THAT S RIGHT FOR YOU PLATINUM BLUESM WITH RX (COST) Medical and prescription drug benefits you want. Value you deserve. FIND THE PLAN CORE CHOICE

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1 2016 PLATINUM BLUESM WITH RX (COST) Medical and prescription drug benefits you want. Value you deserve. OPTIONS YOU WANT Platinum Blue can help pay the deductibles, copayments and coinsurance Original Medicare doesn t cover. And, with three medical plan options available at different price points with different coverage levels, you have a choice about how much coverage you need. You can even add prescription drug coverage for greater convenience. FLEXIBILITY FOR YOUR CHANGING LIFESTYLE If you meet the eligibility requirements and are not locked in to your current plan you can: Enroll in Platinum Blue anytime COVERAGE WHEN YOU NEED IT, WHERE YOU NEED IT We want to keep you well wherever you are. See any provider in the large Platinum Blue network with no referral needed. However, if you choose to see a out-of-network provider you may only receive Original Medicare coverage for those services. When you add our robust prescription drug coverage, you can fill your prescriptions at more than 64,000 pharmacies nationwide, or choose mail-order for greater cost savings Travel for up to nine months throughout the United States and receive in-network coverage for medically necessary services from any provider that accepts Medicare Costs incurred under the travel benefit apply toward your out-ofpocket maximum FIND THE PLAN THAT S RIGHT FOR YOU CORE Lowest plan premium More copays and coinsurance Protection with an out-of-pocket maximum CHOICE Mid-priced premium Fewer copays and coinsurance Lower out-of-pocket maximum COMPLETE Higher premium for more benefits Little or no copays or coinsurance Lower out-of-pocket maximum OPTIONAL RX Part D prescription drug coverage Low copays and $0 on some generics H2461_082515_Z01 CMS Accepted 08/30/2015

2 PLATINUM BLUE MEDICAL BENEFITS OVERVIEW The charts on these pages provide a snapshot of Platinum Blue medical benefits. For more detailed information including coverage limits that may apply, refer to the Summary of Benefits found in the 2016 enrollment kit and on our website at bluecrossmn.com/medicare. You can also call us at the number on the back page to request a copy. Benefits shown are the amounts you pay for in-network, Medicare-eligible services and supplies. HELPFUL RESOURCES FOR HEALTHY HABITS Good health is about taking time for your health every day. We ve identified habits that impact your health and wellbeing: Managing stress, eating right, staying active, managing a healthy weight, quitting tobacco, and making health care decisions. The tools and resources below are integrated into your health plan benefits to help you create healthier habits and reach your healthy goals. LOOKING FOR ANSWERS? Health Guides Online health and wellbeing resources UNDER THE WEATHER? Nurse line SEEKING SUPPORT? Quitting tobacco support SAVING MONEY? Silver&Fit Exercise and Healthy Aging Program MEDICAL BENEFIT CATEGORY Monthly plan premium You must also continue to pay your Part B premium Deductible Amount you pay before coverage begins Doctor office visits Primary care, specialists, chiropractic and podiatry services Diagnostic tests, X-rays, lab services and radiology services Preventive services Welcome to Medicare and Medicare-covered annual wellness visits, annual physical examinations, routine eye exams and routine hearing tests Immunizations Flu vaccine, hepatitis B vaccine (for people at risk), pneumonia vaccine Cancer screenings Health and wellness education Emergency care Urgently needed care Within the United States Inpatient hospital care Skilled nursing facility care Outpatient services/surgery Ambulatory surgical center visits, outpatient hospital facility visits Prescription drugs Part B drugs Diabetes programs and supplies Durable medical equipment, prosthetics Annual medical out-of-pocket maximum This information is not a complete description of benefits. Limitations, copayments, and restrictions may apply.

3 PLATINUM BLUE CORE PLATINUM BLUE CHOICE PLATINUM BLUE COMPLETE $29 $74 $109 $0 $0 $0 20% coinsurance $15 copay $0 $0 for lab services, $0 to 20% coinsurance for diagnostic procedures and tests, 20% coinsurance for: X-rays Diagnostic radiology services (not including X-rays) Therapeutic radiology services $0 for one Medicare-covered annual wellness visit and one physical examination per year and one glaucoma screening; routine eye exams and routine hearing tests are not covered. No allowance for eyewear or hearing aids. $0 $0 $0 for one Medicare-covered annual wellness visit, one physical examination and one routine eye exam per year; $15 copay for one routine hearing test per year. Limited allowance for eyewear and hearing aids. $0 $0 $0 $0 for one Medicare-covered annual wellness visit, one physical examination, one routine eye exam and one routine hearing test per year. Limited allowance for eyewear and hearing aids. $0; Original Medicare limits apply $0; Original Medicare limits apply $0; Original Medicare limits apply Silver&Fit Exercise and Healthy Aging Program with fitness facility membership or home exercise kit options Nurse line included $0 for smoking cessation counseling $50 copay Silver&Fit Exercise and Healthy Aging Program with fitness facility membership or home exercise kit options Nurse line included $0 for smoking cessation counseling $50 copay $25 copay $25 copay $0 $500 copay per stay; plan covers 90 days each benefit period plus 60 lifetime reserve days Days 1 20: $0 Days : $150 copay per day $100 copay per stay; no limit to the number of days covered each benefit period $0 for up to 100 days each benefit period 20% coinsurance $0 to $50 copay $0 Silver&Fit Exercise and Healthy Aging Program with fitness facility membership or home exercise kit options Nurse line included $0 for smoking cessation counseling $0 $0; no limit to the number of days covered each benefit period $0 for up to 100 days each benefit period 20% coinsurance 20% coinsurance 0 20% coinsurance; Does not apply to drugs administered during an office visit $0 for self-management training; 20% coinsurance for supplies $0 for self-management training; 20% coinsurance for supplies 20% coinsurance 20% coinsurance $0 $5,000 $3,000 $3,000 Contact the plan for more information. $0

4 OPTIONAL PRESCRIPTION DRUG COVERAGE OVERVIEW COVERAGE CATEGORY Monthly plan premiums You must also continue to pay your Part B premium Deductible Amount you pay for prescription drugs before coverage begins PLATINUM BLUE CORE WITH RX $38.90 ($29.00 medical + $9.90 Rx) PLATINUM BLUE CHOICE WITH RX $ ($74.00 medical + $29.40 Rx) $360 $360, applies to Tiers 3 5 only Initial coverage Amount you pay for a 30-day supply after paying the annual deductible Tier 1: Preferred Generic $4 $5 $3 Tier 2: Non-Preferred Generic $13 $15 $10 Tier 3: Preferred Brand $40 $40 $35 Tier 4: Non-Preferred Brand 50% 50% 50% Tier 5: Specialty Drugs 25% 25% 25% Tier 6: Select Care Drugs $0 $2 $0 Coverage gap 58% of the plan s costs for covered generic drugs Amount you pay for a 30-day 45% of the plan s costs for covered brand name drugs supply after your total yearly drug costs reach $3,310 Catastrophic coverage Amount you pay for a 30-day supply after your total yearly out-of-pocket drug costs reach $4,850 PLATINUM BLUE COMPLETE WITH RX $ ($ medical + $55.50 Rx) $360, applies to Tiers 3 5 only The greater of $2.95 copay for covered generic and $7.40 copay for all other covered drugs or 5% of the cost of covered drugs PLATINUM BLUE WITH RX DRUG FORMULARY The Platinum Blue Formulary lists drugs covered by Platinum Blue. Check the printed formulary or the online drug cost calculator to see if your medications are covered Review the six different tiers of covered drugs. This will determine the amount you will pay for your drugs. The formulary can change throughout the year. For the most up-to-date formulary, call member services or use the online drug cost calculator at myprime.com. HELPFUL INFORMATION Coverage gap Your total yearly drug costs represents the total amount you have paid for covered drugs plus what the plan has paid for the calendar year. This does not include the plan premium you pay. The brand-name drug coverage in the coverage gap is subject to agreements between Centers for Medicare & Medicaid Services (CMS) and drug manufacturers. Not all brand drugs may be discounted. Call us if you have any questions. Catastrophic coverage Your out-of-pocket costs means the amount you have paid for covered drugs for the calendar year. This does not include the amount the plan has paid or the plan premium you pay.

5 MORE CONVENIENCE WITH BUILT-IN OPTIONAL DRUG COVERAGE Platinum Blue members can roll their medical and prescription drug coverage into one easy-to-use plan. When you purchase a Platinum Blue with Rx plan, you ll have greater: Ease of use One member ID card for medical and prescription drugs One customer service center One billing system Affordability Affordable premiums and copays Mail-order up to three-month supply for extra savings Convenience 64,000 in-network pharmacies nationwide Coverage when you travel continuously for up to nine months outside of Minnesota

6 Eligibility and enrollment: You are eligible to enroll in Platinum Blue if you have Medicare Part A and Medicare Part B (or have Medicare Part B only) and reside in Minnesota. You can be a member of only one Medicare Advantage or Medicare Cost plan at a time. By enrolling in Platinum Blue, you will automatically be disenrolled from any other Medicare Advantage or Medicare Cost plan of which you are a member. You may not be eligible to enroll if you have permanent end-stage renal disease (kidney disease requiring dialysis or a kidney transplant) unless you are currently enrolled in a Blue Cross and Blue Shield of Minnesota plan. Provider network: Blue Cross has formed a contracted network of doctors, specialists, hospitals and other providers for Platinum Blue. You can use any provider who is part of this network without a referral. The health care providers in the network may change at any time. You may search for providers on our website, request a provider directory or contact us at the number below to see if your providers are in the network. Each provider is an independent contractor and is not our agent. Beginning with your effective date, to receive the highest level of benefits while in the service area, you must get all of your health care from network providers, with the exception of emergency and urgently needed services. If you go to a provider outside of the Platinum Blue network (in the plan s service area) who accepts Medicare patients, your coverage will be the same as Original Medicare. Original Medicare deductibles, copayments and coinsurance apply. You will receive in-network benefits for eligible services received outside the service area within the United States for up to nine (9) months each year. In addition to being covered in the United States, emergency services are covered worldwide. Prescription drugs, formulary, pharmacy network, mail order service: If you enroll in Platinum Blue with Rx, you must receive your Medicare prescription drug coverage through this plan. Drug coverage benefits are subject to limitations. Prescription drugs, without optional Rx plan: Other than those covered by Medicare Part B, Platinum Blue does not include coverage for prescription drugs. If you enroll in Platinum Blue and want prescription drug coverage, you must enroll in either the Platinum Blue with Rx prescription drug plan or a separate Medicare Part D prescription drug plan for an additional monthly premium. MedicareBlue Rx is a stand-alone prescription drug plan with a Medicare contract. Enrollment in MedicareBlue Rx depends on contract renewal. To learn more, contact a Blue Cross Medicare consultant or your local licensed agent. Federal contract: Platinum Blue is a Cost plan with a Medicare contract. Enrollment in Platinum Blue depends on contract renewal. Enrollment in the plan after December 31, 2016, cannot be guaranteed. Either CMS or the plan may choose not to renew the contract, or the plan may choose to change the area it serves. Any such change may result in termination of your enrollment. Benefits, premiums and/or copayments/coinsurance may change on January 1 of each year. The formulary, pharmacy network and/ or provider network may change at any time. You will receive notice when necessary. Plan ratings: Medicare rates how well plans perform in such areas as detecting and preventing illness, and customer service. The ratings are online at medicare.gov, or see the enrollment kit, visit our website or call us at the number below to get a copy. Learn more: To learn more about any of the important information in this benefits overview, contact a Blue Cross Medicare consultant or your local licensed agent. Information is also available online at bluecrossmn.com/medicare or by writing: Platinum Blue, P.O. Box 64024, St. Paul, MN You may also contact Medicare at , 24 hours a day, 7 days a week. TTY users should call The Silver&Fit program is provided by American Specialty Health Fitness, Inc., a subsidiary of American Specialty Health Incorporated (ASH), an independent company providing personal health and wellness programs. Silver&Fit is a federally registered trademark of ASH and used with permission herein. Prime Therapeutics LLC is an independent company providing pharmacy benefit management services. Contact a Blue Cross Medicare consultant or your local licensed agent / TTY a.m. to 8 p.m. Central Time, daily bluecrossmn.com/medicare Blue Cross and Blue Shield of Minnesota and Blue Plus are nonprofit independent licensees of the Blue Cross and Blue Shield Association. F9606R06 (9/15)