Medicare Advantage plans

Transcription

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

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

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

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

5 Eligibility requirements for enrolling in a plan First things first: who is eligible To be eligible for a Blue Medicare HMO or Blue Medicare PPO plan, you must: + Be entitled to Medicare Part A and enrolled in Medicare Part B + Live in the plan s service area (see map and chart of counties) Due to Federal regulations, you may not be eligible to join a Blue Medicare HMO or Blue Medicare PPO plan if you are medically determined to have end-stage renal disease (ESRD) unless you meet exception qualifications. Please call for more information. Part D late enrollment penalties Everyone with Medicare is eligible for Part D coverage, but it s not mandatory. Part D coverage is a voluntary program that you may choose to purchase annually. However, if you do not enroll when you first become eligible, you may have to pay more for prescription drug coverage if you decide to enroll later. You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for extra help, call: MEDICARE ( ). TTY users should call , 24 hours a day/7 days a week; + The Social Security Office at between 7 a.m. and 7 p.m., Mon. through Fri. TTY users should call, ; or + Your State Medicaid Office Enrollment periods Initial coverage enrollment period begins three months immediately before you become eligible for both Medicare Part A and Part B and ends on the later of either: + The last day of the month preceding your eligibility to both Part A and Part B, or + The last day of your Part B initial enrollment period. Annual enrollment period October 15 through December 7 of every year. Annual disenrollment period January 1 through February 14 of every year. Special enrollment period If you didn t sign up for Medicare coverage under Part A, Part B or Part D when you were first eligible, you may be eligible to sign up without waiting for an open enrollment period. Additionally, you may be able to sign up without paying a penalty (higher premium). Call the BCBSNC Sales Department at , 7 days a week, 8 a.m. 8 p.m. For the hearing and speech impaired (TTY/TDD), call: PAGE 5 of 120

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

24 Section 1 Introduction to Summary of Benefits (continued) continue only in certain areas. Also, Medicare may decide to end a contract with a plan. Even if your Medicare Advantage Plan leaves the program, you will not lose Medicare coverage. If a plan decides not to continue for an additional calendar year, it must send you a letter at least 90 days before your coverage will end. The letter will explain your options for Medicare coverage in your area. As a member of Blue Medicare HMO plans, you have the right to request an organization determination, which includes the right to file an appeal if we deny coverage for an item or service, and the right to file a grievance. You have the right to request an organization determination if you want us to provide or pay for an item or service that you believe should be covered. If we deny coverage for your requested item or service, you have the right to appeal and ask us to review our decision. You may ask us for an expedited (fast) coverage determination or appeal if you believe that waiting for a decision could seriously put your life or health at risk, or affect your ability to regain maximum function. If your doctor makes or supports the expedited request, we must expedite our decision. Finally, you have the right to file a grievance with us if you have any type of problem with us or one of our network providers that does not involve coverage for an item or service. If your problem involves quality of care, you also have the right to file a grievance with the Quality Improvement Organization (QIO) for your state. Please refer to the Evidence of Coverage (EOC) for the QIO contact information. As a member of Blue Medicare HMO plans, 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 PAG E 24 of 120 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 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. If your problem involves quality of care, you also have the right to file a grievance with the Quality Improvement Organization (QIO) for your state. Please refer to the Evidence of Coverage (EOC) for the QIO contact information. What is a Medication Therapy Management (MTM) program? A Medication Therapy Management (MTM) Program is a free service we 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 Blue Medicare HMO for more details. What types of drugs may be covered under Medicare Part B? Some outpatient prescription drugs may be covered under Medicare Part B. These may include, but are not limited to, the following types of drugs. Contact Blue Medicare HMO 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 osteoporosis drugs for some women. Erythropoietin: 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.

25 Injectable Drugs: Most injectable drugs administered incident to a physician s service. Immunosuppressive Drugs: Immunosuppressive drug therapy for transplant patients if the transplant took place in a Medicare-certified facility and was paid for by Medicare or by a private insurance company that was the primary payer for Medicare Part A coverage. 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 administered through Durable Medical Equipment. Where can I find information on plan ratings? The Medicare program rates how well plans perform in different categories (for example, detecting and preventing illness, ratings from patients and customer service). If you have access to the web, you can find the Plan Ratings information by using the Find health & drug plans web tool on medicare.gov to compare the plan ratings for Medicare plans in your area. You can also call us directly to obtain a copy of the plan ratings for this plan. Our customer service number is listed below. Please call Blue Cross and Blue Shield of North Carolina for more information about Blue Medicare HMO plans. Visit us at or, call us: Customer Service Hours for October 1 February 14: Sunday, Monday, Tuesday, Wednesday, Thursday, Friday, Saturday, 8:00 a.m. 8:00 p.m. Eastern Customer Service Hours for February 15 September 30: Sunday, Monday, Tuesday, Wednesday, Thursday, Friday, Saturday, 8:00 a.m. 8:00 p.m. Eastern Current members should call toll-free (888) for questions related to the Medicare Advantage Program. (TTY/TDD) (888) Prospective members should call toll-free (800) for questions related to the Medicare Advantage Program. (TTY/TDD) (800) Current members should call locally (888) for questions related to the Medicare Advantage Program. (TTY/TDD) (888) Prospective members should call locally (800) for questions related to the Medicare Advantage Program. (TTY/TDD) (800) Current members should call toll-free (888) for questions related to the Medicare Part D Prescription Drug program. (TTY/TDD) (888) Prospective members should call toll-free (800) for questions related to the Medicare Part D Prescription Drug program. (TTY/TDD) (800) Current members should call locally (888) for questions related to the Medicare Part D Prescription Drug program. (TTY/TDD) (888) Prospective members should call locally (800) for questions related to the Medicare Part D Prescription Drug program. (TTY/TDD) (800) For more information about Medicare, please call Medicare at MEDICARE ( ). TTY users should call You can call 24 hours a day, 7 days a week. Or, visit on the web. This document may be available in other formats such as Braille, large print or other alternate formats. This document may be available in a non-english language. For additional information, call customer service at the phone number listed above. If you have any questions about these plans benefits or costs, please contact Blue Cross and Blue Shield of North Carolina for details. PAG E 25 of 120

26 Section 2 Summary of Benefits Benefit Original Medicare IMPORTANT INFORMATION Blue Medicare HMO Medical Only (HMO) (H3449, Plan 012) 1 In 2013, the monthly Part B Premium and Premium was $ and may $0 monthly plan premium in addition to your Other Important Information monthly Medicare Part B premium. change for 2014 and the annual Part B deductible amount was $147 and may change for If a doctor or supplier does not accept assignment, their costs are often higher, which means you pay more. Most people will pay the standard monthly Part B premium. However, some people will pay a higher premium because of their yearly income (over $85,000 for singles, $170,000 for married couples). For more information about Part B premiums based on income, call Medicare at MEDICARE ( ). TTY users should call You may also call Social Security at TTY users should call Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However, some people will pay a higher premium because of their yearly income (over $85,000 for singles, $170,000 for married couples). For more information about Part B premiums based on income, call Medicare at MEDICARE ( ). TTY users should call You may also call Social Security at TTY users should call $2,500 out-of-pocket limit for Medicare-covered services. 2 You may go to any doctor, Doctor and Hospital Choice specialist or hospital that accepts Medicare. (For more information, see Emergency Care - #15 and Urgently Needed Care- #16.) You must go to network doctors, specialists, and hospitals. No referral required for network doctors, specialists, and hospitals. PAG E 26 of 120

27 Blue Medicare HMO Standard (HMO) (H3449, Plan 013) Blue Medicare HMO Enhanced (HMO) (H3449, Plan 005) $0 monthly plan premium in addition to your monthly Medicare Part B premium. Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However, some people will pay higher Part B and Part D premiums because of their yearly income (over $85,000 for singles, $170,000 for married couples). For more information about Part B and Part D premiums based on income, call Medicare at MEDICARE ( ). TTY users should call You may also call Social Security at TTY users should call $3,400 out-of-pocket limit for Medicare-covered services. $18.90 monthly plan premium in addition to your monthly Medicare Part B premium. Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However, some people will pay higher Part B and Part D premiums because of their yearly income (over $85,000 for singles, $170,000 for married couples). For more information about Part B and Part D premiums based on income, call Medicare at MEDICARE ( ).TTY users should call You may also call Social Security at TTY users should call $3,400 out-of-pocket limit for Medicare-covered services. You must go to network doctors, specialists, and hospitals. No referral required for network doctors, specialists, and hospitals. You must go to network doctors, specialists, and hospitals. No referral required for network doctors, specialists, and hospitals. PAGE 27 of 120

28 Section 2 Summary of Benefits (continued) Benefit Original Medicare Call MEDICARE ( ) for information about lifetime reserve days. Lifetime reserve days can only be used once. A benefit period starts the day you go into a hospital or skilled nursing facility. It ends when you go for 60 days in a row without hospital or skilled nursing care. 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. Blue Medicare HMO Medical Only (HMO) (H3449, Plan 012) SUMMARY OF BENEFITS - INPATIENT CARE 3 In 2013 the amounts for each Inpatient Hospital benefit period were: No limit to the number of days covered by the Care (includes Days 1-60: $1,184 deductible plan each hospital stay. Substance Abuse Days 61-90: $296 per day For Medicare-covered hospital stays: and Rehabilitation Days : $592 per lifetime Services) Days 1-7: $100 copay per day reserve day. These amounts may change Days 8-90: $0 copay per day for $0 copay for each additional non-medicarecovered hospital day. Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital. 4 In 2013 the amounts for each Inpatient Mental benefit period were: You get up to 190 days of inpatient psychiatric Health Care Days 1-60: $1,184 deductible hospital care in a lifetime. Inpatient psychiatric hospital services count toward the 190-day Days 61-90: $296 per day lifetime limitation only if certain conditions are Days : $592 per lifetime met. This limitation does not apply to inpatient reserve day. These amounts psychiatric services furnished in a general may change for hospital. You get up to 190 days of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital. For Medicare-covered hospital stays: Days 1-7: $100 copay per day Days 8-90: $0 copay per day Plan covers 60 lifetime reserve days. Cost per lifetime reserve day: Days 1-60: $0 copay per day Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital. PAGE 28 of 120

29 Blue Medicare HMO Standard (HMO) (H3449, Plan 013) Blue Medicare HMO Enhanced (HMO) (H3449, Plan 005) No limit to the number of days covered by the plan each hospital stay. For Medicare-covered hospital stays: Days 1-7: $220 copay per day Days 8-90: $0 copay per day $0 copay for each additional non-medicare-covered hospital day. Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital. No limit to the number of days covered by the plan each hospital stay. For Medicare-covered hospital stays: Days 1-7: $170 copay per day Days 8-90: $0 copay per day $0 copay for each additional non-medicare-covered hospital day. Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital. You get up to 190 days of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital. For Medicare-covered hospital stays: Days 1-7: $220 copay per day Days 8-90: $0 copay per day Plan covers 60 lifetime reserve days. Cost per lifetime reserve day: Days 1-60: $0 copay per day Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital. You get up to 190 days of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital. For Medicare-covered hospital stays: Days 1-7: $170 copay per day Days 8-90: $0 copay per day Plan covers 60 lifetime reserve days. Cost per lifetime reserve day: Days 1-60: $0 copay per day Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital. PAGE 29 of 120

30 Section 2 Summary of Benefits (continued) Benefit 5 Skilled Nursing Facility (SNF) (in a Medicarecertified skilled nursing facility) Original Medicare In 2013 the amounts for each benefit period after at least a 3-day Medicare-covered hospital stay were: Days 1-20: $0 per day Days : $148 per day These amounts may change for days for each benefit period. A benefit period starts the day you go into a hospital or SNF. It ends when you go for 60 days in a row without hospital or skilled nursing care. 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. Blue Medicare HMO Medical Only (HMO) (H3449, Plan 012) Authorization rules may apply. Plan covers up to 100 days each benefit period No prior hospital stay is required. For Medicare-covered SNF stays: Days 1-10: $0 copay per day Days : $50 copay per day 6 Home Health Care (includes medically necessary intermittent skilled nursing care, home health aide services, and rehabilitation services, etc.) $0 copay. Authorization rules may apply. 0% of the cost for each Medicare-covered home health visit. 7 Hospice You pay part of the cost for outpatient drugs and inpatient respite care. You must get care from a Medicare-certified hospice. You must get care from a Medicare-certified hospice. You must consult with your plan before you select hospice. PAGE 30 of 120

31 Blue Medicare HMO Standard (HMO) (H3449, Plan 013) Authorization rules may apply. Plan covers up to 100 days each benefit period No prior hospital stay is required. For Medicare-covered SNF stays: Days 1-10: $0 copay per day Days : $50 copay per day Blue Medicare HMO Enhanced (HMO) (H3449, Plan 005) Authorization rules may apply. Plan covers up to 100 days each benefit period No prior hospital stay is required. For Medicare-covered SNF stays: Days 1-10: $0 copay per day Days : $50 copay per day Authorization rules may apply. 0% of the cost for each Medicare-covered home health visit. Authorization rules may apply. 0% of the cost for each Medicare-covered home health visit. You must get care from a Medicare-certified hospice. You must consult with your plan before you select hospice. You must get care from a Medicare-certified hospice. You must consult with your plan before you select hospice. PAGE 31 of 120

32 Section 2 Summary of Benefits (continued) Benefit Original Medicare Blue Medicare HMO Medical Only (HMO) (H3449, Plan 012) OUTPATIENT CARE 8 20% coinsurance Doctor Office Visits $5 copay for each Medicare-covered primary care doctor visit. $20 copay for each Medicare-covered specialist visit. 9 Supplemental routine care not Chiropractic Services covered. 20% coinsurance for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part). $5 copay for each Medicare-covered chiropractic visit. Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part). 10 Supplemental routine care not Podiatry Services covered. 20% coinsurance for $20 copay for each Medicare-covered medically necessary foot care, podiatry visit. including care for medical conditions affecting the lower limbs. Medicare-covered podiatry visits are for medically-necessary foot care % coinsurance for most Outpatient Mental outpatient mental health services. Authorization rules may apply. Health Care Specified copayment for outpatient partial hospitalization $20 copay for each Medicare-covered individual program services furnished by a hospital or community therapy visit. mental health center (CMHC). $20 copay for each Medicare-covered group Copay cannot exceed the Part therapy visit A inpatient hospital deductible. Partial hospitalization program" is a structured program of active $20 copay for each Medicare-covered individual therapy visit with a psychiatrist. outpatient psychiatric treatment $20 copay for each Medicare-covered group that is more intense than the care received in your doctor s therapy visit with a psychiatrist or therapist s office and is an alternative to inpatient hospitalization. $20 copay for Medicare-covered partial hospitalization program services PAGE 32 of 120

33 Blue Medicare HMO Standard (HMO) (H3449, Plan 013) Blue Medicare HMO Enhanced (HMO) (H3449, Plan 005) $15 copay for each Medicare-covered primary care doctor visit. $40 copay for each Medicare-covered specialist visit. $10 copay for each Medicare-covered primary care doctor visit. $35 copay for each Medicare-covered specialist visit. $15 copay for each Medicare-covered chiropractic visit. Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part). $40 copay for each Medicare-covered podiatry visit. Medicare-covered podiatry visits are for medically-necessary foot care. Authorization rules may apply. $40 copay for each Medicare-covered individual therapy visit. $40 copay for each Medicare-covered group therapy visit $40 copay for each Medicare-covered individual therapy visit with a psychiatrist. $40 copay for each Medicare-covered group therapy visit with a psychiatrist $40 copay for Medicare-covered partial hospitalization program services $10 copay for each Medicare-covered chiropractic visit. Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part). $35 copay for each Medicare-covered podiatry visit. Medicare-covered podiatry visits are for medically-necessary foot care. Authorization rules may apply. $35 copay for each Medicare-covered individual therapy visit. $35 copay for each Medicare-covered group therapy visit $35 copay for each Medicare-covered individual therapy visit with a psychiatrist. $35 copay for each Medicare-covered group therapy visit with a psychiatrist $35 copay for Medicare-covered partial hospitalization program services PAG E 33 of 120

34 Section 2 Summary of Benefits (continued) Benefit 12 Outpatient Substance Abuse Care 13 Outpatient Services 14 Ambulance Services (medically necessary ambulance services) 15 Emergency Care (You may go to any emergency room if you reasonably believe you need emergency care.) Original Medicare 20% coinsurance 20% coinsurance for the doctor's services. Specified copayment for outpatient hospital facility services. Copay cannot exceed the Part A inpatient hospital deductible. 20% coinsurance for ambulatory surgical center facility services. 20% coinsurance 20% coinsurance for the doctor's services. Specified copayment for outpatient hospital facility emergency services. Emergency services copay cannot exceed Part A inpatient hospital deductible for each service provided by the hospital. You don t have to pay the emergency room copay if you are admitted to the hospital as an inpatient for the same condition within 3 days of the emergency room visit. NOT covered outside the U.S. except under limited circumstances. Blue Medicare HMO Medical Only (HMO) (H3449, Plan 012) Authorization rules may apply. $20 copay for Medicare-covered individual substance abuse outpatient treatment visits. $20 copay for Medicare-covered group substance abuse outpatient treatment visits. Authorization rules may apply. $0 copay for each Medicare-covered ambulatory surgical center visit. $0 copay for each Medicare-covered outpatient hospital facility visit. Authorization rules may apply. $100 copay for Medicare-covered ambulance benefits. $50 copay for Medicare-covered emergency room visits. Worldwide coverage. If you are admitted to the hospital within 48-hour(s) for the same condition, you pay $0 for the emergency room visit. 16 Urgently Needed Care (This is NOT emergency care, and in most cases, is out of the service area.) 20% coinsurance, or a set copay. If you are admitted to the hospital within 3 days for the same condition, you pay $0 for the urgently-needed-care visit. NOT covered outside the U.S. except under limited circumstances. $20 copay for Medicare-covered urgently-needed care visits. PAG E 34 of 120

35 Blue Medicare HMO Standard (HMO) (H3449, Plan 013) Authorization rules may apply. $40 copay for Medicare-covered individual substance abuse outpatient treatment visits. $40 copay for Medicare-covered group substance abuse outpatient treatment visits. Authorization rules may apply. $195 copay for each Medicare-covered ambulatory surgical center visit. $195 copay for each Medicare-covered outpatient hospital facility visit. Authorization rules may apply. $100 copay for Medicare-covered ambulance benefits. $50 copay for Medicare-covered emergency room visits. Worldwide coverage. If you are admitted to the hospital within 48-hour(s) for the same condition, you pay $0 for the emergency room visit. Blue Medicare HMO Enhanced (HMO) (H3449, Plan 005) Authorization rules may apply. $35 copay for Medicare-covered individual substance abuse outpatient treatment visits. $35 copay for Medicare-covered group substance abuse outpatient treatment visits. Authorization rules may apply. $125 copay for each Medicare-covered ambulatory surgical center visit. $125 copay for each Medicare-covered outpatient hospital facility visit. Authorization rules may apply. $100 copay for Medicare-covered ambulance benefits. $50 copay for Medicare-covered emergency room visits. Worldwide coverage. If you are admitted to the hospital within 48-hour(s) for the same condition, you pay $0 for the emergency room visit. $40 copay for Medicare-covered urgently-needed care visits. $35 copay for Medicare-covered urgently-needed care visits. PAG E 35 of 12 0

36 Section 2 Summary of Benefits (continued) Benefit 17 Outpatient Rehabilitation Services (Occupational Therapy, Physical Therapy, Speech and Language Therapy) Original Medicare Blue Medicare HMO Medical Only (HMO) (H3449, Plan 012) 20% coinsurance Medically necessary physical Authorization rules may apply. therapy, occupational therapy, Medically necessary physical therapy, and speech and language occupational therapy, and speech and language pathology services are covered. pathology services are covered. $20 copay for Medicare-covered Occupational Therapy visits. $20 copay for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits. OUTPATIENT MEDICAL SERVICES AND SUPPLIES 18 20% coinsurance Durable Medical Equipment (includes wheelchairs, oxygen, etc.) Authorization rules may apply. 20% of the cost for Medicare-covered durable medical equipment. 19 Prosthetic Devices (includes braces, artificial limbs and eyes, etc.) 20% coinsurance 20% coinsurance for Medicarecovered medical supplies related to prosthetics, splints, and other devices. Authorization rules may apply. 20% of the cost for Medicare-covered prosthetic devices. 20% of the cost for Medicare-covered medical supplies related to prosthetics, splints, and other devices. 20 Diabetes Programs and Supplies 20% coinsurance for diabetes self-management training 20% coinsurance for diabetes supplies 20% coinsurance for diabetic therapeutic shoes or inserts 0% of the cost for Medicare-covered Diabetes self-management training. 0% of the cost for Medicare-covered Diabetes monitoring supplies. 20% of the cost for Medicare-covered Therapeutic shoes or inserts. PAGE 36 of 120

37 Blue Medicare HMO Standard (HMO) (H3449, Plan 013) Authorization rules may apply. Medically necessary physical therapy, occupational therapy, and speech and language pathology services are covered. $40 copay for Medicare-covered Occupational Therapy visits. $40 copay for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits. Blue Medicare HMO Enhanced (HMO) (H3449, Plan 005) Authorization rules may apply. Medically necessary physical therapy, occupational therapy, and speech and language pathology services are covered. $35 copay for Medicare-covered Occupational Therapy visits. $35 copay for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits. Authorization rules may apply. 20% of the cost for Medicare-covered durable medical equipment. Authorization rules may apply. 20% of the cost for Medicare-covered durable medical equipment. Authorization rules may apply. 20% of the cost for Medicare-covered prosthetic devices. 20% of the cost for Medicare-covered medical supplies related to prosthetics, splints, and other devices. Authorization rules may apply. 20% of the cost for Medicare-covered prosthetic devices. 20% of the cost for Medicare-covered medical supplies related to prosthetics, splints, and other devices. 0% of the cost for Medicare-covered Diabetes self-management training. 0% of the cost for Medicare-covered Diabetes monitoring supplies. 20% of the cost for Medicare-covered Therapeutic shoes or inserts. 0% of the cost for Medicare-covered Diabetes self-management training. 0% of the cost for Medicare-covered Diabetes monitoring supplies. 20% of the cost of Medicare-covered Therapeutic shoes or inserts. PAGE 37 of 120

38 Section 2 Summary of Benefits (continued) Benefit 21 Diagnostic Tests, X-Rays, Lab Services, and Radiology Services 22 Cardiac and Pulmonary Rehabilitation Services Original Medicare 20% coinsurance for diagnostic tests and X-rays. $0 copay for Medicare-covered lab services. Lab Services: Medicare covers medically necessary diagnostic lab services that are ordered by your treating doctor when they are provided by a Clinical Laboratory Improvement Amendments (CLIA) certified laboratory that participates in Medicare. Diagnostic lab services are done to help your doctor diagnose or rule out a suspected illness or condition. Medicare does not cover most supplemental routine screening tests, like checking your cholesterol. 20% coinsurance for Cardiac Rehabilitation services 20% coinsurance for Pulmonary Rehabilitation services 20% coinsurance for Intensive Cardiac Rehabilitation services Blue Medicare HMO Medical Only (HMO) (H3449, Plan 012) Authorization rules may apply. 5% of the cost for Medicare-covered lab services. 5% of the cost for Medicare-covered diagnostic procedures and tests. 5% of the cost for Medicare-covered X-rays. 5% of the cost for Medicare-covered diagnostic radiology services (not including X-rays). 0% of the cost for Medicare-covered therapeutic radiology services. If the doctor provides you services in addition to Outpatient Diagnostic Procedures, Tests and Lab Services, separate cost sharing of $5 to $20 may apply. If the doctor provides you services in addition to Outpatient Diagnostic and Therapeutic Radiology Services, separate cost sharing of $5 to $20 may apply. Authorization rules may apply 0% of the cost for Medicare-covered Cardiac Rehabilitation Services 0% of the cost for Medicare-covered Intensive Cardiac Rehabilitation Services 0% of the cost for Medicare-covered Pulmonary Rehabilitation Services PAG E 38 of 120

39 Blue Medicare HMO Standard (HMO) (H3449, Plan 013) Authorization rules may apply. 20% of the cost for Medicare-covered lab services. 20% of the cost for Medicare-covered diagnostic procedures and tests. 20% of the cost for Medicare-covered X-rays. 20% of the cost for Medicare-covered diagnostic radiology services (not including X-rays). 0% of the cost for Medicare-covered therapeutic radiology services. If the doctor provides you services in addition to Outpatient Diagnostic Procedures, Tests and Lab Services, separate cost sharing of $15 to $40 may apply. If the doctor provides you services in addition to Outpatient Diagnostic and Therapeutic Radiology Services, separate cost sharing of $15 to $40 may apply. Authorization rules may apply 0% of the cost for Medicare-covered Cardiac Rehabilitation Services 0% of the cost for Medicare-covered Intensive Cardiac Rehabilitation Services 0% of the cost for Medicare-covered Pulmonary Rehabilitation Services Blue Medicare HMO Enhanced (HMO) (H3449, Plan 005) Authorization rules may apply. 15% of the cost for Medicare-covered lab services. 15% of the cost for Medicare-covered diagnostic procedures and tests. 15% of the cost for Medicare-covered X-rays. 15% of the cost for Medicare-covered diagnostic radiology services (not including X-rays). 0% of the cost for Medicare-covered therapeutic radiology services. If the doctor provides you services in addition to Outpatient Diagnostic Procedures, Tests and Lab Services, separate cost sharing of $10 to $35 may apply. If the doctor provides you services in addition to Outpatient Diagnostic and Therapeutic Radiology Services, separate cost sharing of $10 to $35 may apply. Authorization rules may apply 0% of the cost for Medicare-covered Cardiac Rehabilitation Services 0% of the cost for Medicare-covered Intensive Cardiac Rehabilitation Services 0% of the cost for Medicare-covered Pulmonary Rehabilitation Services PAGE 39 of 120

40 Section 2 Summary of Benefits (continued) Benefit Original Medicare PREVENTIVE SERVICES 23 No coinsurance, copayment or Preventive Services deductible for the following: Abdominal Aortic Aneurysm Screening Bone Mass Measurement. Covered once every 24 months (more often if medically necessary) if you meet certain medical conditions. Cardiovascular Screening Cervical and Vaginal Cancer Screening. Covered once every 2 years. Covered once a year for women with Medicare at high risk. Colorectal Cancer Screening Diabetes Screening Influenza Vaccine Hepatitis B Vaccine for people with Medicare who are at risk HIV Screening. $0 copay for the HIV screening, but you generally pay 20% of the Medicare-approved amount for the doctor s visit. HIV screening is covered for people with Medicare who are pregnant and people at increased risk for the infection, including anyone who asks for the test. Medicare covers this test once every 12 months or up to three times during a pregnancy. Breast Cancer Screening (Mammogram). Medicare covers screening mammograms once every 12 months for all women with Medicare age 40 and older. Medicare covers one baseline mammogram for women between ages Blue Medicare HMO Medical Only (HMO) (H3449, Plan 012) $0 copay for all preventive services covered under Original Medicare at zero cost sharing. Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare. 0% of the cost for a supplemental annual physical exam (continued) PAGE 40 of 120

41 Blue Medicare HMO Standard (HMO) (H3449, Plan 013) Blue Medicare HMO Enhanced (HMO) (H3449, Plan 005) $0 copay for all preventive services covered under Original Medicare at zero cost sharing. Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare. 0% of the cost for a supplemental annual physical exam $0 copay for all preventive services covered under Original Medicare at zero cost sharing. Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare. 0% of the cost for a supplemental annual physical exam PAGE 41 of 120

42 Section 2 Summary of Benefits (continued) Benefit 23 Preventive Services (Continued) 24 Kidney Disease and Conditions Original Medicare Medical Nutrition Therapy Services. Nutrition therapy is for people who have diabetes or kidney disease (but aren t on dialysis or haven t had a kidney transplant) when referred by a doctor. These services can be given by a registered dietitian and may include a nutritional assessment and counseling to help you manage your diabetes or kidney disease. Personalized Prevention Plan Services (Annual Wellness Visits). Pneumococcal Vaccine. You may only need the Pneumonia vaccine once in your lifetime. Call your doctor for more information. Prostate Cancer Screening. Prostate Specific Antigen (PSA) test only. Covered once a year for all men with Medicare over age 50. Smoking and Tobacco Use Cessation (counseling to stop smoking and tobacco use). Covered if ordered by your doctor. Includes two counseling attempts within a 12-month period. Each counseling attempt includes up to four face-to-face visits. Screening and behavioral counseling interventions in primary care to reduce alcohol misuse Screening for depression in adults Screening for sexually transmitted infections (STI) and high-intensity behavioral counseling to prevent STIs Intensive behavioral counseling for Cardiovascular Disease (bi-annual) Intensive behavioral therapy for obesity Welcome to Medicare Preventive Visits (initial preventive physical exam). When you join Medicare Part B, then you are eligible as follows. During the first 12 months of your new Part B coverage, you can get either a Welcome to Medicare Preventive Visits or an Annual Wellness Visit. After your first 12 months, you can get one Annual Wellness Visit every 12 months. 20% coinsurance for renal dialysis 20% coinsurance for kidney disease education services Blue Medicare HMO Medical Only (HMO) (H3449, Plan 012) 0% of the cost for Medicarecovered renal dialysis 0% of the cost for Medicarecovered kidney disease education services PAGE 42 of 120

43 Blue Medicare HMO Standard (HMO) (H3449, Plan 013) Blue Medicare HMO Enhanced (HMO) (H3449, Plan 005) 0% of the cost for Medicare- covered renal dialysis 0% of the cost for Medicare-covered kidney disease education services 0% of the cost for Medicare- covered renal dialysis 0% of the cost for Medicare- covered kidney disease education services PAGE 43 of 120

44 Section 2 Summary of Benefits (continued) Benefit 25 Outpatient Prescription Drugs Original Medicare PRESCRIPTION DRUG BENEFITS Most drugs are not covered under Original Medicare. You can add prescription drug coverage to Original Medicare by joining a Medicare Prescription Drug Plan, or you can get all your Medicare coverage, including prescription drug coverage, by joining a Medicare Advantage Plan or a Medicare Cost Plan that offers prescription drug coverage. Blue Medicare HMO Medical Only (HMO) (H3449, Plan 012) Drugs covered under Medicare Part B Most drugs not covered. 20%of the cost for Medicare Part B chemotherapy drugs and other Part B drugs. Drugs covered under Medicare Part D This plan does not offer prescription drug coverage. PAGE 44 of 120

45 Blue Medicare HMO Standard (HMO) (H3449, Plan 013) Blue Medicare HMO Enhanced (HMO) (H3449, Plan 005) Drugs covered under Medicare Part B 20% of the cost for Medicare Part B chemotherapy drugs and other Part B drugs. Drugs covered under Medicare Part D This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at formulary-home.htm on the web. Different out-of-pocket costs may apply for people who: have limited incomes, live in long term care facilities, or have access to Indian/Tribal/Urban (Indian Health Service) providers. The plan offers national in-network prescription coverage (i.e., this would include 50 states and the District of Columbia). This means that you will pay the same cost-sharing amount for your prescription drugs if you get them at an in-network pharmacy outside of the plan's service area (for instance when you travel). Total yearly drug costs are the total drug costs paid by both you and a Part D plan. The plan may require you to first try one drug to treat your condition before it will cover another drug for that condition. Some drugs have quantity limits. Your provider must get prior authorization from Blue Medicare HMO Standard (HMO) for certain drugs. You must go to certain pharmacies for a very limited number of drugs, due to special handling, provider coordination, or patient education requirements that cannot be met by most pharmacies in your network. These drugs are listed on the plan's website, formulary, printed materials, as well as on the Medicare Prescription Drug Plan Finder on Medicare.gov. If the actual cost of a drug is less than the normal cost-sharing amount for that drug, you will pay the actual cost, not the higher cost-sharing amount. If you request a formulary exception for a drug and Blue Medicare HMO Standard (HMO) approves the exception, you will pay Tier 4: Non-Preferred Brand cost-sharing for that drug. (Continued) Drugs covered under Medicare Part B 20% of the cost for Medicare Part B chemotherapy drugs and other Part B drugs. Drugs covered under Medicare Part D This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at formulary-home.htm on the web. Different out-of-pocket costs may apply for people who: have limited incomes, live in long term care facilities, or have access to Indian/Tribal/Urban (Indian Health Service) providers. The plan offers national in-network prescription coverage (i.e., this would include 50 states and the District of Columbia). This means that you will pay the same cost-sharing amount for your prescription drugs if you get them at an in-network pharmacy outside of the plan's service area (for instance when you travel). Total yearly drug costs are the total drug costs paid by both you and a Part D plan. The plan may require you to first try one drug to treat your condition before it will cover another drug for that condition. Some drugs have quantity limits. Your provider must get prior authorization from Blue Medicare HMO Enhanced (HMO) for certain drugs. You must go to certain pharmacies for a very limited number of drugs, due to special handling, provider coordination, or patient education requirements that cannot be met by most pharmacies in your network. These drugs are listed on the plan's website, formulary, printed materials, as well as on the Medicare Prescription Drug Plan Finder on Medicare.gov. If the actual cost of a drug is less than the normal cost-sharing amount for that drug, you will pay the actual cost, not the higher cost-sharing amount. If you request a formulary exception for a drug and Blue Medicare HMO Enhanced (HMO) approves the exception, you will pay Tier 4: Non-Preferred Brand cost sharing for that drug. (Continued) PAGE 45 of 120

46 Section 2 Summary of Benefits (continued) Benefit 25 Outpatient Prescription Drugs (Continued) Original Medicare PRESCRIPTION DRUG BENEFITS Blue Medicare HMO Medical Only (HMO) (H3449, Plan 012) PAGE 46 of 120

47 Blue Medicare HMO Standard (HMO) (H3449, Plan 013) Blue Medicare HMO Enhanced (HMO) (H3449, Plan 005) $0 deductible. Initial Coverage You pay the following until total yearly drug costs reach $2,850: Retail Pharmacy Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed. You can get drugs from a preferred and non-preferred pharmacy the following way(s): Tier 1: Preferred Generic $3 copay for a one-month (30-day) supply of drugs in this tier from a preferred pharmacy $6 copay for a two-month (60-day) supply of drugs in this tier from a preferred pharmacy $9 copay for a three-month (90-day) supply of drugs in this tier from a preferred pharmacy $8 copay for a one-month (30-day) supply of drugs in this tier from a non-preferred pharmacy $16 copay for a two-month (60-day) supply of drugs in this tier from a non-preferred pharmacy $24 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred pharmacy Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. Tier 2: Non-Preferred Generic $6 copay for a one-month (30-day) supply of drugs in this tier from a preferred pharmacy $12 copay for a two-month (60-day) supply of drugs in this tier from a preferred pharmacy $18 copay for a three-month (90-day) supply of drugs in this tier from a preferred pharmacy $25 copay for a one-month (30-day) supply of drugs in this tier from a non-preferred pharmacy $50 copay for a two-month (60-day) supply of drugs in this tier from a non-preferred pharmacy $75 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred pharmacy Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. (Continued) $0 deductible. Initial Coverage You pay the following until total yearly drug costs reach $2,850: Retail Pharmacy Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed. You can get drugs from a preferred and non-preferred pharmacy the following way(s): Tier 1: Preferred Generic $3 copay for a one-month (30-day) supply of drugs in this tier from a preferred pharmacy $6 copay for a two-month (60-day) supply of drugs in this tier from a preferred pharmacy $9 copay for a three-month (90-day) supply of drugs in this tier from a preferred pharmacy $8 copay for a one-month (30-day) supply of drugs in this tier from a non-preferred pharmacy $16 copay for a two-month (60-day) supply of drugs in this tier from a non-preferred pharmacy $24 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred pharmacy Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. Tier 2: Non-Preferred Generic $6 copay for a one-month (30-day) supply of drugs in this tier from a preferred pharmacy $12 copay for a two-month (60-day) supply of drugs in this tier from a preferred pharmacy $18 copay for a three-month (90-day) supply of drugs in this tier from a preferred pharmacy $20 copay for a one-month (30-day) supply of drugs in this tier from a non-preferred pharmacy $40 copay for a two-month (60-day) supply of drugs in this tier from a non-preferred pharmacy $60 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred pharmacy Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. (Continued) PAGE 47 of 120

48 Section 2 Summary of Benefits (continued) Benefit 25 Outpatient Prescription Drugs (Continued) Original Medicare PRESCRIPTION DRUG BENEFITS Blue Medicare HMO Medical Only (HMO) (H3449, Plan 012) PAGE 48 of 120

49 Blue Medicare HMO Standard (HMO) (H3449, Plan 013) Blue Medicare HMO Enhanced (HMO) (H3449, Plan 005) Tier 3: Preferred Brand $40 copay for a one-month (30-day) supply of drugs in this tier from a preferred pharmacy $80 copay for a two-month (60-day) supply of drugs in this tier from a preferred pharmacy $120 copay for a three-month (90-day) supply of drugs in this tier from a preferred pharmacy $45 copay for a one-month (30-day) supply of drugs in this tier from a non-preferred pharmacy $90 copay for a two-month (60-day) supply of drugs in this tier from a non-preferred pharmacy $135 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred pharmacy Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. Tier 4: Non-Preferred Brand $80 copay for a one-month (30-day) supply of drugs in this tier from a preferred pharmacy $160 copay for a two-month (60-day) supply of drugs in this tier from a preferred pharmacy $240 copay for a three-month (90-day) supply of drugs in this tier from a preferred pharmacy $95 copay for a one-month (30-day) supply of drugs in this tier from a non-preferred pharmacy $190 copay for a two-month (60-day) supply of drugs in this tier from a non-preferred pharmacy $285 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred pharmacy Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. (Continued) Tier 3: Preferred Brand $30 copay for a one-month (30-day) supply of drugs in this tier from a preferred pharmacy $60 copay for a two-month (60-day) supply of drugs in this tier from a preferred pharmacy $90 copay for a three-month (90-day) supply of drugs in this tier from a preferred pharmacy $45 copay for a one-month (30-day) supply of dugs in this tier from a non-preferred pharmacy $90 copay for a two-month (60-day) supply of drugs in this tier from a non-preferred pharmacy $135 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred pharmacy Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. Tier 4: Non-Preferred Brand $70 copay for a one-month (30-day) supply of drugs in this tier from a preferred pharmacy $140 copay for a two-month (60-day) supply of drugs in this tier from a preferred pharmacy $210 copay for a three-month (90-day) supply of drugs in this tier from a preferred pharmacy $95 copay for a one-month (30-day) supply of drugs in this tier from a non-preferred pharmacy $190 copay for a two-month (60-day) supply of drugs in this tier from a non-preferred pharmacy $285 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred pharmacy Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. (Continued) PAGE 49 of 120

50 Section 2 Summary of Benefits (continued) Benefit 25 Outpatient Prescription Drugs (Continued) Original Medicare PRESCRIPTION DRUG BENEFITS Blue Medicare HMO Medical Only (HMO) (H3449, Plan 012) PAGE 50 of 120

51 Blue Medicare HMO Standard (HMO) (H3449, Plan 013) Blue Medicare HMO Enhanced (HMO) (H3449, Plan 005) Tier 5: Specialty Tier 33% coinsurance for a one-month (30-day) preferred pharmacy 33% coinsurance for a two-month (60-day) preferred pharmacy 33% coinsurance for a three-month (90-day) preferred pharmacy 33% coinsurance for a one-month (30-day) non-preferred pharmacy 33% coinsurance for a two-month (60-day) supply of drugs in this tier from a non-preferred pharmacy 33% coinsurance for a three-month (90-day) non-preferred pharmacy Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. Long-Term Care Pharmacy Long-Term care pharmacies must dispense brand name drugs in amounts less than a 14 days supply at a time. They may also dispense less than a month's supply of generic drugs at a time. Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed. You can get drugs the following way(s): Tier 1: Preferred Generic $8 copay for a one-month (31-day) supply of drugs in this tier Tier 2: Non-Preferred Generic $25 copay for a one-month (31-day) supply of drugs in this tier Tier 3: Preferred Brand $45 copay for a one-month (31-day) supply of drugs in this tier Tier 4: Non-Preferred Brand $95 copay for a one-month (31-day) supply of drugs in this tier Tier 5: Specialty Tier 33% coinsurance for a one-month (31-day) supply of drugs in this tier (Continued) Tier 5: Specialty Tier 33% coinsurance for a one-month (30-day) preferred pharmacy 33% coinsurance for a two-month (60-day) preferred pharmacy 33% coinsurance for a three-month (90-day) preferred pharmacy 33% coinsurance for a one-month (30-day) non-preferred pharmacy 33% coinsurance for a two-month (60-day) non-preferred pharmacy 33% coinsurance for a three-month (90-day) non-preferred pharmacy Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. Long-Term Care Pharmacy Long-Term care pharmacies must dispense brand name drugs in amounts less than a 14 days supply at a time. They may also dispense less than a month's supply of generic drugs at a time. Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed. You can get drugs the following way(s): Tier 1: Preferred Generic $8 copay for a one-month (31-day) supply of drugs in this tier Tier 2: Non-Preferred Generic $20 copay for a one-month (31-day) supply of drugs in this tier Tier 3: Preferred Brand $45 copay for a one-month (31-day) supply of drugs in this tier Tier 4: Non-Preferred Brand $95 copay for a one-month (31-day) supply of drugs in this tier Tier 5: Specialty Tier 33% coinsurance for a one-month (31-day) supply of drugs in this tier (Continued) PAGE 51 of 120

52 Section 2 Summary of Benefits (continued) Benefit 25 Outpatient Prescription Drugs (Continued) Original Medicare PRESCRIPTION DRUG BENEFITS Blue Medicare HMO Medical Only (HMO) (H3449, Plan 012) PAGE 52 of 120

53 Blue Medicare HMO Standard (HMO) (H3449, Plan 013) Blue Medicare HMO Enhanced (HMO) (H3449, Plan 005) Mail Order Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed. You can get drugs from a preferred and non-preferred mail order pharmacy the following way(s): Tier 1: Preferred Generic $3 copay for a one-month (30-day) supply of drugs in this tier from a preferred mail order pharmacy. $0 copay for a two-month (60-day) supply of drugs in this tier from a preferred mail order pharmacy. $0 copay for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy. $8 copay for a one-month (30-day) supply of drugs in this tier from a non-preferred mail order pharmacy. $16 copay for a two-month (60-day) supply of drugs in this tier from a non-preferred mail order pharmacy. $24 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred mail order pharmacy. Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. Tier 2: Non-Preferred Generic $6 copay for a one-month (30-day) supply of drugs in this tier from a preferred mail order pharmacy. 12 copay for a two-month (60-day) supply of drugs in this tier from a preferred mail order pharmacy. $15 copay for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy. $25 copay for a one-month (30-day) supply of drugs in this tier from a non-preferred mail order pharmacy. $50 copay for a two-month (60-day) supply of drugs in this tier from a non-preferred mail order pharmacy. $75 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred mail order pharmacy. Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. (Continued) Mail Order Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed. You can get drugs from a preferred and non-preferred mail order pharmacy the following way(s): Tier 1: Preferred Generic $3 copay for a one-month (30-day) supply of drugs in this tier from a preferred mail order pharmacy. $0 copay for a two-month (60-day) supply of drugs in this tier from a preferred mail order pharmacy. $0 copay for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy. $8 copay for a one-month (30-day) supply of drugs in this tier from a non-preferred mail order pharmacy. $16 copay for a two-month (60-day) supply of drugs in this tier from a non-preferred mail order pharmacy. $24 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred mail order pharmacy. Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. Tier 2: Non-Preferred Generic $6 copay for a one-month (30-day) supply of drugs in this tier from a preferred mail order pharmacy. $12 copay for a two-month (60-day) supply of drugs in this tier from a preferred mail order pharmacy. $15 copay for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy. $20 copay for a one-month (30-day) supply of drugs in this tier from a non-preferred mail order pharmacy. $40 copay for a two-month (60-day) supply of drugs in this tier from a non-preferred mail order pharmacy. $60 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred mail order pharmacy. Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. (Continued) PAGE 53 of 120

54 Section 2 Summary of Benefits (continued) Benefit 25 Outpatient Prescription Drugs (Continued) Original Medicare PRESCRIPTION DRUG BENEFITS Blue Medicare HMO Medical Only (HMO) (H3449, Plan 012) PAG E 54 of 120

55 Blue Medicare HMO Standard (HMO) (H3449, Plan 013) Blue Medicare HMO Enhanced (HMO) (H3449, Plan 005) Tier 3: Preferred Brand $40 copay for a one-month (30-day) supply of drugs in this tier from a preferred mail order pharmacy. $80 copay for a two-month (60-day) supply of drugs in this tier from a preferred mail order pharmacy. $100 copay for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy. $45 copay for a one-month (30-day) supply of drugs in this tier from a non-preferred mail order pharmacy. $90 copay for a two-month (60-day) supply of drugs in this tier from a non-preferred mail order pharmacy. $135 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred mail order pharmacy. Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. Tier 4: Non-Preferred Brand $80 copay for a one-month (30-day) supply of drugs in this tier from a preferred mail order pharmacy. $160 copay for a two-month (60-day) supply of drugs in this tier from a preferred mail order pharmacy. $200 copay for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy. $95 copay for a one-month (30-day) supply of drugs in this tier from a non-preferred mail order pharmacy. $190 copay for a two-month (60-day) supply of drugs in this tier from a non-preferred mail order pharmacy. $285 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred mail order pharmacy. Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. (Continued) Tier 3: Preferred Brand $30 copay for a one-month (30-day) supply of drugs in this tier from a preferred mail order pharmacy. $60 copay for a two-month (60-day) supply of drugs in this tier from a preferred mail order pharmacy. $75 copay for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy. $45 copay for a one-month (30-day) supply of drugs in this tier from a non-preferred mail order pharmacy. $90 copay for a two-month (60-day) supply of drugs in this tier from a non-preferred mail order pharmacy. $135 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred mail order pharmacy. Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. Tier 4: Non-Preferred Brand $70 copay for a one-month (30-day) supply of drugs in this tier from a preferred mail order pharmacy. $140 copay for a two-month (60-day) supply of drugs in this tier from a preferred mail order pharmacy. $175 copay for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy. $95 copay for a one-month (30-day) supply of drugs in this tier from a non-preferred mail order pharmacy. $190 copay for a two-month (60-day) supply of drugs in this tier from a non-preferred mail order pharmacy. $285 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred mail order pharmacy. Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. (Continued) PAG E 55 of 120

56 Section 2 Summary of Benefits (continued) Benefit 25 Outpatient Prescription Drugs (Continued) Original Medicare PRESCRIPTION DRUG BENEFITS Blue Medicare HMO Medical Only (HMO) (H3449, Plan 012) PAGE 56 of 120

57 Blue Medicare HMO Standard (HMO) (H3449, Plan 013) Blue Medicare HMO Enhanced (HMO) (H3449, Plan 005) Tier 5: Specialty Tier 33% coinsurance for a one-month (30-day) supply of drugs in this tier from a preferred mail order pharmacy. 33% coinsurance for a two-month (60-day) supply of drugs in this tier from a preferred mail order pharmacy. 33% coinsurance for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy. 33% coinsurance for a one-month (30-day) supply of drugs in this tier from a non-preferred mail order pharmacy. 33% coinsurance for a two-month (60-day) supply of drugs in this tier from a non-preferred mail order pharmacy. 33% coinsurance for a three-month (90-day) supply of drugs in this tier from a non-preferred mail order pharmacy. Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. Coverage Gap After your total yearly drug costs reach $2,850, you receive limited coverage by the plan on certain drugs. You will also receive a discount on brand name drugs and generally pay no more than 47.5% for the plan's costs for brand drugs and 72% of the plan's costs for generic drugs until your yearly out-of-pocket drug costs reach $4,550. (Continued) Tier 5: Specialty Tier 33% coinsurance for a one-month (30-day) preferred mail order pharmacy. 33% coinsurance for a two-month (60-day) preferred mail order pharmacy. 33% coinsurance for a three-month (90-day) preferred mail order pharmacy. 33% coinsurance for a one-month (30-day) non-preferred mail order pharmacy. 33% coinsurance for a two-month (60-day) non-preferred mail order pharmacy. 33% coinsurance for a three-month (90-day) non-preferred mail order pharmacy. Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. Coverage Gap After your total yearly drug costs reach $2,850, you receive limited coverage by the plan on certain drugs. You will also receive a discount on brand name drugs and generally pay no more than 47.5% for the plan s costs for brand drugs and 72% of the plan s costs for generic drugs until your yearly out-of-pocket drug costs reach $4,550. (Continued) PAGE 57 of 120

58 Section 2 Summary of Benefits (continued) Benefit 25 Outpatient Prescription Drugs (Continued) Original Medicare PRESCRIPTION DRUG BENEFITS Blue Medicare HMO Medical Only (HMO) (H3449, Plan 012) PAGE 58 of 120

59 Blue Medicare HMO Standard (HMO) (H3449, Plan 013) Blue Medicare HMO Enhanced (HMO) (H3449, Plan 005) Additional Coverage Gap The plan covers some formulary generics (10%-64% of formulary generic drugs) through the coverage gap. The plan offers additional coverage in the gap for the following tiers. You pay the following: Retail Pharmacy Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed. Tier 1: Preferred Generic $3 copay for a one-month (30-day) supply of all drugs covered within this tier from a preferred pharmacy $6 copay for a two-month (60-day) supply of all drugs covered within this tier from a preferred pharmacy $9 copay for a three-month (90-day) supply of all drugs covered within this tier from a preferred pharmacy $8 copay for a one-month (30-day) supply of all drugs covered within this tier from a non-preferred pharmacy $16 copay for a two-month (60-day) supply of all drugs covered within this tier from a non-preferred pharmacy $24 copay for a three-month (90-day) supply of all drugs covered within this tier from a non-preferred pharmacy Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. (Continued) PAGE 59 of 120

60 Section 2 Summary of Benefits (continued) Benefit 25 Outpatient Prescription Drugs (Continued) Original Medicare PRESCRIPTION DRUG BENEFITS Blue Medicare HMO Medical Only (HMO) (H3449, Plan 012) PAGE 60 of 120

61 Blue Medicare HMO Standard (HMO) (H3449, Plan 013) Blue Medicare HMO Enhanced (HMO) (H3449, Plan 005) Long Term Care Pharmacy Long term care pharmacies must dispense brand name drugs in amounts less than a 14 days supply at a time. They may also dispense less than a month's supply of generic drugs at a time. Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed. Tier 1: Preferred Generic $8 copay for a one-month (31-day) supply of all drugs covered within this tier Mail Order Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed. Tier 1: Preferred Generic $3 copay for a one-month (30-day) supply of all drugs covered within this tier from a preferred mail order pharmacy $0 copay for a two-month (60-day) supply of all drugs covered within this tier from a preferred mail order pharmacy $0 copay for a three-month (90-day) supply of all drugs covered within this tier from a preferred mail order pharmacy $8 copay for a one-month (30-day) supply of all drugs covered within this tier from a non-preferred mail order pharmacy $16 copay for a two-month (60-day) supply of all drugs covered within this tier from a non-preferred mail order pharmacy $24 copay for a three-month (90-day) supply of all drugs covered within this tier from a non-preferred mail order pharmacy Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. (Continued) PAGE 61 of 120

62 Section 2 Summary of Benefits (continued) Benefit 25 Outpatient Prescription Drugs (Continued) Original Medicare PRESCRIPTION DRUG BENEFITS Blue Medicare HMO Medical Only (HMO) (H3449, Plan 012) PAGE 62 of 120

63 Blue Medicare HMO Standard (HMO) (H3449, Plan 013) Blue Medicare HMO Enhanced (HMO) (H3449, Plan 005) Catastrophic Coverage After your yearly out-of-pocket drug costs reach $4,550, you pay the greater of: 5% coinsurance, or $2.55 copay for generic (including brand drugs treated as generic) and a $6.35 copay for all other drugs. Out-of-Network Plan drugs may be covered in special circumstances, for instance, illness while traveling outside of the plan's service area where there is no network pharmacy. You may have to pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy. In addition, you will likely have to pay the pharmacy's full charge for the drug and submit documentation to receive reimbursement from Blue Medicare HMO Standard (HMO). You can get out-of-network drugs the following way: Out-of-Network Initial Coverage You will be reimbursed up to the plan's cost of the drug minus the following for drugs purchased out-of-network until total yearly drug costs reach $2,850: Tier 1: Preferred Generic $8 copay for a one-month (30-day) supply of drugs in this tier Tier 2: Non-Preferred Generic $25 copay for a one-month (30-day) supply of drugs in this tier Tier 3: Preferred Brand $45 copay for a one-month (30-day) supply of drugs in this tier Tier 4: Non-Preferred Brand $95 copay for a one-month (30-day) supply of drugs in this tier Tier 5: Specialty Tier 33% coinsurance for a one-month (30-day) supply of drugs in this tier You will not be reimbursed for the difference between the out-of-network Pharmacy charge and the plan's in-network allowable amount. (Continued) Catastrophic Coverage After your yearly out-of-pocket drug costs reach $4,550, you pay the greater of: 5% coinsurance, or $2.55 copay for generic (including brand drugs treated as generic) and a $6.35 copay for all other drugs. Out-of-Network Plan drugs may be covered in special circumstances, for instance, illness while traveling outside of the plan's service area where there is no network pharmacy. You may have to pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy. In addition, you will likely have to pay the pharmacy's full charge for the drug and submit documentation to receive reimbursement from Blue Medicare HMO Enhanced (HMO). You can get out-of-network drugs the following way: Out-of-Network Initial Coverage You will be reimbursed up to the plan's cost of the drug minus the following for drugs purchased out-of-network until total yearly drug costs reach $2,850. Tier 1: Preferred Generic $8 copay for a one-month (30-day) supply of drugs in this tier Tier 2: Non-Preferred Generic $20 copay for a one-month (30-day) supply of drugs in this tier Tier 3: Preferred Brand $45 copay for a one-month (30-day) supply of drugs in this tier Tier 4: Non-Preferred Brand $95 copay for a one-month (30-day) supply of drugs in this tier Tier 5: Specialty Tier 33% coinsurance for a one-month (30-day) supply of drugs in this tier You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's allowable amount. (Continued) PAGE 63 of 120

64 Section 2 Summary of Benefits (continued) Benefit 25 Outpatient Prescription Drugs (Continued) Original Medicare PRESCRIPTION DRUG BENEFITS Blue Medicare HMO Medical Only (HMO) (H3449, Plan 012) PAGE 64 of 120

65 Blue Medicare HMO Standard (HMO) (H3449, Plan 013) Blue Medicare HMO Enhanced (HMO) (H3449, Plan 005) Out-of-Network Coverage Gap You will be reimbursed up to 28% of the plan allowable cost for generic drugs purchased out-ofnetwork until total yearly out-of-pocket drug costs reach $4,550. Please note that the plan allowable cost may be less than the out-of-network pharmacy price paid for your drug(s). You will be reimbursed up to 52.5% of the plan allowable cost for brand name drugs purchased out-of-network until your total yearly out-of-pocket drug costs reach $4,550. Please note that the plan allowable cost may be less than the out-of-network pharmacy price paid for your drug(s). Out-of-Network Catastrophic Coverage After your yearly out-of-pocket drug costs reach $4,550, you will be reimbursed for drugs purchased out-of-network up to the plan's cost of the drug minus your cost share, which is the greater of: 5% coinsurance, or $2.55 copay for generic (including brand drugs treated as generic) and a $6.35 copay for all other drugs. You will not be reimbursed for the difference between the out-of-network pharmacy charge and the plan's in-network allowable amount. Out-of-Network Coverage Gap You will be reimbursed up to 28% of the plan allowable cost for generic drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4,550. Please note that the plan allowable cost may be less than the out-ofnetwork pharmacy price paid for your drug(s). You will be reimbursed up to 52.5% of the plan allowable cost for brand name drugs purchased out-of-network until your total yearly out-ofpocket drug costs reach $4,550. Please note that the plan allowable cost may be less than the out-of-network pharmacy price paid for your drug(s). Additional Out-of-Network Coverage Gap You will be reimbursed for these drugs purchased out-of-network up to the plan's cost of the drug minus the following: Tier 1: Preferred Generic $8 copay for a one-month (30-day) supply of all drugs covered within this tier. Out-of-Network Catastrophic Coverage After your yearly out-of-pocket drug costs reach $4,550, you will be reimbursed for drugs purchased out-of-network up to the plan's cost of the drug minus your cost share, which is the greater of: 5% coinsurance, or $2.55 copay for generic (including brand drugs treated as generic) and a $6.35 copay for all other drugs. You will not be reimbursed for the difference between the out-of-network pharmacy charge and the plan's in-network allowable amount. PAGE 65 of 120

66 Section 2 Summary of Benefits (continued) Benefit Original Medicare OUTPATIENT MEDICAL SERVICES AND SUPPLIES Blue Medicare HMO Medical Only (HMO) (H3449, Plan Preventive dental services Dental Services (such as cleaning) not covered. In general, preventive dental benefits (such as cleaning) not covered. $20 copay for Medicare-covered dental benefits 27 Supplemental routine hearing Hearing Services exams and hearing aids In general, supplemental routine hearing exams and not covered hearing aids not covered 20% coinsurance for diagnostic hearing exams $20 copay for Medicare covered diagnostic hearing exams 28 20% coinsurance for diagnosis Vision Services and treatment of diseases and $0 to $20 copay for Medicare-covered exams to conditions of the eye, including diagnose and treat diseases and conditions of the an annual glaucoma screening eye, including an annual glaucoma screening for for people at risk people at risk Supplemental routine eye $20 copay for up to 1 supplemental routine eye exams and eyeglasses (lenses exam(s) and frames) not covered 20% of the cost for one pair of Medicare-covered Medicare pays for one pair of eyeglasses (lenses and frames) or contact lenses eyeglasses or contact lenses after cataract surgery after cataract surgery $100 plan coverage limit for supplemental routine eye exams Wellness/ Not Covered Education The plan covers the following supplemental and Other education/wellness programs: Supplemental Health Club Membership/Fitness Classes Benefits Nursing Hotline & Services Over-the-Counter Items Not Covered The plan does not cover over-the-counter items PAG E 66 of 120

67 Blue Medicare HMO Standard (HMO) (H3449, Plan 013) Blue Medicare HMO Enhanced (HMO) (H3449, Plan 005) In general, preventive dental benefits (such as cleaning) not covered. $40 copay for Medicare-covered dental benefits In general, preventive dental benefits (such as cleaning) not covered. $35 copay for Medicare-covered dental benefits In general, supplemental routine hearing exams and hearing aids not covered $40 copay for Medicare-covered diagnostic hearing exams In general, supplemental routine hearing exams and hearing aids not covered $35 copay for Medicare-covered diagnostic hearing exams $0 to $40 copay for Medicare-covered exams to diagnose and treat diseases and conditions of the eye, including an annual glaucoma screening for people at risk $40 copay for up to 1 supplemental routine eye exam(s) 20% of the cost for one pair of Medicare-covered eyeglasses (lenses and frames) or contact lenses after cataract surgery. $100 plan coverage limit for supplemental routine eye exams $0 to $35 copay for Medicare-covered exams to diagnose and treat diseases and conditions of the eye, including an annual glaucoma screening for people at risk $35 copay for up to 1 supplemental routine eye exam(s) 20% of the cost for one pair of Medicare-covered eyeglasses (lenses and frames) or contact lenses after cataract surgery $100 plan coverage limit for supplemental routine eye exams The plan covers the following supplemental education/wellness programs: Health Club Membership/Fitness Classes Nursing Hotline The plan covers the following supplemental education/wellness programs: Health Club Membership/Fitness Classes Nursing Hotline The plan does not cover over-the-counter items The plan does not cover over-the-counter items PAG E 67 of 120

68 Section 2 Summary of Benefits (continued) Benefit Original Medicare OUTPATIENT MEDICAL SERVICES AND SUPPLIES Transportation (Routine) Not Covered Blue Medicare HMO Medical Only (HMO) (H3449, Plan 012 This plan does not cover supplemental routine transportation Acupuncture and Other Alternative Therapies Not Covered This plan does not cover Acupuncture and other alternative therapies. PAGE 68 of 120

69 Blue Medicare HMO Standard (HMO) (H3449, Plan 013) Blue Medicare HMO Enhanced (HMO) (H3449, Plan 005) This plan does not cover supplemental routine transportation This plan does not cover supplemental routine transportation This plan does not cover Acupuncture and other alternative therapies This plan does not cover Acupuncture and other alternative therapies. PAG E 69 of 120

70 Contact information Notes Winston-Salem location: 5660 University Parkway Winston-Salem, NC TTY/TDD days a week 8 a.m. 8 p.m. Satellite office: 8701 Red Oak Blvd, Suite 300 Charlotte, NC TTY/TDD days a week 8 a.m. 8 p.m. For more information about Medicare: Call MEDICARE ( ) TTY hours a day, 7 days a week Benefits, premium and/or copayment/ coinsurance may change on January 1 of each year. Blue Cross and Blue Shield of North Carolina is an HMO and PPO plan with a Medicare contract. Enrollment in Blue Cross and Blue Shield of North Carolina depends on contract renewal. BCBSNC does not discriminate based on race, ethnicity, national origin, religion, gender, age, mental or physical disability, health status, claims experience, medical history, genetic information, evidence of insurability or geographic location within the service area. All BCBSNC items and services are available to all eligible beneficiaries in the service area. Limitations, copayments, and restrictions may apply. You must be entitled to Medicare Part A and enrolled in Medicare Part B and must reside in the CMS-approved service area. You must continue to pay your Medicare Part B premium. An independent licensee of the Blue Cross and Blue Shield Association., SM Marks of the Blue Cross and Blue Shield Association. SM1 Mark of Blue Cross and Blue Shield of North Carolina. PAG E 70 of 120

71 2014 Summary of Benefits (Contract H3404, Plans 001 and 002) January 1, 2014 December 31, 2014 FOR RESIDENTS OF: Alamance, Alexander, Alleghany, Anson, Ashe, Avery, Beaufort, Bertie, Bladen, Brunswick, Buncombe, Cabarrus, Caldwell, Carteret, Caswell, Catawba, Chatham, Chowan, Cleveland, Columbus, Cumberland, Davidson, Davie, Duplin, Durham, Edgecombe, Forsyth, Franklin, Gaston, Gates, Granville, Greene, Guilford, Halifax, Harnett, Haywood, Henderson, Hertford, Hoke, Hyde, Iredell, Johnston, Jones, Lee, Lincoln, Madison, Martin, McDowell, Mecklenburg, Mitchell, Montgomery, Nash, New Hanover, Northampton, Onslow, Orange, Pamlico, Pender, Perquimans, Person, Pitt, Polk, Randolph, Richmond, Robeson, Rockingham, Rowan, Sampson, Scotland, Stanly, Stokes, Surry, Transylvania, Tyrrell, Union, Vance, Wake, Warren, Washington, Watauga, Wayne, Wilkes, Wilson, Yadkin and Yancey. Y0079_6256 CMS Accepted U5047c, 9/13 PAGE 71 of 120

72 Section 1 Introduction to Summary of Benefits Thank you for your interest in Blue Medicare PPO (PPO) plans. Our plans are offered by Blue Cross and Blue Shield of North Carolina, a Medicare Advantage Preferred Provider Organization (PPO) that contracts with the Federal government. This Summary of Benefits tells you some features of our plans. It doesn t list every service that we cover or list every limitation or exclusion. To get a complete list of our benefits, please call Blue Medicare PPO and ask for the Evidence of Coverage. You have choices in your health care As a Medicare beneficiary, you can choose from different Medicare options. One option is the Original (Fee-For-Service) Medicare Plan. Another option is a Medicare health plan, like Blue Medicare PPO plans. You may have other options too. You make the choice. No matter what you decide, you are still in the Medicare Program. You may be able to join or leave a plan only at certain times. Please call Blue Medicare PPO at the number listed at the end of this introduction or MEDICARE ( ) for more information. TTY/TDD users should call You can call this number 24 hours a day, 7 days a week. How can I compare my options? You can compare Blue Medicare PPO plans and the Original Medicare Plan using this Summary of Benefits. The charts in this booklet list some important health benefits. For each benefit, you can see what our plans cover and what the Original Medicare Plan covers. Our members receive all of the benefits that the Original Medicare Plan offers. We also offer more benefits, which may change from year to year. Where are Blue Medicare PPO plans available? The service area for these plans includes: Alamance, Alexander, Alleghany, Anson, Ashe, Avery, Beaufort, Bertie, Bladen, Brunswick, Buncombe Cabarrus, Caldwell, Carteret, Caswell, Catawba, Chatham, Chowan, Cleveland, Columbus, Cumberland, Davidson, Davie, Duplin, Durham, Edgecombe, Forsyth, Franklin, Gaston, Gates, Granville, Greene, Guilford, Halifax, Harnett, Haywood, Henderson, Hertford, Hoke, Hyde, Iredell, Johnston, Jones, Lee, Lincoln, Madison, Martin, McDowell, Mecklenburg, Mitchell, Montgomery, Nash, New Hanover, Northampton, Onslow, Orange, Pamlico, Pender, Perquimans, Person, Pitt, Polk, Randolph, Richmond, Robeson, Rockingham, Rowan, Sampson, Scotland, Stanly, Stokes, Surry, Transylvania, Tyrrell, Union, Vance, Wake, Warren, Washington, Watauga, Wayne, Wilkes, Wilson, Yadkin, Yancey Counties, NC. You must live in one of these areas to join one of the plans. Who is eligible to join Blue Medicare PPO plans? You can join Blue Medicare PPO if you are entitled to Medicare Part A and enrolled in Medicare Part B and live in the service area. However, individuals with End-Stage Renal Disease generally are not eligible to enroll in Blue Medicare PPO plans unless they are members of our organization and have been since their dialysis began. Can I choose my doctors? Blue Medicare PPO plans have 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 updated list, visit us at medicare. Our customer service number is listed at the end of this introduction. What happens if I go to a doctor who s not in your network? 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. Where can I get my prescriptions if I join one of these plans? Blue Medicare PPO plans have formed a network of pharmacies. You must use a network pharmacy to receive plan benefits. We may not pay for your prescriptions if you use an out-of-network pharmacy, except in certain cases. The pharmacies in our network can change at any time. (continued on the next page) PAGE 72 of 120

73 You can ask for a pharmacy directory or visit us at MyPrime/MedicareD/pharmacy/BCBSNC. Our customer service number is listed at the end of this introduction. Blue Medicare PPO plans have a list of preferred pharmacies. At these pharmacies, you may get your drugs at a lower co-pay or co-insurance. You may go to a non-preferred pharmacy, but you may have to pay more for your prescription drugs. What if my doctor prescribes less than a month's supply? In consultation with your doctor or pharmacist, you may receive less than a month's supply of certain drugs. Also, if you live in a long-term care facility, you will receive less than a month's supply of certain brand and generic drugs. Dispensing fewer drugs at a time can help reduce cost and waste in the Medicare Part D program, when this is medically appropriate. The amount you pay in these circumstances will depend on whether you are responsible for paying coinsurance (a percentage of the cost of the drug) or a copay (a flat dollar amount for the drug). If you are responsible for coinsurance for the drug, you will continue to pay the applicable percentage of the drug cost. If you are responsible for a copay for the drug, a "daily cost-sharing rate" will be applied. If your doctor decides to continue the drug after a trial period, you should not pay more for a month's supply than you otherwise would have paid. Contact your plan if you have questions about cost-sharing when less than a one-month supply is dispensed. Does my plan cover Medicare Part B or Part D drugs? Blue Medicare PPO plans do cover both Medicare Part B prescription drugs and Medicare Part D prescription drugs. What is a prescription drug formulary? Blue Medicare PPO plans use a formulary. A formulary is a list of drugs covered by your plan to meet patient needs. We may periodically add, remove, or make changes to coverage limitations on certain drugs or change how much you pay for a drug. If we make any formulary change that limits our members ability to fill their prescriptions, we will notify the affected members before the change is made. We will send a formulary to you and you can see our complete formulary on our Web site at: formulary-home.htm. If you are currently taking a drug that is not on our formulary or subject to additional requirements or limits, you may be able to get a temporary supply of the drug. You can contact us to request an exception or switch to an alternative drug listed on our formulary with your physician s help. Call us to see if you can get a temporary supply of the drug or for more details about our drug transition policy. How can I get extra help with my prescription drug plan costs or get extra help with other Medicare costs? You may be able to get extra help to pay for your prescription drug premiums and costs as well as get help with other Medicare costs. To see if you qualify for getting extra help, call: MEDICARE ( ). TTY/TDD users should call , 24 hours a day/7 days a week; and see 'Programs for People with Limited Income and Resources' in the publication Medicare & You. The Social Security Administration at between 7 a.m. and 7 p.m., Monday through Friday. TTY/TDD users should call ; or Your State Medicaid Office. What are my protections in this plan? All Medicare Advantage Plans agree to stay in the program for a full calendar year at a time. Plan benefits and cost-sharing may change from calendar year to calendar year. Each year, plans can decide whether to continue to participate with Medicare Advantage. A plan may continue in their entire service area (geographic area where the plan accepts members) or choose to continue only in certain areas. Also, Medicare may decide to end a contract with a plan. Even if your Medicare Advantage Plan leaves the program, you will not lose Medicare coverage. If a plan decides not to continue for an additional calendar year, it must send you a letter at least 90 days before your coverage will end. The letter will explain your options for Medicare coverage in your area. (continued on the next page) PAGE 73 of 120

74 Section 1 Introduction to Summary of Benefits (continued) As a member of Blue Medicare PPO plans, you have the right to request an organization determination, which includes the right to file an appeal if we deny coverage for an item or service, and the right to file a grievance. You have the right to request an organization determination if you want us to provide or pay for an item or service that you believe should be covered. If we deny coverage for your requested item or service, you have the right to appeal and ask us to review our decision. You may ask us for an expedited (fast) coverage determination or appeal if you believe that waiting for a decision could seriously put your life or health at risk, or affect your ability to regain maximum function. If your doctor makes or supports the expedited request, we must expedite our decision. Finally, you have the right to file a grievance with us if you have any type of problem with us or one of our network providers that does not involve coverage for an item or service. If your problem involves quality of care, you also have the right to file a grievance with the Quality Improvement Organization (QIO) for your state. Please refer to the Evidence of Coverage (EOC) for the QIO contact information. As a member of Blue Medicare PPO plans, 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 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. If your problem involves quality of care, you also have the right to file a grievance with the Quality Improvement Organization (QIO) for your state. Please refer to the Evidence of Coverage (EOC) for the QIO contact information. What is a Medication Therapy Management (MTM) program? A Medication Therapy Management (MTM) Program is a free service we 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 Blue Medicare PPO plans for more details. What types of drugs may be covered under Medicare Part B? Some outpatient prescription drugs may be covered under Medicare Part B. These may include, but are not limited to, the following types of drugs. Contact Blue Medicare 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 osteoporosis drugs for some women. Erythropoietin: 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. (continued on the next page) PAGE 74 of 120

75 Immunosuppressive Drugs: Immunosuppressive drug therapy for transplant patients if the transplant took place in a Medicare-certified facility and was paid for by Medicare or by a private insurance company that was the primary payer for Medicare Part A coverage. 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 administered through Durable Medical Equipment. Where can I find information on plan ratings? The Medicare program rates how well plans perform in different categories (for example, detecting and preventing illness, ratings from patients and customer service). If you have access to the web, you can find the Plan Ratings information by using the Find health & drug plans web tool on medicare.gov to compare the plan ratings for Medicare plans in your area. You can also call us directly to obtain a copy of the plan ratings for this plan. Our customer service number is listed below. Please call Blue Cross and Blue Shield of North Carolina for more information about Blue Medicare PPO plans. Visit us at or, call us: Customer Service Hours for October 1 February 14: Sunday, Monday, Tuesday, Wednesday, Thursday, Friday, Saturday, 8:00 a.m. 8:00 p.m. Eastern Customer Service Hours for February 15 September 30: Sunday, Monday, Tuesday, Wednesday, Thursday, Friday, Saturday, 8:00 a.m. 8:00 p.m. Eastern Current members should call toll-free (877) for questions related to the Medicare Advantage Program. (TTY/TDD (888) ) Prospective members should call toll-free (800) for questions related to the Medicare Advantage Program. (TTY/TDD (800) ) Current members should call locally (877) for questions related to the Medicare Advantage Program. (TTY/TDD (888) ) Prospective members should call locally (800) for questions related to the Medicare Advantage Program. (TTY/TDD (800) ) Current members should call toll-free (877) for questions related to the Medicare Part D Prescription Drug program. (TTY/TDD (888) ) Prospective members should call toll-free (800) for questions related to the Medicare Part D Prescription Drug program. (TTY/TDD (800) ) Current members should call locally (877) for questions related to the Medicare Part D Prescription Drug program. (TTY/TDD (888) ) Prospective members should call locally (800) for questions related to the Medicare Part D Prescription Drug program. (TTY/TDD (800) ). For more information about Medicare, please call Medicare at MEDICARE ( ). TTY users should call You can call 24 hours a day, 7 days a week. Or, visit on the web. This document may be available in other formats such as Braille, large print or other alternate formats. This document may be available in a non-english language. For additional information, call customer service at the phone number listed above. If you have any questions about these plans benefits or costs, please contact Blue Cross and Blue Shield of North Carolina for details. PAGE 75 of 120

76 Section 2 Summary of Benefits Benefit IMPORTANT INFORMATION 1 Premium and Other Important Information Original Medicare In 2013, the monthly Part B Premium was $ and may change for 2014 and the annual Part B deductible amount was $147 and may change for If a doctor or supplier does not accept assignment, their costs are often higher, which means you pay more. Most people will pay the standard monthly Part B premium. However, some people will pay a higher premium because of their yearly income (over $85,000 for singles, $170,000 for married couples). For more information about Part B premiums based on income, call Medicare at MEDICARE ( ). TTY users should call You may also call Social Security at TTY users should call PAGE 76 of 120

77 Blue Medicare PPO Enhanced (PPO) (H3404, Plan 001) Blue Medicare PPO Enhanced Freedom (PPO) (H3404, Plan 002) $38 monthly plan premium in addition to your monthly Medicare Part B premium. Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However, some people will pay higher Part B and Part D premiums because of their yearly income (over $85,000 for singles, $170,000 for married couples). For more information about Part B and Part D premiums based on income, call Medicare at MEDICARE ( ). TTY users should call You may also call Social Security at TTY users should call Some physicians, providers and suppliers that are out of a plan's network (i.e., out-of-network) accept "assignment" from Medicare and will only charge up to a Medicare-approved amount. If you choose to see an out-of-network physician who does NOT accept Medicare "assignment," your coinsurance can be based on the Medicare-approved amount plus an additional amount up to a higher Medicare "limiting charge." If you are a member of a plan that charges a copay for out-of-network physician services, the higher Medicare "limiting charge" does not apply. See the publications Medicare & You or Your Medicare Benefits available on for a full listing of benefits under Original Medicare, as well as for explanations of the rules related to "assignment" and "limiting charges" that apply by benefit type. To find out if physicians and DME suppliers accept assignment or participate in Medicare, visit or You can also call MEDICARE, or ask your physician, provider, or supplier if they accept assignment. $3,400 out-of-pocket limit for Medicare-covered services. In and Out-of-Network $5,100 out-of-pocket limit for Medicare-covered services $ monthly plan premium in addition to your monthly Medicare Part B premium. Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However, some people will pay higher Part B and Part D premiums because of their yearly income (over $85,000 for singles, $170,000 for married couples). For more information about Part B and Part D premiums based on income, call Medicare at MEDICARE ( ). TTY users should call You may also call Social Security at TTY users should call Some physicians, providers and suppliers that are out of a plan's network (i.e., out-of-network) accept "assignment" from Medicare and will only charge up to a Medicare-approved amount. If you choose to see an out-of-network physician who does NOT accept Medicare "assignment," your coinsurance can be based on the Medicare-approved amount plus an additional amount up to a higher Medicare "limiting charge." If you are a member of a plan that charges a copay for out-of-network physician services, the higher Medicare "limiting charge" does not apply. See the publications Medicare & You or Your Medicare Benefits available on medicare.gov for a full listing of benefits under Original Medicare, as well as for explanations of the rules related to "assignment" and "limiting charges" that apply by benefit type. To find out if physicians and DME suppliers accept assignment or participate in Medicare, visit or You can also call MEDICARE, or ask your physician, provider, or supplier if they accept assignment. $3,400 out-of-pocket limit. All plan services included. In and Out-of-Network $5,100 out-of-pocket limit for Medicare-covered services PAGE 77 of 120

78 Section 2 Summary of Benefits (continued) Benefit Original Medicare 2 Doctor and Hospital Choice (For more information, see Emergency Care - #15 and Urgently Needed Care - #16.) You may go to any doctor, specialist or hospital that accepts Medicare. SUMMARY OF BENEFITS - INPATIENT CARE 3 Inpatient Hospital Care (includes Substance Abuse and Rehabilitation Services) In 2013 the amounts for each benefit period were: Days 1-60: $1,184 deductible Days 61-90: $296 per day Days : $592 per lifetime reserve day These amounts may change for Call MEDICARE ( ) for information about lifetime reserve days. Lifetime reserve days can only be used once. A benefit period starts the day you go into a hospital or skilled nursing facility. It ends when you go for 60 days in a row without hospital or skilled nursing care. 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 Inpatient Mental Health Care In 2013 the amounts for each benefit period were: Days 1-60: $1,184 deductible Days 61-90: $296 per day Days : $592 per lifetime reserve day These amounts may change for You get up to 190 days of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital. PAGE 78 of 120

79 Blue Medicare PPO Enhanced (PPO) (H3404, Plan 001) No referral required for network doctors, specialists, and hospitals. In and Out-of-Network You can go to doctors, specialists, and hospitals in or out of the network. It will cost more to get out of network benefits. Out of Service Area Plan covers you when you travel in the U.S. or its territories. Blue Medicare PPO Enhanced Freedom (PPO) (H3404, Plan 002) No referral required for network doctors, specialists, and hospitals. In and Out-of-Network You can go to doctors, specialists, and hospitals in or out of the network. It will cost more to get out of network benefits. Out of Service Area Plan covers you when you travel in the U.S. or its territories. No limit to the number of days covered by the plan each hospital stay. For Medicare-covered hospital stays: Days 1-7: $220 copay per day Days 8-90: $0 copay per day $0 copay for each additional non-medicare-covered hospital day. Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital. Out-of-Network For Medicare-covered hospital stays: Days 1 and beyond: 20% of the cost per day You get up to 190 days of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital. For Medicare-covered hospital stays: Days 1-7: $220 copay per day Days 8-90: $0 copay per day Plan covers 60 lifetime reserve days. Cost per lifetime reserve day: Days 1-60: $0 copay per day Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital. Out-of-Network For Medicare-covered hospital stays: Days 1-190: 20% of the cost per day No limit to the number of days covered by the plan each hospital stay. For Medicare-covered hospital stays: Days 1-7: $170 copay per day Days 8-90: $0 copay per day $0 copay for each additional non-medicare-covered hospital day. Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital. Out-of-Network For Medicare-covered hospital stays: Days 1-7: $170 copay per day Days 8-90: $0 copay per day You get up to 190 days of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital. For Medicare-covered hospital stays: Days 1-7: $170 copay per day Days 8-90: $0 copay per day Plan covers 60 lifetime reserve days. Cost per lifetime reserve day: Days 1-60: $0 copay per day Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital. Out-of-Network For Medicare-covered hospital stays: Days 1-7: $170 copay per day Days 8-90: $0 copay per day PAGE 79 of 120

80 Section 2 Summary of Benefits (continued) Benefit 5 Skilled Nursing Facility (SNF) (in a Medicare-certified skilled nursing facility) Original Medicare In 2013 the amounts for each benefit period after at least a 3-day Medicare-covered hospital stay were: Days 1-20: $0 per day Days : $148 per day These amounts may change for days for each benefit period. A benefit period starts the day you go into a hospital or SNF. It ends when you go for 60 days in a row without hospital or skilled nursing care. 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. 6 Home Health Care (includes medically necessary intermittent skilled nursing care, home health aide services, and rehabilitation services, etc.) $0 copay. 7 Hospice You pay part of the cost for outpatient drugs and inpatient respite care. You must get care from a Medicare-certified hospice. OUTPATIENT CARE 8 Doctor Office Visits 20% coinsurance PAG E 80 of 120

81 Blue Medicare PPO Enhanced (PPO) (H3404, Plan 001) Authorization rules may apply. Plan covers up to 100 days each benefit period No prior hospital stay is required. For Medicare-covered SNF stays: Days 1-10: $0 copay per day Days : $50 copay per day Out-of-Network 20% of the cost for each Medicare-covered SNF stay. For each Medicare-covered SNF stay: Days 1-100: 20% of the cost per SNF day. Authorization rules may apply. 0% of the cost for each Medicare-covered home health visit. Out-of-Network 20% of the cost for Medicare-covered home health visits. You must get care from a Medicare-certified hospice. You must consult with your plan before you select hospice. Blue Medicare PPO Enhanced Freedom (PPO) (H3404, Plan 002) Authorization rules may apply. Plan covers up to 100 days each benefit period No prior hospital stay is required. For Medicare-covered SNF stays: Days 1-10: $0 copay per day Days : $50 copay per day Out-of-Network For each Medicare-covered SNF stay: Days 1-10: $0 copay per SNF day Days : $50 copay per SNF day Authorization rules may apply. 0% of the cost for each Medicare-covered home health visit. Out-of-Network $0 copay for Medicare-covered home health visits. You must get care from a Medicare-certified hospice. You must consult with your plan before you select hospice. $20 copay for each Medicare-covered primary care doctor visit. $40 copay for each Medicare-covered specialist visit. Out-of-Network 20% of the cost for each Medicare-covered primary care doctor visit. 20% of the cost for each Medicare-covered specialist visit. $15 copay for each Medicare-covered primary care doctor visit. $35 copay for each Medicare-covered specialist visit. Out-of-Network $35 copay for each Medicare-covered primary care doctor visit. $35 copay for each Medicare-covered specialist visit. PAGE 81 of 120

82 Section 2 Summary of Benefits (continued) Benefit 9 Chiropractic Services Original Medicare Supplemental routine care not covered. 20% coinsurance for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part) 10 Podiatry Services Supplemental routine care not covered. 20% coinsurance for medically necessary foot care, including care for medical conditions affecting the lower limbs. 11 Outpatient Mental Health Care 20% coinsurance for most outpatient mental health services. Specified copayment for outpatient partial hospitalization program services furnished by a hospital or community mental health center (CMHC). Copay cannot exceed the Part A inpatient hospital deductible. "Partial hospitalization program" is a structured program of active outpatient psychiatric treatment that is more intense than the care received in your doctor's or therapist's office and is an alternative to inpatient hospitalization. 12 Outpatient Substance Abuse Care 20% coinsurance PAG E 82 of 120

83 Blue Medicare PPO Enhanced (PPO) (H3404, Plan 001) Blue Medicare PPO Enhanced Freedom (PPO) (H3404, Plan 002) $20 copay for each Medicare-covered $15 copay for each Medicare-covered chiropractic visit. chiropractic visit. Medicare-covered chiropractic visits are for manual Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or (a displacement or misalignment of a joint or body part). body part). Out-of-Network Out-of-Network 20% of the cost for Medicare-covered chiropractic visits. $35 copay for Medicare-covered chiropractic visits. $40 copay for each Medicare-covered podiatry visit. Medicare-covered podiatry visits are for medically-necessary foot care. Out-of-Network 20% of the cost for Medicare-covered podiatry visits. $35 copay for each Medicare-covered podiatry visit. Medicare-covered podiatry visits are for medically-necessary foot care. Out-of-Network $35 copay for Medicare-covered podiatry visits. Authorization rules may apply. $40 copay for each Medicare-covered individual therapy visit $40 copay for each Medicare-covered group therapy visit $40 copay for each Medicare-covered individual therapy visit with a psychiatrist $40 copay for each Medicare-covered group therapy visit with a psychiatrist $40 copay for Medicare-covered partial hospitalization program services Out-of-Network 20% of the cost for Medicare-covered Mental Health visits with a psychiatrist 20%of the cost for Medicare-covered Mental Health visits 20% of the cost for Medicare-covered partial hospitalization program services Authorization rules may apply. $40 copay for Medicare-covered individual substance abuse outpatient treatment visits. $40 copay for Medicare-covered group substance abuse outpatient treatment visits. Out-of-Network 20% of the cost for Medicare-covered substance abuse outpatient treatment visits. Authorization rules may apply. $35 copay for each Medicare-covered individual therapy visit $35 copay for each Medicare-covered group therapy visit $35 copay for each Medicare-covered individual therapy visit with a psychiatrist $35 copay for each Medicare-covered group therapy visit with a psychiatrist $35 copay for Medicare-covered partial hospitalization program services Out-of-Network $35 copay for Medicare-covered Mental Health visits with a psychiatrist $35 copay for Medicare-covered Mental Health visits $35 copay for Medicare-covered partial hospitalization program services Authorization rules may apply. $35 copay for Medicare-covered individual substance abuse outpatient treatment visits. $35 copay for Medicare-covered group substance abuse outpatient treatment visits. Out-of-Network $35 copay for Medicare-covered substance abuse outpatient treatment visits. PAGE 83 of 120

84 Section 2 Summary of Benefits (continued) Benefit 13 Outpatient Services Original Medicare 20% coinsurance for the doctor's services. Specified copayment for outpatient hospital facility services. Copay cannot exceed the Part A inpatient hospital deductible. 20% coinsurance for ambulatory surgical center facility services. 14 Ambulance Services (medically necessary ambulance services) 20% coinsurance 15 Emergency Care (You may go to any emergency room if you reasonably believe you need emergency care.) 16 Urgently Needed Care (This is NOT emergency care, and in most cases, is out of the service area.) 17 Outpatient Rehabilitation Services (Occupational Therapy, Physical Therapy, Speech and Language Therapy) 20% coinsurance for the doctor's services. Specified copayment for outpatient hospital facility emergency services. Emergency services copay cannot exceed Part A inpatient hospital deductible for each service provided by the hospital. You don t have to pay the emergency room copay if you are admitted to the hospital as an inpatient for the same condition within 3 days of the emergency room visit. Not covered outside the U.S. except under limited circumstances. 20% coinsurance, or a set copay. If you are admitted to the hospital within 3 days for the same condition, you pay $0 for the urgently-needed-care visit. NOT covered outside the U.S. except under limited circumstances. 20% coinsurance Medically necessary physical therapy, occupational therapy, and speech and language pathology services are covered. PAGE 84 of 120

85 Blue Medicare PPO Enhanced (PPO) (H3404, Plan 001) Authorization rules may apply. $190 copay for each Medicare-covered ambulatory surgical center visit. $190 copay for each Medicare-covered outpatient hospital facility visit. Out-of-Network 20% of the cost for Medicare-covered outpatient hospital facility visits. 20% of the cost for Medicare-covered ambulatory surgical center visits. Blue Medicare PPO Enhanced Freedom (PPO) (H3404, Plan 002) Authorization rules may apply. $125 copay for each Medicare-covered ambulatory surgical center visit. $125 copay for each Medicare-covered outpatient hospital facility visit. Out-of-Network $125 copay for Medicare-covered outpatient hospital facility visits. $125 copay for Medicare-covered ambulatory surgical center visits. $100 copay for Medicare-covered ambulance benefits. $100 copay for Medicare-covered ambulance benefits. Out-of-Network Out-of-Network $100 copay for Medicare-covered ambulance benefits. $100 copay for Medicare-covered ambulance benefits. $50 copay for Medicare-covered emergency room visits. Worldwide coverage. If you are admitted to the hospital within 48-hour(s) for the same condition, you pay $0 for the emergency room visit. $50 copay for Medicare-covered emergency room visits. Worldwide coverage. If you are admitted to the hospital within 48-hour(s) for the same condition, you pay $0 for the emergency room visit. $40 copay for Medicare-covered urgently-needed-care visits. $35 copay for Medicare-covered urgentlyneeded-care visits. Medically necessary physical therapy, occupational therapy, and speech and language pathology services are covered. $40 copay for Medicare-covered Occupational Therapy visits. $40 copay for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits. Out-of-Network 20% of the cost for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits. 20% of the cost for Medicare-covered Occupational Therapy visits. Medically necessary physical therapy, occupational therapy, and speech and language pathology services are covered. $35 copay for Medicare-covered Occupational Therapy visits. $35 copay for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits. Out-of-Network $35 copay for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits. $35 copay for Medicare-covered Occupational Therapy visits. PAG E 85 of 120

86 Section 2 Summary of Benefits (continued) Benefit Original Medicare OUTPATIENT MEDICAL SERVICES AND SUPPLIES 18 Durable Medical Equipment (includes wheelchairs, oxygen, etc.) 20% coinsurance 19 Prosthetic Devices (includes braces, artificial limbs and eyes, etc.) 20% coinsurance 20% coinsurance for Medicare-covered medical supplies related to prosthetics, splints, and other devices. 20 Diabetes Programs and Supplies 20% coinsurance for diabetes self-management training 20% coinsurance for diabetes supplies 20% coinsurance for diabetic therapeutic shoes or inserts PAGE 86 of 120

87 Blue Medicare PPO Blue Medicare PPO Enhanced (PPO) Enhanced Freedom (PPO) (H3404, Plan 001) (H3404, Plan 002) Authorization rules may apply. 20% of the cost for Medicare-covered durable medical equipment. Out-of-Network 20% of the cost for Medicare-covered durable medical equipment. Authorization rules may apply. 20% of the cost for Medicare-covered durable medical equipment. Out-of-Network 20% of the cost for Medicare-covered durable medical equipment. Authorization rules may apply. 20% of the cost for Medicare-covered prosthetic devices. 20% of the cost for Medicare-covered medical supplies related to prosthetics, splints, and other devices. Out-of-Network 20% of the cost for Medicare-covered prosthetic devices. 0% of the cost for Medicare-covered Diabetes self-management training 0% of the cost for Medicare-covered Diabetes monitoring supplies 20% of the cost for Medicare-covered Therapeutic shoes or inserts Out-of-Network $0 copay for Medicare-covered Diabetes self-management training 20% of the cost for Medicare-covered Diabetes monitoring supplies 20% of the cost for Medicare-covered Therapeutic shoes or inserts Authorization rules may apply. 20% of the cost for Medicare-covered prosthetic devices. 20% of the cost for Medicare-covered medical supplies related to prosthetics, splints, and other devices. Out-of-Network 20% of the cost for Medicare-covered prosthetic devices. 0% of the cost for Medicare-covered Diabetes self-management training 0% of the cost for Medicare-covered Diabetes monitoring supplies 20% of the cost for Medicare-covered Therapeutic shoes or inserts Out-of-Network 20% of the cost for Medicare-covered Diabetes monitoring supplies 20% of the cost for Medicare-covered Therapeutic shoes or inserts $0 copay for Medicare-covered Diabetes self-management training PAGE 87 of 120

88 Section 2 Summary of Benefits (continued) Benefit 21 Diagnostic Tests, X-Rays, Lab Services, and Radiology Services Original Medicare 20% coinsurance for diagnostic tests and X-rays. $0 copay for Medicare-covered lab services. Lab Services: Medicare covers medically necessary diagnostic lab services that are ordered by your treating doctor when they are provided by a Clinical Laboratory Improvement Amendments (CLIA) certified laboratory that participates in Medicare. Diagnostic lab services are done to help your doctor diagnose or rule out a suspected illness or condition. Medicare does not cover most supplemental routine screening tests, like checking your cholesterol. 22 Cardiac and Pulmonary Rehabilitation Services 20% coinsurance for Cardiac Rehabilitation services 20% coinsurance for Pulmonary Rehabilitation services 20% coinsurance for Intensive Cardiac Rehabilitation services PAG E 88 of 120

89 Blue Medicare PPO Enhanced (PPO) (H3404, Plan 001) Authorization rules may apply. 20% of the cost for Medicare-covered lab services. 20% of the cost for Medicare-covered diagnostic procedures and tests. 20% of the cost for Medicare-covered X-rays. 20% of the cost for Medicare-covered diagnostic radiology services (not including X-rays). 0% of the cost for Medicare-covered therapeutic radiology services. If the doctor provides you services in addition to Outpatient Diagnostic Procedures, Tests and Lab Services, separate cost sharing of $20 to $40 may apply. If the doctor provides you services in addition to Outpatient Diagnostic and Therapeutic Radiology Services, separate cost sharing of $20 to $40 may apply. Out-of-Network $0 copay for Medicare-covered therapeutic radiology services 20% of the cost for Medicare-covered outpatient X-rays 20% of the cost for Medicare-covered diagnostic radiology services 20% of the cost for Medicare-covered diagnostic procedures and tests 20% of the cost for Medicare-covered lab services 0% of the cost for Medicare-covered Cardiac Rehabilitation Services 0% of the cost for Medicare-covered Intensive Cardiac Rehabilitation Services 0% of the cost for Medicare-covered Pulmonary Rehabilitation Services Out-of-Network 20% of the cost for Medicare-covered Cardiac Rehabilitation Services 20% of the cost for Medicare-covered Intensive Cardiac Rehabilitation Services 20% of the cost for Medicare-covered Pulmonary Rehabilitation Services Blue Medicare PPO Enhanced Freedom (PPO) (H3404, Plan 002) Authorization rules may apply. 15% of the cost for Medicare-covered lab services. 15% of the cost for Medicare-covered diagnostic procedures and tests. 15% of the cost for Medicare-covered X-rays. 15% of the cost for Medicare-covered diagnostic radiology services (not including X-rays). 0% of the cost for Medicare-covered therapeutic radiology services. If the doctor provides you services in addition to Outpatient Diagnostic Procedures, Tests and Lab Services, separate cost sharing of $15 to $35 may apply. If the doctor provides you services in addition to Outpatient Diagnostic and Therapeutic Radiology Services, separate cost sharing of $15 to $35 may apply. Out-of-Network $0 copay for Medicare-covered therapeutic radiology services 15% of the cost for Medicare-covered outpatient X-rays 15% of the cost for Medicare-covered diagnostic radiology services 15% of the cost for Medicare-covered diagnostic procedures and tests 15% of the cost for Medicare-covered lab services 0% of the cost for Medicare-covered Cardiac Rehabilitation Services 0% of the cost for Medicare-covered Intensive Cardiac Rehabilitation Services 0% of the cost for Medicare-covered Pulmonary Rehabilitation Services Out-of-Network $35 copay for Medicare-covered Cardiac Rehabilitation Services $35 copay for Medicare-covered Intensive Cardiac Rehabilitation Services $35 copay for Medicare-covered Pulmonary Rehabilitation Services PAG E 89 of 120

90 Section 2 Summary of Benefits (continued) Benefit PREVENTIVE SERVICES 23 Preventive Services Original Medicare No coinsurance, copayment or deductible for the following: Abdominal Aortic Aneurysm Screening Bone Mass Measurement. Covered once every 24 months (more often if medically necessary) if you meet certain medical conditions. Cardiovascular Screening Cervical and Vaginal Cancer Screening. Covered once every 2 years. Covered once a year for women with Medicare at high risk. Colorectal Cancer Screening Diabetes Screening Influenza Vaccine Hepatitis B Vaccine for people with Medicare who are at risk HIV Screening. $0 copay for the HIV screening, but you generally pay 20% of the Medicare approved amount for the doctor's visit. HIV screening is covered for people with Medicare who are pregnant and people at increased risk for the infection, including anyone who asks for the test. Medicare covers this test once every 12 months or up to three times during a pregnancy. Breast Cancer Screening (Mammogram). Medicare covers screening mammograms once every 12 months for all women with Medicare age 40 and older. Medicare covers one baseline mammogram for women between ages Medical Nutrition Therapy Services. Nutrition therapy is for people who have diabetes or kidney disease (but aren't on dialysis or haven't had a kidney transplant) when referred by a doctor. These services can be given by a registered dietitian and may include a nutritional assessment and counseling to help you manage your diabetes or kidney disease Personalized Prevention Plan Services (Annual Wellness Visits) Pneumococcal Vaccine. You may only need the Pneumonia vaccine once in your lifetime. Call your doctor for more information. Prostate Cancer Screening. Prostate Specific Antigen (PSA) test only. Covered once a year for all men with Medicare over age 50. Smoking and Tobacco Use Cessation (counseling to stop smoking and tobacco use). Covered if ordered by your doctor. Includes two counseling attempts within a 12-month period. Each counseling attempt includes up to four face-toface visits. Screening and behavioral counseling interventions in primary care to reduce alcohol misuse Screening for depression in adults Screening for sexually transmitted infections (STI) and high-intensity behavioral counseling to prevent STIs Intensive behavioral counseling for Cardiovascular Disease (bi-annual) Intensive behavioral therapy for obesity Welcome to Medicare Preventive Visits (initial preventive physical exam). When you join Medicare Part B, then you are eligible as follows. During the first 12 months of your new Part B coverage, you can get either a Welcome to Medicare Preventive Visits or an Annual Wellness Visit. After your first 12 months, you can get one Annual Wellness Visit every 12 months. PAGE 90 of 120

91 Blue Medicare PPO Enhanced (PPO) (H3404, Plan 001) Blue Medicare PPO Enhanced Freedom (PPO) (H3404, Plan 002) $0 copay for all preventive services covered under Original Medicare at zero cost sharing. Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare. 0% of the cost for a supplemental annual physical exam Out-of-Network $0 copay for Medicare-covered preventive services $0 copay for a supplemental annual physical exam $0 copay for all preventive services covered under Original Medicare at zero cost sharing. Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare. 0% of the cost for a supplemental annual physical exam Out-of-Network $0 copay for Medicare-covered preventive services $0 copay for a supplemental annual physical exam PAG E 91 of 120

92 Section 2 Summary of Benefits (continued) Benefit 24 Kidney Disease and Conditions Original Medicare 20% coinsurance for renal dialysis 20% coinsurance for kidney disease education services PAGE 92 of 120

93 Blue Medicare PPO Enhanced (PPO) (H3404, Plan 001) 0% of the cost for Medicare-covered renal dialysis 0% of the cost for Medicare-covered kidney disease education services Out-of-Network $0 copay for Medicare-covered kidney disease education services 20% of the cost for Medicare-covered renal dialysis Blue Medicare PPO Enhanced Freedom (PPO) (H3404, Plan 002) 0% of the cost for Medicare-covered renal dialysis 0% of the cost for Medicare-covered kidney disease education services Out-of-Network $0 copay for Medicare-covered kidney disease education services $0 copay for Medicare-covered renal dialysis PAGE 93 of 120

94 Section 2 Summary of Benefits (continued) Benefit Original Medicare Blue Medicare PPO Enhanced (PPO) (H3404, Plan 001) Blue Medicare PPO Enhanced Freedom (PPO) (H3404, Plan 002) PRESCRIPTION DRUG BENEFITS 25 Most drugs are Drugs covered under Drugs covered under Outpatient not covered Medicare Part B Medicare Part B Prescription Drugs under Original Medicare. You can add prescription drug coverage to Original Medicare by joining a Medicare 20% of the cost for Medicare Part B chemotherapy drugs and other Part B drugs. 20% of the cost for Medicare Part B drugs out-of-network. 20% of the cost for Medicare Part B chemotherapy drugs and other Part B drugs. 20% of the cost for Medicare Part B drugs out-of-network. Prescription Drug Plan, or you can get Drugs covered under Medicare Drugs covered under Medicare all your Medicare Part D Part D coverage, including prescription drug coverage, by joining a Medicare Advantage Plan or a Medicare Cost Plan that offers prescription drug coverage. This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at medicare/formulary-home.htm on the web. Different out-of-pocket costs may apply for people who have limited incomes, live in long term care facilities, or have access to Indian/Tribal/ Urban (Indian Health Service) providers. The plan offers national in-network prescription coverage (i.e., this would include 50 states and the District of Columbia). This means that you will pay the same cost-sharing amount for your prescription drugs if you get them at an in-network pharmacy outside of the plan s service area (for instance when you travel). Total yearly drug costs are the total drug costs paid by both you and a Part D plan. This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at medicare/formulary-home.htm on the web. Different out-of-pocket costs may apply for people who have limited incomes, live in long term care facilities, or have access to Indian/Tribal/ Urban (Indian Health Service) providers. The plan offers national in-network prescription coverage (i.e., this would include 50 states and the District of Columbia). This means that you will pay the same cost-sharing amount for your prescription drugs if you get them at an in-network pharmacy outside of the plan s service area (for instance when you travel). Total yearly drug costs are the total drug costs paid by both you and a Part D plan. PAGE 94 of 120

95 Benefit Original Medicare Blue Medicare PPO Enhanced (PPO) (H3404, Plan 001) Blue Medicare PPO Enhanced Freedom (PPO) (H3404, Plan 002) 25 The plan may require you to first The plan may require you to first Outpatient try one drug to treat your condition try one drug to treat your condition Prescription Drugs before it will cover another drug for before it will cover another drug for (Continued) that condition. Some drugs have quantity limits. that condition. Some drugs have quantity limits. Your provider must get prior authorization from Blue Medicare PPO Enhanced (PPO) for certain drugs. You must go to certain pharmacies for a very limited number of drugs, due to special handling, provider coordination, or patient education requirements that cannot be met by most pharmacies in your network. These drugs are listed on the plan s website, formulary, printed materials, as well as on the Medicare Prescription Drug Plan Finder on Medicare.gov. If the actual cost of a drug is less than the normal cost-sharing amount for that drug, you will pay the actual cost, not the higher cost-sharing amount. If you request a formulary exception for a drug and Blue Medicare PPO Enhanced (PPO) approves the exception, you will pay Tier 4: Non-Preferred Brand cost sharing for that drug. Your provider must get prior authorization from Blue Medicare PPO Enhanced Freedom (PPO) for certain drugs. You must go to certain pharmacies for a very limited number of drugs, due to special handling, provider coordination, or patient education requirements that cannot be met by most pharmacies in your network. These drugs are listed on the plan s website, formulary, printed materials, as well as on the Medicare Prescription Drug Plan Finder on Medicare.gov. If the actual cost of a drug is less than the normal cost-sharing amount for that drug, you will pay the actual cost, not the higher cost-sharing amount. If you request a formulary exception for a drug and Blue Medicare PPO Enhanced Freedom (PPO) approves the exception, you will pay Tier 4: Non-Preferred Brand cost sharing for that drug. $0 deductible. $0 deductible. PAGE 95 of 120

96 Section 2 Summary of Benefits (continued) Benefit Original Medicare Blue Medicare PPO Enhanced (PPO) (H3404, Plan 001) Blue Medicare PPO Enhanced Freedom (PPO) (H3404, Plan 002) 25 Initial Coverage Initial Coverage Outpatient You pay the following until total You pay the following until total yearly Prescription yearly drug costs reach $2,850: drug costs reach $2,850: Drugs Retail Pharmacy Retail Pharmacy (Continued) Contact your plan if you have Contact your plan if you have questions about cost-sharing or billing questions about cost-sharing or billing when less than a one-month supply is dispensed. You can get drugs from a preferred and non-preferred pharmacy the following way(s): Tier 1 - Preferred Generic when less than a one-month supply is dispensed. You can get drugs from a preferred and non-preferred pharmacy the following way(s): Tier 1 - Preferred Generic $3 copay for a one-month (30-day) $3 copay for a one-month (30-day) preferred pharmacy preferred pharmacy $6 copay for a two-month $6 copay for a two-month (60-day) (60-day) supply of drugs in this tier from a preferred pharmacy preferred pharmacy $9 copay for a three-month $9 copay for a three-month (90-day) (90-day) supply of drugs in this tier from a preferred pharmacy preferred pharmacy $8 copay for a one-month $8 copay for a one-month (30-day) (30-day) supply of drugs in this tier from a non-preferred pharmacy non-preferred pharmacy $16 copay for a two-month $16 copay for a two-month (60-day) (60-day) supply of drugs in this tier from a non-preferred pharmacy non-preferred pharmacy $24 copay for a three-month $24 copay for a three-month (90-day) (90-day) supply of drugs in this tier from a non-preferred pharmacy non-preferred pharmacy Not all drugs on this tier are available Not all drugs on this tier are available at this extended day supply. Please at this extended day supply. Please contact the plan for more information. contact the plan for more information. PAGE 96 of 120 Tier 2 - Non-Preferred Generic $6 copay for a one-month (30-day) preferred pharmacy $12 copay for a two-month (60-day) preferred pharmacy $18 copay for a three-month (90-day) preferred pharmacy $25 copay for a one-month (30-day) non-preferred pharmacy $50 copay for a two-month (60-day) non-preferred pharmacy $75 copay for a three-month (90-day) non-preferred pharmacy Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. Tier 2 - Non-Preferred Generic $6 copay for a one-month (30-day) preferred pharmacy $12 copay for a two-month (60-day) preferred pharmacy $18 copay for a three-month (90-day) preferred pharmacy $20 copay for a one-month (30-day) non-preferred pharmacy $40 copay for a two-month (60-day) non-preferred pharmacy $60 copay for a three-month (90-day) non-preferred pharmacy Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.

97 Benefit Original Medicare Blue Medicare PPO Enhanced (PPO) (H3404, Plan 001) Blue Medicare PPO Enhanced Freedom (PPO) (H3404, Plan 002) 25 Tier 3 - Preferred Brand Tier 3 - Preferred Brand Outpatient $40 copay for a one-month (30-day) $30 copay for a one-month (30-day) Prescription preferred pharmacy preferred pharmacy Drugs $80 copay for a two-month (60-day) $60 copay for a two-month (60-day) (Continued) preferred pharmacy $120 copay for a three-month (90-day) supply of drugs in this tier from a preferred pharmacy $45 copay for a one-month (30-day) non-preferred pharmacy $90 copay for a two-month (60-day) non-preferred pharmacy $135 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred pharmacy preferred pharmacy $90 copay for a three-month (90-day) preferred pharmacy $45 copay for a one-month (30-day) non-preferred pharmacy $90 copay for a two-month (60-day) non-preferred pharmacy $135 copay for a three-month (90-day) non-preferred pharmacy Not all drugs on this tier are available Not all drugs on this tier are available at this extended day supply. Please at this extended day supply. Please contact the plan for more information. contact the plan for more information. Tier 4 - Non-Preferred Brand Tier 4 - Non-Preferred Brand $80 copay for a one-month (30-day) $70 copay for a one-month (30-day) preferred pharmacy preferred pharmacy $160 copay for a two-month (60-day) preferred pharmacy $240 copay for a three-month (90-day) supply of drugs in this tier from a preferred pharmacy $95 copay for a one-month (30-day) non-preferred pharmacy $190 copay for a two-month (60-day) non-preferred pharmacy $285 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred pharmacy Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. $140 copay for a two-month (60-day) preferred pharmacy $210 copay for a three-month (90-day) preferred pharmacy $95 copay for a one-month (30-day) non-preferred pharmacy $190 copay for a two-month (60-day) non-preferred pharmacy $285 copay for a three-month (90-day) non-preferred pharmacy Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. PAGE 97 of 120

98 Section 2 Summary of Benefits (continued) Benefit Original Medicare Blue Medicare PPO Enhanced (PPO) (H3404, Plan 001) Blue Medicare PPO Enhanced Freedom (PPO) (H3404, Plan 002) 25 Tier 5 - Specialty Tier Tier 5 - Specialty Tier Outpatient 33% coinsurance for a one-month Prescription (30-day) supply of drugs in this tier from a preferred pharmacy Drugs 33% coinsurance for a two-month (Continued) (60-day) supply of drugs in this tier from a preferred pharmacy 33% coinsurance for a three-month (90-day) supply of drugs in this tier from a preferred pharmacy 33% coinsurance for a one-month (30-day) supply of drugs in this tier from a non-preferred pharmacy 33% coinsurance for a two-month (60-day) supply of drugs in this tier from a non-preferred pharmacy 33% coinsurance for a three-month (90-day) supply of drugs in this tier from a non-preferred pharmacy Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. Long-Term Care Pharmacy Long-term care pharmacies must dispense brand name drugs in amounts less than a 14 days supply at a time. They may also dispense less than a month's supply of generic drugs at a time. Contact your plan if you have questions about cost sharing or billing when less than a one-month supply is dispensed. You can get drugs the following way(s): Tier 1 - Preferred Generic $8 copay for a one-month (31-day) supply of drugs in this tier Tier 2 - Non-Preferred Generic $25 copay for a one-month (31-day) supply of drugs in this tier Tier 3 - Preferred Brand $45 copay for a one-month (31-day) supply of drugs in this tier Tier 4 - Non-Preferred Brand $95 copay for a one-month (31-day) supply of drugs in this tier Tier 5 - Specialty Tier 33% coinsurance for a one-month (31-day) supply of drugs in this tier 33% coinsurance for a one-month (30-day) supply of drugs in this tier from a preferred pharmacy 33% coinsurance for a two-month (60-day) supply of drugs in this tier from a preferred pharmacy 33% coinsurance for a three-month (90-day) supply of drugs in this tier from a preferred pharmacy 33% coinsurance for a one-month (30-day) supply of drugs in this tier from a non-preferred pharmacy 33% coinsurance for a two-month (60-day) supply of drugs in this tier from a non-preferred pharmacy 33% coinsurance for a three-month (90-day) supply of drugs in this tier from a non-preferred pharmacy Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. Long-Term Care Pharmacy Long-term care pharmacies must dispense brand name drugs in amounts less than a 14 days supply at a time. They may also dispense less than a month's supply of generic drugs at a time. Contact your plan if you have questions about cost sharing or billing when less than a one-month supply is dispensed. You can get drugs the following way(s): Tier 1 - Preferred Generic $8 copay for a one-month (31-day) supply of drugs in this tier Tier 2 - Non-Preferred Generic $20 copay for a one-month (31-day) supply of drugs in this tier Tier 3 - Preferred Brand $45 copay for a one-month (31-day) supply of drugs in this tier Tier 4 - Non-Preferred Brand $95 copay for a one-month (31-day) supply of drugs in this tier Tier 5 - Specialty Tier 33% coinsurance for a one-month (31-day) supply of drugs in this tier PAG E 98 of 120

99 Benefit Original Medicare Blue Medicare PPO Enhanced (PPO) (H3404, Plan 001) Blue Medicare PPO Enhanced Freedom (PPO) (H3404, Plan 002) 25 Mail Order: Mail Order: Outpatient Contact your plan if you have questions Contact your plan if you have questions Prescription about cost-sharing or billing when less about cost-sharing or billing when less Drugs than a one-month supply is dispensed. than a one-month supply is dispensed. You can get drugs from a preferred and You can get drugs from a preferred and (Continued) non-preferred mail order pharmacy the non-preferred mail order pharmacy the following way(s): following way(s): Tier 1 - Preferred Generic $3 copay for a one-month (30-day) preferred mail order pharmacy. $0 copay for a two-month (60-day) preferred mail order pharmacy. $0 copay for a three-month (90-day) preferred mail order pharmacy. $8 copay for a one-month (30-day) non-preferred mail order pharmacy. $16 copay for a two-month (60-day) non-preferred mail order pharmacy. $24 copay for a three-month (90-day) non-preferred mail order pharmacy. Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. Tier 1 - Preferred Generic $3 copay for a one-month (30-day) preferred mail order pharmacy. $0 copay for a two-month (60-day) preferred mail order pharmacy. $0 copay for a three-month (90-day) preferred mail order pharmacy. $8 copay for a one-month (30-day) non-preferred mail order pharmacy. $16 copay for a two-month (60-day) non-preferred mail order pharmacy. $24 copay for a three-month (90-day) non-preferred mail order pharmacy. Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. PAGE 99 of 120

100 Section 2 Summary of Benefits (continued) Benefit Original Medicare Blue Medicare PPO Enhanced (PPO) (H3404, Plan 001) Blue Medicare PPO Enhanced Freedom (PPO) (H3404, Plan 002) 25 Tier 2 - Non-Preferred Generic Tier 2 - Non-Preferred Generic Outpatient $6 copay for a one-month (30-day) $6 copay for a one-month (30-day) Prescription Drugs preferred mail order pharmacy. preferred mail order pharmacy. (Continued) $12 copay for a two-month (60-day) preferred mail order pharmacy. $15 copay for a three-month (90-day) preferred mail order pharmacy. $25 copay for a one-month (30-day) non-preferred mail order pharmacy. $50 copay for a two-month (60-day) non-preferred mail order pharmacy. $75 copay for a three-month (90-day) non-preferred mail order pharmacy. Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. Tier 3 - Preferred Brand $40 copay for a one-month (30-day) preferred mail order pharmacy. $80 copay for a two-month (60-day) preferred mail order pharmacy. $100 copay for a three-month (90-day) preferred mail order pharmacy. $45 copay for a one-month (30-day) non-preferred mail order pharmacy. $90 copay for a two-month (60-day) non-preferred mail order pharmacy. $135 copay for a three-month (90-day) non-preferred mail order pharmacy. Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. $12 copay for a two-month (60-day) preferred mail order pharmacy. $15 copay for a three-month (90-day) preferred mail order pharmacy. $20 copay for a one-month (30-day) non-preferred mail order pharmacy. $40 copay for a two-month (60-day) non-preferred mail order pharmacy. $60 copay for a three-month (90-day) non-preferred mail order pharmacy. Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. Tier 3 - Preferred Brand $30 copay for a one-month (30-day) preferred mail order pharmacy. $60 copay for a two-month (60-day) preferred mail order pharmacy. $75 copay for a three-month (90-day) preferred mail order pharmacy. $45 copay for a one-month (30-day) non-preferred mail order pharmacy. $90 copay for a two-month (60-day) non-preferred mail order pharmacy. $135 copay for a three-month (90-day) non-preferred mail order pharmacy. Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. PAG E 100 of 120

101 Benefit Original Medicare Blue Medicare PPO Enhanced (PPO) (H3404, Plan 001) Blue Medicare PPO Enhanced Freedom (PPO) (H3404, Plan 002) 25 Tier 4- Non-Preferred Brand Tier 4 - Non-Preferred Brand Outpatient $80 copay for a one-month (30-day) $70 copay for a one-month (30-day) supply Prescription of drugs in this tier from a preferred mail Drugs preferred mail order pharmacy. order pharmacy. (Continued) $160 copay for a two-month (60-day) $140 copay for a two-month (60-day) supply of drugs in this tier from a preferred mail preferred mail order pharmacy. $200 copay for a three-month (90-day) preferred mail order pharmacy. $95 copay for a one-month (30-day) non-preferred mail order pharmacy. $190 copay for a two-month (60-day) non-preferred mail order pharmacy. $285 copay for a three-month (90-day) non-preferred mail order pharmacy. Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. Tier 5 - Specialty Tier 33% coinsurance for a one-month (30-day) supply of drugs in this tier from a preferred mail order pharmacy. 33% coinsurance for a two-month (60-day) supply of drugs in this tier from a preferred mail order pharmacy. 33% coinsurance for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy. 33% coinsurance for a one-month (30-day) supply of drugs in this tier from a non-preferred mail order pharmacy. 33% coinsurance for a two-month (60-day) supply of drugs in this tier from a non-preferred mail order pharmacy. 33% coinsurance for a three-month (90-day) supply of drugs in this tier from a non-preferred mail order pharmacy. Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. order pharmacy. $175 copay for a three-month (90-day) preferred mail order pharmacy. $95 copay for a one-month (30-day) supply of drugs in this tier from a non-preferred mail order pharmacy. $190 copay for a two-month (60-day) supply of drugs in this tier from a non-preferred mail order pharmacy. $285 copay for a three-month (90-day) non-preferred mail order pharmacy. Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. Tier 5 - Specialty Tier 33% coinsurance for a one-month (30-day) supply of drugs in this tier from a preferred mail order pharmacy. 33% coinsurance for a two-month (60-day) supply of drugs in this tier from a preferred mail order pharmacy. 33% coinsurance for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy. 33% coinsurance for a one-month (30-day) supply of drugs in this tier from a non-preferred mail order pharmacy. 33% coinsurance for a two-month (60-day) supply of drugs in this tier from a non-preferred mail order pharmacy. 33% coinsurance for a three-month (90-day) supply of drugs in this tier from a non-preferred mail order pharmacy. Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. PAG E 101 of 120

102 Section 2 Summary of Benefits (continued) Benefit Original Medicare Blue Medicare PPO Enhanced (PPO) (H3404, Plan 001) Blue Medicare PPO Enhanced Freedom (PPO) (H3404, Plan 002) 25 Coverage Gap Coverage Gap Outpatient After your total After your total yearly drug costs reach $2,850, you receive Prescription yearly drug costs limited coverage by the plan on certain drugs. You will also Drugs reach $2,850, receive a discount on brand name drugs and generally pay (Continued) you receive limited no more than 47.5% for the plan s costs for brand drugs and 72% of the plan s costs for generic drugs until your yearly coverage by the out-of-pocket drug costs reach $4,550. plan on certain drugs. You will also receive Additional Coverage Gap a discount on brand The plan covers some formulary generics (10%-64% of name drugs and formulary generic drugs) through the coverage gap. The plan generally pay no more than 47.5% for the plan s costs for brand drugs and 72% of the plan s costs for generic drugs until your yearly out-ofpocket drug costs reach $4,550. offers additional coverage in the gap for the following tiers. You pay the following: Retail Pharmacy Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed. Tier 1: Preferred Generic $3 copay for a one-month (30-day) supply of all drugs covered within this tier from a preferred pharmacy $6 copay for a two-month (60-day) supply of all drugs covered within this tier from a preferred pharmacy $9 copay for a three-month (90-day) supply of all drugs covered within this tier from a preferred pharmacy $8 copay for a one-month (30-day) supply of all drugs covered within this tier at a non-preferred pharmacy $16 copay for a two-month (60-day) supply of all drugs covered within this tier from a non-preferred pharmacy $24 copay for a three-month (90-day) supply of all drugs covered within this tier from a non-preferred pharmacy Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. PAG E 102 of 12 0

103 Benefit Original Medicare Blue Medicare PPO Enhanced (PPO) (H3404, Plan 001) Blue Medicare PPO Enhanced Freedom (PPO) (H3404, Plan 002) 25 Long-Term Care Pharmacy Outpatient Long-term care pharmacies must dispense brand name Prescription drugs in amounts less than a 14 days supply at a time. Drugs They may also dispense less than a month's supply of generic drugs at a time. Contact your plan if you have (Continued) questions about cost-sharing or billing when less than a one-month supply is dispensed. Tier 1: Preferred Generic $8 copay for a one-month (31-day) supply of all drugs covered within this tier Mail Order Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed. Tier 1: Preferred Generic $3 copay for a one-month (30-day) supply of all drugs covered within this tier from a preferred mail order pharmacy $0 copay for a two-month (60-day) supply of all drugs covered within this tier from a preferred mail order pharmacy $0 copay for a three-month (90-day) supply of all drugs covered within this tier from a preferred mail order pharmacy $8 copay for a one-month (30-day) supply of all drugs covered within this tier from a non-preferred mail order pharmacy $16 copay for a two-month (60-day) supply of all drugs covered within this tier from a non-preferred mail order pharmacy $24 copay for a three-month (90-day) supply of all drugs covered within this tier from a non-preferred mail order pharmacy Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. PAG E 103 of 12 0

104 Section 2 Summary of Benefits (continued) Benefit Original Medicare Blue Medicare PPO Enhanced (PPO) (H3404, Plan 001) Blue Medicare PPO Enhanced Freedom (PPO) (H3404, Plan 002) 25 Catastrophic Coverage Catastrophic Coverage Outpatient After your yearly out-of-pocket After your yearly out-of-pocket Prescription drug costs reach $4,550, you pay drug costs reach $4,550, you pay Drugs the greater of: the greater of: (Continued) 5% coinsurance, or $2.55 copay for generic (including brand drugs treated as generic) and a $6.35 copay for all other drugs. Out-of-Network Plan drugs may be covered in special circumstances, for instance, illness while traveling outside of the plan s service area where there is no network pharmacy. You may have to pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy. In addition, you will likely have to pay the pharmacy s full charge for the drug and submit documentation to receive reimbursement from Blue Medicare PPO Enhanced (PPO). You can get out-of-network drugs the following way: 5% coinsurance, or $2.55 copay for generic (including brand drugs treated as generic) and a $6.35 copay for all other drugs. Out-of-Network Plan drugs may be covered in special circumstances, for instance, illness while traveling outside of the plan s service area where there is no network pharmacy. You may have to pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy. In addition, you will likely have to pay the pharmacy s full charge for the drug and submit documentation to receive reimbursement from Blue Medicare PPO Enhanced Freedom (PPO). You can get out-of-network drugs the following way: (Continued) (Continued) PAG E 104 of 120

105 Benefit 25 Outpatient Prescription Drugs (Continued) Original Medicare Blue Medicare PPO Enhanced (PPO) (H3404, Plan 001) Out-of-Network Initial Coverage You will be reimbursed up to the plan's cost of the drug minus the following for drugs purchased out-of-network until total yearly drug costs reach $2,850: Tier 1: Preferred Generic $8 copay for a one-month (30-day) supply of drugs in this tier Tier 2: Non-Preferred Generic $25 copay for a one-month (30-day) supply of drugs in this tier Tier 3: Preferred Brand $45 copay for a one-month (30-day) supply of drugs in this tier Tier 4: Non-Preferred Brand $95 copay for a one-month (30-day) supply of drugs in this tier Tier 5: Specialty Tier 33% coinsurance for a one-month (30-day) supply of drugs in this tier You will not be reimbursed for the difference between the Out-of- Network Pharmacy charge and the plan's allowable amount. Blue Medicare PPO Enhanced Freedom (PPO) (H3404, Plan 002) Out-of-Network Initial Coverage You will be reimbursed up to the plan's cost of the drug minus the following for drugs purchased out-of-network until total yearly drug costs reach $2,850: Tier 1: Preferred Generic $8 copay for a one-month (30-day) supply of drugs in this tier Tier 2: Non-Preferred Generic $20 copay for a one-month (30-day) supply of drugs in this tier Tier 3: Preferred Brand $45 copay for a one-month (30-day) supply of drugs in this tier Tier 4: Non-Preferred Brand $95 copay for a one-month (30-day) supply of drugs in this tier Tier 5: Specialty Tier 33% coinsurance for a one-month (30-day) supply of drugs in this tier You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's allowable amount. PAG E 105 of 12 0

106 Section 2 Summary of Benefits (continued) Benefit Original Medicare Blue Medicare PPO Enhanced (PPO) (H3404, Plan 001) Blue Medicare PPO Enhanced Freedom (PPO) (H3404, Plan 002) Out-of-Network Coverage Gap You will be reimbursed up to 28% of the plan allowable cost for generic drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4,550. Please note that the plan allowable cost may be less than the out-of-network pharmacy price paid for your drug(s). 25 Outpatient Prescription Drugs (Continued) Out-of-Network Coverage Gap You will be reimbursed up to 28% of the plan allowable cost for generic drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4,550. Please note that the plan allowable cost may be less than the out-of-network pharmacy price paid for your drug(s). You will be reimbursed up to 52.5% of the plan allowable cost for brand name drugs purchased out-of-network until your total yearly out-of-pocket drug costs reach $4,550. Please note that the plan allowable cost may be less than the out-of-network pharmacy price paid for your drug(s). You will be reimbursed up to 52.5% of the plan allowable cost for brand name drugs purchased out-of-network until your total yearly out-of-pocket drug costs reach $4,550. Please note that the plan allowable cost may be less than the out-of-network pharmacy price paid for your drug(s). Additional Out-of-Network Coverage Gap You will be reimbursed for these drugs purchased out-of-network up to the plan's cost of the drug minus the following: Tier 1: Preferred Generic $8 copay for a one-month (30-day) supply of all drugs covered within this tier PAG E 106 of 12 0

107 Benefit Original Medicare Blue Medicare PPO Enhanced (PPO) (H3404, Plan 001) Blue Medicare PPO Enhanced Freedom (PPO) (H3404, Plan 002) Out-of-Network Catastrophic Coverage After your yearly out-of-pocket drug costs reach $4,550, you will be reimbursed for drugs purchased out-of-network up to the plan's cost of the drug minus your cost share, which is the greater of: 5% coinsurance, or $2.55 copay for generic (including brand drugs treated as generic) and a $6.35 copay for all other drugs You will not be reimbursed for the difference between the Out-of- Network Pharmacy charge and the plan's allowable amount. 25 Outpatient Prescription Drugs (Continued) Out-of-Network Catastrophic Coverage After your yearly out-of-pocket drug costs reach $4,550, you will be reimbursed for drugs purchased out-of-network up to the plan's cost of the drug minus your cost share, which is the greater of: 5% coinsurance, or $2.55 copay for generic (including brand drugs treated as generic) and a $6.35 copay for all other drugs You will not be reimbursed for the difference between the Out-of- Network Pharmacy charge and the plan's allowable amount. PAG E 107 of 12 0

108 Section 2 Summary of Benefits (continued) Benefit Original Medicare OUTPATIENT MEDICAL SERVICES AND SUPPLIES 26 Dental Services Preventive dental services (such as cleaning) not covered. 27 Hearing Services Supplemental routine hearing exams and hearing aids not covered. 20% coinsurance for diagnostic hearing exams. 28 Vision Services 20% coinsurance for diagnosis and treatment of diseases and conditions of the eye, including an annual glaucoma screening for people at risk Supplemental routine eye exams and eyeglasses (lenses and frames) not covered. Medicare pays for one pair of eyeglasses or contact lenses after cataract surgery. Wellness/Education and Other Supplemental Benefits & Services Not covered. Over-the-Counter Items Not covered. Transportation (Routine) Not covered. Acupuncture and Other Alternative Therapies Not covered. PAG E 108 of 12 0

109 Blue Medicare PPO Enhanced (PPO) (H3404, Plan 001) Blue Medicare PPO Enhanced Freedom (PPO) (H3404, Plan 002) In general, preventive dental benefits (such as cleaning) not covered. $40 copay for Medicare-covered dental benefits. Out-of-Network 20% of the cost for Medicare-covered comprehensive dental benefits. In general, preventive dental benefits (such as cleaning) not covered. $35 copay for Medicare-covered dental benefits. Out-of-Network $35 copay for Medicare-covered comprehensive dental benefits. In general, supplemental routine hearing exams and hearing aids not covered. $40 copay for Medicare-covered diagnostic hearing exams. Out-of-Network 20% of the cost for Medicare-covered diagnostic hearing exams. In general, supplemental routine hearing exams and hearing aids not covered. $35 copay for Medicare-covered diagnostic hearing exams. Out-of-Network $35 copay for Medicare-covered diagnostic hearing exams. $0 to $40 copay for Medicare-covered exams to diagnose and treat diseases and conditions of the eye, including an annual glaucoma screening for people at risk. $40 copay for up to 1 supplemental routine eye exam(s). 20% of the cost for one pair of Medicare-covered eyeglasses (lenses and frames) or contact lenses after cataract surgery. $100 plan coverage limit for supplemental routine eye exams. Out-of-Network 20% of the cost for Medicare-covered eye exams. 20% of the cost for supplemental routine eye exams. 20% of the cost for Medicare-covered eye wear. $0 to $35 copay for Medicare-covered exams to diagnose and treat diseases and conditions of the eye, including an annual glaucoma screening for people at risk. $35 copay for up to 1 supplemental routine eye exam(s). 20% of the cost for one pair of Medicare-covered eyeglasses (lenses and frames) or contact lenses after cataract surgery. $100 plan coverage limit for supplemental routine eye exams. Out-of-Network $35 copay for Medicare-covered eye exams. $35 copay for supplemental routine eye exams. 20% of the cost for Medicare-covered eye wear. The plan covers the following supplemental education/wellness programs: Health Club Membership/Fitness Classes Nursing Hotline Out-of-Network $0 copay for supplemental education/wellness programs. The plan does not cover Over-the-Counter items. This plan does not cover supplemental routine transportation. This plan does not cover Acupuncture and other alternative therapies. The plan covers the following supplemental education/wellness programs: Health Club Membership/Fitness Classes Nursing Hotline Out-of-Network $0 copay for supplemental education/wellness programs. The plan does not cover Over-the-Counter items. This plan does not cover supplemental routine transportation. This plan does not cover Acupuncture and other alternative therapies. PAG E 109 of 12 0

110 Contact information Notes Winston-Salem location: 5660 University Parkway Winston-Salem, NC TTY/TDD days a week 8 a.m. 8 p.m. Satellite office: 8701 Red Oak Blvd, Suite 300 Charlotte, NC TTY/TDD days a week 8 a.m. 8 p.m. For more information about Medicare: Call MEDICARE ( ) TTY hours a day, 7 days a week Benefits, premium and/or copayment/ coinsurance may change on January 1 of each year. Blue Cross and Blue Shield of North Carolina is an HMO and PPO plan with a Medicare contract. Enrollment in Blue Cross and Blue Shield of North Carolina depends on contract renewal. BCBSNC does not discriminate based on race, ethnicity, national origin, religion, gender, age, mental or physical disability, health status, claims experience, medical history, genetic information, evidence of insurability or geographic location within the service area. All BCBSNC items and services are available to all eligible beneficiaries in the service area. Limitations, copayments, and restrictions may apply. You must be entitled to Medicare Part A and enrolled in Medicare Part B and must reside in the CMS-approved service area. You must continue to pay your Medicare Part B premium. An independent licensee of the Blue Cross and Blue Shield Association., SM Marks of the Blue Cross and Blue Shield Association. SM1 Mark of Blue Cross and Blue Shield of North Carolina. PAG E 110 of 12 0

111 Appendix 4 Multi-Language Insert Multi-language Multi-language Multi-language Interpreter Interpreter Interpreter Services Services Services English: English: English: We We We have have have free free free interpreter interpreter interpreter services services services to to to answer answer answer any any any questions questions questions you you you may may may have have have about about about our our our health health health Multi-language or or or drug drug drug plan. plan. plan. To To To Interpreter get get get an an interpreter, interpreter, interpreter, Services just just just call call call us us us at at at [1- [1- [1- xxx-xxx-xxxx]. xxx-xxx-xxxx]. xxx-xxx-xxxx]. Someone Someone Someone who who who speaks speaks speaks English/Language English/Language English/Language can can can help help help you. you. you. This This This English: is is a free free free We service. service. service. have free interpreter services to answer any questions you may have about our health or drug plan. To get an interpreter, just call us at Someone who speaks English/Language can Spanish: Spanish: Spanish: help you. Tenemos Tenemos Tenemos This is a free servicios servicios servicios service. de de de intérprete intérprete intérprete sin sin sin costo costo costo alguno alguno alguno para para para responder responder responder cualquier cualquier cualquier pregunta pregunta pregunta que que que pueda pueda pueda tener tener tener sobre sobre sobre nuestro nuestro nuestro plan plan plan de de de salud salud salud o Spanish: medicamentos. medicamentos. medicamentos. Tenemos servicios Para Para Para hablar hablar hablar de intérprete con con con un un un sin intérprete, intérprete, intérprete, costo alguno por por por para favor favor favor responder llame llame llame cualquier al [1-xxx-xxxxxxx]. [1-xxx-xxxxxxx]. [1-xxx-xxxxxxx]. pregunta que pueda tener Alguien Alguien Alguien sobre que que que nuestro hable hable hable plan español español español de salud o le le le medicamentos. podrá podrá podrá ayudar. ayudar. ayudar. Para Este Este Este hablar es es con un un un un servicio servicio servicio intérprete, por favor llame gratuito. gratuito. gratuito. al Alguien que hable español le podrá ayudar. Este es un servicio gratuito. Chinese Chinese Chinese Mandarin: Mandarin: Mandarin: 我 我 们 们 提 供 免 费 费 的 的 翻 翻 译 服 译 务 服, 务 帮 助, 您 帮 解 助 答 您 关 于 解 健 答 康 关 或 于 药 健 物 康 保 或 险 的 药 任 物 何 保 疑 险 问 的 任 如 何 果 疑 需 要 此 翻 问 译 服 如 务, 果 请 您 致 需 电 要 <phone 此 翻 译 number> 服 务, 请 致 我 电 们 的 1-xxx-xxx-xxxx 1-xxx-xxx-xxxx 1-xxx-xxx-xxxx 中 文 工 作 人 员 很 我 乐 意 们 帮 的 助 中 您 文 工 这 是 作 一 人 项 员 免 很 费 服 乐 务 意 帮 助 您 这 是 一 项 免 费 服 务 服 務 如 Chinese Chinese Chinese 需 翻 譯 Cantonese: Cantonese: Cantonese: 服 務, 請 致 您 電 對 我 們 的 健 康 或 藥 物 我 保 們 險 講 可 中 能 文 存 的 有 人 疑 員 問 將, 樂 為 意 此 為 我 您 們 提 供 幫 免 助 費 的 這 翻 是 譯 一 項 免 費 服 服 務 務 如 需 翻 譯 服 務, 請 致 電 1-xxx-xxx-xxxx 1-xxx-xxx-xxxx 1-xxx-xxx-xxxx 我 們 講 中 文 的 人 員 將 樂 意 為 您 提 供 幫 助 這 Tagalog: 是 一 項 免 Mayroon 費 服 務 kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot. Upang makakuha ng Tagalog: Tagalog: Tagalog: tagasaling-wika, Mayroon Mayroon Mayroon tawagan kaming kaming kaming lamang libreng libreng libreng kami sa serbisyo serbisyo serbisyo sa sa sa pagsasaling-wika pagsasaling-wika pagsasaling-wika Maaari kayong tulungan upang upang upang ng isang nakakapagsalita masagot masagot masagot ang ang anumang anumang anumang Tagalog. Ito mga mga mga ay libreng katanungan katanungan katanungan serbisyo. ninyo ninyo ninyo hinggil hinggil hinggil sa aming aming aming planong planong planong pangkalusugan pangkalusugan pangkalusugan o panggamot. panggamot. panggamot. Upang Upang Upang makakuha makakuha makakuha ng ng tagasaling-wika, tagasaling-wika, tagasaling-wika, French: tawagan tawagan tawagan Nous lamang lamang lamang proposons kami kami kami des sa sa sa services [1-xxx-xxx-xxxx]. [1-xxx-xxx-xxxx]. [1-xxx-xxx-xxxx]. gratuits d'interprétation Maaari Maaari Maaari pour kayong kayong kayong répondre tulungan tulungan tulungan à toutes vos ng ng ng questions isang isang isang nakakapagsalita nakakapagsalita nakakapagsalita relatives à notre régime ng ng ng Tagalog. Tagalog. Tagalog. de santé ou Ito Ito Ito d'assurance-médicaments. ay ay ay libreng libreng libreng serbisyo. serbisyo. serbisyo. Pour accéder au service d'interprétation, il vous suffit de nous appeler au Un interlocuteur parlant Français pourra French: French: French: vous Nous Nous Nous aider. proposons proposons proposons Ce service est des des des gratuit. services services services gratuits gratuits gratuits d'interprétation d'interprétation d'interprétation pour pour pour répondre répondre répondre à toutes toutes toutes vos vos vos questions questions questions relatives relatives relatives à notre notre notre régime régime régime de de de santé santé santé ou ou ou d'assurancemédicaments. d'assurancemédicaments. d'assurancemédicaments. Vietnamese: Chúng Pour Pour Pour tôi có accéder accéder accéder dịch vụ thông au au au service service service dịch miễn d'interprétation, d'interprétation, d'interprétation, phí để trả lời các câu il il il vous vous vous hỏi về suffit suffit suffit chương de de de sức nous nous nous khỏe và chương appeler appeler appeler trình au au au thuốc [1-xxx-xxx-xxxx]. [1-xxx-xxx-xxxx]. [1-xxx-xxx-xxxx]. men. Nếu quí vị cần Un Un Un thông interlocuteur interlocuteur interlocuteur dịch viên xin parlant parlant parlant gọi Français Français Français pourra pourra pourra sẽ có nhân vous vous vous viên nói tiếng aider. aider. aider. Việt Ce Ce Ce giúp service service service đỡ quí est est est vị. Đây gratuit. gratuit. gratuit. là dịch vụ miễn phí. Vietnamese: Vietnamese: Vietnamese: Chúng Chúng Chúng tôi tôi tôi có có có dịch dịch dịch vụ vụ vụ thông thông thông dịch dịch dịch miễn miễn miễn phí phí phí để để để trả trả trả lời lời lời các các các câu câu câu hỏi hỏi hỏi German: Unser kostenloser Dolmetscherservice beantwortet Ihren Fragen zu unserem Gesundheitsvề về về chương chương chương sức sức sức khỏe khỏe khỏe và và và chương chương chương trình trình trình thuốc thuốc thuốc men. men. men. Nếu Nếu Nếu quí quí quí vị vị vị cần cần cần thông thông thông dịch dịch dịch und Arzneimittelplan. Unsere Dolmetscher erreichen Sie unter Man wird Ihnen dort viên viên viên xin xin xin gọi gọi gọi [1-xxx-xxx-xxxx] [1-xxx-xxx-xxxx] [1-xxx-xxx-xxxx] sẽ sẽ sẽ có có có nhân nhân nhân viên viên viên nói nói nói tiếng tiếng tiếng Việt Việt Việt giúp giúp giúp đỡ đỡ đỡ quí quí quí vị. vị. vị. auf Deutsch weiterhelfen. Dieser Service ist kostenlos. Đây Đây Đây là là là dịch dịch dịch vụ vụ vụ miễn miễn miễn phí phí phí. Korean: 당사는 의료 보험 또는 약품 보험에 관한 질문에 답해 드리고자 무료 통역 서비스를 제공하고 있습니다. 통역 서비스를 이용하려면 전화 번으로 문의해 주십시오. 한국어를 하는 담당자가 도와 드릴 것입니다. 이 서비스는 무료로 운영됩니다 Y0079_6200 CMS Approved U5047d, 7/13 PAGE 111 of 120

112 Multi-language Interpreter Services (continued) Russian: Если у вас возникнут вопросы относительно страхового или медикаментного плана, вы можете воспользоваться нашими бесплатными услугами переводчиков. Чтобы воспользоваться услугами переводчика, позвоните нам по телефону Вам окажет помощь сотрудник, который говорит по-pусски. Данная услуга бесплатная. ةيودألا لودج وأ ةحصلاب قلعتت ةلئسأ يأ نع ةباجإلل ةيناجملا يروفلا مجرتملا تامدخ مدقن اننإ: Arabic صخش موقيس ىلع انب لاصتالا ىوس كيلع سيل يروف مجرتم ىلع لوصحلل.انيدل.ةيناجم ةمدخ هذه.كتدعاسمب ةيبرعلا ثدحتي ام Hindi: हम र स व स थ य य दव क य जन क ब र म आपक क स भ प रश न क जव ब द न क ल ए हम र प स म फ त द भ ष य स व ए उपलब ध ह. एक द भ ष य प र प त करन क ल ए, बस हम पर फ न कर. क ई व यक त ज ह न द ब लत ह आपक मदद कर सकत ह. यह एक म फ त स व ह. Italian: È disponibile un servizio di interpretariato gratuito per rispondere a eventuali domande sul nostro piano sanitario e farmaceutico. Per un interprete, contattare il numero Un nostro incaricato che parla Italianovi fornirà l'assistenza necessaria. È un servizio gratuito. Portugués: Dispomos de serviços de interpretação gratuitos para responder a qualquer questão que tenha acerca do nosso plano de saúde ou de medicação. Para obter um intérprete, contacte-nos através do número Irá encontrar alguém que fale o idioma Português para o ajudar. Este serviço é gratuito. French Creole: Nou genyen sèvis entèprèt gratis pou reponn tout kesyon ou ta genyen konsènan plan medikal oswa dwòg nou an. Pou jwenn yon entèprèt, jis rele nou nan Yon moun ki pale Kreyòl kapab ede w. Sa a se yon sèvis ki gratis. Polish: Umożliwiamy bezpłatne skorzystanie z usług tłumacza ustnego, który pomoże w uzyskaniu odpowiedzi na temat planu zdrowotnego lub dawkowania leków. Aby skorzystać z pomocy tłumacza znającego język polski, należy zadzwonić pod numer Ta usługa jest bezpłatna. Japanese: 当 社 の 健 康 健 康 保 険 と 薬 品 処 方 薬 プランに 関 するご 質 問 にお 答 えするために 無 料 の 通 訳 サービスがありますございます 通 訳 をご 用 命 になるには にお 電 話 ください 日 本 語 を 話 す 人 者 が 支 援 いたします これは 無 料 のサービスです PAGE 112 of 120

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119 Notes Limitations & Exclusions Following is a list of some of the Blue Medicare HMO and Blue Medicare PPO plans limitations and exclusions. Please refer to the plan s Evidence of Coverage for a full list of limitations and exclusions. Blue Cross and Blue Shield of North Carolina (BCBSNC) provides services according to the coverage guidelines established by Medicare. The medical care, services, supplies, and equipment that are described as covered services must be medically necessary. Some services are covered only if your doctor or other network provider gets Prior Approval from BCBSNC. There are some drugs that may require prior authorization or be limited in quantity. These are indicated in our formulary. There are some drugs that don t meet the government s definition of a Part D drug, so those are excluded from coverage for Part D plans. Prescriptions filled at out-of-network pharmacies will only be covered in limited, non-routine circumstances. The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Additional information about benefits is available to assist you in making a decision about your coverage. This is an advertisement; for more information contact the plan. Benefits, premium and/or copayment/coinsurance may change on January 1 of each year. Please contact BCBSNC for details. Blue Cross and Blue Shield of North Carolina is an HMO and PPO plan with a Medicare contract. Enrollment in Blue Cross and Blue Shield of North Carolina depends on contract renewal. BCBSNC does not discriminate based on race, ethnicity, national origin, religion, gender, age, mental or physical disability, health status, claims experience, medical history, genetic information, evidence of insurability or geographic location within the service area. All BCBSNC items and services are available to all eligible beneficiaries in the service area. Limitations, copayments, and restrictions may apply. You must be entitled to Medicare Part A and enrolled in Medicare Part B and must reside in the CMS-approved service area. You must continue to pay your Medicare Part B premium., SM Marks of the Blue Cross and Blue Shield Association. SM1 Mark of Blue Cross and Blue Shield of North Carolina. BCBSNC is an independent licensee of the Blue Cross and Blue Shield Association. U5047e, 8/13 PAGE 119 of 120

120 Compare plans Please see the chart below for an in-network, side-by-side comparison of Blue Medicare HMO and Blue Medicare PPO plan options. Medical-only Standard Enhanced Enhanced 1 2 Enhanced Freedom Plan premium $0 $0 $18.90 $38 $ Provider choice In-network benefits only; must visit a participating provider; no referrals required to see network specialists In- and out-of-network benefits; member cost share may be higher out of network; no referrals required to see specialists Physician office visits (PCP/Specialists) $5/$20 copayment $15/$40 copayment $10/$35 copayment $20/$40 copayment $15/$35 copayment Inpatient hospital* $100/day $220/day $170/day $220/day $170/day Medicare prescription drug coverage** None Standard Enhanced Standard Enhanced Diabetic supplies 0% 0% 0% 0% 0% Outpatient surgery $0 $195 $125 $190 $125 Diagnostic tests, lab work and X-rays Total out-of-pocket maximum 5% 20% 15% 20% 15% $2,500 $3,400 $3,400 $3,400/$5,100 Routine physical exam*** $0 Emergency room visit $50 Ambulance service $100 * Up to 7 days. ** Members must continue to pay their Part B premium. *** Limit one (1) in-network routine physical exam per year. 1 You must receive routine care from plan providers. 2 With the exception of emergencies or urgent care, it may cost more to get care from out-of-network providers. 3 Awarded by the Ethisphere Institute, which reviewed nominations from companies in more than 100 countries and 36 industries. (Accessed April, 2013) This brochure may be available in alternate formats upon request. How can we help? For more information, or to enroll, call Hearing and speech impaired (TTY/TDD), call days a week, 8 a.m. 8 p.m. Or visit PAGE 120 of Y0079_6201 CMS Approved