2016 Summary of Benefits

Transcription

1 Freedom Blue PPO 2016 Summary of Benefits West Virginia H5106_15_0269 Accepted

2 SUMMARY OF BENEFITS January 1, December 31, 2016 This booklet gives you a summary of what we cover and what you pay. It doesn't list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, call us and ask for the "Evidence of Coverage." YOU HAVE CHOICES ABOUT HOW TO GET YOUR MEDICARE BENEFITS 1 One choice is to get your Medicare benefits through Original Medicare (fee-for-service Medicare). Original Medicare is run directly by the Federal government. 1 Another choice is to get your Medicare benefits by joining a Medicare health plan (such as Freedom Blue PPO ValueRx (PPO) and Freedom Blue PPO Standard (PPO)). TIPS FOR COMPARING YOUR MEDICARE CHOICES This Summary of Benefits booklet gives you a summary of what Freedom Blue PPO ValueRx (PPO) and Freedom Blue PPO Standard (PPO) cover and what you pay. 1 If you want to compare our plans with other Medicare health plans, ask the other plans for their Summary of Benefits booklets. Or, use the Medicare Plan Finder on 1 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 SECTIONS IN THIS BOOKLET 1 Things to Know About Freedom Blue PPO ValueRx (PPO) and Freedom Blue PPO Standard (PPO) 1 Monthly Premiums, Deductibles, and Limits on How Much You Pay for Covered Services 1 Covered Medical and Hospital Benefits 1 Prescription Drug Benefits This document is available in other formats such as Braille and large print. This document may be available in a non-english language. For additional information, call us at (TTY/TDD 711). 2

3 THINGS TO KNOW ABOUT FREEDOM BLUE PPO VALUERX (PPO) AND FREEDOM BLUE PPO STANDARD (PPO) HOURS OF OPERATION You can call us 7 days a week from 8:00 a.m. to 8:00 p.m. Eastern time. FREEDOM BLUE PPO VALUERX (PPO) AND FREEDOM BLUE PPO STANDARD (PPO) PHONE NUMBERS AND WEBSITE 1 If you are a member of this plan, call toll-free us at (TTY/TDD 711). 1 If you are not a member of this plan, call toll-free (TTY/TDD ). 1 Our website: WHO CAN JOIN? To join Freedom Blue PPO ValueRx (PPO) or Freedom Blue PPO Standard (PPO), you must be entitled to Medicare Part A, be enrolled in Medicare Part B, and live in our service area. Our service area includes the following counties in West Virginia: Barbour, Berkeley, Brooke, Cabell, Doddridge, Fayette, Greenbrier, Hampshire, Hardy, Harrison, Jackson, Jefferson, Kanawha, Lewis, Marion, Mason, Mercer, Mingo, Monongalia, Nicholas, Ohio, Pendleton, Putnam, Ritchie, Summers, Taylor, Tucker, Tyler, Upshur, Wetzel, Wirt, Wood, and Wyoming. WHICH DOCTORS, HOSPITALS, AND PHARMACIES CAN I USE? Freedom Blue PPO ValueRx (PPO) and Freedom Blue PPO Standard (PPO) have a network of doctors, hospitals, pharmacies, and other providers. If you use the providers in our network, you may pay less for your covered services. But if you want to, you can also use providers that are not in our network. You must generally use network pharmacies to fill your prescriptions for covered Part D drugs. You can see our plan's provider and pharmacy directory at our website ( Or, call us and we will send you a copy of the provider and pharmacy directories. WHAT DO WE COVER? Like all Medicare health plans, we cover everything that Original Medicare covers - and more. 1 Our plan members get 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. 1 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. 3

4 1 You can see the complete plan formulary (list of Part D prescription drugs) and any restrictions on our website, client.formularynavigator.com/clients/ hm/default.html. 1 Or, call us and we will send you a copy of the formulary. HOW WILL I DETERMINE MY DRUG COSTS? Our plans group each medication into one of five "tiers." You will need to use your formulary to locate what tier your drug is on to determine how much it will cost you. The amount you pay depends on the drug's tier and what stage of the benefit you have reached. Later in this document we discuss the benefit stages that occur: Initial Coverage, Coverage Gap, and Catastrophic Coverage. Highmark Senior Solutions Company is a PPO plan with a Medicare contract. Enrollment in Highmark Senior Solutions Company depends on contract renewal. 4

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6 SUMMARY OF BENEFITS January 1, December 31, 2016 BENEFIT CATEGORY Freedom Blue PPO ValueRx (PPO) Freedom Blue PPO Standard (PPO) MONTHLY PREMIUM, DEDUCTIBLE, AND LIMITS ON HOW MUCH YOU PAY FOR COVERED SERVICES How much is the monthly premium? $75.50 per month. In addition, you must keep $ per month. In addition, you must keep paying your Medicare Part B premium. paying your Medicare Part B premium. How much is the deductible? Is there any limit on how much I will pay for my covered services? Is there a limit on how much the plan will pay? This plan does not have a deductible. Yes. Like all Medicare health plans, our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care. Your yearly limit(s) in this plan: 1 $6,700 for services you receive from in-network providers. 1 $10,000 for services you receive from any provider. Your limit for services received from in-network providers will count toward this limit. If you reach the limit on out-of-pocket costs, you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year. Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs. Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply. This plan does not have a deductible. Yes. Like all Medicare health plans, our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care. Your yearly limit(s) in this plan: 1 $6,700 for services you receive from in-network providers. 1 $10,000 for services you receive from any provider. Your limit for services received from in-network providers will count toward this limit. If you reach the limit on out-of-pocket costs, you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year. Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs. Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply. 6

7 BENEFIT CATEGORY Freedom Blue PPO ValueRx (PPO) COVERED MEDICAL AND HOSPITAL BENEFITS Note: 1 Services with a 1 may require prior authorization. Freedom Blue PPO Standard (PPO) OUTPATIENT CARE AND SERVICES Acupuncture Not covered Not covered Ambulance Chiropractic Care 1 Dental Services 1 1 In-network: $200 copay 1 In-network: $175 copay 1 Out-of-network: $200 copay or 30% of the 1 Out-of-network: $175 copay or 30% of the cost, depending on the service cost, depending on the service Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): 1 In-network: $20 copay 1 In-network: $20 copay Routine chiropractic visit (for up to 8 every year): Routine chiropractic visit (for up to 8 every year): 1 In-network: $20 copay 1 In-network: $20 copay Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): 1 In-network: $ copay, depending on the service 1 In-network: $ copay, depending on the service Preventive dental services: Preventive dental services: 1 Dental x-ray(s) (for up to 1): 1 Dental x-ray(s) (for up to 1): 4 In-network: $25 copay 4 In-network: $25 copay 4 Out-of-network: 50% of the cost 4 Out-of-network: 50% of the cost A single office visit that includes: A single office visit that includes: 7

8 BENEFIT CATEGORY Dental Services 1 (continued) Diabetes Supplies and Services 1 Diagnostic Tests, Lab and Radiology Services, and X-Rays (Costs for these services may vary based on place of service) 1 Freedom Blue PPO ValueRx (PPO) 1 Cleaning (for up to 1 every year) 1 Oral exam (for up to 1 every year) 4 In-network: $30 copay 4 Out-of-network: 50% of the cost Diabetes monitoring supplies: 1 In-network: 0-20% of the cost, depending on the supply Diabetes self-management training: 1 In-network: You pay nothing 1 Out-of-network: You pay nothing Therapeutic shoes or inserts: 1 In-network: 20% of the cost Diagnostic radiology services (such as MRIs, CT scans): 1 In-network: $200 copay Diagnostic tests and procedures: 1 In-network: $5-15 copay, depending on the service Lab services: 1 In-network: $5-15 copay, depending on the service Outpatient x-rays: 1 In-network: $25 copay Freedom Blue PPO Standard (PPO) 1 Cleaning (for up to 1 every year) 1 Oral exam (for up to 1 every year) 4 In-network: $30 copay 4 Out-of-network: 50% of the cost Diabetes monitoring supplies: 1 In-network: 0-20% of the cost, depending on the supply Diabetes self-management training: 1 In-network: You pay nothing 1 Out-of-network: You pay nothing Therapeutic shoes or inserts: 1 In-network: 20% of the cost Diagnostic radiology services (such as MRIs, CT scans): 1 In-network: $100 copay Diagnostic tests and procedures: 1 In-network: $0-10 copay, depending on the service Lab services: 1 In-network: $0-10 copay, depending on the service Outpatient x-rays: 1 In-network: $25 copay 8

9 BENEFIT CATEGORY Freedom Blue PPO ValueRx (PPO) Freedom Blue PPO Standard (PPO) Diagnostic Tests, Lab and Radiology Services, and X-Rays (Costs for these services may vary based on place of service) 1 (continued) Therapeutic radiology services (such as radiation treatment for cancer): 1 In-network: You pay nothing Therapeutic radiology services (such as radiation treatment for cancer): 1 In-network: You pay nothing Doctor's Office Visits Durable Medical Equipment (wheelchairs, oxygen, etc.) 1 Emergency Care Foot Care (podiatry services) Primary care physician visit: 1 In-network: $15 copay 1 Out-of-network: $30 copay Specialist visit: 1 In-network: $40 copay 1 Out-of-network: $50 copay 1 In-network: 20% of the cost $75 copay If you are admitted to the hospital within 3 days, you do not have to pay your share of the cost for emergency care. See the "Inpatient Hospital Care" section of this booklet for other costs. Emergency Care is covered worldwide. Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: 1 In-network: $40 copay Routine foot care (for up to 10 visit(s) every year): 1 In-network: $40 copay Primary care physician visit: 1 In-network: $10 copay 1 Out-of-network: $30 copay Specialist visit: 1 In-network: $35 copay 1 Out-of-network: $45 copay 1 In-network: 20% of the cost $75 copay If you are admitted to the hospital within 3 days, you do not have to pay your share of the cost for emergency care. See the "Inpatient Hospital Care" section of this booklet for other costs. Emergency Care is covered worldwide. Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: 1 In-network: $35 copay Routine foot care (for up to 10 visit(s) every year): 1 In-network: $35 copay 9

10 BENEFIT CATEGORY Hearing Services Home Health Care 1 Freedom Blue PPO ValueRx (PPO) Exam to diagnose and treat hearing and balance issues: Freedom Blue PPO Standard (PPO) Exam to diagnose and treat hearing and balance issues: 1 In-network: $40 copay 1 In-network: $35 copay Routine hearing exam (for up to 1 every year): Routine hearing exam (for up to 1 every year): 1 In-network: $40 copay 1 In-network: $35 copay Hearing aid fitting/evaluation (for up to 1 every year): Hearing aid fitting/evaluation (for up to 1 every year): 1 In-network: $40 copay 1 In-network: $35 copay Hearing aid: Hearing aid: 1 In-network: $ copay for each hearing 1 In-network: $ copay for each hearing aid, depending on the type aid, depending on the type 1 Out-of-network: $ copay for each 1 Out-of-network: $ copay for each hearing aid, depending on the type hearing aid, depending on the type Copayment for hearing aids applies only to TruHearing Chime products. TruHearing is the exclusive provider of the Chime 500 and Chime 900 hearing aids. Up to two Chime hearing aids once every calendar year. Copayment for hearing aids applies only to TruHearing Chime products. TruHearing is the exclusive provider of the Chime 500 and Chime 900 hearing aids. Up to two Chime hearing aids once every calendar year. 1 In-network: You pay nothing 1 In-network: You pay nothing Mental Health Care 1 Inpatient visit: Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital. Inpatient visit: Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital. 10

11 BENEFIT CATEGORY Mental Health Care 1 (continued) Freedom Blue PPO ValueRx (PPO) Freedom Blue PPO Standard (PPO) Our plan covers 90 days for an inpatient hospital Our plan covers 90 days for an inpatient hospital stay. stay. Our plan also covers 60 "lifetime reserve days." Our plan also covers 60 "lifetime reserve days." These are "extra" days that we cover. If your These are "extra" days that we cover. If your hospital stay is longer than 90 days, you can use hospital stay is longer than 90 days, you can use these extra days. But once you have used up these these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage extra 60 days, your inpatient hospital coverage will be limited to 90 days. will be limited to 90 days. 1 In-network: 1 In-network: 4 $300 copay per day for days 1 through 5 4 $150 copay per day for days 1 through 7 4 You pay nothing per day for days 6 4 You pay nothing per day for days 8 through 90 through 90 1 Out-of-network: 1 Out-of-network: 4 30% of the cost per stay 4 30% of the cost per stay Outpatient group therapy visit: Outpatient group therapy visit: 1 In-network: $40 copay 1 In-network: $35 copay Outpatient individual therapy visit: Outpatient individual therapy visit: 1 In-network: $40 copay 1 In-network: $35 copay Outpatient Rehabilitation 1 Cardiac (heart) rehab services (for a maximum Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): sessions up to 36 weeks): 1 In-network: You pay nothing 1 In-network: You pay nothing Occupational therapy visit: Occupational therapy visit: 1 In-network: $40 copay 1 In-network: $35 copay Physical therapy and speech and language therapy Physical therapy and speech and language therapy visit: visit: 11

12 BENEFIT CATEGORY Outpatient Rehabilitation 1 (continued) Outpatient Substance Abuse 1 Outpatient Surgery 1 Freedom Blue PPO ValueRx (PPO) Freedom Blue PPO Standard (PPO) 1 In-network: $40 copay 1 In-network: $35 copay Group therapy visit: Group therapy visit: 1 In-network: $40 copay 1 In-network: $35 copay Individual therapy visit: Individual therapy visit: 1 In-network: $40 copay 1 In-network: $35 copay Ambulatory surgical center: Ambulatory surgical center: 1 In-network: $250 copay 1 In-network: $100 copay Outpatient hospital: Outpatient hospital: 1 In-network: $350 copay 1 In-network: $200 copay Over-the-Counter Items Not Covered Not Covered Prosthetic Devices (braces, artificial limbs, etc.) 1 Renal Dialysis Transportation Prosthetic devices: Prosthetic devices: 1 In-network: 20% of the cost 1 In-network: 20% of the cost Related medical supplies: Related medical supplies: 1 In-network: 20% of the cost 1 In-network: 20% of the cost 1 In-network: You pay nothing 1 In-network: You pay nothing 1 Out-of-network: 0-30% of the cost, depending 1 Out-of-network: 0-30% of the cost, depending on the service on the service 1 In-network: $40 copay 1 In-network: $40 copay 1 Out-of-network: 50% of the cost 1 Out-of-network: 50% of the cost 12

13 BENEFIT CATEGORY Urgently Needed Services Freedom Blue PPO ValueRx (PPO) $50 copay. Not waived if admitted. Urgently Needed Services are covered worldwide. Freedom Blue PPO Standard (PPO) $50 copay. Not waived if admitted. Urgently Needed Services are covered worldwide. Vision Services Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): 1 In-network: $0-40 copay, depending on the service 1 In-network: $0-35 copay, depending on the service 1 Out-of-network: $50 copay 1 Out-of-network: $45 copay Routine eye exam (for up to 1 every year): Routine eye exam (for up to 1 every year): 1 In-network: $0 copay 1 In-network: $0 copay 1 Out-of-network: $40 copay 1 Out-of-network: $40 copay Contact lenses (for up to 1 every year): Contact lenses (for up to 1 every year): 1 In-network: $0 copay 1 In-network: $0 copay 1 Out-of-network: $0 copay 1 Out-of-network: $0 copay Our plan pays up to $100 every year for contact lenses from any provider. Eyeglass frames (for up to 1 every year): Our plan pays up to $100 every year for contact lenses from any provider. Eyeglass frames (for up to 1 every year): 1 In-network: $0 copay 1 In-network: $0 copay 1 Out-of-network: $0 copay 1 Out-of-network: $0 copay Our plan pays up to $100 every year for eyeglass frames from any provider. Eyeglass lenses (for up to 1 every year): Our plan pays up to $100 every year for eyeglass frames from any provider. Eyeglass lenses (for up to 1 every year): 1 In-network: $0 copay 1 In-network: $0 copay 1 Out-of-network: $0 copay 1 Out-of-network: $0 copay Our plan pays up to $100 every year for eyeglass lenses from any provider. Our plan pays up to $100 every year for eyeglass lenses from any provider. 13

14 BENEFIT CATEGORY Vision Services (continued) Preventive Care Freedom Blue PPO ValueRx (PPO) Freedom Blue PPO Standard (PPO) Eyeglasses or contact lenses after cataract surgery: Eyeglasses or contact lenses after cataract surgery: 1 In-network: $0 copay 1 In-network: $0 copay 1 Out-of-network: $0 copay 1 Out-of-network: $0 copay A $200 benefit max applies to upgrades to post-cataract surgery eyewear that are not medically necessary. Available following cataract surgery once per operated eye. A $200 benefit max applies to upgrades to post-cataract surgery eyewear that are not medically necessary. Available following cataract surgery once per operated eye. 1 In-network: You pay nothing 1 In-network: You pay nothing 1 Out-of-network: You pay nothing 1 Out-of-network: You pay nothing Our plan covers many preventive services, including: Our plan covers many preventive services, including: 1 Abdominal aortic aneurysm screening 1 Abdominal aortic aneurysm screening 1 Alcohol misuse counseling 1 Alcohol misuse counseling 1 Bone mass measurement 1 Bone mass measurement 1 Breast cancer screening (mammogram) 1 Breast cancer screening (mammogram) 1 Cardiovascular disease (behavioral therapy) 1 Cardiovascular disease (behavioral therapy) 1 Cardiovascular screenings 1 Cardiovascular screenings 1 Cervical and vaginal cancer screening 1 Cervical and vaginal cancer screening 1 Colorectal cancer screenings (Colonoscopy, 1 Colorectal cancer screenings (Colonoscopy, Fecal occult blood test, Flexible sigmoidoscopy) Fecal occult blood test, Flexible sigmoidoscopy) 1 Depression screening 1 Depression screening 1 Diabetes screenings 1 Diabetes screenings 1 HIV screening 1 HIV screening 1 Medical nutrition therapy services 1 Medical nutrition therapy services 1 Obesity screening and counseling 1 Obesity screening and counseling 1 Prostate cancer screenings (PSA) 1 Prostate cancer screenings (PSA) 1 Sexually transmitted infections screening and 1 Sexually transmitted infections screening and counseling 1 Tobacco use cessation counseling (counseling 1 counseling Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease) for people with no sign of tobacco-related disease) 14

15 BENEFIT CATEGORY Preventive Care (continued) Freedom Blue PPO ValueRx (PPO) Freedom Blue PPO Standard (PPO) 1 Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots 1 Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots 1 "Welcome to Medicare" preventive visit 1 "Welcome to Medicare" preventive visit (one-time) (one-time) 1 Yearly "Wellness" visit 1 Yearly "Wellness" visit Any additional preventive services approved by Medicare during the contract year will be covered. Any additional preventive services approved by Medicare during the contract year will be covered. Hospice You pay nothing for hospice care from a Medicare-certified hospice. You may have to pay part of the costs for drugs and respite care. Hospice is covered outside of our plan. Please contact us for more details. You pay nothing for hospice care from a Medicare-certified hospice. You may have to pay part of the costs for drugs and respite care. Hospice is covered outside of our plan. Please contact us for more details. INPATIENT CARE Inpatient Hospital Care 1 Our plan covers an unlimited number of days for an inpatient hospital stay. 1 In-network: Our plan covers an unlimited number of days for an inpatient hospital stay. 1 In-network: 4 $300 copay per day for days 1 through 5 4 $150 copay per day for days 1 through 7 4 You pay nothing per day for days 6 4 You pay nothing per day for days 8 through 90 4 You pay nothing per day for days 91 and 4 through 90 You pay nothing per day for days 91 and beyond beyond 1 Out-of-network: 1 Out-of-network: 4 30% of the cost per stay 4 30% of the cost per stay Inpatient Mental Health Care For inpatient mental health care, see the "Mental Health Care" section of this booklet. For inpatient mental health care, see the "Mental Health Care" section of this booklet. Skilled Nursing Facility (SNF) 1 Our plan covers up to 100 days in a SNF. Our plan covers up to 100 days in a SNF. 1 In-network: 1 In-network: 4 You pay nothing per day for days 1 4 You pay nothing per day for days 1 through 20 through 20 15

16 BENEFIT CATEGORY Skilled Nursing Facility (SNF) 1 (continued) PRESCRIPTION DRUG BENEFITS How much do I pay? Initial Coverage Freedom Blue PPO ValueRx (PPO) 4 $160 copay per day for days 21 through Out-of-network: 4 30% of the cost per stay For Part B drugs such as chemotherapy drugs 1 : 1 In-network: 0-20% of the cost depending on the drug 1 Out-of-network: 0-30% of the cost, depending on the drug Other Part B drugs 1 : 1 In-network: 0-20% of the cost depending on the drug 1 Out-of-network: 0-30% of the cost, depending on the drug You pay the following until your total yearly drug costs reach $3,310. Total yearly drug costs are the total drug costs paid by both you and our Part D plan. You may get your drugs at network retail pharmacies and mail order pharmacies. Standard Retail Cost-Sharing One-month Three-month Tier supply supply Tier 1 (Preferred $3 copay $9 copay Generic) Tier 2 (Generic)$15 copay $45 copay Tier 3 (Preferred Brand) $47 copay $141 copay Freedom Blue PPO Standard (PPO) 4 $160 copay per day for days 21 through Out-of-network: 4 30% of the cost per stay For Part B drugs such as chemotherapy drugs 1 : 1 In-network: 0-20% of the cost depending on the drug 1 Out-of-network: 0-30% of the cost, depending on the drug Other Part B drugs 1 : 1 In-network: 0-20% of the cost depending on the drug 1 Out-of-network: 0-30% of the cost, depending on the drug You pay the following until your total yearly drug costs reach $3,310. Total yearly drug costs are the total drug costs paid by both you and our Part D plan. You may get your drugs at network retail pharmacies and mail order pharmacies. Standard Retail Cost-Sharing One-month Tier supply Tier 1 (Preferred Generic) $3 copay Tier 2 (Generic)$15 copay Tier 3 (Preferred $44 copay Brand) Three-month supply $9 copay $45 copay $132 copay 16

17 BENEFIT CATEGORY Initial Coverage (continued) Freedom Blue PPO ValueRx (PPO) One-month Tier supply Tier 4 (Non-Preferred Brand) Tier 5 (Specialty Tier) Three-month supply 45% of the cost 45% of the cost 33% of the cost Not Offered Standard Mail Order Cost-Sharing One-month Tier supply Tier 1 (Preferred Generic) Not Offered Tier 2 (Generic)Not Offered Tier 3 (Preferred Not Offered Brand) Tier 4 (Non-Preferred Brand) Not Offered Three-month supply $7.50 copay $37.50 copay $ copay 45% of the cost Tier 5 33% of the cost Not Offered (Specialty Tier) If you reside in a long-term care facility, you pay the same as at a retail pharmacy. You may get drugs from an out-of-network pharmacy, but may pay more than you pay at an in-network pharmacy. Freedom Blue PPO Standard (PPO) One-month Tier supply Tier 4 (Non-Preferred Brand) Tier 5 (Specialty Tier) Three-month supply 45% of the cost 45% of the cost 33% of the cost Not Offered Standard Mail Order Cost-Sharing One-month Three-month Tier supply supply Tier 1 (Preferred Not Offered $7.50 copay Generic) Tier 2 (Generic)Not Offered $37.50 copay Tier 3 (Preferred Not Offered $110 copay Brand) Tier 4 (Non-Preferred Not Offered 45% of the cost Brand) Tier 5 33% of the cost Not Offered (Specialty Tier) If you reside in a long-term care facility, you pay the same as at a retail pharmacy. You may get drugs from an out-of-network pharmacy, but may pay more than you pay at an in-network pharmacy. Coverage Gap Most Medicare drug plans have a coverage gap (also called the "donut hole"). This means that there's a temporary change in what you will pay Most Medicare drug plans have a coverage gap (also called the "donut hole"). This means that there's a temporary change in what you will pay for your drugs. The coverage gap begins after the for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan total yearly drug cost (including what our plan has paid and what you have paid) reaches $3,310. has paid and what you have paid) reaches $3,

18 BENEFIT CATEGORY Coverage Gap (continued) Catastrophic Coverage Freedom Blue PPO ValueRx (PPO) After you enter the coverage gap, you pay 45% of the plan's cost for covered brand name drugs and 58% of the plan's cost for covered generic drugs until your costs total $4,850, which is the end of the coverage gap. Not everyone will enter the coverage gap. After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4,850, you pay the greater of: 1 5% of the cost, or 1 $2.95 copay for generic (including brand drugs treated as generic) and a $7.40 copayment for all other drugs. Freedom Blue PPO Standard (PPO) After you enter the coverage gap, you pay 45% of the plan's cost for covered brand name drugs and 58% of the plan's cost for covered generic drugs until your costs total $4,850, which is the end of the coverage gap. Not everyone will enter the coverage gap. After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4,850, you pay the greater of: 1 5% of the cost, or 1 $2.95 copay for generic (including brand drugs treated as generic) and a $7.40 copayment for all other drugs. 18

19 PREMIUM TABLE As a member of our plan, you pay a monthly plan premium. The table below shows the monthly plan premium amount for each region we serve. The service area for Freedom Blue PPO ValueRx (PPO) and Freedom Blue PPO Standard (PPO) includes the following counties in West Virginia: Barbour, Berkeley, Brooke, Cabell, Doddridge, Fayette, Greenbrier, Hampshire, Hardy, Harrison, Jackson, Jefferson, Kanawha, Lewis, Marion, Mason, Mercer, Mingo, Monongalia, Nicholas, Ohio, Pendleton, Putnam, Ritchie, Summers, Taylor, Tucker, Tyler, Upshur, Wetzel, Wirt, Wood, and Wyoming. Plan Name Freedom Blue PPO ValueRx (PPO) Freedom Blue PPO Standard (PPO) Premium $75.50 $

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24 Highmark Senior Solutions Company and Highmark Blue Cross Blue Shield are independent licensees of the Blue Cross and Blue Shield Association. Blue Cross, Blue Shield and the Cross and Shield symbols are registered service marks of the Blue Cross and Blue Shield Association. Freedom Blue is a service mark of the Blue Cross and Blue Shield Association. Highmark is a registered mark of Highmark Inc (R9/15)