LEARN. COMPARE. ENROLL.

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1 LEARN. COMPARE. ENROLL. How to apply for coverage and more! ving select Idaho counties Medicare Advantage Plans 2019 INFORMATION KIT in the Gem State Area 1 Service Area 1 Select Counties Form No (09-18)

2 YOUR GUIDE TO THE 2019 MEDICARE ADVANTAGE PLANS Here s what s inside: UNDERSTANDING THE BASICS Learn why Medicare Advantage is a good choice over Original Medicare, how HMOs work, terms to help you understand the benefits and more. TRUE BLUE (HMO) SUMMARY OF BENEFITS In an easy-to-read chart, take a good look at our plans and what they cover. DETAILS ABOUT THE EXTRAS With Blue Cross of Idaho Care Plus, you get even more than Original Medicare: hearing and vision, fitness discounts, and more. TRUE BLUE (HMO) PROVIDER LISTING We partner with doctors and clinics all over Idaho. See who s waiting to serve you. TRUE BLUE (HMO) PHARMACY DIRECTORY A convenient pharmacy is pretty important to our everyday lives. We have pharmacy partners all over the state. Check out our pharmacy directory, conveniently sorted by location.

3 Understanding the Basics Understanding the Basics Understanding the Basics Learn why Medicare Advantage is a good choice over Original Medicare, how HMOs work, terms to help you understand the benefits and more.

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5 When you understand the basics, you ll make better choices. Choosing the right health insurance can seem overwhelming and confusing. We are here to make Medicare less complicated, so you can get on with enjoying this exciting time in your life with more financial peace of mind. If you are new to Medicare, you probably have lots of questions. We ll help answer questions here about what Medicare is, explain its different parts and show you how to enroll. Let s get started. Peter Sorensen, Vice President of Medicare Advantage You have the ADVANTAGE of MEDICARE ADVANTAGE BLUE CROSS OF IDAHO CARE PLUS INFORMATION KIT 5

6 HOW WE CAN SERVE YOU. To join a True Blue plan, you must be entitled to Medicare Part A, be enrolled in Medicare Part B, and live in one of our 22 counties. Service Area 1 consists of the following counties: Ada, Boise, Bonner, Boundary, Canyon, Clark, Elmore, Gem, Kootenai, Nez Perce, Owyhee, and Payette. Service Area 2 consists of the following counties: Bannock, Bingham, Bonneville, Cassia, Fremont, Jefferson, Madison, Minidoka, Power, and Twin Falls. Service Area for True Blue Rx Preferred (HMO) plan consists of Ada and Canyon counties. Boundary Bonner Kootenai Benewah Shoshone Latah Nez Perce Clearwater Lewis Idaho Lemhi Adams Valley Payette Gem Canyon Boise Butte Elmore Owyhee INFORMATION KIT BLUE CROSS OF IDAHO CARE PLUS Blaine Camas Gooding Ada 6 Clark Custer Fremont Madison Jefferson Bonneville Teton Washington Bingham Lincoln Jerome Twin Falls Minidoka N O M AT T E R WHICH SERVICE AREA YOU LIVE I N, Y O U L L H AV E THE SAME ACCESS TO OUR TRUE BLUE PROVIDER NETWORK, WHICH HAS THOUSANDS OF DOCTORS ALL OVER IDAHO. Power Caribou Bannock Cassia Oneida Franklin Bear Lake

7 WHY CHOOSE MEDICARE ADVANTAGE OVER ORIGINAL MEDICARE? Original Medicare (Parts A and B) pays only 80 percent for covered services. Original Medicare does not put a yearly limit on your out-of-pocket expenses for covered services. If you suddenly need more services, you could end up paying thousands, because there is no yearly limit to your financial responsibility. With our Medicare Advantage plans, you have the protection and financial peace of mind knowing there is a yearly out-of pocket maximum. If you reach the maximum amount, you pay nothing for your covered medical services for the rest of the year. A FEW OTHER QUESTIONS TO CONSIDER: ARE MY DOCTORS IN YOUR NETWORK? We have more Idaho healthcare providers than any other plan in Idaho, so your doctors are probably already part of the True Blue network. Check to see if your doctors are in your plan by turning to the Provider Listing section of this booklet. For the most up-to-date listing, please visit bcidaho.com/findaprovider and select the MAHMO True Blue HMO plan. WHAT DO YOU COVER AND WHAT WILL I PAY? We cover everything Original Medicare covers and more! Check out the Benefits at a Glance brochure you got with this booklet. It shows a short comparison of our plans, so you can see what you get with each plan and what you will pay. See the Summary of Benefits section of this booklet for more information on what you get with each plan. ARE MY PRESCRIPTIONS COVERED? Our list of covered drugs has a wide range of both generic and brandname drugs. Almost all of our plans include Part D drug coverage and give you preferred generic drugs at no cost from preferred network pharmacies. To easily see if your drugs are covered, and what pharmacies are part of our network, visit bcidaho.com/findapharmacy. BLUE CROSS OF IDAHO CARE PLUS INFORMATION KIT 7

8 Why our HMO plan is a great choice YOU PICK A PCP. THEY HELP YOU NAVIGATE. Our True Blue HMO plans come with a primary care provider (PCP). This person serves as your personal health advisor, helping you know what care you need and how to get it. NO REFERRALS REQUIRED. None of our HMO plans require you to have a referral from your PCP to see other doctors. Some specialists might ask you to check in with your PCP before they agree to see you. MORE DOCTORS TO CHOOSE FROM. We have the state s largest network of Medicare Advantage providers. Chances are excellent that the doctors you use are in our network. COPAYS MAKE IT EASY. One of the main features of HMO plans is that they generally feature set copays for most services $20 copay versus 20 percent coinsurance. WHAT IF I AM TRAVELING? All our plans feature worldwide coverage for urgent care and emergency services. You ll also have Easy Travel while traveling in the US outside of Idaho. This benefit offers a limited amount of coverage to see out-ofnetwork providers without the out-of-network costs. 8 INFORMATION KIT BLUE CROSS OF IDAHO CARE PLUS

9 T E R M S T O H E L P Y O U U N D E R S TA N D H O W H E A LT H P L A N S W O R K PREMIUM The fixed cost you pay each month to be a member of the health plan. MEDICAL DEDUCTIBLE The amount you pay before the health plan helps with medical costs. Good news for you: none of our plans have a medical deductible. COPAY A kind of cost sharing where you pay a fixed dollar amount for some covered services. COINSURANCE A kind of cost sharing where you pay a percentage of the cost for some covered services. MAXIMUM OUT-OF-POCKET AMOUNT A yearly limit on how much money you have to spend out of your own pocket for covered healthcare. Once you reach that limit, you don t pay anything for covered care for the rest of your plan year. BLUE CROSS OF IDAHO CARE PLUS INFORMATION KIT 9

10 Get Ready to Enroll! If you are ready to enroll in a Medicare WHAT HAPPENS NEXT HOW IT HAPPENS BRIEF DESCRIPTION Advantage plan, simply turn the page. You ll find everything you need to get started, Complete your enrollment form and send it to us Website, or phone Fill out the enrollment form found in the back of this booklet. You can get help from your insurance agent or call us. You can also apply online at medicare.bcidaho.com. including an enrollment form, Medicare Star Ratings for our plans, and a pre-paid return Verification of your plan selection By Mail You ll get a letter letting you know we got your enrollment form. It describes the plan you enrolled in and lets you know what to do if you need to make a change. envelope. If you need help, please give us a call at Enrollment Confirmation and Plan Materials By Mail You get a letter confirming your enrollment in our plan. Congratulations! There is also important plan information included, like your Evidence of Coverage , or TTY You can also contact your insurance agent for assistance. Member ID Card Welcome Kit By Mail By Mail Doctors will need information on your Member ID card when you visit them. Carry it with you at all times. Your welcome kit includes more information on your plan benefits, plus details on wellness programs. Enrollment online to access member tools Website Take advantage of the great resources included with your plan! Enroll in just a few minutes by visiting bcidaho.com/registernow BLUE CROSS OF IDAHO CARE PLUS INFORMATION KIT 10

11 True Blue (HMO) Summary of Benefits True Blue (HMO) Summary of Benefits Every important decision begins with information. On the next few pages, you can see detailed benefit information about our True Blue (HMO) plans, including your out-of-pocket costs, your monthly premium, what we cover and more. With low office visit copays, a gym membership discount, $0 preferred generic prescriptions, low out-of-pocket maximums, and no referrals for specialists visits, True Blue gives you an all-around approach to good health with healthcare services from local providers you know and trust.

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13 Medicare Advantage Plans True Blue (HMO) 2019 SUMMARY OF BENEFITS SERVING SELECT COUNTIES IN IDAHO True Blue Rx Gem (HMO) True Blue Rx (HMO) True Blue Rx Option I (HMO) True Blue Rx Option II (HMO) True Blue no Rx (HMO) True Blue Rx Preferred (HMO) H1350_MK19078_M_Accepted 08/28/2018 Form No (09-18)

14 For more information: PROSPECTIVE MEMBERS TTY CURRENT MEMBERS TTY HOURS OF OPERATION October 1 to March 31, you can call us 7 days a week form 8 a.m. to 8 p.m. April 1 to September 30, you can call us Monday Friday from 8 a.m. to 8 p.m. FOR MORE INFORMATION Online: medicare.bcidaho.com bcidaho.com/findaprovider bcidaho.com/druglist sales@bcidaho.com The benefit information provided is a summary of what we cover and what you pay. It does not list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, please request the Evidence of Coverage. You can request an Evidence of Coverage by calling Blue Cross of Idaho at the numbers listed above. 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 medicare.gov or get a copy by calling MEDICARE ( ), 24 hours a day, 7 days a week. TTY users should call This document is available in accessible formats such as Braille, large print or audio. Blue Cross of Idaho Care Plus, Inc. is a HMO health plan with a Medicare contract. Enrollment in Blue Cross of Idaho Care Plus, Inc. depends on contract renewal.this information is not a complete description of benefits. Contact Blue Cross of Idaho at (TTY: ) for more information. Out-of-network/non-contracted providers are under no obligation to treat Blue Cross of Idaho Care Plus members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services. 2 SUMMARY OF BENEFITS BLUE CROSS OF IDAHO CARE PLUS

15 SUMMARY OF DRUG AND HEALTH SERVICES COVERED BY TRUE BLUE (HMO) PLANS, FROM JANUARY 1, TO DECEMBER 31, HOW WE CAN SERVE YOU. To join a True Blue plan, you must be entitled to Medicare Part A, be enrolled in Medicare Part B, and live in one of our 22 counties. Service Area 1 consists of the following counties: Ada, Boise, Bonner, Boundary, Canyon, Clark, Elmore, Gem, Kootenai, Nez Perce, Owyhee, and Payette. Service Area 2 consists of the following counties: Bannock, Bingham, Bonneville, Cassia, Fremont, Jefferson, Madison, Minidoka, Power, and Twin Falls. Boundary Bonner Kootenai Shoshone Latah No matter which service area you live in, you ll have the same access to our True Blue provider network, which has thousands of doctors all over Idaho. Lewis Idaho Lemhi Adams Valley Washington Clark Custer Payette Gem Canyon Boise Elmore Camas Gooding Ada Butte Owyhee Blaine Fremont Madison Jefferson Bonneville Bingham Lincoln Jerome Twin Falls Minidoka Nez Perce Clearwater Teton Benewah Service Area for True Blue Rx Preferred (HMO) plan consists of Ada and Canyon counties. Power Caribou Bannock Cassia Oneida BLUE CROSS OF IDAHO CARE PLUS Franklin Bear Lake SUMMARY OF BENEFITS 3

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17 WHICH DOCTORS, HOSPITALS AND PHARMACIES CAN I USE? True Blue plans have a network of doctors, hospitals, pharmacies, and other providers. If you use providers that are not in our network, the plan may not pay for these services. Our True Blue plans come with a primary care provider (PCP). This person serves as your personal health advisor, helping you know what care you need and how to get it. None of our HMO plans require you to have a referral from your PCP to see other doctors. You can see our plan s provider directory by visiting bcidaho.com/findaprovider. You can find pharmacies in our network by visiting bcidaho.com/findapharmacy. Or call us and we can help you find a doctor or pharmacy, or send you a provider directory. ARE MY PRESCRIPTION DRUGS COVERED? Almost all of our True Blue plans cover Part D drugs. We also cover Part B drugs such as chemotherapy drugs and other medicines given directly by your doctor. Not all True Blue plans use the same list of covered drugs (called a formulary). This means covered prescription drugs for each plan with Part D prescription drug coverage may be different. True Blue Rx (HMO), True Blue Rx Preferred (HMO), and True Blue Rx Gem (HMO) use the Essential formulary. True Blue Rx Option I (HMO) and True Blue Rx Option II (HMO) use the Performance formulary. See the complete covered drug list and any restrictions for each plan on our website at medicare.bcidaho.com. Choose Prescription Resources from the menu at the top of the page. You can search for drugs and their costs by visiting bcidaho.com/druglist. BLUE CROSS OF IDAHO CARE PLUS SUMMARY OF BENEFITS 5

18 Premiums and Benefits TRUE BLUE RX PREFERRED (HMO)* Plan Number Monthly Plan Premium H TRUE BLUE RX GEM (HMO) H and H TRUE BLUE RX (HMO) H and H You must continue to pay your Medicare Part B premium. *True Blue Rx Preferred (HMO) is only available in Ada and Canyon counties Service Area 1 N/A You pay $15 You pay $49 Service Area 2 N/A You pay $29 You pay $70 Service Area for True Blue Rx Preferred plan is Ada & Canyon counties only* Medical Deductible You pay $0 N/A N/A These plans do not have a medical deductible. You pay nothing Part D Prescription Drug Deductible Maximum Out-of-Pocket Responsibility Does not include prescription drugs or monthly plan premium Inpatient Hospital Coverage True Blue Rx Preferred and True Blue Rx Gem have Part D Deductibles. There is no deductible for Tier 1 and Tier 2 generic prescription drugs. $100 per year for prescriptions in Tiers 3 5 $125 per year for prescriptions in Tiers 3 5 You pay nothing The most you pay for copays, coinsurance and other costs for covered Part A and Part B medical services for the year. $5,900 $5,900 $6,700 Prior authorization may be required for some services. Our plans cover an unlimited number of days for an inpatient hospital stay. Outpatient Hospital Coverage Outpatient Hospital & Ambulatory Surgical Center Services Doctor Visits $325 per day days 1-4 $0 per day days 5-90 Primary Care Tier 1 - $0 / Tier 2 - $10 $325 per day days 1-4 $0 per day days 5-90 $250 per day days 1-6 $0 per day days 7-90 $250 copay $300 copay $250 copay No referral required for specialist visits. $5 copay $10 copay Specialists $40 copay $40 copay $35 copay Preventive Care You pay nothing 6 SUMMARY OF BENEFITS BLUE CROSS OF IDAHO CARE PLUS

19 Premiums and Benefits Plan Number Monthly Plan Premium Service Area 1 TRUE BLUE RX OPTION I (HMO) H and H TRUE BLUE RX OPTION II (HMO) H and H TRUE BLUE NO RX (HMO) H You must continue to pay your Medicare Part B premium. You pay $139 You pay $89 You pay $29 Service Area 2 You pay $146 You pay $89 You pay $29 Service Area for True Blue Rx Preferred plan is Ada & Canyon counties only* Medical Deductible N/A N/A N/A These plans do not have a medical deductible. You pay nothing Part D Prescription Drug Deductible Maximum Out-of-Pocket Responsibility Does not include prescription drugs or monthly plan premium Inpatient Hospital Coverage Outpatient Hospital Coverage Outpatient Hospital & Ambulatory Surgical Center Services Doctor Visits Primary Care True Blue Rx Option II has a Part D Deductible. There is no deductible for Tier 1 and Tier 2 generic prescription drugs. You pay nothing $200 per year for prescriptions in Tiers 3 5 Not covered. Not covered. The most you pay for copays, coinsurance and other costs for covered Part A and Part B medical services for the year. $6,700 $6,700 $3,000 Prior authorization may be required for some services. Our plans cover an unlimited number of days for an inpatient hospital stay. $225 per day days 1-5 $0 per day days 6-90 $300 per day days 1-5 $0 per day days 6-90 $100 per day days 1-5 $0 per day days 6-90 $250 copay $325 copay $100 copay No referral required for specialist visits. $5 copay $10 copay $10 copay Specialists $30 copay $40 copay $25 copay Preventive Care You pay nothing BLUE CROSS OF IDAHO CARE PLUS SUMMARY OF BENEFITS 7

20 Premiums and Benefits TRUE BLUE RX PREFERRED (HMO)* Plan Number Emergency Care H TRUE BLUE RX GEM (HMO) H and H TRUE BLUE RX (HMO) H and H If you are admitted to the hospital within 24 hours for the same condition, you do not have to pay your share of the cost for emergency care. $90 copay Urgently Needed Services Urgent Care Worldwide Emergency & Urgent Coverage ($25,000 benefit maximum) Diagnostic Services/ Labs/Imaging Diagnostic Tests and Procedures Lab Services Diagnostic Radiology (MRI, CT, PET) X-rays Hearing Services Medicare-Covered exam to diagnose and treat hearing and balance issues Additional Hearing Benefits Annual Routine Hearing Exam Hearing Aids Cost sharing for necessary urgently needed services furnished out-of-network is the same as for such services furnished in-network. Tier 1 - $0 / Tier 2 - $40 $40 copay $40 copay $90 copay Prior authorization is required for some services by your doctor or other network provider. Please contact the plan for more information. 20% of the cost 20% of the cost 20% of the cost Tier 1 $0 / Tier 2 $20 $10 copay $5 copay 20% of the cost 20% of the cost 20% of the cost Tier 1 $0 / Tier 2 $15 $15 copay $15 copay $45 copay $45 copay Up to two TruHearing-branded hearing aids every year (one per ear per year). Benefit is limited to the TruHearing Advanced and Premium hearing aids. Advanced $699 copay; Premium $999 copay Dental Services Additional Dental Benefits Limited Medicare dental benefit (does not include services in connection with care, treatment, filling, removal, or replacement of teeth) $40 copay $40 copay $35 copay Includes two oral exams, two cleanings, and two bitewing X-rays every year; $500 coverage limit per year $10 copay 8 SUMMARY OF BENEFITS BLUE CROSS OF IDAHO CARE PLUS

21 Premiums and Benefits Plan Number Emergency Care TRUE BLUE RX OPTION I (HMO) H and H TRUE BLUE RX OPTION II (HMO) H and H TRUE BLUE NO RX (HMO) H If you are admitted to the hospital within 24 hours for the same condition, you do not have to pay your share of the cost for emergency care. $90 copay Urgently Needed Services Urgent Care Worldwide Emergency & Urgent Coverage ($25,000 benefit maximum) Diagnostic Services/ Labs/Imaging Diagnostic Tests and Procedures Lab Services Diagnostic Radiology (MRI, CT, PET) X-rays Hearing Services Medicare-Covered exam to diagnose and treat hearing and balance issues Additional Hearing Benefits Annual Routine Hearing Exam Hearing Aids Cost sharing for necessary urgently needed services furnished out-of-network is the same as for such services furnished in-network. $25 copay $40 copay $25 copay $90 copay Prior authorization is required for some services by your doctor or other network provider. Please contact the plan for more information. 10% of the cost 15% of the cost You pay nothing 10% of the cost You pay nothing You pay nothing 10% of the cost 15% of the cost $175 copay 10% of the cost $15 copay You pay nothing $45 copay $45 copay Up to two TruHearing-branded hearing aids every year (one per ear per year). Benefit is limited to the TruHearing Advanced and Premium hearing aids. Advanced $699 copay; Premium $999 copay Dental Services Additional Dental Benefits Limited Medicare dental benefit (does not include services in connection with care, treatment, filling, removal, or replacement of teeth) $25 copay $30 copay $25 copay Not included Not included Includes two oral exams, two cleanings, and two bitewing X-rays every year; $500 coverage limit per year $10 copay BLUE CROSS OF IDAHO CARE PLUS SUMMARY OF BENEFITS 9

22 Premiums and Benefits TRUE BLUE RX PREFERRED (HMO)* Plan Number H TRUE BLUE RX GEM (HMO) H and H TRUE BLUE RX (HMO) H and H Optional Supplemental Dental Plan Healthy Smiles Basic Healthy Smiles Basic Healthy Smiles Basic For more information about our optional dental plans, see the Additional Benefits section of this booklet. $50 deductible; Basic dental services (fillings, extractions) covered at 80% of maximum allowance after deductible; $750 benefix maximum 6-month waiting period for all basic services Vision Services Medicare-Covered eye exam to diagnose & treat diseases and conditions Additional Vision Benefits Annual Routine Eye Exam You pay nothing $20 copay $20 copay $20 copay Eyewear Mental Health Services Inpatient Visit Outpatient Mental Health Care (Individual & Group) Skilled Nursing Facility (SNF) $35 copay for one pair of glasses (lenses and frames in the VSP Genesis Collection); $50 allowance for non-genesis frames. In lieu of glasses there is a $100 allowance towards contacts. Benefit is for every two years. $325 per day for days 1-4 $0 per day for days 5-90 $300 per day for days 1-4 $0 per day for days 5-90 $40 copay $265 per day for days 1-6 $0 per day for days 7-90 Our plan covers up to 100 days per benefit period in a Skilled Nursing Facility. Prior authorization may be required for some services. Outpatient Rehabilitation Physical Therapy, Speech Therapy, Occupational Therapy Ambulance Ground or Air transport Transportation Medicare Part B Prescription Drugs $0 per day days 1-20 $160 per day days $0 per day days $0 per day days 1-20 $160 per day days $0 per day days $40 copay $0 per day days 1-20 $160 per day days $0 per day days Prior authorization is required for non-emergency transportation. $270 copay Not covered Part B drugs are usually administered in a inpatient hospital setting, like chemotherapy drugs. These are not the same as Part D prescription drugs. 20% of the cost 10 SUMMARY OF BENEFITS BLUE CROSS OF IDAHO CARE PLUS

23 Premiums and Benefits Plan Number TRUE BLUE RX OPTION I (HMO) H and H TRUE BLUE RX OPTION II (HMO) H and H TRUE BLUE NO RX (HMO) H Optional Supplemental Dental Plan Healthy Smiles Plus Healthy Smiles Plus Healthy Smiles Basic For more information about our optional dental plans, see the Additional Benefits section of this booklet. Vision Services Medicare-Covered eye exam to diagnose & treat diseases and conditions Additional Vision Benefits Annual Routine Eye Exam Eyewear Mental Health Services Inpatient Visit Outpatient Mental Health Care (Individual & Group) Skilled Nursing Facility (SNF) Outpatient Rehabilitation Physical Therapy, Speech Therapy, Occupational Therapy Ambulance Ground or Air transport Transportation Medicare Part B Prescription Drugs Includes the benefits of Healthy Smiles Basic, plus preventive dental services (oral exams, cleanings, & x-rays) with no deductible or benefit maximum for in-network care You pay nothing $20 copay $50 deductible; Basic dental services (fillings, extractions) covered at 80% of maximum allowance after deductible; $750 benefit maximum 6-month waiting period for all basic services $35 copay for one pair of glasses (lenses and frames in the VSP Genesis Collection); $50 allowance for non-genesis frames. In lieu of glasses there is a $100 allowance towards contacts. Benefit is for every two years. $175 per day for days 1-5 $0 per day for days 6-90 $25 copay $275 per day for days 1-5 $0 per day for days 6-90 $40 copay $100 per day for days 1-5 $0 per day for days 6-90 $25 copay Our plan covers up to 100 days per benefit period in a Skilled Nursing Facility. Prior authorization may be required for some services. $0 per day days 1-20 $125 per day days $0 per day days $0 per day days 1-20 $125 per day days $0 per day days $0 per day days 1-20 $150 per day days $25 copay $40 copay $15 copay Prior authorization is required for non-emergency transportation. $250 copay $275 copay $175 copay Not covered Part B drugs are usually administered in a inpatient hospital setting, like chemotherapy drugs. These are not the same as Part D prescription drugs. 20% of the cost 20% of the cost 10% of the cost BLUE CROSS OF IDAHO CARE PLUS SUMMARY OF BENEFITS 11

24 Premiums and Benefits TRUE BLUE RX PREFERRED (HMO)* Plan Number Podiatry Services Medicare-Covered Foot Exams and Treatment Additional Podiatry Services Routine Foot Care Medical Supplies Durable Medical Equipment (wheelchairs, oxygen) Prosthetics (braces, artificial limbs) Diabetes Supplies Diabetes Shoes and Inserts Wellness Programs Silver&Fit Gym Membership Silver&Fit Home Exercise kits Over-the-Counter (OTC) Items H TRUE BLUE RX GEM (HMO) H and H TRUE BLUE RX (HMO) H and H Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions. $40 copay per visit; 6 visits per year $40 allowance every three months $40 copay Not covered 20% of the cost 20% of the cost You pay nothing 20% of the cost Silver&Fit Exercise and Healthy Aging Program $50 annually $10 annually $40 allowance every three months Not covered $60 allowance every three months 12 SUMMARY OF BENEFITS BLUE CROSS OF IDAHO CARE PLUS

25 Premiums and Benefits Plan Number Podiatry Services Medicare-Covered Foot Exams and Treatment Additional Podiatry Services Routine Foot Care Medical Supplies Durable Medical Equipment (wheelchairs, oxygen) Prosthetics (braces, artificial limbs) Diabetes Supplies Diabetes Shoes and Inserts Wellness Programs Silver&Fit Gym Membership Silver&Fit Home Exercise kits Over-the-Counter (OTC) Items TRUE BLUE RX OPTION I (HMO) H and H TRUE BLUE RX OPTION II (HMO) H and H TRUE BLUE NO RX (HMO) H Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions. $25 copay $40 copay $25 copay Not covered 20% of the cost 20% of the cost 10% of the cost 20% of the cost 20% of the cost 10% of the cost You pay nothing 20% of the cost 20% of the cost 10% of the cost Silver&Fit Exercise and Healthy Aging Program $50 annually $10 annually $60 allowance every three months BLUE CROSS OF IDAHO CARE PLUS SUMMARY OF BENEFITS 13

26 We pay You pay HOW PART D PRESCRIPTION DRUG COVERAGE WORKS The costs you pay may change depending on the pharmacy you choose and when you enter another stage of the Part D benefit. For more information on your pharmacy-specific costs and the stages of your Part D benefit, please call us or get an Evidence of Coverage online at medicare.bcidaho.com. STAGE 1 Annual Deductible You are responsible for the cost of your prescription drugs until you have met the deductible. STAGE 2 Initial Coverage Period You are responsible for a limited copay or coinsurance. STAGE 3 Coverage Gap You are responsible for a larger copay or coinsurance until you have met your true out-of-pocket costs. Tier 1 and 2 generic drugs do not have a deductible. You pay a small amount until you reach $3,820 in total drug costs. See the chart at the right for what you might pay. In most cases, you pay 37% for covered generic drugs, and 25% (plus dispensing fee) for covered brand drugs until you pay $5,100 in true out-of-pocket costs. STAGE 4 Catastrophic Coverage You pay the greater of You are responsible for a limited copay or 5% coinsurance or $3.40 coinsurance. for generic drugs $8.50 for other drugs for the remainder of the plan year. 14 SUMMARY OF BENEFITS BLUE CROSS OF IDAHO CARE PLUS

27 STAGE 2 INITIAL COVERAGE PERIOD The costs you pay may change depending on the pharmacy you choose and when you enter another stage of the Part D benefit. For more information on your pharmacy-specific costs and the stages of your Part D benefit, please call us or get an Evidence of Coverage online at medicare.bcidaho.com. True Blue Rx Preferred* True Blue Rx Gem* True Blue Rx True Blue Rx Option I True Blue Rx Option II* Formulary Name Essential Essential Essential Performance Performance Part D Deductible $100 for Tiers 3,4,5 $125 for Tiers 3,4,5 $0 $0 $200 for Tiers 3,4,5 Preferred Retail Cost 30-day supply Tier 1 (Preferred Generic) $0 $0 $0 $0 $0 Tier 2 (Generic) $6 copay $6 copay $6 copay $6 copay $12 copay Tier 3 (Preferred Brand) $31 copay $31 copay $31 copay $35 copay $37 copay Tier 4 (Non-Preferred) $90 copay $90 copay $90 copay $85 copay $90 copay Tier 5 (Specialty Tier) 31% of cost 30% of cost 33% of cost 33% of cost 29% of cost Non-Preferred Retail Cost 30-day supply Tier 1 (Preferred Generic) $15 copay $15 copay $15 copay $5 copay $10 copay Tier 2 (Generic) $20 copay $20 copay $20 copay $12 copay $20 copay Tier 3 (Preferred Brand) $47 copay $47 copay $47 copay $45 copay $47 copay Tier 4 (Non-Preferred) $100 copay $100 copay $100 copay $95 copay $100 copay Tier 5 (Specialty Tier) 31% of cost 30% of cost 33% of cost 33% of cost 29% of cost Mail Order Cost 90-day supply Tier 1 (Preferred Generic) $0 $0 $0 $0 $0 Tier 2 (Generic) $18 copay $18 copay $18 copay $18 copay $36 copay Tier 3 (Preferred Brand) $93 copay $93 copay $93 copay $105 copay $111 copay Tier 4 (Non-Preferred) $270 copay $270 copay $270 copay $255 copay $270 copay Tier 5 (Specialty Tier) 31% of cost (30-day supply only) 30% of cost (30-day supply only) 33% of cost (30-day supply only) 33% of cost (30-day supply only) 29% of cost (30-day supply only) *True Blue Rx Preferred, True Blue Rx Gem, and True Blue Rx Option II Part D deductibles do not apply to Tier 1 and Tier 2 generic drugs. Initial coverage period begins immediately for Tier 1 and Tier 2 generic drugs. BLUE CROSS OF IDAHO CARE PLUS SUMMARY OF BENEFITS 15

28 Benefits you get with our True Blue plans Below, we ve listed some of the benefits you get with our Medicare Advantage plans. The copay or coinsurance for each benefit depends on the plan you pick. For more information, please see the Details About the Extras in this booklet. ADDITIONAL BENEFITS THAT COME WITH OUR TRUE BLUE HEALTH PLANS ROUTINE EYEWEAR HEARING AIDS OVER-THE-COUNTER $35 COPAY COMPLETE PAIR OF GLASSES COPAYS OF $999 OR LESS $40 - $60 EVERY THREE MONTHS ON APPROVED ITEMS VISION COVERAGE Get low out-of-pocket costs with Vision Service Plan (VSP) providers for your yearly vision exam. $20 copay for your yearly vision exam $35 copay for a complete pair of glasses from the Genesis Collection (frames and lenses) Call VSP at or visit vsp.com to learn more. HEARING AID COVERAGE Save big on your hearing with coverage through TruHearing. A hearing exam plus three follow-up visits Hearing aids with copays of $999 or less Call TruHearing at or visit truhearing.com for more information. OVER-THE-COUNTER (OTC) COVERAGE Now you also get help with OTC products such as vitamins, pain relievers, cold medicine and bandages. $40 to $60 every three months to spend on approved items Your allowance resets January, April, July and October 16 SUMMARY OF BENEFITS BLUE CROSS OF IDAHO CARE PLUS

29 WELLNESS PROGRAM EASY TRAVEL NURSE ADVICE $50 ANNUAL COPAY FOR GYM MEMBERSHIP $2,500 MAXIMUM FOR EACH CALENDAR YEAR CALL 24-HOURS A DAY, SEVEN DAYS A WEEK SILVER&FIT EASY TRAVEL 24/7 NURSE ADVICE For only $50 a year, For care while you are LINE Silver&Fit gets you a membership at network fitness clubs and exercise centers around the state and across the country. If you aren t up for heading to the gym, you can get two Home Fitness kits a year for only $10. traveling in the U.S. outside of Idaho, our Easy Travel program gives you a $2,500 travel allowance at no additional cost to you. Some restrictions apply. See the Evidence of Coverage for complete details. Any time, day or night, you can speak with a registered nurse at no cost to you. Ask questions about your prescriptions, finding a doctor or specialist, or understanding a health condition. OPTIONAL SUPPLEMENTAL DENTAL PLANS HEALTHY SMILES BASIC If you enroll in True Blue Rx, True Blue no Rx, True Blue Rx Gem, or True Blue Rx Preferred, you can add Healthy Smiles Basic for an additional $9.20 per month. Basic dental services have a six-month waiting period. HEALTHY SMILES PLUS If you enroll in True Blue Rx Option I or True Blue Rx Option II, you can add Healthy Smiles Plus for an additional $23.60 per month. Preventive and diagnostic dental services have no waiting period; basic dental services have a six-month waiting period. BLUE CROSS OF IDAHO CARE PLUS SUMMARY OF BENEFITS 17

30 2019 Pre-Enrollment Checklist True Blue Rx Gem (HMO), True Blue Rx (HMO), True Blue Rx Option I (HMO), True Blue Rx Option II (HMO), True Blue Rx Preferred (HMO) Before making an enrollment decision, it is important that you fully understand our benefits and rules. If you have any questions, you can call and speak to a customer service representative at (TTY ), 8 a.m. to 8 p.m. seven days a week, from October 1 to March 31 and Monday through Friday from April 1 to September 30. UNDERSTANDING YOUR BENEFITS Review the full list of benefits found in the Evidence of Coverage (EOC), especially for those services that you routinely see a doctor. Visit medicare.bcidaho.com or call (TTY ) to view a copy of your EOC. Review the Provider Directory (or ask your doctor) to make sure the doctors you see now are in the network. If they are not listed, it means you will likely have to select a new doctor. Review the Pharmacy Directory to make sure the pharmacy you use for any prescription medications is in the network. If the pharmacy is not listed, you will likely have to select a new pharmacy for your prescriptions. UNDERSTANDING IMPORTANT RULES In addition to your monthly plan premium, you must continue to pay your Medicare Part B premium. This premium is normally taken out of your Social Security check each month. Benefits, premiums and/or copayments/co-insurance may change on January 1, Our plan allows you to see providers outside of our network (non-contracted providers). However, while we will pay for covered services provided by a non-contracted provider, the provider must agree to treat you. Except in an emergency or urgent situations, non-contracted providers may deny care. For more information, we are available 8 a.m. to 8 p.m., seven days a week from October 1 to March 31 and Monday through Friday from April 1 to September 30. Call us at (TTY ). Or visit us at medicare.bcidaho.com. This document is available in accessible formats such as Braille, large print or audio. Blue Cross of Idaho Care Plus, Inc. is a HMO health plan with a Medicare contract. Enrollment in Blue Cross of Idaho Care Plus, Inc. depends on contract renewal. Blue Cross of Idaho Care Plus, Inc. complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: ). 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY: ) 2018 by Blue Cross of Idaho Care Plus Inc., an independent licensee of the Blue Cross and Blue Shield Association, with services provided by Blue Cross of Idaho

31 Nondiscrimination Statement: Discrimination is Against the Law Blue Cross of Idaho complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. Blue Cross of Idaho does not exclude people or treat them differently because of race, color, national origin, age, disability or sex. Blue Cross of Idaho: Provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: Qualified interpreters Information written in other languages If you need these services, contact Blue Cross of Idaho s Customer Service Department. Call (TTY: ), or call the customer service phone number on the back of your card. If you believe that Blue Cross of Idaho has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you can file a grievance with Blue Cross of Idaho s Grievances and Appeals Department at: Manager, Grievances and Appeals 3000 East Pine Avenue, Meridian, Idaho Telephone: (800) ext.3838, Fax: (208) grievances&appeals@bcidaho.com TTY: You can file a grievance in person or by mail, fax, or . If you need help filing a grievance, our Grievances and Appeals team is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, , (TTY). Complaint forms are available at Reference: ATTENTION: If you speak Arabic, Chinese, French, German, Korean, Japanese, Persian (Farsi), Romanian, Russian, Serbo- Croatian, Spanish, Sudanic Fulfulde, Tagalog, Ukrainian, or Vietnamese, language assistance services, free of charge, are available to you. Call (TTY: ). Arabic. ملظوحة: إ اذ كنت تتحدث اذكر اللغة فا ن خدمات المساعدة اللغویة تتوافر لك بالمجان. اتصل برقم (رقم اھتف الصم ولابكم : ) Chinese 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY: ) French ATTENTION : Si vous parlez français, des services d aide linguistique vous sont proposés gratuitement. Appelez le (ATS: ). German ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (TTY: ). Japanese 注意事項 : 日本語を話される場合 無料の言語支援をご利用いただけます (TTY: ) まで お電話にてご連絡ください Korean 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: ) 번으로전화해주십시오. Persian-Farsi تماس بگیرد ی. توجھ:گ ار بھ ابزن فارسی گفتگو می دینک تسھیلات ینابزوص برت اگی ارن بریا شما فرا مھ می دش ا ب. با ( (TTY: Romanian ATENȚIE: Dacă vorbiți limba română, vă stau la dispoziție servicii de asistență lingvistică, gratuit. Sunați la (TTY: ). Russian ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: ). Serbo-Croation OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno. Nazovite (TTY- Telefon za osobe sa oštećenim govorom ili sluhom: ). Spanish ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: ). Sudanic Fulfulde MAANDO: To a waawi [Adamawa], e woodi ballooji-ma to ekkitaaki wolde caahu. Noddu (TTY: ). Tagalog PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: ). Ukrainian УВАГА! Якщо ви розмовляєте українською мовою, ви можете звернутися до безкоштовної служби мовної підтримки. Телефонуйте за номером (телетайп: ). Vietnamese CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY: ). Form No (10-16)

32 3000 East Pine Avenue Meridian, Idaho PO Box 8406 Boise, Idaho TTY We are available from 8 a.m. to 8 p.m., seven days a week, from October 1 to March 31. The rest of the year, we are available Monday through Friday, from 8 a.m. to 8 p.m. Visit medicare.bcidaho.com

33 Details About the Extras Details About the Extras With Blue Cross of Idaho, you get more than original Medicare. Our plans come with more benefits than you d get from just original Medicare. We offer hearing exams, discounts on hearing aids, regular vision exams, benefits for glasses or contacts, discounted gym memberships, additional dental plans, and more. Get all the details in this section.

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35 Included in your plan A Comprehensive Vision Solution SEEING IS BELIEVING! With a Blue Cross of Idaho vision plan administered by Vision Service Plan (VSP), you get comprehensive coverage that helps keep your eyes healthy. Many health plans, including traditional Medicare, don t offer a vision benefit. A Medicare Advantage policy from Blue Cross of Idaho Care Plus will help keep your vision in check. Your Comprehensive Vision Benefit Includes: Wellvision Exam You ll get the highest level of care with a $20 copayment,* including a WellVision Exam the most comprehensive exam designed to detect eye and health conditions. Plan Information VSP Coverage Effective Date: 01/01/2019 Elements Advantage and VSP provide you with an affordable eyecare plan. Y0010_MK19088_M_Accepted 08/19/2018 Prescription Glasses You'll receive prescription glasses with a $35 copayment** Frames (Genesis Collection) included Lenses included Fully covered Standard progressive lenses Fully covered Scratch-resistant coatings Fully covered UV Coating 2018 by Blue Cross of Idaho Care Plus Inc., an independent licensee of the Blue Cross and Blue Shield Association, with services provided by Blue Cross of Idaho Using your benefit is easy as Find an eye care provider who s right for you. To find a VSP provider, call (TTY 711) or visit vsp.com and select the VSP Advantage Network. At your appointment, tell them you have VSP. If you d like a card as a reference, you can print one at vsp.com after you register on the site. That s it! We ll handle the rest there are no claim forms to complete when you see a VSP provider. See reverse for copayment details Form No NI (09-18)

36 BENEFIT DESCRIPTION IN-NETWORK OUT-OF-NETWORK Routine Eye Exam One routine eye exam every calendar year available from a VSP Advantage network provider. *$20 copay for one routine eye exam every year *The copayment you pay for a routine eye exam does not apply to your yearly maximum out-of-pocket. **$35 copay for prescription glasses Eyewear benefit is available every two years. You may select from one pair of prescription eyeglasses (or replacement lenses in your frames) OR prescription contacts and contact lens fitting and evaluation. Prescription glasses: - Frame: Covered in full when you select a frame from the Genesis Eyewear Collection (only available through a VSP Advantage network provider), or you will receive an $50 retail allowance for frames outside the Genesis Eyewear Collection - Lenses: Single vision, lined bifocal, lined trifocal, and lenticular lenses are covered in full - Lens enhancements: Standard progressives, scratch resistant coating, and UV coating are covered in full Elective contact lenses and contact lens fitting exam (instead of glasses): - Contact Lens Fitting/Evaluation and prescription contacts are covered in full up to the retail allowance of $100 Medically necessary contact lenses (instead of glasses) and contact lens exam: - Covered in full after $35 copay and requires VSP doctor to obtain prior authorization **$35 copay for medically necessary contact lenses (instead of glasses) and contact lens exam You pay 100% of the cost when you receive services from a non-vsp provider. After your service, send claims to VSP for reimbursement up to the following limits: $50 frames; $30 for single vision lenses; $50 for bifocal lenses; $60 for trifocal lenses; $50 for progressive lenses; $75 for lenticular lenses; $100 for elective contact lenses/fitting evaluation; $210 for medically necessary contact lenses and contact lens fitting/ evaluation. Doctor must obtain prior authorization. ** The copayment you pay for eyewear (glasses, contact lenses) does not apply to your yearly maximum out-of-pocket. OUT OF NETWORK SERVICES Out-of-network claims must be sent to VSP when requesting reimbursement. Do not send your claim or request for reimbursement to Blue Cross of Idaho Care Plus as the reimbursement will take longer to process. Please contact VSP at (TTY 711) if you need assistance submitting your request for reimbursement. Send the required documents and your reimbursement request to: Vision Service Plan Attention: Claim Services P. O. Box Birmingham, AL If you are eligible and obtain services from a nonparticipating provider, you will be responsible for full payment to the provider. You will be reimbursed by VSP in accordance with the out-of-network reimbursement schedule, less the same applicable copays. GET UP TO $110 BACK Members can save big with VSP exclusive mail-in rebates on eligible popular contact lens brands from Bausch + Lomb and CooperVision. $1,000 SAVINGS ON LASIK Members can save on LASIK at NVISION Eye Centers and TLC Laser Eye Centers. SAVE UP TO $2,500 Exclusive member extras, members can save with special offers and rebates through VSP and other leading industry partners. LEARN MORE Visit vsp.com/specialoffers or call (TTY 711) to learn more. Blue Cross of Idaho Care Plus, Inc. is a Medicare Advantage health plan with a Medicare contract. Enrollment in Blue Cross of Idaho Care Plus, Inc. depends on contract renewal. Blue Cross of Idaho Care Plus, Inc. complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: ). 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY: ) Y0010_MK19088_M_Accepted 08/19/2018

37 Included in your plan A Comprehensive Hearing Solution GOOD HEARING IS IMPORTANT TO YOUR HEALTH. That s why Blue Cross of Idaho's hearing aid plan, administered by TruHearing, offers you a hearing aid benefit. Hearing aids can be expensive an average of $2,400 per aid 1 but your benefit makes addressing hearing loss more affordable with copayments of $999 or less. Your Comprehensive Hearing Benefit Includes: N S Advances in hearing technology Enjoy natural, lifelike sound in virtually all listening situations. Hear speech clearly, even in noisy environments. Stream audio and phone calls directly to your ears from your smartphone 2. Learn how to adapt to your new hearing aids at TruHearing.com/GetStarted. Personalized care from our team Schedule a hearing exam plus three follow-up visits for fitting and adjustments. Three follow-up visits must be used within one year after the date of initial purchase. Receive local, professional care from an accredited TruHearing provider in your area. Help on the journey to better hearing Make purchases worry free with a 45-day trial and 3-year warranty. Hearing aid, repairs, and replacements subject to provider and manufacturer fees. For questions regarding fees, contact TruHearing customer service. Get 48 free batteries per aid with non-rechargeable models. Y0010_MK19064_M_Accepted 08/19/018 See reverse for copayment details 2018 by Blue Cross of Idaho Care Plus Inc., an independent licensee of the Blue Cross and Blue Shield Association, with services provided by Blue Cross of Idaho Form No NI (09-18)

38 2019 HEARING AID COVERAGE Your plan covers up to two hearing aids per year. Your Plan: TruHearing Advanced 19 TruHearing Premium 19* 32 Channels 6 Programs 48 Channels 6 Programs Routine Exam In-Network 3 Retail: $2,455/aid Retail: $3,125/aid True Blue Rx (HMO) True Blue Rx Gem (HMO) True Blue Rx Option I (HMO) True Blue Rx Option II (HMO) True Blue no Rx (HMO) True Blue Rx Preferred (HMO) True Blue SNP (HMO SNP) Secure Blue no Rx (PPO) $ copay/aid $999 copay/aid $ 4 5 exam copay * Rechargeable battery upgrade option on TruHearing Premium 19 RIC Li for $75 per aid Call TruHearing to learn more and schedule an appointment Hours: 8 a.m. 8 p.m., Monday Friday For TTY, dial Aging America & Hearing Loss: Imperative of Improved Hearing Technologies." President s Council of Advisors on Science -and Technology. October Smartphone compatible hearing aids connect directly to iphone, ipad, and ipod Touch devices. Connectivity also available to many Android phones with use of an accessory. 3 Must be performed by a TruHearing network provider, except Secure Blue where an out-of-network service is provided. Blue Cross of Idaho Care Plus, Inc. is a Medicare Advantage health plan with a Medicare and Idaho Medicaid contract. Enrollment in Blue Cross of Idaho Care Plus depends on contract renewal. Idaho Medicaid pays the Medicare Part B premium for Full-Benefit Dual-Eligible members. Each member s cost share may vary based on the level of extra help you receive. This plan is available to full-benefit dual-eligible beneficiaries who are at least 21 years of age, live in our service area, and receive medical assistance from Medicare and Idaho Medicaid. Please contact the plan for further details. Blue Cross of Idaho Care Plus, Inc. complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: ). 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY: ) All content 2018 TruHearing, Inc. All Rights Reserved. TruHearing is a registered trademark of TruHearing, Inc. All other trademarks, product names, and company names are the property of their respective owners. Three follow-up visits must be used within one year after the date of initial purchase. Free battery offer is not applicable to the purchase of rechargeable hearing aid models. Three-year warranty includes repairs and one-time loss and damage replacement. Hearing aid repairs and replacements are subject to provider and manufacturer fees. For questions regarding fees, contact a TruHearing hearing consultant. BCID_S_AEPF_0518

39 HEALTHY SMILES BASIC MORE COVERAGE BEYOND PREVENTIVE DENTAL CARE Your teeth are important indicators of your overall health, which is why Blue Cross of Idaho gladly offers additional dental coverage you can add into your Medicare Advantage plan for only $9.20 more a month. OPTIONAL SUPPLEMENTAL DENTAL COVERAGE FOR: TRUE BLUE RX (HMO) TRUE BLUE NO RX (HMO) TRUE BLUE RX GEM (HMO) TRUE BLUE RX PREFERRED (HMO) SECURE BLUE NO RX (PPO) YOUR COMPREHENSIVE DENTAL COVERAGE INCLUDES: PREVENTIVE BENEFITS INCLUDED Your medical plan includes embedded preventive benefits, including oral exams, X-rays and cleanings. Check your policy for complete benefit description. Additionally you may choose to upgrade your dental coverage and purchase the Healthy Smiles Basic plan. ADDITIONAL BASIC DENTAL SERVICES You may purchase a seperate plan and upgrade your dental coverage. Healthy Smiles Basic offers the following basic dental services after satisfying a six-month waiting period and $50 deductible. Fillings same tooth surface restoration covered once in a two-year period Extractions With Healthy Smiles Basic, you'll receive coverage of basic dental services. Y0010_MK19073_M_Accepted 08/19/ by Blue Cross of Idaho Care Plus Inc., an independent licensee of the Blue Cross and Blue Shield Association, with services provided by Blue Cross of Idaho See reverse for copayment details Form No (09-18)

40 MORE COVERAGE BEYOND PREVENTIVE DENTAL CARE Our plan offers some extra benefits that are not covered by Original Medicare and not included in your benefits package as a plan member. These extra benefits are called "Optional Supplemental Benefits." If you want these optional supplemental benefits, you must sign up for them. For only $9.20 more per month, you are provided a low premium plan that encourages good oral habits while maintaining a healthy smile. After a $50 deductible, your basic dental services are covered at 80 percent. Call (TTY ) to learn more. Basic Deductible Benefit Period Maximum Basic Dental Services (fillings, extractions) IN-NETWORK OUT-OF- NETWORK $50 per member, per benefit period $750 per member, per benefit period Covered at 80% of the maximum allowance after deductible Covered at 50% of maximum allowance after deductible All BASIC dental services have a six-month waiting period. Blue Cross of Idaho Care Plus, Inc. is a Medicare Advantage health plan with a Medicare contract. Enrollment in Blue Cross of Idaho Care Plus, Inc. depends on contract renewal. Blue Cross of Idaho Care Plus, Inc. complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: ). 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY: ) Y0010_MK19073_M_Accepted 08/19/2018

41 HEALTHY SMILES PLUS COMPREHENSIVE COVERAGE FOR PREVENTIVE AND BASIC DENTAL SERVICES Your teeth are important indicators of your overall health, which is why Blue Cross of Idaho gladly offers additional dental coverage you can add into your Medicare Advantage plan for only $23.60 more a month. OPTIONAL SUPPLEMENTAL DENTAL COVERAGE AVAILABLE FOR: TRUE BLUE RX (HMO) OPTION I TRUE BLUE RX (HMO) OPTION II YOUR COMPREHENSIVE DENTAL COVERAGE INCLUDES: PREVENTIVE BENEFITS INCLUDE: Oral examinations once in a six-month period Emergency oral examination Panoramic X-ray or full mouth series X-ray one time in any five consecutive years Bitewing X-rays once per benefit period Periapical X-rays ADDITIONAL BASIC DENTAL SERVICES Healthy Smiles Plus offers the following basic dental services after satisfying a six-month waiting period and $50 deductible (in-network preventive services don t apply to deductible). Fillings same tooth surface restoration covered once in a two-year period Extractions Cleanings regular cleaning or periodontal maintenance once in a six-month period Y0010_MK19062_M Accepted 08/14/2018 See reverse for copayment details 2018 by Blue Cross of Idaho Care Plus Inc., an independent licensee of the Blue Cross and Blue Shield Association, with services provided by Blue Cross of Idaho Form No (09-18)

42 NO MAXIMUM LIMITS, IN-NETWORK DEDUCTIBLES OR WAITING PERIODS For only $23.60 more per month, you are provided a low premium plan that encourages good oral habits while maintaining a healthy smile. After a $20 copayment, Blue Cross of Idaho covers 100 percent of your in-network preventive services. HEALTHY SMILES PLUS is available to True Blue Rx (HMO) Option I and True Blue Rx (HMO) Option II. Call (TTY ) to learn more. Preventive Deductible Benefit Period Maximum Preventive Dental Services (oral exams, cleanings, x-rays) IN-NETWORK $0 Covered at 100% of maximum allowance after $20 copayment per visit None OUT-OF- NETWORK $50 per member, per benefit period Covered at 50% of maximum allowance after deductible Plus IN-NETWORK OUT-OF- NETWORK Deductible Benefit Period Maximum $50 per member, per benefit period $1,000 per member, per benefit period Basic Dental Services (fillings, extractions) Covered at 80% of the maximum allowance after deductible Covered at 50% of maximum allowance after deductible Blue Cross of Idaho Care Plus, Inc. is a Medicare Advantage health plan with a Medicare contract. Enrollment in Blue Cross of Idaho Care Plus, Inc. depends on contract renewal. Blue Cross of Idaho Care Plus, Inc. complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: ). 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY: ) Y0010_MK19062_M Accepted 08/14/2018

43 THE SILVER&FIT EXERCISE&HEALTHY AGING PROGRAM: SOMETHING FOR EVERYONE! Did you know that as a Silver&Fit member you can go to a fitness center or YMCA for only $50? It s true! Some have classes designed for older adults that you might like. They may also offer dance or yoga studios and/or swimming pools.* Don t want to go to a fitness center? No problem! You can enroll in the Home Fitness program (for only $10 per year) and choose up to 2 home fitness kits each benefit year. These kits may include DVDs, guides, and other items to help you get fit on your own terms. *Services that call for an added fee are not part of the Silver&Fit program. All members can also get:» Healthy Aging classes 4 times a year (online or by mail)» The Silver Slate newsletter 4 times a year (online, by , or by mail)» The Silver&Fit Connected! program, a fun and easy way to track your exercise at a fitness center or through a wearable fitness device or app and earn rewards*» Other web tools like a fitness center search, challenges, and online classes *Rewards subject to change; purchase of a wearable fitness device or application may be required and is not reimbursed by the Silver&Fit program. Website: Silver&Fit Phone Number: Toll-free (TTY/TDD: 711) Hours: Monday Friday, 6 a.m. 7 p.m. Mountain Time Fitness center or YMCA to collect annual member fee of $50 Y0010_MK19059_M Fitness Card Member Name: Date of Birth: (month/day) Member Information Form No (09-18)