Introduction to the Summary of Benefits for Traditional Blue Medicare PPO 701 Plus, 751 Part D and 752 Part D

Transcription

1 Introduction to the Summary of Benefits for, 751 Part D and 752 Part D January 1, December 31, 2007 BlueCross BlueShield of Western New York CMS Contract #H5526 Thank you for your interest in PPO. Our plans are offered by HealthNow New York Inc., a Advantage Preferred Provider Organization (PPO). This Summary of Benefits tells you some features of our plans. It doesn t list every service that we cover or list every limitation or exclusion. To get a complete list of our benefits, please call PPO and ask for our Evidence of Coverage. You Have Choices In Your Health Care As a beneficiary, you can choose from different options. One option is the Original (fee-for-service) Plan. Another option is a health plan, like Traditional Blue PPO. You may have other options too. You make the choice. No matter what you decide, you are still in the program. You may join or leave a plan only at certain times. Please call PPO at the number listed at the end of this introduction or MEDICARE ( ) for more information. TTY users should call You can call this number 24 hours a day, 7 days a week. How Can I Compare My Options? You can compare, 751 Part D, 752 Part D and the Original Plan using this Summary of Benefits. The charts in this booklet list some important health benefits. For each benefit, you can see what our plans cover and what the Original Plan covers. Our members receive all of the benefits that the Original Plan offers. We also offer more benefits, which may change from year to year. Where Is PPO Available? The service area for this plan includes the following counties: Allegany, Cattaraugus, Chautauqua, Erie, Genesee, Niagara, Orleans and Wyoming Counties, New York. You must live in one of these places to join the plan. There is more than one plan listed in this Summary of Benefits. If you are enrolled in one plan and wish to switch to another plan, you may do so only during certain times of the year. Please call Customer Service for more information. H SOB WNY PPO 9_2006

2 Who is Eligible to Join PPO? You can join PPO if you are entitled to Part A and enrolled in Part B and live in the service area. However, individuals with End Stage Renal Disease are not eligible to enroll in PPO. Can I Choose My Doctors? PPO has formed a network of doctors, specialists and hospitals. You can use any doctor who is part of our network. You may also go to doctors outside of our network. The health providers in our network can change at any time. You can ask for a current Provider Directory for an up-to-date list or visit us at Our customer service number is listed at the end of this introduction. What Happens If I Go To A Doctor Who s Not In Your Network? You can go to doctors, specialists or hospitals in or out-of-network. You may have to pay more for the services you receive outside the network, and you may have to follow special rules prior to getting services in and/or out-of-network. For more information, please call the customer service number at the end of this introduction. Does My Plan Cover Part B or Part D Drugs? does cover Part B prescription Traditional Blue does NOT cover Part D prescription and cover both Part B prescription drugs and Part D prescription What Types of Drugs May Be Covered Under Part B? The following outpatient prescription drugs may be covered under Part B. This may include, but is not limited to, the following types of Contact PPO for more details. Some Antigens: If they are prepared by a doctor and administered by a properly instructed person (who could be the patient) under doctor supervision. Osteoporosis Drugs: Injectable drugs for osteoporosis for certain women with. Erythropoietin (Epoetin alpha or Epogen ): By injection if you have end-stage renal disease (permanent kidney failure requiring either dialysis or transplantation) and need this drug to treat anemia. Hemophilia Clotting Factors: Self-administered clotting factors if you have hemophilia. Injectable Drugs: Most Injectable drugs administered incident to a physician s service. Immunosuppressive Drugs: Immunosuppressive drug therapy for transplant patients if the transplant was paid for by, or paid by a private insurance that paid as a primary payer to your Part A coverage, in a -certified facility. Some Oral Cancer Drugs: If the same drug is available in injectable form. Oral Anti-Nausea Drugs: If you are part of an anti-cancer chemotherapeutic regimen. Inhalation and infusion drugs provided through DME. 2

3 Where Can I Get My Prescriptions If I Join This Plan? and PPO 752 Part D has formed a network of pharmacies. You must use a network pharmacy to receive plan benefits. We may not pay for your prescriptions if you use an out-of-network pharmacy, except in certain cases. The pharmacies in our network can change at any time. You can ask for a current Pharmacy Network List or visit us at Our customer service number is listed at the end of this introduction. What is a Prescription Drug Formulary? and uses a formulary. A formulary is a list of drugs by your plan to meet patient needs. We may periodically add, remove, make changes to the coverage limitations on certain drugs or change how much you pay for a drug. If we make any formulary changes that limits our members ability to fill their prescriptions, we will notify the affected enrollees before the change is made. We will send a formulary to you and you can see our complete formulary on our web site at If you are currently taking a drug that is not on our formulary or subject to additional requirements or limits, you may be able to get a temporary supply of the drug. You can contact us to request an exception or switch to an alternative drug listed on our formulary with your physician s help. Call us to see if you can get a temporary supply of the drug or for more details about our drug transition policy. How Can I Get Extra Help With Prescription Drug Plan Costs? If you qualify for extra help with your prescription drug plan costs, your premium and costs at the pharmacy will be lower. When you join or, will tell us how much extra help you are getting. Then we will let you know the amount you will pay. If you are not getting this extra help, you can see if you qualify by calling MEDICARE ( ), TTY users should call You can call this number 24 hours a day, 7 days a week. What Are My Protections in this Plan? All Advantage Plans agree to stay in the program for a full year at a time. Each year, the plans decide whether to continue for another year. Even if a Advantage Plan leaves the program, you will not lose coverage. If a plan decides not to continue, it must send you a letter at least 90 days before your coverage will end. The letter will explain your options for coverage in your area. As a member of 751 Part D or PPO 752 Part D, you have the right to request a coverage determination which includes the right to request an exception, the right to file an appeal if we deny coverage for a prescription drug, and the right to file a grievance. You have the right to request a coverage determination if you want us to cover a Part D drug that you believe should be covered. An exception is a type of coverage determination. You may ask us for an exception if you believe you need a drug that is not on our list of covered drugs or believe you should get a non-preferred drug at a lower out of pocket cost. You can also ask for an exception to cost utilization rules, such as a limit on the quantity of a drug. If you think you need an exception, you should contact us before you try to fill your prescription at a pharmacy. Your doctor must provide a statement to support your exception request. If we deny coverage for

4 your prescription drug(s), you have the right to appeal and ask us to review our decision. Finally, you have the right to file a grievance if you have any type of problem with us or one of our network pharmacies that does not involve coverage for a prescription drug. What Is A Medication Therapy Management (MTM) Program? A Medication Therapy Management (MTM) Program is a free service we may offer. You may be invited to participate in a program designed for your specific health and pharmacy needs. You may decide not to participate but it is recommended that you take full advantage of this covered service if you are selected. Contact or for more details. For more information about: Advantage program & Part D Prescription Drug program please call us at one of the numbers below or visit us at Current Members: (TTY/TDD ) The Call Center hours are Monday through Friday from 8:00 a.m. to 8:00 p.m. EST. For your added convenience, we re also available Saturday and Sunday from 8:00 a.m. to 8:00 p.m. EST from November 15, 2006 to March 1, Prospective Members: (TTY/TDD ) please call us at (TTY/TDD ) 24 hours a day, 7 days a week, or visit If you have special needs, this document may be available in other formats.

5 Summary Of Benefits If you have any questions about this plan s benefits or costs, please contact PPO. Original IMPORTANT INFORMATION 1. Premium and Other important information You pay the Part B premium of $93.50 each month You pay $35 each month for your plan benefits. You also continue to pay the Part B premium of $93.50 each month. Most people will pay the standard Part B premium. However, starting January 1, 2007, some people will have to pay a higher premium because of their yearly income (over $80,000 for singles, $160,000 for married couples). For more information on Part B premiums based on income, call Social Security at TTY users should call You pay $75 each month for your plan benefits and no additional premium for your Part D prescription benefits. You also continue to pay the Part B premium of $93.50 each month. Most people will pay the standard Part B premium. However, starting January 1, 2007, some people will have to pay a higher premium because of their yearly income (over $80,000 for singles, $160,000 for married couples). For more information on Part B premiums based on income, call Social Security at TTY users should call You pay $120 each month for your plan benefits and no additional premium for your Part D prescription benefits. You also continue to pay the Part B premium of $93.50 each month. Most people will pay the standard Part B premium. However, starting January 1, 2007, some people will have to pay a higher premium because of their yearly income (over $80,000 for singles, $160,000 for married couples). For more information on Part B premiums based on income, call Social Security at TTY users should call

6 Original 1. Premium and Other important information (continued) There is a $3000 maximum outof-pocket limit every year for all plan services when received innetwork and out-of-network. If there is no note on an out-ofnetwork service, then the note describes the in-network service. Contact plan for details on the covered out-of-network service. There is a $3000 maximum outof-pocket limit every year for all plan services when received innetwork and out-of-network. If there is no note on an out-ofnetwork service, then the note describes the in-network service. Contact plan for details on the covered out-of-network service. There is a $3000 maximum outof-pocket limit every year for all -covered plan services when received in-network and out-of-network. If there is no note on an out-ofnetwork service, then the note describes the in-network service. Contact plan for details on the covered out-of-network service. 2. Doctor and Hospital Choice (For more information, see Emergency - #15 and Urgently Needed Care - #16) You may go to any doctor, specialist or hospital that accepts. You can go to doctors, specialists and hospitals in or out of the network. Higher costs apply for out-of-network You do NOT need a referral to go to network doctors, specialists and hospitals. A separate doctor office visit copayment may apply for certain You can go to doctors, specialists and hospitals in or out of the network. Higher costs apply for out-of-network You do NOT need a referral to go to network doctors, specialists and hospitals. A separate doctor office visit copayment may apply for certain You can go to doctors, specialists and hospitals in or out of the network. Higher costs apply for out-of-network You do NOT need a referral to go to network doctors, specialists and hospitals. A separate doctor office visit copayment may apply for certain

7 Original inpatient care 3. Inpatient Hospital Care (includes Substance Abuse and Rehabilitation Services) You pay for each benefit period: (3) Days 1-60: an initial deductible of $992. Days 61-90: $248 each day. Days : $496 each lifetime reserve day. (4) Please call MEDICARE ( ) for information about lifetime reserve days. (4) You pay $250 for each covered stay at a network hospital. You pay 20% of the cost for each stay at an out-of-network hospital. additional days received at a network hospital. There is a $250 maximum out-ofpocket limit every year. You are covered for unlimited days each benefit period. (3) Except in an emergency, your provider must obtain authorization from Traditional Blue PPO. You pay $250 for each covered stay at a network hospital. You pay 20% of the cost for each stay at an out-of-network hospital. additional days received at a network hospital. There is a $250 maximum out-ofpocket limit every year. You are covered for unlimited days each benefit period. (3) Except in an emergency, your provider must obtain authorization from Traditional Blue PPO. You pay $100 for each covered stay at a network hospital. You pay 20% of the cost for each stay at an out-of-network hospital. additional days received at a network hospital. There is a $100 maximum out-ofpocket limit every year. You are covered for unlimited days each benefit period. (3) Except in an emergency, your provider must obtain authorization from Traditional Blue PPO. (3) A benefit period begins the day you go to a hospital or skilled nursing facility. The benefit period ends when you have not received hospital or skilled nursing care for 60 days in a row. If you go into the hospital after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods you can have. (4) Lifetime reserve days can only be used once.

8 Original 4. Inpatient Mental Health Care You pay the same deductible and copayments as inpatient hospital care (above) except beneficiaries may only receive 190 days in a Psychiatric Hospital in a lifetime. You pay $250 for each covered stay at a network hospital. You pay 20% of the cost for each stay at an out-of-network hospital. There is a $250 maximum out-ofpocket limit every year. beneficiaries may only receive 190 days in a Psychiatric Hospital in a lifetime. Except in an emergency, your provider must obtain authorization from Traditional Blue PPO. You pay $250 for each covered stay at a network hospital. You pay 20% of the cost for each stay at an out-of-network hospital. There is a $250 maximum out-ofpocket limit every year. beneficiaries may only receive 190 days in a Psychiatric Hospital in a lifetime. Except in an emergency, your provider must obtain authorization from Traditional Blue PPO. You pay $100 for each covered stay at a network hospital. You pay 20% of the cost for each stay at an out-of-network hospital. There is a $100 maximum out-ofpocket limit every year. beneficiaries may only receive 190 days in a Psychiatric Hospital in a lifetime. Except in an emergency, your provider must obtain authorization from Traditional Blue PPO. 5. Skilled Nursing Facility (in a -certified Skilled Nursing Facility) You pay for each benefit period (3), following at least a 3 day covered hospital stay: Days 1-20: $0 for each day. Days : $124 for each day There is a limit of 100 days for each benefit period. (3) You pay $250 for each stay at a Skilled Nursing Facility. You pay 20% of the cost for services at an out-of-network Skilled Nursing Facility. There is a $250 maximum out-ofpocket limit every year. You pay $250 for each stay at a Skilled Nursing Facility. You pay 20% of the cost for services at an out-of-network Skilled Nursing Facility. There is a $250 maximum out-ofpocket limit every year. You pay $100 for each stay at a Skilled Nursing Facility. You pay 20% of the cost for services at an out-of-network Skilled Nursing Facility. There is a $100 maximum out-ofpocket limit every year. (3) A benefit period begins the day you go to a hospital or skilled nursing facility. The benefit period ends when you have not received hospital or skilled nursing care for 60 days in a row. If you go into the hospital after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods you can have.

9 Original 5. Skilled Nursing Facility (in a -certified Skilled Nursing Facility) (continued) Three day prior hospital stay is required. You are covered for 100 days each benefit period. Three day prior hospital stay is required. You are covered for 100 days each benefit period. Three day prior hospital stay is required. You are covered for 100 days each benefit period. 6. Home Health Care (includes medically necessary intermittent skilled nursing care, home health aide services and rehabilitation services, etc.) all covered home health visits. -covered home health visits. -covered home health visits. -covered home health visits. You pay $25 for out-of-network home health visits. You pay $20 for out-of-network home health visits. You pay $10 for out-of-network home health visits. 7. Hospice You pay part of the cost for outpatient drugs and inpatient respite care. You must receive care from a -certified hospice. You must receive care from a -certified hospice. You must receive care from a -certified hospice. You must receive care from a -certified hospice.

10 10 Original OUTPATIENT CARE 8. Doctor Office Visits You pay 20% of approved amounts. (1)(2) You pay $10 for each primary care doctor office visit for -covered You pay $10 for each primary care doctor office visit for -covered You pay $5 for each primary care doctor office visit for covered You pay $15 for each out-ofnetwork primary care doctor office visit. You pay $15 for each out-ofnetwork primary care doctor office visit. You pay $10 for each out-ofnetwork primary care doctor office visit. You pay $20 for each specialist visit for -covered You pay $15 for each specialist visit for -covered You pay $5 for each specialist visit for -covered You pay $25 for each out-ofnetwork specialist visit. You pay $20 for each out-ofnetwork specialist visit. You pay $10 for each out-ofnetwork specialist visit. See 32 Physical Exams for more information. See 32 Physical Exams for more information. See 32 Physical Exams for more information. 9. Chiropractic Services You are covered for manual manipulation of the spine to correct subluxation, provided by chiropractors or other qualified providers. You pay 100% for routine care. You pay $20 for each -covered visit (manual manipulation of the spine to correct subluxation). You pay $25 for out-of-network chiropractic You pay $15 for each -covered visit (manual manipulation of the spine to correct subluxation). You pay $20 for out-of-network chiropractic You pay $5 for each covered visit (manual manipulation of the spine to correct subluxation). You pay $10 for out-of-network chiropractic You pay 20% of approved amounts. (1)(2) (1) Each year, you pay a total of one $131 deductible. (2) If a doctor or supplier chooses not to accept assignment, their costs are often higher, which means you may pay more.

11 Original 10. Podiatry Services You pay 20% of approved amounts. (1)(2) You are covered for medically necessary foot care, including care for medical conditions affecting the lower limbs. You pay 100% for routine care. You pay: - $20 for each -covered visit (medically necessary foot care). - $20 for each routine visit up to 3 visit(s) every year. You pay $25 for out-of-network podiatry You pay: - $15 for each -covered visit (medically necessary foot care). - $15 for each routine visit up to 3 visit(s) every year. You pay $20 for out-of-network podiatry You pay: - $5 for each -covered visit (medically necessary foot care). - $5 for each routine visit up to 3 visit(s) every year. You pay $10 for out-of-network podiatry 11. Outpatient Mental Health Care You pay 50% of approved amounts with the exception of certain situations and services for which you pay 20% of approved charges. (1)(2) For -covered Mental Health services, you pay 50% of the cost for each individual/group therapy visit. You pay 55% of the cost for out-of-network Mental Health For -covered Mental Health services with a psychiatrist, you pay 20% of the cost for each individual/group therapy visit. You pay 55% of the cost for out-of-network Mental Health services with a psychiatrist. For -covered Mental Health services, you pay 50% of the cost for each individual/group therapy visit. You pay 55% of the cost for out-of-network Mental Health For -covered Mental Health services with a psychiatrist, you pay 20% of the cost for each individual/group therapy visit. You pay 55% of the cost for out-of-network Mental Health services with a psychiatrist. For -covered Mental Health services, you pay 50% of the cost for each individual/group therapy visit. You pay 55% of the cost for out-of-network Mental Health For -covered Mental Health services with a psychiatrist, you pay 20% of the cost for each individual/group therapy visit. You pay 55% of the cost for out-of-network Mental Health services with a psychiatrist. (1) Each year, you pay a total of one $131 deductible. (2) If a doctor or supplier chooses not to accept assignment, their costs are often higher, which means you may pay more. 11

12 12 Original 12. Outpatient Substance Abuse Care You pay 20% of approved amounts. (1)(2) For -covered services, you pay 50% of the cost for each individual/group visit. You pay 55% of the cost for outof-network outpatient substance abuse Except in an emergency, your provider must obtain authorization from Traditional Blue PPO. For -covered services, you pay 50% of the cost for each individual/group visit. You pay 55% of the cost for outof-network outpatient substance abuse Except in an emergency, your provider must obtain authorization from Traditional Blue PPO. For -covered services, you pay 50% of the cost for each individual/group visit. You pay 55% of the cost for outof-network outpatient substance abuse Except in an emergency, your provider must obtain authorization from Traditional Blue PPO. 13. Outpatient Services/Surgery You pay 20% of approved amounts for the doctor. (1)(2) You pay 20% of outpatient facility charges. (1)(2) You pay $50 for each covered visit to an ambulatory surgical center. You pay $50 for each covered visit to an outpatient hospital facility. You pay $75 for services at an out-of-network ambulatory surgical center. You pay $75 for services at an out-of-network outpatient hospital facility. You pay $50 for each covered visit to an ambulatory surgical center. You pay $50 for each covered visit to an outpatient hospital facility. You pay $75 for services at an out-of-network ambulatory surgical center. You pay $75 for services at an out-of-network outpatient hospital facility. You pay $35 for each covered visit to an ambulatory surgical center. You pay $35 for each covered visit to an outpatient hospital facility. You pay $50 for services at an out-of-network ambulatory surgical center. You pay $50 for services at an out-of-network outpatient hospital facility. (1) Each year, you pay a total of one $131 deductible. (2) If a doctor or supplier chooses not to accept assignment, their costs are often higher, which means you may pay more.

13 Original 14. Ambulance Services (medically necessary ambulance services) You pay 20% of approved amounts or applicable fee schedule charge. (1)(2) You pay $50 for covered ambulance services; you do not pay this amount if you are admitted to the hospital. You pay $50 for out-of-network ambulance You pay $50 for covered ambulance services; you do not pay this amount if you are admitted to the hospital. You pay $50 for out-of-network ambulance You pay $50 for covered ambulance services; you do not pay this amount if you are admitted to the hospital. You pay $50 for out-of-network ambulance 15. Emergency Care (You may go to any emergency room if you reasonably believe you need emergency care) You pay 20% of the facility charge or applicable Copayment for each emergency room visit; you do NOT pay this amount if you are admitted to the hospital for the same condition within 3 days of the emergency room visit. (1)(2) You pay 20% of doctor charges. (1)(2) NOT covered outside the U.S. except under limited circumstances. You pay $50 for each covered emergency room visit; you do not pay this amount if you are admitted to the hospital within 1 day for the same condition. Worldwide coverage. You pay $50 for each covered emergency room visit; you do not pay this amount if you are admitted to the hospital within 1 day for the same condition. Worldwide coverage. You pay $50 for each covered emergency room visit; you do not pay this amount if you are admitted to the hospital within 1 day for the same condition. Worldwide coverage. (1) Each year, you pay a total of one $131 deductible. (2) If a doctor or supplier chooses not to accept assignment, their costs are often higher, which means you may pay more. 13

14 14 Original 16. Urgently Needed Care (This is NOT emergency care, and in most cases, is out of the service area) You pay 20% of approved amounts or applicable Copayment. (1)(2) NOT covered outside the U.S. except under limited circumstances. You pay $20 for each covered urgently needed care visit; you do not pay this amount if you are admitted to the hospital within 1 day for the same condition. Worldwide coverage. You pay $15 for each covered urgently needed care visit; you do not pay this amount if you are admitted to the hospital within 1 day for the same condition. Worldwide coverage. You pay $5 for each covered urgently needed care visit; you do not pay this amount if you are admitted to the hospital within 1 day for the same condition. Worldwide coverage. 17. Outpatient Rehabilitation Services (Occupational Therapy, Physical Therapy, Speech and Language Therapy) You pay 20% of approved amounts. (1)(2) You pay $20 for each covered Occupational Therapy visit. You pay $20 for each covered Physical Therapy and/or Speech/Language Therapy visit. You pay $25 for out-of-network Occupational Therapy You pay $25 for out-of-network Physical Therapy and/or Speech language therapy You pay $15 for each covered Occupational Therapy visit. You pay $15 for each covered Physical Therapy and/or Speech/Language Therapy visit. You pay $20 for out-of-network Occupational Therapy You pay $20 for out-of-network Physical Therapy and/or Speech language therapy You pay $5 for each covered Occupational Therapy visit. You pay $5 for each covered Physical Therapy and/or Speech/Language Therapy visit. You pay $10 for out-of-network Occupational Therapy You pay $10 for out-of-network Physical Therapy and/or Speech language therapy (1) Each year, you pay a total of one $131 deductible. (2) If a doctor or supplier chooses not to accept assignment, their costs are often higher, which means you may pay more.

15 Original OUTPATIENT MEDICAL SERVICES AND SUPPLIES 18. Durable Medical Equipment (includes wheelchairs, oxygen, etc.) You pay 20% of approved amounts. (1)(2) You pay 30% of the cost for each -covered item. You pay 30% of the cost for each -covered item. You pay 30% of the cost for each -covered item. You pay 35% of the cost for durable medical equipment purchased out-of-network. You pay 35% of the cost for durable medical equipment purchased out-of-network. You pay 35% of the cost for durable medical equipment purchased out-of-network. 19. Prosthetic Devices (includes braces, artificial limbs and eyes, etc.) You pay 20% of approved amounts. (1)(2) You pay 30% of the cost for each -covered item. You pay 30% of the cost for each -covered item. You pay 30% of the cost for each -covered item. You pay 35% of the cost for prosthetic devices purchased outof-network. You pay 35% of the cost for prosthetic devices purchased outof-network. You pay 35% of the cost for prosthetic devices purchased outof-network. (1) Each year, you pay a total of one $131 deductible. (2) If a doctor or supplier chooses not to accept assignment, their costs are often higher, which means you may pay more. 15

16 16 Original 20. Diabetes Self-Monitoring Training and Supplies (includes coverage for glucose monitors, test strips, test screenings, lancets, and self-management training) You pay 20% of approved amounts. (1)(2) You pay $20 for covered Diabetes self-monitoring training. You pay $25 for out-of-network Diabetes self-monitoring training. You pay 30% of the cost for each -covered Diabetes Supply item. You pay 35% of the cost for each Diabetes Supply item purchased out-of-network. You pay $15 for covered Diabetes self-monitoring training. You pay $20 for out-of-network Diabetes self-monitoring training. You pay 30% of the cost for each -covered Diabetes Supply item. You pay 35% of the cost for each Diabetes Supply item purchased out-of-network. You pay $5 for -covered Diabetes self-monitoring training. You pay $10 for out-of-network Diabetes self-monitoring training. You pay 30% of the cost for each -covered Diabetes Supply item. You pay 35% of the cost for each Diabetes Supply item purchased out-of-network. 21. Diagnostic Tests, X-Rays and Lab Services You pay 20% of approved amounts, except for approved lab (1)(2) -approved lab You pay: - $0 for each -covered clinical/diagnostic lab service. - $20 for each -covered radiation therapy service. You pay: - $0 for each -covered clinical/diagnostic lab service. - $15 for each -covered radiation therapy service. You pay: - $0 for each -covered clinical/diagnostic lab service. - $5 for each -covered radiation therapy service. - $20 for each -covered X-ray visit. - $15 for each -covered X-ray visit. - $5 for each -covered X-ray visit. (1) Each year, you pay a total of one $131 deductible. (2) If a doctor or supplier chooses not to accept assignment, their costs are often higher, which means you may pay more.

17 Original 21. Diagnostic Tests, X-Rays and Lab Services (continued) - $25 each out-of-network clinical/diagnostic lab service. - $25 for each out-of-network radiation therapy service. - $25 for out-of-network X-ray - $20 each out-of-network clinical/diagnostic lab service. - $20 for each out-of-network radiation therapy service. - $20 for out-of-network X-ray - $10 each out-of-network clinical/diagnostic lab service. - $10 for each out-of-network radiation therapy service. - $10 for out-of-network X-ray PREVENTIVE SERVICES 22. Bone Mass Measurement (for people with who are at risk) You pay 20% of approved amounts. (1)(2) each -covered Bone Mass Measurement. each -covered Bone Mass Measurement. each -covered Bone Mass Measurement. You pay $25 for each outof-network Bone Mass Measurement. You pay $20 for each outof-network Bone Mass Measurement. You pay $10 for each outof-network Bone Mass Measurement. 23. Colorectal Screening Exams (for people with age 50 and older) You pay 20% of approved amounts. (1)(2) -covered Colorectal Screening Exams. -covered Colorectal Screening Exams. -covered Colorectal Screening Exams. You pay $25 for each out-ofnetwork Colorectal Screening exam. You pay $20 for each out-ofnetwork Colorectal Screening exam. You pay $10 for each out-ofnetwork Colorectal Screening exam. (1) Each year, you pay a total of one $131 deductible. (2) If a doctor or supplier chooses not to accept assignment, their costs are often higher, which means you may pay more. 17

18 18 Original 24. Immunizations (Flu vaccine, Hepatitis B vaccine - for people with who are at risk, Pneumonia vaccine) the Pneumonia and Flu vaccines. the Pneumonia and Flu vaccines. the Pneumonia and Flu vaccines. the Pneumonia and Flu vaccines. You pay 20% of approved amounts for Hepatitis B vaccine. (1)(2) No referral necessary for -covered influenza and pneumococcal vaccines. No referral necessary for -covered influenza and pneumococcal vaccines. No referral necessary for -covered influenza and pneumococcal vaccines. You may only need the Pneumonia vaccine once in your lifetime. Please contact your doctor for further details. the Hepatitis B vaccine. You pay $25 for each out-ofnetwork Immunization. the Hepatitis B vaccine. You pay $20 for each out-ofnetwork Immunization. the Hepatitis B vaccine. You pay $10 for each out-ofnetwork Immunization. 25. Mammograms (Annual Screening) (for women with age 40 and older) You pay 20% of approved amounts. (2) No referral necessary for -covered screenings. -covered Screening Mammograms. You pay $25 for each out-ofnetwork Screening Mammogram. -covered Screening Mammograms. You pay $20 for each out-ofnetwork Screening Mammogram. -covered Screening Mammograms. You pay $10 for each out-ofnetwork Screening Mammogram. No referral necessary for -covered screenings. No referral necessary for -covered screenings No referral necessary for -covered screenings. (1) Each year, you pay a total of one $131 deductible. (2) If a doctor or supplier chooses not to accept assignment, their costs are often higher, which means you may pay more.

19 Original 26. Pap Smears and Pelvic Exams (for women with ) a Pap Smear once every 2 years, annually for beneficiaries at high risk. (2) You pay 20% of approved amounts for Pelvic Exams. (2) : - -covered Pap Smears and Pelvic Exams - Additional Pelvic Exams You pay $25 for each out-ofnetwork Pap Smear and Pelvic Exam. : - -covered Pap Smears and Pelvic Exams - Additional Pelvic Exams You pay $20 for each out-ofnetwork Pap Smear and Pelvic Exam. : - -covered Pap Smears and Pelvic Exams - Additional Pelvic Exams You pay $10 for each out-ofnetwork Pap Smear and Pelvic Exam. You are covered for an unlimited number of Pelvic Exams. You are covered for an unlimited number of Pelvic Exams. You are covered for an unlimited number of Pelvic Exams. 27. Prostate Cancer Screening Exams (for men with age 50 and older) approved lab services and a copayment of 20% of approved amounts for other related (1)(2) -covered Prostate Cancer Screening exams. You pay $25 for each out-ofnetwork Prostate Screening Exam. -covered Prostate Cancer Screening exams. You pay $20 for each out-ofnetwork Prostate Screening Exam. -covered Prostate Cancer Screening exams. You pay $10 for each out-ofnetwork Prostate Screening Exam. 28. Prescription Drugs - Drugs covered under Part B (Original ) You pay 100% for most prescription drugs, unless you enroll in the Part D Prescription Drug program. You pay 100% for most prescription You pay 20% of the cost for Part B-covered You pay 20% of the cost for Part B-covered You pay 20% of the cost for Part B-covered (1) Each year, you pay a total of one $131 deductible. (2) If a doctor or supplier chooses not to accept assignment, their costs are often higher, which means you may pay more. 19

20 20 Original 28. Prescription Drugs - Drugs covered under Part D (Prescription Drug Benefit) This plan does not cover Part D prescription Please contact the plan for details. This plan uses a formulary. A formulary is a list of drugs covered by your plan to meet patient needs. We may periodically add, remove, make changes to coverage limitations on certain drugs or change how much you pay for a drug. If we make any formulary change that limits our members ability to fill their prescriptions, we will notify the affected enrollees before the change is made. We will send a formulary to you and you can see our complete formulary on our web site at People who have limited incomes, who live in long-term care facilities, or who have access to Indian/Tribal/Urban (Indian Health Service) facilities may have different out-of-pocket drug costs. Contact the plan for details. This plan uses a formulary. A formulary is a list of drugs covered by your plan to meet patient needs. We may periodically add, remove, make changes to coverage limitations on certain drugs or change how much you pay for a drug. If we make any formulary change that limits our members ability to fill their prescriptions, we will notify the affected enrollees before the change is made. We will send a formulary to you and you can see our complete formulary on our web site at People who have limited incomes, who live in long-term care facilities, or who have access to Indian/Tribal/Urban (Indian Health Service) facilities may have different out-of-pocket drug costs. Contact the plan for details. 28. Prescription Drugs - Deductible There is no deductible. There is no deductible.

21 Original 28. Prescription Drugs - Initial Coverage In-Network Retail Pharmacy Before the total yearly drug costs (paid by both you and your plan) reach $2400, you pay the following for prescription drugs: - $5 for a one-month (30 day) supply of Formulary Generic - $30 for a one-month (30 day) supply of Formulary Brand - 50% coinsurance for a onemonth (30 day) supply of Nonpreferred Brand/Generic - 30% coinsurance for a onemonth (30 day) supply of Specialty Injectables - $10 for a three-month (90 day) supply of Formulary Generic - $60 for a three-month (90 day) supply of Formulary Brand - 33% coinsurance for a threemonth (90) day supply of Nonpreferred Brand/Generic - 20% coinsurance for a threemonth (90 day) supply of Specialty Injectables In-Network Retail Pharmacy Before the total yearly drug costs (paid by both you and your plan) reach $2400, you pay the following for prescription drugs: - $5 for a one-month (30 day) supply of Formulary Generic - $30 for a one-month (30 day) supply of Formulary Brand - 50% coinsurance for a onemonth (30 day) supply of Nonpreferred Brand/Generic - 30% coinsurance for a onemonth (30 day) supply of Specialty Injectables - $10 for a three-month (90 day) supply of Formulary Generic - $60 for a three-month (90 day) supply of Formulary Brand - 33% coinsurance for a threemonth (90) day supply of Nonpreferred Brand/Generic - 20% coinsurance for a threemonth (90 day) supply of Specialty Injectables 21

22 22 Original 28. Prescription Drugs - Initial Coverage (continued) Mail Order Before the total yearly drug costs (paid by both you and your plan) reach $2400, you pay the following for prescription drugs: - $5 for a one-month (30 day) supply of Formulary Generic - $30 for a one-month (30 day) supply of Formulary Brand - 50% coinsurance for a onemonth (30 day) supply of Nonpreferred Brand/Generic - 30% coinsurance for a onemonth (30 day) supply of Specialty Injectables - $10 for a three-month (90 day) supply of Formulary Generic - $60 for a three-month (90 day) supply of Formulary Brand - 33% coinsurance for a threemonth (90 day) supply of Non- Preferred Brand/Generic - 20% coinsurance for a threemonth (90 day) supply of Specialty Injectables Mail Order Before the total yearly drug costs (paid by both you and your plan) reach $2400, you pay the following for prescription drugs: - $5 for a one-month (30 day) supply of Formulary Generic - $30 for a one-month (30 day) supply of Formulary Brand - 50% coinsurance for a onemonth (30 day) supply of Nonpreferred Brand/Generic - 30% coinsurance for a onemonth (30 day) supply of Specialty Injectables - $10 for a three-month (90 day) supply of Formulary Generic - $60 for a three-month (90 day) supply of Formulary Brand - 33% coinsurance for a threemonth (90 day) supply of Non- Preferred Brand/Generic - 20% coinsurance for a threemonth (90 day) supply of Specialty Injectables

23 Original 28. Prescription Drugs - Coverage After You Reach Your Initial Coverage Limit After the total yearly drug costs (paid by both you and your plan) reach $2400, you pay 100% of your prescription drug costs until your yearly out-of-pocket drug costs reach $3850. You pay the following: In-Network Retail Pharmacy - $5 for a one-month (30 day) supply of Formulary Generic - $10 for a three-month (90 day) supply of Formulary Generic Mail Order - $5 for a one-month (30 day) supply of Formulary Generic - $10 for a three-month (90 day) supply of Formulary Generic For all other covered drugs and after the total yearly drug costs (paid by both you and your plan) reach $2400, you pay 100% of your prescription drug costs until your yearly out-of-pocket drug costs reach $

24 24 Original 28. Prescription Drugs - Catastrophic Coverage After your yearly out-of-pocket drug costs reach $3850, you pay the greater of: - $2.15 for generic (including brand drugs treated as generic) - $5.35 for all other drugs, or - 5% coinsurance. After your yearly out-of-pocket drug costs reach $3850, you pay the greater of: - $2.15 for generic (including brand drugs treated as generic) - $5.35 for all other drugs, or - 5% coinsurance. 28. Prescription Drugs - General Information In some cases, the plan requires you to first try one drug to treat your medical condition before they will cover another drug for that condition. Certain prescription drugs will have maximum quantity limits. Your provider must get prior authorization from Traditional Blue for certain prescription In some cases, the plan requires you to first try one drug to treat your medical condition before they will cover another drug for that condition. Certain prescription drugs will have maximum quantity limits. Your provider must get prior authorization from Traditional Blue for certain prescription

25 Original 28. Prescription Drugs - General Information (continued) Covered Part D drugs are available at out-of-network pharmacies in special circumstances including illness while traveling outside of the plan s service area where there is no network pharmacy. You may also incur an additional cost for drugs received at an out-ofnetwork pharmacy. Please contact the plan for details. Covered Part D drugs are available at out-of-network pharmacies in special circumstances including illness while traveling outside of the plan s service area where there is no network pharmacy. You may also incur an additional cost for drugs received at an out-ofnetwork pharmacy. Please contact the plan for details. ADDITIONAL BENEFITS (WHAT ORIGINAL MEDICARE DOES NOT COVER) 29. Dental Services In general, you pay 100% for preventive dental In general, you pay 100% for preventive dental the following: the following: - oral exams - oral exams - cleanings - cleanings - fluoride treatments - fluoride treatments - dental X-rays - dental X-rays Additional comprehensive dental benefits are available. Contact plan for details. Additional comprehensive dental benefits are available. Contact plan for details. You are covered up to $65 for in-network and out-of-network non- dental services every year. You are covered up to $65 for in-network and out-of-network non- dental services every year. 25

26 26 Original 30. Hearing Services You pay 100% for routine hearing exams and hearing aids. You pay 20% of approved amounts for diagnostic hearing exams. (1)(2) In general, you pay 100% for routine hearing exams and hearing aids. You pay: - $20 for each -covered hearing exam (diagnostic hearing exams). In general, you pay 100% for routine hearing exams and hearing aids. You pay: - $15 for each -covered hearing exam (diagnostic hearing exams). In general, you pay 100% for routine hearing exams and hearing aids. You pay: - $5 for each -covered hearing exam (diagnostic hearing exams). You pay $25 for out-of-network hearing exams. You pay $20 for out-of-network hearing exams. You pay $10 for out-of-network hearing exams. 31. Vision Services You are covered for one pair of eyeglasses or contact lenses after each cataract surgery. (1)(2) For people with who are at risk, you are covered for annual glaucoma screenings. (1)(2) the following items: - -covered eye wear (one pair of eyeglasses or contact lenses after each cataract surgery). the following items: - -covered eye wear (one pair of eyeglasses or contact lenses after each cataract surgery). the following items: - -covered eye wear (one pair of eyeglasses or contact lenses after each cataract surgery). You pay 100% for routine eye exams and glasses. - Glasses - Contacts - Glasses - Contacts - Lenses - Lenses - Frames - Frames (1) Each year, you pay a total of one $131 deductible. (2) If a doctor or supplier chooses not to accept assignment, their costs are often higher, which means you may pay more.

27 Original 31. Vision Services (continued) You pay: - $20 for each -covered eye exam (diagnosis and treatment for diseases and conditions of the eye). - $20 for each routine eye exam, limited to 1 exam every year. You pay $25 for out-of-network eye exams. You pay: - $15 for each -covered eye exam (diagnosis and treatment for diseases and conditions of the eye). - $15 for each routine eye exam, limited to 1 exam every year. You pay $20 for out-of-network eye exams. You are covered up to $75 for eye wear every year. You pay: - $5 for each -covered eye exam (diagnosis and treatment for diseases and conditions of the eye). - $5 for each routine eye exam, limited to 1 exam every year. You pay $10 for out-of-network eye exams. You are covered up to $75 for eye wear every year. 32. Physical Exams If your coverage to Part B begins on or after January 1, 2005, you may receive a one-time physical exam within the first six months of your new Part B coverage. This will not include laboratory tests. Please contact your plan for further details. You pay 20% of the approved amount. (1)(2) If your coverage to Part B begins on or after January 1, 2005, you may receive a one-time physical exam within the first six months of your new Part B coverage. This will not include laboratory tests. Please contact your plan for further details. If your coverage to Part B begins on or after January 1, 2005, you may receive a one-time physical exam within the first six months of your new Part B coverage. This will not include laboratory tests. Please contact your plan for further details. If your coverage to Part B begins on or after January 1, 2005, you may receive a one-time physical exam within the first six months of your new Part B coverage. This will not include laboratory tests. Please contact your plan for further details. (1) Each year, you pay a total of one $131 deductible. (2) If a doctor or supplier chooses not to accept assignment, their costs are often higher, which means you may pay more. 27

28 28 Original 32. Physical Exams (continued) You pay $10 for covered You pay $10 for covered You pay $5 for covered You pay $15 for each out-ofnetwork routine physical exam. You pay $15 for each out-ofnetwork routine physical exam. You pay $10 for each out-ofnetwork routine physical exam. You pay $10 for each exam. You pay $10 for each exam. You pay $5 for each exam. You are covered up to 1 exam every year. You are covered up to 1 exam every year. You are covered up to 1 exam every year. 33. Health/Wellness Education You pay 100%. You are covered for the following: You are covered for the following: You are covered for the following: - Written health education materials, including Newsletter - Written health education materials, including Newsletter - Written health education materials, including Newsletter - Nutritional Training - Nutritional Training - Nutritional Training - Smoking Cessation - Smoking Cessation - Smoking Cessation - Health Club Membership/ Fitness Classes - Health Club Membership/ Fitness Classes - Health Club Membership/ Fitness Classes - Nursing Hotline - Nursing Hotline - Nursing Hotline 34. Transportation (Routine) You pay 100%. each round trip to Plan-approved location. each round trip to Plan-approved location. There is no copayment each round trip to Plan-approved location. You pay $25 for out-of-network transportation You pay $20 for out-of-network transportation You pay $10 for out-of-network transportation

29 It s All About Choice! Affordable and Simple If your healthcare plan is confusing, we may have something for you. PPO is an option for your health care a plan that combines simplicity and affordability with the freedom to make choices. PPO offers you the best of both worlds more control over your health care and more control over the cost of that care. No longer will you be confused about what you will pay when you go to the doctor. For those of you with Medigap and/or supplemental coverage, you can now determine how much you can expect to pay as a member of this plan. For those of you who are tired of the restrictions HMO plans place on you, you now have a plan that gives you the freedom you deserve. PPO stands for Preferred Provider Organization, a health insurance plan that allows you the freedom to choose any doctor, whether they are down the street or across the country, without a referral! You may lower your out-of-pocket expenses if you choose a provider that is in the PPO network, but the choice is still yours. What Should You Expect To Pay? In-Network: When you use a doctor/provider who is in our network, you simply present your ID card at each visit and pay the appropriate copay, if any. For example, $0 for most preventative services (i.e. immunizations/flu shots, colorectal screenings, mammograms, prostate cancer screenings) $50 for any service from an outpatient facility or freestanding facility ($35 for ) $250 for any service from an inpatient hospital, skilled nursing facility ($100 from Traditional Blue ) Out-of-Network: If you decide to see a doctor who is not in our network, here is what you can expect to pay: $75 for the cost of services from an outpatient facility or freestanding facility ($50 from ) 20% for any service from an inpatient hospital, skilled nursing facility There is a $3000 maximum out-of-pocket limit every year for all plan services when received innetwork and out-of-network. How Will I Be Billed? In-Network: If you see a provider in the PPO network, simply present your PPO ID card and pay the applicable copay at the time you receive Out-of-Network: If you see a doctor who is not in our network, they may bill us directly. Your doctor can find our billing address on the back of your ID card. You may not have to pay anything at the doctor s office. If your doctor bills us, we will pay our share of that claim. Your doctor will then receive a statement from us along with a check for our share of the bill. Traditional Blue PPO will send you an Explanation of Benefits that will detail what was billed, 29