LMA 2025 Enrollment Guide : simplebooklet.com

2 | ABOUT LIBERTYA NEW MEDICARE ADVANTAGE CHOICE FROM A TRUSTED,LOCAL NAMELiberty Health is more than a company. It is a NorthCarolina family who answered a calling to serve others withcompassion. The values, traditions and trust established bythe McNeills at a small-town pharmacy in the 1870scontinue to be passed down from generation to generation. Principal Owners Ronnie and Sandy McNeill are now thefourth generation of McNeills immersed in the healthcareindustry. They grew up working in their family’s pharmacyin Whiteville like their father, their grandfather and theirgreat grandfather. They grew up serving families, who forgenerations, trusted and depended on them for medicine,advice and care. The McNeills and Liberty's family ofcompanies proudly continue that tradition of service and careto this day.Over the past century, Liberty Health has expanded to nowoffer a full continuum of care to older adults across theCarolinas and neighboring states.Those services include skilled nursing care, short-termrehabilitation, home care, hospice care, palliative care,assisted and independent living, pharmacy and medicalequipment. Liberty Medicare Advantage was naturally the next step forthe company, allowing us to take our experience in caringfor patients in the post-acute setting and applying that to thehome setting with a focus on preventative care.ABOUT LIBERTYH6351_2025EnrollmentGuideCSNP

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4 | TABLE OF CONTENTS TABLE OF CONTENTSAbout Liberty......................................................................2Summary of Benefits...........................................................5Financial Help...................................................................17Most Common Drugs........................................................18Supplemental Benefits......................................................21Pre-Enrollment Checklist..................................................22Scope of Sales Form..........................................................23Pre-Enrollment Qualification Assessment Tool................24Enrollment Request Form.................................................26Health Risk Assessment....................................................31Medicare Star Ratings.......................................................36Interpreter Services...........................................................37H6351_2025EnrollmentGuideCSNP

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SUMMARY OF BENEFITS6 | SUMMARY OF BENEFITSPLAN OVERVIEWLiberty Medicare Advantage (HMO C-SNP) is a Medicare Advantage HMO Plan with a Medicarecontract. Enrollment in the plan depends on contract renewal. This plan, Liberty Medicare Advantage,is offered by Liberty Advantage, LLC dba Liberty Medicare Advantage. To receive a complete list ofservices we cover, access our Evidence of Coverage at www.LibertyMedicareAdvantage.com, or callMember Services at 1-844-854-6884 (TTY 711).ELIGIBILITYTo join Liberty Medicare Advantage (HMO C-SNP), you must be entitled to Medicare Part A, beenrolled in Medicare Part B, and live in our service area.Our service area includes these North Carolina counties: Alamance, Bertie, Bladen, Brunswick, Buncombe, Burke, Cabarrus, Caldwell, Catawba, Chatham,Columbus, Cumberland, Davidson, Davie, Durham, Forsyth, Franklin, Granville, Greene, Guilford,Halifax, Harnett, Haywood, Henderson, Hyde, Johnston, Lee, Lenoir, Martin, Mecklenburg,Moore, New Hanover, Orange, Pender, Person, Pitt, Polk, Randolph, Richmond, Robeson,Rockingham, Rowan, Sampson, Scotland, Stokes, Union, Vance, Wake, Warren, Watauga,Wayne, Wilkes, Wilson and YadkinYou must also have one of the following conditions: Chronic Heart Failure (CHF)DiabetesCardiovascular Disorders (CVD)DOCTORS, HOSPITALS AND PHARMACIESLiberty Medicare Advantage (HMO C-SNP) has a network of doctors, hospitals, pharmacies and otherproviders that can be found on our website at www.LibertyMedicareAdvantage.com. If you useproviders that are not in our network, the plan may not pay for these services. The formulary, pharmacynetwork, and/or provider network may change at any time. You will receive notice when necessary. ADDITIONAL MEDICARE INFORMATIONThis document is also available in Braille and in large print. Benefits, premium, deductible, and/orcopayments/coinsurance may change on January 1 of each year. If you want to know more about thecoverage and costs of Original Medicare, look in your current “Medicare & You” handbook. View itonline at www.Medicare.gov or receive a copy by calling 1-800- MEDICARE (1-800-633-4227), 24hours a day, 7 days a week. TTY users should call 1-877-486-2048.LIBERTY MEDICARE ADVANTAGE (HMO C-SNP)H6351, PLAN 004H6351_2025EnrollmentGuideCSNP

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Liberty Medicare Advantage(HMO C-SNP)Original MedicarePREMIUMS AND BENEFITSMonthly Plan Premium$0You must continue to pay yourMedicare Part B premium.Part A: $0Part B: $164.90 – $560.50Deductible$0Part A: $1,600 per benefitperiodPart B: $226 per yearMaximum Out-of-Pocket (Does not include Part Dprescription drugs.)$3,500NoneINPATIENT HOSPITAL COVERAGEYou are admitted to the hospitalfor an inpatient stay after anofficial doctor’s order, which saysyou need inpatient hospital care totreat your illness or injury.Prior authorization is required.$250 for days 1-6$0 for days 6-90After $1,600 deductible is met:$0 for days 0-60$400 for days 61-90$800 for days 91+OUTPATIENT REHABILITATION SERVICESCovered services include physicaltherapy, occupational therapy, andspeech language therapy.Outpatient rehabilitation servicesare provided in various outpatientsettings, such as hospital outpatientdepartments, independent therapistoffices, and ComprehensiveOutpatient Rehabilitation Facilities(CORFs).Prior authorization is required.$25 copay per visit20% coinsurance for Medicare-covered services8 | SUMMARY OF BENEFITSDOCTOR VISITSPrimary Care Providers$0 copay20% coinsurance for Medicare-covered servicesSpecialists$0 for Cardiologist,Endocrinologist and Podiatrist $10 per visit for all otherspecialists20% coinsurance for Medicare-covered servicesH6351_2025EnrollmentGuideCSNP

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Liberty Medicare Advantage(HMO C-SNP)Original MedicarePREVENTIVE CAREExamples include:Annual MammogramColonoscopy per MedicareguidelinesAnnual Wellness Exam$0 copayTypically $0 copay, reviewMedicare GuidelinesEMERGENCY CAREEmergency care refers to servicesthat are:Furnished by a provider qualifiedto furnish emergency services,andNeeded to evaluate or stabilize anemergency medical conditionA medical emergency is when you, orany other prudent layperson with anaverage knowledge of health andmedicine, believe that you havemedical symptoms that requireimmediate medical attention toprevent loss of life, loss of a limb, orloss of function of a limb. Themedical symptoms may be an illness,injury, severe pain, or a medicalcondition that is quickly gettingworse.Cost sharing for necessary emergencyservices furnished out-of-network isthe same as for such servicesfurnished in-network.Coverage within the U.S. only.Authorization is required if the resultis an inpatient stay.$100 per visit$100 is waived if you areadmitted to a hospitalAfter $1,600 deductible is met:20% coinsurance for theMedicare-approved amountof your doctor servicesIf you are admitted to thehospital within 3 days of yourvisit to the ER, your visit iscovered as part of inpatientstay.SUMMARY OF BENEFITS | 9H6351_2025EnrollmentGuideCSNP

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Liberty Medicare Advantage(HMO C-SNP)Original MedicareURGENTLY NEEDED SERVICESUrgently needed services are providedto treat a non-emergency, unforeseenmedical illness, injury, or conditionthat requires immediate medical carebut given your circumstances, it is notpossible, or it is unreasonable, toobtain services from networkproviders. Examples of urgently needed servicesthe plan must cover out-of-networkare:You need immediate care duringthe weekend, or You are temporarily outside theservice area of the plan.Services must be immediatelyneeded and medically necessary.If it is unreasonable given yourcircumstances to immediatelyobtain the medical care from anetwork provider, then your planwill cover the urgently neededservices from a provider out-of-network. Coverage within the U.S. only.$25 copayWaived if you are admitted to ahospital within 3 days20% coinsurance after deductibleis metDIAGNOSTIC SERVICES/LABS/IMAGESOutpatient Diagnostic Tests andTherapeutic ServicesNo authorization required whenservices are rendered in a NursingFacility or Physician’s Office.In office: $0Urgent Care: $50Outpatient Hospital: $75Advanced Imaging Services:$200 copay (All POS, excludingIP and Office)20% coinsuranceOutpatient DiagnosticRadiological ServicesA member pays multiple copays,even if receiving multiple serviceson the same day at the samelocation.Min: $0 / Max: $125In office: $0Urgent Care/FreestandingRadiology Facility: $50Outpatient Hospital: $12520% coinsuranceOutpatient X-Ray Services$1020% coinsurance10 | SUMMARY OF BENEFITSH6351_2025EnrollmentGuideCSNP

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SUMMARY OF BENEFITS | 11Liberty Medicare Advantage(HMO C-SNP)Original MedicareHEARING SERVICESHearing Exam $0 copay for annual routine exam20% coinsuranceHearing AidsAuthorization is required.Part of Liberty MedicareAdvantage's Freedom Flex Cardthat allows a maximum of$2,000 per year to be used foreither vision, dental or hearingNot coveredVISION SERVICESYearly Eye Exam$0 copayNot coveredEyeglasses, Lenses, Frames,ContactsPart of Liberty MedicareAdvantage's Freedom Flex Cardthat allows a maximum of$2,000 per year to be used foreither vision, dental or hearingNot coveredDENTALBi-Annual Exam$0Not coveredComprehensive andPreventative ServicesPart of Liberty MedicareAdvantage's Freedom Flex Cardthat allows a maximum of$2,000 per year to be used foreither vision, dental or hearingNot coveredH6351_2025EnrollmentGuideCSNP

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Liberty Medicare Advantage(HMO C-SNP)Original MedicareMENTAL HEALTH SERVICESInpatient VisitPrior authorization is required.Days 1 – 60: $0 coinsuranceDays 61- 90: $400 coinsuranceper dayDays 91 and beyond: $800coinsurance per each lifetimereserve day after day 90 for eachbenefit period (up to 60 daysover your lifetime)Beyond lifetime reserved days:All costs$1,600 deductible is appliedonce during the defined benefitperiod:Days 1 – 60: $0coinsurance Days 61- 90: $400coinsurance per dayDays 91 and beyond: $800coinsurance per eachlifetime reserve day afterday 90 for each benefitperiod (up to 60 days overyour lifetime)Beyond lifetime reserveddays: All costsOutpatient Psychiatric GroupTherapy Visit$50 copay20% coinsuranceOutpatient PsychiatricIndividual Therapy Visit$50 copayTelehealth: $50 copay20% coinsurance12 | SUMMARY OF BENEFITSTHERAPIESIncludes:Occupational TherapySpeech PathologyPhysical TherapyPrior authorization is required.$25 per visit20% coinsurance for Medicare-covered servicesAMBULANCE SERVICESGround AmbulancePrior authorization is required.$275 per trip20% coinsurance for Medicare-approved amountAir or Water AmbulancePrior authorization is required.$300 per trip20% coinsurance for Medicare-approved amountH6351_2025EnrollmentGuideCSNP

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Liberty Medicare Advantage(HMO C-SNP)Original MedicareTRANSPORTATION (NON-EMERGENCY)Part of a Liberty MedicareAdvantage's Freedom FlexCard that allows a maximum of$40 per month with month-to-month rollover to be used foreither non-emergencytransportation or fitness.20% coinsurance for Medicare-approved amountMEDICARE PART B PRESCRIPTION DRUGSChemotherapy Drugs20% coinsurance for Medicare-covered servicesAmounts are paid until themaximum out-of-pocket isachieved.Authorization is required for initialadministration of chemotherapy.20% coinsurance for Medicare-covered Part B drugsMember pays 100% of non-covered Part B drugsOther Part B drugs20% coinsurance for Medicare-covered servicesAmounts are paid until themaximum out-of-pocket isachieved.Prior authorization is required.20% coinsurance for Medicare-covered Part B drugsMember pays 100% of non-covered Part B drugsAMBULATORY SURGICAL CENTERAuthorization is required.$0 - $250 max copay $0 copay for colonoscopy20% coinsurance after deductibleand any applicable copays are metSUMMARY OF BENEFITS | 13H6351_2025EnrollmentGuideCSNP

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Liberty Medicare Advantage(HMO C-SNP)Original MedicareMEDICAL EQUIPMENT/SUPPLIESDurable Medical Equipment(e.g., wheelchairs, oxygen)Authorization is required.20% coinsurance for Medicare-covered devices20% coinsurance for Medicare-covered devicesProsthetics(e.g., braces, artificial limbs)Authorization is required.20% coinsurance for Medicare-covered devices20% coinsurance for Medicare-covered devicesDiabetic SuppliesLimit to blood glucosemonitors and diabetic teststrips from specificmanufacturersAuthorization is Required$0 copay20% coinsurance for Medicare-covered devicesPULMONARY REHABILITATION SERVICESSupervised Exercise Therapy(SET) for SymptomaticPeripheral Artery Disease(PAD)Prior authorization is required.$0 copay20% coinsurance of servicescompleted in a doctor’s officeIf in an outpatient setting, youalso pay the hospital copay.CARDIAC REHABILITATION SERVICES$0 copay20% coinsurance of servicescompleted in a doctor’s officeIf in an outpatient setting, youalso pay the hospital copay.SKILLED NURSING FACILITYPrior authorization is required.Follows Original Medicare Feefor Service:Days 1-20: $0 coinsuranceper dayDays 21-100: $200coinsurance per dayDays 101 and beyond: AllcostsPart A covers for a limitedtime.Days 1 - 20: $0coinsuranceDays 21-100: Up to $200coinsurance per dayDays 101 and beyond: Allcosts14 | SUMMARY OF BENEFITSH6351_2025EnrollmentGuideCSNP

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SUMMARY OF BENEFITS | 15Liberty Medicare Advantage (HMO C-SNP) --- Outpatient Prescription DrugsCost sharing may changedepending on the pharmacyyou choose.STANDARD 30-DAYSUPPLYSTANDARD60-DAYSUPPLYSTANDARD90-DAYSUPPLYLONG-TERMCARE (LTC) COSTSHARING(UP TO 31-DAYSUPPLY)OUT-OF-NETWORKCOSTSHARINGDeductible for Part DPrescription Drugs$0$0$0$0$0COST SHARING FOR COVERED DRUGSTier 1 – Preferred Genericand Mail Order$0$0$0$0$0Tier 2 – Generic and MailOrder$0$0$0$0$0Tier 3 – Preferred Brand$35$70$105$35$35Tier 3 – Preferred BrandMail Order$30$60$90$35$35Tier 4 – Non-PreferredBrand$95$190$285$95$95Tier 4 – Non-PreferredBrand Mail Order$90$180$270$95$95Tier 5 – Specialty Tier andMail Order33%33%33%33%33%Tier 6 – Diabetic Drugs andMail Order$0$0$0$0$0H6351_2025EnrollmentGuideCSNP

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Freedom Flex Card$75$40Fitness &TransportationGroceries & OTC Items$2,000Dental, Vision& HearingYOU are in control of where andhow you spend YOUR dollars!16 | SUMMARY OF BENEFITSLiberty Medicare Advantage (HMO C-SNP) --- Combined BenefitsThe following benefits are at no cost to you. Some benefits are previously listed, but here is a complete list:Liberty Medicare Advantage offers a “Freedom Flex Card” to use for certain benefits that areimportant to you. We have three cards with a variety of benefits, and you are in control of where/howyou spend the dollars. Card payments may not be offered in the form of cash or monetary rebates,including reduced cost-sharing or premiums.The Vision, Hearing and Dental Flex Card allows you to spend $2,000 annually for the servicesyou need.The Fitness and Transportation Flex Card allows you to spend $40 per month with month-to-month rollover. This includes fitness and transportation.The OTC Drugs and Groceries Flex Card allows you to spend $75 per month with no rollover.This includes OTC or groceries.Post-Acute Meal Benefit: (28 meals total)Two meals per day for up to seven days following an inpatient stay, two events per year Chronic Meal Benefit: (360 meals total)Two meals per day for up to 90 days, two events per yearAn RN referral is required.H6351_2025EnrollmentGuideCSNP

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18 | MOST COMMON DRUGS Most Common DrugsDRUGTIERSUBSTITUTIONSAbilify Maintena5Abiraterone Acetate1Abrysvo3Actemra5Advair3Advair Diskus*WixelaAlbuterol1Allopurinol1Amlodipine1Anoro Ellipta3Aptiom4Arexvy3Aripiprazole1 & 2Aristada5Atorvastatin1Atrovent HFA3Austedo5Baclofen1Biktarvy5Basaglar Kwikpen*LantusBosulif5Breo Ellipta3Breyna3Breztri3Brilinta3Brimonidine tartrate/timolol 1 & 2Brukinsa5Budesonide/FormoterolFumarate2Buprenorphine 1 & 2Bupropion1Cabometyx5Caplyta4Carvedilol1KEY: BOLD = BRAND NON-BOLD = GENERIC *NOT COVERED BLUE: QUALIFYING C-SNP DRUGSA PARTIAL LIST OF COMMONLY PRESCRIBED DRUGS COVERED BY OUR PLANDRUGTIERSUBSTITUTIONSCimzia5Clopidogrel1Clozapine2Colchicine1 & 2Combigan*BrimonidineTartrate/TimololCombivent 3Copaxone *Glatiramer AcetateCosentyx5Creon3Cyclosporine1Descovy5Diclofenac Sodium1 & 2Dimethyl Fumarate1Donepezil1 & 2Dovato5Duloxetine Hydrochloride1Dupixent5Eliquis3Emgality3Enbrel5Entresto3Escitalopram Oxalate1 & 2Evrysdi5Famotidine1Farxiga3Febuxostat2Flovent*Fluticasone PropionateFluticasone Propionate1Forteo*TeriparatideFurosemide1 & 2Gabapentin1Gattex5Glatiramer Acetate1CopaxoneH6351_2025EnrollmentGuideCSNP

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MOST COMMON DRUGS | 19KEY: BOLD = BRAND NON-BOLD = GENERIC *NOT COVERED BLUE: QUALIFYING C-SNP DRUGSDRUGTIERSUBSTITUTIONSGlatopa1Humulin6Ibrance5Imbruvica5Incruse Ellipta3Ingrezza5Insulin Glargine6Invega Sustenna4Invega Trinza4Janumet3Janumet XR3Januvia3Jardiance3Januluca 5Kesimpta 5Krystexxa*Allopurinol,Colchicine, FebuxostatLacosamide1VimpatLamotrigine1Lantus6Latuda*LurasidoneLevetiracetam1Levothyroxine Sodium1Linzess4Lisinopril1Losartan Potassium1Lumigan3Lynparza5Mavyret5MemantineHydrochloride1 & 2Metformin1Metoprolol Succinate1Mirtazapine1Mirabegron 2Montelukast Sodium1DRUGTIERSUBSTITUTIONSMounjaro3Novolog*Humalog KwikpenNubeqa5Nucala5Nuedexta3Nuplazid4Nurtec*UbrelvyOctogam5Odefsey5Ofev5Olanzapine1 & 2Omeprazole1Ondansetron1Opsumit5Orencia5Otezla5Oxycontin3Ozempic3Paliperidone ER2Pantoprazole1Potassium Chloride 1 & 21 & 2Pradaxa*Dabigatran EtexilatePravastatin Sodium1Pregabalin1Premarin3Prezcobix5Privigen5Prolia4Promacta5Pyridostigmine1Quetiapine Fumarate1Radicava5Repatha3Revlimid5Rexulti4Rinvoq5H6351_2025EnrollmentGuideCSNP

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KEY: BOLD = BRAND NON-BOLD = GENERIC *NOT COVERED BLUE: QUALIFYING C-SNP DRUGS 20 | MOST COMMON DRUGS DRUGTIERSUBSTITUTIONSRisperidone1 & 2Rosuvastatin Calcium1Rybelsus3Santyl3Scemblix5Sertaline HCL1Shingrix3Simvastatin1Skyrizi5Sofosbuvir/Velpatasvir5Soliris*PyridostigmineSprycel5Stelara5Stiolto Respimat3Sublocade*BuprenorphineSucralfate1 & 2Symbicort*Budesonide/FormoterolSymtuza5Tagrisso5Tamsulosin1Tetrabenazine1Tivicay5Toujeo6Tradjenta3Trelegy Ellipta3Tremfya5Tresiba6Trikafta5Trintellix3Triumeq3 & 5Trulance3Trulicity3Ubrelvy3NurtecVarenicline2Venclexta3 & 5Ventolin3DRUGTIERSUBSTITUTIONSVimpat*LacosamideVivitrol5Vraylar4Vyndamax5Wixela1Advair DiskusXarelto3Xeljanz5Xeljanz XR5Xifaxan3Xolair5Xtandi5Xyrem*Sodium OxybateH6351_2025EnrollmentGuideCSNP

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PRE-ENROLLMENT CHECKLISTIn addition to your monthly plan premium, you must continue to pay your Medicare Part Bpremium. This premium is normally taken out of your Social Security check each month. Benefits, premiums and/or copayments/co-insurance may change on January 1, 2025.Except in emergency or urgent situations, we do not cover services by out-of-network providers (doctors who are not listed in the provider directory). This plan is a chronic condition special needs plan (C-SNP). Your ability to enroll will be based on verification that you have a qualifying specific severe or disabling chronic condition. Before making an enrollment decision, it is important that you fully understand our benefits andrules. If you have any questions, you can call and speak to a customer service representative at1-844-854-6884 (TTY 711).Review the full list of benefits found in the Evidence of Coverage (EOC), especially forthose services for which you routinely see a doctor. Visit LibertyMedicareAdvantage.com orcall 1-844-854-6884 (TTY 711) to view a copy of the EOC.Review the provider directory (or ask your doctor) to make sure the doctors you see now arein the network. If they are not listed, it means you will likely have to select a new doctor. Review the pharmacy directory to make sure the pharmacy you use for any prescriptionmedicine is in the network. If the pharmacy is not listed, you will likely have to select a newpharmacy for your prescriptions. Understanding the Benefits Understanding Important Rules H6351_2025PEC_CSNP_C 22 | PRE-ENROLLMENT CHECKLISTH6351_2025EnrollmentGuideCSNP

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SCOPE OF SALES APPOINTMENTCONFIRMATION FORMThe Centers for Medicare and Medicaid Services (CMS) requires agents to document the scope of a marketingappointment prior to any face-to-face sales meeting to ensure understanding of what will be discussed between theagent and the Medicare beneficiary (or their authorized representative). All information provided on this form isconfidential and should be completed by each person with Medicare or his/her authorized representative. Liberty Medicare Advantage is a Medicare Advantage Plan with Prescription Drug Coverage (MAPD), alsoknown as Medicare Part C & D. Our plans include all the benefits of Original Medicare Parts A and B, along withcoverage for prescription drugs, vision, dental, hearing, and more. Liberty Medicare Advantage Plans: Medicare Health Maintenance Organization (HMO) -- A Medicare Advantage Plan that provides all OriginalMedicare Part A and Part B health coverage and sometimes covers Part D prescription drug coverage. Inmost HMOs, you can only get your care from doctors or hospitals in the plan’s network (except inemergencies).Medicare HMO Special Needs Plan (HMO SNP) -- An HMO Medicare Advantage Plan that has a benefitpackage designed for people with special health care needs. Examples of the specific groups served includepeople who have both Medicare and Medicaid, people who reside in nursing homes, and people who havecertain chronic medical conditions. Liberty’s HMO SNP is specific to those with chronic conditions.By signing this form, you agree to a meeting with a sales agent to discuss Liberty Medicare Advantage Plans. Pleasenote, the person who will discuss the products is either employed or contracted by a Medicare plan. They do notwork directly for the Federal government. This individual may also be paid based on your enrollment in a plan.Signing this form does NOT obligate you to enroll in a plan, affect your current or future enrollment, or enroll you ina Medicare plan. DATE BENEFICIARY SIGNATUREIf you are the beneficiary’s authorized representative, you must sign above and provide the following information: AUTHORIZED REPRESENTATIVE SIGNATURE AUTHORIZED REPRESENTATIVE FIRST NAMERELATIONSHIP TO BENEFICIARY PHONE NUMBERTO BE COMPLETED BY AGENTAGENT LAST NAME*BENEFICIARY LAST NAME*AGENT FIRST NAME* PHONE NUMBER*BENEFICIARY FIRST NAME* PHONE NUMBER*DATE AGENT SIGNATUREBENEFICIARY ADDRESSINITIAL METHOD OF CONTACT DATE OF APPOINTMENT* H6351_SOA_CY22R081820_C *Required Field SCOPE OF SALES | 23

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Liberty Medicare Advantage (HMO C-SNP) offers Special Needs Plans that coordinate health carebenefits for people with chronic or disabling conditions. You may be eligible to join if you can answerYES to any of the questions below. Our Plan will need to verify your chronic condition with your doctoror provider within 30 days of enrollment. We must disenroll you from the special needs plan if we areunable to verify your condition. That means it is very important to let your doctor or provider know thatwe will need this verification and to provide accurate contact information. PRE-ENROLLMENT QUALIFICATIONASSESSMENT TOOLBENEFICIARY INFORMATIONLast Name:First Name:Initial:Date of Birth: ____________________ (Month / Day / Year)Medicare Beneficiary Identifier:Phone Number #1:Phone Number #2:CLINICAL QUESTIONS TO QUALIFY CHRONIC CONDITION(S)DIABETES MELLITUSHave you been diagnosed by your doctor or other licensed healthcare professional withDiabetes?□ YES□ NOHave you had problems with high blood sugar? □ YES□ NODo you take medications and/or have been put on a special diet to control your bloodsugar?□ YES□ NOCHRONIC HEART FAILURE (CHF)Have you been diagnosed by your doctor or other licensed healthcare professional withchronic or congestive heart failure?□ YES□ NOHave you had problems with fluid retention in your lungs or swelling in your legs due toheart problem?□ YES□ NODo you take medications to prevent legs or hand swelling?□ YES□ NOCARDIOVASCULAR DISORDERS (CVD)Have you been diagnosed by your doctor or other licensed healthcare professional withcardiac arrhythmia, or coronary artery disease (Angina), blood clots or vasculardisease of legs?□ YES□ NOHave you had palpitations in your chest?□ YES□ NOHave you had problems with chest pain or tightness, shortness of breath, heart attack(cardiac infarction) or stroke?□ YES□ NO24 | PRE-ENROLLMENT FORMH6351_2025PreEnr_CSNP-DRAFT

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PRE-ENROLLMENT QUALIFICATIONASSESSMENT TOOLHEALTH CARE PROVIDER(S) WHO CAN VERIFY YOUR CONDITION(S) Healthcare Provider #1 Name:Address:Healthcare Provider Phone Number: Healthcare Provider Fax Number:Healthcare Provider #2 Name:Address:Healthcare Provider Phone Number: Healthcare Provider Fax Number:AUTHORIZATION FOR DISCLOSURE OF HEALTH INFORMATION TO VERIFY CHRONICCONDITION(S) I hereby authorize the providers listed above to disclose my protected health information to LibertyMedicare Advantage, to verify that I have been diagnosed with a chronic condition which qualifies me forenrollment in Liberty Medicare Advantage’s chronic special needs plan. This authorization applies to allhealth information maintained by the provider concerning my medical history for the chronic condition(s)indicated above. Note: Information disclosed as a result of this authorization will be protected by LibertyMedicare Advantage in accordance with applicable state and federal laws and requirements. Call us if youhave questions or need help with this form. You can reach us at 1-844-854-6884 (TTY 711)Beneficiary Signature:Date:PROVIDER ATTESTATION (to be completed after enrollment)I hereby attest that my patient listed above has one or more of the following conditions:Diabetes Mellitus □ YES □ NOChronic Heart Failure (CHF) □ YES □ NOCardiovascular Disorders (CVD) □ YES □ NOProvider Name:Provider Signature:Today's Date:Provider Address:H6351_2025PreEnr_CSNP-DRAFTPLEASE SEND COMPLETED ENROLLMENT FORMS TO:Enrollment@LibertyMedicareAdvantage.comLiberty Medicare Advantage complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llameal 1-844-854-6884 (TTY 711). 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 1-844-854-6884 (TTY 711)PRE-ENROLLMENT FORM | 25

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INDIVIDUAL ENROLLMENT REQUEST FORM TOENROLL IN A MEDICARE ADVANTAGE PLAN (PART C) Who can use this form? People with Medicare who want to join a MedicareAdvantage PlanImportant: To join a Medicare Advantage Plan,you must also have both:Medicare Part A (Hospital Insurance) Medicare Part B (Medical Insurance) You can join a plan: Between October 15 - December 7 each year(for coverage starting January 1)Within 3 months of first getting MedicareIn certain situations where you’re allowed tojoin or switch plansTo join a plan, you must: Be a United States citizen or be lawfullypresent in the U.S. Live in the plan’s service area When do I use this form?Visit Medicare.gov to learn more about when youcan sign up for a plan. Reminders:If you want to join a plan during fall openenrollment (October 15–December 7), the planmust get your completed form by December 7.Your plan will send you a bill for the plan’spremium. You can choose to sign up to haveyour premium payments deducted from yourbank account or your monthly Social Security(or Railroad Retirement Board) benefit.Your Medicare Number (the number on your red,white, and blue Medicare card)Your permanent address and phone number What do I need to complete this form?Note: You must complete all items in Section 1.The items in Section 2 are optional — you can’tbe denied coverage because you don’t fill themout. Send your completed and signed form to:What happens next?Once they process your request to join, they’llcontact you. Liberty Medicare AdvantagePO Box 3325Spring Hill, FL 34611Enrollment@LibertyMedicareAdvantage.comFax: 877-760-3620Call Liberty Medicare Advantage at 1-833-354-1498. TTY users can call 711. How do I get help with this form?En español: Llame a Liberty Medicare Advantageal 1-833-354-1498/TTY 711 o a Medicare gratis al1-800-633-4227 y oprima el 2 para asistencia enespañol y un representante estará disponible paraasistirle.Or, call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMBcontrol number. The valid OMB control number for this information collection is 0938-1378. The time required to complete this information isestimated to average 20 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, andcomplete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions forimproving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland21244-1850.IMPORTANTDo not send this form or any items with your personal information (such as claims, payments, medical records, etc.) to the PRA Reports Clearance Office.Any items we get that aren’t about how to improve this form or its collection burden (outlined in OMB 0938-1378) will be destroyed. It will not be kept,reviewed, or forwarded to the plan. See “What happens next?” on this page to send your completed form to the plan.If you want to join a plan but have no permanentresidence, a Post Office Box, an address of ashelter or clinic, or the address where you receivemail (e.g., social security checks) may beconsidered your permanent residence address.Individuals Experiencing Homelessness:26 | ENROLLMENTOMB No. 0938-1378Expires: 6/30/2026H6351_2025EnrollmentGuideCSNP

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2025 ENROLLMENTREQUESTSection 1 - All fields on this page are required (unless marked optional) FIRST Name: LAST Name:Will you have other prescription drug coverage (like VA, TRICARE) in addition to Liberty MedicareAdvantage? Select the plan you want to join: M.I.:Birth Date (MM/DD/YYYY):Sex:Male FemalePhone Number:Permanent Residence Street Address (Don't enter a PO Box. Note: For individuals experiencinghomelessness, a PO Box may be considered your permanent residence address.):City: County:State:Zip Code:Mailing address, if different from your permanent address (PO Box allowed):City:State:Zip Code:Your Medicare InformationMedicare Number:Answer These Important Questions:YesNoName of Other Coverage: Member Number for this Coverage:Group Number for this Coverage:_______________________ _____________________________ ____________________________004 - Liberty Medicare Advantage Plan (HMO C-SNP) $0 per monthDo you have one of the following conditions: Diabetes Mellitus (DM), Chronic Heart Failure (CHF), orCardiovascular Disease (CVD): Yes NoStreet Address:_ _ _ _ - _ _ _ - _ _ _ _ENROLLMENT | 27H6351_2025_ENRFORM004_C File & Use 10092021

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2025 ENROLLMENTREQUESTIMPORTANT: Read and Sign Below:I must keep both Hospital (Part A) and Medical (Part B) to stay in Liberty Medicare Advantage.By joining this Medicare Advantage, I acknowledge that Liberty Medicare Advantage will share myinformation with Medicare, who may use it to track my enrollment, to make payments, and for otherpurposes allowed by Federal law that authorize the collection of this information (see Privacy ActStatement below). Your response to this form is voluntary. However, failure to respond may affectenrollment in the plan.I understand that I can be enrolled in only one MA plan at a time – and that enrollment in this planwill automatically end my enrollment in another MA plan (exceptions apply for MA PFFS, MAMSA plans).I understand that when my Liberty Medicare Advantage coverage begins, I must get all of mymedical and prescription drug benefits from Liberty Medicare Advantage. Benefits and servicesprovided by Liberty Medicare Advantage and contained in my Liberty Medicare Advantage“Evidence of Coverage” document (also known as a member contract or subscriber agreement) willbe covered. Neither Medicare nor Liberty Medicare Advantage will pay for benefits or services thatare not covered.The information on this enrollment form is correct to the best of my knowledge. I understand that ifI intentionally provide false information on this form, I will be disenrolled from the plan.I understand that my signature (or the signature of the person legally authorized to act on my behalf)on this application means that I have read and understand the contents of this application. If signedby an authorized representative (as described above), this signature certifies that:1.) This person is authorized under State law to complete this enrollment, and2.) Documentation of this authority is available upon request by Medicare.Signature: Today's Date:If you’re the authorized representative, sign above and fill out these fields: Name:Phone Number:Address:Relationship to Enrollee:28 | ENROLLMENTH6351_2025_ENRFORM004_C File & Use 10092021

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Please contact Liberty Medicare Advantage at 1-833-354-1498 if you need information in an accessible format other than what’s listedabove. Our office hours are Monday-Friday from 8:00 am – 8:00 pm. Between October 1st and March 31st, we are available Monday-Sunday from 8:00 am – 8:00 pm. During certain parts of the year, we may use alternate technologies to answer your call on weekends andFederal holidays. TTY users can call 711.Your Medicare InformationEmail Address: ___________________________________________________________________2025 ENROLLMENTREQUESTSection 2 - All fields on this page are optionalAnswering these questions is your choice. You can’t be denied coverage because you don’t fill them out.Are you Hispanic, Latino/a, or Spanish origin? Select all that apply.No, not of Hispanic, Latino/a, or Spanish originYes, Mexican, Mexican American, Chicano/aSelect one if you want us to send you information in a language other than English. Select one if you want us to send you information in an accessible format. Yes, another Hispanic, Latino/a, or Spanish originYes, Puerto RicanYes, CubanI choose not to answerWhat’s your race? Select all that apply.American Indian or Alaska NativeChineseJapaneseOther AsianVietnameseAsian IndianFilipinoKoreanOther Pacific IslanderWhiteBlack or African AmericanGuamanian or ChamorroNative HawaiianSomoanI choose not to answerEspanolBrailleLarge PrintAudio CDDo you work? Yes No Does your spouse work? Yes NoList your Primary Care Physician (PCP), clinic, or health center:I want to get the following materials via email:Asian:Native Hawaiian and Pacific Islander:NoneWhich of the following best represents how you think of yourself? Select one.Lesbian or gayStraight, that is, not gay or lesbianBisexualI use a different term: __________________I don’t knowWhat is your gender? Select one.WomanManNon-Binary I use a different term: __________________I choose not to answerI choose not to answerNoneData CDFirst Name: __________________________________ Last Name: ____________________________Plan CommunicationsAnnual Notic of Change (ANOC)ENROLLMENT | 29H6351_2025_ENRFORM004_C File & Use 10092021

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2025 ENROLLMENTREQUESTPaying Your Plan PremiumsYou can pay your monthly plan premium (including any late enrollment penalty that youcurrently have or may owe) by mail each month. You can also choose to pay your premium byhaving it automatically taken out of your Social Security or Railroad Retirement Board (RRB)benefit each month.If you have to pay a Part D-Income Related Monthly Adjustment Amount (Part D-IRMAA), youmust pay this extra amount in addition to your plan premium. DON’T pay Liberty MedicareAdvantage the Part D-IRMAA.For individuals helping enrollee with completing this form onlyComplete this section if you’re an individual (i.e. agents, brokers, SHIP counselors, family members,or other third parties) helping an enrollee fill out this form.Name: _____________________________ Relationship to Enrollee: _________________________ Signature: __________________________National Producer Number (Agents/Brokers only): ___________________________ Plan Received Date: ___________________ Effective Date of Coverage: __________________Election Type: __ICEP/IEP __MA OEP ___SEP ___AEP ___OEPIPRIVACY ACT STATEMENTThe Centers for Medicare & Medicaid Services (CMS) collects information from Medicare plans totrack beneficiary enrollment in Medicare Advantage (MA) Plans, improve care, and for the payment ofMedicare benefits. Sections 1851 of the Social Security Act and 42 CFR §§ 422.50 and 422.60 authorizethe collection of this information. CMS may use, disclose and exchange enrollment data from Medicarebeneficiaries as specified in the System of Records Notice (SORN) “Medicare Advantage PrescriptionDrug (MARx)”, System No. 09-70-0588. Your response to this form is voluntary. However, failure torespond may affect enrollment in the plan.H6351_2025_ENRFORM004_C File & Use 1009202130 | ENROLLMENT

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HEALTH RISK ASSESSMENTThe following questions will help Health Plan give you the best care possible. The answers will not affect yourbenefits. If you need help answering this survey, please call Member Services. What is your preferred language? ________________________________________________________________GENERAL INFORMATIONName: ______________________________ Date of Birth: _____________ Member ID: ____________________Address: _____________________________________________________________________________________Primary Doctor: _______________________________ Date of Last Physicians Visit: _____________________Phone Number: ______________________ Consent to Receive Text Messages: □ Yes □ NoDo you have a healthcare power of attorney or guardian? □ Yes □ NoWhat is your race?Guamanian or ChamorroJapaneseKoreanNative HawaiianOther AsianAmerican Indian or Alaska NativeAsian IndianBlack or African AmericanChineseFilipinoOther Pacific IslanderSamoanVietnameseWhitePrefer not to answerWhat is your ethnicity?Not of Hispanic, Latino/a or Spanish originPuerto RicanAnother Hispanic, Latino or Spanish originMexican, Mexican American, Chicano/aCubanPrefer not to answerWhat is your highest level of education you have completed?8th grade or lessHigh School Graduate or GEDSome CollegeCollege DegreeAdvanced DegreeGENERAL HEALTH INFORMATIONHave you been admitted to the Hospital in the past 6 months? Yes NoIf yes, why? ______________________________________________________________________________Have you been to the Emergency Room in the past 6 months?If yes, why? ______________________________________________________________________________Are you receiving any of the following services?Yes NoOxygen?If yes, what company provides this service? _______________________________________________Yes NoMedical Equipment?If yes, list equipment: _________________________________________________________________Yes NoIf yes, what company provides this service? ________________________________________________HEALTH RISK ASSESSMENT | 31H6351_2025EnrollmentGuideCSNP

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How would you rate your overall physical health?Excellent Good Fair PoorDo you have a hearing aid or use TTY?Yes NoDo you have glasses or contacts?Yes NoDuring the past 4 weeks, did a medical problem keep you from being able to work or do any of your normalactivities?Yes NoHEALTH RISK ASSESSMENTGENERAL HEALTH INFORMATIONYes NoRehab/Physical Therapy?Yes NoHome Health?Yes NoRadiation Therapy?Do you have any hospitalizations, surgeries or procedures scheduled?Yes NoIV Medication/Chemotherapy?Are you receiving any of the following services?Yes NoOther Equipment?If yes, list equipment: _________________________________________________________________If yes, what company provides this service? ________________________________________________If yes, what company provides this service? ________________________________________________If yes, what company provides this service? ________________________________________________If yes, what company provides this service? ________________________________________________If yes, what company provides this service? ________________________________________________If yes, what type? _________________________________________________________________________If yes, what date? _________________________________________________________________________If yes, what is the location? _________________________________________________________________If yes, what company provides this service? ____________________________________________________Yes No32 | HEALTH RISK ASSESSMENT H6351_2025EnrollmentGuideCSNP

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HEALTH RISK ASSESSMENTGENERAL HEALTH INFORMATIONDo you have, or have you been told you have, any of the following health conditions now?AsthmaCancerDiabetesHeart AttackHeart Issues (rhythm, clogged arteries,high blood pressure)Heart FailureKidney DiseaseLung Issues (COPD, Emphysema, Fibrosis)Mental Health (Anxiety, Bipolar, Depression,Schizophrenia)Neurological (Alzheimer’s, Dementia, Parkinson’s)StrokeOther ______________________________________What is your main health concern right now?__________________________________________________________________________________________________________________________________________________________________________________How many days a week do you normally get 20 minutes or more of exercise/activity?0 to 2 days 3 to 5 days 6 to 7 daysHow many prescription medications do you take?None 1 to 5 medications 6 or more medicationsDo you take your medications regularly?Yes NoDo you have problems obtaining medications?Yes NoIn the past 7 days, did you need help with any of these activities?Bathing Brushing your teeth or hair DressingEatingGetting in and out of a bed or chairUsing the bathroomWalkingIn the past 7 days, did you need help to do any of these activities?Housework Laundry ShoppingUsing the phoneMaking your mealsIn the past 7 days, how much pain have you felt?None SomeA lotWhere do you have pain? ____________________________________________________________________Do you fasten your seat belt in the car?Yes NoWhat pharmacy do you use?Walmart CVS Walgreens Harris Teeter CostcoHEALTH RISK ASSESSMENT | 33H6351_2025EnrollmentGuideCSNP

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HEALTH RISK ASSESSMENTGENERAL HEALTH INFORMATIONDo you have stable housing?Yes NoDo you need help getting food?Yes NoDo you have reliable transportation?Yes NoIf you had a fasting blood glucose test done in the last year, what were the results?100 mg/dL or lower Between 100-125 mg/dL126 mg/dL or higherI don’t knowIf your blood pressure was checked in the last year, what were the results?120/80 or lower121/81 to 139/89140/90 or higherI don’t knowIf your cholesterol was checked in the past year, what were the results?200 mg/dL or lowerHigher than 200 mg/dLI don’t knowIf you had an HbA1C drawn in the last year, was it less than 7.0%? (This test is done for people with diabetes)YesNo, it was ____________________ I don’t knowNot applicable Have you had a flu shot in the past 12 months?Yes NoHave you had a pneumonia shot in the past 12 months?Yes No Not applicableHave you had a colonoscopy done in the past 10 years?Yes No Not applicableWhere did you have the colonoscopy done? ___________________________________________________Have you had a stool test for blood in the past 12 months?Yes No Not applicableHave you had a pap smear (cervical cancer screening) in the past 12 months?YesNoNot applicableHave you had a total hysterectomy?Yes No Not applicable34 | HEALTH RISK ASSESSMENT H6351_2025EnrollmentGuideCSNP

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HEALTH RISK ASSESSMENTGENERAL HEALTH INFORMATIONHave you had a mammogram in the past 12 months?Yes No Not applicableWhat is your height? _______ feet _______ inches What is your weight? _________________ poundsDENTAL HEALTH INFORMATIONHow would you rate your overall dental/oral health?Excellent Good Fair PoorHave you seen a dentist in the past year?Yes NoDo you brush your teeth every day?Yes NoMENTAL HEALTH INFORMATIONHow would you rate your overall mental health?Excellent Good Fair PoorIn the past 2 weeks, how often have you felt little interest or pleasure in doing things?Not at allSeveral daysMore than half the daysNearly every dayIn the past 2 weeks how often have you felt down, depressed or hopeless?Not at allSeveral daysMore than half the daysNearly every dayHow stressful is your life right now?Not stressful at all Somewhat stressful Really stressfulDuring the past 4 weeks, did any emotional or psychological problem keep you from being able to work or doany normal daily activities?Yes NoDo you use any of the following products?Cigarettes E-Cigarettes Smokeless tobacco Cigars PipeAre you interested in quitting? Yes NoHow many alcoholic drinks (like wine, beer, mixed drinks) do you have in a normal week?0 drinks1-6 drinks7-13 drinks14 or more drinksHave you had a total mastectomy?Yes No Not applicableHEALTH RISK ASSESSMENT | 35H6351_2025EnrollmentGuideCSNP

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IMPORTANT INFORMATION:2024 MEDICARE STAR RATINGSLiberty Medicare Advantage - H6351For 2024, Liberty Medicare Advantage - H6351 received the following Star Ratings from Medicare:Overall Star Rating: Health Services Rating:Drug Services Rating:Not enough data available*Not enough data available**Some plans do not have enough data to rate performance.Every year, Medicare evaluates plans based on a 5-star rating system.Why Star Ratings Are ImportantMedicare rates plans on their health and drug services.This lets you easily compare plans based on quality andperformance.Star Ratings are based on factors that include: Feedback from members about the plan’s service and careThe number of members who left or stayed with the planThe number of complaints Medicare got about the planData from doctors and hospitals that work with the planMore stars mean a better plan – for example, members mayget better care and better, faster customer service. The number of stars show howwell a plan performs.EXCELLENTABOVE AVERAGEAVERAGEBELOW AVERAGEPOORGet More Information on Star Ratings OnlineCompare Star Ratings for this and other plans online at medicare.gov/plan-compare.Questions about this plan?Contact Liberty Medicare Advantage 7 days a week from 8:00 a.m. to 8:00 p.m. Eastern time at844-854-6884 (toll-free) or 711 (TTY). Current members please call 844-854-6884 (toll-free) or 711 (TTY). 36 | MEDICARE STAR RATINGSH6351_2025EnrollmentGuideCSNP

LMA 2025 Enrollment Guide

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