H1230_2024013SB_M
PBP #: 013
KAH4034
January 1–December 31, 2024
2024
Summary
of Benefits
Kaiser Permanente Senior Advantage Maui Plan (HMO)
1
About this Summary of Benefits
Thank you for considering Kaiser Permanente Senior Advantage. You can use this
Summary of Benefits to learn more about our plan. It includes information about:
• Premiums
• Benefits and costs
• Part D prescription drugs
• Optional supplemental benefits (Advantage Plus)
• Additional benefits
• Member discounts for products and services
• Who can enroll
• Coverage rules
• Getting care
For definitions of some of the terms used in this booklet, see the glossary at the end.
For more details
This document is a summary. It doesn't include everything about what's covered and not covered or all
the plan rules. For details, see the Evidence of Coverage (EOC), which is located on our website at
kp.org/eochi or ask for a copy from Member Services by calling 1-800-805-2739 (TTY 711), 7 days a
week, 8 a.m. to 8 p.m.
Have questions?
• If you're not a member, please call 1-877-408-3494 (TTY 711).
• If you're a member, please call Member Services at 1-800-805-2739 (TTY 711).
• 7 days a week, 8 a.m. to 8 p.m.
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What's covered and what it costs
*Your plan provider may need to provide a referral.
†Prior authorization may be required.
Benefits and premiums
You pay
Monthly plan premium $166
Deductible
None
Your maximum out-of-pocket responsibility
Doesn't include Medicare Part D drugs
$5,100
Inpatient hospital services*†
There's no limit to the number of medically
necessary inpatient hospital days.
• $340 per day for days 1–6 of your stay
• $70 per day for days 7–30 of your stay
• $0 for the rest of your stay
Outpatient hospital services*
†
$0–$225
per visit
Ambulatory Surgical Center (ASC)*†
$225 per visit
Doctor's visits
• Primary care providers
$10 per visit
• Specialists*†
$35 per visit
Preventive care*†
See the EOC for details.
$0
Emergency care
We cover emergency care anywhere in the
world.
$120 per Emergency Department visit
Urgently needed services
We cover urgent care anywhere in the world.
$50 per visit
Diagnostic services, lab, and imaging*†
•
A1c lab tests for persons with diabetes, LDL
lab tests for persons with heart disease, and
INR lab tests for persons with liver disease or
certain blood disorders
$0
• All other lab tests
$10 per day
• X-rays and ultrasounds
$20 per X-ray or ultrasound
• Diagnostic tests and procedures (like EKGs)
$20 per test
• MRI, CT, and PET
$180 per test
Hearing services*†
• Evaluations to diagnose medical conditions
• Routine hearing exams
$10 per visit
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Benefits and premiums
You pay
Dental services
Covered preventive dental services listed below
are provided by Hawaii Dental Service (HDS)
Medicare Advantage Network:
• Two preventive oral exams and teeth
cleanings per calendar year
• One bite-wing X-ray per calendar year
$0
• One full-mouth X-ray every five years
• Nonroutine dental care: anesthesia,
consultation, and minor pain relief*†
For the list of HDS Medicare Advantage Network
dentists, see the Provider and Pharmacy
Directory, visit hawaiidentalservice.com, or
call HDS customer service at 1-844-379-4325
(Monday through Friday, 7:30 a.m. to 4:30 p.m.).
If you sign up for optional benefits, you receive
additional dental benefits, see "Advantage Plus
(optional benefits)" for details.
30% coinsurance
Vision services
• Visits to diagnose and treat eye diseases and
conditions*†
• Routine eye exams*†
$10 per visit
• Preventive glaucoma screening and diabetic
retinopathy services*†
$0
• Eyeglasses or contact lenses after cataract
surgery
• Other eyewear isn't covered unless you sign
up for optional benefits, see "Advantage Plus
(optional benefits)" for details.
20% coinsurance up to Medicare's limit and you
pay any amounts beyond that limit.
Mental health services*†
• Inpatient mental health
$300 per day for days 1–6 ($0 for the rest of your
stay).
• Outpatient group therapy
$10
per visit
• Outpatient individual therapy
$35 per visit
Skilled nursing facility*†
We cover up to 100 days per benefit period.
Per benefit period:
• $0 for days 1–20
• $190 per day for days 21–40
• $0 for days 41–100
Physical therapy*†
$10 per visit
Ambulance $200 per one-way trip
Transportation Not covered
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Benefits and premiums
You pay
Medicare Part B drugs†
Medicare Part B drugs are covered when you
get them from a plan provider. See the EOC for
details.
• Drugs that must be administered by a health
care professional
0%–20% coinsurance depending on the drug.
Some drugs may be less than 20% if those drugs
are determined to exceed the amount of inflation.
• Up to a 30-day supply from a plan pharmacy
• $14 for generic drugs
• $47 for brand-name drugs, except you pay $35
for Part B insulin drugs furnished through an
item of DME.
Medicare Part D prescription drug coverage†
The amount you pay for drugs will be different depending on:
• The tier your drug is in. There are 6 drug tiers. To find out which of the 6 tiers your drug is in,
see our Part D formulary at kp.org/seniorrx or call Member Services to ask for a copy at
1-800-805-2739 (TTY 711), 7 days a week, 8 a.m. to 8 p.m.
• The day supply quantity you get (like a 30-day or 90-day supply). Note: A supply greater than a
30-day supply isn't available for all drugs.
• Whether you get your prescription filled by one of our retail plan pharmacies or our mail-order
pharmacy. Note: Not all drugs can be mailed.
• The coverage stage you're in (deductible, initial coverage, coverage gap, or catastrophic
coverage stages).
Note: Medicare provides Extra Help to pay prescription drug costs for people who have limited income
and resources. If you are entitled to Extra Help, the cost-sharing below may not apply to you; instead,
please refer to the Evidence of Coverage Rider for People Who Get Extra Help Paying for
Prescription Drugs.
Deductible stage
Because we have no deductible, this payment stage does not apply to you and you start the year in
the initial coverage stage.
Initial coverage stage
You pay the copays and coinsurance shown in the chart below until your total yearly drug costs reach
$5,030. (Total yearly drug costs are the amounts paid by both you and any Part D plan during a
calendar year.) If you reach the $5,030 limit in 2024, you move on to the coverage gap stage and your
coverage changes.
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Drug tier
Retail plan pharmacy
Up to a 30-day supply
31- to 60-day supply
61- to 90-day supply
Tier 1 (Preferred
generic)
$6 $12 $18
Tier 2 (Generic)
$14
$28
$42
Tier 3* (Preferred
brand-name)
$47 $94 $141
Tier 4*
(Nonpreferred
drugs)
$100 $200 $300
Tier 5* (Specialty)
33%
Tier 6**
(Vaccines)
$0 N/A N/A
*For each insulin product covered by our plan, you will not pay more than $35 for a 30-day supply,
$70 for a 31- to 60-day supply, and $105 for a 61- to 90-day supply, regardless of the tier.
**Our plan covers most Part D vaccines at no cost to you.
Drug tier
Mail-order plan pharmacy
Up to a 30-day
supply
31- to 60-day
supply
61- to 90-day
supply
Tier 1 (Preferred generic)
$0
$0
$0
Tier 2 (Generic)
$14
$28
$28
Tier 3*
(Preferred brand-name)
$47
$94
$94
Tier 4* (Nonpreferred drugs)
$100
$200
$200
Tier 5* (Specialty)
33%
Note: Tier 6 (vaccines) are not available through mail order.
*For each insulin product covered by our plan, you will not pay more than $35 for a 30-day supply,
$70 for a 31- to 60-day supply, or $94 for a 61- to 90-day supply of Tier 3 drugs and $105 for a
61- to 90-day supply of Tiers 4-5 drugs, regardless of the tier.
Coverage gap stage
The coverage gap stage begins if you or a Part D plan spends $5,030 on your drugs during 2024. You
pay the following copays and coinsurance during the coverage gap stage:
Drug tier
You pay
Tiers 1, 2, and 6
The same copays listed above that you pay during the initial coverage stage
Tiers 3, 4, and 5
25%
coinsurance
6
Catastrophic coverage stage
If you or others on your behalf spend $8,000 on your Part D prescription drugs in 2024, you'll enter the
catastrophic coverage stage. Most people never reach this stage, but if you do, you pay nothing for
covered Part D drugs in 2024.
Long-term care, plan home-infusion, and non-plan pharmacies
• If you live in a long-term care facility and get your drugs from their pharmacy, you pay the
same as at a retail plan pharmacy and you can get up to a 31-day supply.
• Covered Part D home infusion drugs from a plan home-infusion pharmacy are provided at no
charge.
• If you get covered Part D drugs from a non-plan pharmacy, you pay the same as at a retail
plan pharmacy and you can get up to a 30-day supply. Generally, we cover drugs filled at a
non-plan pharmacy only when you can't use a network pharmacy, like during a disaster. See
the Evidence of Coverage for details.
Advantage Plus (optional benefits)
In addition to the benefits that come with your plan, you can choose to buy a supplemental benefit
package called Advantage Plus. Advantage Plus gives you extra coverage for an additional monthly
cost that's added to your monthly plan premium. See the Evidence of Coverage for details.
*Your plan provider may need to provide a referral.
†Prior authorization may be required.
Advantage Plus benefits and premiums
You pay
Additional monthly premium
$44
Eyewear
Allowance every January 1st
$300 allowance. If your eyewear costs
more than $300, you pay the difference.
Hearing aids*†
• Allowance every 36 months for up to two hearing
aids
$1,500 allowance for both ears. If your
hearing aid(s) cost more than $1,500,
you pay the difference
.
• Exams for fitting and evaluation of hearing aids
$0
Dental services
Covered dental services listed below are provided by
Hawaii Dental Service (HDS) Medicare Advantage
Network:
• Comprehensive dental care that includes fillings,
extractions, crowns, endodontics, periodontics,
bridges, and dentures.
For the list of HDS Medicare Advantage Network
dentists, see the Provider and Pharmacy
Directory, visit hawaiidentalservice.com, or call
0%–50% coinsurance, depending on the
service, up to a $1,000 annual benefit
limit. After our plan has paid $1,000, you
pay 100% for the rest of the calendar
year. See the Evidence of Coverage for
details.
7
HDS customer service at 1-844-379-4325 (Monday
through Friday, 7:30 a.m. to 4:30 p.m.).
Additional benefits
These benefits are available to you as a plan member:
You pay
Fitness benefit — (the Silver&Fit
®
Healthy Aging and
Exercise Program)
Includes a standard membership to any of the participating
fitness centers in the Silver&Fit program. You can also choose
one Home Fitness Kit annually from a selection of kits to help
you stay fit at home.
The Silver&Fit program is provided by American Specialty Health
Fitness, Inc., a subsidiary of American Specialty Health
Incorporated (ASH). Silver&Fit is a federally registered
trademark of ASH and used with permission herein. Participating
fitness centers and fitness chains may vary by location and are
subject to change.
• $50 annual member fee for
a standard fitness center
membership
• $10 per calendar year for a
home fitness kit to exercise
at home.
You also have the option to
access the Silver&Fit Premium
fitness network (an expanded
network of select fitness
centers) at additional costs,
which may include initiation
and nonrefundable
membership fees.
Acupuncture and chiropractic care not covered by Medicare
We provide 20 visits total per calendar year for acupuncture and
chiropractic care not covered by Medicare.
$20 per visit
Member discounts for products and services
Kaiser Permanente partners with leading companies to support your health, safety, and well-being —
and offer substantial savings and discounts.
Lively™ Mobile Plus
Get a personal emergency response system that provides 24/7 help with the push of a button. Receive
a reduced one-time device fee and choice of two monthly service plans (coverage limits may apply).
Visit greatcall.com/KP or call 1-800-205-6548 (TTY 711) for more information.
Kaiser Permanente members may continue to use or select these products or services from any
company of their choice but Kaiser Permanente discounts are only available with the partner listed
above. The products and services described above are neither offered nor guaranteed under our
contract with the Medicare program. In addition, they are not subject to the Medicare appeals process.
Any disputes regarding these products and services may be subject to the Kaiser Permanente Senior
Advantage grievance process. BEST BUY HEALTH, GREATCALL, LIVELY and LINK are trademarks
of Best Buy and its affiliated companies. ©2022 Best Buy. All rights reserved.
Who can enroll
You can sign up for our plan if:
• You have both Medicare Part A and Part B. (To get and keep Medicare, most people must pay
Medicare premiums directly to Medicare. These are separate from the premiums you pay our
plan.)
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• You're a citizen or lawfully present in the United States.
• You live in this plan's service area, which is the following ZIP codes in Maui County: 96708,
96713, 96732, 96733, 96753, 96761, 96767, 96768, 96779, 96784, 96788, 96790, and 96793.
Coverage rules
We cover the services and items listed in this document and the Evidence of Coverage, if:
• The services or items are medically necessary.
• The services and items are considered reasonable and necessary according to Original
Medicare's standards.
• You get all covered services and items from plan providers listed in our Provider and
Pharmacy Directory. But there are exceptions to this rule. We also cover:
o Care from plan providers in another Kaiser Permanente Region
o Emergency care
o Out-of-area dialysis care
o Out-of-area urgent care (covered inside the service area from plan providers and in rare
situations from non-plan providers)
o Referrals to non-plan providers if you got approval in advance (prior authorization) from our
plan in writing
Note: You pay the same plan copays and coinsurance when you get covered care listed above
from non-plan providers. If you receive non-covered care or services, you must pay the full
cost.
For details about coverage rules, including non-covered services (exclusions), see the
Evidence of Coverage.
Getting care
At most of our plan facilities, you can usually get all the covered services you need, including specialty
care, pharmacy, and lab work. You aren't restricted to a particular plan facility or pharmacy, and we
encourage you to use the plan facility or pharmacy that will be most convenient for you. To find our
provider locations, see our Provider and Pharmacy Directory at kp.org/directory or ask us to mail
you a copy by calling Member Services at 1-800-805-2739 (TTY 711), 7 days a week, 8 a.m. to 8 p.m.
The formulary, pharmacy network, and/or provider network may change at any time. You will receive
notice when necessary.
Your personal doctor
Your personal doctor (also called a primary care physician) will give you primary care and will help
coordinate your care, including hospital stays, referrals to specialists, and prior authorizations. Most
personal doctors are in internal medicine or family practice. You must choose one of our available plan
providers to be your personal doctor. You can change your doctor at any time and for any reason. You
can choose or change your doctor by calling Member Services or at kp.org/finddoctors.
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Help managing conditions
If you have more than one ongoing health condition and need help managing your care, we can help.
Our case management programs bring together nurses, social workers, and your personal doctor to
help you manage your conditions. The program provides education and teaches self-care skills. If
you're interested, please ask your personal doctor for more information.
Notices
Appeals and grievances
You can ask us to provide or pay for an item or service you think should be covered by submitting a
claim to us within a specific time period that includes the date you received the item or service. If we
say no, you can ask us to reconsider our decision. This is called an appeal. You can ask for a fast
decision if you think waiting could put your health at risk. If your doctor agrees, we'll speed up our
decision.
If you have a complaint that's not about coverage, you can file a grievance with us. See the
Evidence of Coverage for details about the processes for making complaints and making coverage
decisions and appeals, including fast or urgent decisions for drugs, services, or hospital care.
Kaiser Foundation Health Plan
Kaiser Foundation Health Plan Inc., Hawaii Region is a nonprofit corporation and a Medicare
Advantage plan called Kaiser Permanente Senior Advantage. We offer several Senior Advantage
plans in our Hawaii Region's service area, which includes Honolulu County, most of Hawaii County
(Big Island), and the Island of Maui.
Each plan has different benefits, copays, coinsurance, premiums, and plan service areas. But you can
get care from plan providers anywhere in our Hawaii Region.
If you move from your plan's service area to another service area in our Hawaii Region, you'll have to
enroll in a Senior Advantage plan in your new service area.
Privacy
We protect your privacy. See the Evidence of Coverage or view our Notice of Privacy Practices on
kp.org/privacy to learn more.
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Helpful definitions (glossary)
Allowance
A dollar amount you can use toward the purchase of an item. If the price of the item is more than
the allowance, you pay the difference.
Benefit period
The way our plan measures your use of skilled nursing facility services. A benefit period starts
the day you go into a hospital or skilled nursing facility (SNF). The benefit period ends when you
haven't gotten any inpatient hospital care or skilled care in an SNF for 60 days in a row. The
benefit period isn't tied to a calendar year. There's no limit to how many benefit periods you can
have or how long a benefit period can be.
Calendar year
The year that starts on January 1 and ends on December 31.
Coinsurance
A percentage you pay of our plan's total charges for certain services or prescription drugs. For
example, a 20% coinsurance for a $200 item means you pay $40.
Copay
The set amount you pay for covered services — for example, a $20 copay for an office visit.
Deductible
It's the amount you must pay for Medicare Part D drugs before you will enter the initial coverage
stage.
Evidence of Coverage
A document that explains in detail your plan benefits and how your plan works.
Maximum out-of-pocket responsibility
The most you'll pay in copays or coinsurance each calendar year for services that are subject to
the maximum. If you reach the maximum, you won't have to pay any more copays or coinsurance
for services subject to the maximum for the rest of the year.
Medically necessary
Services, supplies, or drugs that are needed for the prevention, diagnosis, or treatment of your
medical condition and meet accepted standards of medical practice.
Non-plan provider
A provider or facility that doesn't have an agreement with Kaiser Permanente to deliver care to
our members.
Plan
Kaiser Permanente Senior Advantage.
Plan premium
The amount you pay for your Senior Advantage health care and prescription drug coverage.
Plan provider
A plan or network provider can be a facility, like a hospital or pharmacy, or a health care
professional, like a doctor or nurse.
Prior authorization
Some services or items are covered only if your plan provider gets approval in advance from our
plan (sometimes called prior authorization). Services or items subject to prior authorization are
flagged with a † symbol in this document.
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Region
A Kaiser Foundation Health Plan organization. We have Kaiser Permanente Regions located in
Northern California, Southern California, Colorado, Georgia, Hawaii, Maryland, Oregon, Virginia,
Washington, and Washington, D.C.
Retail plan pharmacy
A plan pharmacy where you can get prescriptions. These pharmacies are usually located at plan
medical offices.
Service area
The geographic area where we offer Senior Advantage plans. To enroll and remain a member
of our plan, you must live in one of our Senior Advantage plan's service area.
Kaiser Permanente is an HMO plan with a Medicare contract. Enrollment in Kaiser Permanente
depends on contract renewal. This contract is renewed annually by the Centers for Medicare & Medicaid
Services (CMS). By law, our plan or CMS can choose not to renew our Medicare contract.
For information about Original Medicare, refer to your "Medicare & You" handbook. You can view it
online at medicare.gov or get a copy by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day,
7 days a week. TTY users should call 1-877-486-2048.
KAH3854 | 930428982 M-22
Notice of nondiscrimination
Kaiser Permanente complies with applicable federal civil rights laws and does not
discriminate on the basis of race, color, national origin, age, disability, or sex. Kaiser
Permanente does not exclude people or treat them differently because of race, color,
national origin, age, disability, or sex. We also:
• Provide no cost aids and services to people with disabilities to communicate
effectively with us, such as:
♦ Qualified sign language interpreters.
♦ Written information in other formats, such as large print, audio, and accessible
electronic formats.
• Provide no cost language services to people whose primary language is not English,
such as:
♦ Qualified interpreters.
♦ Information written in other languages.
If you need these services, call Member Services at 1-800-805-2739 (TTY 711),
8 a.m. to 8 p.m., seven days a week.
If you believe that Kaiser Permanente 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
a grievance with our Civil Rights Coordinator by writing to 711 Kapiolani Blvd, Honolulu, HI
96813 or calling Member Services at the number listed above. You can file a grievance by
mail or phone. If you need help filing a grievance, our Civil Rights Coordinator is available to
help you. 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/portal/lobby.jsf, or by mail or
phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW.,
Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 800-537-7697 (TDD).
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
Form Approved
OMB# 0938-1421
Form CMS-10802
(Expires 12/31/25)
Y0043_N00036258_C
Multi-Language Insert
Multi-language Interpreter Services
English: We have free interpreter services to answer any questions you may
have about our health or drug plan. To get an interpreter, just call us at
1-800-805-2739 (TTY 711). Someone who speaks English/Language can help you.
This is a free service.
Spanish: Tenemos servicios de intérprete sin costo alguno para responder cualquier
pregunta que pueda tener sobre nuestro plan de salud o medicamentos. Para hablar
con un intérprete, por favor llame al 1-800-805-2739 (TTY 711). Alguien que hable español
le podrá ayudar. Este es un servicio gratuito.
Chinese Mandarin: 我们提供免费的翻译服务，帮助您解答关于健康或药物保险的任何疑 问。
如果您需要此翻译服务，请致电 1-800-805-2739 (TTY 711)。我们的中文工作人员很乐意帮助您。
这是一项免费服务。
Chinese Cantonese: 您對我們的健康或藥物保險可能存有疑問，為此我們提供免費的翻譯 服
務。如需翻譯服務，請致電 1-800-805-2739 (TTY 711)。我們講中文的人員將樂意為您提供幫助。
這 是一項免費服務。
Tagalog: Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot
ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan
o panggamot. Upang makakuha ng tagasaling-wika, tawagan lamang kami sa
1-800-805-2739 (TTY 711). Maaari kayong tulungan ng isang nakakapagsalita ng
Tagalog. Ito ay libreng serbisyo.
French: Nous proposons des services gratuits d'interprétation pour répondre à toutes
vos questions relatives à notre régime de santé ou d'assurance-médicaments. Pour
accéder au service d'interprétation, il vous suffit de nous appeler au 1-800-805-2739
(TTY 711)
. Un interlocuteur parlant Français pourra vous aider. Ce service est gratuit.
Vietnamese: Chúng tôi có dịch vụ thông dịch miễn phí để trả lời các câu hỏi
về chương sức khỏe và chương trình thuốc men. Nếu quí vị cần thông dịch viên
xin gọi 1-800-805-2739 (TTY 711). sẽ có nhân viên nói tiếng Việt giúp đỡ quí vị. Đây là dịch
vụ miễn phí .
German: Unser kostenloser Dolmetscherservice beantwortet Ihren Fragen zu unserem
Gesundheits- und Arzneimittelplan. Unsere Dolmetscher erreichen Sie unter
1-800-805-2739 (TTY 711). Man wird Ihnen dort auf Deutsch weiterhelfen. Dieser Service
ist kostenlos.
Form Approved
OMB# 0938-1421
Form CMS-10802
(Expires 12/31/25)
1140849898
June 2023
Korean: 당사는 의료 보험 또는 약품 보험에 관한 질문에 답해 드리고자 무료 통역 서비스를
제공하고 있습니다. 통역 서비스를 이용하려면 전화 1-800-805-2739 (TTY 711). 번으로 문의해
주십시오. 한국어를 하는 담당자가 도와 드릴 것입니다. 이 서비스는 무료로 운영됩니다.
Russian: Если у вас возникнут вопросы относительно страхового или
медикаментного плана, вы можете воспользоваться нашими бесплатными
услугами переводчиков. Чтобы воспользоваться услугами переводчика, позвоните
нам по телефону 1-800-805-2739 (TTY 711). Вам окажет помощь сотрудник, который
говорит по-pусски. Данная услуга бесплатная.
:Arabic ﻰﻠﻋ لوﺻﺣﻠﻟ .ﺎﻧﯾدﻟ ﺔﯾودﻷا لودﺟ وأ ﺔﺣﺻﻟﺎﺑ ﻖﻠﻌﺗﺗ ﺔﻠﺋﺳأ يأ نﻋ ﺔﺑﺎﺟﻺﻟ ﺔﯾﻧﺎﺟﻣﻟا يروﻔﻟا مﺟرﺗﻣﻟا تﺎﻣدﺧ مدﻘﻧ ﺎﻧﻧإ
ﻰﻠﻋ ﺎﻧﺑ لﺎﺻﺗﻻا ىوﺳ كﯾﻠﻋ سﯾﻟ ،يروﻓ مﺟرﺗﻣ
1-800-805-2739 (TTY 711) ﺔﯾﺑرﻌﻟا ثدﺣﺗﯾ ﺎﻣ صﺧﺷ موﻘﯾﺳ .
ﺔﯾﻧﺎﺟﻣ ﺔﻣدﺧ هذھ .كﺗدﻋﺎﺳﻣﺑ.
Hindi:
1-800-805-2739 (TTY 711)
Italian: È disponibile un servizio di interpretariato gratuito per rispondere a eventuali
domande sul nostro piano sanitario e farmaceutico. Per un interprete, contattare il
numero 1-800-805-2739 (TTY 711). Un nostro incaricato che parla Italianovi fornirà
l'assistenza necessaria. È un servizio gratuito.
Portuguese: Dispomos de serviços de interpretação gratuitos para responder a
qualquer questão que tenha acerca do nosso plano de saúde ou de medicação.
Para obter um intérprete, contacte-nos através do número 1-800-805-2739 (TTY 711). Irá
encontrar alguém que fale o idioma Português para o ajudar. Este serviço é gratuito.
French Creole: Nou genyen sèvis entèprèt gratis pou reponn tout kesyon ou ta genyen
konsènan plan medikal oswa dwòg nou an. Pou jwenn yon entèprèt, jis rele nou nan
1-800-805-2739 (TTY 711). Yon moun ki pale Kreyòl kapab ede w. Sa a se yon sèvis ki
gratis.
Polish: Umożliwiamy bezpłatne skorzystanie z usług tłumacza ustnego, który pomoże
w uzyskaniu odpowiedzi na temat planu zdrowotnego lub dawkowania leków. Aby
skorzystać z pomocy tłumacza znającego język polski, należy zadzwonić pod numer
1-800-805-2739 (TTY 711). Ta usługa jest bezpłatna.
Japanese: 当社の健康 健康保険と薬品 処方薬プランに関するご質問にお答えするため に、
無料の通訳サービスがありますございます。通訳をご用命になるには、
1-800-805-2739
(TTY 711).
にお電話ください。日本語を話す人 者 が支援いたします。これは無料のサー ビス
です。
Form Approved
OMB# 0938-1421
Form CMS-10802
(Expires 12/31/25)
1140849898
June 2023
Tongan: 'Oku 'i ai 'emau sēvesi fakatonu lea ta'etotongi ke ne ala tali ha'o ngaahi fehu'i
fekau'aki mo 'emau palani mo'ui leleí pe faito'ó. Te ke ma'u ha tokotaha fakatonulea 'i
ha'o fetu'utaki ki he 1-800-805-2739 (TTY
711). 'E 'i ai ha tokotaha 'oku lea Faka-Pilitānia ke
ne tokoni'i koe. Ko e sēvesi ta'etotongi eni.
Ilocano: Addaankami kadagiti libre a serbisio ti mangitarus tapno sungbatan ti aniaman a
saludsod nga addaan ka maipapan ti plano iti salun-at wenno agasmi. Tapno mangala ti
mangitarus, maidawat a tawagannakam iti 1-800-805-2739 (TTY 711). Maysa a tao nga
agsasao iti Ilocano ti makatulong kenka. Daytoy ket libre a serbisio.
Pohnpeian: Mie sahpis ni soh isepe oang kawehwe peidek kan me komwi sohte wehwehki
oang palien roson mwahu de wasa me pwain kohdahn wini. Komwi en kak iang alehdi
sawas wet, komw telepwohndo reht ni 1-800-805-2739 (TTY 711). Mie me kak Lokaiahn
Pohnpei me pahn seweseiuk. Sawas wet sohte isepe.
Samoan: E iai a matou auaunaga faaliliuupu e tali i soo sau fesili e uiga i lou soifua
maloloina poo fuafuaga o vailaau. A fia maua se faaliliuupu, na’o lou valaau mai lava ia
matou i le 1-800-805-2739 (TTY 711). O le fesoasoani atu se tasi e tautala Gagana Samoa.
E le totogia lea auaunaga.
Laotian:
ພວກເຮົ າມີ ບໍ ລິ ການລ່າມແປພາສາຟຣີ ເພື
່
ອຕອບຄໍ າຖາມຕ່າງໆທີ
່
ທ່ານອາດຈະມີ ກ່ຽວກັ ບແຜນສ
ຸ
ຂະພາບ
ຫ
ຼ
ື ແຜນຢາຂອງພວກເຮົ າ. ເພື
່
ອຂໍ ລ່າມແປພາສາ, ພຽງແຕ່ໂທຫາພວກເຮົ າທີ
່
ເບີ 1-800-805-2739
(TTY 711)
. ຄົ ນ ທີ
່
ເ ວົ
້
ພາສາລາວສາມາດຊ່ວຍທ່ ານໄດ້. ນີ
້
ເ ປັ ນ ບໍ ລິ ກ າ ນ ຟ ຣີ .
Bisayan: Duna mi’y libreng serbisyo sa tig-interpret aron motubag sa bisan unsa nimong
mga pangutana mahitungod sa imong panglawas o plan sa tambal. Aron mokuha og tig-
interpret, tawagi lang mi sa 1-800-805-2739 (TTY 711). Ang usa ka tawo nga nagsulti og
Pinulongan makatabang kanimo. Kini usa ka libreng serbisyo.
Marshallese: Ewor ad jerbal in ukok ko ñan uak jabdewōt kajitok emaroñ in wōt am
ikijen būlāān in ājmour ako uno ko rekajur. Ñan bukot juon riukok, kurtok kij ilo
1-1-800-805-2739 (TTY 711). Juon armij ej kajiton Kajin eo ñan jibañ eok. Ejelok onean jerbal in.
Hawaiian: Inā kekahi mau nīnau nāu e pili ana i kā mākou papahana ʻinikua mālama olakino
a i ʻole ka ʻinikua lāʻau kuhikuhi, loaʻa ia pū ke kōkua unuhi manuahi i ka ʻōlelo Hawaiʻi. Inā
makemake ʻoe i kēia kōkua, e ʻoluʻolu ke kelepona mai iā mākou i ka helu
1-800-805-2739
(TTY 711). no ka walaʻau ʻana e pili ana i kēia mau papahana i ka ʻōlelo Hawaiʻi. Eia la ke
kōkua manuahi.
Chuukese: Mi kawor aninisin chiaku ika awewen kapas ika epwe wor omw kapas eis fan
iten ach kei okot ren pekin manaw me sefei. Ika ke mochen nóunóu emon chon chiaku,
kopwe kori kich ren en namba 1-800-805-2739 (TTY 711). Emon aramas mi sine Chuuk mi
tongeni anisuk. Ei aninis ese kamo.
