Medicare Advantage plans

Transcription

1 2014 Blue Medicare HMO SM Blue Medicare PPO SM Medicare Advantage plans No additional cost! 1 Y0079_6204 CMS Approved U5047a, 8/13

2 Contents The benefits of Original Medicare plus additional coverage... 3 Compare our plans...4 Eligibility requirements... 5 Service area map...6 Understanding your Part D benefits... 7 Additional member benefits...10 What You Get Enrollment is easy with these simple steps Understanding how your benefits work Important information Summary of Benefits Contact information Multi-language Interpreter Services $0 monthly premium plans available* + No referrals required to see specialists + Predictable copayments and costs + Health care benefits and Medicare prescription drug coverage in one plan + All from a local company you can trust Understanding your choices Original Medicare and Medicare Advantage plans can sometimes be overwhelming, especially when there are so many choices. That s why we want to give you information to help you decide which options work best for you. In this guide, you ll find: information about Blue Medicare HMO and Blue Medicare PPO Medicare Advantage plans, charts to help you compare plan options, information about Medicare Prescription Drug (Part D) coverage, details about how to enroll in a plan, summaries of benefits for available plans, and more. Footnote: 1 The SilverSneakers program is provided by Healthways, Inc., a third-party vendor independent of BCBSNC. The program is available only to members covered under Blue Medicare HMO, Blue Medicare PPO and Blue Medicare Supplement plans. BCBSNC is not liable in any way for the services received; results are not guaranteed. Decisions regarding medical care should be made with the advice of a doctor. SilverSneakers is a registered trademark of Healthways, Inc. * Rate is for Blue Medicare HMO Standard and Blue Medicare HMO Medical-Only plans, PAGE 2 of 120

3 The benefits of Original Medicare plus additional coverage Health benefits and Medicare prescription drug coverage all in one plan Blue Medicare HMO and Blue Medicare PPO plans can provide you with more coverage than Original Medicare and help limit your out-ofpocket costs. And since Medicare prescription drug (Part D) coverage is built right into most plans, there s no need to buy one plan for enhanced medical benefits and another plan for your Medicare prescription drug benefits. Additional benefits that help limit your out-of-pocket costs Both Blue Medicare HMO and Blue Medicare PPO plans offer coverage for: + Inpatient/outpatient services + Skilled nursing facility care + Home health care + Worldwide emergency medical care + Ambulance and urgent care + Preventive care + And more Choices to meet your needs and budget Blue Medicare HMO offers you health coverage within an extensive network of doctors and specialists 2 that you can see without referrals. You can also select a plan with $0 monthly premiums* with or without Part D coverage. 3 Blue Medicare PPO gives you the freedom to see providers in or out of network. 4 You can see specialists without a referral, and all medically necessary benefits are covered in and out of network. All PPO plans include Part D coverage. 3 Footnotes: 2 You must use the plan s providers except in emergency or urgent care situations or for out-of-area renal dialysis. If you obtain routine care from out-of-network providers neither Medicare nor BCBSNC will be responsible for the costs. 3 Formulary applies for all plans that include Medicare prescription drug coverage. 4 With the exception of emergency or urgent care, member liability with Blue Medicare PPO may be greater for services received out-of-network than services received in-network. Many out-of-network services are subject to coinsurance, which are based on the Medicare allowed amount and not on the potentially lower contract amount. * Rate is for Blue Medicare HMO Standard and Blue Medicare HMO Medical-Only plans, PAGE 3 of 120

4 Compare our plans Review the chart below to find out which plan is best for you. Please note that limitations, copayments, and restrictions may apply. For a complete outline of coverage, please refer to the Blue Medicare HMO and Blue Medicare PPO Summary of Benefits starting on page 21. Medical only Standard Enhanced Enhanced Enhanced Freedom Additional monthly premium 5 $0 $0 $18.90 $38 $ Provider choice + In-network benefits only; must visit a participating provider + No referrals required to see network specialists + In- and out-of-network benefits + Choose any in-network provider for less cost; or choose an out-of-network provider for a higher cost + In- and out-of-network benefits + Choose any in-network or out-of-network provider and pay virtually the same costs Primary care/ Specialist office visits $5/$20 copayment for in-network visits only $15/$40 copayment for in-network visits only $10/$35 copayment for in-network visits only $20/$40 copayment for in-network visits; 20% coinsurance for out-of-network primary care and specialist visits $15/$35 copayment for in-network visits; $35 copayment for out-of-network primary care and specialist visits Inpatient hospital $100 per day up to 7 days $220 per day up to 7 days $170 per day up to 7 days $220 per day up to 7 days $170 per day up to 7 days Diagnostic tests, lab work and X-rays 5% coinsurance 20% coinsurance 15% coinsurance 20% coinsurance in-network and out-of-network 15% coinsurance in-network and out-of-network Medicare prescription drug coverage 6 None Standard drug benefits Enhanced drug benefits Standard drug benefits Enhanced drug benefits Footnotes: 5 You must continue to pay the Medicare Part B premium in addition to your plan premium. 6 Formulary applies for all plans that include Medicare prescription drug coverage. PAGE 4 of 120

5 Eligibility requirements for enrolling in a plan First things first: who is eligible To be eligible for a Blue Medicare HMO or Blue Medicare PPO plan, you must: + Be entitled to Medicare Part A and enrolled in Medicare Part B + Live in the plan s service area (see map and chart of counties) Due to Federal regulations, you may not be eligible to join a Blue Medicare HMO or Blue Medicare PPO plan if you are medically determined to have end-stage renal disease (ESRD) unless you meet exception qualifications. Please call for more information. Part D late enrollment penalties Everyone with Medicare is eligible for Part D coverage, but it s not mandatory. Part D coverage is a voluntary program that you may choose to purchase annually. However, if you do not enroll when you first become eligible, you may have to pay more for prescription drug coverage if you decide to enroll later. 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 Office at between 7 a.m. and 7 p.m., Mon. through Fri. TTY users should call, ; or + Your State Medicaid Office Enrollment periods Initial coverage enrollment period begins three months immediately before you become eligible for both Medicare Part A and Part B and ends on the later of either: + The last day of the month preceding your eligibility to both Part A and Part B, or + The last day of your Part B initial enrollment period. Annual enrollment period October 15 through December 7 of every year. Annual disenrollment period January 1 through February 14 of every year. Special enrollment period If you didn t sign up for Medicare coverage under Part A, Part B or Part D when you were first eligible, you may be eligible to sign up without waiting for an open enrollment period. Additionally, you may be able to sign up without paying a penalty (higher premium). Call the BCBSNC Sales Department at , 7 days a week, 8 a.m. 8 p.m. For the hearing and speech impaired (TTY/TDD), call: PAGE 5 of 120

6 Service area map 2014 HMO and PPO Service Area Blue Medicare HMO and Blue Medicare PPO plans are available in the following counties:* Alamance Catawba Granville Madison Pitt Vance Alexander Chatham Greene Martin Polk Wake Alleghany Chowan Guilford McDowell Randolph Warren Anson Cleveland Halifax Mecklenburg Richmond Washington Ashe Columbus Harnett Mitchell Robeson Watauga Avery Cumberland Haywood Montgomery Rockingham Wayne Beaufort Davidson Henderson Nash Rowan Wilkes Bertie Davie Hertford New Hanover Sampson Wilson Bladen Duplin Hoke Northampton Scotland Yadkin Brunswick Durham Hyde Onslow Stanly Yancey Buncombe Edgecombe Iredell Orange Stokes Cabarrus Forsyth Johnston Pamlico Surry Caldwell Franklin Jones Pender Transylvania Carteret Gaston Lee Perquimans Tyrrell Caswell Gates Lincoln Person Union * Bold counties are new for 2014 PAG E 6 of 120

7 Understanding your Part D benefits Medicare offers prescription drug (Part D) coverage to help you pay for your prescription drugs. With this coverage, you can fill your prescriptions at participating pharmacies close to where you live. You may go to any participating pharmacy, but you will see your greatest savings by going to one of our preferred pharmacies. BCBSNC s Preferred Pharmacy Network includes CVS, Walmart, Kerr and Epic Pharmacies. This select network of national and local independent pharmacies has worked with BCBSNC to get you the savings and value that you are looking for by offering lower costs and better value from your prescription plan, without sacrificing convenience. Our plans also offer the convenience of using the preferred mail-order pharmacy at a reduced cost to you. You pay a $3 copay for a 30 day supply of preferred generic drugs ordered through mail order, and a $0 copay for a 60-day and 90-day supply of covered preferred generic drugs. Medicare prescription drug coverage is available with most Blue Medicare HMO and Blue Medicare PPO plans. That means you can have your medical benefits and prescription drug coverage with one plan, for one premium. (You must continue to pay your Medicare Part B premium.) Please review the preferred and non-preferred benefit charts to understand the Part D benefits that are included with the Blue Medicare HMO and Blue Medicare PPO benefits. The total amount you spend on prescription drugs increases during the calendar year as you move through some or all of the phases of coverage. Remember, you must always present your plan s member ID card to fill your prescriptions. NOTE: For members who qualify for low-income assistance, benefits may vary. PAGE 7 of 120

8 Preferred Pharmacy Network benefits Our preferred network includes CVS, Walmart, Kerr and Epic Pharmacies Initial Plan Feature Drug List (Formulary) Tier 1: Preferred Generic Tier 2: Non-Preferred Generic Tier 3: Preferred Brand Tier 4: Non-Preferred Brand Tier 5: Specialty Annual deductible Retail Preferred mail order Standard Enhanced Enhanced Enhanced Freedom Includes nearly 100% of the drugs covered by Medicare Part D $3 $3 $3 $3 $6 $6 $6 $6 $40 $30 $40 $30 $80 $70 $80 $70 33% coinsurance You pay $0 You pay no annual deductible. You + Plan = $2,850 You pay the copayment per 30-day supply or coinsurance for your drugs, and the plan pays the remainder until total drug costs reach $2,850. You pay $0 copay for a 60- or 90-day supply of preferred generic drugs at our preferred mail-order pharmacy through the initial phase. You pay $3 at our preferred mail-order pharmacy for a 30-day supply of preferred generic drugs. Coverage gap Catastrophic Retail Preferred mail order Catastrophic coverage You pay 72% on all generic drugs. You receive a discount for brand-name drugs. You pay 72% for all generic drugs You pay $3 for Tier 1 Preferred Generic drugs; You pay 72% for all other generic drugs. You receive a discount for brand-name drugs. You pay $3 for Tier 1 Preferred Generic drugs; You pay 72% for all other generic drugs. You pay 72% on all generic drugs. You receive a discount for brand-name drugs. You pay 72% for all generic drugs You pay $3 for Tier 1 Preferred Generic drugs; You pay 72% for all other generic drugs. You receive a discount for brand-name drugs. You pay $3 for Tier 1 Preferred Generic drugs; You pay 72% for all other generic drugs. You receive a discount for brand-name drugs. You remain in the coverage gap until your yearly out-of-pocket drug costs (not including premiums) equal $4,550. You pay 5% After you reach $4,550 in out-of-pocket costs, the plan pays the majority of the drug costs until the end of the year. You pay the greater of $2.55 for generic, $6.35 for brand-name or 5% of the total drug cost. PAGE 8 of 120

9 Non-Preferred Pharmacy Network benefits Initial Coverage gap Plan Feature Drug List (Formulary) Tier 1: Preferred Generic Tier 2: Non-Preferred Generic Tier 3: Preferred Brand Tier 4: Non-Preferred Brand Tier 5: Specialty Annual deductible Retail Non-preferred mail order Retail Non-preferred mail order Standard Enhanced Enhanced Enhanced Freedom Includes nearly 100% of the drugs covered by Medicare Part D $8 $8 $8 $8 $25 $20 $25 $20 $45 $45 $45 $45 $95 $95 $95 $95 33% coinsurance You pay $0 You pay no annual deductible. You + Plan = $2,850 You pay the copayment per 30-day supply or coinsurance for your drugs, and the plan pays the remainder until total drug costs reach $2,850. You pay $8 for a 30-day supply of preferred generic drugs. Pay 3 times the copay for a 90-day supply of preferred generic and brand-name drugs at our mail-order pharmacy through the initial phase. You pay 72% on all generic drugs. You receive a discount for brand-name drugs. You pay 72% for all generic drugs You pay $8 for Tier 1 Preferred Generic drugs; You pay 72% for all other generic drugs. You receive a discount for brand-name drugs. You pay $8 for Tier 1 Preferred Generic drugs; You pay 72% for all other generic drugs. You pay 72% on all generic drugs. You receive a discount for brand-name drugs. You pay 72% for all generic drugs You pay $8 for Tier 1 Preferred Generic drugs; You pay 72% for all other generic drugs. You receive a discount for brand-name drugs. You pay $8 for Tier 1 Preferred Generic drugs; You pay 72% for all other generic drugs. You receive a discount for brand-name drugs. You remain in the coverage gap until your yearly out-of-pocket drug costs (not including premiums) equal $4,550. Catastrophic Catastrophic coverage You pay 5% After you reach $4,550 in out-of-pocket costs, the plan pays the majority of the drug costs until the end of the year. You pay the greater of $2.55 for generic, $6.35 for brand-name or 5% of the total drug cost. PAG E 9 of 120

10 Additional member benefits SilverSneakers a fitness program that also offers health education and social events is included with Blue Medicare HMO and PPO plans at no additional cost. 7 PPO Travel Program Save with exclusive member discounts through Blue365., 8 This program offers discounts on a variety of products and services that can help you live a more healthy and active lifestyle all at no additional cost. Save on: + Hearing aids + Medical bracelets + Laser eye surgery + Healthy eating + Vision services + And more! Our Blue Medicare PPO Travel Program enables Blue Medicare PPO members traveling in certain states and Puerto Rico to use the networks of other participating Blue Cross and/or Blue Shield Medicare Advantage PPO plans. Please call for more details. States/territory with visitor/traveler benefits for PPO members only Alabama Georgia Massachusetts New Jersey Pennsylvania Washington Arkansas Hawaii Michigan New Mexico South Carolina West Virginia California Idaho Missouri New York Tennessee Wisconsin Colorado Indiana Montana Ohio Texas Connecticut Kentucky Nevada Oklahoma Utah Puerto Rico Florida Maine New Hampshire Oregon Virginia Footnote: 7 The SilverSneakers program is provided by Healthways, Inc., a third-party vendor independent of BCBSNC. The program is available only to members covered under Blue Medicare HMO, Blue Medicare PPO and Blue Medicare Supplement plans. BCBSNC is not liable in any way for the services received; results are not guaranteed. Decisions regarding medical care should be made with the advice of a doctor. SilverSneakers is a registered trademark of Healthways, Inc. 8 Blue365 offers access to savings on items that Members may purchase directly from independent vendors, which are different from items that are covered under the policies with BCBSNC. Any disputes regarding these products and services may be subject to BCBSNC s grievance process. Blue Cross and Blue Shield Association (BCBSA) may receive payments from Blue365 vendors. Neither BCBSNC nor BCBSA recommends, endorses, warrants or guarantees any specific Blue365 vendor or item. This program may be modified or discontinued at any time without prior notice. Gym membership offered on website does not replace Silver Sneakers benefit. PAGE 10 of 120

11 Enrollment is easy with these simple steps Choose a plan After reviewing the enclosed material, decide in which plan you want to enroll. (You will indicate your plan choice on the enrollment form by checking the appropriate box beside the plan you select.) Select a primary care provider (PCP) In order to select a PCP, please visit to review the plan s participating providers. If you need assistance finding a provider, you may contact your agent or speak to an authorized sales representative by calling , 7 days a week, 8 a.m. 8 p.m. For the hearing and speech impaired (TTY/TDD), please call Complete the enrollment form Fill out the enrollment form. You must complete one enrollment form per person. Do not forget to sign and date the form. Do not forget to check the appropriate box beside the plan you want. After completing your enrollment form, return it in the envelope provided. 4 5 Option enroll online If you want to enroll online, please visit Medicare beneficiaries may also enroll in Blue Medicare HMO or Blue Medicare PPO through the Centers for Medicare & Medicaid Services online Enrollment Center, located at For more information, contact BCBSNC at Hearing and speech impaired (TTY/TDD), call , 7 days a week, 8 a.m. 8 p.m., or visit Enrollment confirmation You will receive acknowledgement of your enrollment request via mail. NOTE: There are some limits set by the federal government on when and how often Medicare beneficiaries may enroll in or change Medicare Advantage and Medicare Prescription Drug Plans. For more information on these enrollment rules, refer to Enrollment Periods on page 5, or call the BCBSNC Sales Department at , 7 days a week, 8 a.m. 8 p.m. For the hearing and speech impaired (TTY/TDD), call: PAG E 11 of 120

12 Understanding how your benefits work Visiting the doctor Blue Medicare HMO As a member of Blue Medicare HMO, you may only visit doctors within the network of contracted doctors in order to access your benefits. You must choose a primary care provider (PCP) from within that network to coordinate your care. For your PCP, you can select a family practice doctor, general practice doctor, internal medicine doctor, or nurse practitioner or physician assistant, where available. You must use the plan s providers except in emergency or urgent care situations or for out-of-area renal dialysis. If you obtain routine care from out-of-network providers neither Medicare nor BCBSNC will be responsible for the costs. Blue Medicare PPO As a member of Blue Medicare PPO, you have access to a network of doctors. You must choose a PCP to coordinate your care. For your PCP, you can select a family practice doctor, general practice doctor, internal medicine doctor, or nurse practitioner or physician assistant, where available. You may visit a doctor outside of the network; however, you may be responsible for more of the cost. You may also visit a doctor or specialist at any time without a referral. Using your Part D benefits Covered prescription drugs Enhanced and standard benefits are both based on a formulary (a preferred list of prescription drugs) that was developed using guidelines from the Federal government. The formulary covers many drugs eligible for coverage under Medicare Part D more than 1,800 drugs. The formulary includes generic, brand-name and specialty drugs. Both the standard and enhanced benefits cover: prescription drugs, vaccines (not all vaccines are covered), insulin, and certain medical supplies associated with injection of insulin (syringes, needles, alcohol swabs and gauze). Prescription drugs that are not covered Medicare Part D plans do not cover certain drugs, or classes of drugs, which are excluded by law, such as over-the-counter medications, prescription vitamins and erectile dysfunction drugs. In general, all drugs covered by Medicare prescription drug benefits must be: + Available only by prescription + Approved by the FDA + Used for a medically accepted indication PAGE 12 of 120

13 How to find out if your prescriptions are covered by the formulary All plans include Prior Approval (PA), Quantity Limit (QL) and Step Therapy (ST) programs for select drugs. 2 Go to Click on the Find a Drug link and then select the appropriate formulary. Call , 7 days a week, 8 a.m. 8 p.m. and speak to an authorized sales representative to determine if a specific drug is covered. Hearing and speech impaired (TTY/TDD users) call Filling your prescriptions You can fill your prescriptions at a network of participating pharmacies throughout North Carolina. Most of the major chain pharmacies are part of the network, and you can fill your prescriptions at any of their locations nationwide. You must use participating pharmacies to fill your prescriptions in order to receive coverage, except in the case of an emergency or in certain situations when traveling outside of the service area. Quantity limitations and restrictions may also apply. Mail order You can also fill your prescriptions through our Preferred mail order prescription program. To enroll in the mail order program, you must complete a mail order form. To request this form, please call: for Blue Medicare HMO or for Blue Medicare PPO, 7 days a week, 8 a.m. 8 p.m. Hearing and speech impaired (TTY/TDD), please call day supply If your doctor writes you a prescription for a 90-day supply of covered prescription drugs, you can receive the full supply at one time at most network pharmacies or through mail order. Your cost for a 90-day supply will vary depending on your phase of coverage. Finding a participating pharmacy Our network includes a variety of pharmacies, including retail, home infusion, Indian/Tribal/ Urban organizations, extended supply and long-term care pharmacies. In order to obtain the greatest savings on your prescription medications, please visit one of our preferred network providers (CVS, Walmart, Kerr, and Epic Pharmacies). To locate a pharmacy near you, you can: 1 2 Go to Click on Find a Pharmacy. Speak with an authorized sales representative by calling , 7 days a week, 8 a.m. 8 p.m. Hearing and speech impaired (TTY/TDD), please call Representatives can help find a pharmacy near you. Compare Medicare plans + Find out which Medicare plans are available in your area. + Learn about plan benefits and costs. + Compare ratings by quality, premium, estimated annual costs and more. + Compare BCBSNC Plan ratings, included in the enrollment kit, or visit Plan ratings are available upon request for this plan by calling BCBSNC directly at , 7 days a week, 8 a.m.-8 p.m. For the hearing impaired (TTY/TDD), call PAG E 13 of 120

14 Important information Qualifying for financial assistance If you have both Medicare and Medicaid, you already qualify for low-income assistance. If you do not qualify for Medicaid, you may still qualify for some assistance. The amount of assistance will depend on your income and resources and will be applied to the cost of the Medicare prescription drug coverage portion of your Medicare Advantage plan. Once you have enrolled in Blue Medicare HMO or Blue Medicare PPO, Medicare will tell the plan how much assistance you are receiving and you will be sent information on the amount you will pay. People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If you qualify, Medicare could pay for up to seventy-five (75) percent or more of your drug costs including monthly prescription drug premiums, annual deductibles, and co-insurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don t even know it. For more information about this Extra Help, contact your local Social Security office or call MEDICARE ( ), 24 hours per day, 7 days per week. TTY/TTD users should call 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/TDD users should call , 24 hours a day/7 days a week; + The Social Security Office at , between 7 a.m. and 7 p.m., Mon. through Fri. TTY/TDD users should call ; or + Your State Medicaid Office About your benefits + BCBSNC provides services according to the coverage guidelines established by Medicare. + The medical care, services, supplies and equipment that are described as covered services must be medically necessary. + Some services are covered only if your doctor or other network provider gets Prior Approval (PA) from BCBSNC. Frequently asked questions What happens to my Medicare coverage when I join a Medicare Advantage plan? Once you become a member of Blue Medicare HMO or Blue Medicare PPO, you transfer the administration of your Medicare benefits to the plan. This means you maintain your status as a Medicare beneficiary, plus you gain the enhanced coverage available through your Medicare Advantage health plan. You will receive a member ID card that you must present when using your benefits. PAGE 14 of 120

15 Are annual physicals covered? Yes. Routine health examinations are covered and encouraged for all members. What happens if I have a medical emergency? If you have a medical emergency, go to the nearest medical facility or call 911. Emergency medical services are covered for you in or out of the service area. Please contact your primary care provider (PCP) within 48 hours so your PCP can coordinate your follow-up care. Emergency services require a copayment, but it will be waived if you are admitted to the hospital for the same condition on an inpatient basis within 48 hours. This coverage is available worldwide. Members can get help locating providers and obtain information regarding submitting a claim for out-ofcountry emergency services by calling BLUE or by calling collect at If I am a military retiree, can I join a Medicare Advantage plan without losing my military benefits? Once you join Blue Medicare HMO or Blue Medicare PPO, you can continue to use your military benefits at military facilities, and you can use your Medicare Advantage plan benefits outside of the military system. Can I buy a stand-alone Medicare prescription drug package? Yes, but if you enroll in Medicare Advantage plan and want Medicare prescription drug coverage, you must enroll in a Medicare Advantage Prescription Drug Plan one that includes both medical and prescription drug benefits. Enrollment in a stand-alone prescription drug plan automatically disenrolls you from a Medicare Advantage plan. Enrollment in a Medicare Advantage plan automatically disenrolls you from a stand-alone prescription drug plan. If I choose the Blue Medicare HMO plan that does not include Medicare prescription drug coverage, can I buy this drug coverage separately from another source? No. If you choose to enroll in a Medicare Advantage plan that does not include drug coverage, like our Medical-Only plan, federal regulations prohibit you from purchasing a separate Medicare prescription drug plan. Can I use my Medicare prescription drug coverage to order my drugs from Canada? No. Only drugs purchased in the United States are eligible for Medicare prescription drug coverage. Can I continue to use my drug discount card? There are non-medicare approved drug discount cards that may continue to exist. If you enroll in a Medicare Advantage plan that includes Medicare prescription drug coverage, you should contact the issuer of the card to see if you can keep your non-medicare-approved drug discount card to use in addition to your coverage. PAGE 15 of 120

16 Coverage determinations, appeals and grievances for prescription drug coverage Requesting a coverage determination Standard: To ask for a standard decision, you or your appointed representative may call the Customer Service Department at for Blue Medicare HMO or for Blue Medicare PPO, 7 days a week, 8 a.m. 8 p.m. (Hearing and speech impaired TTY/TDD, call: ). You can also deliver a written request to BCBSNC, 5660 University Parkway, Winston-Salem, NC 27105, Mon. through Fri from 8 a.m. 5 p.m. You may fax your request to Fast: To ask for a fast decision, you, your physician, or your appointed representative may call the Customer Service Department at for Blue Medicare HMO or for Blue Medicare PPO, 7 days a week, 8 a.m. 8 p.m. (Hearing and speech impaired TTY/TDD, call: ). You can also deliver a written request to BCBSNC, 5660 University Parkway, Winston-Salem, NC 27105, Mon. through Fri. from 8 a.m. 5 p.m. You may fax your request to After regular business hours, you should consult with a contracting pharmacy regarding your need for an emergency or temporary supply of medication. You may also call our Customer Service Department and leave a message on the Part D After Hours Exception Request Voic . Be sure to ask for a fast, expedited, or 24-hour review. NOTE: You cannot ask for a fast decision on a request for coverage of a drug already purchased. Receiving your coverage determination decision ly, you will receive a decision no later than 72 hours after your request has been received, but it may be made sooner if your health condition requires. If your request involves a request for an exception (including a formulary exception or an exception from utilization management rules, such as dosage or quantity limits), a decision must be made no later than 72 hours after your doctor s supporting statement (explaining why the drug you are asking for is medically necessary) has been received. If you are requesting an exception, you should submit your prescribing doctor s supporting statement with the request, if possible. You will be notified verbally about the prescription drug you have requested. You will get this notification when a decision has been made under the timeframe explained above. If your request is not approved, you will receive an explanation in writing and be advised of your right to appeal the decision. If you get a fast review, you will receive a decision within 24 hours after you or your doctor asks for a fast review sooner if your health requires. If your request involves a request for an exception, you must receive a decision no later than 24 hours after we get your doctor s supporting statement. Exceptions to coverage rules Exceptions are part of the coverage determination process. You, your authorized representative, or your prescribing physician may request an exception to seek coverage of a drug that: + Is not on the formulary + Requires prior authorization + Has quantity limitations PAGE 16 of 120

17 Example of an exception request If the Plan s formulary does not include a drug that you or your prescribing physician feel is necessary, then you or your prescribing physician may request an exception so that you may obtain coverage of this drug. If the Plan does not grant the requested exception, then you or your prescribing physician may file an appeal. Making an exception request You or your prescribing physician may request an exception to the coverage rules for your Medicare prescription drug plan via: + Phone: for Blue Medicare HMO or for Blue Medicare PPO, (Hearing and speech impaired TTY/TDD: ), 7 days a week, 8 a.m. 8 p.m. Physicians should call: or Mail: BCBSNC, Attn: MAPD Exceptions Request, P.O. Box 17509, Winston-Salem, NC A specific form is not required for you to make an exception request. The request must include your prescribing physician s statement that he/ she has determined that the preferred drug either would not be as effective for you and/or would have adverse effects for you. Receiving an exception request decision Your exception request will be reviewed and both you and your prescribing physician will be notified of the decision as soon as your health requires, but no later than 72 hours from the time physician s supporting statement was received. Faster exception decisions are available if this 72-hour timeframe could seriously harm your health or ability to function. If the decision is not in your favor, the notice will be given by phone followed by a written notice within three business days. The notice will tell you how to pursue your appeal rights if you are dissatisfied with the decision. Appeals process An appeal is your opportunity to request a re-determination of an adverse coverage determination, which includes denied exception requests. Example of an appeal If we deny your request for an exception to cover a non-formulary drug, then you may file an appeal of the denial. An appeal can only be filed after an exception has been requested and denied by the Plan. Filing an appeal If you receive a coverage determination denial, you or your appointed representative or your doctor or other prescriber may file an appeal. A specific form is not required for you to file an appeal. An appeal must be filed within 60 calendar days of the date of the denial notice and must be in writing, unless you are filing an expedited or fast appeal. You may submit it via: + Mail: BCBSNC, Attn: Appeals and Grievance Unit, P.O. Box 17509, Winston-Salem, NC Fax: or In person: Blue Cross and Blue Shield of North Carolina, 5660 University Parkway, Winston-Salem, NC (continued on the next page) PAG E 17 of 120

18 Coverage determinations, appeals and grievances for prescription drug coverage (continued) Receiving a decision on your appeal A standard review of your appeal will be performed as soon as your health requires but no later than seven calendar days after your appeal is received. Requests for an expedited or fast appeal will be reviewed as soon as possible, but no later than 72 hours following the receipt of the request. An individual who was not involved with your original coverage determination will make a decision on your appeal. You will receive a written response to your appeal. The decision on an expedited appeal will be provided by phone followed by the written notice. If the decision is to deny the appeal, the notice will advise you of your right to submit your appeal to the Independent Review Entity (IRE) with instructions on how to do so. If timeframes are missed for claims adjudication or review of the appeal, the appeal will automatically be forwarded to the IRE for a decision. There may be additional levels of appeal available to you. You will be informed of your additional rights in the notice, or you may refer to your Evidence of Coverage for further details. Grievance process A grievance is a complaint that you may file if you are dissatisfied with Blue Medicare HMO or Blue Medicare PPO or with a contracted provider for reasons other than a decision on a coverage determination. Grievances also include complaints regarding the timeliness, appropriateness, access to, or setting of a covered prescription drug. Example of a grievance If you are dissatisfied with the service you received from a pharmacist or plan representative, then you may file a grievance. Filing a grievance The grievance must be filed within 60 days after the event or incident that caused you to be dissatisfied. A specific form is not required for you to file a grievance. You or your appointed representative may file a grievance via: + Phone: for Blue Medicare HMO or for Blue Medicare PPO, (Hearing and speech impaired TTY/TDD: ), 7 days a week, 8 a.m. 8 p.m. + Mail: BCBSNC, Attn: Appeals and Grievance Unit, P.O. Box 17509, Winston-Salem, NC Fax: In person: Blue Cross and Blue Shield of North Carolina, 5660 University Parkway, Winston-Salem, NC PAGE 18 of 120

19 Receiving a grievance decision The resolution of a grievance will be made as quickly as your concern requires, but no more than 30 calendar days after our receipt of the grievance. We may extend the timeframe by up to 14 calendar days if you request the extension, or if we justify a need for additional information and the delay is in your best interest. If you request a written response to an oral grievance, one will be provided within 30 days after receipt of the grievance. A written response will be provided for all written grievances. Our decision on a grievance is final and is not subject to an appeal. You have the right to an expedited review of a grievance concerning our refusal to grant an expedited coverage determination or expedited appeal. This type of grievance will be responded to within 24 hours after our receipt of the grievance. Quality improvement If you have a concern relating to the quality of services that you received through your Medicare Advantage prescription drug benefits, then, in addition to the review, you can also request review by the following organizations: + The Carolinas Center for Medical Excellence (CCME) Quality Improvement Organization (QIO) in North Carolina. CCME, formerly known as Medical Review of North Carolina Inc., is a nonprofit, medical care quality improvement organization. CCME has been designated by the Centers for Medicare & Medicaid Services as the Quality Improvement Organization (QIO) for North Carolina. The QIO conducts case reviews to ensure that Medicare beneficiaries receive the quality of medical care that they expect and are entitled to receive. CCME serves as an independent, impartial third party to review Medicare beneficiary complaints. Quality of care complaints filed with the QIO must be made in writing. You can write to CCME at The Carolinas Center for Medical Excellence, 100 Regency Forest Drive, Suite 200, Cary, NC Assistance is available, Mon. through Fri., 8 a.m. 5 p.m. by calling: + QIO number for appeals and complaints: TTY/TDD users dial: Web inquiries: Seniors Health Insurance Information Program (SHIIP) SHIIP is a state consumer division of the North Carolina Department of Insurance. SHIIP assists senior citizens with Medicare, Medicare Part D, Medicare supplements, Medicare Advantage, Medicare fraud and abuse and long-term care insurance questions. Assistance is available by calling , Mon. through Fri., 8 a.m. 5 p.m. You may also send an to ncshiip@ncdoi.gov or visit SHIIP s Web site at (continued on the next page) PAGE 19 of 120

20 Coverage determinations, appeals and grievances for prescription drug coverage (continued) Notice of possible contract termination Blue Cross and Blue Shield of North Carolina is an HMO and PPO plan with a Medicare contract. Enrollment in Blue Cross and Blue Shield of North Carolina depends on contract renewal. CMS is the government agency that runs Medicare. This contract renews each year. At the end of each year, the contract is reviewed and BCBSNC or CMS can decide to end it. Members will get a 90-day advance, written notice in this situation. It is also possible for our contract to end at some other time. If the contract is going to end, we will generally tell members 90 days in advance. Advance notice may be as little as 30 days or even fewer days if CMS ends our contract in the middle of the year. In this notice, we would provide a written description of alternatives available for obtaining Medicare services within the service area. We are also required to notify the general public of a contract termination via local newspapers. If BCBSNC decides to stop offering Medicare Advantage plans or change our service area so that it no longer includes the area where you live, membership in Medicare Advantage plans will end for everyone in that service area, and members will have to change to a different plan. Members will continue to get services through BCBSNC until the contract ends. The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Additional information about benefits is available to assist you in making a decision about your coverage. This is an advertisement; for more information contact the plan. Benefits, premium and/or copayment/ coinsurance may change on January 1 of each year. Please contact BCBSNC for details. This brochure may be available in alternate formats upon request. PAGE 20 of 120

21 2014 Summary of Benefits (Contract H3449, Plans 005, 012 and 013) January 1, 2014 December 31, 2014 FOR RESIDENTS OF: Alamance, Alexander, Alleghany, Anson, Ashe, Avery, Beaufort, Bertie, Bladen, Brunswick, Buncombe, Cabarrus, Caldwell, Carteret, Caswell, Catawba, Chatham, Chowan, Cleveland, Columbus, Cumberland, Davidson, Davie, Duplin, Durham, Edgecombe, Forsyth, Franklin, Gaston, Gates, Granville, Greene, Guilford, Halifax, Harnett, Haywood, Henderson, Hertford, Hoke, Hyde, Iredell, Johnston, Jones, Lee, Lincoln, Madison, Martin, McDowell, Mecklenburg, Mitchell, Montgomery, Nash, New Hanover, Northampton, Onslow, Orange, Pamlico, Pender, Perquimans, Person, Pitt, Polk, Randolph, Richmond, Robeson, Rockingham, Rowan, Sampson, Scotland, Stanly, Stokes, Surry, Transylvania, Tyrrell, Union, Vance, Wake, Warren, Washington, Watauga, Wayne, Wilkes, Wilson, Yadkin and Yancey. Y0079_6255 CMS Accepted U5047b, 9/13 PAG E 21 of 120

22 Section 1 Introduction to Summary of Benefits Thank you for your interest in Blue Medicare HMO (HMO) plans. Our plans are offered by Blue Cross and Blue Shield of North Carolina, a Medicare Advantage Health Maintenance Organization (HMO) that contracts with the Federal government. This Summary of Benefits tells you some features of our plans. It doesn t list every service that we cover or list every limitation or exclusion. To get a complete list of our benefits, please call Blue Medicare HMO and ask for the Evidence of Coverage. You have choices in your health care As a Medicare beneficiary, you can choose from different Medicare options. One option is the Original (fee-for-service) Medicare Plan. Another option is a Medicare health plan, like Blue Medicare HMO plans. You may have other options too. You make the choice. No matter what you decide, you are still in the Medicare Program. You may join or leave a plan only at certain times. Please call Blue Medicare HMO at the telephone number listed at the end of this introduction or MEDICARE ( ) for more information. TTY/TDD users should call You can call this number 24 hours a day, 7 days a week. How can I compare my options? You can compare Blue Medicare HMO plans and the Original Medicare Plan using this Summary of Benefits. The charts in this booklet list some important health benefits. For each benefit, you can see what our plans cover and what the Original Medicare Plan covers. Our members receive all of the benefits that the Original Medicare Plan offers. We also offer more benefits, which may change from year to year. Where are Blue Medicare HMO plans available? The service area for these plans includes: Alamance, Alexander, Alleghany, Anson, Ashe, Avery, Beaufort, Bertie, Bladen, Brunswick, Buncombe, Cabarrus, Caldwell, Carteret, Caswell, Catawba, Chatham, Chowan, Cleveland, Columbus, Cumberland, Davidson, Davie, Duplin, Durham, Edgecombe, Forsyth, Franklin, Gaston, Gates, Granville, Greene, Guilford, Halifax, Harnett, Haywood, Henderson, Hertford, Hoke, Hyde, Iredell, Johnston, Jones, Lee, Lincoln, Madison, Martin, McDowell, Mecklenburg, Mitchell, Montgomery, Nash, New Hanover, Northampton, Onslow, Orange, Pamlico, Pender, Perquimans, Person, Pitt, Polk, Randolph, Richmond, Robeson, Rockingham, Rowan, Sampson, Scotland, Stanly, Stokes, Surry, Transylvania, Tyrrell, Union, Vance, Wake, Warren, Washington, Watauga, Wayne, Wilkes, Wilson, Yadkin, Yancey Counties, NC. You must live in one of these areas to join the plan. Who is eligible to join Blue Medicare HMO? You can join Blue Medicare HMO plans if you are entitled to Medicare Part A and enrolled in Medicare Part B and live in the service area. However, individuals with End-Stage Renal Disease generally are not eligible to enroll in Blue Medicare HMO plans unless they are members of our organization and have been since their dialysis began. Can I choose my doctors? Blue Medicare HMO plans have formed a network of doctors, specialists, and hospitals. You can only use doctors who are part of our network. The health providers in our network can change at any time. You can ask for a current provider directory. For an updated list, visit us at com/medicare. Our customer service number is listed at the end of this introduction. What happens if I go to a doctor who s not in your network? If you choose to go to a doctor outside of our network, you must pay for these services yourself. Neither the plan nor the Original Medicare Plan will pay for these services except in limited situations (for example, emergency care). Where can I get my prescriptions if I join one of these plans? Blue Medicare HMO plans have formed a network of pharmacies. You must use a network pharmacy to receive plan benefits. We may not pay for your prescriptions if you use an out-ofnetwork pharmacy, except in certain cases. The pharmacies in our network can change at any time. You can ask for a pharmacy directory or PAG E 22 of 120

23 visit us at MyPrime/MedicareD/pharmacy/BCBSNC. Our customer service number is listed at the end of this introduction. Blue Medicare HMO plans have a list of preferred pharmacies. At these pharmacies, you may get your drugs at a lower co-pay or co-insurance. You may go to a non-preferred pharmacy, but you may have to pay more for your prescription drugs. What if my doctor prescribes less than a month's supply? In consultation with your doctor or pharmacist, you may receive less than a month's supply of certain drugs. Also, if you live in a long-term care facility, you will receive less than a month's supply of certain brand and generic drugs. Dispensing fewer drugs at a time can help reduce cost and waste in the Medicare Part D program, when this is medically appropriate. The amount you pay in these circumstances will depend on whether you are responsible for paying coinsurance (a percentage of the cost of the drug) or a copay (a flat dollar amount for the drug). If you are responsible for coinsurance for the drug, you will continue to pay the applicable percentage of the drug cost. If you are responsible for a copay for the drug, a "daily cost-sharing rate" will be applied. If your doctor decides to continue the drug after a trial period, you should not pay more for a month's supply than you otherwise would have paid. Contact your plan if you have questions about costsharing when less than a one-month supply is dispensed. Does my plan cover Medicare Part B or Part D drugs? Most Blue Medicare HMO plans cover both Medicare Part B prescription drugs and Medicare Part D prescription drugs. However, Blue Medicare HMO Medical only covers Medicare Part B prescription drugs, but does NOT cover Medicare Part D prescription drugs. What is a prescription drug formulary? Most Blue Medicare HMO plans use a formulary. A formulary is a list of drugs covered by your plan to meet patient needs. We may periodically add, remove, or make changes to coverage limitations on certain drugs or change how much you pay for a drug. If we make any formulary change that limits our members ability to fill their prescriptions, we will notify the affected members before the change is made. We will send a formulary to you and you can see our complete formulary on our Web site at: If you are currently taking a drug that is not on our formulary or subject to additional requirements or limits, you may be able to get a temporary supply of the drug. You can contact us to request an exception or switch to an alternative drug listed on our formulary with your physician s help. Call us to see if you can get a temporary supply of the drug or for more details about our drug transition policy. How can I get extra help with my prescription drug plan costs or get extra help with other Medicare costs? You may be able to get extra help to pay for your prescription drug premiums and costs as well as get help with other Medicare costs. To see if you qualify for getting extra help, call: MEDICARE ( ) TTY/TDD users should call , 24 hours a day/7 days a week; and see 'Programs for People with Limited Income and Resources' in the publication Medicare & You. The Social Security Administration at between 7 a.m. and 7 p.m., Monday Friday. TTY/TDD users should call ; or Your State Medicaid Office What are my protections in this plan? All Medicare Advantage Plans agree to stay in the program for a full calendar year at a time. Plan benefits and cost-sharing may change from calendar year to calendar year. Each year, plans can decide whether to continue to participate with Medicare Advantage. A plan may continue in their entire service area (geographic area where the plan accepts members) or choose to (continued on the next page) PAG E 23 of 120