Drug Sponsor Name Aetna Medicare Drug Plan Name Aetna Golden Medicare Premier Plan (H2212-014) Phone Number Current Members: 1-800-282-5366 TTY/TDD: 1-800-628-3323 Prospective Members: 1-800-455-1560 TTY/TDD: 1-800-628-3323 Website www.aetnamedicare.com Total monthly premium $99.00 SPDAP monthly subsidy Up to $25 per month Monthly premium after subsidy $74.00 Deductible $0 1st tier copay $5.00 2nd tier copay $15.00 3rd tier copay $27.00 4th tier copay $68.00 5th tier copay, and description (such as injectibles, if applicable) 25% Initial coverage limit [as defined in 42 CFR Part 423.104(d)(3)] $2,700.00 Benefits available in coverage gap None Average drug price discount percentage below wholesale drug price available in coverage gap (for example, 95% equals a 5% price discount) Contact plan for details Mail order offered $10.00 for a 90-day supply of Preferred Generic drugs $30.00 for a 90-day supply of Non-Preferred Generic drugs $54.00 for a 90-day supply of Preferred Brand drugs $136.00 for 90-day supply of Non-Preferred Brand drugs 25% co-insurance for a 90-day supply of Specialty drugs Does this plan option’s formulary differ from plan sponsor’s other options Contact plan for details Medical management requirements (UM, PA) Contact plan for details MA-PD plan summary, including plan cost sharing for Part A & B benefits, and any supplemental benefits Contact plan for details Maryland SPDAP Coverage Gap Subsidy Not offered in this plan option Available in which Maryland Counties Anne Arundel, Baltimore, Calvert, Carroll, Cecil, Charles, Frederick, Harford, Howard, Montgomery, and Prince George’s

The information on this summary sheet was provided by the Drug Plan Sponsor named above, or obtained through research on Medicare.gov.