Benefits Summary of. BlueMedicare SM Preferred HMO A Medicare Advantage HMO Plan. Pinellas County

Transcription

1 Summary of 2017 BlueMedicare SM HMO A Medicare Advantage HMO Plan Pinellas County HMO coverage is offered by BeHealthy Florida, Inc., DBA Florida Blue HMO, an affiliate of Blue Cross and Blue Shield of Florida, Inc. These companies are Independent Licensees of the Blue Cross and Blue Shield Association. Y0011_ CMS Accepted

2 BlueMedicare HMO (Plan and BlueMedicare HMO POS Summary of January 1, December 31, 2017 This booklet provides a summary of what BlueMedicare HMO (plan and BlueMedicare HMO POS (plan 008) and what you pay for covered services and supplies. To get a complete list of services we cover, call our Member Services Department and ask for the "Evidence of Coverage." You may also view the Evidence of Coverage on our website, Things to Know About BlueMedicare HMO (Plan and BlueMedicare HMO POS Eligibility requirements To join BlueMedicare HMO (plan or BlueMedicare HMO POS (plan 008), you must be entitled to Medicare Part A, enrolled in Medicare Part B, and live in our service area. Our service area includes the following County in Florida: Pinellas Which doctors, hospitals, and pharmacies can I use? BlueMedicare HMO (plan and BlueMedicare HMO POS (plan 008) have a network of doctors, hospitals and other providers. In most cases, you must receive care from network providers; care you receive from out-of-network providers is not generally covered by our plan. There are three exceptions to this requirement: We cover emergency care and urgently needed services you receive from out-of-network providers. If providers in our network cannot provide a type of Medicare-covered care you need, we will cover the care if you receive it from an out-of-network provider. You must receive authorization from our plan before seeking care from an out-of-network provider in this situation. We will cover care you receive at a Medicare-certified dialysis facility when you are temporarily outside our plan s service area. In most situations, you must use our network pharmacies to fill your prescriptions for covered Part D drugs. Some of our network pharmacies offer preferred cost-sharing. You may pay less if you use these pharmacies. You can see our plan's provider directory on our website, You can see our plan's pharmacy directory on our website, You can see our plan's comprehensive formulary (list of covered Part D drugs) on our website, Or call us and we will send you a copy of the provider and pharmacy directories and the formulary. What do we cover? Our plan includes all of the benefits covered by Original Medicare. For some of these benefits, you may pay more in our plan than you would in Original Medicare. For others, you may pay less. Our plan members also get more than what is covered by Original Medicare. Some of the extra benefits are outlined in this booklet. We cover Part D drugs. In addition, we cover Part B drugs such as chemotherapy and some drugs administered by your provider. [Page 1]

3 Hours of Operation From: 8:00 a.m. 8:00 p.m. local time, 7 days a week. Phone Numbers and Website If you are a current member of BlueMedicare HMO (plan or BlueMedicare HMO POS (plan 008): If you are not currently a member of one of these plans, call TTY users: Call Our website: If you want to know more about the coverage and costs of Original Medicare, look in your current Medicare & You handbook. View it online at or get a copy by calling MEDICARE ( ), 24 hours a day, 7 days a week. TTY users should call This document is available in other formats such as Braille and large print. Florida Blue HMO is an HMO plan with a Medicare contract. Enrollment in Florida Blue HMO depends on contract renewal. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply., premiums and/or copayments/coinsurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium. The formulary and/or pharmacy network may change at any time. You will receive notice when necessary. [Page 2]

4 Inpatient Hospital Coverage Monthly Plan Premium BlueMedicare HMO (Plan You pay $0.00 per month. You must continue to pay your Medicare Part B premium. BlueMedicare HMO POS You pay $39.00 per month. You must continue to pay your Medicare Part B premium. Deductible This plan does not have a deductible. This plan does not have a deductible. Maximum Out-of- Pocket Responsibility (does not include prescription drugs) Inpatient Hospital Coverage Doctor Visits You yearly limit(s) in this plan: $3,400 for services from innetwork providers. If you reach the limit on out-of-pocket costs, we will pay the full cost of covered medical services and supplies for the rest of the year. non-emergency Inpatient Hospital stays. Days 1-5: $120 copay per day After day 5: You pay nothing specialist visits. You pay nothing per primary care visit $25 copay per specialist visit You yearly limit(s) in this plan: $4,700 for services from innetwork providers. $8,000 for services from out-ofnetwork providers. If you reach the limit on out-of-pocket costs, we will pay the full cost of covered medical services and supplies for the rest of the year. You will still need to pay your monthly plan premium. non-emergency Inpatient Hospital stays. Days 1-5: $120 copay per day After day 5: You pay nothing After you have met the Medicare deductible of $1,288 per benefit period: Days 1-60: $0 copayment per day for Medicare-covered hospital care. Days 61-90: $322 copayment per day for Medicare-covered hospital care. Lifetime Reserve Days: $644 copayment for days 1 60 specialist visits. You pay nothing per primary care visit $25 copay per specialist visit [Page 3]

5 Doctor Visits (continued) Preventive Care BlueMedicare HMO (Plan You pay nothing. Covered preventive services include: Abdominal aortic aneurysm screening Alcohol misuse counseling Annual Wellness visit Bone mass measurement Breast cancer screening (mammograms) Cardiovascular disease risk reduction visit (yearly) Cardiovascular disease testing Cervical and vaginal cancer screening Colorectal cancer screening (Colonoscopy, Fecal occult blood test, Flexible sigmoidoscopy or barium enema, Cologuard test) Depression screening Diabetes screening Diabetes self-management training HIV screening Medical nutrition therapy services Obesity screening and therapy to promote sustained weight loss Prostate cancer screening exams Screening for sexually transmitted infections (STIs) and screening and counseling to prevent STIs Smoking and tobacco use cessation counseling Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots "Welcome to Medicare" preventive visit (one-time) Lung Cancer Screening [Page 4] BlueMedicare HMO POS $30 copay per primary care visit $45 copay per specialist visit You pay nothing. Covered preventive services include: Abdominal aortic aneurysm screening Alcohol misuse counseling Annual Wellness visit Bone mass measurement Breast cancer screening (mammograms) Cardiovascular disease risk reduction visit (yearly) Cardiovascular disease testing Cervical and vaginal cancer screening Colorectal cancer screening (Colonoscopy, Fecal occult blood test, Flexible sigmoidoscopy or barium enema, Cologuard test) Depression screening Diabetes screening Diabetes self-management training HIV screening Medical nutrition therapy services Obesity screening and therapy to promote sustained weight loss Prostate cancer screening exams Screening for sexually transmitted infections (STIs) and screening and counseling to prevent STIs Smoking and tobacco use cessation counseling Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots "Welcome to Medicare" preventive visit (one-time) Lung Cancer Screening

6 Diagnostic Services/Labs/Imaging Diagnostic Services/Labs/Imaging Diagnostic Services/Labs/Imaging Preventive Care (Continued) BlueMedicare HMO (Plan Any additional preventive services approved by Medicare during the contract year will be covered. BlueMedicare HMO POS Any additional preventive services approved by Medicare during the contract year will be covered. Emergency Care Urgently Needed Services Diagnostic Services/Labs/ Imaging $75 copay per visit If you are admitted to the hospital within 48 hours, you do not have to pay your share of the cost for emergency care. Emergency coverage is provided worldwide. Worldwide emergency coverage has a $25,000 limit and does not include emergency transportation. Worldwide Emergency Care $75 copay (copay will not be waived if admitted to the hospital) $25 copay at an Urgent Care Center If you are admitted to the hospital within 48 hours, you do not have to pay your share of the cost for urgently needed services. See the "Inpatient Hospital Coverage" section of this booklet for other costs. certain services. Call Member Services for additional information. Laboratory Services You pay nothing at an Independent Clinical Laboratory. You pay nothing at an outpatient hospital facility X-Rays $5 copay Advanced Imaging Services (e.g., Magnetic Resonance Imaging [MRI], Positron Emission Tomography [PET], Computer Tomography [CT] $75 copay per visit If you are admitted to the hospital within 48 hours, you do not have to pay your share of the cost for emergency care. Emergency coverage is provided worldwide. Worldwide emergency coverage has a $25,000 limit and does not include emergency transportation. Worldwide Emergency Care $75 copay (copay will not be waived if admitted to the hospital) $25 copay at an Urgent Care Center If you are admitted to the hospital within 48 hours, you do not have to pay your share of the cost for urgently needed services. See the "Inpatient Hospital Coverage" section of this booklet for other costs. certain services. Call Member Services for additional information. Laboratory Services You pay nothing. X-Rays $5 copay Advanced Imaging Services (e.g., Magnetic Resonance Imaging [MRI], Positron Emission Tomography [PET], Computer Tomography [CT] [Page 5]

7 Diagnostic Services/Labs/Imaging Diagnostic Services/Labs/ Imaging (continued) Hearing Services BlueMedicare HMO (Plan Scan) $120 copay Radiation Therapy 20% coinsurance Medicare-covered hearing exams. Medicare-Covered Hearing Services Exams to diagnose and treat hearing and balance issues: $0 copay for PCP $25 copay for Specialist Routine hearing exam (1 every year): You pay nothing Hearing aid fitting/evaluation: You pay nothing (1 every year) BlueMedicare HMO POS Scan) $120 copay Radiation Therapy 20% coinsurance Medicare-covered hearing exams. Medicare-Covered Hearing Services Exams to diagnose and treat hearing and balance issues: $0 copay for PCP $25 copay for Specialist Routine hearing exam (1 every year): You pay nothing Hearing aid fitting/evaluation: You pay nothing (1 every year) [Page 6]

8 Dental Services Dental Services Dental Services BlueMedicare HMO (Plan Medicare-covered comprehensive dental services. Medicare-Covered Dental Services (non-routine dental care such as setting fractures of the jaw or facial bones, jaw surgery, extraction of teeth to prepare for radiation therapy, services covered when provided by a physician) $50 copay Additional Dental Services (cleanings, oral exams, X-rays, extraction of erupted tooth or exposed root, adjustment of complete or partial denture) BlueMedicare HMO POS Medicare-covered comprehensive dental services. Medicare-Covered Dental Services (non-routine dental care such as setting fractures of the jaw or facial bones, jaw surgery, extraction of teeth to prepare for radiation therapy, services covered when provided by a physician) $50 copay You pay nothing. Note: See the Dental Schedule for complete information about additional dental services covered by the plan. [Page 7]

9 Vision Services Vision Services Mental Health Services BlueMedicare HMO (Plan Medicare-covered exam. $25 copay for physician services to diagnose and treat eye diseases and conditions You pay nothing for glaucoma screening (once per year for members at high risk of glaucoma). You pay nothing for one pair of eyeglasses or contact lenses after each cataract surgery. Additional Vision Services You pay nothing for one routine eye exam every 12 months. The maximum plan benefit amount for all eyewear is $100 every 2 years. Note: See the Vision Schedule for complete information about the additional vision benefits covered by the plan. Inpatient Mental Health Services non-emergency services. Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. This limit does not apply to inpatient mental health services provided in a general hospital. Days: 1-5: $120 copay per day Days: 6-190: You pay nothing. : BlueMedicare HMO POS Medicare-covered exam. $25 copay for physician services to diagnose and treat eye diseases and conditions You pay nothing for glaucoma screening (once per year for members at high risk of glaucoma). You pay nothing for one pair of eyeglasses or contact lenses after each cataract surgery. Additional Vision Services You pay nothing for one routine eye exam every 12 months. The maximum plan benefit amount for all eyewear is $100 every 2 years. Note: See the Vision Schedule for complete information about the additional vision benefits covered by the plan. Inpatient Mental Health Services non-emergency services. Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. This limit does not apply to inpatient mental health services provided in a general hospital. Days 1-5: $120 copay per day Days 6-190: You pay nothing. : After you have met the Medicare deductible of $1,288 per benefit period: Days 1-60: $0 copayment per day for Medicare-covered hospital care. [Page 8]

10 Mental Health Services Mental Health Services Mental Health Services (Continued) Skilled Nursing Facility (SNF) Rehabilitation Services BlueMedicare HMO (Plan Outpatient Mental Health Services non-emergency services. $25 copay SNF stays. Our plan covers up to 100 days in a SNF per benefit period. Days 1-20: You pay nothing. Days : $150 copay per day all therapy services. Occupational, physical therapy and speech and language therapy visits BlueMedicare HMO POS Days 61-90: $322 copayment per day for Medicare-covered hospital care. Lifetime Reserve Days: $644 copayment for days 1 60 Outpatient Mental Health Services non-emergency services. $25 copay SNF stays. Our plan covers up to 100 days in a SNF per benefit period. Days 1-20: You pay nothing. Days : $150 copay per day all therapy services. Occupational, physical therapy and speech and language therapy visits $25 copay $25 copay A $1,960 yearly Medicare limit applies to outpatient physical and speech therapy services. This limit is for 2016 and may change in A separate $1,960 yearly Medicare limit applies to outpatient occupational therapy services. This limit is for 2016 and may change in A $1,960 yearly Medicare limit applies to outpatient physical and speech therapy services. This limit is for 2016 and may change in A separate $1,960 yearly Medicare limit applies to outpatient occupational therapy services. This limit is for 2016 and may change in [Page 9]

11 Medical Equipment/ Supplies Ambulance Transportation (Routine) Foot Care (podiatry services) Medical Equipment/ Supplies BlueMedicare HMO (Plan non-emergency ambulance services. $150 copay for each Medicarecovered trip (one-way) If you are admitted to the hospital, you do not have to pay your share of the cost for ambulance services. non-emergency transportation. You pay nothing 20 one-way trips per calendar year to plan-approved locations for healthrelated services within a 20 mile radius of your permanent residence. Locations include provider offices, hospitals and pharmacies. Transportation to Alignment's Care Centers does not have a mile limitation and does not count against the 20 one-way trip limit. all podiatry services. Diagnosis and treatment of injuries and diseases of the feet. Routine care for members with certain conditions affecting the lower limbs. $25 copay : certain equipment/supplies. Call Member Services for additional information. Durable Medical Equipment 20% coinsurance BlueMedicare HMO POS non-emergency ambulance services. $150 copay for each Medicarecovered trip (one-way) If you are admitted to the hospital, you do not have to pay your share of the cost for ambulance services. all podiatry services. Diagnosis and treatment of injuries and diseases of the feet. Routine care for members with certain conditions affecting the lower limbs. $25 copay : $45 copay certain equipment/supplies. Call Member Services for additional information. Durable Medical Equipment 20% coinsurance [Page 10]

12 Medical Equipment/ Supplies Medical Equipment/ Supplies Medical Equipment/ Supplies (continued) Wellness Programs BlueMedicare HMO (Plan Prosthetics 20% coinsurance Diabetic Supplies You pay nothing Healthways SilverSneakers Fitness Program - For more information, visit silversneakers.com or call (TTY: 711), Monday through Friday, 8:00 a.m. to 8:00 p.m. ET. BlueMedicare HMO POS Prosthetics 20% coinsurance Diabetic Supplies You pay nothing Healthways SilverSneakers Fitness Program - For more information, visit silversneakers.com or call (TTY: 711), Monday through Friday, 8:00 a.m. to 8:00 p.m. ET. Health Education Health Education Enhanced Disease Management Enhanced Disease Management Medicare Part B Drugs Nursing Hotline You pay nothing to participate in these programs. Medicare Part B-covered prescription drugs except for allergy injections. 20% coinsurance for chemotherapy drugs and other Medicare Part B-covered drugs Nursing Hotline You pay nothing to participate in these programs. Medicare Part B-covered prescription drugs except for allergy injections. 20% coinsurance for chemotherapy drugs and other Medicare Part B-covered drugs [Page 11]

13 BlueMedicare HMO (Plan BlueMedicare HMO POS Part D Prescription Drug - Call the Plan for more information or access the Evidence of Coverage online. Initial Coverage Stage You begin in this stage when you fill your first prescription of the year. During this stage, the plan pays its share of the cost of your drugs and you pay your share of the cost. You remain in this stage until your total yearly drug costs (total drug costs paid by you and any Part D plan) reach $3,700. You may get your drugs at network retail pharmacies and mail order pharmacies. Cost-Sharing for a one-month (up to 30 days) of a covered Part D prescription drug) 1 ( 2 ( 3 ( Brand) 4 (Non- Brand) Retail Retail $0 copay $14 copay $42 copay $35 copay $92 copay $85 copay Mail Order/ Mail Order $0 copay $14 copay $42 copay $35 copay $92 copay $85 copay Cost-Sharing for a one-month (up to 30 days) of a covered Part D prescription drug) 1 ( 2 ( 3 ( Brand) 4 (Non- Brand) Retail Retail $0 copay $14 copay $42 copay $35 copay $92 copay $85 copay Mail Order/ Mail Order $0 copay $14 copay $42 copay $35 copay $92 copay $85 copay 5 (Specialty ) 33% of the cost 33% of the cost 5 (Specialty ) 33% of the cost 33% of the cost 6 (Select Care ) If you reside in a long-term care facility, you pay the preferred retail cost-sharing amount. If you purchase drugs from an out-of-network pharmacy (limited 10 day ), you pay the standard retail cost-sharing amount. 6 (Select Care ) If you reside in a long-term care facility, you pay the preferred retail cost-sharing amount. If you purchase drugs from an out-of-network pharmacy (limited 10 day ), you pay the standard retail cost-sharing amount. [Page 12]

14 Coverage Gap Stage Coverage Gap Stage Coverage Gap Stage BlueMedicare HMO (Plan The Coverage Gap Stage begins after total yearly drug costs (what any Part D plan has paid and what you have paid) reach $3,700. For generic drugs in 1 ( Generics) and 6 (Select Care), you pay the same copayments that you paid in the Initial Coverage Stage or 51% of the price, whichever is lower. For generic drugs in all other tiers, you pay 51% of the price. For brand-name drugs, you pay 40% of the price (plus a portion of the dispensing fee). You stay in this stage until your year-to-date out-of-pocket costs (your payments) reach a total of $4,950. Retail Cost-Sharing 30 day 100 day BlueMedicare HMO POS The Coverage Gap Stage begins after total yearly drug costs (what any Part D plan has paid and what you have paid) reach $3,700. For generic drugs in 1 ( Generics) and 6 (Select Care), you pay the same copayments that you paid in the Initial Coverage Stage or 51% of the price, whichever is lower. For generic drugs in all other tiers, you pay 51% of the price. For brand-name drugs, you pay 40% of the price (plus a portion of the dispensing fee). You stay in this stage until your year-to-date out-of-pocket costs (your payments) reach a total of $4,950. Retail Cost-Sharing 30 day 100 day 1 ( 1 ( 6 (Select Care ) 6 (Select Care ) Retail Cost-Sharing 30 day 100 day Retail Cost-Sharing 30 day 100 day 1 ( 1 ( 6 (Select Care ) 6 (Select Care ) [Page 13]

15 Coverage Gap Stage (continued) and Mail Order Cost-Sharing 30 day 100 day and Mail Order Cost-Sharing 30 day 100 day 1 ( 1 ( 6 (Select Care ) 6 (Select Care ) Catastrophic Coverage Stage After your yearly out-of-pocket drug costs reach $4,950, you pay the greater of: 5% of the cost, or $3.30 copay for generic (including brand drugs treated as generic) and an $8.25 copay for all other drugs After your yearly out-of-pocket drug costs reach $4,950, you pay the greater of: 5% of the cost, or $3.30 copay for generic (including brand drugs treated as generic) and an $8.25 copay for all other drugs [Page 14]