Comerío, Corozal, Culebra, Dorado, Fajardo, Florida,Guánica, Guayama, Guayanilla, Guaynabo, Gurabo, Hatillo, Hormigueros, Humacao, Isabela,Jayuya, Juana Díaz, Juncos, Lajas, Lares, Las Marías, Las Piedras, Loíza, Luquillo, Manatí, Maricao,Maunabo, Mayagüez, Moca, Morovis, Naguabo, Naranjito, Orocovis, Patillas, Peñuelas, Ponce,Quebradillas, Rincón, Río Grande, Sabana Grande, Salinas, San Germán, San Juan, San Lorenzo,San Sebastián, Santa Isabel, Toa Alta, Toa Baja, Trujillo Alto, Utuado, Vega Alta, Vega Baja,Vieques, Villalba, Yabucoa, and Yauco.H5577 037E0618 M

MCS Classicare InteliCare (HMO) has a network of doctors, hospitals, pharmacies, andother providers. If you use the providers that are not in our network, the plan may not pay forthese services.Getting Help from MedicareIf you want to know more about the coverage and costs of Original Medicare, look in yourcurrent “Medicare & You” handbook. View it online at http://www.medicare.gov or get acopy by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY usersshould call 1-877-486-2048.Plan documents in Other Formats and LanguagesThis document is available in other formats such as Braille, large print or audio CD.ATTENTION: If you speak English, language assistance services, free of charge, are available toyou. Call 1-866-627-8183 (TTY: 1-866-627-8182).ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al1-866-627-8183 (TTY: 致電 1-866-627-8183(TTY: 1-866-627-8182).Non-discriminationMCS Advantage, Inc. complies with applicable federal civil rights laws and does not discriminateon the basis of race, color, national origin, age, disability or sex.MCS Advantage, Inc. cumple con las leyes federales de derechos civiles aplicables y no discrimina pormotivos de raza, color, nacionalidad, edad, discapacidad o sexo.MCS Advantage, Inc. ��別而歧視任何人。Plan Phone Numbers and WebsiteFor more information, please call us at the phone number below or visit us atwww.mcsclassicare.com.If you are a member of this plan, call toll free 1-866-627-8183. TTY users should call1-866-627-8182.

If you are not a member of this plan, call toll free 1-866-627-8181. TTY users should call1-866-627-8182.Hours of OperationFrom October 1 to March 31, you can call us 7 days a week from 8:00 a.m. to 8:00 p.m.From April 1 to September 30, you can call us Monday through Friday from 8:00 a.m. to 8:00p.m., and Saturday from 8:00 a.m. to 4:30 p.m.After these business hours, for general information on your benefits you may leave us a voicemessage. We will return your call on our next business day.Evidence of CoverageYou can see your Evidence of Coverage at our website and-services/coverages/evidencecoverage.aspx.Plan DirectoriesYou can see our plan’s providers directory at our website -directory.aspx.You can see our plan’s pharmacies directory at our website -directory.aspx.Drug coverageWe cover Part D drugs. In addition, we cover Part B drugs such as chemotherapy and somedrugs administered by your provider.You can see the complete plan formulary (list of Part D prescription drugs) and any restrictionson our website ion-coverages/prescription-drugformulary.aspx.

Monthly Premium, Deductible, and Limits for Covered ServicesPremiums and LimitsMCS ClassicareInteliCare (HMO)What YouShould KnowMonthly Plan PremiumYou pay 0You must continue to payyour Medicare Part Bpremium.Part B premiumreductionMCS Classicare will reduceYour Part B premium will beyour Medicare Part B monthly reduced on a monthly basis.premium by up to 17.DeductibleYou pay nothingThis plan does not have adeductible.Maximum Out-of-PocketResponsibility (does notinclude prescription drugs) 3,400 annuallyThe most you pay forcopays, coinsurance andother costs for in-networkmedical services for theyear.

Medical and Hospital BenefitsMCS ClassicareInteliCare (HMO)BenefitsInpatient HospitalCoverageOutpatient HospitalCoverageWhat YouShould KnowYour costs may vary depending Our plan covers an unlimitedon the network:number of days for inpatienthospital stays. The chargeapplies per stay.Special Network (SN):You pay nothing per staySome services may requirepreauthorization. ContactGeneral Network (GN):the plan for details.You pay 50 copay per stayYou pay nothing per visit.Some services or itemsrequire referral from yourPCP. Some exceptions mayapply. Contact the plan fordetails.Some services may requirepreauthorization. Contactthe plan for details.Some services or itemsrequire referral from yourPCP. Some exceptions mayapply. Contact the plan fordetails.

BenefitsDoctor Visitso Primary CareProviderso SpecialistsMCS ClassicareInteliCare (HMO)o You pay nothing per visito Your costs may varydepending on the network:What YouShould KnowSpecialist visits requirereferral from your PCP.Some exceptions may apply.Contact the plan for details.Special Network (SN):You pay 3 copay per visitGeneral Network (GN):You pay 6 copay per visitPreventive Care(e.g., flu vaccine, diabeticscreenings)Emergency Careo Emergency Roomo Worldwide CoverageYou pay nothing per serviceo You pay 75 copay pervisito You pay 75 copay pervisitAny additional preventiveservices approved byMedicare during the contractyear will be covered.There may be some itemsthat are not covered at 0cost.If you are admitted to thehospital within 24 hours, youdo not have to pay yourshare of the cost foremergency care.Some plan rules andrequirements may apply forpost-stabilization care.Contact the plan for details.Worldwide coverage ismanaged throughreimbursement based ondifferent fee schedulesallowed by our plan, whichare applied according to theservice received, less thecorresponding cost sharingamount.

BenefitsUrgently NeededServiceso Urgent Careo Worldwide CoverageDiagnostic Services/Labs/Imagingo Diagnostic testsand procedureso Lab servicesMCS ClassicareInteliCare (HMO)If you are admitted to thehospital within 24 hours, youo You pay 10 copay per visit do not have to pay yourshare of the cost for urgentlyneeded services.o You pay 75 copay pervisitSome plan rules andrequirements may apply forpost-stabilization care.Contact the plan for details.o You pay 0-15% of the cost,depending on the serviceo Your costs may varydepending on the network:Special Network (SN):You pay 0% of the cost perserviceGeneral Network (GN):You pay 20% of the costper serviceo MRI, CT Scano X-RaysWhat YouShould Knowo You pay 0-15% of the cost,depending on the serviceo You pay nothing perserviceWorldwide coverage ismanaged throughreimbursement based ondifferent fee schedulesallowed by our plan, whichare applied according to theservice received, less thecorresponding cost sharingamount.Some services may requirepreauthorization. Contactthe plan for details.Some services or itemsrequire referral from yourPCP. Some exceptions mayapply. Contact the plan fordetails.

BenefitsHearing Serviceso Medicare-coveredhearing examo Routine hearing examo Hearing aidsDental Serviceso Medicare-coveredservicesMCS ClassicareInteliCare (HMO)o You pay nothing perhearing examo You pay nothing perroutine hearing examo Hearing aids coveredo You pay 5% of the cost forMedicare-covered serviceso Oral exam & cleaningo You pay 5 copay peroffice visito Fillingso You pay 5% of the costper serviceo Complete and/orpartial removabledenturesVision Serviceso Medicare-covered eyeexamo You pay 33% of the costo Routine eye examo You pay nothing per routineeye examo Eyewear coveredo Non-Medicarecovered eyeglasses(frames and lenses)Mental Health Serviceso Inpatient visito Outpatient individualtherapy visito Outpatient grouptherapy visito You pay nothing per eyeexamo You pay nothing per stayo You pay 10 copay peroutpatient individualtherapy visito You pay 10 copay peroutpatient group therapyvisitWhat YouShould KnowUp to 300 every year forhearing aids.Some services or itemsrequire referral from yourPCP. Contact the plan fordetails.Up to 500 every year fordental benefits.Up to 750 every five yearsfor prosthodontics.Some services may requirepreauthorization. Contactthe plan for details.Up to 200 every year foreyewear.Provider and/or membermust verify remainingcombined maximum planbenefit coverage amountavailable.Inpatient visit: Our plancovers up to 190 days in alifetime for inpatient mentalhealth care in a psychiatrichospital. The inpatienthospital care limit does notapply to psychiatric inpatienthospital services provided ina general hospital.

BenefitsSkilled Nursing FacilityMCS ClassicareInteliCare (HMO)You pay nothing per stayWhat YouShould KnowSome services may requirepreauthorization. Contactthe plan for details.Our plan covers up to100 days in a SNF.Some services may requirepreauthorization. Contactthe plan for details.Physical TherapyYou pay 3 copay per visitSome services or itemsrequire referral from yourPCP. Some exceptions mayapply. Contact the plan fordetails.We also cover occupationaltherapy and speech andlanguage therapy. Review theEvidence of Coverage orcontact the plan to getinformation about applicablecost shares.Some services may requirepreauthorization. Contactthe plan for details.AmbulanceYou pay nothing per serviceTransportationYou pay nothingSome services or itemsrequire referral from yourPCP. Some exceptions mayapply. Contact the plan fordetails.Some services may requirepreauthorization. Contactthe plan for details.Six (6) trips (one-way trip orreturn trip) to plan-approvedlocations every year. Someplan rules and requirementsmay apply, contact the planfor details.