DECISION GUIDE 2015 Regence Medicare Advantage PPO Plans Regence BlueShield serves select counties in the state of Washington and is an Independent Licensee of the Blue Cross and Blue Shield Association Y0062_07978 Approved WA PPO 2015
GET STARTED READ. This booklet gives you all the tools you need to make an informed decision in choosing a Regence Medicare Advantage Plan. It provides important information you need to evaluate your options and find the plan that best fits your needs. It has easy-toread charts that compare benefits, gives you information about additional programs and benefits you can enjoy as a Regence BlueShield member and provides directions for how to enroll. CALL. If you need additional help, or if you would prefer an in-person meeting with one of our Plan s Medicare sales representatives, call us at 1-844-REGENCE (1-844-734-3623) from 8 a.m. to 5 p.m., Monday through Friday. TTY users should call 711. ATTEND. We offer free informational meetings for you to learn more about our Medicare Advantage plans. For the most current list of meetings in your area, visit regence.com/medicare. GO ONLINE. A wealth of information is available at your fingertips at regence.com/medicare. You can search for your provider in our network and check our formulary (list of covered prescription drugs) for the prescription drugs you take. OR CALL YOUR INSURANCE AGENT. Either way, there s plenty of help available if you have questions.
MEDICARE MADE EASY Are you confused about how Medicare benefits work? Unsure if you re covered when you're traveling? Are you effectively using all of your benefits to support your health? Regence BlueShield makes it easy to choose, and use, your Medicare Advantage plan. You can access all your benefits with one member identification card and virtually no paperwork. Should you have a question or need assistance, our customer service team is only a phone call away. Regence Medicare Advantage Plans combine all of the benefits of Original Medicare Parts A (hospital) and B (physician), and in some cases Part D prescription drug coverage, into one easy-to-use plan. You also get extra benefits and programs beyond what Original Medicare has to offer. Get EXTRA BENEFITS and PROGRAMS u Worldwide coverage for urgent and emergency care. Travel without worrying about access to care if you need it with the BlueCard Worldwide program. u Large national PPO provider network through the Blue Medicare Advantage PPO Network Sharing Program and no referrals needed to see a provider of your choice. u SilverSneakers Fitness program. Receive a free fitness membership and access to more than 11,000 participating locations across the country. Unable to get to a SilverSneakers location? A home fitness kit is available to help you get fit at home or on the go. u Regence Advice24. Get the medical advice you need from a registered nurse any time, day or night, using our toll-free medical advice line. u My Advocate. Find out if you qualify for, but are not receiving, assistance with medical costs, heating bills, meal programs or other programs and social services. WA PPO 2015 1
REGENCE MEDICARE ADVANTAGE PLANS Regence MedAdvantage + Rx CLASSIC (PPO) Regence MedAdvantage BASIC (PPO) (no Rx) $ 15 primary care copay Deductible waived for in-network primary care services Freedom to see any provider across the United States No referrals required In-network travel benefits Routine eye exam Vision hardware Preventive dental Concierge Service $ 15 primary care copay Deductible waived for in-network primary care services Freedom to see any provider across the United States No referrals required In-network travel benefits Routine eye exam Vision hardware Preventive dental All PPO plan members receive: Worldwide emergency and urgent care when you travel domestically or abroad Vision: One routine eye exam per year Annual physical exam: An annual physical exam with no copay, coinsurance or deductible, in addition to the Medical Annual Wellness Visit Vision hardware: An allowance toward the purchase of glasses, lenses and contact lenses Preventive dental: Up to $500 annually for preventive dental services, such as twice-yearly cleanings, X-rays and preventive dental exams NEW! Additional dental coverage available for PPO plan members Regence PPO members can receive restorative dental services such as oral surgery, extractions and implants with no deductible. This optional dental coverage is available for an additional premium. See the Summary of Benefits for details. 2 WA PPO 2015
WE HAVE YOU COVERED across the country and around the world! Travel the world with complete peace of mind. Through the BlueCard Worldwide program, you have access to medical assistance services and doctors and hospitals in more than 200 countries and territories around the world. 1 When you receive care from a participating provider, you ll pay the out-of-pocket expenses (deductible, copay and coinsurance) that you would normally pay under your PPO plan. Get in-network benefits across the country a special advantage for Regence PPO members. Regence PPO plan members can see any Medicare-contracted provider anywhere in the United States. When traveling outside the service area, PPO members will also receive in-network benefits by seeing Medicare Advantage PPO Blue Cross and/or Blue Shield -contracted providers through the Blue Medicare Advantage PPO Network Program available in 35 states across the country. 2 Wyoming Michigan In-network coverage Out-of-network coverage PUERTO RICO Finding a Blue Medicare Advantage PPO provider is easy. Download the Blue National Doctor & Hospital Finder App at bcbs.com/mobile, or use the National Doctor and Hospital Finder at provider.bcbs.com. 1 Part D prescription drug coverage is not available outside the United States and its territories. 2 The Medicare Advantage PPO Network Sharing Program is only available with Regence Medicare Advantage PPO plans. WA PPO 2015 3
REGENCE SUPPORTS YOUR HEALTH AND WELLNESS Feel better and healthier regardless of your current fitness level. Get fit, have fun and make friends by using your SilverSneakers membership. You ll have access to more than 11,000 participating fitness facility locations across the country where on-site staff members can help you meet your wellness goals. Locations offer amenities such as exercise equipment and SilverSneakers fitness classes that are designed specifically for active older adults and are taught by certified instructors (classes and amenities vary by location). Don t have access to a participating fitness location? SilverSneakers will send you a home fitness kit that contains tools to achieve a healthier lifestyle at home or on the go. Regence Advice24. Get the medical advice you need from a registered nurse any time, day or night, using our toll-free medical advice line. 4 WA PPO 2015
Save money when you fill a three-month supply of your maintenance medication prescriptions. Take advantage of greater savings and convenience for your ongoing prescription needs when you order a three-month supply of your maintenance medications from an in-network retail pharmacy or mail-order pharmacy. You pay only two times your monthly copay for a three-month supply of generic drugs; brand-name prescriptions are only two and a half times your monthly copay. You can get prescription drugs shipped to your home through our network mail order delivery program. Typically, you should expect to receive your prescription drugs within 14 days from the time that the mail order pharmacy receives the order. Should a prescription drug order not arrive within the estimated time frame, help is available from Customer Service at 1 (800) 541-8981 from 8 a.m. to 8 p.m. Monday through Friday (from October 1 through February 14, our telephone hours are 8 a.m. to 8 p.m., seven days a week). TTY users should call 711. WA PPO 2015 5
3 EASY STEPS TO CHOOSING THE RIGHT PLAN FOR YOU 1 Search for your provider in our network. 2 Check our formulary for your prescription drugs. Search for providers and view our formulary online at regence.com/medicare. Call us at 1-844-REGENCE (1-844-734-3623). TTY users should call 711. Our Plan s Medicare sales representatives are happy to answer your questions, find a doctor or look up your medication for you. 3 Review our plans and identify the one with the benefits that are most important to you. Each plan has different premiums, copays and out-of-pocket maximums. Review the highlights of our Medicare Advantage plans in the pages that follow. A comprehensive list of benefits can be found in the Summary of Benefits that is included in this packet. 6 WA PPO 2015
SERVICE AREAS AND PREMIUMS WHATCOM SAN JUAN SKAGIT ISLAND CLALLAM SNOHOMISH KITSAP KING THURSTON PIERCE WAHKIAKUM LEWIS YAKIMA COLUMBIA COWLITZ SKAMANIA WALLA WALLA KLICKITAT Clallam, Columbia, Cowlitz, Island, King, Kitsap, Klickitat, Lewis, Pierce, San Juan, Skagit, Skamania, Snohomish, Thurston, Wahkiakum, Walla Walla, Whatcom, Yakima Regence MedAdvantage Basic (PPO) (no Rx) $145 Regence MedAdvantage + Rx Classic (PPO) $167 WA PPO 2015 7
PPO BENEFIT HIGHLIGHTS Medical Benefits Regence MedAdvantage + Rx CLASSIC (PPO) Regence MedAdvantage BASIC (PPO) (no Rx) Monthly premium $167 $145 Annual medical deductible 1 (waived for in-network primary care services) Out-of-pocket maximum $125 $50 $3,400 in-network $5,100 combined $3,400 in-network $5,100 combined Network In Out In Out Preventive services and screenings (including an Annual Wellness Visit) Primary care office visit $15 $25 $15 $25 Specialist office visit $40 $50 $40 $50 X-rays $0 20% $0 20% Lab services $0 $0 $0 $0 Inpatient hospital Days 1-4: $400 per day Days 1-4: $500 per day $0 Days 1-4: $400 per day Days 1-4: $500 per day Outpatient surgery ambulatory surgery center $150 $200 $150 $200 Outpatient surgery hospital $250 $350 $250 $350 Emergency room $65 (in or out of network, waived if admitted within 48 hours) Urgent care $30 $30 $30 $30 Durable medical equipment 20% 30% 20% 30% Skilled nursing facility (days 1-100; no benefit after 100 days) $40 per day $70 per day $40 per day $70 per day 1 Deductible waived for in-network primary care office visits, Medicare-covered preventive services and in-network Medicare-covered Part B prescription drugs. Deductible also waived for preventive dental, routine vision exam and routine vision hardware. 8 WA PPO 2015
PPO BENEFIT HIGHLIGHTS Medical Benefits Regence MedAdvantage + Rx CLASSIC (PPO) Regence MedAdvantage BASIC (PPO) (no Rx) Additional Benefits and Programs Network In Out In Out Annual physical exam $0 Hearing aid No coverage No coverage Routine eye exam (one per year) 1 $40 $40 $40 $40 Routine vision hardware Preventive dental (cleanings and X-rays) Comprehensive dental (optional, additional premium applies) SilverSneakers Fitness program Part D prescription drug coverage Up to $100 allowed per year, in or out of network Up to $100 allowed per year, in or out of network 50%, up to $500 allowed per year, in or out of network 50%, up to $1,000 allowed per year, in or out of network Included in plan at no additional cost Included in plan; see page 10 for details No coverage 1 Routine vision care must be received from a Vision Service Plan (VSP) provider to be eligible for in-network cost sharing. Visit vsp.com to search for a provider in your area. WA PPO 2015 9
PRESCRIPTION DRUG COVERAGE Benefit information Prescription Drug Coverage Regence MedAdvantage + Rx CLASSIC (PPO) Annual Rx Deductible $235 STAGE 1: Initial Coverage Stage 1-Month supply (in-network retail pharmacy) Tier 1: Preferred generics $8 Tier 2: Non-preferred generics $15 Tier 3: Preferred brands $45 Tier 4: Non-preferred brands $95 Tier 5: Specialty drugs 26% 3-Month supply (in-network retail pharmacy or mail-order pharmacy) Tier 1: Preferred generics $16 Tier 2: Non-preferred generics $30 Tier 3: Preferred brands $112.50 Tier 4: Non-preferred brands $237.50 Tier 5: Specialty drugs Not applicable; limited to a 30-day supply STAGE 2: Coverage Gap Stage (after prescription costs reach $2,960) Generic drugs You pay 65% Brand drugs You pay 45% STAGE 3: Catastrophic Coverage Stage (after you have paid $4,700 out of pocket) Generic drugs You pay the greater of 5% or $2.65 Brand drugs You pay the greater of 5% or $6.60 10 WA PPO 2015
THE COVERAGE GAP How it works $ STAGE 1: Initial Coverage STAGE 2: Coverage Gap STAGE 3: Catastrophic Coverage You pay a little Plan pays most You pay most You pay a little Plan pays a little Plan pays most After you pay your annual deductible (if applicable), you pay a copay or coinsurance for each prescription you fill. Your plan pays the rest until the total that you and the plan pay reaches $2,960. After your total drug costs reach $2,960, you pay 65% of the cost of generic prescription drugs and 45% of the cost of most brand-name prescription drugs until your total out-ofpocket prescription drug costs reach $4,700. Total out-of-pocket costs are the amounts paid by you in the first two stages plus any applicable drug manufacturer discounts applied in the Coverage Gap stage. After your total drug costs reach $4,700, you pay the greater of 5% coinsurance or $2.65 copay for generic drugs, and the greater of 5% coinsurance or $6.60 copay for brand-name drugs. Your plan pays the rest of the cost of your prescription drugs for the rest of the calendar year (through December 31, 2015). Need extra help with prescription drug costs? To determine if you qualify for extra help from Medicare to pay for your prescription drug premiums and costs, call the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday (TTY users should call 1-800-325-0778); or your State Medicaid Office. WA PPO 2015 11
READY TO ENROLL? LET S GET STARTED! Enrolling is easy: ENROLL BY PHONE. Have one of our Plan s Medicare sales representatives enroll you over the phone by calling 1-844-REGENCE (1-844-734-3623). TTY users should call 711. ENROLL ONLINE. Enjoy the convenience of applying online. Visit regence.com/medicare and follow the instructions for applying online. ENROLL BY MAIL. An enrollment application is included in this packet or you can visit regence.com/medicare and download an enrollment application. 1. Complete and sign your application. Verify that the information from your Medicare card is listed correctly on your enrollment application, or make a copy of your Medicare card and attach it to your enrollment application. 2. Use the postage-paid return envelope included in this information packet to mail your completed and signed application. Applications can also be mailed to: PO Box 1827, B32M, Medford, OR 97501. Please make sure you have sufficient postage. 3. Do not send any payment with your enrollment application. Regence BlueShield is a Medicare Advantage plan with a Medicare contract. Enrollment in Regence BlueShield depends on contract renewal. The benefit information provided is a brief summary, not a complete description of benefits. For more information, contact the plan. Limitations, copayments, and restrictions may apply. Benefits, formulary, pharmacy network, provider network, premium and/or copayments/coinsurance may change on January 1 of each year. Anyone who resides in our service area may apply. Individuals must have both Part A and Part B to enroll. You must continue to pay your Medicare Part B premium. 12 WA PPO 2015
For more information, call one of our Plan s Medicare sales representatives, 8 a.m. to 5 p.m., Monday through Friday toll-free: 1-844-REGENCE (1-844-734-3623) TTY users should call 711 P.O. Box 21267 Seattle, WA 98111 08497-wa/07-14 2014 Regence BlueShield regence.com/medicare