Enjoy more benefits, including preventive, vision and hearing care

Transcription

1 199883_S84_PG1 Milton Hershey School Post 65 - School 120 Fifth Avenue, Pittsburgh, PA Reference Code 13FB9883 Z_G199883_S84 Dear Plan Participant: Thank you for considering enrollment in Freedom Blue PPO, which is a Medicare Advantage Preferred-Provider Organization (PPO) backed by the experience and financial strength of Highmark Blue Shield. Freedom Blue PPO gives you broad coverage for virtually every health care service you may need and the freedom to choose your own doctors and hospitals anywhere in the United States. Freedom Blue PPO gives you access to a national network of participating providers That s because Blue Plans across the country share their Medicare Advantage PPO networks. You may see any Blue Cross and/or Blue Shield Medicare Advantage PPO contracted doctor or hospital in the United States and receive covered services at the higher, network level of reimbursement. Freedom Blue PPO members also may choose to see providers outside of our shared Medicare Advantage network. However, if a member chooses to go to a non-participating provider when a participating Blue Cross and/or Blue Shield Medicare Advantage PPO contracted provider is available in that location, covered services will be reimbursed at the lower out-of-network level. If a Freedom Blue PPO group member lives or travels in a location where there are no participating Blue Cross and/or Blue Shield Medicare Advantage PPO providers, the member can go to any Medicare-eligible provider and receive covered services at the higher, network level of reimbursement. Members should confirm that the provider is Medicare-eligible before receiving services. Highmark will not pay for any service received from a provider who has opted out of the Medicare program. Emergency and urgently needed care is always reimbursed at the higher, network level, regardless of where the care is received. Enjoy more benefits, including preventive, vision and hearing care 1

2 199883_S84_PG2 As a Freedom Blue PPO member, you re covered for doctor visits, hospital stays, outpatient services, emergency care, even annual routine vision and hearing exams, eyeglasses and hearing aids. You ll also enjoy valuable preventive care benefits, including an annual routine physical exam, immunizations and important screenings. Keep yourself and your budget in shape Take advantage of full access at one of the participating senior-friendly fitness centers located throughout the United States through the award-winning SilverSneakers Fitness Program. Use the center s equipment on your own or join a SilverSneakers class designed especially for people with Medicare. There s no cost for any services you use. Save money on prescription drugs Enjoy enhanced Part D Medicare Prescription Drug Coverage with Freedom Blue PPO. All generic and brand name drugs allowed by Medicare are covered. Personal, knowledgeable Member Service Friendly, dedicated Member Service representatives offer you outstanding support. If you have any questions about your benefits, providers, Medicare, or how Freedom Blue PPO works, call toll-free any day of the week between 8:00 a.m. and 8:00 p.m. Eastern. Have questions now call toll-free If you have any questions now about Freedom Blue PPO, please call , TTY users call 711, between 8:00 a.m. and 8:00 p.m. Eastern, seven days a week. Great benefits, network-level coverage throughout the country, a fitness center membership and the peace of mind knowing your coverage is backed by Highmark Blue Shield, a name people know and trust for over 70 years there are many reasons to have Freedom Blue PPO. We look forward to serving you. Sincerely, Jill Hollingshead Sales Manager, Highmark Senior Markets 2

3 199883_S84_PG3 Table of Contents Section 1 Section 2 Section 3 Section 4 Section 5 Section 6 Plan Highlights and Frequently Asked Questions Enrollment Information Summary of Benefits Health and Wellness Network Provider Information - This section contains participating network doctors near your home and network hospitals within 150 miles of your home. If you would like a complete list of participating network providers, contact Freedom Blue PPO at , TTY users call 711, between 8:00 a.m. and 8:00 p.m. Eastern, seven days a week. Prescription Drug Benefits 3

4 199883_S84_PG4 Section 1 Enjoy the Flexibility of a PPO, Plus the Dependability of Highmark Blue Shield

5 199883_S84_PG5 SM Freedom Blue PPO gives you exactly what you want from your health care coverage freedom of choice Freedom Blue PPO, a Medicare Advantage Preferred-Provider Organization from Highmark Blue Shield, offers comprehensive benefits and the freedom to use the doctors, hospitals and other professional providers of your choice, both inside and outside the network with no referrals needed. When you receive eligible care from doctors, hospitals and other professional providers in the network, your care is covered at the higher, network level of benefits and you pay lower, in-network costs. When you receive eligible care from doctors, hospitals and other professional providers in an area without a network, your care is covered at the higher, network level of benefits and you pay lower, in-network costs. When you receive eligible care from doctors, hospitals and other professional providers outside of the network, your care is covered at the lower, out-of-network level of benefits and you pay slightly higher, out-of-network costs. Enjoy the higher, network-level of benefits at lower, in-network costs throughout the United States great for snowbirds and people on the move! Freedom Blue PPO offers you unique opportunities to get the health care you need wherever you live or travel throughout the U.S. and you pay only your network level of cost sharing. Freedom Blue PPO features one of the largest Medicare Advantage PPO networks in the country. It includes thousands of family doctors, general practitioners, internists, all types of specialists and most hospitals. Freedom Blue PPO participating providers are carefully screened before joining the network and regularly reviewed in an ongoing effort to ensure that they meet strict criteria for quality service. If you travel, Freedom Blue PPO allows you to receive care from any participating Blue Cross and/or Blue Shield Medicare Advantage PPO doctor, professional provider or hospital available in 31 states and Puerto Rico including Florida, California, the Carolinas, Ohio, New York and more. 5

6 199883_S84_PG6 It s easy to find a participating Blue Cross and/or Blue Shield Medicare Advantage PPO provider. Just call Member Service at the number printed on the Freedom Blue PPO ID card you will receive after you enroll, visit the Highmark website, or go to Find a Doctor, Hospital or other Medical Provider at If you live in or travel to locations where a participating network is not available, you may visit any Medicare-eligible provider. Again, when you do, eligible services will be covered at the higher, network level of benefits. Please refer to the Freedom Blue PPO Network Provider Information section for more information. Important Notes: 1. If you decide to go to a non-participating provider, but a participating Blue Cross and/or Blue Shield Medicare Advantage PPO provider is available in the location where you received eligible services, those services will be covered at the lower, out-of-network level of benefits. 2. Highmark cannot pay a provider who has opted out of the Medicare program. Check with your provider before you receive care to confirm that they have not opted out of Medicare. 3. Emergency and urgently needed care is always covered at the higher network level of benefits, regardless of where the care is received. Freedom from claim forms and referrals Freedom Blue PPO was designed to eliminate the hassle that many people associate with health insurance. There are no claim forms to file when you show your Freedom Blue PPO ID card at any of our Freedom Blue PPO network provider locations or participating Blue Cross and/or Blue Shield Medicare Advantage PPO providers throughout the U.S. They will process all the paperwork for you. When you see a provider who is not in the network, always ask the provider or facility to file a claim for you to Freedom Blue PPO. No referrals are needed for you to get the care you need. Certain services, however, like inpatient admissions or outpatient surgery, do require pre-certification. Enjoy personal, reliable Member Service If you ever have a question about Medicare or Freedom Blue PPO plan benefits, or about how to get care or how to locate a provider in short, any concern related to your health care coverage help is just a toll-free call away. You can reach a friendly, knowledgeable, dedicated Member Service representative any day of the week, between 8:00 a.m. and 8:00 p.m. Eastern, by calling the number printed on your Freedom Blue PPO identification card. Our Member Service representatives specialize in understanding Medicare and the needs of people with Medicare. They are carefully trained to answer your questions and those of your providers a valuable resource to you, if needed, when you receive care. 6

7 199883_S84_PG7 you all the benefits of Medicare and more. As a PPO, Freedom Blue PPO lets you get care from the doctors and hospitals of your choice either in or out of the network. And no referrals are needed. Trust the plan that s backed by Highmark Blue Shield Freedom Blue PPO is backed by more than 70 years of financial strength and experience with Highmark Blue Shield a name millions of people know and trust. Highmark Blue Shield has been dedicated to offering quality, affordable health care coverage to people with Medicare since the Medicare program began in Answers to frequently asked questions Q. Is Freedom Blue PPO a Medicare supplement? A. No. Freedom Blue PPO is a Medicare Advantage PPO that makes supplemental insurance unnecessary. Freedom Blue PPO gives 7 Q. Is everything covered by Freedom Blue PPO? A. All Medicare benefits are covered, such as periodic physical exams, immunizations and screenings. Limitations, copayments and coinsurance apply. Please refer to the benefits chart and other information in this brochure for the specific benefits your group provides. Q. Can I be sure I ll receive quality care with Freedom Blue PPO? A. Highmark participating health care providers are carefully screened before joining the Highmark Medicare Advantage PPO Provider Network. They must meet our strict selection criteria and submit to an evaluation by a medical review committee. Then they are reviewed on an ongoing basis. Q. Am I still covered by original Medicare Part A and Part B as a Freedom Blue PPO member? A. Once you are a member of Freedom Blue PPO, you still have Medicare, but now you are getting your Medicare as a Freedom Blue PPO member. You no longer have to pay original Medicare deductibles and coinsurance charges because Freedom Blue PPO will cover all services and supplies offered by original Medicare, plus some additional services and supplies not covered by original Medicare. Members must continue to pay their Medicare Part B premium. In addition, Freedom Blue PPO does require you to pay a copayment and coinsurance for certain network services and for out-of-network care you receive. Q. What if I sign up for Freedom Blue PPO and later want to drop it? A. If you disenroll from Freedom Blue PPO outside of the open enrollment period and go to original Medicare insurance, you may have

8 199883_S84_PG8 the option (if available in your county of residence) to switch to a Medicare Supplement plan. Be sure to talk to your group benefits office before you disenroll from Freedom Blue PPO and follow the disenrollment guidelines of your former employer or trust fund regarding open enrollment or special election periods. 8

9 199883_S84_PG9 Section 2 Enrolling In Freedom Blue PPO

10 199883_S84_PG10 It s easy to enroll Follow all enrollment instructions from your employer or trust fund. If you have questions or need help applying for Freedom Blue PPO Please call , TTY users call , between 8:00 a.m. and 8:00 p.m., seven days a week for answers to your questions about Freedom Blue PPO benefits, how the plan works, or how to enroll. 10

11 It s easy to enroll! Please follow the enrollment instructions provided by your former employer. Please Read Carefully Highmark Blue Shield is a Medicare Advantage Plan so you will need to keep your Medicare Parts A and B. You can only have one Medicare Advantage Plan at a time. If you enroll in another Medicare Advantage [or Prescription Drug Plan] it will automatically disenroll you from Highmark Blue Shield. It is your responsibility to inform Highmark and/or your former employer of any prescription drug coverage that you have or may get in the future. You can only join one Medicare Prescription Drug Plan. To receive additional information about this plan, please contact Highmark at , TTY , between 8:00 a.m. and 8:00 p.m., seven days a week. You can also contact Medicare for information on other Medicare Health Plan options that might be available by calling Medicare. TTY users should call , 24 hours a day/7days a week. Counseling services may be available in your state to provide advice concerning Medicare supplement insurance or other Medicare Advantage or Prescription Drug plan options as well as medical assistance through the state Medicaid program and the Medicare Savings Program. Highmark Blue Shield members can reside anywhere in the United States. If you move outside of the U.S., you need to notify the plan and disenroll. You may contact your former employer to discuss other possible coverage. Once you are a member of Highmark Blue Shield, you have the right to appeal plan decisions about payment or services if you disagree. You should read the Evidence of Coverage document from Highmark Blue Shield when you get it to know which rules you must follow to get coverage with this Medicare Advantage plan. People with Medicare aren't usually covered under Medicare while out of the country except for limited coverage near the U.S. border. You understand that beginning on the date Highmark Blue Shield coverage begins, you must get all of your health care from Highmark Blue Shield except for emergency or urgently needed services or out-of-area dialysis services. Services authorized by Highmark Blue Shield and other services contained in the Highmark Blue Shield Evidence of Coverage document (also known as a member contract or subscriber agreement) will be covered. Without authorization, NEITHER MEDICARE NOR Highmark Blue Shield WILL PAY FOR THE SERVICES. You understand that if you are getting assistance from a sales agent, broker, or other individual employed by or contracted with Highmark Blue Shield he/she may be paid based on your enrollment in Highmark Blue Shield. You acknowledge that the Medicare health plan will release your information to Medicare and other plans as is necessary for treatment, payment and health care operations. You also acknowledge that Highmark Blue Shield will release your information, including any prescription drug data to Medicare, who may release it for research and other purposes which follow all applicable Federal statutes and regulations. EGHP_10_

12 199883_S84_PG12 Section 3 Freedom Blue PPO Covers Most Health Care Services You Need

13 199883_S84_PG13 Freedom Blue PPO offers comprehensive coverage in and out of the network, including: Hospital care both inpatient and outpatient Emergency and urgent care always covered at the higher network level Annual routine physical exam and other doctors visits, including specialist visits X-ray, diagnostic tests, lab work, annual mammogram and PAP test, flu and pneumonia shots (authorization may be required for some services) Hearing care Routine vision Mental health and substance abuse treatment Screenings, such as bone mass, colorectal and prostate cancer, plus diabetes monitoring Home health care Please be sure to read the enclosed Summary of Benefits for a more detailed description of your covered benefits. Coverage for important preventive care Freedom Blue PPO offers preventive benefits to help you stay healthy. You are encouraged to use your wellness benefits that include, for example, immunizations, screenings and annual physical exams. Emergency and urgently needed care is covered at the highest level anywhere in the world In any medical emergency, at home or while traveling when you believe that serious jeopardy to your health or impairment or dysfunction of your body may result if you don t get immediate attention go to the nearest emergency facility and get treatment. Or call 911 or the local emergency telephone numbers for help. You are responsible for paying a copayment for each emergency room visit, unless you are admitted to the hospital for the same condition within three days and your inpatient admission is authorized. Urgently needed care is also covered in full after you pay any applicable copayment. Urgently needed care includes services which are provided while you are temporarily outside the Freedom Blue PPO service area or, in extraordinary cases, while you are in the plan s service area when the Freedom Blue PPO network is unavailable or inaccessible due to an unusual event. 13

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15 199883_S84_PG15 Milton Hershey School Post 65 - School Reference Code 13FB9883 In-Network Plan Deductible $0 Plan Coinsurance (Member Cost Sharing) No Plan level coinsurance applied In Network Out-of-Pocket Max $0 Total In and Out of Network Out-of-Pocket Outpatient Services Doctor Office Visit Preventive Testing/Screenings $10 PCP, $15 Specialist cost sharing Covered in Full $3,400 Out-of-Network 20% 20% coinsurance Covered in Full Diagnostic Testing including Lab, X-Rays and Advanced $0 cost sharing 20% coinsurance Imaging Outpatient Surgery $0 cost sharing 20% coinsurance Emergent and Urgent Services Ambulance $0 cost sharing 20% coinsurance Emergency Room $50 cost sharing $50 cost sharing Inpatient Hospital Stay $0 per stay 20% coinsurance Skilled Nursing Facility (days per benefit period) Supplies and Additional Services $0 per day 20% coinsurance Durable Medical Equipment 0% coinsurance 50% coinsurance Standard eyeglass lenses and frames or contact lenses are Routine Vision covered in full. A $100 benefit $100 benefit maximum for (covered every two calendar maximum applies to specialty frames or specialty years) non-standard frames and a $100 contact lenses. benefit maximum for specialty contact lenses. Hearing Aids (covered every three calendar years) $500 coverage Freedom Blue PPO Your 2013 Benefits at a Glance 15 Benefits continued on next page.

16 199883_S84_PG16 Milton Hershey School Post 65 - School Medicare Part D Drugs (Up to 34 Day Supply) Initial Coverage (Up to $2970 in total drug costs) Coverage Gap In-Network $8 Generic $20 Pref. Brand $50 Non-Pref. Brand $50 Specialty $8 Generic $20 Pref. Brand $50 Non-Pref. Brand $50 Specialty During this stage, the plan will pay most of the cost for your drugs. Your 2013 Benefits at a Glance Out-of-Network Please see Summary of Benefits for detailed Information * See below -Either - coinsurance of 5% of the cost of the drug Catastrophic Coverage -Or- $2.65 copayment for a generic drug or a drug that is treated like a generic. Or a $6.60 copayment for all other drugs. Our plan pays the rest of the cost. Questions? Call (TTY Users, call 711) 7 days a week between 8 a.m. - 8 p.m. Eastern Reference Code 13FB9883 Please have this number ready when you call. Please see Summary of Benefits for detailed information. *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. 16

17 199883_S84_PG17 SECTION ONE: INTRODUCTION TO SUMMARY OF BENEFITS Freedom Blue PPO January 1, 2013 through December 31, 2013 Thank you for your interest in Freedom Blue PPO. Our plan is offered by Highmark Inc., a Medicare Advantage Preferred-Provider Organization (PPO). This Summary of Benefits tells you some features of our plan. It doesn t list every service that we cover or list every limitation or every exclusion. To get a complete list of our benefits, please call Freedom Blue 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 Freedom Blue PPO. 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 Freedom Blue PPO 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, seven days a week. HOW CAN I COMPARE MY OPTIONS? You can compare Freedom Blue PPO 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 plan covers 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 IS FREEDOM BLUE PPO AVAILABLE? The service area for this plan varies. Please contact Freedom Blue PPO for more information. WHO IS ELIGIBLE TO JOIN FREEDOM BLUE PPO? You can join Freedom Blue PPO if you are entitled to Medicare Part A and enrolled in Medicare Part B. However, individuals with End Stage Renal Disease are not eligible to enroll in Freedom Blue PPO. Some exceptions do exist; please contact Highmark for more information. CAN I CHOOSE MY DOCTORS? Freedom Blue PPO has formed a network of doctors, specialists, and hospitals. You can use any doctor who is part of our network. You may also go to doctors outside of our network. The health providers within our network can change at any time. Also, the doctors and hospitals available to you may vary, depending on where you reside. You can ask for a current Provider Directory or for an up-to-date list visit us at 17

18 199883_S84_PG18 Our Customer Service number is listed at the end of this introduction. WHAT HAPPENS IF I GO TO A DOCTOR WHO S NOT IN OUR NETWORK? You can go to doctors, specialists, or hospitals in or out of network. You may have to pay more for the services you receive outside the network, and you may have to follow special rules prior to getting services in and/or out of network. For more information, please call the Customer Service number at the end of this introduction. DOES MY PLAN COVER MEDICARE PART B OR PART D DRUGS? Freedom Blue PPO does cover Medicare Part B Prescription Drugs. Freedom Blue PPO also covers Medicare Part D Prescription Drugs. WHERE CAN I GET MY PRESCRIPTIONS IF I JOIN THIS PLAN? Freedom Blue PPO has formed a network of pharmacies. You must use a network pharmacy to receive plan benefits. We may not pay for your prescriptions if you use an out-of-network pharmacy, except in certain cases. The pharmacies in our network can change at any time. You can ask for a current pharmacy directory, or visit us at Our Customer Service number is listed at the end of this introduction. WHAT IS A PRESCRIPTION DRUG FORMULARY? Freedom Blue PPO uses 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 enrollees before the change is made. We will send a formulary to you and you can see our complete formulary on our Web site at If you are currently taking a drug that is not on our formulary or subject to additional requirement or limits, you may be able to get a temporary supply of the drug. You can contact us to request an exception or switch to an alternative drug listed on our formulary with your physician s help. Call us to see if you can get a temporary supply of the drug or for more details about our drug transition policy. HOW CAN I GET EXTRA HELP WITH PRESCRIPTION DRUG PLAN COSTS? You may be able to get extra help for your prescription drug premiums and costs. To see if you qualify for getting extra help, call: MEDICARE ( ). TTY/TDD users should call , 24 hours a day, seven days a week; 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 THE PLAN? All Medicare Advantage plans agree to stay in the Medicare program for a full year at a time. Each year, the plans decide whether to continue for another year. Even if a Medicare Advantage plan leaves the program, you will not lose Medicare coverage. If a plan decides not to continue, it must send you a letter at least 90 days before your coverage will end. The letter will explain your options 18

19 199883_S84_PG19 for Medicare coverage in your area. As a member of Freedom Blue PPO, 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. As a member of Freedom Blue PPO, 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. WHAT IS A MEDICATION THERAPY MANAGEMENT (MTM) PROGRAM? A Medication Therapy Management (MTM) Program is a free service we may offer. You may be invited to participate in a program designed for your specific health and pharmacy needs. You may decide not to participate, but it is recommended that you take full advantage of this covered service if you are selected. Contact Freedom Blue PPO for more details. WHAT TYPE 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 Freedom Blue PPO for more details. Some Antigens: If they are prepared by a doctor and administered by a properly instructed person (who could be the patient) under doctor supervision. Osteoporosis Drugs: Injectable drugs for osteoporosis for certain women with Medicare. Erythropoietin (Epoetin alpha or Epogen ): By injection if you have end stage renal disease (permanent kidney failure requiring either dialysis or transplantation) and need this drug to treat anemia. Hemophilia Clotting Factors: Self-administered clotting factors if you have hemophilia. 19

20 199883_S84_PG20 Injectable Drugs: Most injectable drugs administered incident to a physician s service. Immunosuppressive Drugs: Immunosuppressive drug therapy for transplant patients if the transplant was paid for by Medicare, or paid by a private insurance that paid as a primary payer to your Medicare Part A coverage, in a Medicare-certified facility. Some Oral Cancer Drugs: If the same drug is available in injectable form. Oral Anti-Nausea Drugs: If you are part of an anti-cancer chemotherapeutic regimen. Inhalation and infusion drugs provided through DME. 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 may use the Web tools on and select Health and Drug Plans or Compare Drug and Health Plans to compare the plan ratings of Medicare plans in your area. You can also call us directly at to obtain a copy of the plan ratings for this plan. TTY users call 711. Please call Highmark Inc. for more information about this plan. Visit us at or, call us: Customer Service Hours: Sunday, Monday, Tuesday, Wednesday, Thursday, Friday, Saturday 8:00 a.m. - 8:00 p.m. Eastern. Current members should call for questions related to the Medicare Advantage Program or Medicare Part D Prescription Drug program.(tty/tdd(888) ) Prospective members should call for questions related to the Medicare Advantage or Medicare Part D Prescription Drug Program. (TTY/TDD (800) ) For more information about Medicare, call MEDICARE ( ). TTY users should call You can call 24 hours a day, seven 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. 20

21 199883_S84_PG21 Summary of Benefits Employer Group Plan Milton Hershey School Post 65 - School General Provisions Freedom Blue PPO In-Network Freedom Blue PPO Out-of-Network Benefit Period-Calendar Year Plan Deductible $0 Plan Coinsurance (Member Cost Sharing) None 20% In Network Out-of-Pocket Maximum $0 Total In and Out-of-Network Out-of-Pocket Maximum $3,400 Benefit Category Original Medicare Freedom Blue PPO Employer Group Plan 21 IMPORTANT INFORMATION Premium and Other Important Information In 2012 the monthly Part B Premium was You may pay a premium each month to your $99.90 and may change for 2013 and the retiree/employer group/trust fund. You also annual Part B deductible amount was $140 continue to pay the Medicare Part B premium and may change for each month. If a doctor or supplier does not accept assignment, their costs are often higher, which means you pay more. Continued on next page For questions about this plan's benefits or costs, please contact Freedom Blue PPO. Current members call (TTY users call 711) and prospective members call , (TTY users call 711), seven days a week, between 8 a.m. and 8 p.m. Eastern.

22 199883_S84_PG22 Benefit Category Original Medicare Freedom Blue PPO Employer Group Plan IMPORTANT INFORMATION Premium and Other Important Information Continued from previous page 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 Doctor and Hospital Choice You may go to any doctor, specialist or In-Network (For more information, see Emergency Care hospital that accepts Medicare. No referral required for network doctors, and Urgently Needed Care.) specialists, and hospitals. In and Out-of-Network You can go to doctors, specialists and hospitals in or out of the network that accept Medicare. It will cost you more to get out-of-network benefits. Out-of-Service Area Plan covers you when you travel in the U.S. or its territories. For questions about this plan's benefits or costs, please contact Freedom Blue PPO. Current members call (TTY users call 711) and prospective members call , (TTY users call 711), seven days a week, between 8 a.m. and 8 p.m. Eastern. 22

23 199883_S84_PG23 Benefit Category Original Medicare Freedom Blue PPO Employer Group Plan INPATIENT CARE Inpatient Hospital Care In 2012 the amounts for each benefit period Authorization rules may apply. (includes Substance Abuse and Rehabilitation were: Services) Days 1-60: $1,156 deductible In-Network Days 61-90: $289 per day You pay cost sharing of $0 for each Days : $578 per lifetime reserve day Medicare-covered stay at a network hospital. These amounts may change for There is no limit to the number of days covered by the plan each benefit period. Call MEDICARE ( ) for information about lifetime reserve days. Except in an emergency, your doctor must tell Lifetime reserve days can only be used once. the plan that you are going to be admitted to A benefit period starts the day you go into a the hospital. hospital or skilled nursing facility. It ends when you go for 60 days in a row without Out-of-Network hospital or skilled nursing care. If you go into You pay 20% coinsurance for each the hospital after one benefit period has Medicare-covered stay at an out-of-network ended, a new benefit period begins. hospital. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods you can have. For questions about this plan's benefits or costs, please contact Freedom Blue PPO. Current members call (TTY users call 711) and prospective members call , (TTY users call 711), seven days a week, between 8 a.m. and 8 p.m. Eastern. 23

24 199883_S84_PG24 Benefit Category Original Medicare Freedom Blue PPO Employer Group Plan Inpatient Mental Health Care Same deductible and copay as inpatient Authorization rules may apply. hospital care (see "Inpatient Hospital Care" above). 190 day lifetime limit in a Psychiatric In-Network Hospital. You pay cost sharing of $0 for each Medicare-covered stay at a network hospital. You get up to 190 days in a Psychiatric Hospital in a lifetime. Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital. Out-of-Network You pay 20% coinsurance for each Medicare-covered stay at an out-of-network hospital. For questions about this plan's benefits or costs, please contact Freedom Blue PPO. Current members call (TTY users call 711) and prospective members call , (TTY users call 711), seven days a week, between 8 a.m. and 8 p.m. Eastern. 24

25 199883_S84_PG25 Benefit Category Original Medicare Freedom Blue PPO Employer Group Plan Skilled Nursing Facility (SNF) In 2012 the amounts for each benefit period Authorization rules may apply. (in a Medicare-certified skilled nursing facility) after at least a 3-day covered hospital stay were: In-Network Days 1-20: $0 per day You pay cost sharing of $0 per admission for Days : $ per day Medicare-covered services at a skilled nursing facility. These amounts may change for Plan covers up to 100 days each benefit 100 days for each benefit period. A benefit period. period starts the day you go into a hospital or SNF. It ends when you go for 60 days in a No prior hospital stay is required. row without hospital or skilled nursing care. If you go into the hospital after one benefit Out-of-Network period has ended, a new benefit period You pay 20% coinsurance for begins. Medicare-covered services, days 1-100, at an out-of-network skilled nursing facility. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods you can have. Home Health Care $0 copay. Authorization rules may apply. (includes medically necessary intermittent skilled nursing care, home health aide In-Network services, and rehabilitation services, etc.) You pay cost sharing of $0 for Medicare-covered home health services. Out-of-Network You pay 20% coinsurance for Medicare-covered out-of-network home health visits. For questions about this plan's benefits or costs, please contact Freedom Blue PPO. Current members call (TTY users call 711) and prospective members call , (TTY users call 711), seven days a week, between 8 a.m. and 8 p.m. Eastern. 25

26 199883_S84_PG26 Benefit Category Original Medicare Freedom Blue PPO Employer Group Plan Hospice You pay part of the cost for outpatient drugs You must get care from a Medicare-certified and inpatient respite care. You must get care hospice. Your plan will pay for a consultative from a Medicare-certified hospice. visit before you select a hospice. OUTPATIENT CARE Doctor Office Visits 20% coinsurance In-Network You pay cost sharing of $10 for each Office Visit copays are not applied to Medicare-covered primary care doctor visit. In-Network out of pocket maximum but are applied to the Total In and Out of Network You pay a cost sharing of $15 for each Out of Pocket Maximum. Medicare-covered specialist visit. Out-of-Network You pay 20% coinsurance for each Medicare-covered out-of-network primary care doctor office visit. You pay 20% coinsurance for each Medicare-covered out-of-network specialist visit. For questions about this plan's benefits or costs, please contact Freedom Blue PPO. Current members call (TTY users call 711) and prospective members call , (TTY users call 711), seven days a week, between 8 a.m. and 8 p.m. Eastern. 26

27 199883_S84_PG27 Benefit Category Original Medicare Freedom Blue PPO Employer Group Plan Chiropractic Services Supplemental routine care not covered. In-Network You pay cost sharing of $15 for each Office Visit copays are not applied to 20% coinsurance for manual manipulation of Medicare-covered visit. In-Network out of pocket maximum but are the spine to correct subluxation (a applied to the Total In and Out of Network displacement or misalignment of a joint or Medicare-covered chiropractic visits are for Out of Pocket Maximum. body part) if you get it from a chiropractor or manual manipulation of the spine to correct other qualified providers. subluxation (a displacement or misalignment of a joint or body part) if you get it from a chiropractor or other qualified providers. Out-of-Network You pay 20% coinsurance for Medicare-covered out-of-network chiropractic benefits. Podiatry Services Supplemental routine care not covered. In-Network You pay cost sharing of $15 for each Office Visit copays are not applied to 20% coinsurance for medically necessary foot Medicare-covered visit. In-Network out of pocket maximum but are care, including care for medical conditions applied to the Total In and Out of Network affecting the lower limbs. Medicare-covered podiatry benefits are for Out of Pocket Maximum. medically-necessary foot care. Out-of-Network You pay 20% coinsurance for Medicare-covered out-of-network podiatry benefits. For questions about this plan's benefits or costs, please contact Freedom Blue PPO. Current members call (TTY users call 711) and prospective members call , (TTY users call 711), seven days a week, between 8 a.m. and 8 p.m. Eastern. 27

28 199883_S84_PG28 Benefit Category Original Medicare Freedom Blue PPO Employer Group Plan Outpatient Mental Health Care 35% coinsurance for most outpatient mental Authorization rules may apply. health services. Office Visit copays are not applied to In-Network In-Network out of pocket maximum but are Specified copayment for outpatient partial You pay cost sharing of $15 for each applied to the Total In and Out of Network hospitalization program services furnished by Medicare-covered individual or group therapy Out of Pocket Maximum. a hospital or community mental health center visits. (CMHC). Copay cannot exceed the Part A inpatient hospital deductible. You pay cost sharing of $0 for each Medicare-covered partial hospitalization Partial hospitalization program is a program services. structured program of active outpatient psychiatric treatment that is more intense Out-of-Network than the care received in your doctor s or You pay 20% coinsurance for therapist s office and is an alternative to Medicare-covered out-of-network mental inpatient hospitalization. health benefits. You pay 20% coinsurance for Medicare-covered out-of-network mental health benefits with a psychiatrist. You pay 20% coinsurance for Medicare-covered partial hospitalization program services. Outpatient Substance Abuse Care 20% coinsurance Authorization rules may apply. In-Network You pay cost sharing of $15 for each Medicare-covered individual or group visits. Out-of-Network You pay 20% coinsurance for Medicare-covered out-of-network outpatient substance abuse services. For questions about this plan's benefits or costs, please contact Freedom Blue PPO. Current members call (TTY users call 711) and prospective members call , (TTY users call 711), seven days a week, between 8 a.m. and 8 p.m. Eastern. 28

29 199883_S84_PG29 Benefit Category Original Medicare Freedom Blue PPO Employer Group Plan Outpatient Services/Surgery 20% coinsurance for the doctor's services. Authorization rules may apply. Specified copayment for outpatient hospital facility services. Copay cannot exceed the Part In-Network A inpatient hospital deductible 20% You pay cost sharing of $0 for each coinsurance for ambulatory surgical center Medicare-covered ambulatory surgical center facility services. and/or outpatient hospital facility visit per provider/per day. Out-of-Network You pay 20% coinsurance for Medicare-covered services at an out-of-network ambulatory surgical center. You pay 20% coinsurance for Medicare-covered services at an out-of-network outpatient hospital facility. Ambulance Services 20% coinsurance In-Network (medically necessary ambulance services) You pay cost sharing of $0 for Medicare-covered ambulance benefits. Out-of-Network Emergency - You pay cost sharing of $0 for Medicare-covered ambulance benefits. Non-Emergency - You pay cost sharing of 20% for Medicare-covered ambulance benefits. For questions about this plan's benefits or costs, please contact Freedom Blue PPO. Current members call (TTY users call 711) and prospective members call , (TTY users call 711), seven days a week, between 8 a.m. and 8 p.m. Eastern. 29

30 199883_S84_PG30 Benefit Category Original Medicare Freedom Blue PPO Employer Group Plan Emergency Care 20% coinsurance for the doctor s services. You pay $50 cost sharing for each (You may go to any emergency room if you Medicare-covered emergency room visit. reasonably believe you need emergency Specified copayment for outpatient hospital care.) facility emergency services. Worldwide coverage for emergency and Emergency services copay cannot exceed Part urgently needed care. A inpatient hospital deductible for each service provided by the hospital. If you are admitted to the hospital within You don t have to pay the emergency room 3-day(s) for the same condition, your copay is copay if you are admitted to the hospital as waived for the emergency room visit. an inpatient for the same condition within 3 days of the emergency room visit. Not covered outside the U.S. except under limited circumstances. Urgently Needed Care 20% coinsurance, or a set copay. You pay cost sharing of $40 for (This is NOT emergency care, and in most NOT covered outside the U.S. except under Medicare-covered urgently needed care visits. cases, is out of the service area.) limited circumstances. For questions about this plan's benefits or costs, please contact Freedom Blue PPO. Current members call (TTY users call 711) and prospective members call , (TTY users call 711), seven days a week, between 8 a.m. and 8 p.m. Eastern. 30

31 199883_S84_PG31 Benefit Category Original Medicare Freedom Blue PPO Employer Group Plan Outpatient Rehabilitation Services 20% coinsurance Authorization rules may apply. (Occupational Therapy, Physical Therapy, Speech and Language Therapy) In-Network You pay a $15 cost sharing for Office Visit copays are not applied to Medicare-covered occupational therapy visits. In-Network out of pocket maximum but are applied to the Total In and Out of Network You pay a $15 cost sharing for Out of Pocket Maximum. Medicare-covered physical therapy and/or speech and language pathology visits. Out-of-Network You pay 20% coinsurance for Medicare-covered occupational therapy visits. You pay 20% coinsurance for Medicare-covered physical therapy and/or speech and language pathology visits. OUTPATIENT MEDICAL SERVICES AND SUPPLIES Durable Medical Equipment 20% coinsurance Authorization rules may apply. (includes wheelchairs, oxygen, etc.) Payment for deluxe or special features for Oxygen and oxygen-related equipment durable medical equipment may be made covered in full. only when such features are prescribed by the attending physician and when medical In-Network necessity is established. You pay 0% coinsurance for Medicare-covered durable medical equipment. Out-of-Network You pay 50% coinsurance for Medicare-covered durable medical equipment. For questions about this plan's benefits or costs, please contact Freedom Blue PPO. Current members call (TTY users call 711) and prospective members call , (TTY users call 711), seven days a week, between 8 a.m. and 8 p.m. Eastern. 31

32 199883_S84_PG32 Benefit Category Original Medicare Freedom Blue PPO Employer Group Plan Prosthetic Devices 20% coinsurance Authorization rules may apply. (includes braces, artificial limbs and eyes, etc.) Payment for deluxe or special features for In-Network durable medical equipment may be made You pay 0% coinsurance for only when such features are prescribed by the Medicare-covered prosthetic devices. attending physician and when medical necessity is established. Out-of-Network You pay 50% coinsurance for Medicare-covered prosthetic devices. Diabetes Programs and Supplies 20% coinsurance for diabetes Authorization rules may apply. (includes coverage for glucose monitors, test self-management training strips, lancets, screening tests, In-Network self-management training, retinal 20% coinsurance for diabetes supplies Diabetes self-monitoing training covered in exam/glaucoma test, and foot full. exam/therapeutic soft shoes) 20% coinsurance for diabetic therapeutic shoes or inserts Nutrition therapy for diabetes covered in full. You pay 0% coinsurance for Medicare-covered diabetes supplies and therapeutic shoes or inserts. If the doctor provides you additional services, separate doctor office visit cost sharing may apply. Out-of-Network You pay 50% coinsurance for Medicare-covered diabetes self-monitoring training, nutrition therapy, and supplies. For questions about this plan's benefits or costs, please contact Freedom Blue PPO. Current members call (TTY users call 711) and prospective members call , (TTY users call 711), seven days a week, between 8 a.m. and 8 p.m. Eastern. 32

33 199883_S84_PG33 Benefit Category Original Medicare Freedom Blue PPO Employer Group Plan Diagnostic Tests, X-Rays, Lab Services, and 20% coinsurance for diagnostic tests and Authorization rules may apply. Radiology Services x-rays In-Network $0 copay for Medicare-covered lab services You pay $0 for the following Medicare-covered services: Lab Services: Medicare covers medically necessary diagnostic lab services that are Lab services ordered by your treating doctor when they Diagnostic procedures and tests are provided by a Clinical Laboratory X-rays Improvement Amendments (CLIA) certified Diagnostic radiology services(not including laboratory that participates in Medicare. X-rays) Diagnostic lab services are done to help your Therapeutic radiology services doctor diagnose or rule out a suspected illness or condition. Medicare does not cover If the doctor provides you additional services, most routine screening tests, like checking separate doctor office visit cost sharing may your cholesterol. apply. 20% coinsurance for digital rectal exam and Out-of-Network other related services. You pay 20% coinsurance for Medicare-covered diagnostic procedures, Covered once a year for all men with tests and lab services. Medicare over age 50. You pay 20% coinsurance for Medicare-covered therapeutic and diagnostic radiology services. You pay 20% coinsurance for each Medicare-covered outpatient x-ray. For questions about this plan's benefits or costs, please contact Freedom Blue PPO. Current members call (TTY users call 711) and prospective members call , (TTY users call 711), seven days a week, between 8 a.m. and 8 p.m. Eastern. 33