BlueMedicare SM Group PPO (Employer PPO) BlueMedicare SM PPO

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1 BlueMedicare SM Group PPO (Employer PPO) BlueMedicare SM PPO 2017 Benefit Schedule for Dental Care Services Hearing Services Vision Care Services A Medicare Advantage Dental, Hearing and Vision Benefit Health coverage is offered by Blue Cross and Blue Shield of Florida, Inc., D/B/A Florida Blue, an Independent Licensee of the Blue Cross and Blue Shield Association. Y0011_ R1 CMS Accepted Y0011_ R1 EGWP C: 09/2016

2 Dental Care Services Taking care of your health includes caring for your teeth, too. In fact, your dental health can have a direct impact on your overall health and well-being, and may have an influence on the development of certain conditions such as diabetes and heart disease. Easy access to preventive dental care is one of the most important things we can provide. That s why members never need a referral or pre-authorization to visit an In-Network dentist. Networks are comprised of independent contracted dentists. Benefits for Covered Services Preventive Services Periodic Oral Examination (D0120) - up to 1 every 6 months Comprehensive Oral Examination (D0150) 1 per lifetime. Per dentist Cleaning (D1110) 1 every 6 months Bitewing X-rays (D0272, D0273, D0274) 1 set every 12 months Full-mouth X-rays (D0210 or D0330) 1 set every 36 months Additional Services Simple Extraction (D7140) for an erupted tooth OR exposed root, up to 2 per year Denture Adjustment Complete or Partial (D5410, D5411, D5421 or D5422) up to 2 per year Your request for reimbursement can be sent to: Florida Combined Life PO Box 1047 Elk Grove Village, IL Florida Combined Life Insurance Company, Inc. is responsible for the administrative functions of the BlueMedicare dental program. If you have an inquiry, call Monday through Friday, 8:00 am to 8:00 pm ET. Toll-free: or TTY To find an In-Network dentist in your area visit www. BlueMedicareFL.com or call toll-free or TTY As a BlueMedicare PPO or Group PPO member, you have access to a large network of providers. Exams and X-rays are covered each year when you receive services from an In-Network dentist. BlueMedicare Group PPO and BlueMedicare PPO In-Network Out-of-Network Member pays 50% Coinsurance Payment is based on the In-Network fee schedule. You may be required to pay for Out-of-Network services up front. Submit your receipt and you will be reimbursed 50% of the In-Network fee for covered services only. Member pays 50% Coinsurance Payment is based on the In-Network fee schedule. You may be required to pay for Out-of-Network services up front. Submit your receipt and you will be reimbursed 50% of the In-Network fee for covered services only If you have a grievance or appeal, submit it in writing to: Florida Blue Attn: Medicare Advantage Member Appeals PO Box Jacksonville, FL

3 Hearing Services If you find that your hearing isn t as good as it used to be, you can rest assured that your BlueMedicare plan can offer you assistance. Under your plan, you have coverage for a comprehensive hearing exam and exclusive savings on hearing devices. This coverage is automatically included in your plan as long as you use our partner, TruHearing. TruHearing offers a national network of providers. All appointments must be scheduled through them. Call TruHearing today at or TTY to start saving! Follow the column in the table that has your plan name for a list of the covered services under your BlueMedicare hearing plan. Benefits for Covered Services BlueMedicare Group PPO BlueMedicare PPO Routine Hearing Exam - one per year Fitting/Evaluation for Hearing Aid - one per year Hearing Aids - Up to two TruHearing Flyte hearing aids every year (one per ear, per year). Benefit is limited to the TruHearing Flyte 700 and Flyte 900 hearing aids, which come in various styles and colors. You must see a TruHearing provider to use this benefit. Hearing aid purchases include: 3 provider visits within first year of hearing aid purchase 45-day trial period 3-year extended warranty 48 batteries per aid In-Network Out-of-Network In-Network Out-of-Network $45 Copay $45 Copay Flyte 700-$699 Copay Flyte 900-$999 Copay Not Covered. However, discounts for hearing exams and hearing aids and batteries are available under the Blue365 Member Discount Program.* Benefit does not include or cover any of the following: ear molds, hearing aid accessories, additional provider visits, extra batteries, hearing aids that are not the TruHearing Flyte 700 or Flyte 900, hearing aid returns fees and loss and damage warranty claims. Costs associated with excluded items are the responsibility of the member and are not covered by the plan. TruHearing is responsible for the administrative functions of the BlueMedicare hearing program. If you have an inquiry, call TruHearing at or TTY Their hours of operation are: February 15 through September 30-8:00 am to 8:00 pm ET, Monday through Friday; and October 1 through February 14-8:00 am to 8:00 pm ET, seven days a week. If you have a grievance or appeal, submit it in writing to: Florida Blue Attn: Medicare Advantage Member Appeals PO Box Jacksonville, FL

4 Vision Care Services Florida Blue understands that you want your vision to be the best it can be. That s why we have included a vision benefit in your BlueMedicare plan. We encourage you to have your eyes examined each year. Eye diseases such as glaucoma can be caught early with a regular checkup. If you have diabetes, an annual eye exam is important for the health of your eyes. To find eye professionals in your area visit or call toll-free Benefits for Covered Services BlueMedicare Group PPO and BlueMedicare PPO Routine Eye Exam - 1 per year, including dilation when necessary Spectacle Lenses 1 pair covered every 12 months Clear Plastic Lenses (Single Vision, Lined Bifocal, Trifocal or Lenticular) Progressive Lenses 4 In-Network Out-of-Network 1 Up to $25 Member $20 copay $65 copay Member based on type of lens Single Vision up to $20 Lined Bifocal up to $30 Trifocal up to $35 Lenticular up to $40 Up to $30 Member Other Lenses - In addition to the spectacle lens member charge. Lenses are covered in full after both the basic and other lens charges. Oversize lenses Polycarbonate Polycarbonate when medically necessary (+/ diopters or greater) Premium Progressive (Varilux, etc.) Ultra Progressive Intermediate-Vision Blended Segment High-Index Polarized Photochromic Glass Plastic Photosensitive $35 copay $105 copay $140 copay $30 copay $20 copay $60 copay $75 copay $20 copay $70 copay 1 For Out-of-Network providers you must pay for services up front and submit your receipt. No Additional Member

5 Vision Care Services (continued) Benefits for Covered Services Coatings - Member charges in addition to the spectacle lens member charge Tinting of plastic lenses Scratch-Resistant Ultraviolet Anti-Reflective (AR) Standard Anti-Reflective (AR) Premium Anti-Reflective (AR) Ultra 5 BlueMedicare Group PPO and BlueMedicare PPO In-Network Out-of-Network 1 $15 copay $15 copay $40 copay $55 copay $69 copay Scratch Protection Plans - Member charges in addition to the spectacle lens member charge No Additional Member Single Vision lenses $20 copay No Additional Member Multifocal lenses $40 copay Frames 1 every 24 months Collection Frames Fashion level Not Applicable Collection Frames Designer level $15 copay Not Applicable Collection Frames Premier level $40 copay Not Applicable Non-Collection Frames additional discounts not available at Sam s Club or Wal-Mart Contact Lenses - in lieu of spectacle lenses and frames every 12 months Standard and Specialty lenses Includes evaluation, fitting and follow-up care. Additional discounts not available at Sam s Club or Wal-Mart Medically Necessary lenses (+/ diopters or greater) Up to a $100 allowance then 20% discount on overage Up to a $100 allowance then 15% discount on overage Low-Vision Benefits - Your vision provider must obtain prior authorization for any Low-Vision benefits Low-Vision Evaluation 1 comprehensive evaluation every 5 years Low-Vision Follow-Up Care - 4 visits in any 5 year period Low-Vision Aids (i.e. magnifiers) Additional Discounts Laser Correction Surgery (i.e. Lasik) Up to a $35 member reimbursement Up to a $55 member reimbursement Up to a $225 member reimbursement Plan pays up to $300 maximum member reimbursement. Member pays all overage Plan pays up to $100 per visit Plan pays up to a $600 annual or $1,200 lifetime member reimbursement. Member pays all overage. 25% off provider s normal rates or a 5% discount on any in network advertised specials 1 For Out-of-Network providers you must pay for services up front and submit your receipt. No Discount

6 Vision Care Services (continued) Your request for reimbursement can be sent to: Vision Care Processing Unit P.O. Box 1525 Latham, NY Davis Vision is responsible for the administrative functions of the BlueMedicare vision program. Call or TTY seven days a week: Monday-Friday, 8 am -11 pm, Saturday, 9 am - 4 pm, Sunday, 12 pm - 4 pm ET. Automated help is available 24/7 by calling If you have a grievance or appeal, submit it in writing to: Florida Blue Attn: Medicare Advantage Member Appeals PO Box Jacksonville FL The amount you spend on copays and coinsurance for the dental, hearing and vision services in this benefit schedule will not go toward meeting the annual maximum out-ofpocket under a BlueMedicare Advantage Group PPO plan or BlueMedicare Advantage PPO plan. *Blue365 offers access to savings on items that members may purchase directly from independent vendors. Blue365 does not include items covered under your policies with Florida Blue or any applicable federal health care program. To find out what is covered under your policies, call Florida Blue. Blue Cross and Blue Shield Association (BCBSA) may receive payments from Blue365 vendors. Neither BCBSA nor any local Blue company recommends, endorses, warrants or guarantees any specific Blue365 vendor or item. For more information about Blue365, go to Florida Blue is a PPO Plan with a Medicare contract. Enrollment in Florida Blue depends on contract renewal. This information is available for free in other languages. Please call our Customer Service number at (TTY users should call ) Hours are 8 a.m. - 8 p.m. local time, seven days a week from October 1 to February 14, except for Thanksgiving and Christmas. From February 15th to September 30th, we are open Monday - Friday, 8 a.m. - 8 p.m., local time. Esta información está disponible de manera gratuita en otros idiomas. Comuníquese con Atención al cliente al ( Usuarios de equipo telescritor TTY llamen al ) Estamos abiertos de 8 a.m. a 8 p.m. hora local los siete días de la semana, desde el 1 de octubre hasta el 14 de febrero, excepto el día de Acción de Gracias (Thanksgiving) y el día de Navidad. Desde el 15 de febrero al 30 de septiembre, estamos abiertos de lunes a viernes de 8:00 a.m. a 8:00 p.m. hora local. 6

Benefits Summary of. BlueMedicare SM Group PPO (Employer PPO) A Medicare Advantage PPO Plan. PPO1 RX1 with Dental, Hearing & Vision

Benefits Summary of. BlueMedicare SM Group PPO (Employer PPO) A Medicare Advantage PPO Plan. PPO1 RX1 with Dental, Hearing & Vision Summary of Benefits 2017 BlueMedicare SM Group PPO (Employer PPO) A Medicare Advantage PPO Plan PPO1 RX1 with Dental, Hearing & Vision Florida Blue is an Independent Licensee of the Blue Cross and Blue