Enrollment Kit. Medicare Advantage. BlueMedicare SM Regional PPO A Medicare Advantage Regional PPO Plan. State of Florida.

Transcription

1 2014 Medicare Advantage Enrollment Kit BlueMedicare SM Regional PPO A Medicare Advantage Regional PPO Plan State of Florida Y0011_ C: 08/2013

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3 Table of contents Table of contents Welcome 1 Benefits at a glance (includes Understanding drug payment stages) 2 Helping your Medicare dollars work for you 5 Networks 6 Frequently asked questions 7 SUMMARY OF BENEFITS Summary of Benefits Multi-language Insert MORE PLAN INFORMATION Vistor/Travel Program Chain Pharmacies PLAN ENROLLMENT Understanding enrollment periods Steps to an easy enrollment: Ready to enroll? Enrollment form Authorization to use and access Protected Health Information Form Outbound Enrollment and Verification (OEV) call checklist Scope of Sales Appointment Confirmation Form What to Expect After You Enroll TOCRPPO (RPPO)

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5 Welcome Thank you for considering a Medicare Advantage plan through Florida Blue. We re a Florida-based, not-for-profit company that has been serving people with Medicare for more than 25 years. Our Corporate Mission is To help people and communities achieve better health. We ve been in Florida for nearly 70 years, and we re here for you. We recognize that when it comes to health care coverage, there s no such thing as one size fits all. We re here to help you find the plan that s right for you, at a price you can afford. That s the benefit of BlueMedicare Solutions. We are here to provide health solutions as your needs evolve. The pursuit of health is a journey that everyone takes, and no matter where yours leads, Florida Blue will be with you every step of the way. Always- optimistic, always- moving forward, always- on the quest for better health! Florida Blue promotes and supports your quality of life by offering total healthcare solutions when, where and how you need them. Local experts help you understand your healthcare choices and empower you to make decisions that save you money and support your lifestyle goals. Comprehensive coordination of services can ease stress and provide peace of mind. Total health solutions support you, your doctor and your family to maximize quality of life. To fully understand the benefits provided under this plan be sure to... review all plan details. review the More Plan Information section. check that your drugs are covered. complete the easy enrollment process. check that your providers are participating in the plan. This information is available for free in other languages. Please call our customer service number at , 8:00 a.m. 9:00 p.m. ET, seven days a week all year long (TTY: ). Esta información está disponible de forma gratuita en otros idiomas. Llame a nuestro Departamento de Servicio al Cliente al Estamos abiertos de 8:00 a.m. a 9:00 p.m., Hora del Este, los siete días de la semana, por todo el año. Usuarios de equipo teleescritor (TTY) deben llamar al Florida Blue is a PPO and RPPO Plan with a Medicare contract.florida Blue HMO is an HMO Plan with a Medicare contract. Enrollment in Florida Blue or Florida Blue HMO depends on contract renewal. 1 Y0011_ CMS Approved

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7 Benefits at a Glance BlueMedicare Regional PPO Monthly Plan Premium $0 1 Amount Member Pays In-Network Amount Member Pays Out-of-Network Doctor Office Visits Family Physician (Family, General, Internal Medicine) Specialist Preventive Services In-Network Wellness services as defined by Medicare Emergency Services $15 Copay $50 Copay $0 Copay Calendar Year Deductible then 50% Coinsurance Calendar Year Deductible then 50% Coinsurance 50% Coinsurance (Immunizations are $0) Urgent Care Centers Emergency Room Facility Services (per visit) (copayment waived if admitted) Ambulance Services (ground, air and water travel) $65 Copay $65 Copay $250 Copay Inpatient Services Inpatient Hospital Facility Services $295 Per Day, Days 1-5 Calendar Year Deductible then $495 Per Day, Days 1-27 Skilled Nursing Facility Outpatient Services Home Health Care Independent Clinical Lab (Blood Work) Independent Diagnostic Testing Facility Services* Ambulatory Surgical Center Facility (ASC) $25 Per Day, Days 1-20 $150 Per Day, Days $0 Copay $0 Copay $50 Copay 30% Coinsurance $250 Per Day, Days 1-58 $0 Per Day, Days Calendar Year Deductible then 50% Coinsurance Calendar Year Deductible then 50% Coinsurance Calendar Year Deductible then 50% Coinsurance Calendar Year Deductible then 50% Coinsurance

8 Part D Prescription Drugs Amount Member Pays Preferred Amount Member Pays Non-Preferred Deductible (applies to all drug Tiers) $30 Generics $10 Copay $33 Copay Brands $45 Copay $95 Copay Specialty Drugs 25% Coinsurance 25% Coinsurance Gap Coverage Out-of-Pocket Maximum Out-of-Pocket Maximum (does not include Part D costs) No Additional Coverage through the Gap outside of Plan's percentage and Manufacturer's rebates Amount Member Pays In-Network Amount Member Pays Out-of-Network $6,700 $10,000 Calendar Year Deductible Amount Member Pays In-Network Amount Member Pays Out-of-Network Calendar Year Deductible $0 $950 3

9 Benefits at a Glance Understanding drug payment stages. DEDUCTIBLE STAGE INITIAL COVERAGE STAGE COVERAGE GAP STAGE CATASTROPHIC COVERAGE STAGE During this stage you pay the full negotiated price of the drug until the prescription drug deductible amount is met. Once your prescription drug deductible of $30 has been met, you move to the initial coverage stage. During this stage you pay a flat fee (copay) or a percentage of a drug s total cost (coinsurance) for each prescription you fill. The plan pays the rest until your total drug costs (paid by you and the plan) reach $2,850. During this stage you pay 47.5% of the total cost for brand name drugs and 72% of the total cost for generic drugs. Once your out-of pocket costs reach $4,550, you move to catastrophic coverage. In this stage you pay only a small copay or coinsurance amount for each filled prescription. The plan and Medicare pay the rest until the end of the calendar year. DEDUCTIBLE STAGE Up to $30 INITIAL COVERAGE Up to $2,850 COVERAGE GAP Up to $4,550 CATASTROPHIC COVERAGE Through end of year This information is available for free in other languages. Please call our customer service number at , 8:00 a.m. 9:00 p.m. ET, seven days a week all year long (TTY: ). Esta información está disponible de forma gratuita en otros idiomas. Llame a nuestro Departamento de Servicio al Cliente al Estamos abiertos de 8:00 a.m. a 9:00 p.m., Hora del Este, los siete días de la semana, por todo el año. Usuarios de equipo teleescritor (TTY) deben llamar al Florida Blue is an RPPO Plan with a Medicare contract. Enrollment in Florida Blue depends on contract renewal. *Except for Advanced Imaging Services. 1 You must also continue to pay your Medicare Part B premium if not otherwise paid for by Medicaid or another third party. The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Limitations, copayments, and restrictions may apply. Benefits, formulary, pharmacy network, premium and/or copayments/co-insurance may change on January 1 of each year. 4 Y0011_ CMS Accepted

10 Helping your Medicare dollars work for you USE HOME DELIVERY THROUGH PRIM Save time and gas by utilizing Home Delivery through Prim and enjoy the convenience of receiving your prescriptions at your door. CHOOSE GENERIC OR LOWER TIER DRUGS You can reduce the amount you pay at the pharmacy by choosing Generic Drugs. New generic drugs are available every day. Check with your doctor to see if any of your drugs may be available as a generic. Many drugs in Tier 1 and Tier 2 (most generic drugs) may work just as well for your condition as drugs in Tier 3, Tier 4 and Tier 5. Check with your doctor to see if a lower-tier drug could work for you. CHOOSE IN-NETWORK DOCTORS AND HOSPITALS Using a doctor or hospital in your plan s network will save you money, time and hassle. No paperwork or worries about authorizations. This information is available for free in other languages. Please call our customer service number at , 8:00 a.m. 9:00 p.m. ET, seven days a week all year long (TTY: ). Esta información está disponible de forma gratuita en otros idiomas. Llame a nuestro Departamento de Servicio al Cliente al Estamos abiertos de 8:00 a.m. a 9:00 p.m., Hora del Este, los siete días de la semana, por todo el año. Usuarios de equipo teleescritor (TTY) deben llamar al Florida Blue is a PPO and RPPO Plan with a Medicare contract. Enrollment in Florida Blue depends on contract renewal. 5 Y0011_ CMS Approved

11 Networks MEDICARE PROVIDER ACCESS Medicare Part A (hospital) and Part B (doctor) coverage is the same throughout the United States so it doesn t matter where you live. Medicare Part C coverage (which includes Part A and B combined) is offered by private companies through Medicare Advantage plans, which have service areas. These are usually counties, states or regions where a plan offers coverage. Generally, you must live in a plan s service area in order to join it. However, all Medicare Advantage plans must offer nationwide coverage for emergency and urgent care. FLORIDA BLUE S STRONG NETWORKS OFFER MORE CHOICES Having access to doctors you trust is something we value at Florida Blue. We have robust networks that allow more of our members to see the doctor of their choice. With this Medicare Advantage plan, you may choose to receive services from any provider who participates with Medicare. However, you will be able to lower the amount you pay by receiving care from an in-network provider that is contracted with your plan. Your plan even offers access to in-network providers outside your services area. Although you have the option to select any provider you choose, we encourage you to select and develop a relationship with an in-network General, Internal Medicine or Family physician. There are several advantages to selecting a General, Internal Medicine or Family physician: They are trained to provide a broad range of medical care and will be a valuable resource to coordinate your overall healthcare needs. Developing and continuing a relationship with a General, Internal Medicine or Family physician allows the physician to become knowledgeable about your current and historical health. They can help you determine when you need to visit an in-network specialist. They will also help you find one based on their knowledge of you and your specific healthcare needs. FINDING A PARTICIPATING PROVIDER To get the most up-to-date information about BlueMedicare network providers in your area, you can visit or call our Customer Service Department at , from 8:00 a.m. to 9:00 p.m. ET, seven days a week, all year long. TTY users should call This information is available for free in other languages. Please call our customer service number at , 8:00 a.m. 9:00 p.m. ET, seven days a week all year long (TTY: ). Esta información está disponible de forma gratuita en otros idiomas. Llame a nuestro Departamento de Servicio al Cliente al Estamos abiertos de 8:00 a.m. a 9:00 p.m., Hora del Este, los siete días de la semana, por todo el año. Usuarios de equipo teleescritor (TTY) deben llamar al Florida Blue is a PPO and RPPO Plan with a Medicare contract. Enrollment in Florida Blue depends on contract renewal. 6 Y0011_ CMS Approved

12 Frequently asked questions Q: Does Original Medicare cover all of my health care needs? A: Very few things are covered 100% by Original Medicare. Your out-of-pocket costs for things like deductibles, coinsurance and copays can add up. While no plan provides 100% coverage for everything, Medicare Advantage plans help you pay less out-of-pocket costs and may provide the coverage and protection you want. Q: If I enroll in a Medicare Advantage plan, will I lose my Original Medicare coverage? A: No. With a Medicare Advantage plan, you re still in the Medicare Program. However, your Medicare Advantage plan will pay your hospital and doctor (Parts A and B) expenses instead of Original Medicare. In other words, your Medicare Advantage plan will REPLACE your Original Medicare coverage. You ll still pay your Medicare Part B premium, if you have one. Q: What is included in a Medicare Advantage plan? A: While each Medicare Advantage plan differs from another, one of the best features of a Medicare Advantage plan is that it combines doctor and hospital coverage that may include prescription drug coverage all in one convenient plan. Q: Am I covered if I leave the country? What happens if I m visiting someone out of state? A: You never need prior authorization for emergency and urgently needed services. No matter where you are in the world, you ll be covered for these services. (Please see your plan for additional benefit information.) Some Medicare Advantage plans offer an out-of-network benefit that would enable you to visit doctors when you re away from home, usually at a higher cost. Prescription drugs obtained out of the country are not covered under your Medicare Advantage plan. Q: What happens if I join a Medicare Advantage plan where I live now, and then I move? Can I take my plan with me? A: That depends on where you re moving. If you re moving within the service area of your current plan, you can keep the plan. If you re moving outside of your plan s service area, you ll need to look at your options. You may have to choose a new Medicare Advantage plan that serves the area where you are moving. Or you may have to return to Original Medicare Part A and Part B (with an optional stand-alone prescription drug plan and/or Medicare supplement policy). If you move or are planning to move, contact Customer Service to find out if your new home is in your plan s service area and to discuss your options. Q: I m looking at a Medicare Advantage plan, but I don t know if my doctors belong to its network. How do I find out? A: To find out if your doctors are included in a plan s network, call the plan s Customer Service number or check the plan s website. You can find Customer Service numbers on the Medicare website or through the Medicare telephone helpline. Or just call your doctor s office and ask if he or she accepts the plan. Q: What if I have trouble paying for prescriptions? A: If you find you need help and your yearly income and resources are below certain limits, you can apply for Extra Help from Medicare. This program is also called the low-income subsidy 7 Y0011_ C: 08/2013

13 or LIS. To see if you qualify for Extra Help, you can call MEDICARE ( ), TTY , 24 hours a day, 7 days a week; or the Social Security Office at , TTY , 7 a.m. 7 p.m., Monday Friday, or your State Medicaid Office. Q: Can a network doctor charge me more than the copay amount? A: No. At Florida Blue we continue to find new ways to provide our members with affordable and quality health plans. Part of this comes from us negotiating with doctors to set standard copays. Your network doctor can t ask you to pay more than the plan s cost-sharing amount. If you have any questions, please contact a Customer Service representative. Q: What is the difference between Medicare Advantage and Medicare supplement sometimes referred to as Medigap plans? A: Medicare Advantage plans are health plans that replace Original Medicare Parts A & B benefits by including those type benefits within their plans. Medicare Supplement (Medigap) plans provide financial assistance with out-of-pocket expenses and generally supplement the 20% cost gap of what Original Medicare pays (80%). Q: What is a Late Enrollment Penalty (LEP) and how does it work if I have a $0 premium plan? A: Some members are required to pay an LEP because they did not join a Medicare prescription drug plan when they first became eligible or because they had a continuous period of 63 days or more without creditable prescription drug coverage. ( Creditable means the drug coverage is at least as good as Medicare Part D s standard drug coverage.) For these members, the Centers for Medicare & Medicaid Services (CMS) advises the plan to bill the designated LEP amount in addition to the member s monthly plan premium. For members enrolled in a $0 monthly premium plan, they are still responsible for paying the LEP, if applicable. Q: What is a Formulary and where can I view a copy? A: A formulary is the list of medications covered by a plan, based on Medicare s guidelines. The formulary is also referred to as the medication list, drug list or medication guide. Our formulary is online at BlueMedicareFL.com or you can visit medicare.gov Q: What is Step Therapy and how does it affect me getting my prescription filled? A: Step therapy requires that you try an equally effective drug on the formulary before the plan will cover the prescribed drug. For example, if Drug A and Drug B treat the same medical condition, the plan may require you to try Drug A first. If Drug A does not work for you, the plan may then cover Drug B. Q: What is the Transition Process? How does it work? A: If you are within the first 90 days of enrollment in a Florida Blue Plan, or a current enrollee and the formulary changes from one contract year to the next, Florida Blue will automatically provide a temporary fill a non-formulary drug when you attempt to fill your prescription (including Part D drugs that are on the formulary but require prior authorization or step therapy). This 90-day timeframe applies to retail, home infusion, long-term care and mail-order pharmacies. In the outpatient retail setting the temporary supply is a one-time 30 day supply of medication, unless the prescription is written for less than 30 days. For a new enrollee in an LTC facility, the temporary supply may be for up to 31 days (unless the prescription is written for less than 31 days) with multiple fills as necessary during the entire length of the 90-day transition period. 8

14 Frequently asked questions It is important that you understand that this is a temporary supply of the drug. Before this supply ends, you should speak to your doctor about prescribing an alternative that is on the formulary or requesting an exception to continue coverage of this drug. Q: What is the Formulary Exception Process? How does it work? A: Asking for coverage of a drug that is not on the Drug List is sometimes called asking for a formulary exception. If a plan agrees to make an exception and cover a drug that is not on the Drug List, you would be required to pay the cost-sharing amount that applies to drugs in Tier 4 Non-Preferred Brand Drugs. Your plan does not cover an exception to the copay or coinsurance amount you are required to pay for the drug Q: What is a Scope of Appointment (SOA) form and why am I being asked to complete the form? A: CMS requires beneficiaries (or their authorized representative) to complete an SOA form prior to any face-to-face meeting that documents the scope of Medicare Advantage and/or Part D products they wish to discuss during the meeting. Agents are required to only discuss the products that have been selected on the SOA form. The SOA form is intended to protect the Medicare beneficiary. Completing this form does not constitute enrollment in the plan. Q: What is a Star Rating? Why is it important? A: A Star Rating is a quality rating assigned by CMS to every Medicare Advantage and/or Part D plan. For plans offering health services, the overall quality score of those services covers 37 different topics in 5 categories. For plans offering prescription drug services, the overall quality score of those services covers 18 different topics in 4 categories. Medicare health and prescription drug plans are given overall and/or summary ratings that combine all categories and measures into a single star rating. The plan s quality or Star rating is determined by measuring the completion rate of routine screenings by persons enrolled in the plan. It also includes the enrollee s satisfaction with the service received from the plan and/or its contracted providers. The star rating along with cost and coverage information is designed to help you compare plans and find a plan that s best for you. Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next. For more information on star ratings and to find out how you can help improve your plan s quality score, you can: Visit Medicare.gov/find-a-plan. Enter the appropriate information for a general or personalized search. Once you see the list of plans, you can view the star ratings by selecting the plan name. Or, you can select up to 3 plans to compare. Call MEDICARE ( ). TTY users should call This information is available for free in other languages. Please call our customer service number at , 8:00 a.m. 9:00 p.m. ET, seven days a week all year long (TTY: ). Esta información está disponible de forma gratuita en otros idiomas. Llame a nuestro Departamento de Servicio al Cliente al Estamos abiertos de 8:00 a.m. a 9:00 p.m., Hora del Este, los siete días de la semana, por todo el año. Usuarios de equipo teleescritor (TTY) deben llamar al Florida Blue is a PPO, RPPO and Rx (PDP) Plan with a Medicare contract. Florida Blue HMO is an HMO Plan with a Medicare contract. Enrollment in Florida Blue or Florida Blue HMO depends on contract renewal. 9

15 2014 Summary of benefits

16 NOTES

17 2014 Summary of benefits BlueMedicare SM Regional PPO A Medicare Advantage Regional PPO Plan State of Florida Y0011_ CMS Accepted

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19 Section 1 - Introduction to Summary of Benefits Thank you for your interest in BlueMedicare Regional PPO. Our plan is offered by BLUE CROSS AND BLUE SHIELD OF FLORIDA, INC. which is also called Florida Blue, a Medicare Advantage Preferred Provider Organization (PPO) that contracts with the Federal government. This Summary of Benefits tells you some features of our plan. It doesn't list every service that we cover or list every limitation or exclusion. To get a complete list of our benefits, please call BlueMedicare Regional PPO and ask for the "Evidence of Coverage." You have choices in your health care As a Medicare beneficiary, you can choose from different Medicare options. One option is the Original (Fee-for-Service) Medicare Plan. Another option is a Medicare health plan, like BlueMedicare Regional PPO. You may have other options too. You make the choice. No matter what you decide, you are still in the Medicare Program. You may be able to join or leave a plan only at certain times. Please call BlueMedicare Regional PPO at the number listed at the end of this introduction or MEDICARE ( ) for more information. TTY/TDD users should call You can call this number 24 hours a day, 7 days a week. How can I compare my options? You can compare BlueMedicare Regional PPO and the Original Medicare Plan using this Summary of Benefits. The charts in this booklet list some important health benefits. For each benefit, you can see what our plan covers and what the Original Medicare Plan covers. Our members receive all of the benefits that the Original Medicare Plan offers. We also offer more benefits, which may change from year to year. Where Is BlueMedicare Regional PPO available? The service area for this plan includes: Florida. You must live in this area to join the plan. Who is eligible to join BlueMedicare Regional PPO? You can join BlueMedicare Regional PPO if you are entitled to Medicare Part A and enrolled in Medicare Part B and live in the service area. However, individuals with End-Stage Renal Disease generally are not eligible to enroll in BlueMedicare Regional PPO unless they are members of our organization and have been since their dialysis began. Can I choose my doctors? BlueMedicare Regional PPO has formed a network of doctors, specialists, and hospitals. You can use any doctor who is part of our network. You may also go to doctors outside of our network. The health providers in our network can change at any time. You can ask for a current provider directory. For an updated list, visit us at Our Member Services number is listed at the end of this introduction. What happens if I go to a doctor who's not in your network? You can go to doctors, specialists, or hospitals in or out of network. You may have to pay more for the services you receive outside the network, and you may have to follow special rules prior to getting services in and/or out of network. For more information, please call the Member Services number at the end of this introduction. Where can I get my prescriptions if I join this plan? BlueMedicare Regional PPO has formed a network of pharmacies. You must use a network pharmacy to receive plan benefits. We may not pay for your prescriptions if you use an out-of-network pharmacy, except in certain cases. The pharmacies in our network can change at any time. You can ask for a pharmacy directory or visit us at Our Member Services number is listed at the end of this introduction. 1

20 What if my doctor prescribes less than a month's supply? In consultation with your doctor or pharmacist, you may receive less than a month's supply of certain drugs. Also, if you live in a long-term care facility, you will receive less than a month's supply of certain brand [and generic] drugs. Dispensing fewer drugs at a time can help reduce cost and waste in the Medicare Part D program, when this is medically appropriate. The amount you pay in these circumstances will depend on whether you are responsible for paying coinsurance (a percentage of the cost of the drug) or a copay (a flat dollar amount for the drug). If you are responsible for coinsurance for the drug, you will continue to pay the applicable percentage of the drug cost. If you are responsible for a copay for the drug, a "daily cost-sharing rate" will be applied. If your doctor decides to continue the drug after a trial period, you should not pay more for a month's supply than you otherwise would have paid. Contact your plan if you have questions about cost-sharing when less than a one-month supply is dispensed. Does my plan cover Medicare Part B or Part D drugs? BlueMedicare Regional PPO does cover both Medicare Part B prescription drugs and Medicare Part D prescription drugs. What is a prescription drug formulary? BlueMedicare Regional PPO uses a formulary. A formulary is a list of drugs covered by your plan to meet patient needs. We may periodically add, remove, or make changes to coverage limitations on certain drugs or change how much you pay for a drug. If we make any formulary change that limits our members' ability to fill their prescriptions, we will notify the affected members before the change is made. We will send a formulary to you and you can see our complete formulary on our Web site at If you are currently taking a drug that is not on our formulary or subject to additional requirements or limits, you may be able to get a temporary supply of the drug. You can contact us to request an exception or switch to an alternative drug listed on our formulary with your physician's help. Call us to see if you can get a temporary supply of the drug or for more details about our drug transition policy. How can I get extra help with my Prescription Drug Plan costs or get extra help with other Medicare costs? You may be able to get extra help to pay for your prescription drug premiums and costs as well as get help with other Medicare costs. To see if you qualify for getting extra help, call: * MEDICARE ( ). TTY/TDD users should call , 24 hours a day/7 days a week; and see 'Programs for People with Limited Income and Resources' in the publication Medicare & You. * The Social Security Administration at between 7 a.m. and 7 p.m., Monday through Friday. TTY/TDD users should call ; or * Your State Medicaid Office. What are my protections in this plan? All Medicare Advantage Plans agree to stay in the program for a full calendar year at a time. Plan benefits and cost-sharing may change from calendar year to calendar year. Each year, plans can decide whether to continue to participate with Medicare Advantage. A plan may continue in their entire service area (geographic area where the plan accepts members) or choose to continue only in certain areas. Also, Medicare may decide to end a contract with a plan. Even if your Medicare Advantage Plan leaves the program, you will not lose Medicare coverage. If a plan decides not to continue for an additional calendar year, it must send you a letter at least 90 days before your coverage will end. The letter will explain your options for Medicare coverage in your area. As a member of BlueMedicare Regional PPO, you have the right to request an organization determination, which includes the right to file an 2

21 appeal if we deny coverage for an item or service, and the right to file a grievance. You have the right to request an organization determination if you want us to provide or pay for an item or service that you believe should be covered. If we deny coverage for your requested item or service, you have the right to appeal and ask us to review our decision. You may ask us for an expedited (fast) coverage determination or appeal if you believe that waiting for a decision could seriously put your life or health at risk, or affect your ability to regain maximum function. If your doctor makes or supports the expedited request, we must expedite our decision. Finally, you have the right to file a grievance with us if you have any type of problem with us or one of our network providers that does not involve coverage for an item or service. If your problem involves quality of care, you also have the right to file a grievance with the Quality Improvement Organization (QIO) for your state. Please refer to the Evidence of Coverage (EOC) for the QIO contact information. As a member of BlueMedicare Regional PPO, you have the right to request a coverage determination, which includes the right to request an exception, the right to file an appeal if we deny coverage for a prescription drug, and the right to file a grievance. You have the right to request a coverage determination if you want us to cover a Part D drug that you believe should be covered. An exception is a type of coverage determination. You may ask us for an exception if you believe you need a drug that is not on our list of covered drugs or believe you should get a non-preferred drug at a lower out-of-pocket cost. You can also ask for an exception to cost utilization rules, such as a limit on the quantity of a drug. If you think you need an exception, you should contact us before you try to fill your prescription at a pharmacy. Your doctor must provide a statement to support your exception request. If we deny coverage for your prescription drug(s), you have the right to appeal and ask us to review our decision. Finally, you have the right to file a grievance if you have any type of problem with us or one of our network pharmacies that does not involve coverage for a prescription drug. If your problem involves quality of care, you also have the right to file a grievance with the Quality Improvement Organization (QIO) for your state. Please refer to the Evidence of Coverage (EOC) for the QIO contact information. What is a Medication Therapy Management (MTM) Program? A Medication Therapy Management (MTM) Program is a free service we offer. You may be invited to participate in a program designed for your specific health and pharmacy needs. You may decide not to participate but it is recommended that you take full advantage of this covered service if you are selected. Contact BlueMedicare Regional PPO for more details. What types of drugs may be covered under Medicare Part B? Some outpatient prescription drugs may be covered under Medicare Part B. These may include, but are not limited to, the following types of drugs. Contact BlueMedicare Regional PPO for more details. Some Antigens: If they are prepared by a doctor and administered by a properly instructed person (who could be the patient) under doctor supervision. Osteoporosis Drugs: Injectable osteoporosis drugs for some women. Erythropoietin: By injection if you have end-stage renal disease (permanent kidney failure requiring either dialysis or transplantation) and need this drug to treat anemia. Hemophilia Clotting Factors: Self-administered clotting factors if you have hemophilia. Injectable Drugs: Most injectable drugs administered incident to a physician's service. 3

22 Immunosuppressive Drugs: Immunosuppressive drug therapy for transplant patients if the transplant took place in a Medicare-certified facility and was paid for by Medicare or by a private insurance company that was the primary payer for Medicare Part A coverage. Some Oral Cancer Drugs: If the same drug is available in injectable form. Oral Anti-Nausea Drugs: If you are part of an anti-cancer chemotherapeutic regimen. Inhalation and Infusion Drugs administered through Durable Medical Equipment. Where can I find information on Plan Ratings? The Medicare program rates how well plans perform in different categories (for example, detecting and preventing illness, ratings from patients and customer service). If you have access to the web, you may use the web tools on and select "Health and Drug Plans" then "Compare Drug and Health Plans" to compare the plan ratings for Medicare plans in your area. You can also call us directly to obtain a copy of the plan ratings for this plan. Our Member Services number is listed below. 4

23 Please call Florida Blue for more information about BlueMedicare Regional PPO. Visit us at or, call us: Current Members Toll Free TTY/TDD Member Services Department is open from 8:00 a.m. - 9:00 p.m. ET, seven days a week, all year long. Prospective Members Toll Free TTY/TDD Hours for October 1 - February 14: Sunday, Monday, Tuesday, Wednesday, Thursday, Friday, Saturday, 8:00 a.m. - 9:00 p.m. ET Hours for February 15 - September 30: Monday, Tuesday, Wednesday, Thursday, Friday, 8:00 a.m. - 9:00 p.m. ET For more information about Medicare, please call Medicare at MEDICARE ( ). TTY users should call You can call 24 hours a day, 7 days a week. Or, visit on the web. This document may be available in other formats such as Braille, large print or other alternate formats. This document may be available in a non-english language. For additional information, call Member Services at the phone number listed above. Este documento puede estar disponible en otros formatos como Braille, letra grande o en otros formatos alternativos. Este documento puede estar disponible en un idioma que no sea inglés. Para información adicional, llame a Atención al Cliente al teléfono que aparece arriba. 5

24 Section 2 - Summary of Benefits If you have any questions about this plan s benefits or costs, please contact Florida Blue for details. Benefit IMPORTANT INFORMATION Original Medicare BlueMedicare Regional PPO 1 Premium and Other Important Information In 2013 the monthly Part B Premium was $ and may change for 2014 and the annual Part B deductible amount was $147 and may change for If a doctor or supplier does not accept assignment, their costs are often higher, which means you pay more. General $0 monthly plan premium in addition to your monthly Medicare Part B premium. Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However, some people will pay higher Part B and Part D premiums because of their yearly income (over $85,000 for singles, $170,000 for married couples). For more information about Part B and Part D premiums based on income, call Medicare at MEDICARE ( ). TTY users should call You may also call Social Security at TTY users should call Most people will pay the standard monthly Part B premium. However, some people will pay a higher premium because of their yearly income (over $85,000 for singles, $170,000 for married couples). For more information about Part B premiums based on income, call Medicare at MEDICARE ( ). TTY users should call Some physicians, providers and You may also call Social Security at suppliers that are out of a plan's TTY users should call network (i.e., out-of-network) accept "assignment" from Medicare and will only charge up to a Medicare-approved amount. If you choose to see an out-of-network physician who does NOT accept Medicare "assignment," your coinsurance can be based on the Medicare-approved amount plus an additional amount up to a higher Medicare "limiting charge." If you are a member of a plan that charges a copay for out-of-network physician services, the higher Medicare "limiting charge" does not apply. See the publications Medicare & You or Your Medicare Benefits available on for a full listing of benefits under Original Medicare, as well as for explanations of the rules related to "assignment" and "limiting charges" that apply by benefit type. 6

25 Benefit 1 Premium and Other Important Information Original Medicare BlueMedicare Regional PPO To find out if physicians and DME suppliers accept assignment or participate in Medicare, visit or You can also call MEDICARE, or ask your physician, provider, or supplier if they accept assignment. In-Network $6,700 out-of-pocket limit for Medicare-covered services. Out-of-Network $950 annual deductible. Contact the plan for services that apply $10,000 out-of-pocket limit for Medicare-covered services. In and Out-of-Network $10,000 out-of-pocket limit for Medicare-covered services. See Page 27 for additional information about Premium and Other Important Information. 2 Doctor and Hospital Choice (For more information, see Emergency Care - #15 and Urgently Needed Care - #16.) You may go to any doctor, specialist or hospital that accepts Medicare. In-Network No referral required for network doctors, specialists, and hospitals. In and Out-of-Network You can go to doctors, specialists, and hospitals in or out of the network. It will cost more to get out of network benefits. Out of Service Area Plan covers you when you travel in the U.S. or its territories. See Page 27 for additional information about Doctor and Hospital Choice. 7

26 Benefit Inpatient Care 3 Inpatient Hospital Care (includes Substance Abuse and Rehabilitation Services) Original Medicare In 2013 the amounts for each benefit period were: Days 1-60: $1,184 deductible Days 61-90: $296 per day Days : $592 per lifetime reserve day These amounts may change for Call MEDICARE ( ) for information about lifetime reserve days. Lifetime reserve days can only be used once. A "benefit period" starts the day you go into a hospital or skilled nursing facility. It ends when you go for 60 days in a row without hospital or skilled nursing care. If you go into the hospital after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods you can have. BlueMedicare Regional PPO In-Network No limit to the number of days covered by the plan each hospital stay. For Medicare-covered hospital stays: Days 1-5: $295 copay per day Days 6-90: $0 copay per day $0 copay for additional non-medicare-covered hospital days Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital. Out-of-Network For Medicare-covered hospital stays: Days 1-27: $495 copay per day Days 28-90: $0 copay per day See Page 27 for more additional information about Inpatient Hospital Care. 4 Inpatient Mental Health Care In 2013 the amounts for each benefit period were: Days 1-60: $1,184 deductible Days 61-90: $296 per day Days : $592 per lifetime reserve day These amounts may change for You get up to 190 days of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital. In-Network You get up to 190 days of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital. For Medicare-covered hospital stays: Days 1-5: $295 copay per day Days 6-90: $0 copay per day Plan covers 60 lifetime reserve days. $0 copay per lifetime reserve day. 8

27 Benefit 4 Inpatient Mental Health Care Original Medicare BlueMedicare Regional PPO Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital. Out-of-Network For Medicare-covered hospital stays: Days 1-27: $495 copay per day Days 28-90: $0 copay per day See Page 27 for additional information about Inpatient Mental Health Care. 5 Skilled Nursing Facility (SNF) (in a Medicare-certified skilled nursing facility) In 2013 the amounts for each benefit period after at least a 3-day Medicare-covered hospital stay were: Days 1-20: $0 per day Days : $148 per day These amounts may change for General Authorization rules may apply. In-Network Plan covers up to 100 days each benefit period No prior hospital stay is required. 100 days for each benefit period. For Medicare-covered SNF stays: A "benefit period" starts the day you go into a hospital or SNF. It ends when you go for 60 days in a row without hospital or skilled nursing care. If you go into the hospital after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods you can have. Days 1-20: $25 copay per day Days : $150 copay per day Out-of-Network For each Medicare-covered SNF stay: Days 1-58: $250 copay per SNF day Days : $0 copay per SNF day See Page 27 for additional information about Skilled Nursing Facitlity (SNF). 9

28 Benefit 6 Home Health Care (includes medically necessary intermittent skilled nursing care, home health aide services, and rehabilitation services, etc.) $0 copay. Original Medicare BlueMedicare Regional PPO In-Network $0 copay for Medicare-covered home health visits Out-of-Network 50% of the cost for Medicare-covered home health visits 7 Hospice OUTPATIENT CARE 8 Doctor Office Visits You pay part of the cost for outpatient drugs and inpatient respite care. You must get care from a Medicare-certified hospice. 20% coinsurance General You must get care from a Medicare-certified hospice. You must consult with your plan before you select hospice. In-Network $15 copay for each Medicare-covered primary care doctor visit. $50 copay for each Medicare-covered specialist visit. Out-of-Network 50% of the cost for each Medicare-covered primary care doctor visit 50% of the cost for each Medicare-covered specialist visit See Page 27 for additional information about Doctor Office Visits. 9 Chiropractic Services Supplemental routine care not covered 20% coinsurance for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part). General Authorization rules may apply. In-Network $15 to $20 copay for each Medicare-covered chiropractic visit Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a 10

29 Benefit 9 Chiropractic Services Original Medicare BlueMedicare Regional PPO displacement or misalignment of a joint or body part). Out-of-Network 50% of the cost for Medicare-covered chiropractic visits. See Page 28 for additional information about Chiropractic Services. 10 Podiatry Services Supplemental routine care not covered. 20% coinsurance for medically necessary foot care, including care for medical conditions affecting the lower limbs. In-Network $50 copay for each Medicare-covered podiatry visit Medicare-covered podiatry visits are for medically necessary foot care. Out-of-Network 50% of the cost for Medicare-covered podiatry visits 11 Outpatient Mental Health Care 20% coinsurance for most outpatient mental health services Specified copayment for outpatient partial hospitalization program services furnished by a hospital or community mental health center (CMHC). Copay cannot exceed the Part A inpatient hospital deductible. "Partial hospitalization program" is a structured program of active outpatient psychiatric treatment that is more intense than the care received in your doctor's or therapist's office and is an alternative to inpatient hospitalization. In-Network $40 copay for each Medicare-covered individual therapy visit $40 copay for each Medicare-covered group therapy visit $40 copay for each Medicare-covered individual therapy visit with a psychiatrist $40 copay for each Medicare-covered group therapy visit with a psychiatrist $40 copay for Medicare-covered partial hospitalization program services Out-of-Network $40 copay for Medicare-covered Mental Health visits with a psychiatrist $40 copay for Medicare-covered Mental Health visits $40 copay for Medicare-covered partial hospitalization program services 11

30 Benefit 12 Outpatient Substance Abuse Care 20% coinsurance Original Medicare BlueMedicare Regional PPO In-Network $40 copay for Medicare-covered individual substance abuse outpatient treatment visits $40 copay for Medicare-covered group substance abuse outpatient treatment visits Out-of-Network $40 coinsurance for Medicare-covered substance abuse outpatient treatment visits 13 Outpatient Services 20% coinsurance for the doctor's services Specified copayment for outpatient hospital facility services. Copay cannot exceed the Part A inpatient hospital deductible. 20% coinsurance for ambulatory surgical center facility services In-Network 30% of the cost for each Medicare-covered ambulatory surgical center visit $30 to $100 copay [or 20% to 30% of the cost] for each Medicare-covered outpatient hospital facility visit Out-of-Network 50% of the cost for Medicare-covered outpatient hospital facility visits 50% of the cost for Medicare-covered ambulatory surgical center visits See Page 28 for additional information about Outpatient Services. 14 Ambulance Services (medically necessary ambulance services) 20% coinsurance In-Network $250 copay for Medicare-covered ambulance benefits. Out-of-Network $250 copay for Medicare-covered ambulance benefits. 12

31 Benefit 15 Emergency Care (You may go to any emergency room if you reasonably believe you need emergency care.) Original Medicare 20% coinsurance for the doctor's services Specified copayment for outpatient hospital facility emergency services. Emergency services copay cannot exceed Part A inpatient hospital deductible for each service provided by the hospital. You don't have to pay the emergency room copay if you are admitted to the hospital as an inpatient for the same condition within 3 days of the emergency room visit. Not covered outside the U.S. except under limited circumstances. BlueMedicare Regional PPO General $65 copay for Medicare-covered emergency room visits Worldwide coverage. If you are immediately admitted to the hospital, you pay $0 for the emergency room visit. See Page 28 for additional information about Emergency Care. 16 Urgently Needed Care (This is NOT emergency care, and in most cases, is out of the service area.) 20% coinsurance, or a set copay If you are admitted to the hospital within 3 days for the same condition, you pay $0 for the urgently-needed-care visit. NOT covered outside the U.S. except under limited circumstances. General $10 to $65 copay for Medicare-covered urgently-needed-care visits See Page 28 for additional information about Urgently Needed Care. 17 Outpatient Rehabilitation Services (Occupational Therapy, Physical Therapy, Speech and Language Therapy) 20% coinsurance Medically necessary physical therapy, occupational therapy, and speech and language pathology services are covered. General Authorization rules may apply. Medically necessary physical therapy, occupational therapy, and speech and language pathology services are covered. In-Network $50 copay for Medicare-covered Occupational Therapy visits $50 copay for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits 13

32 Benefit Original Medicare BlueMedicare Regional PPO Out-of-Network 50% of the cost for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits 50% of the cost for Medicare-covered Occupational Therapy visits. Outpatient Medical Services and Supplies 18 Durable Medical Equipment (includes wheelchairs, oxygen, etc.) 20% coinsurance In-Network 0% to 20% of the cost for Medicare-covered durable medical equipment Out-of-Network 50% of the cost for Medicare-covered durable medical equipment See Page 28 for additional information about Durable Medical Equipment. 19 Prosthetic Devices (includes braces, artificial limbs and eyes, etc.) 20% coinsurance 20% coinsurance for Medicare-covered medical supplies related to prosthetics, splints, and other devices. In-Network $0 copay for Medicare-covered: prosthetic devices medical supplies related to prosthetics, splints, and other devices Out-of-Network 50% of the cost for Medicare-covered prosthetic devices. 20 Diabetes Programs and Supplies 20% coinsurance for diabetes self-management training 20% coinsurance for diabetes supplies 20% coinsurance for diabetic therapeutic shoes or inserts In-Network $0 copay for Medicare-covered Diabetes self-management training $0 copay for Medicare-covered: Diabetes monitoring supplies Therapeutic shoes or inserts Out-of-Network 50% of the cost for Medicare-covered Diabetes self-management training 14

33 Benefit 20 Diabetes Programs and Supplies Original Medicare BlueMedicare Regional PPO 50% of the cost for Medicare-covered Diabetes monitoring supplies 50% of the cost for Medicare-covered Therapeutic shoes or inserts 21 Diagnostic Tests, X-Rays, Lab Services, and Radiology Services 20% coinsurance for diagnostic tests and x-rays $0 copay for Medicare-covered lab services Lab Services: Medicare covers medically necessary diagnostic lab services that are ordered by your treating doctor when they are provided by a Clinical Laboratory Improvement Amendments (CLIA) certified laboratory that participates in Medicare. Diagnostic lab services are done to help your doctor diagnose or rule out a suspected illness or condition. Medicare does not cover most supplemental routine screening tests, like checking your cholesterol. General Authorization rules may apply. In-Network $0 copay for Medicare-covered lab services $0 to $50 copay for Medicare-covered diagnostic procedures and tests $15 to $50 copay [or 30% of the cost] for Medicare-covered X-rays $50 copay [or 30% of the cost] for Medicare-covered diagnostic radiology services (not including X-rays) $50 copay [or 20% of the cost] for Medicare-covered therapeutic radiology services If the doctor provides you services in addition to Outpatient Diagnostic Procedures, Tests and Lab Services, separate cost sharing of $15 to $50 may apply Out-of-Network 50% of the cost for Medicare-covered therapeutic radiology services 50% of the cost for Medicare-covered outpatient X-rays 50% of the cost for Medicare-covered diagnostic radiology services 50% of the cost for Medicare-covered diagnostic procedures and tests 50% of the cost for Medicare-covered lab services 15

34 Benefit Original Medicare BlueMedicare Regional PPO See Page 28 for additional information about Diagnostic Tests, X-Rays, Lab Services, and Radiology Services. 22 Cardiac and Pulmonary Rehabilitation Services PREVENTIVE SERVICES 23 Preventive Services 20% coinsurance for Cardiac Rehabilitation services 20% coinsurance for Pulmonary Rehabilitation services 20% coinsurance for Intensive Cardiac Rehabilitation services No coinsurance, copayment or deductible for the following: Abdominal Aortic Aneurysm Screening Bone Mass Measurement. Covered once every 24 months (more often if medically necessary) if you meet certain medical conditions. Cardiovascular Screening Cervical and Vaginal Cancer Screening. Covered once every 2 years. Covered once a year for women with Medicare at high risk. Colorectal Cancer Screening Diabetes Screening Influenza Vaccine In-Network $50 to $100 copay for Medicare-covered Cardiac Rehabilitation Services $50 to $100 copay for Medicare-covered Intensive Cardiac Rehabilitation Services $50 to $100 copay for Medicare-covered Pulmonary Rehabilitation Services Out-of-Network 50% of the cost for Medicare-covered Cardiac Rehabilitation Services 50% of the cost for Medicare-covered Intensive Cardiac Rehabilitation Services 50% of the cost for Medicare-covered Pulmonary Rehabilitation Services General $0 copay for all preventive services covered under Original Medicare at zero cost sharing. Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare. Out-of-Network 50% of the cost for Medicare-covered preventive services 16

35 Benefit 23 Preventive Services Original Medicare Hepatitis B Vaccine for people with Medicare who are at risk HIV Screening. $0 copay for the HIV screening, but you generally pay 20% of the Medicare-approved amount for the doctor's visit. HIV screening is covered for people with Medicare who are pregnant and people at increased risk for the infection, including anyone who asks for the test. Medicare covers this test once every 12 months or up to three times during a pregnancy. Breast Cancer Screening (Mammogram). Medicare covers screening mammograms once every 12 months for all women with Medicare age 40 and older. Medicare covers one baseline mammogram for women between ages Medical Nutrition Therapy Services Nutrition therapy is for people who have diabetes or kidney disease (but aren't on dialysis or haven't had a kidney transplant) when referred by a doctor. These services can be given by a registered dietitian and may include a nutritional assessment and counseling to help you manage your diabetes or kidney disease Personalized Prevention Plan Services (Annual Wellness Visits) Pneumococcal Vaccine. You may only need the Pneumonia vaccine once in your lifetime. Call your doctor for more information. Prostate Cancer Screening Prostate Specific Antigen (PSA) test only. Covered once a year for all men with Medicare over age 50. BlueMedicare Regional PPO 17

36 Benefit 23 Preventive Services Original Medicare Smoking and Tobacco Use Cessation (counseling to stop smoking and tobacco use). Covered if ordered by your doctor. Includes two counseling attempts within a 12-month period. Each counseling attempt includes up to four face-to-face visits. Screening and behavioral counseling interventions in primary care to reduce alcohol misuse Screening for depression in adults Screening for sexually transmitted infections (STI) and high-intensity behavioral counseling to prevent STIs Intensive behavioral counseling for Cardiovascular Disease (bi-annual) Intensive behavioral therapy for obesity Welcome to Medicare Preventive Visits (initial preventive physical exam) When you join Medicare Part B, then you are eligible as follows. During the first 12 months of your new Part B coverage, you can get either a Welcome to Medicare Preventive Visits or an Annual Wellness Visit. After your first 12 months, you can get one Annual Wellness Visit every 12 months. BlueMedicare Regional PPO 24 Kidney Disease and Conditions 20% coinsurance for renal dialysis 20% coinsurance for kidney disease education services In-Network 20% of the cost for Medicare-covered renal dialysis $0 copay for Medicare-covered kidney disease education services 18

37 Benefit 24 Kidney Disease and Conditions PRESCRIPTION DRUG BENEFITS Original Medicare BlueMedicare Regional PPO Out-of-Network 50% of the cost for Medicare-covered kidney disease education services 20% to 50% of the cost for Medicare-covered renal dialysis 25 Outpatient Prescription Drugs Most drugs are not covered under Original Medicare. You can add prescription drug coverage to Original Medicare by joining a Medicare Prescription Drug Plan, or you can get all your Medicare coverage, including prescription drug coverage, by joining a Medicare Advantage Plan or a Medicare Cost Plan that offers prescription drug coverage. Drugs Covered Under Medicare Part B General 20% of the cost for Medicare Part B chemotherapy drugs and other Part B drugs. 50% of the cost for Medicare Part B drugs out-of-network. See Page 29 for additional information about Outpatient Prescription Drugs. Drugs Covered Under Medicare Part D General This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at on the web. Different out-of-pocket costs may apply for people who have limited incomes, live in long-term care facilities, or have access to Indian/Tribal/Urban (Indian Health Service) providers. The plan offers national in-network prescription coverage (i.e., this would include 50 states and the District of Columbia). This means that you will pay the same cost-sharing amount for your prescription drugs if you get them at an in-network pharmacy outside of the 19

38 Benefit 25 Outpatient Prescription Drugs Original Medicare BlueMedicare Regional PPO plan's service area (for instance when you travel). Total yearly drug costs are the total drug costs paid by both you and a Part D plan. The plan may require you to first try one drug to treat your condition before it will cover another drug for that condition. Some drugs have quantity limits. Your provider must get prior authorization from BlueMedicare Regional PPO for certain drugs. You must go to certain pharmacies for a very limited number of drugs, due to special handling, provider coordination, or patient education requirements that cannot be met by most pharmacies in your network. These drugs are listed on the plan's website, formulary, printed materials, as well as on the Medicare Prescription Drug Plan Finder on Medicare.gov. If the actual cost of a drug is less than the normal cost-sharing amount for that drug, you will pay the actual cost, not the higher cost-sharing amount. If you request a formulary exception for a drug and BlueMedicare Regional PPO approves the exception, you will pay Tier 4: Non-Preferred Brand cost sharing for that drug. In-Network $30 annual deductible. Initial Coverage After you pay your yearly deductible, you pay the following until total yearly drug costs reach $2,850: 20

39 Benefit 25 Outpatient Prescription Drugs Original Medicare BlueMedicare Regional PPO Retail Pharmacy Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed. You can get drugs the following way(s): Tier 1: Preferred Generic $10 copay for a one-month (31-day) supply of drugs in this tier $30 copay for a three-month (90-day) supply of drugs in this tier Tier 2: Non-Preferred Generic $33 copay for a one-month (31-day) supply of drugs in this tier $99 copay for a three-month (90-day) supply of drugs in this tier Tier 3: Preferred Brand $45 copay for a one-month (31-day) supply of drugs in this tier $135 copay for a three-month (90-day) supply of drugs in this tier Tier 4: Non-Preferred Brand $95 copay for a one-month (31-day) supply of drugs in this tier $285 copay for a three-month (90-day) supply of drugs in this tier Tier 5: Specialty Tier 25% coinsurance for a one-month (31-day) supply of drugs in this tier 25% coinsurance for a three-month (90-day) supply of drugs in this tier Long-Term Care Pharmacy Long-term care pharmacies must dispense brand name drugs in amounts less than a 14 days supply at a time. They may also dispense less than a month's supply of generic drugs at a time. Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed. You can get drugs the following way(s): 21

40 Benefit 25 Outpatient Prescription Drugs Original Medicare BlueMedicare Regional PPO Tier 1: Preferred Generic $10 copay for a one-month (31-day) supply of drugs in this tier Tier 2: Non-Preferred Generic $33 copay for a one-month (31-day) supply of drugs in this tier Tier 3: Preferred Brand $45 copay for a one-month (31-day) supply of drugs in this tier Tier 4: Non-Preferred Brand $95 copay for a one-month (31-day) supply of drugs in this tier Tier 5: Specialty Tier 25% coinsurance for a one-month (31-day) supply of drugs in this tier Mail Order Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed. You can get drugs the following way(s): Tier 1: Preferred Generic $10 copay for a one-month (31-day) supply of drugs in this tier $30 copay for a three-month (90-day) supply of drugs in this tier Tier 2: Non-Preferred Generic $33 copay for a one-month (31-day) supply of drugs in this tier $99 copay for a three-month (90-day) supply of drugs in this tier Tier 3: Preferred Brand $45 copay for a one-month (31-day) supply of drugs in this tier $135 copay for a three-month (90-day) supply of drugs in this tier Tier 4: Non-Preferred Brand $95 copay for a one-month (31-day) supply of drugs in this tier $285 copay for a three-month (90-day) supply of drugs in this tier 22

41 Benefit 25 Outpatient Prescription Drugs Original Medicare BlueMedicare Regional PPO Tier 5: Specialty Tier 25% coinsurance for a one-month (31-day) supply of drugs in this tier 25% coinsurance for a three-month (90-day) supply of drugs in this tier Coverage Gap After your total yearly drug costs reach $2,850, you receive limited coverage by the plan on certain drugs. You will also receive a discount on brand name drugs and generally pay no more than 47.5% for the plan's costs for brand drugs and 72% of the plan's costs for generic drugs until your yearly out-of-pocket drug costs reach $4,550. Catastrophic Coverage After your yearly out-of-pocket drug costs reach $4,550, you pay the greater of: 5% coinsurance, or $2.55 copay for generic (including brand drugs treated as generic) and a $6.35 copay for all other drugs. Out-of-Network Plan drugs may be covered in special circumstances, for instance, illness while traveling outside of the plan's service area where there is no network pharmacy. You may have to pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy. In addition, you will likely have to pay the pharmacy's full charge for the drug and submit documentation to receive reimbursement from BlueMedicare Regional PPO. You can get out-of-network drugs the following way: 23

42 Benefit 25 Outpatient Prescription Drugs Original Medicare BlueMedicare Regional PPO Out-of-Network Initial Coverage After you pay your yearly deductible, you will be reimbursed up to the plan's cost of the drug minus the following for drugs purchased out-of-network until your total yearly drug costs reach $2,850: Tier 1: Preferred Generic $10 copay for a one-month (31-day) supply of drugs in this tier Tier 2: Non-Preferred Generic $33 copay for a one-month (31-day) supply of drugs in this tier Tier 3: Preferred Brand $45 copay for a one-month (31-day) supply of drugs in this tier Tier 4: Non-Preferred Brand $95 copay for a one-month (31-day) supply of drugs in this tier Tier 5: Specialty Tier 25% coinsurance for a one-month (31-day) supply of drugs in this tier Out-of-Network Coverage Gap You will be reimbursed up to 28% of the plan allowable cost for generic drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4,550. Please note that the plan allowable cost may be less than the out-of-network pharmacy price paid for your drug(s). You will be reimbursed up to 52.5% of the plan allowable cost for brand name drugs purchased out-of-network until your total yearly out-of-pocket drug costs reach $4,550. Please note that the plan allowable cost may be less than the out-of-network pharmacy price paid for your drug(s). 24

43 Benefit 25 Outpatient Prescription Drugs Original Medicare BlueMedicare Regional PPO Out-of-Network Catastrophic Coverage After your yearly out-of-pocket drug costs reach $4,550, you will be reimbursed for drugs purchased out-of-network up to the plan's cost of the drug minus your cost share, which is the greater of: 5% coinsurance, or $2.55 copay for generic (including brand drugs treated as generic) and a $6.35 copay for all other drugs. Outpatient Medical Services and Supplies 26 Dental Services Preventive dental services (such as cleaning) not covered. In-Network In general, preventive dental benefits (such as cleaning) not covered. $50 copay for Medicare-covered dental benefits Out-of-Network 50% of the cost for Medicare-covered comprehensive dental benefits 27 Hearing Services Supplemental routine hearing exams and hearing aids not covered. 20% coinsurance for diagnostic hearing exams. In-Network In general, supplemental routine hearing exams and hearing aids not covered. $50 copay for Medicare-covered diagnostic hearing exams Out-of-Network 50% of the cost for Medicare-covered diagnostic hearing exams. 28 Vision Services 20% coinsurance for diagnosis and treatment of diseases and conditions of the eye, including an annual glaucoma screening for people at risk In-Network This plan offers only Medicare-covered eye care and eyewear $0 to $50 copay for Medicare-covered exams to diagnose and treat diseases 25

44 Benefit 28 Vision Services Original Medicare Supplemental routine eye exams and eyeglasses (lenses and frames) not covered. Medicare pays for one pair of eyeglasses or contact lenses after cataract surgery. BlueMedicare Regional PPO and conditions of the eye, including an annual glaucoma screening for people at risk $0 copay for one pair of Medicare-covered eyeglasses (lenses and frames) or contact lenses after cataract surgery. Out-of-Network 50% of the cost for Medicare-covered eye exams 50% of the cost for Medicare-covered eyewear See Page 29 for additional information about Vision Services 29 Wellness/Education and Other Supplemental Benefits & Services 30 Over-the-Counter Items Not covered. Not covered. In-Network This plan does not cover supplemental education/wellness programs. General The plan does not cover Over-the-Counter items. 31 Transportation (Routine) Not covered. In-Network This plan does not cover supplemental routine transportation. 32 Acupuncture and Other Alternative Therapies Not covered. In-Network This plan does not cover Acupuncture and other alternative therapies. 26

45 SECTION 3 - ADDITIONAL BENEFIT INFORMATION #1 - Premium and Other Important Information: Maximum out-of-pocket limit. While most expenses apply to the maximum[s], the following do not: Your monthly plan premium Outpatient Part D prescription drugs Dental services not covered by Medicare (refer to #26) Hearing services not covered by Medicare (refer to #27) Vision services not covered by Medicare (refer to #28) All In-Network services are excluded from the Annual Deductible (refer to #1) #2 - Doctor and Hospital Choice: The U.S. Visitor/Travel Program The Visitor/Travel Program will include Blue Medicare Advantage PPO network coverage of all Part A, Part B, and Supplemental benefits offered by your plan outside your service area in 33 states and 1 territory: Alabama, Arkansas, California, Colorado, Connecticut, Georgia, Hawaii, Idaho, Indiana, Kentucky, Maine, Massachusetts, Michigan, Missouri, Montana, North Carolina, Nevada, New Hampshire, New Jersey, New Mexico, New York, Ohio, Oklahoma, Oregon, Pennsylvania, Puerto Rico, South Carolina, Tennessee, Texas, Utah, Virginia, Washington, Wisconsin, and West Virginia. For some of the states listed, MA PPO networks are only available in portions of the state. Under Medicare Advantage rules, if you are absent from the service area for more than six (6) months, you must be disenrolled. However, in areas where we offer the Visitor/Travel Program you may remain in the plan while out of our service area for 12 months. Enrollment materials will identify the states in which the Visitor/Travel Program is available. In addition, you may: 1. Call our Member Services phone line during regular business hours, 2. Call Blue to find a Blue Medicare Advantage PPO provider,or 3. Visit the Doctor & Hospital Finder at to find a Blue Medicare Advantage PPO provider. If you see Medicare Advantage PPO providers in any geographic area where the Visitor/Travel Program is offered, you will pay the same cost sharing level (in-network cost sharing) you would pay if you received covered benefits from in-network providers in your service area. #3 - Inpatient Hospital Care: Notification is required for all inpatient admissions to acute care hospitals. Benefit periods do not apply to Inpatient Hospital Care. You pay the amounts shown in Section 2 each time you're admitted to a hospital, no matter how many days have passed since your last admission. If you are transferred to another Inpatient Facility for example, to a long-term acute care center from an inpatient acute hospital the day range will begin at one. #4 - Inpatient Mental Health Care: Notification is required for all inpatient admissions to psychiatric and substance abuse facilities. Benefit periods do not apply to Inpatient Mental Health Care. You pay the amounts shown in Section 2 each time you're admitted to a hospital, no matter how many days have passed since your last admission. If you are transferred to another Inpatient Facility for example, to a long-term acute care center from an inpatient acute hospital the day range will begin at one. #5 - Skilled Nursing Facility (SNF): Notification is required for all inpatient admissions to Skilled Nursing Facilities. #8 - Doctor Office Visits: Other Healthcare Professional Services: 27

46 Copay for Medicare-covered benefits: $0 copay for e-medicine visits. e-medicine is a secure, web-based communication tool that links patients with their providers that have enrolled in the program. Members can schedule appointments, request Rx refills or referrals, request normal lab results and even receive online, non-urgent care through use of the confidential webvisit. #9 - Chiropractic Services: Prior authorization will be required for certain therapy services. Please call Member Services for additional information. $15 copay at your primary care doctor's office $20 copay at your specialist's office #13 - Outpatient Services: Copay and coinsurance for Medicare-covered outpatient hospital benefits: $40 copay for lab services $30 copay for physical, speech and occupational therapy $100 copay for Cardiac and Pulmonary Rehabilitation 20% coinsurance for dialysis 20% coinsurance for radiation therapy 30% coinsurance for all other services #15 - Emergency Care: Before leaving the United States, you are encouraged to call Florida Blue to understand what emergency benefits are covered outside of the US. Members should call the BlueCard Worldwide Service Center at BLUE (follow the prompts for international provider), or collect at so Florida Blue can assist in arranging a billing agreement with the foreign provider. When leaving the United States we will cover all of the same emergency benefits that you would receive in the United States. Members may be required to pay 100% of charges at the time services are rendered when received outside the United States and its territories. Claims can then be submitted for reimbursement consideration. #16 - Urgently Needed Care Copay for Medicare-covered benefits: $10 copay at Convenient Care Centers. Convenient care Centers are walk-in healthcare clinics that specialize in the treatment of common illnesses and provide basic health screening services. $65 copay at an Urgent Care Center. #18 - Durable Medical Equipment (DME): 20% coinsurance for motorized wheelchairs and scooters 0% coinsurance for all other durable medical equipment #21 - Diagnostic Tests, X-Rays, Lab Services and Radiology Services: Prior authorization will be required for certain radiology procedures/services. Please call Member Services for additional information. Copay for Medicare-covered benefits: $0 copay for allergy testing, cardiovascular and EKG screenings For lab services, you pay: $15 copay at your primary care doctor's office $50 copay at a specialist's office For diagnostic procedures and tests, you pay: $15 copay at your primary care doctor's office $50 copay at a specialist's office $50 copay at an Independent Diagnostic Testing Facility 30% coinsurance at a hospital facility as an outpatient For X-rays and diagnostic radiology services, you pay: $15 copay at your primary care doctor's office $50 copay at a specialist's office $50 copay at an Independent Diagnostic Testing Facility 28

47 30% coinsurance at a hospital facility as an outpatient For advanced imaging (MRI, MRA, PET, Nuclear Medicine or CT Scan) services, you pay: $50 copay at a specialist's office 30% coinsurance at an Independent Diagnostic Testing Facility (IDTF) 30% coinsurance at a hospital facility as an outpatient For therapeutic radiology services (Radiation Therapy), you pay: $50 copay at a specialist's office 20% coinsurance at a hospital facility as an outpatient #25 - Outpatient Prescription Drugs: $0 copay for allergy injections Medicare Part B and Chemotherapy drugs are subject to the 20% coinsurance, plus any applicable copay/coinsurance depending on the location of service. Exception: Medicare-covered inpatient hospital stays are subject only to the per day copay. Any Medicare Part B and Chemotherapy drugs are included. #28 - Vision Services: Eye Exams: $0 copay for glaucoma screening $50 copay for all other services 29

48

49 Multi language Interpreter Services English: We have free interpreter services to answer any questions you may have about our health or drug plan. To get an interpreter, just call us at Someone who speaks English/Language can help you. This is a free service. Spanish: Tenemos servicios de intérprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos. Para hablar con un intérprete, por favor llame al Alguien que hable español le podrá ayudar. Este es un servicio gratuito. Chinese Mandarin: 我们提供免费的翻译服务, 帮助您解答关于健康或药物保险的任何疑问 如果您需要此翻译服务, 请致电 我们的中文工作人员很乐意帮助您 这是一项免费服务 Chinese Cantonese: 您對我們的健康或藥物保險可能存有疑問, 為此我們提供免費的翻譯服務 如需翻譯服務, 請致電 我們講中文的人員將樂意為您提供幫助 這是一項免費服務 Tagalog: Mayroon kaming libreng serbisyo sa pagsasaling wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot. Upang makakuha ng tagasaling wika, tawagan lamang kami sa Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog. Ito ay libreng serbisyo. French: Nous proposons des services gratuits d'interprétation pour répondre à toutes vos questions relatives à notre régime de santé ou d'assurance médicaments. Pour accéder au service d'interprétation, il vous suffit de nous appeler au Un interlocuteur parlant Français pourra vous aider. Ce service est gratuit. Vietnamese: Chúng tôi có dịch vụ thông dịch miễn phí để trả lời các câu hỏi về chương sức khỏe và chương trình thuốc men. Nếu quí vị cần thông dịch viên xin gọi sẽ có nhân viên nói tiếng Việt giúp đỡ quí vị. Đây là dịch vụ miễn phí. German: Unser kostenloser Dolmetscherservice beantwortet Ihren Fragen zu unserem Gesundheits und Arzneimittelplan. Unsere Dolmetscher erreichen Sie unter Man wird Ihnen dort auf Deutsch weiterhelfen. Dieser Service ist kostenlos. Korean: 당사는의료보험또는약품보험에관한질문에답해드리고자무료통역 서비스를제공하고있습니다. 통역서비스를이용하려면전화 번으로 문의해주십시오. 한국어를하는담당자가도와드릴것입니다. 이서비스는무료로 운영됩니다. Y0011_ CMS Accepted Y0011_ EGWP C: 07/2013

50 Russian: Если у вас возникнут вопросы относительно страхового или медикаментного плана, вы можете воспользоваться нашими бесплатными услугами переводчиков. Чтобы воспользоваться услугами переводчика, позвоните нам по телефону Вам окажет помощь сотрудник, который говорит по pусски. Данная услуга бесплатная. إننا نقدم خدمات المترجم الفوري المجانية للا جابة عن أي أسي لة تتعلق بالصحة أو جدول الا دوية لدينا. للحصول على Arabic: بمساعدتك. هذه. سيقوم شخص ما يتحدث العربية مترجم فوري ليس عليك سوى الاتصال بنا على.خدمة مجانية Hindi: हम र व थ य य दव क य जन क ब र म आपक कस भ श न क जव ब द न क लए हम र प स म फ त द भ षय स व ए उपलब ध ह. एक द भ षय प त करन क लए, बस हम पर फ न कर. क ई व य क त ज हन द ब लत ह आपक मदद कर सकत ह. यह एक म फ त स व ह. Italian: È disponibile un servizio di interpretariato gratuito per rispondere a eventuali domande sul nostro piano sanitario e farmaceutico. Per un interprete, contattare il numero Un nostro incaricato che parla Italianovi fornirà l'assistenza necessaria. È un servizio gratuito. Portugués: Dispomos de serviços de interpretação gratuitos para responder a qualquer questão que tenha acerca do nosso plano de saúde ou de medicação. Para obter um intérprete, contacte nos através do número Irá encontrar alguém que fale o idioma Português para o ajudar. Este serviço é gratuito. French Creole: Nou genyen sèvis entèprèt gratis pou reponn tout kesyon ou ta genyen konsènan plan medikal oswa dwòg nou an. Pou jwenn yon entèprèt, jis rele nou nan Yon moun ki pale Kreyòl kapab ede w. Sa a se yon sèvis ki gratis. Polish: Umożliwiamy bezpłatne skorzystanie z usług tłumacza ustnego, który pomoże w uzyskaniu odpowiedzi na temat planu zdrowotnego lub dawkowania leków. Aby skorzystać z pomocy tłumacza znającego język polski, należy zadzwonić pod numer Ta usługa jest bezpłatna. Japanese: 当社の健康健康保険と薬品処方薬プランに関するご質問にお答えするために 無料の通訳サービスがありますございます 通訳をご用命になるには にお電話ください 日本語を話す人者が支援いたします これは無料のサービスです

51 2014 More plan information

52 NOTES

53 Visitor/Travel Program The Visitor/Travel Program will include BlueMedicare Advantage PPO network coverage of all benefits offered by your plan outside your service area in 33 States and 1 Territory: Alabama, Arkansas, California, Colorado, Connecticut, Georgia, Hawaii, Idaho, Indiana, Kentucky, Maine, Massachusetts, Michigan, Missouri, Montana, North Carolina, Nevada, New Hampshire, New Jersey, New Mexico, New York, Ohio, Oklahoma, Oregon, Pennsylvania, Puerto Rico, South Carolina, Tennessee, Texas, Utah, Virginia, Washington, Wisconsin, and West Virginia. For some of the states listed, MA PPO networks are only available in portions of the state. Your enrollment materials will also tell you in which states the Visitor/Travel Program is available. In addition, you may: Call BLUE ( ), 24 hours a day, 7 days a week, to find a BlueMedicare Advantage PPO provider (TTY: ); Visit the National Doctor and Hospital Finder at to find a Medicare Advantage PPO provider; or call our Member Services Department toll free at You will be able to speak to someone from 8:00 a.m. 9:00 p.m. ET, seven days a week all year long (TTY: ). When you receive services from a PPO provider in any area where the Visitor/Travel Program is offered, you will pay the same cost-sharing amounts you pay when you receive covered benefits from network providers in your home service area. 33 STATES AND 1 TERRITORY This information is available for free in other languages. Please call our customer service number at , 8:00 a.m. 9:00 p.m. ET, seven days a week all year long (TTY: ). Esta información está disponible de forma gratuita en otros idiomas. Llame a nuestro Departamento de Servicio al Cliente al Estamos abiertos de 8:00 a.m. a 9:00 p.m., Hora del Este, los siete días de la semana, por todo el año. Usuarios de equipo teleescritor (TTY) deben llamar al Florida Blue is a PPO and RPPO Plan with a Medicare contract. Enrollment in Florida Blue depends on contract renewal. Y0011_ CMS Approved

54 Chain Pharmacies The national or regional chain pharmacies below are network pharmacies because we have made arrangements with them to provide prescription drugs to Plan members. Not all national or regional chain pharmacies have a dedicated toll free phone number. For those pharmacies you will need to call a specific location in your area (TTY: ). If you d like information on network chain or independent pharmacies in your area, please visit our web site at or call our Customer Service number at , 8:00 a.m. 9:00 p.m. ET, seven days a week, all year long. TTY users should call AccessHealth TTY Albertson s LLC TTY American Pharmacy Network Solutions TTY Costco Pharmacies TTY CVS Pharmacy Inc.* TTY Epic Pharmacy Network Inc TTY Family Care Pharmacy Network TTY Gerimed Ltc Network Inc TTY Good Neighbor Pharmacy Provider Network TTY H. D. Smith Third Party Network Hannaford Bros Co Inc TTY K-Mart Pharmacy* TTY Leader Drug Stores Inc. Managed Pharmacy Care and Adm Svcs TTY MaxorXpress TTY Medicine Shoppe Intl Inc.* TTY MHA Long Term Care Network TTY Navarro Discount Pharmacies LLC* TTY Progressive Pharmacies LLC TTY Publix Supermarkets Inc.* TTY Sav Mor Drug Stores Southern Family Markets LLC Y0011_ CMS Approved

55 Sweetbay* TTY Tampa Family Health Ctr Inc Target Corporation* TTY The Kroger Co TTY Third Party Station CP TTY Trinet TTY United Drugs TTY Walgreens Drug Store* TTY Walmart Stores Inc /Sam s Club TTY Winn Dixie Pharmacy* TTY This information is available for free in other languages. Please call our customer service number at , 8:00 a.m. 9:00 p.m. ET, seven days a week all year long (TTY: ). Esta información está disponible de forma gratuita en otros idiomas. Llame a nuestro Departamento de Servicio al Cliente al Estamos abiertos de 8:00 a.m. a 9:00 p.m., Hora del Este, los siete días de la semana, por todo el año. Usuarios de equipo teleescritor (TTY) deben llamar al *These pharmacies participate in our Extended Supply Network (ESN) in Florida Blue is a PPO, RPPO and Rx (PDP) Plan with a Medicare contract. Florida Blue HMO is an HMO Plan with a Medicare Contract. Enrollment in Florida Blue or Florida Blue HMO depends on contract renewal.

56

57 2014 Plan enrollment

58 NOTES

59 Understanding enrollment periods SEPT. OCT. NOV. DEC. JAN. FEB. MCH. APR. MAY JUN. JLY. AUG. ENROLL OCTOBER 15 DECEMBER You can not enroll in our plan after December 7 1 SPECIAL ELECTION PERIOD (YEAR ROUND ENROLLMENT) ANNUAL ENROLLMENT PERIOD October 15, 2013 December 7, 2013 Switch, drop or join a Medicare Advantage plan of your choosing. Your Medicare Advantage plan selection becomes effective January 1, SPECIAL ELECTION PERIOD (Year-Round Enrollment) If you answer yes to any of the following questions, you may be eligible for a Special Election Period. If you think you qualify, talk to your local sales agent. Have you recently moved? Are you currently receiving Extra Help with your prescription drug costs? Do you no longer qualify for Extra Help with your prescription drug costs? Have you recently left a PACE program (Program of All-inclusive Care for the Elderly)? Do you live in a long-term care facility? Have you recently retired and lost your employer or union coverage? Will you be moving into a long-term care facility? Have you recently moved out of a long-term care facility? Are you currently receiving Medicaid? Have you recently stopped receiving Medicaid? Y0011_ C: 08/2013

60 DISENROLLMENT PERIOD January 1, 2014 February 14, 2014 For Medicare Advantage plans, you can leave your plan and switch to Original Medicare. lf you switch to Original Medicare, you have until February 14, 2014, to sign up for a prescription drug plan. During this period you cannot: Switch from Original Medicare to a Medicare Advantage plan. Switch from one Medicare Advantage plan to another. This information is available for free in other languages. Please call our customer service number at , 8:00 a.m. 9:00 p.m. ET, seven days a week all year long (TTY: ). Esta información está disponible de forma gratuita en otros idiomas. Llame a nuestro Departamento de Servicio al Cliente al Estamos abiertos de 8:00 a.m. a 9:00 p.m., Hora del Este, los siete días de la semana, por todo el año. Usuarios de equipo teleescritor (TTY) deben llamar al Unless you qualify for a Special Election Period. Florida Blue is a PPO and RPPO Plan with a Medicare contract. Florida Blue HMO is an HMO Plan with a Medicare contract. Enrollment in Florida Blue or Florida Blue HMO depends on contract renewal..

61 Ready to enroll? HOW TO ENROLL 1 Have your Medicare ID card available Complete the enrollment form in its entirety. You may do this one of three ways: Complete the paper enrollment form included in this booklet; OR Complete an electronic enrollment form via OR Call your local agent for assistance in completing your enrollment form. If you and your spouse both wish to enroll in one of our BlueMedicare plans, you will need to complete separate enrollment forms. Two enrollment forms are included in this booklet. Complete all sections of the enrollment form in full. Missing or incomplete information may cause a delay in the effective date of your coverage. Carefully read and sign all necessary portions of the enrollment form. Complete the Medicare Insurance Information so that we can verify your Medicare eligibility. Fill in the Part A and Part B effective dates from your Medicare ID card. Please select a payment option even if the plan you select has a $0 premium as a Late Enrollment Penalty may apply (See Frequently asked questions section of this booklet). If you select an Electronic Funds Transfer (EFT) as your payment option, please don t forget to write your bank account number and routing number in the appropriate section of the enrollment form. Also, please include a voided check that contains this information. 7 Select the appropriate plan. Be sure to select only ONE plan name. 8 Complete the Authorization to Release Protected Health Information form (if applicable). 9 Please provide the information for your Primary Care Physician or Physician of Choice (when applicable). If you do not have this information, don t worry. It will not slow down the enrollment process. 10 Read and complete applicable information in Section 4. This section highlights enrollment periods. 11 If you have a Durable Power of Attorney, Durable Power of Attorney for Health Care, or you are a legal guardian or conservator, the legal representative must attest that he/she has this authority under state law and that proof can be presented if requested by the Centers for Medicare & Medicaid Services (CMS). 12 If you do not have an agent helping you enroll, mail the original copy of the enrollment form and/or the Authorization to Release Protected Health Information, when applicable, to: Florida Blue P.O. Box 45296, Jacksonville, FL Y0011_ CMS Approved

62 WHEN YOU ARE READY TO ENROLL Contact your local agent to help you choose the best plan and complete the enrollment form; OR Call licensed agents at (TTY users should call ) and a sales agent can help you enroll over the phone. If you choose to use your local agent or you contact a licensed agent at the number above to assist with your enrollment, the person who is discussing plan options with you is a sales agent, broker or other person employed by or contracted with Florida Blue. The person may be paid based on your enrollment in a plan. If you currently have health coverage through an employer or union, joining one of our plans could affect your employer or union health benefits. You could lose your employer or union health coverage if you join this plan. Read the communications your employer or union sends you. If you have questions, contact their office. If you can t find any contact information, your benefits administrator or the office that answers questions about your coverage can help. This information is available for free in other languages. Please call our customer service number at , 8:00 a.m. 9:00 p.m. ET, seven days a week all year long (TTY: ). Esta información está disponible de forma gratuita en otros idiomas. Llame a nuestro Departamento de Servicio al Cliente al Estamos abiertos de 8:00 a.m. a 9:00 p.m., Hora del Este, los siete días de la semana, por todo el año. Usuarios de equipo teleescritor (TTY) deben llamar al Florida Blue is a PPO, RPPO and Rx (PDP) Plan with a Medicare contract. Florida Blue HMO is an HMO Plan with a Medicare contract. Enrollment in Florida Blue or Florida Blue HMO depends on contract renewal.

63

64 2. Paying Your Plan Premium: You can pay your monthly plan premium (including any late enrollment penalty that may apply) by mail or Electronic Funds Transfer (EFT) each month. You can also choose to pay your premium by automatic deduction from your Social Security or Railroad Retirement Board (RRB) benefit check each month. If you are assessed a Part D-Income related Monthly Adjustment Amount, you will be notified by the Social Security Administration. You will be responsible for paying this extra amount in addition to your plan premium. You will either have the amount withheld from your Social Security benefit check or be billed directly by Medicare or the RRB. DO NOT pay BlueMedicare PPO or BlueMedicare Regional PPO the Part D-IRMAA. People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If eligible, Medicare could pay for 75% or more of your drug costs including monthly prescription drug premiums, annual deductibles, and co-insurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don t even know it. For more information about this Extra Help, contact your local Social Security office, or call Social Security at TTY users should call You can also apply for Extra Help online at If you qualify for Extra Help with your Medicare prescription drug coverage costs, Medicare will pay all or part of your plan premium. If Medicare pays only a portion of this premium, we will bill you for the amount that Medicare doesn t cover. You can select to pay for your BlueMedicare PPO premium using one of several options. If you do not select a payment option, you will get a bill each month. BlueMedicare Regional PPO does not have a premium but you may be billed later for a Late Enrollment Penalty. If Medicare determines you are subject to a late enrollment penalty or you have already been notified of a late enrollment penalty, you can elect to pay this penalty by choosing one of the below options. A Late Enrollment Penalty is a Medicare-assessed penalty for delayed enrollment in a plan with Part D prescription drug coverage and is added to the monthly premium. CMS determines the Late Enrollment Penalty amount. If you don t select a payment option, you will get a bill each month. Please select a premium payment option: (if applicable) m Get a bill monthly. m Electronic Funds Transfer (EFT) from your bank account each month. Please enclose a VOIDED check or provide the following: Account holder name: Bank routing number: Bank account number: Account type: m Checking m Saving 3. Please read and answer these important questions: m Automatic deduction from your monthly Social Security benefit check. m Automatic deduction from your monthly Railroad Retirement Board (RRB) benefit check. These deductions may take two or more months to begin after Social Security or RRB approves the deduction. In most cases, if Social Security or RRB accepts your request for automatic deduction, the first deduction from your benefit check will include all premiums due from your enrollment effective date up to the point withholding begins. If Social Security or RRB does not approve your request, we will send you a paper bill for your monthly premium. 1. Do you have End-Stage Renal Disease (ESRD)? If you have had a successful kidney transplant and/or you don t need regular dialysis any more, please attach a note or records from your doctor showing you have had a successful kidney transplant or you don t need dialysis; otherwise we may need to contact you to obtain additional information. m Yes m No 2. Some individuals may have other health and/or drug coverage, including other private insurance, TRICARE, Federal employee health benefits coverage, VA benefits, or State pharmaceutical assistance programs. Will you have other prescription drug coverage in addition to BlueMedicare PPO or BlueMedicare Regional PPO? m Yes m No If yes, please provide the following information: Name of Carrier: Address: Phone #: Policy Holder: Type of Coverage: m Group m Supplemental m Excess m Private (self pay) m Life m Veterans Affairs (VA) ID#: Group#: (if applicable) Effective Date: Term Date: 2 of 5

65 Will you have other health coverage in addition to BlueMedicare PPO or BlueMedicare Regional PPO? m Yes m No Name of Carrier: Address: Phone #: Policy Holder: Type of Coverage: m Group m Supplemental m Excess m Private (self pay) m Life m Veterans Affairs (VA) ID#: Group#: (if applicable) Effective Date: Term Date: 3. Are you a resident in a long-term care facility, such as a nursing home? m Yes m No If yes, please provide the following information: Name of Institution: Address of Institution: Phone Number of Institution: 4. Are you enrolled in your State Medicaid program? m Yes m No If yes, please provide your Medicaid number: 5. Do you work? m Yes m No Does your spouse work? m Yes m No 6. Please provide the name of your Physician of Choice (POC). A POC is a physician that you choose to see for most health reasons. If you wish to change to a different POC after becoming active in this plan, you may contact our Member Services Department. POC First Name POC Last Name Physician Group Name Physician Group s FL Blue Provider ID Number l l l l l l - l l (ie: or 12345A) POC s FL Blue Provider ID Number l l l l l l - l l (ie: or 12345A) POC s 10-digit National Provider ID (NPI) Number l l l l l l l l l l l Are you currently a patient of this POC? m Yes m No Physician Group s 10-digit National Provider ID (NPI) Number l l l l l l l l l l l Are you currently a patient of this Physician Group? m Yes m No Please contact BlueMedicare PPO or BlueMedicare Regional PPO at if you would prefer us to send you information in a language other than English or in another format (e.g. Spanish, Braille, Audio, Large Print). Our Member Services Department is open from 8:00 a.m. 9:00 p.m. ET, seven days a week. TTY users should call Please Read This Important Information If you currently have health coverage from an employer or union, joining BlueMedicare PPO or BlueMedicare Regional PPO could affect your employer or union health benefits. You could lose your employer or union health coverage if you join BlueMedicare PPO or BlueMedicare Regional PPO. Read the communications your employer or union sends you. If you have questions, visit their website, or contact the office listed in their communications. If there isn t any information on whom to contact, your benefits administrator or the office that answers questions about your coverage can help. 4. Information to Determine Enrollment Periods Typically, you may enroll in a Medicare Advantage plan during the Annual Election Period from October 15 through December 7 of each year. There are exceptions that may allow you to enroll in a Medicare Advantage plan outside of this period. Please read the following statements carefully and check the box if the statement applies to you. By checking any of the following boxes, you are certifying that, to the best of your knowledge, you are eligible for an Enrollment Period. If we later determine that this information is incorrect, you may be disenrolled. Initial Election Period Annual Election Period m I am new to Medicare m It is the Annual Election Period (October 15 - December 7) 3 of 5 3

66 Special Election Periods m I recently moved outside of the service area m I recently involuntarily lost my creditable for my current plan or I recently moved and prescription drug coverage (coverage as good this plan is a new option for me. I moved on as Medicare s). I lost my drug coverage on (insert (insert date): (V): l l l l l l l l l l l date) (S): / / m I have both Medicare and Medicaid or my m I am leaving employer or union coverage on (insert state helps pay for my Medicare premiums (S) date) (W): / / m I get Extra Help paying for Medicare m I belong to a pharmacy assistance program prescription drug coverage (U) provided by my state (S) m I no longer qualify for Extra Help paying for my m I recently returned to the United States after living Medicare prescription drug coverage. I stopped permanently outside of the U.S. I returned to the receiving Extra Help on (insert date) (T): U.S. on (insert date) (V): / / / / m My plan is ending its contract with Medicare, or m I am moving into, live in, or recently moved Medicare is ending its contract with my plan (insert out of a Long-Term Care Facility (e.g., a date) (S): / / nursing home or long-term care facility). m I was enrolled in a Special Needs Plan (SNP) but I I moved/will move into/out of the facility on have lost the special needs qualification required (insert date) (S): / / to be in that plan. I was disenrolled from the SNP m I recently left a PACE program on (insert on (insert date) (S): / / date) (S): / / m Other (please specify) (S or Y): If none of these statements applies to you or you re not sure, please contact Florida Blue at (TTY users should call ) to see if you are eligible to enroll. We are open 8:00 a.m. 9:00 p.m. ET, seven days a week. If you are currently covered under a Florida Blue Medicare Supplement policy, do you intend to replace your current coverage with this new Florida Blue Medicare Advantage plan? m Yes m No m By checking here, you request Florida Blue to cancel your Florida Blue Medicare Supplement policy on the day before this Medicare Advantage plan becomes effective. For Example, Florida Blue BlueMedicare PPO or BlueMedicare Regional PPO plan is effective July 1st; Florida Blue will cancel your Florida Blue Medicare Supplement policy effective June 30th. To ensure accurate processing, you must provide your Florida Blue Medicare Supplement Policy ID Number: l_h_l l l l l l l l l l l l (example: H ) 5. Please Read and Sign on the Next Page: By completing this enrollment application, I agree to the following: I understand that health and prescription insurance is offered by Florida Blue. Florida Blue is a trade name for Blue Cross and Blue Shield of Florida an Independent Licensee of the Blue Cross and Blue Shield Association. Please keep in mind that BlueMedicare PPO and BlueMedicare Regional PPO are not Medicare Supplement plans. Florida Blue is a PPO and RPPO Plan with a Medicare contract. Enrollment in Florida Blue depends on contract renewal. I will need to keep my Medicare Parts A and B. I can be in only one Medicare Advantage plan at a time, and I understand that my enrollment in this plan will automatically end my enrollment in another Medicare health plan or prescription drug plan. It is my responsibility to inform you of any prescription drug coverage that I have or may get in the future. Enrollment in this plan is generally for the entire year. Once I enroll, I may leave this plan or make changes if an enrollment period is available, generally during the Medicare Annual Enrollment Period (October 15 - December 7 of every year) or unless I qualify for certain special circumstances. BlueMedicare PPO and BlueMedicare Regional PPO serve specific service areas. If I move out of the area that BlueMedicare PPO or BlueMedicare Regional PPO serves, I need to notify the plan so I can disenroll and find a new plan in my new area. Once I am a member of BlueMedicare PPO or BlueMedicare Regional PPO, I have the right to appeal plan decisions about payment or services if I disagree. I will read the Evidence of Coverage document from BlueMedicare PPO or BlueMedicare Regional PPO when I get it to know which rules I must follow to get coverage with this Medicare Advantage plan. I understand that people with Medicare aren t usually covered under Medicare while out of the country except for limited coverage near the U.S. border. However, once I am a member of BlueMedicare PPO or BlueMedicare Regional PPO, I will have coverage worldwide for emergencies and urgently needed care outside the United States. I understand that beginning on the date BlueMedicare PPO or BlueMedicare Regional PPO coverage begins, using services in-network can cost less than using services out-of-network, except for emergency or urgently needed services or out-of-area dialysis services. BlueMedicare PPO or BlueMedicare Regional PPO provides 4 of 5

67 payment for all medically necessary covered services minus the amount of your required plan cost-sharing, even if you get services out of network. Services authorized by BlueMedicare PPO or BlueMedicare Regional PPO and other services contained in my BlueMedicare PPO or BlueMedicare Regional PPO Evidence of Coverage document (also known as a member contract or subscriber agreement) will be covered. Prior authorization is required only for certain services obtained from a network provider. (Refer to your Evidence of Coverage). Without authorization, neither Medicare nor BlueMedicare PPO or BlueMedicare Regional PPO will pay for the services. You never need prior authorization for out-ofnetwork services from out-of-network providers. I understand that if I am getting assistance from a sales agent, broker, or other individual employed by or contracted with BlueMedicare PPO or BlueMedicare Regional PPO, he/she may be paid based on my enrollment in BlueMedicare PPO or BlueMedicare Regional PPO. Counseling services may be available in my state to provide advice concerning Medicare supplement insurance or other Medicare Advantage or Prescription Drug plan options as well as medical assistance through the state Medicaid program and the Medicare Savings Program. Release of Information: By joining this Medicare health plan, I acknowledge that BlueMedicare PPO or BlueMedicare Regional PPO will release my information to Medicare and other plans as is necessary for treatment, payment and health care operations. I also acknowledge that BlueMedicare PPO or BlueMedicare Regional PPO will release my information, including my prescription drug event data, to Medicare, which may release it for research and other purposes that follow all applicable Federal statutes and regulations. I acknowledge that my information described herein may be disclosed to other entities with which BlueMedicare PPO or BlueMedicare Regional PPO has contracted to perform certain services on its behalf (business associates). I further acknowledge that information released by BlueMedicare PPO or BlueMedicare Regional PPO may, if applicable, include my medical and payment information relating to HIV/AIDS, mental health and substance abuse diagnosis and treatment. This release is for the plan year of 2014, January 1, 2014 to December 31, 2014 and for three years following the plan year of 2014 in order that BlueMedicare PPO or BlueMedicare Regional PPO may complete any required data submission, bids, claims processing, and other similar activities for which my information is necessary. The information on this enrollment form is correct to the best of my knowledge. I understand that if I intentionally provide false information on this form, I will be disenrolled from the plan. I understand that my signature (or the signature of the person authorized to act on my behalf under the laws of the state where I live) on this application means that I have read and understand the contents of this application. If signed by an authorized individual (as described above), this signature certifies that 1) this person is authorized under state law to complete this enrollment and 2) documentation of this authority is available upon request from Medicare. Signature: X Today s Date: If you are the authorized representative, you must sign above and provide the following information: Name Phone Number: l l l l l l l l l l l Address Relationship to Enrollee: What is your preferred method of communication? m Phone m Mail m m By checking here, I request that Florida Blue send me plan materials and customer communications via when these services and materials are available. I understand that I may receive invitations to participate in research activities and that I may choose to opt out of any of these services at any time by contacting Florida Blue s Member Services Department. Address I I I I I I I I I I I I I I I I I I I I I This information is optional and is for data collection only. It will not be used to determine eligibility or claim payment. Ethnicity/Race (check all that apply): m Asian or Pacific Islander m Black or African American m White Language of Preference m Caribbean Islander m Native American m Hispanic m English m Spanish 5 of 5 5 of 5

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