2023 Summary of Benefits - UCare Medicare with M Health Fairview & North Memorial Plans Comparison Guide - UCare Medicare with M Health ...
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Carla
UCare figure-outer
Dani Fitterer, PA-C
Primary Care,
M Health Fairview
Eden Prairie Clinic
2023 Summary of Benefits
UCare Medicare with M Health Fairview & North Memorial
Plans Comparison Guide
Medicare Advantage — Metro
your shopping
checklist Why UCare with M Health Fairview
& North Memorial Health?
enroll in Original Medicare Medicare can feel overwhelming when you’re trying to
figure it out on your own. Our team of de-complicators
select the plan that fits your lifestyle can make it easier.
enroll in a UCare Medicare Advantage plan We’re the figure-outers who can tell you what you need
to know about Medicare and help you pick a plan that’s
right for you.
UCare, M Health Fairview and North Memorial Health
formed a special partnership to offer this network-based
Medicare Advantage plan. You’ll receive high-quality care
3 ways to
enroll
from providers you know and trust — and pay less for
care when you use in-network providers.
UCare Medicare with M Health Fairview & North
Memorial Health gives you peace of mind with coverage
that protects your health and your wallet.
online by mail phone
ucare.org/medicare123 fill out the enrollment call 1-877-671-1064
form and mail it in the to enroll with a
fast and easy
postage-paid envelope licensed Medicare
Sales Specialist This booklet gives you a summary of what we cover and what you pay. It doesn’t list every service that we
secure data transfer cover or list every limitation or exclusion. Some services require prior authorization. To get a complete list
call a trusted UCare of services we cover, call us and ask for the Evidence of Coverage.
save enrollment to finish
broker near you This information is not a complete description of benefits. Call 1-877-671-1064 (TTY users call
at later time
1-800-688-2534) for more information.
UCare Health, Inc. is an HMO-POS plan with a Medicare contract. Enrollment in UCare Health depends on
contract renewal.
ucare.org/medicare123 or call 1-877-671-1064 1
Understanding the four parts of Medicare
ABC &D
Original Medicare is made up of two parts — Part A and Part B
Part A — hospital coverage
the Medicare Part A helps pay for inpatient hospital and skilled nursing facility stays, hospice
care and home health care.
of Medicare Part B — medical coverage
Medicare Part B helps pay for a wide range of medical expenses including doctor visits,
many preventive screenings, lab tests, X-rays, outpatient procedures, mental health
services, durable medical equipment and more.
Confused about Medicare? Our team
of de-complicators is at your service to
answer your toughest questions. We Part C — Medicare Advantage plan
Think of Part C (Medicare Advantage plan) as
help you navigate so you can choose a package.
It combines Part A with Part B, then may add
the health plan that’s right for you. special benefits that Medicare does not cover, such
as vision and dental care. Many packages even
include Part D prescription drug coverage.
Additional coverage
and services Discover the all-in-one convenience of a Medicare
prescription eyewear, hearing aids, Advantage plan. Get all your health benefits in one
dental, health & wellness package and find peace of mind in protecting your
health and managing your out-of-pocket costs.
Medicare
Advantage plan
Part D — outpatient prescription drug coverage
Part D is available to anyone enrolled in Medicare. Keep in mind that if you decline it,
either Medicare Part A or Part B. Part D can but decide you want this coverage later, you
be purchased through two types of health may have to pay a penalty.
plans: Medicare Advantage plans that include
Part D or stand-alone prescription drug plans. Most Part D plans have a monthly premium,
and benefits and drug costs that vary by plan.
If you want to know more about the coverage and costs of Original Medicare, look in your current You must choose whether or not to enroll Each health plan publishes a list of covered
Medicare & You handbook. View online at medicare.gov or get a copy by calling 1-800-MEDICARE in Part D when you first become eligible for drugs called a formulary.
(1-800-633-4227), 24 hours a day, seven days a week. TTY users call 1-877-486-2048.
2 ucare.org/medicare123 or call 1-877-671-1064 3
When am I eligible for Original Medicare? When can I make changes to my Medicare coverage?
You qualify for Medicare if you:
Annual Election Period (AEP)
• Are 65 or older or meet special criteria
Every year between October 15 and December 7, you can make
• Worked for at least 10 years and paid Medicare taxes (or your spouse did) a plan change to be effective on January 1 of the following year.
• Are a citizen and permanent resident of the United States This change may include adding or dropping Medicare Part D. Oct 15 – Dec 7 Jan 1
Note: Medicare Advantage plans release their rates and benefits Annual Election Coverage
How do I enroll in Original Medicare? for the following year on October 1. Period begins
You may apply online at ssa.gov/medicare, via telephone appointment at 1-800-772-1213
(TTY users call 1-800-325-0778), or in person at a local Social Security office. Special Enrollment Periods (SEPs)
You may qualify for a Special Enrollment Period at any point during the year if you:
When can I enroll in a Medicare Advantage plan? • Are leaving or losing coverage through an employer or union (including COBRA)
• Move to an area where your current plan isn’t offered
Medicare has limits to when and how often you can change your Medicare Advantage plan. These
specific time frames, called “election periods,” determine when you can enroll in or leave a Medicare • Are on Medical Assistance or no longer qualify for Medical Assistance
Advantage plan. • Receive Extra Help for Medicare Part D
• Are losing your current coverage or your plan is no longer offered
Initial Coverage Election Period (ICEP)
When you become eligible for Medicare (either by age or disability), you may enroll in Original Medicare Advantage Open Enrollment Period (MA-OEP)
Medicare and a Medicare Advantage plan during your Initial Coverage Election Period (ICEP). When During the MA-OEP, Medicare Advantage members may enroll in another Medicare Advantage plan
you enroll during the ICEP, the soonest Medicare allows us to accept your enrollment application is or disenroll from their Medicare Advantage plan and return to Original Medicare (limited to one
three months before you become eligible. change). This period runs from January 1 through March 31 or if you are newly enrolled in Medicare,
If you have had Part A and are just applying for Part B, the ICEP is limited to the three months prior within your first three months of enrollment.
to your enrollment in Part B.
Enroll when first eligible
You have a seven‑month period (three months before you turn 65, the month you turn 65, and
three months after your birthday month).
Example
birthday is July 4 Apr May Jun July Aug Sept Oct
3 months before 3 months after
Late enrollment penalties
If you don’t sign up for Part B and Part D when you first become eligible, Medicare
may apply a penalty if you decide to sign up later. You’ll pay the penalty for as
long as you have Part B and Part D coverage. Some exceptions apply.
4 ucare.org/medicare123 or call 1-877-671-1064 5
Why choose
Medicare Advantage?
UCare Medicare Advantage plans with M Health Fairview and
North Memorial Health offer all-in-one convenience, with
medical and Medicare Part D prescription drug coverage in
one simple plan. And you’ll get extras like dental, prescription
eyewear, hearing aids, and fitness benefits.
Get the benefits and coverage you need
Network — all M Health Fairview and North Memorial
Health doctors, clinics and hospitals, as well as other
independent providers
Choice — plans and premiums to fit your needs,
lifestyle and budget
Customer service — local and easy to reach
Convenience — medical and Medicare Part D
prescription drug coverage in one plan
Lots of extras — dental, prescription eyewear, hearing aids
and fitness benefits
Online care — 24/7 diagnosis and treatment from an
M Health Fairview or North Memorial Health provider
prescription drug dental coverage over-the-counter
coverage benefit
fitness options caregiver and prescription eyewear
wellness support and hearing aids
6 ucare.org/medicare123 or call 1-877-671-1064 7Picture yourself in one of our plans
UCare partners up
for your health
You can make the most of your health care dollar and access Choose from two plans:
every type of care you may need with our M Health Fairview and • Care Wise: Cindy Robert
North Memorial Health plans. In addition to the high-quality care M Health Fairview Cindy likes that her primary Robert is in good health and
you’ll get from M Health Fairview and North Memorial Health, care doctor is in her plan’s wants an affordable plan that
& North Memorial
provider network. She is willing covers all the care he might
you can also see specialists at the University of Minnesota and (HMO-POS)* to pay a little more when she need. He likes that specialists are
many popular independent providers. And you’ll never need a • Care Core: gets care. With Care Wise, she included in the Care Core network,
referral to see a specialist. M Health Fairview gets great value, a $0 monthly and that he won’t have a copay for
premium and $19 refund on visits to his primary care doctor.
& North Memorial her Part B premium. The dental coverage and online
You’ll get the same great coverage at many out-of-state providers (HMO-POS)* care options are a bonus.
with our expanded MultiPlan national network. You also get
out‑of‑network coverage with any provider that accepts Medicare Care Wise Care Core
but you may pay more. To find a doctor in the plan network or
Plan premium
see if your prescriptions are on our list of covered drugs, go to (you must continue to $0 $42
ucare.org/medicare123 and choose “Medicare with M Health pay your Part B premium)
Fairview & North Memorial Health” under “Pick your plan.”
Medical and hospital
more than 4,350
Fitness programs
650 total
providers
Dental
clinics
12
hospitals
Prescription eyewear
and hearing aids
Over-the-counter
benefit
metro counties Medicare Part D
Anoka, Chisago, Dakota, Hennepin,
prescription drug
coverage
Isanti, Ramsey, Washington
Coverage when traveling
For information about plans available in other counties, call us at Maximum out-of-pocket $5,800 $5,500
1-877-671-1064 (TTY users call 1-800-688-2534),
8 am – 8 pm, seven days a week (Oct. 1 – March 31), *HMO-POS: Health Maintenance Organization with a Point‑of-Service contract
8 am – 8 pm, Monday – Friday (April 1 – Sept. 30).
8 ucare.org/medicare123 or call 1-877-671-1064 9Prescription drug coverage
Refer to the chart on page 22 for more information on these benefits.
Find a drug
Search our List of Covered Drugs (formulary) at ucare.org/medicare123, click on
“Learn more” under “Find a doctor or drug” and open the Drug List tab.
If you prefer, use the printed 2023 List of Covered Drugs provided. Check the
alphabetical index in the back to find your drugs.
Fitness options Find a pharmacy
Fill your prescriptions at one of more than 22,000 preferred and 42,000 standard
pharmacies in our plan network.
One Pass fitness program You’ll save more when you use preferred pharmacies:
One Pass is a fitness program for your body and mind, available to you at no • Preferred retail pharmacies include Fairview, North Memorial Health, CVS/Target,
additional cost. You’ll have access to more than 23,000 participating fitness locations Coborn’s, Costco, Cub Foods, Sam’s Club/Walmart and Hy-Vee
nationwide, plus: • Express Scripts preferred mail order pharmacy provides a 90-day supply for
• More than 32,000 on-demand and live-streaming fitness classes two copays
• Workout builders to create your own workouts You can also fill your prescriptions at standard cost-share pharmacies nationwide,
• A home fitness kit available to members who are physically unable to visit or including Walgreens.
who reside at least 15 miles outside a participating fitness location
Search for a full list of preferred pharmacies at ucare.org/medicare123, click on
• Personalized, online brain training program to help improve memory, attention “Learn more” under “Find a doctor or drug” and open the Pharmacies tab.
and focus
If you prefer, call for help or request a Provider and Pharmacy Directory
• More than 30,000 social activities, community classes, and events available for at 1-877-671-1064.
online or in-person participation
• Find participating locations near you at ucare.org/onepass or call 1-877-504-6830
(TTY 711), 8 am – 9 pm, Monday – Friday Low copays on select formulary insulins
You won’t pay more than $35 for a one-month supply of each insulin product
Health Club Savings
covered by our plan, no matter what cost-sharing tier it’s on even if you haven’t
Join a class, work with weights, swim some laps, or try something new. paid your deductible.
Health Club Savings offers the variety you want and the flexibility you
deserve. If you belong to a participating health club that is not in the
One Pass network, you can receive a reimbursement of up to $30 in
your monthly health club membership fees.
How it works
Bring your UCare member ID card to your health club to sign up. To see a full list of
participating health clubs, visit ucare.org/fitness.
10 ucare.org/medicare123 or call 1-877-671-1064 11Over-the-counter benefit
Refer to the chart on page 21 for more information on these benefits.
Our plans help you save money in lots of ways, including an over-the-counter (OTC)
benefit through Healthy Savings®. You’ll receive an allowance to use twice a year.
Dollars you don’t use will expire on June 30 and Dec. 31. You cannot redeem your
allowance for cash. Eligible items include cough drops, first aid supplies, pain relief,
sinus medications, toothpaste, and much more. Find participating locations, browse
eligible items, and learn more at healthysavings.com/ucare.
Participating stores include:
Use your
• Walmart • Hornbachers
Healthy • Cub • Hy-Vee
Savings OTC • Coborn’s • Kowalski’s
• CVS (not applicable • Lunds & Byerlys
benefit to CVS in Target) • Super One Foods
Prescription eyewear Dental coverage
Refer to the chart on page 20 for more information on these benefits. Refer to the chart on page 19 for more information on these benefits.
Our plans include a vision benefit with a $100 allowance for prescription glasses Both plans include dental coverage. You can make the most of your dental benefits
or contact lenses. when you see providers in the Delta Dental National Medicare Advantage network.
You may pay more for services if you see a provider outside this network.
To find a dentist in the network, go to deltadentalmn.org/find-a-dentist and select
“I want to see if a dentist is in-network” or “I’m looking for a new dentist” if you don’t
Hearing aids have one.
Refer to the chart on page 19 for more information on these benefits.
Members enjoy a deep discount on high-quality hearing aids through TruHearing.®
Choose from a variety of premium and standard hearing aids. All hearing aids include
a 3-year warranty and up to one year of follow-up visits. Premium models include the
option of a rechargeable battery.
12 ucare.org/medicare123 or call 1-877-671-1064 13Caregiver Assurance program
Refer to the chart on page 21 for more information on these benefits.
Caregiver support is just a phone call away with M Health Fairview’s Caregiver
Assurance™ program. A dedicated Caregiver Advisor provides guidance, resources
and service referrals to help ease the stress that caregivers may experience. Caregiver
Advisors are licensed social workers with training and experience in caregiving and
aging. You or your caregiver will receive guidance tailored to your situation and needs.
UCare Wellness Advisor program
Refer to the chart on page 21 for more information on these benefits.
In partnership with M Health Fairview, the UCare Wellness Advisor program provides
members with a dedicated well-being expert who offers support, counseling and
resources to help manage your emotional wellness and improve your overall health.
Help is just a call away and conversations are completely confidential.
Community education discount
Get up to a $15 discount on most Minnesota community education classes. Check
your local community education catalog or contact the local school district for class
Care by phone or online
times and locations. Limit of three discounts in a calendar year (one discount per Refer to the chart on page 18 for more information on these benefits.
class enrollment).
Telehealth visits are included for Medicare-approved services. E-visits through
M Health Fairview MyChart (online evaluation and diagnosis) are covered for
some conditions.
14 ucare.org/medicare123 or call 1-877-671-1064 15Enrollment
Choose a clinic
Select a primary care clinic from the Primary
3 ways to Plan benefit details
Care Clinic Listing found in your plan information
enroll
kit. Within this clinic, you may see any doctor.
You may see any specialist in our network
without a referral.
TABLE OF CONTENTS
Forms by mail
We must receive your enrollment application
by (not postmarked by) the end of the month Monthly Plan Premium. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . page 18
prior to when you want coverage to start (except
during the Annual Election Period — must be ucare.org/medicare123
Maximum Out-of-pocket . . . . . . . . . . . . . . . . . . . . . . . . . . . . . page 18
received by 12/7 for a 1/1 effective date).
fast and easy
Once we receive your enrollment Hospital Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . page 18
secure data transfer
application, you:
• may receive a call from us if any required
online save enrollment to Doctor Visits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . page 18
information is missing from the enrollment form finish at later time
Preventive Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . page 18
• get a letter within 15 days to verify
your enrollment
Diagnostic Tests, Radiation Therapy, X-rays,
• may receive a letter from us if you did not
have a Medicare Part D plan from the date and Lab Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . page 19
you were first eligible fill out the enrollment
• may receive a letter from us if you are leaving form and mail it in the Hearing Aids. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . page 19
an employer group plan to join our plan postage-paid envelope
• will get a new member packet
• will get a UCare member identification card that
by mail Dental Coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . page 19
you can begin using on your effective date Vision Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . page 20
Should you require medical services or
Mental Health Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . page 20
prescription drugs before you receive your
ID card, please call Customer Service at call 1-877-671-1064
1-888-618-2595 (TTY users call 1-800-688-2534). Skilled Nursing Facility Care. . . . . . . . . . . . . . . . . . . . . . . . . . . page 20
to enroll with a
licensed Medicare
How to pay your premiums Sales Specialist
Other Services: Includes Physical Therapy,
You can choose to pay your monthly premium:
• by check
phone call a trusted UCare
Ambulance, Chiropractic and More. . . . . . . . . . . . . . . . page 20
• automatic payment/Electronic Funds
broker near you Coverage When Traveling. . . . . . . . . . . . . . . . . . . . . . . . . . . . . page 21
Transfer (EFT)
• Social Security or Railroad Retirement Medicare Part D Coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . page 22
Board withdrawal
• online at member.ucare.org
Please do not send payment with your
enrollment form.
16 ucare.org/medicare123 or call 1-877-671-1064 17Care Wise Care Core Care Wise Care Core
2023 monthly plan premium (you must $0 $42 Emergency / Urgent Care — network does not apply
continue to pay your Medicare Part B premium)
Emergency care $100 copay $100 copay
Medicare Part B premium reduction $19 $0
Urgently needed services $45 copay $45 copay
Medical deductible $0 $0
Diagnostic Tests, Radiation Therapy, X-rays and Lab Services
Medicare Part D deductible Tier 1 = $0 Tiers 1 & 2 = $0
Tiers 2 – 5 = $480 Tiers 3 – 5 = $395 Diagnostic tests (e.g., MRI and CT scans), 20% coinsurance 10% coinsurance up to a
radiation therapy and X‑rays maximum of $150 per day
Maximum out-of-pocket $5,800; then 100% covered $5,500; then 100% covered
The most you will pay out‑of‑pocket for Lab services (e.g., Protime INR, cholesterol) In-network $0 copay In-network $0 copay
in-network Medicare-covered services each Out-of-network $0 copay Out-of-network $0 copay
year. Excludes Medicare Part D and all other
non‑Medicare covered services and premium. Hearing Services
This is not a deductible.
Diagnostic hearing exam $50 copay $40 copay
Hospital Care
Annual routine hearing exam, hearing aid In-network $0 copay In-network $0 copay
Inpatient hospital care (per admission) $350 copay per day (days $250 copay per day (days
1 – 5); then 100% covered 1 – 5); then 100% covered fitting and evaluation through TruHearing Out-of-network Not covered Out-of-network Not covered
(three per year)
Outpatient hospital or procedure $395 copay $250 copay
TruHearing aids in both Advanced and $699 copay for Advanced $699 copay for Advanced
Ambulatory surgery center $395 copay $250 copay Premium models (two different copay
amounts; two aids per year) $999 copay for Premium $999 copay for Premium
Doctor Visits — in person or telehealth for Medicare-approved services
Dental Coverage — included at no additional cost
Primary $0 copay $0 copay
Deductible $0 $100 per year (does not
Specialist $45 copay $40 copay
apply to preventive
E-visits through M Health Fairview MyChart $0 copay $0 copay services or periodontal
maintenance cleanings)
Preventive Care
Annual plan maximum $300 $2,000
Routine physical exam In-network $0 copay In-network $0 copay
Out-of-network Not covered Out-of-network Not covered
Oral examinations Covered up to $300 Two per year
For the next four rows, the $0 copay applies in-network and out-of-network for both plans. allowance limit
Routine cleanings Two per year
“Welcome to Medicare” preventive visit $0 copay $0 copay
(if in the first 12 months on Part B) X‑rays Annual bitewing and full
mouth every 5 years
Annual Wellness Exam (if you’ve had Part B for $0 copay $0 copay
more than 12 months) Fluoride treatment Covered
Flu and pneumonia vaccines $0 copay $0 copay Periodontal maintenance cleanings Covered
Mammogram screening, prostate cancer $0 copay $0 copay
Basic restorative services (e.g., fillings, root 50% coinsurance
screening exam, bone mass measurement,
diabetes screening, preventive colorectal canals, periodontal services)
cancer screening
Major restorative procedures (e.g., crowns, 70% coinsurance
In general, out-of-network cost-sharing in the U.S. is 25%; cost-sharing is the same both in and out-of-network bridges, implants, dentures)
for some services.
For dental limitations and exclusions, see page 26.
18 ucare.org/medicare123 or call 1-877-671-1064 19Care Wise Care Core Care Wise Care Core
Vision Services Other Services continued
Diagnostic eye exam $50 copay $40 copay Acupuncture Doctor visit copays apply Doctor visit copays apply
(see page 18) (see page 18)
Annual routine eye exam and up to two In-network $0 copay In-network $0 copay Both plans cover acupuncture for chronic low
refractions per year Out-of-network Not covered Out-of-network Not covered back pain, based on Medicare criteria
Podiatry services $45 copay $40 copay
Diabetic retinopathy exam $0 copay $0 copay
Over-the-counter (OTC) benefit $75 allowance twice a year $75 allowance twice a year
Prescription eyeglasses or contact lenses after $0 copay $0 copay
cataract surgery Caregiver Assurance phone consultation $0 copay $0 copay
Annual allowance for prescription eyeglasses $100 $100 UCare Wellness Advisor $0 copay $0 copay
or contacts at your preferred eyewear retailer Covers six 60-minute sessions annually
Mental Health Services Durable medical equipment^ (e.g., oxygen In-network 20% coinsurance In-network 20% coinsurance
equipment, CPAP) Out-of-network Not covered Out-of-network Not covered
Inpatient hospital stay (90-day limit per stay) $350 copay per day $250 copay per day (days
Limited to 190 days in a lifetime in a (days 1 – 5); then 1 – 5); then 100% covered Prosthetic devices (e.g., braces, colostomy 20% coinsurance 20% coinsurance
psychiatric hospital 100% covered bags and supplies)
Diabetic supplies
Outpatient mental health care $40 copay $40 copay
• Continuous blood glucose monitors 20% coinsurance 20% coinsurance
Skilled Nursing Facility Care (or swing bed)^ • Other glucose monitors 20% coinsurance 10% coinsurance
Care in a skilled nursing facility with $0 copay per day for days $0 copay per day for days • Test strips and lancets 20% coinsurance 10% coinsurance
no prior 3-day hospital stay required 1 – 20; $196 copay per 1 – 20; $196 copay per day • Inserts and shoes 20% coinsurance 10% coinsurance
day for days 21 – 100; for days 21 – 100; per
per benefit period benefit period (Insulin and syringes covered under
Medicare Part D)
Other Services
Coverage When Traveling — In addition to the in-network coverage you get at UCare with M Health Fairview
Physical therapy $40 copay per visit $40 copay per visit & North Memorial Health network providers and at out-of-state MultiPlan network providers, you’re also
covered at other providers accepting Medicare, but you may pay more.
Ambulance (within the U.S. and its territories) $300 copay $275 copay
Care from any out-of-network provider 25% of the cost of services 25% of the cost of services
Includes air and/or ground that accepts Medicare
Transportation (non-emergency) Not covered Not covered Emergency care $100 copay $100 copay
Medicare Part B Drugs^ 0 – 20% coinsurance 0 – 20% coinsurance Urgently needed services $45 copay $45 copay
Generally, drugs that must be administered by Ambulance (within the U.S. and its territories) $300 copay $275 copay
a health professional Includes air and/or ground
Chiropractic services through ChiroCare In-network $20 copay In-network $20 copay Worldwide Emergency Care (outside the U.S. and its territories)
network^ Out-of-network Not covered Out-of-network Not covered
Emergency care including post-stabilization $100 copay $100 copay
Manual manipulation of the spine to correct
subluxation Ground ambulance to the nearest hospital for $100 copay $100 copay
emergency care
^Service requires prior authorization. Beginning April 1, 2023, certain drugs may have a lower coinsurance.
Note: Only emergency coverage is worldwide. You may want to consider purchasing a separate travel policy
while traveling outside the U.S. for services such as air ambulance.
20 ucare.org/medicare123 or call 1-877-671-1064 21Care Wise Care Core Care Wise Care Core
Medicare Part D Coverage Coverage Gap
Cost Sharing for Deductible: You pay the full Tier 1 = $0 Tiers 1 & 2 = $0 Once you have reached $4,660 in annual 25% of the cost of generic 25% of the cost of generic
cost of your drugs until you reach this amount Tiers 2 – 5 = $480 Tiers 3 – 5 = $395 prescription drug spending (your cost plus and brand drugs and brand drugs
UCare’s cost), you pay as shown
Initial Coverage Phase: From $0 to $4,660 in annual prescription drug costs. After you meet the
deductible, you pay the amounts listed below Catastrophic Coverage
Cost Sharing (Retail): Our network includes preferred pharmacies, which offer lower cost sharing than Once you have reached $7,400 in annual You pay You pay
standard network pharmacies prescription drug spending (excluding UCare’s The greater of $4.15 or The greater of $4.15 or
cost), you pay as shown 5% coinsurance for 5% coinsurance for
Tier 1 Retail — 30-day supply Retail — 30-day supply generic drugs generic drugs
Preferred generic drugs Preferred: $3 copay Preferred: $3 copay
Standard: $12 copay Standard: $12 copay The greater of $10.35 or The greater of $10.35 or
5% coinsurance for all 5% coinsurance for all
Tier 2 Retail — 30-day supply Retail — 30-day supply other drugs other drugs
Generic drugs Preferred: $15 copay Preferred: $15 copay
Standard: $20 copay Standard: $20 copay
Tier 3 Retail — 30-day supply Retail — 30-day supply
Preferred brand drugs Preferred: 17% coinsurance Preferred: $47 copay Preferred Pharmacies Standard Pharmacies
Standard: 25% coinsurance Standard: $47 copay More savings — Pay less for your More choice — Fill your
Select insulin
Preferred: $30 copay drugs at more than 22,000 pharmacies, prescriptions at more than 42,000
Standard: $35 copay including Fairview, North Memorial Health, standard cost-share pharmacies
CVS/Target, Coborn’s, Costco, Cub Foods, nationwide, including Walgreen’s
Tier 4 Retail — 30-day supply Retail — 30-day supply Sam’s Club/Walmart and Hy-Vee
Non-preferred drugs Preferred: 50% coinsurance Preferred: 50% of the cost
Standard: 50% coinsurance Standard: 50% of the cost Search for a full list of preferred pharmacies at ucare.org/medicare123, click
Tier 5 Retail — 30-day supply Retail — 30-day supply on “Learn more” under “Find a doctor or drug” and open the Pharmacies tab.
Specialty drugs Preferred: 25% coinsurance Preferred: 26% of the cost If you prefer, call for help or request a Provider and Pharmacy Directory
Standard: 25% coinsurance Standard: 26% of the cost
at 1-877-671-1064.
Cost-sharing may differ based on pharmacy type or status (mail-order, retail, long-term care (LTC), home
infusion), whether the pharmacy is in our preferred or standard network or whether the prescription is a
30-, 60-, or 90-day supply.
Additional requirements or limits on covered drugs — Some covered drugs may have additional
requirements or limits on coverage. These may include: Prior Authorization (PA), Quantity Limits (QL), or You may be able to get Extra Help to help pay for your prescription
Step Therapy (ST). Visit ucare.org/medicare123 to find out if your drug has any additional requirements drug premium and costs.
or limits. You can also ask us to make an exception to these restrictions or limits. Details on how to make
these requests are in the formulary and in the Evidence of Coverage.
Extra To see if you qualify, call:
Help for • 1-800-MEDICARE (TTY users call 1-877-486-2048), 24/7
• Social Security Administration at 1-800-772-1213 (TTY users call
Part D vaccines
Medicare 1-800-325-0778), 7 am – 7 pm, Monday – Friday
• Your State Medicaid Office or County Human Services Office
Our plans cover most Part D vaccines at no cost to you, even if you Part D • Senior LinkAge Line at 1-800-333-2433
haven’t paid your deductible. This includes the two-part shingles Some people will pay a higher premium for Medicare Part D
vaccine (SHINGRIX). coverage because their yearly income is over certain amounts.
22 ucare.org/medicare123 or call 1-877-671-1064 23Additional information If we deny a request made by you or your doctor,
for medical services or pharmaceuticals, you or
• Homemaker services include basic household
assistance, including light housekeeping or light
Provider network coverage The Benefits Chart section of the Evidence of your doctor may appeal our decision. When you meal preparation
Coverage includes the information for each of our file an appeal, you or your Doctor may submit • Fees charged for care by your immediate relatives
While you are a member of our plan, you must use additional documentation that is relevant to your
UCare Medicare Plans. This information is also at or members of your household
network providers to get your medical care and appeal. Appeal requests are reviewed against
ucare.org. • Cosmetic surgery or procedures, unless covered
services covered at in-network cost-share levels. current medical evidence and your benefit plan by
Exceptions to this include emergency care, urgent physicians. If we deny your appeal, you will be given in case of an accidental injury or for improvement of
care, out-of-area dialysis services, lab services, Understanding utilization management information on how to file a second level appeal. the functioning of a malformed body part. However,
Medicare-covered preventive screenings, and cases all stages of reconstruction are covered for a breast
Authorization and notification
in which the plan authorizes use of out-of-network Learn more after a mastectomy, as well as for the unaffected
One of the ways UCare makes sure you get excellent
providers. You can obtain certain covered services Go to ucare.org and click on “plan resources.” breast to produce a symmetrical appearance.
care is by partnering with your doctors to review
from out-of-network providers at different UCare members can also look up services in their • Routine chiropractic care, other than manual
certain types of services and procedures. We want
cost-share levels. Evidence of Coverage and Annual Notice of Change manipulation of the spine to correct a subluxation
you to get the care that is best for your needs.
documents. These documents note if notification
Out-of-network/non-contracted providers are under and authorization is required. The Evidence of • Routine foot care, except for the limited coverage
This Summary of Benefits notes which types of care
no obligation to treat UCare members, except in Coverage is provided to new members. Every renewal provided according to Medicare guidelines (e.g., if
or services require notification or authorization. This
emergency situations. Please call our Customer year, members receive an Annual Notice of Change you have diabetes)
list may change from time to time. Some examples
Service number or see your Evidence of Coverage include spine surgery and home health care. that explains any changes to their plan benefits. • Orthopedic shoes, unless the shoes are part of a
for more information, including the cost-sharing that leg brace and are included in the cost of the
applies to out-of-network services. Notification brace, or the shoes are for a person with diabetic
Hospitals are required to notify UCare if you are Consider Medicare coverage limits foot disease
admitted to a hospital, Long Term Care Facility, or The following items and services are not covered
Learn about special services • Supportive devices for the feet, except for
Skilled Nursing Facility. UCare’s clinical team will under Original Medicare or by our plan:
Care Management orthopedic or therapeutic shoes for people
coordinate with your doctors to make sure you get • Services considered not reasonable and necessary,
UCare Medicare with M Health Fairview & North with diabetic foot disease
the care you need. If needed, UCare may set up according to the standards of Original Medicare,
Memorial Health Case Management is a short-term post-hospital care. • Radial keratotomy, LASIK surgery, vision therapy
unless these services are listed by our plan as
(3 – 6 month) telephonic program for members and other low-vision aids. Eyewear except for one
Authorization covered services
challenged by multiple chronic health conditions. pair of eyeglasses (or contact lenses) after cataract
We offer care management to members with select Before some services will be covered, your provider • Experimental medical and surgical procedures, surgery and non Medicare-covered eyewear up to
diagnoses who transition to home from a hospital must get approval from UCare. This is true whether equipment and medications, unless covered by the allowed amount.
or skilled nursing facility. The Case Management the provider participates in a UCare network or is Original Medicare or under a Medicare-approved
• Reversal of sterilization procedures, and/or non
team consists of registered nurses whose primary out-of-network. clinical research study or by our plan. Experimental
prescription contraceptive supplies
focus is on assisting our members with medical procedures and items are those determined by
To make a coverage decision, UCare’s clinical team • Acupuncture (except for chronic low back pain)
case management needs such as health decision our plan and Original Medicare to not be generally
evaluates if the service is medically necessary,
support and disease specific education. The case accepted by the medical community. • Naturopath services (uses natural or
appropriate and effective for your need.
management team also works with internal and • Private room in a hospital, except when it is alternative treatments)
external resources to provide the member with Prior authorization, or preservice review, means considered medically necessary or if it is the only Our plan will not cover the excluded services listed
needed support and help with attaining best health that before you get the service, your provider must option available above. Even if you receive the services at an emergency
outcomes. They conduct care management by provide information to UCare and request approval. facility, the excluded services are still not covered.
phone during business hours. If prior approval is required for that service, it will • Personal items in your room at a hospital or a
only be covered if the approval was granted. skilled nursing facility, such as a telephone or
Prior Authorizations a television
We cover some services listed in the benefits Urgent concurrent and concurrent review often • Full‑time nursing care in your home
chart only if your doctor or other provider gets occurs during a Long Term Care Facility, or Skilled
Nursing Facility stay. UCare will review to see if your • Custodial care — care provided in a nursing home,
approval from us in advance. Some covered
care might need to continue longer or if different hospice, or other facility setting when you do not
services that need such approval include inpatient
care is needed. require skilled medical care or skilled nursing care.
rehabilitation services, genetic, molecular diagnosis
Custodial care is personal care that does not
tests, lumber spine surgery, bariatric surgery, vein Post-service review is needed if your doctor didn’t require the continuing attention of trained medical
procedures, bone growth stimulators, and spinal request pre-service review. Your claim may have or paramedical personnel, such as care that helps
cord stimulators. Other services that require prior already been denied because authorization is you with activities of daily living, such as bathing
authorization are marked with an ^ in the chart. required for coverage. After your doctor requests or dressing.
For more information on services that require prior review, UCare will consider your situation and care
authorization by your provider, go to ucare.org. plan to make sure you get the coverage you are
entitled to as a UCare member.
24 ucare.org/medicare123 or call 1-877-671-1064 25Dental coverage limitations 8. Direct diagnostic surgical or non-surgical Notice of privacy practices What do we do with this information?
treatment procedures applied to jaw joints or We use your information to provide health plan
Frequency limits and waiting periods do not apply muscles, except as provided under Oral Surgery Effective Date: July 1, 2013
services to members and to operate our health plan.
to plans with a yearly dental allowance. Otherwise in the Evidence of Coverage Date of Last Review: July 20, 2022
These routine uses involve coordination of care,
these limitations apply to all plans. This Notice describes how medical information
9. Artificial material implanted or grafted into soft preventive health, and case management programs.
• Endodontics: Limited to one (1) per tooth about you* may be used and disclosed and how
tissue, including surgical removal of implants, For example, we may use your information to
per lifetime. with exceptions you can get access to this information. Please
talk with your doctor to coordinate a referral to a
review it carefully.
• Periodontics (other than periodontal maintenance 10. Oral hygiene instruction and periodontal exam specialist.
cleanings): Coverage is limited to one (1) 11. Services for teeth retained in relation to an *In
this Notice, “you” means the member and “we”
non-surgical periodontal treatment and one (1) We also use your information for coordination of
overdenture. Overdenture appliances are limited means UCare.
surgical periodontal treatment per quadrant every benefits, enrollment and eligibility status, benefits
to an allowance for a standard full denture
36 months. Questions? management, utilization management, premium
12. Any oral surgery that includes surgical If you have questions or want to file a complaint, billing, claims issues, and coverage decisions. For
• Bone grafting: Coverage is limited to once per endodontics (apicoectomy, retrograde filling) example, we may use your information to pay your
you may contact our Privacy Officer at UCare,
site (upper/lower ridge) in conjunction with other than that listed under Oral Surgery in health care claims.
Attn: Privacy Officer, PO Box 52, Minneapolis, MN
building the bony ridge needed for successful the Evidence of Coverage
55440-0052, or by calling our 24 hour Compliance
placement of an implant or removable 13. Analgesia (nitrous oxide) Other uses include customer service activities,
Hotline at 612-676-6525. You may also file a
prosthetics (partial/full dentures). complaints or appeals, health promotion,
14. Removable unilateral dentures complaint with the Secretary of the U.S. Department
• Major restorative services: Benefit for the quality activities, health survey information,
15. Temporary procedures of Health & Human Services at the Office for
replacement of a crown or an onlay will be provided underwriting, actuarial studies, premium rating,
Civil Rights, U.S. Department of Health & Human
only after a 60 month period, measured from the 16. Splinting legal and regulatory compliance, risk management,
Services, 233 N. Michigan Ave., Suite 240, Chicago, IL
last date the covered dental service was performed. 17. Consultations by the treating provider and professional peer review, credentialing, accreditation,
60601. We will not retaliate against you for filing a
office visits antifraud activities, as well as business planning
• Prosthetics — removable and fixed: A prosthetic complaint.
and administration. For example, we may use your
appliance (denture or bridge) for the purpose of 18. Initial installation of implants, full or partial
dentures or fixed bridgework to replace a Why are we telling you this? information to make a decision regarding an appeal
replacing an existing appliance will be covered only filed by you.
tooth or teeth extracted prior to the member’s UCare believes it is important to keep your health
after 60 months.
effective date. Exception: This exclusion will information private. In fact, the law requires us to
• Implant services: Replacing a single missing tooth. We do not use or disclose any genetic information,
not apply for any member who has been do so. The law also requires us to tell you about our
Coverage for implants is limited to once per tooth race, ethnicity, language, sexual orientation or
continuously covered under a UCare Medicare legal duties and privacy practices. We are required
per lifetime (also see Exclusion #18). gender identity for the purpose of underwriting.
Plan for more than 24 months to follow the terms of the Notice currently in effect.
19. Occlusal analysis, occlusal guards (night guards) In addition, we may use your information to provide
Dental coverage exclusions What do we mean by “information?”
and occlusal adjustments (limited and complete) you with appointment reminders, information about
In this Notice, when we talk about “information,”
These exclusions are specific to dental coverage. treatment alternatives, or other health-related
20. Veneers (bonding of coverings to the teeth) “medical information,” or “health information,” we
Some of these exclusions may be covered under benefits and services that may be of interest to you.
your medical benefit: mean information about you that we collect in our
21. Orthodontic treatment procedures We may also share information with family members
business of providing health coverage for you and
1. Dental services that are not necessary or 22. Corrections to congenital conditions, other than or others you identify as involved with your care,
your family. It is information that identifies you.
specifically covered for congenital missing teeth or with the sponsor of a group health plan, as
2. Hospitalization or other facility charges What kinds of information do we use? applicable.
23. Athletic mouth guards
We receive information about you as part of our
3. Prescription drugs We do not sell or rent your information to anyone.
24. Retreatment or additional treatment necessary work in providing health plan services and health
4. Any dental procedure performed solely as a to correct or relieve the results of previous We will not use or disclose your information for
coverage. This information includes your name,
cosmetic procedure treatment, except as noted in the Evidence fundraising without your permission. We will only use
address, and date of birth, race, ethnicity, language,
5. Charges for dental procedures completed prior of Coverage or disclose your information for marketing purposes
sexual orientation, gender identity, telephone
to the member’s effective date of coverage with your authorization. We treat information about
25. Space maintainers numbers, family information, financial information,
former members with the same protection as
6. Anesthesiologist services health records, or other health information.
current members.
7. Dental procedures, appliances or restorations Examples of the kinds of information we collect
that are necessary to alter, restore or maintain include: information from enrollment applications, Who sees your information?
occlusion, including but not limited to: claims, provider information, and customer UCare employees see your information only if
increasing vertical dimension, replacing or satisfaction or health surveys; information you give necessary to do their jobs. We have procedures
stabilizing tooth structure lost by attrition (wear), us when you call us about a question or when you and systems to keep personal information secure
realignment of teeth, periodontal splinting, and file a complaint or appeal; information we need from people who do not have a right to see it.
gnathologic recordings to answer your question or decide your appeal; We may share the information with providers
and information you provide us to help us obtain and other companies or persons working with or
payment for premiums. for us. We have contracts with those companies
26 ucare.org/medicare123 or call 1-877-671-1064 27or persons. In those contracts, we require that For example, you may request that your mailings • You have the right to receive notifications of If you believe that UCare has failed to provide these
they agree to keep your information confidential. be sent to a work address rather than your home breaches of your unsecured protected health services or discriminated in another way on the
This includes our lawyers, accountants, auditors, address. We may ask that you make your request information. basis of race, color, national origin, age, disability or
third party administrators, insurance agents or in writing. sex, you can file an oral or written grievance.
brokers, information systems companies, marketing • You have the right to receive a copy of this Notice
• You have the right to look at or get a copy of from us upon request. This Notice took effect
companies, disease management companies, or Oral grievance
certain information we have about you. This July 1, 2013 and was last revised on July 20, 2022.
consultants. If you are a current UCare member, please call the
information includes records we use to make
number on the back of your membership card.
We also may share your information as required decisions about health coverage, such as payment, How do we protect your information?
enrollment, case, or medical management records. Otherwise please call 612-676-3200 or toll free at
or permitted by law. Information may be shared UCare protects all forms of your information, written,
We may ask you to make your request in writing. electronic and oral. We follow the state and federal 1-800-203-7225 (voice); 612-676-6810 or toll free
with government agencies and their contractors at 1-800-688-2534 (TTY). You can also use these
as part of regulatory reports, audits, encounter We may also ask you to provide information we laws related to the security and confidentiality of
need to answer your request. We have the right to your information. We have many safety procedures numbers if you need assistance filing a grievance.
reports, mandatory reporting such as child abuse,
neglect, or domestic violence; or in response to charge a reasonable fee for the cost of making and in place that physically, electronically and Written grievance
a court or administrative order, subpoena, or mailing the copies. In some cases, we may deny administratively protect your information against
Mailing Address
discovery request. We may share information with your request to inspect or obtain a copy of your loss, destruction or misuse. These procedures
UCare
health oversight agencies for licensure, inspections, information. If we deny your request, we will tell include computer safeguards, secured files and
Attn: Appeals and Grievances
disciplinary actions, audits, investigations, you in writing. We may give you a right to have the buildings and restriction on who may access your
decision reviewed. Please let us know if you have PO Box 52
government program eligibility, government program information.
any questions about this. Minneapolis, MN 55440-0052
standards compliance, and for certain civil rights What else do you need to know? Email: cag@ucare.org Fax: 612-884-2021
enforcement actions. We also may share information • You have the right to ask us to correct or add We may change our privacy policy from time to time.
for research, for law enforcement purposes, with missing information about you that we have in You can also file a civil rights complaint with the
As the law requires, we will send you our Notice if
coroners to permit identification or determine cause our records. Your request needs to be in writing. U.S. Department of Health and Human Services,
you ask us for it. If you have questions about this
of death, or with funeral directors to allow them to In some cases, we may deny a request if the Office for Civil Rights, electronically through the
Notice, please call UCare Customer Service at the
carry out their duties. We may be required to share information is correct and complete, if we did not Office for Civil Rights Complaint Portal, available at
toll-free number listed on the back of your member
information with the Secretary of the Department create it, if we cannot share it, or if it is not part of card. This information is also available in other forms https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by
of Health and Human Services to investigate our our records. All denials will be in writing. You may to people with disabilities. Please ask us for that mail or phone at:
compliance efforts. There may be other situations file a written statement of disagreement with us. U.S. Department of Health and Human Services
information.
when the law requires or permits us to share We have the right to disagree with that statement. 200 Independence Avenue SW
information. Even if we deny your request to change or add to Room 509F, HHH Building
your information, you still have the right to have Notice of nondiscrimination Washington, D.C. 20201
We only share your psychotherapy notes with your written request, our written denial, and your UCare complies with applicable Federal civil rights 1-800-368-1019, 1-800-537-7697 (TDD)
your authorization and in certain other limited statement of disagreement included with your
circumstances. laws and does not discriminate on the basis of race, Complaint forms are available at
information. color, national origin, age, disability or sex. UCare does http://www.hhs.gov/ocr/office/file/index.html
Other uses and disclosures not described above • You have the right to receive a listing of the times not exclude people or treat them differently because
will be made only with your written permission. We when we have shared your information in some of race, color, national origin, age, disability or sex.
will also accept the permission of a person with cases. Please note that we are not required to
authority to represent you. provide you with a listing of information shared We provide aids and services at no charge to people
prior to April 14, 2003; information shared or used with disabilities to communicate effectively with us, Healthy Savings is a registered trademark of
In most situations, permissions to represent you may for treatment, payment, and health care operations such as TTY line, or written information in other Solutran, Inc.
be cancelled at any time. However, the cancellation purposes; information shared with you or someone formats, such as large print. TruHearing is a registered trademark of
will not apply to uses or disclosures we made else as a result of your permission; information TruHearing, Inc.
If you need these services, contact us at
before we received your cancellation. Also, once we that is shared as a result of an allowed use or 612-676-3200 (voice) or toll free at 1-800-203-7225 MultiPlan is a registered trademark of
have permission to release your information, we disclosure; or information shared for national
cannot promise that the person who receives the (voice), 612-676-6810 (TTY), or 1-800-688-2534 (TTY). Multiplan, Inc.
security or intelligence purposes. All requests for
information will not share it. this list must be in writing. We will need you to We provide language services at no charge to SHINGRIX is a registered trademark of the GSK
provide us specific information so we can answer people whose primary language is not English, such group of companies.
What are your rights?
your request. If you request this list more than as qualified interpreters or information written in
• You have the right to ask that we don’t use or share
once in a 12-month period, we may charge you a other languages.
your information in a certain way. Please note that
reasonable fee. If you have questions about this, If you need these services, contact us at the
while we will try to honor your request, we are not
please contact us at the address provided at the
required to agree to your request. number on the back of your membership card or
end of this Notice.
• You have the right to ask us to send information 612-676-3200 or toll free at 1-800-203-7225 (voice);
to you at an address you choose or to request 612-676-6810 or toll free at 1-800-688-2534 (TTY).
that we communicate with you in a certain way.
28 ucare.org/medicare123 or call 1-877-671-1064 29Notes
ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística.
Llame al 612-676-3200/1-800-203-7225 (TTY: 612-676-6810/1-800-688-2534).
LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau
612-676-3200/1-800-203-7225 (TTY: 612-676-6810/1-800-688-2534).
XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni
argama. Bilbilaa 612-676-3200/1-800-203-7225 (TTY: 612-676-6810/1-800-688-2534).
CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số
612-676-3200/1-800-203-7225 (TTY: 612-676-6810/1-800-688-2534).
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 612-676-3200/
1-800-203-7225（TTY：612-676-6810/1-800-688-2534）。
ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги
перевода. Звоните 612-676-3200/1-800-203-7225 (телетайп: 612-676-6810/1-800-688-2534).
ໂປດຊາບ: ຖາ້ ວາ່ ທາ່ ນເວົ້າພາສາ ລາວ, ການບໍລກ
ິ ານຊວ
່ ຍເຫຼືອດາ້ ນພາສາ, ໂດຍບໍ່ ເສັຽຄາ່ ,
ແມນມີ
່ ພອ້ ມໃຫທ
້ າ່ ນ. ໂທຣ 612-676-3200/1-800-203-7225 (TTY: 612-676-6810/1-800-688-2534).
ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት ተዘጋጀተዋል፡ ወደ ሚከተለው ቁጥር
ይደውሉ 612-676-3200/1-800-203-7225 (መስማት ለተሳናቸው: 612-676-6810/1-800-688-2534).
ymol.ymo;=erh>uwdRAunDAusdmtCdAusdmtw>rRpXRvXAwvXmbl.vXmphRAeDwrHRb.ohM.vDRIA
ud; 612-676-3200/1-800-203-7225 (TTY: 612-676-6810/1-800-688-2534).
ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen
zur Verfügung. Rufnummer: 612-676-3200/1-800-203-7225 (TTY: 612-676-6810/1-800-688-2534).
្របយ័ក�៖ េបើសិនជ឵អ� កនិយ឵ ភ឵ស឵រ �ខ� រ, រសវ឵ជំនួយរ �ផ�កភ឵ស឵ េដ឵យមិនគិតឈ��ល
គឺឤចម឵នសំរ឵ប់បរំ រ �អ� ក។ ចូ រ ទូ រស័ព� 612-676-3200/1-800-203-7225 (TTY: 612-676-6810/
1-800-688-2534)។
اﺗﺼﻞ ﺑﺮﻗﻢ. ﻓﺈن ﺧﺪﻣﺎت اﻟﻤﺴﺎﻋﺪة اﻟﻠﻐﻮﯾﺔ ﺗﺘﻮاﻓﺮ ﻟﻚ ﺑﺎﻟﻤﺠﺎن،إذا ﻛﻨﺖ ﺗﺘﺤﺪث اذﻛﺮ اﻟﻠﻐﺔ: ﻣﻠﺤﻮظﺔ
.(612-676-6810/1-800-688-2534 : )رﻗﻢ ھﺎﺗﻒ اﻟﺼﻢ واﻟﺒﻜﻢ612-676-3200/1-800-203-7225
ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés
gratuitement. Appelez le 612-676-3200/1-800-203-7225 (ATS : 612-676-6810/1-800-688-2534).
주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다.
612-676-3200/1-800-203-7225 (TTY: 612-676-6810/1-800-688-2534) 번으로 전화해 주십시오.
PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa
wika nang walang bayad. Tumawag sa 612-676-3200/1-800-203-7225 (TTY: 612-676-6810/
1-800-688-2534).
30 ucare.org/medicare123 or call 1-877-671-1064 31You can also read
