2018 MEDICARE ADVANTAGE PLANS. bsneny.com/medicare. Y0086_MRK1843rev Accepted

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1 2018 MEDICARE ADVANTAGE PLANS bsneny.com/medicare Y0086_MRK1843rev Accepted

2 2018 MEDICARE ADVANTAGE PLANS NEW Premium 1 Premium with EPIC subsidy or full Extra Help 1 Primary care/ specialist Medical/drug deductibles Part D prescriptions Tier 1/2/3/4/5 Preferred pharmacy Standard pharmacy BlueSaver 2 (HMO) $16 $0 $15/$45 $0/$290 tiers 3 5 $2/$12/$42/$85/27 $7/$17/$47/$90/27 HMO Senior Blue (HMO-POS) $46 $7 $15/$50 $0/$0 $3/$15/$42/$94/33 $8/$20/$47/$100/33 Senior Blue (HMO) $129 $90 $0/$26 $0/$0 $4/$10/$42/50/33 $9/$15/$47/50/33 Forever Blue Value 4 (PPO) $85 $46 $25/$36 $0/$0 $7/$15/$42/$94/33 $12/$20/$47/$100/33 PPO Forever Blue (PPO) $184 $145 $10/$22 $0/$0 $2/$12/$42/$94/33 $7/$17/$47/$100/33 Unless otherwise noted, costs shown are for services received in-network. ENROLL Call to enroll over the phone. Meet one-on-one with a consultant who can help you fill out and submit an application. Fill out an application and mail it in. Visit bsneny.com/enrollmedicare to complete the application online.

3 Gap Inpatient hospital care X-rays/advanced radiology (MRI, CAT, PET) Outpatient/ ambulatory surgery Nationwide Out-of-pocket maximum Discounts $360 per day for days 1 5 $1,800 $50/$175 $500/$450 ER, urgent care, and dialysis $6,700 gap $325 per day for days 1 4 $1,300 $50/$175 $325/$275 ER, urgent care, and dialysis 3 $5,500 gap $225 per day for days 1 7 $1,575 $50/$75 $250/$200 ER, urgent care, and dialysis $6,700 gap $240 per day for days 1 7 $1,680 $50/$125 $275/$225 Yes for all covered services $6,700 in-network $10,000 in- and out-of-network gap $205 per day for days 1 7 $1,435 $40/$100 $225/$175 Yes for all covered services $5,500 in-network $8,500 in- and out-of-network Drug deductibles displayed are for non-lis (Low Income Subsidy) members. LIS members may pay a lower drug deductible. CONTACT We re here to help. Call, , or schedule a one-on-one meeting with a dedicated consultant who can talk your plan options and answer your questions. Call us at (TTY 711) or SalesCenterNENY@bsneny.com. October 1 February 14 February 15 September 30 8 a.m. to 8 p.m., 7 days a week 8 a.m. to 8 p.m., Monday Friday

4 The Benefits of BlueShield When you choose BlueShield, you re getting the exceptional support, value, and service you deserve with the stability of a plan backed by more than 70 years of proven experience. Plan perks Partnered with the region's leading health systems and medical practices, including: º Albany Medical Center º CapitalCare Medical Group º Community Care Physicians, P.C. º Ellis Hospital º Glens Falls Hospital º Hudson Headwaters º Irongate º Saratoga Hospital º St. Peter s Health Partners Tier 1 generic drugs covered in gap with Senior Blue 650, Senior Blue 652, Forever Blue Value, and Forever Blue 770. Hearing : routine hearing exam and two hearing aids per year (one per ear) when purchased TruHearing. 6 $0 preventive services More than 20 services are included at no cost when you use providers in our network. $0 gym membership Stay active with home exercise programs and access to more than 14,000 fitness locations nationwide with SilverSneakers. $0 care management Our nationally accredited care management team works with you and your doctor to help manage your health and meet your unique needs. $0 in-home care We ve partnered with Landmark Health to create Care at Home SM care and support available 24/7, provided in the comfort of your home. Add Dental Care Optional supplemental benefits (no network see any dentist) Premium 7 Preventive services (2 cleanings and 2 oral exams/year) Diagnostic and restorative service cost Annual max allowance Basic $19 50 coinsurance 50 coinsurance $500 Enhanced $38 Full 50 coinsurance $1,000 NOTE: Preventive services do not count toward the annual max allowance for dental. Common Plan Elements Part B diabetes supplies and monitors $0 Skilled nursing facility days 1 20 $0 Skilled nursing facility days Hearing aid (specific models) 6 Vision wear (frames/lenses/contact lenses) $167.50/day Worldwide for emergency and urgent care on all plans Unless otherwise noted, costs shown are for services received in-network. $699 or $999/unit Annual allowance on some plans

5 Medicare Part D Coverage Gap The gap or donut hole is a Part D drug stage that changes what you pay for prescriptions. You may not end up in the gap each year, but you should be aware of how it works just in case. Visit bsneny.com/comparerx or contact one of our dedicated consultants Initial Pay a copay or coinsurance for your prescriptions until you reach your limit. Coverage gap Pay a percentage of the cost for your prescriptions. Some of our plans cover tier 1 generics the gap, so you would pay a copay for those drugs. Catastrophic Once you reach the gap limit, continue to pay a smaller copay or coinsurance for your prescriptions until the end of the calendar year. Coverage That Travels All of our plans cover you worldwide for urgent and emergency care but if you travel often, you can enjoy the flexibility of BlueCard Network Sharing with our Forever Blue 770 plan. Links BlueCross and/or BlueShield plans, simplifying billing. Pay the same as you would in-network for all plan-covered services outside of Northeastern New York in participating areas.* Participating BlueCard states and territories: AL, AR, CA, CO, CT, FL, GA, HI, ID, IL, IN, KY, ME, MA, MI, MO, MT, NV, NH, NJ, NM, NY, NC, OH, OK, OR, PA, SC, TN, TX, UT, VA, WA, WI, WV, PR To find out if a doctor or facility participates in the BlueCard Network Sharing program: Call BLUE (2583) and select option 2 Or visit bsneny.com/medicare If you don't travel as much, or want a lower-cost option, our Forever Blue Value plan may work for you. You can still access care out-of-area but will pay more when you visit an out-of-network doctor or hospital. * In order for services to be considered in-network while you re outside of the service area the provider must participate with the local BlueCard Network Sharing program in the service area and both you and the provider must be located in the same service area when you receive care. Outside the U.S. you may be asked to pay 100 of the cost at the time of service. You would then submit a claim to us to be reimbursed for your in-network cost-share.

6 Additional Information 1. You must continue to pay your Medicare Part B premium. 2. You must receive all care from plan providers, with limited exceptions. 3. Coverage out-of-network for specialists, X-rays, diagnostic tests and procedures, lab, occupational and physical therapy, and speech-language pathology services only. The cost-share out-of-network is 50, up to $1,500 annually. 4. You can receive care from Medicare providers outside of the 10 counties of Northeastern New York with your outof-network benefit at a higher cost-share. 5. If you see a participating BlueCard provider outside of the service area, you pay your in-network copay. If you receive care from out-of-network providers, your cost may be higher. 6. Our plans cover one routine hearing exam per year with a TruHearing provider. Please call TruHearing to verify your benefit and schedule a hearing exam. Coverage is for TruHearing Flyte models only. 7. Dental premium is in addition to plan and Part B premium. About our benefits and premiums This information is not a complete description of benefits. Contact the plan for more information. Benefits, premium, and/or copayments/coinsurance may change on January 1 of each year. Limitations, copayments, and restrictions may apply. The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. Eligible beneficiaries must use network pharmacies to access their prescription drug benefit, except under non-routine circumstances, and quantity limitations and restrictions may apply. Other pharmacies/physicians/ providers are available in our network. Out-of-network/noncontracted providers are under no obligation to treat BlueShield members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. 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. About enrollment Individuals must have both Parts A and B to enroll in a Medicare Advantage plan. Individuals may enroll in a plan only during specific times of the year. There are additional enrollment guidelines. Contact BlueShield for more information. About our partners SilverSneakers is a registered trademark of Tivity Health, Inc. Tivity Health is an independent company that administers the SilverSneakers gym benefit. Care at Home SM is a program for BlueShield of Northeastern New York members and is administered by Landmark Health. TruHearing is a registered trademark of TruHearing, Inc. TruHearing is an independent company that administers the hearing-aid benefit. About us BlueShield of Northeastern New York is a Medicare Advantage plan with a Medicare contract and enrollment depends on contract renewal. A division of HealthNow New York Inc., an independent licensee of the BlueCross BlueShield Association. BlueShield of Northeastern New York 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 711). 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 711) _09_17_NENY F10998-A

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