Exhibit_12_MSP_Benefits_Summary.docx

Exhibit 12 Medicare Supplement Plan Benefits Summary All Benefits are Based on Medicare-Approved Amounts [Supplier Name] Plan Year 2026

1. All Part D pharmacy coverage descriptions and benefits listed must reflect compliance with CMS benefit guidance and meet the Creditable Coverage definition. Bidder’s Medicare Supplement Plan (MSP) shall at minimum meet specifications for Medicare Supplement Plan G with a prescription drug component.

a. Bidder may refer to the HealthChoice SilverScript MSP for guidance at https://oklahoma.gov/healthchoice/medicare-member/plans-overview/hc-silverscript-high-low-plan.html.

2. List complete benefits when submitting “PY2026 No Plan Changes” and the “PY2026 With Proposed Plan Changes.”

3. Column “PY2026 No Plan Changes” is required for all Bidders and should list complete plan benefits.

a. For Bidders with current contracts with the OEIBA Program, this column should list the Supplier’s current plan benefits with no changes.

4. Only Bidders with current health contracts have the option to also complete column “PY2026 with Proposed Plan Changes.”

a. This column should include all PY2025 plan benefits along with proposed plan changes for PY2026. Proposed plan changes must be in bold.

5. All plan design options must correspond to Exhibit 13 for MSP premium quotes

6. No more than one (1) MSP plan by the Supplier will be accepted for PY2026.

a. MSP Benefit Summary must be completed and signed by the Supplier’s President, Chief Executive Officer or authorized representative.

7. MSP Benefit Summary must be signed by the Bidder’s President, Chief Executive Officer or authorized representative.

Example

No Plan Changes (Required for all Bidders)

PY2026

With Proposed Plan Changes (Optional only for current Suppliers)

Flu Vaccine

One shot per year

Two flu shots per year

PART A NETWORK SERVICES

All benefits are based on Medicare-approved amounts PY2026 No Plan Changes (Required for all Bidders) PY2026 With Plan Changes (Optional only for current Suppliers)

HOSPITALIZATION

Includes semiprivate room, meals, drugs as part of your inpatient treatment, and other hospital services and supplies

First sixty 60 days

Days 61 through 90

Days 91 and after while using Medicare's 60 lifetime reserve days

Once Medicare's lifetime reserve days are used, the plan provides additional lifetime reserve days

Beyond the plan's lifetime reserve days

SKILLED NURSING FACILITY CARE

Must meet Medicare requirements, including inpatient hospitalization for at least 3 days and entering a Medicare-approved facility within 30 days of leaving the hospital; limited to 100 days per calendar year

First 20 days

Days 21 through 100

Days 101 and after

HOSPICE CARE

Your doctor and hospice provider must certify you are terminally ill and you elect hospice Includes physical care, counseling, equipment, supplies, respite care, inpatient care and drugs for pain and symptom control

BLOOD

Limited to the first 3 pints unless you or someone else donates blood to replace what you use

MEDICAL EXPENSES

Medically necessary outpatient services and supplies

Includes doctor’s visits, out-patient hospital treatment, surgical services, physical and speech therapy and diagnostic tests

CLINICAL DIAGNOSTIC LABORATORY SERVICES

Includes blood tests, urinalysis and tissue pathology

HOME HEALTH CARE

Includes intermittent skilled care and medical supplies

DURABLE MEDICAL EQUIPMENT

Includes items such as nebulizers, wheelchairs and walkers

DIABETES MONITORING SUPPLIES

Includes coverage for glucose monitors, test strips and lancets for those with diabetes Must be requested by your doctor

OSTOMY SUPPLIES

All Medicare beneficiaries who have a need based on their condition. Includes ostomy bags, wafers and other ostomy supplies for those who have a need based on their condition

BLOOD

Includes amounts in addition to the coverage under Part A unless you or someone else donates blood to replace what you use

OUTPATIENT PRESCRIPTIONS

Includes infused, oral end-stage renal disease drugs and some cancer and transplant drugs

Providers who do not accept Medicare assignment cannot charge a Medicare beneficiary more than 115% of the Medicare-approved amount.

Coverage for Other Medical Services

FOREIGN TRAVEL

Medically necessary emergency care services beginning during the first 60 days of each trip outside the U.S.A.

BARIATRIC SURGERY

DIABETES PREVENTION PROGRAM

CDC-recognized

Medicare Preventive Services

INITIAL PREVENTIVE PHYSICAL EXAM

Includes a one-time “Welcome to Medicare Visit” for Medicare beneficiaries during the first 12 months of Part B coverage

ANNUAL WELLNESS VISIT

Includes one visit every 12 months for Medicare beneficiaries who have been enrolled in Part B for more than 12 months

SCREENING MAMMOGRAM

Once every 12 months for female Medicare beneficiaries ages 40 and older

CARDIOVASUCLAR DISEASE SCREENING

Once every five years for all Medicare beneficiaries

PAP TEST AND PELVIC EXAM

Once every 24 months; includes a clinical breast exam

Once every 12 months if high risk or abnormal Pap test in preceding 36 months

BONE MASS MEASUREMENTS

Once every 24 months for all Medicare beneficiaries at risk of losing bone mass

GLAUCOMA SCREENING

Once every 12 months for Medicare beneficiaries at high risk or a family history of glaucoma

Must be performed or supervised by an optometrist or ophthalmologist

COLORECTAL CANCER SCREENING

For all Medicare beneficiaries ages 50 and older

FECAL OCCULT BLOOD TEST

Once every 12 months

FLEXIBLE SIGNOIDOSCOPY

Once every 4 years for those at high risk for colorectal cancer

For those at normal risk, once every 4 years, or 119 months after a previous screening colonoscopy

COLONOSCOPY

Once every 2 years for those at high risk for colorectal cancer

For those at normal risk, once every 10 years, or 47 months after a previous flexible sigmoidoscopy

BARIUM ENEMA

Doctor can substitute this test for a sigmoidoscopy or colonoscopy

Procedure must be performed in an outpatient hospital setting or an ambulatory surgical center

PROSTATE CANCER SCREENING

For all male Medicare beneficiaries ages 50 and older

DIGITAL RECTAL EXAM

Once every 12 months

PROSTATE SPECIFIC ANTIGEN TEST (PSA)

Once every 12 months

Providers who do not accept Medicare assignment cannot charge a Medicare beneficiary more than 115% of the Medicare-approved amount.

Preventive Services - Vaccinations

Medicare covers the vaccine and administration at 100% if the provider accepts Medicare assignment.

Flu Vaccination

One per flu season

Pneumonia Vaccination

A pneumococcal vaccination is approved annually for members ages 50 and older.

Hepatitis B Vaccination

Medicare beneficiaries at medium to high risk for Hepatitis B

Providers who do not accept Medicare assignment cannot charge a Medicare beneficiary more than 115% of the Medicare-approved amount.

Pharmacy Copay Structure for Network Benefits

Note: If the plan has more than five (5) tiers, insert a new row below the “Tier 5” row within the 30-day supply or the 31 to 90-day supply sections to include pharmacy benefit tier information.

These plans use a formulary Mandatory generic and formulary medications you get at a Network Pharmacy

30- Day Supply Specify any differences between Preferred and Standard Retail

[Tier 1 and name, ex. Preferred Generic Drugs]

[Tier 1 and name]

[Tier 2 and name]

[Tier 3 and name]

[Tier 4 and name]

[Tier 5 and name]

CMS regulated changes to Part D coverage must be included in bold regardless of if Supplier is proposing plan changes.

Once the out-of-pocket maximum is reached, member pays 0% of Allowable Fees for covered prescription drugs purchased

Signature Printed Name Date

Title Supplier Name (To be signed by the Supplier’s President, Chief Executive Officer or authorized representative.)