2017 MEDICARE ADVANTAGE PLANS. Y0086_MRK1688 Accepted

Transcription

1 2017 MEDICARE ADVANTAGE PLANS Y0086_MRK1688 Accepted

2 2017 MEDICARE ADVANTAGE PLANS Premium 1 Premium with EPIC subsidy or full Extra Help 1 Primary care doctor/specialist Part D prescriptions Tier 1/2/3/4/5 Preferred pharmacy Standard pharmacy Gap coverage Inpatient hospital days 1-7 X-rays/advanced radiology (MRI, CAT, PET) Outpatient/ ambulatory surgery Annual routine eye exam Nationwide coverage HMO (HMO) $0 N/A $25/$45 N/A Not $280 $1,960 max $45/$75 $275/$225 $45 HMO HMO Select 3 (HMO) $41 $0 $30/$50 $10/$15/$42/$94/33% $15/$20/$47/$100/33% $280 $1,960 max $50/$175 $350/$300 $50 HMO (HMO) $108 $67 $20/$35 $7/$15/$42/$94/33% $12/$20/$47/$100/33% and tier 1 generic drug coverage through coverage gap $225 $1,575 max $40/$75 $275/$225 $35 PPO Focus 4,5 (PPO) $78 $37 $30/$50 $10/$15/$42/$94/33% $15/$20/$47/$100/33% $270 $1,890 max $50/$150 $325/$275 $50 Must reside in Erie or Niagara county PPO PPO Value 5 (PPO) $111 $70 $20/$40 $7/$15/$42/$94/33% $12/$20/$47/$100/33% $250 $1,750 max $50/$150 $300/$250 $40 PPO (PPO) $198 $157 $10/$30 $5/$15/$42/$94/33% $10/$20/$47/$100/33% and tier 1 generic drug coverage through coverage gap $205 $1,435 max $40/$75 $275/$225 $30 COMMON PLAN ELEMENTS Diabetes supplies and monitors $0 Skilled nursing facility days 1-20 $0 Out-of-pocket maximum $6,700 In- and out-of-network combined out-of-pocket max for PPO plans $10,000 Skilled nursing facility days NEW! Vision wear (frames/lenses/contact lens) NEW! Hearing aid (coverage for specific models only) $164.50/day $100 annual allowance $699 or $999/unit Lab copay $5 No deductibles on drug or medical coverage Worldwide coverage for emergency and $75/$65 Unless otherwise noted, costs shown are for received in-network.

3 The Benefits of Blue When you choose Blue, you choose the exceptional support, value, and service you deserve. You ll get the stability of a plan that s backed by nearly 80 years of proven experience and the support of knowledgeable customer service representatives. NEW! Benefits in 2017 $100 annual allowance for eyewear Annual routine eye exam coverage $0 annual diabetic retinal eye exam Tier 1 generic drugs in gap on two plans Routine hearing exam and hearing aid coverage low cost of $699 or $999 per unit; coverage is for specific models only $0 preventive More than 20 included at no cost when you use providers in our network. $0 gym membership Access fitness locations nationwide through SilverSneakers. $0 care management Coordinated care with your doctors and other health professionals. Care at Home SM Care provided in the comfort of your home, like traditional house calls. Coverage that travels All of our plans cover you worldwide for urgent and emergency care. However, if you travel often, you can enjoy the flexibility of BlueCard Network Sharing with our Forever Blue PPO 751 plan. Links BlueCross and/or BlueShield plans, which makes billing simple Pay the same as you would in-network for all plan- outside of Western New York in participating areas * Participating BlueCard states and territories: AL, AR, CA, CO, CT, FL, GA, HI, ID, IL, IN, KY, ME, MA, MI, MO, MT, NV, NH, NJ, NM, NY, NC, OH, OK, OR, PA, SC, TN, TX, UT, VA, WA, WI, WV, PR To find out if a doctor or facility participates in the BlueCard Network Sharing program: Call BLUE (2583) and select option 2 Or visit provider.bcbs.com and enter prefix YJX in the Already a Member field If you don't travel as much, or want a lower-cost option, our Forever Blue PPO Value or Focus may work for you. You can still access care out-of-area, but pay more when you visit an out-ofnetwork doctor or hospital. * In order for your to be considered in-network while you re outside of the service area the provider must participate with the local BlueCard Network Sharing program in the service area and both you and the provider must be located in the same service area when you receive care. Outside the U.S. you may be asked to pay 100% of the cost at the time of service. You would then submit a claim to us to be reimbursed for your in-network cost-share

4 Special Network Coverage Call customer service or visit bcbswny.com/medicare to check your facilities. HMO Select covers emergency at any hospital; however, routine or scheduled medical at Catholic Health facilities (excluding Mount St. Mary s Hospital) will not be when the provided are billed by Catholic Health. PPO Focus covers emergency at any hospital; however, routine or scheduled medical at certain facilities, including Kaleida Health and ECMC, will be considered out of network when billed by those facilities and result in a higher cost share. You must reside in Erie or Niagara county to enroll in this plan. Part D Coverage Gap Initial coverage Pay a copay or coinsurance for your prescriptions until you reach your coverage limit, $3,700. Coverage gap Pay a percentage of the cost for your prescriptions, 51% or 40%, unless you have HMO 651 or PPO 751 then you pay your copay for tier 1 generic drugs. Catastrophic coverage Once you reach the gap limit, $4,950, continue to pay a smaller copay or coinsurance for your prescriptions until the end of the calendar year. Add Dental Care Optional supplemental benefits (no network see any dentist) Premium 7 Preventive (2 cleanings and 2 oral exams/year) Diagnostic and restorative service cost Annual max allowance Basic $17 50% 50% $500 Enhanced $31 Full coverage 50% (20% for crowns and cementing/recementing) NOTE: Preventive do not count towards the annual max allowance for dental. $1,000 ENROLL Call us at (TTY 711) or SalesCenterWNY@bcbswny.com. Meet one-on-one with one of our consultants who can help you fill out and submit an application. Fill out an application and mail it in. Visit bcbswny.com/enrollmedicare to complete the application online. CONTACT We re available to talk through your plan options and answer your questions: October 1 February 14: 8 a.m. to 8 p.m., 7 days a week February 15 September 30: 8 a.m. to 8 p.m., Monday Friday Or go to bcbswny.com/medicare.

5 ADDITIONAL INFORMATION 1 You must continue to pay your Part B premium. 2 You must receive all routine care from plan providers. 3 You must receive all routine care from plan providers. There is a select facility network with the HMO Select plan. Call us for a full list of participating facilities. 4 There is a select facility network with the PPO Focus plan. Call us for a full list of participating facilities. You must reside in Erie or Niagara county to enroll in this plan. 5 You can receive care from providers outside of the eight counties of Western New York with your out-of-network benefit at a higher cost-share. Please see the Summary of Benefits for a full list of and costs. 6 If you see a participating BlueCard provider, you pay your in-network copay. If you receive care from out-of-network providers, your cost may be higher. Please see the Summary of Benefits for a full list of and costs. 7 Dental premium is in addition to plan and Part B premium. About our benefits and premiums This information is not a complete description of benefits. Contact the plan for more information. Benefits, premium, and/ or copayments/coinsurance may change on January 1 of each year. Limitations, copayments, and restrictions may apply. The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. Eligible beneficiaries must use network pharmacies to access their prescription drug benefit, except under non-routine circumstances, and quantity limitations and restrictions may apply. Out-of-network/non-contracted providers are under no obligation to treat BlueCross BlueShield members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network. About enrollment Individuals must have both Parts A and B to enroll in a Advantage plan. Individuals may enroll in a plan only during specific times of the year. There are additional enrollment guidelines. Contact BlueCross BlueShield for more information. About our partners SilverSneakers is a registered mark of Healthways, Inc. Healthways is an independent company that administers the SilverSneakers gym benefit. About us BlueCross BlueShield of Western New York is a Advantage plan with a contract and enrollment depends on contract renewal. A division of HealthNow New York Inc., an independent licensee of the BlueCross BlueShield Association. BlueCross BlueShield of Western New York complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: 711). 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 TTY: (711) _9_16 F10998