Annual Notice of Changes for 2014 (This 2014 Annual Notice of Changes is effective October 1, 2013 December 31, 2014.)

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "Annual Notice of Changes for 2014 (This 2014 Annual Notice of Changes is effective October 1, 2013 December 31, 2014.)"

Transcription

1 Blue Shield 65 Plus (HMO) offered by Blue Shield of California Annual Notice of Changes for 2014 (This 2014 Annual Notice of Changes is effective October 1, 2013 December 31, 2014.) You are currently enrolled as a member of Blue Shield 65 Plus. Next year, there will be some changes to the plan s costs and benefits. This booklet tells about the changes. You can make changes to your Medicare coverage for next year during your former employer group/union s Open Enrollment Period. Additional Resources Member Services has free language interpreter services available for non-english speakers (phone numbers are in Section 8.1 of this booklet). This information may be available in a different format, including large print. Please call Member Services at the number listed on the back cover of this booklet if you need plan information in another format. About Blue Shield 65 Plus Blue Shield of California is an HMO plan with a Medicare contract. Enrollment in Blue Shield of California depends on contract renewal. When this booklet says we, us, or our, it means Blue Shield of California. When it says plan or our plan, it means Blue Shield 65 Plus. H0504_13_ Self-Insured Schools of California MA5031

2 Blue Shield 65 Plus Annual Notice of Changes for Think about Your Medicare Coverage for Next Year Each year, you may change your Medicare health and drug coverage during your former employer group/union s open enrollment period. It s important to review your coverage now to make sure it will meet your needs next year. Important things to do: Check the changes to our benefits and costs to see if they affect you. Do the changes affect the services you use? It is important to review benefit and cost changes to make sure they will work for you next year. Look in Sections 1.5 and 1.6 for information about benefit and cost changes for our plan. Check the changes to our prescription drug coverage to see if they affect you. Will your drugs be covered? Are they in a different tier? Can you continue to use the same pharmacies? It is important to review the changes to make sure our drug coverage will work for you next year. Look in Section 1.6 for information about changes to our drug coverage. Check to see if your doctors and other providers will be in our network next year. Are your doctors in our network? What about the hospitals or other providers you use? Look in Section 1.3 for information about our Provider Directory. Think about your overall health care costs. How much will you spend out-of-pocket for the services and prescription drugs you use regularly? How much will you spend on your premium? How do the total costs compare to other Medicare coverage options? Think about whether you are happy with our plan. If you decide to stay with Blue Shield 65 Plus: If you want to stay with us next year, it s easy - you don t need to do anything. If you don t make a change during your former employer group/union s open enrollment period, you will automatically stay enrolled in our plan. If you decide to change plans: If you decide other coverage will better meet your needs, you can switch plans during your former employer group/union s open enrollment period. If you enroll in a new plan, your new coverage will begin on October 1, 2013 Look in Section 2.2 to learn more about your choices.

3 Blue Shield 65 Plus Annual Notice of Changes for Summary of Important Costs for 2014 The table below compares the 2013 costs and 2014 costs for Blue Shield 65 Plus in several important areas. Please note this is only a summary of changes. It is important to read the rest of this Annual Notice of Changes and review the attached Evidence of Coverage to see if other benefit or cost changes affect you (this year) 2014 (next year) Monthly plan premium* * Your premium may be higher or lower than this amount. See Section 1.1 for details. Maximum out-of-pocket amount This is the most you will pay out-of-pocket for your covered Part A and Part B services. (See Section 1.2 for details.) If you are responsible for any contribution to the monthly plan premium, and your contributions are changing for 2014, your former employer group/union will tell you the amount and where to send payment. $1,500 $1,500 Doctor office visits Primary care visits: $20 copay per visit Specialist visits: $20 copay per visit Primary care visits: $20 copay per visit Specialist visits: $20 copay per visit In-patient hospital stays $0 copay per admission $0 copay per admission Part D prescription drug coverage (See Section 1.6 for details.) Deductible: $0 Deductible: $0 Copays during the Initial Coverage Stage: Drug Tier 1: $10 copay Drug Tier 2: $30 copay Drug Tier 3: $50 copay Drug Tier 4: 20% coinsurance (up to a $100 copay maximum) per prescription Drug Tier 5: 20% coinsurance (up to a $100 copay maximum) per prescription Copays during the Initial Coverage Stage: Drug Tier 1: $10 copay Drug Tier 2: $30 copay Drug Tier 3: $50 copay Drug Tier 4: 20% coinsurance (up to a $100 copay maximum) per prescription Drug Tier 5: 20% coinsurance (up to a $100 copay maximum) per prescription

4 Blue Shield 65 Plus Annual Notice of Changes for Annual Notice of Changes for 2014 Table of Contents Think about Your Medicare Coverage for Next Year... 1 Summary of Important Costs for SECTION 1 Changes to Benefits and Costs for Next Year... 4 Section 1.1 Changes to the Monthly Premium...4 Section 1.2 Changes to Your Maximum Out-of-Pocket Amount...4 Section 1.3 Changes to the Provider Network...5 Section 1.4 Changes to the Pharmacy Network...5 Section 1.5 There are no changes to your benefits or amounts you pay for Medical Services...5 Section 1.6 Changes to Part D Prescription Drug Coverage...6 SECTION 2 Deciding Which Plan to Choose... 9 Section 2.1 If you want to stay in Blue Shield 65 Plus...9 Section 2.2 If you want to change plans...9 SECTION 3 Deadline for Changing Plans SECTION 4 Programs That Offer Free Counseling about Medicare SECTION 5 Programs That Help Pay for Prescription Drugs SECTION 6 Questions? Section 6.1 Getting Help from Blue Shield 65 Plus...11 Section 6.2 Getting Help from Medicare...12

5 Blue Shield 65 Plus Annual Notice of Changes for SECTION 1 Changes to Benefits and Costs for Next Year Section 1.1 Changes to the Monthly Premium 2013 (this year) 2014 (next year) Monthly premium (You must also continue to pay your Medicare Part B premium.) If you are responsible for any contribution to the monthly plan premium, and your contributions are changing for 2014, your former employer group/union will tell you the amount and where to send payment. Your monthly plan premium may be more if you are required to pay a late enrollment penalty. Contact your Benefits Administrator for more details. If you have a higher income, you may have to pay an additional amount each month directly to the government for your Medicare prescription drug coverage. Your monthly premium will be less if you are receiving Extra Help with your prescription drug costs. Section 1.2 Changes to Your Maximum Out-of-Pocket Amount To protect you, Medicare requires all health plans to limit how much you pay out-of-pocket during the year. This limit is called the maximum out-of-pocket amount. Once you reach the maximum out-of-pocket amount, you generally pay nothing for covered Part A and Part B services for the rest of the year (this year) 2014 (next year) Maximum out-of-pocket amount Your costs for covered medical services (such as copays) count toward your maximum out-of-pocket amount. Any plan premium you may be responsible for paying to your former employer group/union and your costs for prescription drugs do not count toward your maximum outof-pocket amount. $1,500 $1,500 Once you have paid $1,500 out-of-pocket for covered Part A and Part B services, you will pay nothing for your covered Part A and Part B services for the rest of the calendar year.

6 Blue Shield 65 Plus Annual Notice of Changes for Section 1.3 Changes to the Provider Network There are changes to our network of doctors and other providers for next year. An updated Provider Directory is located on our Web site at blueshieldca.com/findaprovider. You may also call Member Services for updated provider information or to ask us to mail you a Provider Directory. Please review the 2014 Provider Directory to see if your providers are in our network. Section 1.4 Changes to the Pharmacy Network Amounts you pay for your prescription drugs may depend on which pharmacy you use. Medicare drug plans have a network of pharmacies. In most cases, your prescriptions are covered only if they are filled at one of our network pharmacies. Our network includes preferred pharmacies, which may offer you lower cost sharing than other pharmacies within the network. There are changes to our network of pharmacies for next year. An updated Pharmacy Directory is located on our Web site at blueshieldca.com/med_pharmacy. You may also call Member Services for updated provider information or to ask us to mail you a Pharmacy Directory. Please review the 2014 Pharmacy Directory to see which pharmacies are in our network. Section 1.5 There are no changes to your benefits or amounts you pay for Medical Services Our benefits and what you pay for these covered medical services will be exactly the same in 2014 as they are in 2013.

7 Blue Shield 65 Plus Annual Notice of Changes for Section 1.6 Changes to Part D Prescription Drug Coverage Changes to Our Drug List Our list of covered drugs is called a Formulary or Drug List. A copy of our Drug List is in this booklet. We made changes to our Drug List, including changes to the drugs we cover and changes to the restrictions that apply to our coverage for certain drugs. Review the Drug List to make sure your drugs will be covered next year and to see if there will be any restrictions. If you are affected by a change in drug coverage you can: Work with your doctor (or other prescriber) and ask the plan to make an exception to cover the drug. Current members can ask for an exception before next year and we will give you an answer within 72 hours after we receive your request (or your prescriber s supporting statement). If we approve your request, you ll be able to get your drug at the start of the new plan year. o To learn what you must do to ask for an exception, see Chapter 9 of your Evidence of Coverage (What to do if you have a problem or complaint (coverage decisions, appeals, complaints)) or call Member Services. Find a different drug that we cover. You can call Member Services to ask for a list of covered drugs that treat the same medical condition. In some situations, we will cover a one-time, temporary supply. (To learn more about when you can get a temporary supply and how to ask for one, see Chapter 5, Section 5.2 of the Evidence of Coverage.) During the time when you are getting a temporary supply of a drug, you should talk with your doctor to decide what to do when your temporary supply runs out. You can either switch to a different drug covered by the plan or ask the plan to make an exception for you and cover your current drug. If we make an exception and cover a drug that is not on our drug list, this coverage will expire at the end of your plan benefit year, unless you were otherwise informed at the time the exception was made. See Chapter 9 of your Evidence of Coverage for details on how to request an exception. Changes to Prescription Drug Costs Note: If you are in a program that helps pay for your drugs ( Extra Help ), the information about costs for Part D prescription drugs may not apply to you. We sent you a separate insert, called the Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs (also called the Low Income Subsidy Rider or the LIS Rider ), which tells you about your drug coverage. If you get Extra Help and haven t received this insert by September 30, 2013, please call Member Services and ask

8 Blue Shield 65 Plus Annual Notice of Changes for for the LIS Rider. Phone numbers for Member Services are in Section 6.1 of this booklet. There are four drug payment stages. How much you pay for a Part D drug depends on which drug payment stage you are in. (You can look in Chapter 6, Section 2 of your Evidence of Coverage for more information about the stages.) The information below shows the changes for next year to the first two stages the Yearly Deductible Stage and the Initial Coverage Stage. (Most members do not reach the other two stages the Coverage Gap Stage or the Catastrophic Coverage Stage. To get information about your costs in these stages, look at Chapter 6, Sections 6 and 7, in the attached Evidence of Coverage.) In addition to the changes in costs described below, there is a change to daily cost sharing that might affect your costs in the Initial Coverage Stage. Starting in 2014, when your doctor first prescribes less than a full month s supply of certain drugs, you may no longer need to pay the copay for a full month. (For more information about daily cost sharing, look at Chapter 6, Section 5.3, in the attached Evidence of Coverage.) Changes to the Deductible Stage 2013 (this year) 2014 (next year) Stage 1: Yearly Deductible Stage Because we have no deductible, this payment stage does not apply to you. Because we have no deductible, this payment stage does not apply to you. Changes to Your Copayments in the Initial Coverage Stage

9 Blue Shield 65 Plus Annual Notice of Changes for (this year) 2014 (next year) Stage 2: Initial Coverage Stage During this stage, the plan pays its share of the cost of your drugs and you pay your share of the cost. The costs in this row are for a one-month (30-day) supply when you fill your prescription at a network pharmacy. For information about the costs for a long-term supply, at preferred pharmacies, or for mail-order prescriptions, look in Chapter 6, Section 5 of your Evidence of Coverage. We changed the tier for some of the drugs on our Drug List. To see if your drugs will be in a different tier, look them up on the Drug List. Your cost for a one-month supply filled at a network pharmacy: Tier 1 Preferred Generic Drugs You pay $10 per prescription Tier 2 Preferred Brand Drugs You pay $30 per prescription Tier 3 Non-Preferred Brand Drugs You pay $50 per prescription Tier 4 Injectable Drugs You pay 20% of Blue Shield s contracted rate (up to a $100 copayment maximum) per prescription. Tier 5 Specialty Tier Drugs You pay 20% of Blue Shield s contracted rate (up to a $100 copayment maximum) per prescription. Once you have paid $4,750 out-of-pocket for Part D drugs, you will move to the next stage (the Catastrophic Coverage Stage). Your cost for a one-month supply filled at a network pharmacy: Tier 1 Preferred Generic Drugs You pay $10 per prescription Tier 2 Preferred Brand Drugs You pay $30 per prescription Tier 3 Non-Preferred Brand Drugs You pay $50 per prescription Tier 4 Injectable Drugs You pay 20% of Blue Shield s contracted rate (up to a $100 copayment maximum) per prescription. Tier 5 Specialty Tier Drugs You pay 20% of Blue Shield s contracted rate (up to a $100 copayment maximum) per prescription. Once you have paid $4,550 out-of-pocket for Part D drugs, you will move to the next stage (the Catastrophic Coverage Stage). There is another important change that might affect your costs in the Initial Coverage Stage. Generally, your copay has been the same whether you filled your prescription for a full month s supply or for fewer days. However, starting in 2014, your copay for some drugs will be based on the actual number of days supply you receive rather than a set amount for a month. There may be times when you want to ask your doctor about prescribing less than a full month s supply of a

10 Blue Shield 65 Plus Annual Notice of Changes for drug (for example, when your doctor first prescribes a drug that is known to cause side effects). If your doctor prescribes less than a full month s supply of certain drugs, and you are required to pay a copay, you will no longer have to pay for a month s supply. Instead, you will pay a lower copay (a daily cost-sharing rate) based on the number of days of the drug that you receive. Changes to the Coverage Gap and Catastrophic Coverage Stages The other two drug coverage stages the Coverage Gap Stage and the Catastrophic Coverage Stage are for people with high drug costs. Most members do not reach the Coverage Gap Stage or the Catastrophic Coverage Stage. For information about your costs in these stages, look at Chapter 6, Sections 6 and 7, in your Evidence of Coverage. SECTION 2 Deciding Which Plan to Choose Section 2.1 If you want to stay in Blue Shield 65 Plus To stay in our plan you don t need to do anything. If you do not sign up for a different plan or change to Original Medicare during your former employer group/union s open enrollment period, you will automatically stay enrolled as a member of our plan for You may want to contact your Benefits Administrator to verify whether you are required to complete any paperwork for your former employer group/union. Section 2.2 If you want to change plans We hope to keep you as a member next year but if you want to change for 2014 follow these steps: Step 1: Learn about and compare your choices Contact your Benefits Administrator to find out what other plan options might be available to you. If you decide to leave Blue Shield 65 Plus, you can change your coverage during your former employer group/union s Open Enrollment Period. -- OR-- You can change to Original Medicare. If you change to Original Medicare, you will need to decide whether to join a Medicare drug plan and whether to buy a Medicare supplement (Medigap) policy. Please speak to your Benefits Administrator before making a change as doing so may cause you to lose coverage through your former employer group/union.

11 Blue Shield 65 Plus Annual Notice of Changes for To learn more about Original Medicare and the different types of Medicare plans, read Medicare & You 2014, call your State Health Insurance Assistance Program (see Section 5), or call Medicare (see Section 6.2). You can also find information about plans in your area by using the Medicare Plan Finder on the Medicare Web site. Go to and click Compare Drug and Health Plans. Here, you can find information about costs, coverage, and quality ratings for Medicare plans. Step 2: Change your coverage To change to a different Medicare health plan, enroll in the new plan. You will automatically be disenrolled from Blue Shield 65 Plus. To change to Original Medicare with a prescription drug plan, enroll in the new drug plan. You will automatically be disenrolled from Blue Shield 65 Plus. To change to Original Medicare without a prescription drug plan, you can either: o Send us a written request to disenroll. Contact Member Services if you need more information on how to do this (phone numbers are in Section 6.1 of this booklet). o or Contact Medicare, at MEDICARE ( ), 24 hours a day, 7 days a week, and ask to be disenrolled. TTY users should call Please speak to your Benefits Administrator before making a change as doing so may cause you to lose coverage through your former employer group/union. SECTION 3 Deadline for Changing Plans If you want to change to a different plan for next year, you can do it during your former employer group/union s open enrollment period. The change will take effect on October 1, Are there other times of the year to make a change? In certain situations, changes are also allowed at other times of the year. For example, people with Medicaid, those who get Extra Help paying for their drugs, and those who move out of the service area are allowed to make a change at other times of the year. For more information, see Chapter 10, Section 2.3 of the Evidence of Coverage. If you enrolled in a Medicare Advantage plan during your former employer group/union s open enrollment period, and don t like your plan choice, you can switch to Original Medicare between January 1 and February 14, For more information, see Chapter 10, Section 2.2 of the Evidence of Coverage. Please speak to your Benefits Administrator before making a change as doing so may cause you to lose coverage through your former employer group/union.

12 Blue Shield 65 Plus Annual Notice of Changes for SECTION 4 Programs That Offer Free Counseling about Medicare The State Health Insurance Assistance Program (SHIP) is a government program with trained counselors in every state. In California, the SHIP is called Health Insurance Counseling and Advocacy Program (HICAP). HICAP is independent (not connected with any insurance company or health plan). It is a state program that gets money from the Federal government to give free local health insurance counseling to people with Medicare. HICAP counselors can help you with your Medicare questions or problems. They can help you understand your Medicare plan choices and answer questions about switching plans. You can call HICAP at (In-State calls only) or (Out-of-State calls). You can learn more about HICAP by visiting their Web site (www.cahealthadvocates.org). SECTION 5 Programs That Help Pay for Prescription Drugs You may qualify for help paying for prescription drugs. Extra Help from Medicare. People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If you qualify, Medicare could pay up to seventy-five (75) percent or more of your drug costs including monthly prescription drug premiums, annual deductibles, and coinsurance. Additionally, those who qualify will not have a coverage gap or late enrollment penalty. Many people are eligible and don t even know it. To see if you qualify, call: o MEDICARE ( ). TTY users should call , 24 hours a day/7 days a week; o The Social Security Office at between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, ; or o Your State Medicaid Office. SECTION 6 Questions? Section 6.1 Getting Help from Blue Shield 65 Plus Questions? We re here to help. Please call Member Services at (800) (TTY only, call (800) ) We are available for phone calls 7:00 a.m. to 8:00 p.m., seven days a week, from October 1 through February 14. However, after February 14, your call will be handled by our automated phone system on Saturdays, Sundays, and holidays. Calls to these numbers are free.

13 Blue Shield 65 Plus Annual Notice of Changes for Read your 2014 Evidence of Coverage (it has details about next year's benefits and costs) This Annual Notice of Changes gives you a summary of changes in your benefits and costs for For details, look in the 2014 Evidence of Coverage for Blue Shield 65 Plus. The Evidence of Coverage is the legal, detailed description of your plan benefits. It explains your rights and the rules you need to follow to get covered services and prescription drugs. A copy of the Evidence of Coverage was included in this envelope. Visit our Web site You can also visit our Web site at blueshieldca.com. As a reminder, our Web site has the most up-to-date information about our provider network (Provider Directory) and our list of covered drugs (Formulary/Drug List). Section 6.2 Getting Help from Medicare To get information directly from Medicare: Call MEDICARE ( ) You can call MEDICARE ( ), 24 hours a day, 7 days a week. TTY users should call Visit the Medicare Web site You can visit the Medicare Web site (http://www.medicare.gov). It has information about cost, coverage, and quality ratings to help you compare Medicare health plans. You can find information about plans available in your area by using the Medicare Plan Finder on the Medicare Web site. (To view the information about plans, go to and click on Compare Drug and Health Plans. ) Read Medicare & You 2014 You can read Medicare & You 2014 Handbook. Every year in the fall, this booklet is mailed to people with Medicare. It has a summary of Medicare benefits, rights and protections, and answers to the most frequently asked questions about Medicare. If you don t have a copy of this booklet, you can get it at the Medicare Web site (http://www.medicare.gov) or by calling MEDICARE ( ), 24 hours a day, 7 days a week. TTY users should call

14 October 31, 2013 December 31, 2014 Evidence of Coverage: Your Medicare Health Benefits and Services and Prescription Drug Coverage as a Member of Blue Shield 65 Plus (HMO) This booklet gives you the details about your Medicare health care and prescription drug coverage from October 1, 2013 December 31, It explains how to get coverage for the health care services and prescription drugs you need. This is an important legal document. Please keep it in a safe place. This plan, Blue Shield 65 Plus, is offered by Blue Shield of California. (When this Evidence of Coverage says we, us, or our, it means Blue Shield of California. When it says plan or our plan, it means Blue Shield 65 Plus.) Blue Shield of California is an HMO plan with a Medicare contract. Enrollment in Blue Shield of California depends on contract renewal. This information is available for free in a different format, such as large print. Please contact our Member Services number at (800) for additional information. (TTY users should call (800) ). Hours are 7:00 a.m. to 8:00 p.m., seven days a week, from October 1 through February 14. However, after February 14, your call will be handled by our automated phone system on Saturdays, Sunday, and holidays. Member Services has free language interpreter services available for non-english speakers. Benefits, formulary, pharmacy network, premium, and/or copayments/coinsurance may change on January 1, H0504_13_ Self-Insured Schools of California MA5031

15 Table of Contents 2014 Evidence of Coverage Table of Contents This list of chapters and page numbers is your starting point. For more help in finding information you need, go to the first page of a chapter. You will find a detailed list of topics at the beginning of each chapter. Chapter 1. Getting started as a member... 1 Explains what it means to be in a Medicare health plan and how to use this booklet. Tells about materials we will send you, your plan premium, your plan membership card, and keeping your membership record up to date. Chapter 2. Important phone numbers and resources Tells you how to get in touch with our plan (Blue Shield 65 Plus) and with other organizations including Medicare, the State Health Insurance Assistance Program (SHIP), the Quality Improvement Organization, Social Security, Medicaid (the state health insurance program for people with low incomes), programs that help people pay for their prescription drugs, and the Railroad Retirement Board. Chapter 3. Using the plan s coverage for your medical services Explains important things you need to know about getting your medical care as a member of our plan. Topics include using the providers in the plan s network and how to get care when you have an emergency. Chapter 4. Medical Benefits Chart (what is covered and what you pay) Gives the details about which types of medical care are covered and not covered for you as a member of our plan. Explains how much you will pay as your share of the cost for your covered medical care. Chapter 5. Using the plan s coverage for your Part D prescription drugs Explains rules you need to follow when you get your Part D drugs. Tells how to use the plan s List of Covered Drugs (Formulary) to find out which drugs are covered. Tells which kinds of drugs are not covered. Explains several kinds of restrictions that apply to coverage for certain drugs. Explains where to get your prescriptions filled. Tells about the plan s programs for drug safety and managing medications.

16 Table of Contents Chapter 6. What you pay for your Part D prescription drugs Tells about the three stages of drug coverage (Initial Coverage Stage, Coverage Gap Stage, Catastrophic Coverage Stage) and how these stages affect what you pay for your drugs. Explains the five cost-sharing tiers for your Part D drugs and tells what you must pay for a drug in each costsharing tier. Tells about the late enrollment penalty. Chapter 7. Asking us to pay our share of a bill you have received for covered medical services or drugs Explains when and how to send a bill to us when you want to ask us to pay you back for our share of the cost for your covered services or drugs. Chapter 8. Your rights and responsibilities Explains the rights and responsibilities you have as a member of our plan. Tells what you can do if you think your rights are not being respected. Chapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) Tells you step-by-step what to do if you are having problems or concerns as a member of our plan. Explains how to ask for coverage decisions and make appeals if you are having trouble getting the medical care or prescription drugs you think are covered by our plan. This includes asking us to make exceptions to the rules or extra restrictions on your coverage for prescription drugs, and asking us to keep covering hospital care and certain types of medical services if you think your coverage is ending too soon. Explains how to make complaints about quality of care, waiting times, customer service, and other concerns. Chapter 10. Ending your membership in the plan Explains when and how you can end your membership in the plan. Explains situations in which our plan is required to end your membership. Chapter 11. Legal notices Includes notices about governing law and about nondiscrimination. Chapter 12. Definitions of important words Explains key terms used in this booklet.

17 Chapter 1: Getting started as a member 1 Chapter 1. Getting started as a member SECTION 1 Introduction... 3 Section 1.1 You are enrolled in Blue Shield 65 Plus, which is a Medicare HMO...3 Section 1.2 What is the Evidence of Coverage booklet about?...3 Section 1.3 What does this Chapter tell you?...3 Section 1.4 What if you are new to Blue Shield 65 Plus?...4 Section 1.5 Legal information about the Evidence of Coverage...4 SECTION 2 What makes you eligible to be a plan member?... 4 Section 2.1 Your eligibility requirements...4 Section 2.2 What are Medicare Part A and Medicare Part B?...5 Section 2.3 Here is the plan service area for Blue Shield 65 Plus...5 SECTION 3 What other materials will you get from us?... 8 Section 3.1 Section 3.2 Your plan membership card Use it to get all covered care and prescription drugs...8 The Provider Directory: Your guide to all providers in the plan s network...9 Section 3.3 The Pharmacy Directory: Your guide to pharmacies in our network...10 Section 3.4 The plan s List of Covered Drugs (Formulary)...11 Section 3.5 The Explanation of Benefits (the EOB ): Reports with a summary of payments made for your Part D prescription drugs...11 SECTION 4 Your monthly premium for Blue Shield 65 Plus Section 4.1 How much is your plan premium?...11 Section 4.2 If you pay a Part D late enrollment penalty, there are several ways you can pay your penalty...13

18 Chapter 1: Getting started as a member 2 Section 4.3 Can we change your monthly plan premium during the year?...15 SECTION 5 Please keep your plan membership record up to date Section 5.1 How to help make sure that we have accurate information about you...15 SECTION 6 We protect the privacy of your personal health information Section 6.1 We make sure that your health information is protected...16 SECTION 7 How other insurance works with our plan Section 7.1 Which plan pays first when you have other insurance?...16

19 Chapter 1: Getting started as a member 3 SECTION 1 Section 1.1 Introduction You are enrolled in Blue Shield 65 Plus, which is a Medicare HMO You are covered by Medicare, and you have chosen to get your Medicare health care and your prescription drug coverage through our plan, Blue Shield 65 Plus. There are different types of Medicare health plans. Blue Shield 65 Plus is a Medicare Advantage HMO Plan (HMO stands for Health Maintenance Organization). Like all Medicare health plans, this Medicare HMO is approved by Medicare and run by a private company. Blue Shield 65 Plus combines standard Medicare Part D prescription drug coverage along with supplemental drug coverage purchased by your former employer group/union. Standard Medicare Part D coverage is defined by Medicare and includes an annual deductible, a gap in coverage, and cost-sharing for drugs that would be higher if you didn t have supplemental drug coverage provided by your former employer group/union. The supplemental drug coverage provided by Blue Shield 65 Plus is in addition to standard Part D coverage and includes coverage of the Part D deductible, reduced cost-sharing for Part D drugs, coverage through the Coverage Gap, and coverage for certain non-part D drugs. The rules for the supplemental drug coverage provided by Blue Shield 65 Plus differ in some ways from the rules for Medicare s standard Part D coverage and we call that out in several places throughout this document. For example, payments that you make for non-part D drugs will not be included in your out-of-pocket costs. (See Chapter 6, Section 5.5.) Section 1.2 What is the Evidence of Coverage booklet about? This Evidence of Coverage booklet tells you how to get your Medicare medical care and prescription drugs covered through our plan. This booklet explains your rights and responsibilities, what is covered, and what you pay as a member of the plan. This plan, Blue Shield 65 Plus is offered by Blue Shield of California. (When this Evidence of Coverage says we, us, or our, it means Blue Shield of California. When it says plan or our plan, it means Blue Shield 65 Plus.) The word coverage and covered services refers to the medical care and services and the prescription drugs available to you as a member of Blue Shield 65 Plus. Section 1.3 What does this Chapter tell you? Look through Chapter 1 of this Evidence of Coverage to learn: What makes you eligible to be a plan member? What is your plan s service area?

20 Chapter 1: Getting started as a member 4 What materials will you get from us? What is your plan premium and how can you pay it? How do you keep the information in your membership record up to date? Section 1.4 What if you are new to Blue Shield 65 Plus? If you are a new member, then it s important for you to learn what the plan s rules are and what services are available to you. We encourage you to set aside some time to look through this Evidence of Coverage booklet. If you are confused or concerned or just have a question, please contact our plan s Member Services (phone numbers are printed on the back cover of this booklet). Section 1.5 Legal information about the Evidence of Coverage It s part of our contract with you This Evidence of Coverage is part of our contract with you about how Blue Shield 65 Plus covers your care. Other parts of this contract include your enrollment form, the List of Covered Drugs (Formulary), and any notices you receive from us about changes to your coverage or conditions that affect your coverage. These notices are sometimes called riders or amendments. The contract is in effect for months in which you are enrolled in Blue Shield 65 Plus between October 1, 2013 and December 31, Each calendar year, Medicare allows us to make changes to the plans that we offer. This means we can change the costs and benefits of Blue Shield 65 Plus after December 31, We can also choose to stop offering the plan, or to offer it in a different service area, after December 31, Medicare must approve our plan each year Medicare (the Centers for Medicare & Medicaid Services) must approve Blue Shield 65 Plus each year. You can continue to get Medicare coverage as a member of our plan as long as we choose to continue to offer the plan and Medicare renews its approval of the plan. SECTION 2 Section 2.1 What makes you eligible to be a plan member? Your eligibility requirements You are eligible for membership in our plan as long as: You live in our geographic service area (section 2.3 below describes our service area)

21 Chapter 1: Getting started as a member 5 -- and -- you have both Medicare Part A and Medicare Part B -- and -- you do not have End-Stage Renal Disease (ESRD), with limited exceptions, such as if you develop ESRD when you are already a member of a plan that we offer, or you were a member of a different plan that was terminated -- and -- you meet your former employer group/union s eligibility requirements. Section 2.2 What are Medicare Part A and Medicare Part B? When you first signed up for Medicare, you received information about what services are covered under Medicare Part A and Medicare Part B. Remember: Medicare Part A generally helps cover services furnished by institutional providers such as hospitals (for inpatient services), skilled nursing facilities, or home health agencies. Medicare Part B is for most other medical services (such as physician s services and other outpatient services) and certain items (such as durable medical equipment and supplies). Section 2.3 Here is the plan service area for Blue Shield 65 Plus Although Medicare is a Federal program, Blue Shield 65 Plus is available only to individuals who live in our plan service area. A Post Office box or rental mailbox cannot be used to determine whether you meet the residence eligibility requirements for this plan. Your permanent residence must be used to determine eligibility. To remain a member of our plan, you must keep living in this service area. The service area is described below. In instances when a ZIP code spans more than one county, your permanent residence must be in the portion of the ZIP code that is in the county that is in our plan service area. That means, even if your ZIP code is listed below, your home would not be inside our service area if you live in a county that is not part of our plan service area and you would not be eligible for this plan. Subject to approval by the Centers for Medicare & Medicaid Services (CMS), we may reduce our plan service area effective any time after January 1 by giving prior written notice to your former employer group/union. We may expand our plan service area at any time by giving written notice to your former employer group/union. ZIP codes are subject to change by the U.S. Postal Service. If you have a question about whether a ZIP code is currently included in the plan service area, please contact your Benefits Administrator or Blue Shield 65 Plus Member Services at the number on the back of your member ID card. Our service area includes these counties in California: Contra Costa County Los Angeles County Orange County Sacramento County

22 Chapter 1: Getting started as a member 6 San Diego County San Mateo County Fresno County San Francisco County Santa Clara County San Joaquin San Luis Obispo County County Santa Cruz County Ventura County Our service area includes these parts of counties in California: (Note: In instances when a ZIP code spans more than one county, your permanent residence must be in the portion of the ZIP code that is in the county that is in our plan service area.) Imperial County, the following ZIP codes only: Kern County, the following ZIP codes only: Madera County, the following ZIP codes only: Nevada County, the following ZIP codes only: Riverside County, the following ZIP codes only:

23 Chapter 1: Getting started as a member

24 Chapter 1: Getting started as a member 8 San Bernardino County, the following ZIP codes only: If you plan to move out of the service area, please contact Member Services (phone numbers are printed on the back cover of this booklet). When you move, you will have a Special Enrollment Period that will allow you to switch to Original Medicare or enroll in a Medicare health or drug plan that is available in your new location. It is also important that you call Social Security if you move or change your mailing address. You can find phone numbers and contact information for Social Security in Chapter 2, Section 5. SECTION 3 Section 3.1 What other materials will you get from us? Your plan membership card Use it to get all covered care and prescription drugs While you are a member of our plan, you must use your membership card for our plan whenever you get any services covered by this plan and for prescription drugs you get at network pharmacies. Here s a sample membership card to show you what yours will look like:

25 Chapter 1: Getting started as a member 9 As long as you are a member of our plan you must not use your red, white, and blue Medicare card to get covered medical services (with the exception of routine clinical research studies and hospice services). Keep your red, white, and blue Medicare card in a safe place in case you need it later. Here s why this is so important: If you get covered services using your red, white, and blue Medicare card instead of using your Blue Shield 65 Plus membership card while you are a plan member, you may have to pay the full cost yourself. If your plan membership card is damaged, lost, or stolen, call Member Services right away and we will send you a new card. (Phone numbers for Member Services are printed on the back cover of this booklet.) Section 3.2 The Provider Directory: Your guide to all providers in the plan s network The Provider Directory lists our network providers. What are network providers? Network providers are the doctors and other health care professionals, medical groups, hospitals, and other health care facilities that have an agreement with us to accept our payment

26 Chapter 1: Getting started as a member 10 and any plan cost sharing as payment in full. We have arranged for these providers to deliver covered services to members in our plan. Why do you need to know which providers are part of our network? It is important to know which providers are part of our network because, with limited exceptions, while you are a member of our plan you must use network providers to get your medical care and services. The only exceptions are emergencies, urgently needed care when the network is not available (generally, when you are out of the area), out-of-area dialysis services, and cases in which Blue Shield 65 Plus authorizes use of out-of-network providers. See Chapter 3 (Using the plan s coverage for your medical services) for more specific information about emergency, outof-network, and out-of-area coverage. If you don t have your copy of the Provider Directory, you can request a copy from Member Services (phone numbers are printed on the back cover of this booklet). You may ask Member Services for more information about our network providers, including their qualifications. You can also search the Provider Directory at blueshieldca.com/findaprovider. Both Member Services and the Web site can give you the most up-to-date information about changes in our network providers. Section 3.3 The Pharmacy Directory: Your guide to pharmacies in our network What are network pharmacies? Our Pharmacy Directory gives you a complete list of our network pharmacies that means all of the pharmacies that have agreed to fill covered prescriptions for our plan members. Why do you need to know about network pharmacies? You can use the Pharmacy Directory to find the network pharmacy you want to use. This is important because, with few exceptions, you must get your prescriptions filled at one of our network pharmacies if you want our plan to cover (help you pay for) them. The Pharmacy Directory will also tell you which of the pharmacies in our network are preferred network pharmacies. Preferred pharmacies may have lower cost sharing for covered drugs compared to other network pharmacies. If you don t have the Pharmacy Directory, you can get a copy from Member Services (phone numbers are printed on the back cover of this booklet). At any time, you can call Member Services to get up-to-date information about changes in the pharmacy network. You can also find this information on our Web site at blueshieldca.com/med_pharmacy.

27 Chapter 1: Getting started as a member 11 Section 3.4 The plan s List of Covered Drugs (Formulary) The plan has a List of Covered Drugs (Formulary). We call it the Drug List for short. It tells which Part D and non-part D prescription drugs are covered by Blue Shield 65 Plus. The drugs on this list are selected by the plan with the help of a team of doctors and pharmacists. The list of Part D drugs must meet requirements set by Medicare. Medicare has approved all Part D prescription drugs on the Blue Shield 65 Plus Drug List. The Drug List also tells you if there are any rules that restrict coverage for your drugs. We will send you a copy of the Drug List. To get the most complete and current information about which drugs are covered, you can visit the plan s Web site (blueshieldca.com/med_formulary) or call Member Services (phone numbers are printed on the back cover of this booklet). Section 3.5 The Explanation of Benefits (the EOB ): Reports with a summary of payments made for your Part D prescription drugs When you use your Part D prescription drug benefits, we will send you a summary report to help you understand and keep track of payments for your Part D prescription drugs. This summary report is called the Explanation of Benefits (or the EOB ). The Explanation of Benefits tells you the total amount you have spent on your Part D prescription drugs and the total amount we have paid for each of your Part D prescription drugs during the month. Chapter 6 (What you pay for your Part D prescription drugs) gives more information about the Explanation of Benefits and how it can help you keep track of your drug coverage. An Explanation of Benefits summary is also available upon request. To get a copy, please contact Member Services (phone numbers are printed on the back cover of this booklet). SECTION 4 Section 4.1 Your monthly premium for Blue Shield 65 Plus How much is your plan premium? Your former employer group/union is responsible for paying any monthly plan premium to the plan. Please contact your former employer group/union's Benefits Administrator for information about your plan premium. In addition, you must continue to pay your Medicare Part B premium (unless your Part B premium is paid for by Medicaid or another third party). In some situations, your plan premium could be less The Extra Help program helps people with limited resources pay for their drugs. Chapter 2, Section 7 tells more about this program. If you qualify, enrolling in the program might lower your monthly plan premium.

28 Chapter 1: Getting started as a member 12 If you are already enrolled and getting help from one of these programs, some of the information about premiums in this Evidence of Coverage may not apply to you. We send you a separate insert, called the Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs (also known as the Low Income Subsidy Rider or the LIS Rider ), which tells you about your drug coverage. If you don t have this insert, please call Member Services and ask for the LIS Rider. (Phone numbers for Member Services are printed on the back cover of this booklet.) In some situations, your plan premium could be more In some situations, your plan premium could be more than the amount listed above in Section 4.1. This situation is described below. Some members are required to pay a late enrollment penalty because they did not join a Medicare drug plan when they first became eligible or because they had a continuous period of 63 days or more when they didn t have creditable prescription drug coverage. ( Creditable means the drug coverage is expected to pay, on average, at least as much as Medicare s standard prescription drug coverage.) For these members, the late enrollment penalty is added to the plan s monthly premium. Their premium amount will be the monthly plan premium plus the amount of their late enrollment penalty. o If you are required to pay the late enrollment penalty, the amount of your penalty depends on how long you waited before you enrolled in drug coverage or how many months you were without drug coverage after you became eligible. Chapter 6, Section 10 explains the late enrollment penalty. o If you have a late enrollment penalty and do not pay it, you could be disenrolled from the plan. Many members are required to pay other Medicare premiums In addition to paying the monthly plan premium, many members are required to pay other Medicare premiums. As explained in Section 2 above, in order to be eligible for our plan, you must be entitled to Medicare Part A and enrolled in Medicare Part B. For that reason, some plan members (those who aren t eligible for premium-free Part A) pay a premium for Medicare Part A. And most plan members pay a premium for Medicare Part B. You must continue paying your Medicare premiums to remain a member of the plan. Some people pay an extra amount for Part D because of their yearly income. If your income is $85,000 or above for an individual (or married individuals filing separately) or $170,000 or above for married couples, you must pay an extra amount directly to the government (not the Medicare plan or your former employer group/union) for your Medicare Part D coverage. If you are required to pay the extra amount and you do not pay it, you will be disenrolled from the plan and lose prescription drug coverage.

Annual Notice of Changes for 2015

Annual Notice of Changes for 2015 Kaiser Permanente Senior Advantage Essential Plus plan (HMO) offered by Kaiser Foundation Health Plan, Inc., Hawaii Region Annual Notice of Changes for 2015 You are currently enrolled as a member of Kaiser

More information

Piedmont WellStar Medicare Choice (HMO) offered by Piedmont WellStar HealthPlans, Inc.

Piedmont WellStar Medicare Choice (HMO) offered by Piedmont WellStar HealthPlans, Inc. Piedmont WellStar Medicare Choice (HMO) offered by Piedmont WellStar HealthPlans, Inc. Annual Notice of Changes for 2015 You are currently enrolled as a member of Piedmont WellStar Medicare Choice HMO.

More information

Annual Notice of Changes for 2016

Annual Notice of Changes for 2016 Kaiser Permanente Senior Advantage Core (HMO) offered by Kaiser Foundation Health Plan of Colorado Annual Notice of Changes for 2016 You are currently enrolled as a member of Kaiser Permanente Senior Advantage

More information

Your Medicare Health Benefits and Services and Prescription Drug Coverage as a Member of Molina Medicare Options Plus HMO SNP

Your Medicare Health Benefits and Services and Prescription Drug Coverage as a Member of Molina Medicare Options Plus HMO SNP January 1 December 31, 2015 Evidence of Coverage: Your Medicare Health Benefits and Services and Prescription Drug Coverage as a Member of Molina Medicare Options Plus HMO SNP This booklet gives you the

More information

evidence of coverage

evidence of coverage evidence of coverage Your Medicare Health Benefits and Services and Prescription Drug Coverage as a Member of Blue Shield 65 Plus Choice Plan (HMO) Los Angeles (partial) and Orange counties January 1 December

More information

Evidence of Coverage:

Evidence of Coverage: January 1 December 31, 2015 Evidence of Coverage: Your Medicare Health Benefits and Services and Prescription Drug Coverage as a Member of Health Net Ruby (HMO) This booklet gives you the details about

More information

ANNUAL NOTICE OF CHANGES FOR 2016

ANNUAL NOTICE OF CHANGES FOR 2016 Cigna-HealthSpring Preferred (HMO) offered by Cigna-HealthSpring ANNUAL NOTICE OF CHANGES FOR 2016 You are currently enrolled as a member of Cigna-HealthSpring Preferred (HMO). Next year, there will be

More information

Annual Notice of Changes for 2017

Annual Notice of Changes for 2017 ATRIO Bronze Rx (Umpqua) (PPO) offered by ATRIO Health Plans Annual Notice of Changes for 2017 You are currently enrolled as a member of ATRIO Bronze Rx (Umpqua) (PPO). Next year, there will be some changes

More information

CCPOA Medical Plan Prescription Drug Plan (PDP)

CCPOA Medical Plan Prescription Drug Plan (PDP) CCPOA Medical Plan Prescription Drug Plan (PDP) Blue Shield of California Medicare Rx Plan (PDP) Evidence of Coverage Effective January 1, 2016 Sponsored by California Correctional Peace Officers Association

More information

Annual Notice of Changes for 2017

Annual Notice of Changes for 2017 Gateway Health Medicare Assured Prime SM (HMO) offered by Gateway Health Plan of Ohio, Inc. Annual Notice of Changes for 2017 You are currently enrolled as a member of Gateway Health Medicare Assured Prime.

More information

Prescription Drug Plan (PDP)

Prescription Drug Plan (PDP) Prescription Drug Plan (PDP) Blue Shield of California Medicare Rx Plan (PDP) Evidence of Coverage Effective January 1, 2015 Blue Shield of California is a PDP with a Medicare contract. Enrollment in Blue

More information

You have from October 15 until December 7 to make changes to your Medicare coverage for next year.

You have from October 15 until December 7 to make changes to your Medicare coverage for next year. Geisinger Gold Classic Rx (HMO) offered by Geisinger Health Plan Annual Notice of Changes for 2016 You are currently enrolled as a member of Geisinger Gold Classic Rx. Next year, there will be some changes

More information

2015 Evidence of Coverage

2015 Evidence of Coverage Molina Medicare Options Plus HMO SNP Member Services Method Member Services Contact Information CALL (800) 665-1029 Calls to this number are free. 7 days a week, 8 a.m. to 8 p.m., local time. Member Services

More information

Annual Notice of Changes for 2016

Annual Notice of Changes for 2016 Premera Blue Cross Medicare Advantage (HMO) offered by Premera Blue Cross Annual Notice of Changes for 2016 You are currently enrolled as a member of Premera Blue Cross Medicare Advantage (HMO). Next year,

More information

Harvard Pilgrim s Stride SM. (HMO) Medicare Advantage Plan. Value Rx Plus Annual Notice of Change

Harvard Pilgrim s Stride SM. (HMO) Medicare Advantage Plan. Value Rx Plus Annual Notice of Change HP15ANOCMNEPLUS 2015 Harvard Pilgrim s Stride SM (HMO) Medicare Advantage Plan Value Rx Plus Annual Notice of Change Maine Cumberland and York Y0098_15092 Accepted Harvard Pilgrim Stride Value RX Plus

More information

Scripps Classic offered by SCAN Health Plan (HMO) Scripps Signature offered by SCAN Health Plan (HMO)

Scripps Classic offered by SCAN Health Plan (HMO) Scripps Signature offered by SCAN Health Plan (HMO) Scripps Classic offered by (HMO) Scripps Signature offered by (HMO) Evidence of Coverage for 2015 San Diego County Y0057_SCAN_8642_2014F File & Use Accepted 08272014 G8659 09/14 January 1 December 31,

More information

Evidence of Coverage. H8067_C_EOC_0915 CMS Accepted/File & Use 9/28/2015

Evidence of Coverage. H8067_C_EOC_0915 CMS Accepted/File & Use 9/28/2015 2016 Evidence of Coverage For more recent information or other questions, please contact Provider Partners Health Plan at 1-800-405-9681 or, for TTY users, 711, from 8 a.m. to 8 p.m. Monday through Friday,

More information

Evidence of Coverage:

Evidence of Coverage: January 1 December 31, 2016 Evidence of Coverage: Your Medicare Health Benefits and Services and Prescription Drug Coverage as a Member of Advantra Silver (HMO) This booklet gives you the details about

More information

Annual Notice of Changes for 2016

Annual Notice of Changes for 2016 Upper Peninsula Health Plan Advantage (HMO) offered by Upper Peninsula Health Plan, LLC Annual Notice of Changes for 2016 You are currently enrolled as a member of Upper Peninsula Health Plan Advantage

More information

Evidence. of Coverage. ATRIO Gold Rx (Rogue) (PPO) Member Handbook. Serving Medicare Beneficiaries in Josephine and Jackson Counties

Evidence. of Coverage. ATRIO Gold Rx (Rogue) (PPO) Member Handbook. Serving Medicare Beneficiaries in Josephine and Jackson Counties 2016 Evidence of Coverage ATRIO Gold Rx (Rogue) (PPO) Member Handbook Serving Medicare Beneficiaries in Josephine and Jackson Counties H6743_017_EOC_16 CMS Accepted January 1 December 31, 2016 Evidence

More information

Annual Notice of Changes for 2017

Annual Notice of Changes for 2017 Gateway Health Medicare Assured Diamond (HMO-SNP) offered by Gateway Health Plan of Ohio, Inc. Annual Notice of Changes for 2017 You are currently enrolled as a member of Gateway Health Medicare Assured

More information

Annual Notice of Changes for 2014

Annual Notice of Changes for 2014 True Blue Rx Option Il (HMO) offered by Blue Cross of Idaho Health Service, Inc. (Blue Cross of Idaho) Annual Notice of Changes for 2014 You are currently enrolled as a member of True Blue Rx Option Il

More information

Annual Notice of Changes for 2014

Annual Notice of Changes for 2014 ConnectiCare VIP Employer Group (HMO-POS) offered by ConnectiCare, Inc. Connecticut Business & Industry Association (CBIA) Annual Notice of Changes for 2014 You are currently enrolled as a member of ConnectiCare

More information

Annual Notice of Changes for 2014

Annual Notice of Changes for 2014 Blue Medicare HMO SM Standard offered by Blue Cross and Blue Shield of North Carolina (BCBSNC) Annual Notice of Changes for 2014 You are currently enrolled as a member of Blue Medicare HMO Standard. Next

More information

Annual Notice of Changes

Annual Notice of Changes SM An Independent Licensee of the Blue Cross and Blue Shield Association CAPITAL HEALTH PLAN PREFERRED ADVANTAGE (HMO) 2016 Annual Notice of Changes H5938_DP 945 CMS Accepted 08272015 Capital Health Plan

More information

DeanCare Gold Basic (Cost) offered by Dean Health Plan

DeanCare Gold Basic (Cost) offered by Dean Health Plan DeanCare Gold Basic (Cost) offered by Dean Health Plan Annual Notice of Changes for 2016 You are currently enrolled as a member of DeanCare Gold Basic (Cost). Next year, there will be some changes to the

More information

Evidence of Coverage

Evidence of Coverage January 1 December 31, 2014 Evidence of Coverage Your Medicare Health Benefits and Services and Prescription Drug Coverage as a Member of Kaiser Permanente Senior Advantage (HMO) This booklet gives you

More information

EVIDENCE OF COVERAGE Molina Medicare Options Plus HMO SNP

EVIDENCE OF COVERAGE Molina Medicare Options Plus HMO SNP Molina Medicare Options Plus HMO SNP Member Services CALL (866) 440-0012 Calls to this number are free. 7 days a week, 8 a.m. to 8 p.m., local time. Member Services also has free language interpreter services

More information

Annual Notice of Changes for 2014

Annual Notice of Changes for 2014 True Blue Rx Option II (HMO) offered by Blue Cross of Idaho Health Service, Inc. (Blue Cross of Idaho) Annual Notice of Changes for 2014 You are currently enrolled as a member of True Blue Freedom (HMO).

More information

2016 Evidence of Coverage for Passport Advantage

2016 Evidence of Coverage for Passport Advantage 2016 Evidence of Coverage for Passport Advantage EVIDENCE OF COVERAGE January 1, 2016 - December 31, 2016 Your Medicare Health Benefits and Services and Prescription Drug Coverage as a Member of Passport

More information

UPMC for Life HMO Deductible with Rx (HMO) offered by UPMC Health Plan

UPMC for Life HMO Deductible with Rx (HMO) offered by UPMC Health Plan UPMC for Life HMO Deductible with Rx (HMO) offered by UPMC Health Plan Annual Notice of Changes for 2016 You are currently enrolled as a member of UPMC for Life HMO Deductible with Rx. Next year, there

More information

Essentials Rx 15 (HMO) Plan offered by PacificSource Medicare. Annual Notice of Changes for 2014

Essentials Rx 15 (HMO) Plan offered by PacificSource Medicare. Annual Notice of Changes for 2014 Essentials Rx 15 (HMO) Plan offered by PacificSource Medicare Annual Notice of Changes for 2014 You are currently enrolled as a member of Essentials Rx 15 (HMO) Plan. Next year, there will be some changes

More information

CA Seniority Plus (Employer HMO) Plan

CA Seniority Plus (Employer HMO) Plan CA Seniority Plus (Employer HMO) Plan Evidence of Coverage and Plan Document Effective January 1, 2015 Contracted by the CalPERS Board of Administration Under the Public Employees Medical & Hospital Care

More information

Evidence of Coverage:

Evidence of Coverage: Keystone 65 HMO January 1 December 31, 2016 Evidence of Coverage: Your Medicare Health Benefits and Services and Prescription Drug Coverage as a Member of Keystone 65 Focus Rx HMO This booklet gives you

More information

2015 Evidence of Coverage

2015 Evidence of Coverage 2015 Evidence of Coverage Akamai Advantage Complete Plus (PPO) HMSA Akamai Advantage An Independent Licensee of the Blue Cross and Blue Shield Association H3832_1127_15_AA_Complete_Plus Accepted January

More information

Annual Notice of Changes for 2015

Annual Notice of Changes for 2015 BlueRx (PDP) Local Government Health Insurance Plan (LGHIP) Prescription Drug Coverage for Medicare Members offered by Blue Cross and Blue Shield of Alabama Annual Notice of Changes for 2015 You are currently

More information

You have from October 15 until December 7 to make changes to your Medicare coverage for next year.

You have from October 15 until December 7 to make changes to your Medicare coverage for next year. Advantra Gold (HMO) offered by HealthAmerica Pennsylvania, Inc. Annual Notice of Changes for You are currently enrolled as a member of Advantra Gold (HMO). Next year, there will be some changes to the

More information

Annual Notice of Changes for 2015

Annual Notice of Changes for 2015 SeniorHealth Basic and Plus Plans Combined Annual Notice of Change and Evidence of Coverage Contract Year 2015 Contra Costa Health Plan s SeniorHealth Plan, a Medicare Cost Plan offered by Contra Costa

More information

Evidence of Coverage:

Evidence of Coverage: January 1 December 31, 2010 Evidence of Coverage: Your Medicare Health Benefits and Services and Prescription Drug Coverage as a Member of Advantra Option 2 This booklet gives you the details about your

More information

Annual Notice of Changes for 2016

Annual Notice of Changes for 2016 Healthy Advantage Plus HMO offered by Molina Healthcare of Utah Annual Notice of Changes for 2016 You are currently enrolled as a member of Healthy Advantage Plus HMO. Next year, there will be some changes

More information

Evidence of Coverage

Evidence of Coverage January 1 December 31, 2016 Evidence of Coverage Your Medicare Health Benefits and Services and Prescription Drug Coverage as a Member of Kaiser Permanente Senior Advantage Medicare Medicaid (HMO SNP)

More information

San Diego County. SCAN Health Plan. Evidence of Coverage. Scripps Signature offered by SCAN Health Plan (HMO)

San Diego County. SCAN Health Plan. Evidence of Coverage. Scripps Signature offered by SCAN Health Plan (HMO) San Diego County 2016 SCAN Health Plan Evidence of Coverage Scripps Signature offered by SCAN Health Plan (HMO) Y0057_SCAN_9180_2015F File & Use Accepted G9308 09/15 16C-EOC701 January 1 December 31,

More information

TexanPlus Classic (HMO) offered by SelectCare Health Plans, Inc.

TexanPlus Classic (HMO) offered by SelectCare Health Plans, Inc. TexanPlus Classic (HMO) offered by SelectCare Health Plans, Inc. Annual Notice of Changes for 2016 You are currently enrolled as a member of TexanPlus Classic (HMO). Next year, there will be some changes

More information

Evidence of Coverage:

Evidence of Coverage: January 1 December 31, 2014 Evidence of Coverage: Your Medicare Health Benefits and Services and Prescription Drug Coverage as a Member of First Choice VIP Care (HMO-SNP) This booklet gives you the details

More information

Annual Notice of Changes for 2015

Annual Notice of Changes for 2015 Prescription Blue SM PDP, Option B, offered by Blue Cross Blue Shield of Michigan Annual Notice of Changes for 2015 You are currently enrolled as a member of Prescription Blue Option B. Next year, there

More information

Annual Notice of Changes for 2014

Annual Notice of Changes for 2014 Advocare Spirit Rx (HMO-POS) offered by Security Health Plan of Wisconsin, Inc. Annual Notice of Changes for 2014 You are currently enrolled as a member of Advocare Spirit Rx (HMO-POS). Next year there

More information

First Health Part D Value Plus (PDP) offered by First Health Life & Health Insurance Company

First Health Part D Value Plus (PDP) offered by First Health Life & Health Insurance Company First Health Part D Value Plus (PDP) offered by First Health Life & Health Insurance Company Annual Notice of Changes for 2016 You are currently enrolled as a member of First Health Part D Value Plus (PDP).

More information

Annual Notice of Changes for 2015

Annual Notice of Changes for 2015 Dear Member: Liberty Health Advantage Dual Power (HMO SNP) Offered by Liberty Health Advantage, Inc. Annual Notice of Changes for 2015 You are currently enrolled as a member of Liberty Health Advantage

More information

Annual Notice of Changes for 2015

Annual Notice of Changes for 2015 First Health Part D Value Plus (PDP) Plan offered by First Health Life & Health Insurance Company Annual Notice of Changes for 2015 You are currently enrolled as a member of First Health Part D Essentials

More information

Evidence of Coverage

Evidence of Coverage January 1 December 31, 2015 Evidence of Coverage Your Medicare Health Benefits and Services and Prescription Drug Coverage as a Member of Kaiser Permanente Senior Advantage (HMO) This booklet gives you

More information

Annual Notice of Changes/ Evidence of Coverage 2015

Annual Notice of Changes/ Evidence of Coverage 2015 Annual Notice of Changes/ Evidence of Coverage 2015 Indiana University Health Plans Medicare Select HMO 950 N. Meridian St., Suite 200 Indianapolis, IN 46204-1202 800.455.9776 TTY users call Relay Indiana

More information

Y0067_POST_16AE _CMS 16AE

Y0067_POST_16AE _CMS 16AE Today's Options Advantage 200 (PPO) offered by American Progressive Life & Health Insurance Company of New York, Inc. Annual Notice of Changes for 2016 You are currently enrolled as a member of Today's

More information

Evidence of Coverage:

Evidence of Coverage: January 1 December 31, 2015 Evidence of Coverage: Your Medicare Health Benefits and Services and Prescription Drug Coverage as a Member of Health Net Violet Option 1 (PPO) This booklet gives you the details

More information

Annual Notice of Changes for 2016

Annual Notice of Changes for 2016 Central Health Medicare Plan (HMO) offered by Central Health Plan of California Annual Notice of Changes for 2016 You are currently enrolled as a member of Central Health Medicare Plan. Next year, there

More information

Annual Notice of Changes for 2015

Annual Notice of Changes for 2015 UPMC for You Advantage (HMO SNP) offered by UPMC for You, Inc. Annual Notice of Changes for 2015 You are currently enrolled as a member of UPMC for You Advantage. Next year, there will be some changes

More information

Advocare Essence (HMO-POS)

Advocare Essence (HMO-POS) Advocare Essence (HMO-POS) offered by Security Health Plan of Wisconsin, Inc. You are currently enrolled as a member of Advocare Essence (HMO-POS). Next year there will be some changes to the plan s costs

More information

Evidence of Coverage

Evidence of Coverage January 1 December 31, 2016 Evidence of Coverage Your Medicare Health Benefits and Services and Prescription Drug Coverage as a Member of Kaiser Permanente Senior Advantage (HMO) This booklet gives you

More information

SCAN Classic (HMO) offered by SCAN Health Plan Evidence of Coverage for 2015 Los Angeles, Orange, Riverside and San Bernardino Counties

SCAN Classic (HMO) offered by SCAN Health Plan Evidence of Coverage for 2015 Los Angeles, Orange, Riverside and San Bernardino Counties SCAN Classic (HMO) offered by SCAN Health Plan Evidence of Coverage for 2015 Los Angeles, Orange, Riverside and San Bernardino Counties Y0057_SCAN_8636_2014F File & Use Accepted 08262014 G8653 09/14 January

More information

Paramount Elite Standard Medical and Drug (HMO) offered by Paramount Care, Inc.

Paramount Elite Standard Medical and Drug (HMO) offered by Paramount Care, Inc. Paramount Elite Standard Medical and Drug (HMO) offered by Paramount Care, Inc. Annual Notice of Changes for 2016 You are currently enrolled as a member of Paramount Elite Standard Medical and Drug (HMO).

More information

Annual Notice of Changes for 2015

Annual Notice of Changes for 2015 Express Scripts Medicare (PDP) for Consolidated Associations of Railroad Employees (CARE) Annual Notice of Changes for 2015 You are currently enrolled as a member of Express Scripts Medicare (PDP). The

More information

ANNUAL NOTICE OF CHANGES FOR 2016

ANNUAL NOTICE OF CHANGES FOR 2016 Cigna-HealthSpring Preferred Plus (HMO) offered by Cigna-HealthSpring ANNUAL NOTICE OF CHANGES FOR 2016 You are currently enrolled as a member of Cigna-HealthSpring Preferred Plus (HMO). Next year, there

More information

EVIDENCE OF COVERAGE Your Medicare Benefits and Services as a Member of EmblemHealth MLTC Plus (HMO SNP) January 1 December 31, 2015 H3330_124504

EVIDENCE OF COVERAGE Your Medicare Benefits and Services as a Member of EmblemHealth MLTC Plus (HMO SNP) January 1 December 31, 2015 H3330_124504 EVIDENCE OF COVERAGE Your Medicare Benefits and Services as a Member of EmblemHealth MLTC Plus (HMO SNP) January 1 December 31, 2015 H3330_124504 January 1 December 31, 2015 Evidence of Coverage: Your

More information

You have from October 15 until December 7 to make changes to your Medicare coverage for next year.

You have from October 15 until December 7 to make changes to your Medicare coverage for next year. Blue Cross MedicareRx Basic (PDP) SM offered by HCSC Insurance Services Company Annual Notice of Changes for 2016 You are currently enrolled as a member of Blue Cross MedicareRx Basic (PDP) SM. Next year,

More information

Annual Notice of Changes for 2016

Annual Notice of Changes for 2016 SCAN Connections at Home (HMO SNP) offered by SCAN Health Plan Annual Notice of Changes for 2016 You are currently enrolled as a member of SCAN Connections at Home. Next year, there will be some changes

More information

Annual Notice of Changes for 2014

Annual Notice of Changes for 2014 First Health Part D Premier Plus (PDP) offered by Cambridge Life Insurance Company Annual Notice of Changes for 2014 Dear Member, You are currently enrolled as a member of First Health Part D Premier Plus

More information

Coverage as a Member of Kaiser Permanente Senior Advantage Medicare Medi-Cal Plan North (HMO SNP)

Coverage as a Member of Kaiser Permanente Senior Advantage Medicare Medi-Cal Plan North (HMO SNP) January 1 December 31, 2016 0BEvidence of Coverage 1BYour Medicare Health Benefits and Services and Prescription Drug Coverage as a Member of Kaiser Permanente Senior Advantage Medicare Medi-Cal Plan North

More information

Annual Notice of Changes/ Evidence of Coverage 2016

Annual Notice of Changes/ Evidence of Coverage 2016 Annual Notice of Changes/ Evidence of Coverage 2016 Indiana University Health Plans Medicare Select Plus HMO 950 N. Meridian St., Suite 200 Indianapolis, IN 46204-1202 800.455.9776 TTY users call Relay

More information

!nnual Notice of Changes for 2015

!nnual Notice of Changes for 2015 Central Health Medi-Medi Plan (HMO SNP) offered by Central Health Plan of California!nnual Notice of Changes for 2015 You are currently enrolled as a member of Central Health Medi-Medi Plan (HMO SNP).

More information

Annual Notice of Changes for 2016

Annual Notice of Changes for 2016 Gateway Health Medicare Assured DiamondSM (HMO SNP) offered by Gateway Health Plan of Ohio, Inc. Annual Notice of Changes for 2016 You are currently enrolled as a member of Gateway Health Medicare Assured

More information

Annual Notice of Changes for 2016

Annual Notice of Changes for 2016 Central Health Focus Plan (HMO SNP) offered by Central Health Plan of California Annual Notice of Changes for 2016 You are currently enrolled as a member of Central Health Focus Plan. Next year, there

More information

evidence of coverage

evidence of coverage evidence of coverage Your Medicare Health Benefits and Services and Prescription Drug Coverage as a Member of Blue Shield 65 Plus (HMO) San Diego County January 1 December 31, 2015 H0504_14_138E CMS Accepted

More information

Geisinger Gold Preferred Complete Rx (PPO) offered by Geisinger Indemnity Insurance Company

Geisinger Gold Preferred Complete Rx (PPO) offered by Geisinger Indemnity Insurance Company Geisinger Gold Preferred Complete Rx (PPO) offered by Geisinger Indemnity Insurance Company Annual Notice of Changes for 2016 You are currently enrolled as a member of Geisinger Gold Preferred Complete

More information

Classic Plan (HMO-POS)

Classic Plan (HMO-POS) Classic Plan (HMO-POS) Offered by Health First Health Plans You are currently enrolled as a member of the Classic Plan (HMO-POS). Next year, there will be some changes to the plan s costs and benefits.

More information

2015 HMO Evidence of Coverage

2015 HMO Evidence of Coverage hap.org/medicare 2015 HMO Evidence of Coverage HAP Senior Plus (hmo)-henry Ford Individual Plan 006 Option 1 Your Medicare Health Benefits and Services as a Member of HAP Senior Plus (hmo)-henry Ford.

More information

Annual Notice of Changes for 2016

Annual Notice of Changes for 2016 GlobalHealth Medicare Option 1 (HMO) offered by GlobalHealth, Inc. Annual Notice of Changes for 2016 You are currently enrolled as a member of GlobalHealth Medicare Option 1 (HMO). Next year, there will

More information

Special Needs Plan. Your Medicare Health Benefits and Services and Prescription Drug Coverage as a Member of True Blue Special Needs Plan (HMO).

Special Needs Plan. Your Medicare Health Benefits and Services and Prescription Drug Coverage as a Member of True Blue Special Needs Plan (HMO). 2010 Evidence of Coverage HMO Special Needs Plan Your Medicare Health Benefits and Services and Prescription Drug Coverage as a Member of True Blue Special Needs Plan (HMO). This booklet gives you the

More information

Evidence of Coverage:

Evidence of Coverage: January 1 December 31, 2015 Evidence of Coverage: Your Medicare Health Benefits and Services and Prescription Drug Coverage as a Member of Allegian Advantage (HMO) This booklet gives you the details about

More information

Evidence of Coverage

Evidence of Coverage January 1 December 31, 2015 Evidence of Coverage Your Medicare Health Benefits and Services and Prescription Drug Coverage as a Member of Kaiser Permanente Senior Advantage Medicare Medi-Cal Plan North

More information

Annual Notice of Changes for 2016

Annual Notice of Changes for 2016 Aetna Medicare Rx (PDP) Offered by Aetna Life Insurance Company Annual Notice of Changes for 2016 November 2015 Dear Member, Thank you for your membership in Aetna Medicare Rx (PDP). Enclosed are your

More information

Evidence of Coverage:

Evidence of Coverage: January 1 December 31, 2016 Evidence of Coverage: Your Medicare Health Benefits and Services as a Member of Keystone 65 Select Medical-Only HMO This booklet gives you the details about your Medicare health

More information

Annual Notice of Changes for 2015

Annual Notice of Changes for 2015 BlueCHiP for Medicare Plus (HMO) offered by Blue Cross & Blue Shield of Rhode Island Annual Notice of Changes for 2015 You are currently enrolled as a member of BlueCHiP for Medicare Plus. Next year, there

More information

ANNUAL NOTICE OF CHANGES FOR 2016

ANNUAL NOTICE OF CHANGES FOR 2016 Cigna-HealthSpring Preferred (HMO) offered by Cigna-HealthSpring ANNUAL NOTICE OF CHANGES FOR 2016 You are currently enrolled as a member of Cigna-HealthSpring Preferred (HMO). Next year, there will be

More information

2015 Annual Notice of Change

2015 Annual Notice of Change 2015 Annual Notice of Change Colorado Access Advantage Peak Plan (HMO) COLORADO ACCESS ADVANTAGE PEAK PLAN (HMO) offered by Colorado Access Annual Notice of Changes for 2015 You are currently enrolled

More information

Evidence of Coverage:

Evidence of Coverage: January 1 December 31, 2015 Evidence of Coverage: Your Medicare Health Benefits and Services and Prescription Drug Coverage as a Member of HealthSpan Medicare Standard (HMO) This booklet gives you the

More information

ANNUAL NOTICE OF CHANGES FOR 2016

ANNUAL NOTICE OF CHANGES FOR 2016 Cigna-HealthSpring Preferred (HMO) offered by Cigna-HealthSpring ANNUAL NOTICE OF CHANGES FOR 2016 You are currently enrolled as a member of Cigna-HealthSpring Preferred (HMO). Next year, there will be

More information

2016 Annual Notice of Changes & Evidence of Coverage

2016 Annual Notice of Changes & Evidence of Coverage 2016 Annual Notice of Changes & Evidence of Coverage UCare for Seniors Value Plus (HMO-POS) Minnesota H2459_082715_1 CMS Accepted (08272015) UCare for Seniors Value Plus (HMO-POS) offered by UCare Minnesota

More information

Aetna Medicare Rx (PDP) Offered by Aetna Life Insurance Company

Aetna Medicare Rx (PDP) Offered by Aetna Life Insurance Company Aetna Medicare Rx (PDP) Offered by Aetna Life Insurance Company Annual Notice of Changes for 2016 Enclosed are your 2016 Annual Notice of Changes (ANOC), Evidence of Coverage (EOC), and Formulary (list

More information

2016 Evidence of Coverage Sunshine Health Advantage. All rights reserved.

2016 Evidence of Coverage Sunshine Health Advantage. All rights reserved. 2016 Evidence of Coverage 2016 Sunshine Health Advantage. All rights reserved. January 1 December 31, 2016 Evidence of Coverage: Your Medicare Health Benefits and Services and Prescription Drug Coverage

More information

Your Medicare Health Benefits and Services and Prescription Drug Coverage as a Member of Aetna Medicare SM Plan (PPO).

Your Medicare Health Benefits and Services and Prescription Drug Coverage as a Member of Aetna Medicare SM Plan (PPO). January 1, 2014 December 31, 2014 Evidence of Coverage: Your Medicare Health Benefits and Services and Prescription Drug Coverage as a Member of Aetna Medicare SM Plan (PPO). This booklet gives you the

More information

Annual Notice of Changes for 2015

Annual Notice of Changes for 2015 Kaiser Permanente Senior Advantage Enhanced Greater Sacramento Area and Sonoma County plan (HMO) offered by Kaiser Foundation Health Plan, Inc., Northern California Region Annual Notice of Changes for

More information

EVIDENCE OF COVERAGE

EVIDENCE OF COVERAGE Samaritan Advantage Health Plan (HMO) EVIDENCE OF COVERAGE Conventional Plan 2016 H3811_MM170_2016B Form CMS 10260-ANOC/EOC OMB Approval 0938-1051 (Approved 03/2014) January 1 December 31, 2016 Evidence

More information

Evidence of Coverage

Evidence of Coverage January 1 December 31, 2016 Evidence of Coverage Your Medicare Health Benefits and Services and Prescription Drug Coverage as a Member of Kaiser Permanente Medicare Plus (Cost) This booklet gives you the

More information

You have from October 15 until December 7, to make changes to your Medicare coverage for next year.

You have from October 15 until December 7, to make changes to your Medicare coverage for next year. UPMC for Life HMO (HMO) offered by UPMC Health Plan Annual Notice of Changes for 2016 You are currently enrolled as a member of UPMC for Life HMO. Next year, there will be some changes to the plan s costs

More information

Annual Notice of Changes for 2016

Annual Notice of Changes for 2016 1 Cigna-HealthSpring Preferred Plus HMO offered by Cigna HealthCare of Arizona, Inc. Annual Notice of Changes for 2016 You are currently enrolled as a member of Cigna-HealthSpring Preferred Plus. Next

More information

You have from October 15 until December 7, to make changes to your Medicare coverage for next year.

You have from October 15 until December 7, to make changes to your Medicare coverage for next year. UPMC for Life HMO (HMO) offered by UPMC Health Plan Annual Notice of Changes for 2015 You are currently enrolled as a member of UPMC for Life HMO. Next year, there will be some changes to the plan s costs

More information

ANNUAL NOTICE OF CHANGES FOR 2016

ANNUAL NOTICE OF CHANGES FOR 2016 Cigna-HealthSpring Preferred KNX (HMO) offered by Cigna-HealthSpring ANNUAL NOTICE OF CHANGES FOR 2016 You are currently enrolled as a member of Cigna-HealthSpring Preferred KNX (HMO). Next year, there

More information

Essentials Choice Rx 25 (HMO-POS) offered by PacificSource Medicare

Essentials Choice Rx 25 (HMO-POS) offered by PacificSource Medicare Essentials Choice Rx 25 (HMO-POS) offered by PacificSource Medicare Annual Notice of Changes for 2016 You are currently enrolled as a member of Essentials Choice Rx 25 (HMO-POS). Next year, there will

More information

Evidence of Coverage:

Evidence of Coverage: January 1 December 31, 2015 Evidence of Coverage: Your Medicare Health Benefits and Services and Prescription Drug Coverage as a Member of Memorial Hermann Advantage PPO This booklet gives you the details

More information

Evidence of Coverage:

Evidence of Coverage: Table of Contents January 1 December 31, 2015 Evidence of Coverage: Your Medicare Health Benefits and Services and Prescription Drug Coverage as a Member of Mercy Care Advantage (HMO SNP) This booklet

More information

Essentials Choice Rx 24 (HMO-POS) offered by PacificSource Medicare

Essentials Choice Rx 24 (HMO-POS) offered by PacificSource Medicare Essentials Choice Rx 24 (HMO-POS) offered by PacificSource Medicare Annual Notice of Changes for 2016 You are currently enrolled as a member of Essentials Choice Rx 24 (HMO-POS). Next year, there will

More information