Medicare Advantage Plans

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1 2016 BlueCross BlueShield of Western New York Medicare Advantage Plans Gloria and Anai, Members Y0086_MRK1528rev2 Accepted

2 The benefits of Blue Understanding Medicare and choosing a health plan are not always easy. That s why we re here to be your partner and help you along the way. Everyone is different, so please contact us. We can help guide you to the plan that works best for you. When you choose Blue, you choose the exceptional support, value, and service you deserve. $0 preventive services * More than 20 services included at no cost with your plan: Diabetes, blood pressure, and cholesterol screenings Flu and pneumonia vaccines Routine mammograms and colonoscopies Annual wellness visit NEW! Receive a Discover rewards card when you complete your annual wellness visit. $0 gym membership Access to more than 12,000 fitness locations nationwide through SilverSneakers Home exercise programs with walking, strength, and yoga workouts to choose from $0 community health and wellness classes More than 150 wellness classes throughout the community Topics include heart health, physical activity and fitness, weight management, and nutrition $0 care management Team of nationally accredited nurses, physicians, dietitians, chiropractors, and health coaches to provide you with support Care is coordinated with your doctor(s) and other health care professionals NEW! Care at Home SM program for members with complex health needs: Provided in the comfort of your home, like traditional house calls Always coordinated with your primary doctor Available 24/7, at no cost to you * When you use providers in our network.

3 2016 Medicare Advantage Plans Senior Blue HMO 601 (HMO) 3 (without drug coverage) Senior Blue HMO Select (HMO) 4 (see note below) Senior Blue HMO 651 (HMO) 3 Forever Blue Medicare PPO Value (PPO) 5 Forever Blue Medicare PPO 751 (PPO) 6 Primary doctor/specialist $25/$45 $35/$50 $15/$35 $35/$50 $15/$40 Inpatient hospital $270 per day you pay $1,890 per year $275 per day you pay $1,925 per year $225 per day you pay $1,575 per year $270 per day you pay $1,890 per year Skilled nursing facility $0 per day for days 1-20, $160 per day for days $0 per day for days 1-20, $160 per day for days $225 per day you pay $1,575 per year Part B diabetes supplies $0 $0 $0 $0 $0 X-rays/advanced radiology $45/$75 $60/$100 $40/$75 $50/$75 $40/$75 Urgent care copay waived if admitted within one day Emergency room visit copay waived if admitted within one day $65 $65 $65 $65 $65 $75 $75 $75 $75 $75 Outpatient surgery $250 $300 $250 $275 $275 Out-of-pocket maximum $6,700 $6,700 $6,700 Optional supplemental dental 1 $6,700 in-network $10,000 in- and out-of-network $6,700 in-network $10,000 in- and out-of-network Nationwide coverage ER and urgent care only ER and urgent care only ER and urgent care only Yes, for all covered services 5 Yes, for all covered services BlueCard travel included 6 Tiers 1/2/3/4/5 (Preferred pharmacies include Rite Aid and Walmart; see Provider Listing for full list) $17 monthly premium for Basic plan, or $31 monthly premium for NEW Enhanced plan Prescription drugs (30-day supply at a retail pharmacy) Not covered $10/$15/$42/$94/33% $15/$20/$47/$100/33% $7/$15/$42/$94/33% $12/$20/$47/$100/33% $17 monthly premium for Basic plan, or $31 monthly premium for NEW Enhanced plan Prescription drugs (30-day supply at a retail pharmacy) $7/$15/$42/$94/33% $12/$20/$47/$100/33% $5/$15/$42/$94/33% $10/$20/$47/$100/33% Gap coverage Discounts Discounts Discounts Discounts Plan premium Plan premium 2016 Premium 2 $0 $39.70 $109 $99 $191 Premium with EPIC subsidy or full Extra Help 2 N/A As low as $0 As low as $69.27 As low as $59.27 As low as $ Note for Senior Blue HMO Select only Members of Senior Blue HMO Select can see any doctor or specialist that participates with us, but this plan does not cover any routine or scheduled medical services at facilities in the Catholic Health System (excluding Mount St. Mary s Hospital) when the services are provided and billed by Catholic Health, as opposed to the doctor or specialist. However, emergency services will be covered at any hospital. Costs shown here are copayments for in-network providers.

4 Coverage that travels with you All of our plans cover you worldwide for urgent and emergency care. You simply show your ID card and pay the same as you would in-network for these services. Rest easy knowing that you re covered anytime, anywhere. If you travel often, you can enjoy the flexibility of BlueCard Network Sharing with our Forever Blue Medicare PPO 751 plan. BlueCard links all BlueCross and/or BlueShield plans so when you travel, you receive the same great care you re used to getting at home. And, you pay the same as you would innetwork for all plan-covered services when you receive care outside of Western New York.* BlueCard participating states Participating BlueCard states and territories: Alabama, Arkansas, California, Colorado, Connecticut, Florida, Georgia, Hawaii, Idaho, Illinois, Indiana, Kentucky, Maine, Massachusetts, Michigan, Missouri, Montana, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oklahoma, Oregon, Pennsylvania, South Carolina, Tennessee, Texas, Utah, Virginia, Washington, West Virginia, Wisconsin, and Puerto Rico. To find out if a doctor or facility participates in the BlueCard Network Sharing program: Call BLUE (2583) and select option 2, or Visit provider.bcbs.com and enter prefix YJX in the Already a Member field. Looking for another option? If you don t travel much or are looking for a lower-cost option, our Forever Blue Medicare PPO Value plan may work better for you. With this plan, you pay less out-of-pocket for in-network services, but a little more when you visit an out-of-network doctor or hospital. *In order for your services to be considered in-network while you are outside of the service area: The provider must participate with the local BlueCard Network Sharing program in the service area. Both you and the provider must be located in the same service area when you receive care. Outside of the U.S., you may be asked to pay 100% of the cost at the time of service. You would then submit a claim to us to be reimbursed for your in-network cost-share.

5 Save on dental costs Dental care is important to your overall health. That s why you have the choice to add an optional supplemental dental benefit to one of our plans. You can pick between our two low-premium options, and you ll have the convenience of seeing any dentist. Basic plan NEW! Enhanced plan Premium 1 $17 $31 Preventive services* Cleanings (two per plan year) and oral exams (two per plan year). Preventive services don t apply to the annual maximum allowance. You pay 50% Covered in full Diagnostic and restorative services* You pay 50% You pay 50% (only 20% for crowns and cementing/recementing) Annual maximum allowance This is the most we pay for diagnostic and restorative services during the year. Network $500 $1,000 No network; you can see any dentist To enroll in one of these dental benefits, you can select it on the application included in your kit or call us at (TTY 711). *See your Summary of Benefits for a full list of covered services. Enrolling is easy If you re ready to enroll in one of our plans, there are four easy ways: Call us at (TTY 711) and we can complete an application with you over the phone. Meet with one of our consultants, who can help you fill out an application and submit it for you. Fill out the application in this kit and mail it in the envelope provided. Visit bcbswny.com/medicare and complete the application online.

6 The value you deserve We want to make sure you have everything you need to get and stay healthy. That s why with Blue, you get: Security of a card that s recognized worldwide includes worldwide coverage for urgent and emergency care with all of our plans Stability of a plan that s backed by nearly 80 years of proven experience Support of experienced and knowledgeable customer service representatives We d be happy to help you over the phone or meet with you. If you have any questions, please don t hesitate to call us at (TTY 711). We re available: October 1-February 14 February 15-September 30 8 a.m. to 8 p.m., 7 days a week 8 a.m. to 8 p.m., Monday-Friday You can also find more information at bcbswny.com/medicare. We re here to help you understand your options and find the plan that s right for you. Stacy, Representative BlueCross BlueShield of Western New York

7 Additional Information 1 Dental premium is in addition to plan and Part B premium. 2 You must continue to pay your Medicare Part B premium. 3 You must receive all routine care from plan providers. 4 You must receive all routine care from plan providers. There is a select facility network with the Senior Blue HMO Select plan. See the Provider Listing in this kit for a full list of participating facilities. 5 You can receive care from Medicare providers outside of the eight counties of Western New York with your out-of-network benefit at a higher cost-share. Please see the Summary of Benefits in this kit for a full list of covered services and costs. 6 If you see a participating BlueCard provider, you pay your in-network copay. If you receive care from out-of-network providers, your cost may be higher. Please see the Summary of Benefits in this kit for a full list of covered services and costs. About our benefits and premiums This information is not a complete description of benefits. Contact the plan for more information. Benefits, premium, and/or copayments/coinsurance may change on January 1 of each year. Limitations, copayments, and restrictions may apply. The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. Eligible beneficiaries must use network pharmacies to access their prescription drug benefit, except under non-routine circumstances, and quantity limitations and restrictions may apply. You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for Extra Help, call: MEDICARE ( ). TTY users should call , 24 hours a day/7 days a week; The Social Security offce at They are available Monday through Friday between 7 a.m. and 7 p.m. TTY users should call, ; or Your state Medicaid offce. About enrollment Individuals must have both Parts A and B to enroll in a Medicare Advantage plan. Individuals may enroll in a plan only during specific times of the year. There are additional enrollment guidelines. Contact BlueCross BlueShield for more information. About our partners SilverSneakers is a registered mark of Healthways, Inc. Healthways is an independent company that administers the SilverSneakers gym benefit. About us BlueCross BlueShield of Western New York is a Medicare Advantage plan with a Medicare contract and enrollment depends on contract renewal. A division of HealthNow New York Inc., an independent licensee of the BlueCross BlueShield Association _9_15

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