Booklet Contents. Senior Blue (HMO) (H3384) Summary of Benefits. Forever Blue Medicare (PPO) (H5526) Summary of Benefits

Transcription

1 MEDICARE ADVANTAGE 2017 Booklet Contents Senior Blue (HMO) (H3384) Summary of Benefits Forever Blue Medicare (PPO) (H5526) Summary of Benefits Optional Supplemental Dental Benefits Summary of Benefits Additional information regarding your coverage 3503_09_2016

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3 2017 Senior Blue HMO H3384 Summary of Benefits

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5 BlueCross BlueShield Senior Blue HMO 601 (HMO) Summary of Benefits January 1, December 31, 2017 This booklet gives you a summary of what we cover and what you pay. It doesn't list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, call us and ask for the "Evidence of Coverage." Tips for comparing your Medicare choices This Summary of Benefits booklet gives you a summary of what BlueCross BlueShield Senior Blue HMO 601 (HMO) covers and what you pay. If you want to compare our plan with other Medicare health plans, ask the other plans for their Summary of Benefits booklets. Or, use the Medicare Plan Finder on If you want to know more about the coverage and costs of Original Medicare, look in your current "Medicare & You" handbook. View it online at or get a copy by calling MEDICARE ( ), 24 hours a day, 7 days a week. TTY users should call Hours of Operation From October 1 to February 14, you can call us 7 days a week from 8:00 a.m. to 8:00 p.m. Eastern time. From February 15 to September 30, you can call us Monday through Friday from 8:00 a.m. to 8:00 p.m. Eastern time. BlueCross BlueShield Senior Blue HMO 601 (HMO) Phone Numbers and Website If you are a member of this plan, call toll-free (TTY 711) If you are not a member of this plan, call toll-free (TTY 711) Our website: bcbswny.com/medicare Who can join? To join BlueCross BlueShield Senior Blue HMO 601 (HMO), you must be entitled to Medicare Part A, be enrolled in Medicare Part B, and live in our service area. Our service area includes the following counties in New York: Allegany, Cattaraugus, Chautauqua, Erie, Genesee, Niagara, Orleans, Wyoming. Which doctors, hospitals, and pharmacies can I use? BlueCross BlueShield Senior Blue HMO 601 (HMO) has a network of doctors, hospitals, pharmacies, and other providers. If you use the providers that are not in our network, the plan may not pay for these services. 1 Y0086_COM416 Accepted

6 You can see our plan's provider directory at our website, bcbswny.com/medicare. Or, call us and we will send you a copy of the provider directory. What do we cover? Like all Medicare health plans, we cover everything that Original Medicare covers and more. Our plan members get all of the benefits covered by Original Medicare. For some of these benefits, you may pay more in our plan than you would in Original Medicare. For others, you may pay less. Our plan members also get more than what is covered by Original Medicare. Some of the extra benefits are outlined in this booklet. We cover Part B drugs such as chemotherapy and some drugs administered by your provider. However, this plan does not cover Part D prescription drugs. 2

7 Summary of Benefits Report for Contract H3384, Plan 022 BlueCross BlueShield Senior Blue HMO 601 (HMO) January 1, 2017 December 31, 2017 Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services Monthly plan premium $0 per month. In addition, you must keep paying your Medicare Part B premium. Deductible Maximum out-ofpocket responsibility (does not include prescription drugs) Is there a limit on how much the plan will pay? This plan does not have a deductible. Our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care. Your yearly limit(s) in this plan: $6,700 for services you receive from in-network providers. If you reach the limit on out-of-pocket costs, you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year. No. There are no limits on how much our plan will pay. Covered Medical and Hospital Benefits Note: Services with a 1 may require prior authorization. Inpatient Hospital Care 1 Our plan covers an unlimited number of days for an inpatient hospital stay. In-network: $280 copay per day for days 1 through 7 You pay nothing per day for days 8 through 90 You pay nothing per day for days 91 and beyond Your annual in-network out-of-pocket limit (what you pay) for inpatient hospital care is $1,960. After your limit has been reached you pay nothing for inpatient hospital care for the remainder of the year. Inpatient Mental Health Care For inpatient mental health care, see the "Mental Health Care" section of this booklet. 3

8 Doctor's Office Visits Primary care physician visit: $25 copay You pay $0 for a follow up visit with your PCP within 14 days following a discharge from a hospital, skilled nursing facility, Community Mental Health Centers stay, outpatient observation, or partial hospitalization, that meet the requirements as defined by Medicare. Specialist visit: In-network: $45 copay Preventive Care In-network: You pay nothing Our plan covers many preventive services, including: Abdominal aortic aneurysm screening Alcohol misuse counseling Bone mass measurement Breast cancer screening (mammogram) Cardiovascular disease (behavioral therapy) Cardiovascular screenings Cervical and vaginal cancer screening Colorectal cancer screenings (Colonoscopy, Fecal occult blood test, Flexible sigmoidoscopy) Depression screening Diabetes screenings HIV screening Medical nutrition therapy services Obesity screening and counseling Prostate cancer screenings (PSA) Sexually transmitted infections screening and counseling Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease) Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots "Welcome to Medicare" preventive visit (one-time) Yearly "Wellness" visit Any additional preventive services approved by Medicare during the contract year will be covered. 4

9 Emergency Care Urgently Needed Services Diagnostic Tests, Lab and Radiology Services, and X-Rays 1 $75 copay If you are admitted to the hospital within 1 day, you do not have to pay your share of the cost for emergency care. See the "Inpatient Hospital Care" section of this booklet for other costs. $65 copay If you are admitted to the hospital within 1 day, you do not have to pay your share of the cost for urgently needed services. See the "Inpatient Hospital Care" section of this booklet for other costs. Diagnostic radiology services (such as MRIs, CT scans): In-network: $75 copay Diagnostic tests and procedures: In-network: $45 copay Lab services: In-network: $5 copay Outpatient x-rays: In-network: $45 copay Hearing Services Therapeutic radiology services (such as radiation treatment for cancer): In-network: $45 copay Exam to diagnose and treat hearing and balance issues: In-network: $45 copay Routine hearing exam (one per year)*: $45 copay Hearing Aids (one per ear per year)*: $699 copayment per aid for Flyte 700 $999 copayment per aid for Flyte 900 *A TruHearing provider must be used. Dental Services Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): In-network: $45 copay 5

10 Vision Services Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): In-network: $45 copay Annual retinal eye exam for diabetes: In-network: $0 copay Routine eye exam (up to one every year)**: In-network: $45 copay Eyeglasses or contact lenses after cataract surgery: In-network: You pay nothing $100 annual allowance for eyewear **An EyeMed provider must be used Mental Health Care 1 Inpatient visit: Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital. Our plan covers 90 days for an inpatient hospital stay. Our plan also covers 60 "lifetime reserve days." These are "extra" days that we cover. If your hospital stay is longer than 90 days, you can use these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days. In-network: $260 copay per day for days 1 through 6 You pay nothing per day for days 7 through 90 Outpatient group therapy visit: In-network: $40 copay Outpatient individual therapy visit: In-network: $40 copay Your annual in-network out-of-pocket limit (what you pay) for inpatient mental health care is $1,560. After your limit has been reached you pay nothing for the remainder of the year. 6

11 Skilled Nursing Facility (SNF) 1 Our plan covers up to 100 days in a SNF. In-network: You pay nothing per day for days 1 through 20 $ copay per day for days 21 through 100 Our plan benefit period applies for any SNF stay. This means that if the member is discharged from the SNF for more than 60 days and readmitted a new benefit period starts. The Plan covers up to 100 days each benefit period. In this situation the members cost sharing applied starts at "day one". If the member is readmitted to the SNF within 60 days from their discharge date, they are still considered to be in the same benefit period. If the member is transferred from one SNF to another within 60 days, they are still considered to be in the same benefit period. In these situations, the member pays the per day copay that was in effect on the last day of the discharge or transfer. Outpatient Rehabilitation Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): In-network: $15 copay Occupational therapy visit: In-network: $25 copay Ambulance $150 copay Physical therapy and speech and language therapy visit: In-network: $25 copay Transportation Foot Care (podiatry services) Not covered Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: In-network: $45 copay Routine foot care (for up to 3 visit(s) every year): In-network: $45 copay Durable Medical Equipment (wheelchairs, oxygen, etc.) 1 Wellness Programs (e.g. fitness) In-network: 20% of the cost, depending on the equipment In-network: $0 copay for compression stockings There is no charge to participate in our Health and Wellness Education Programs. There is no charge for the SilverSneakers Fitness Program 7

12 Prescription Drug Benefits Medicare Part B Drugs 1 For Part B drugs such as chemotherapy drugs 1 : In-network: 20% of the cost Other Part B drugs: In-network: $25 copay or 20% of the cost, depending on the drug Optional Supplemental Benefits (you must pay an extra premium each month for these benefits) Package 1: Optional Supplemental Dental Basic How much is the monthly premium? How much is the deductible? Is there a limit on how much the plan will pay? Benefits include: Preventive Dental Comprehensive Dental Additional $17 per month. You must keep paying your Medicare Part B premium and your $0 monthly plan premium. This package does not have a deductible. Our plan pays up to $500 every year. Our plan has additional coverage limits for certain benefits. Optional Supplemental Benefits (you must pay an extra premium each month for these benefits) Package 2: Optional Supplemental Dental Enhanced How much is the monthly premium? How much is the deductible? Is there a limit on how much the plan will pay? Benefits include: Preventive Dental Comprehensive Dental Additional $31 per month. You must keep paying your Medicare Part B premium and your $0 monthly plan premium. This package does not have a deductible. Our plan pays up to $1,000 every year. Our plan has additional coverage limits for certain benefits. 8

13 Additional Benefits Chiropractic Care Diabetes Supplies and Services 1 Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): In-network: $20 copay Diabetes monitoring supplies: In-network: You pay nothing Diabetes self-management training: In-network: You pay nothing Therapeutic shoes or inserts: In-network: You pay nothing Home Health Care In-network: You pay nothing Outpatient Substance Abuse 1 Group therapy visit: In-network: 50% of the cost Individual therapy visit: In-network: 50% of the cost Outpatient Surgery 1 Ambulatory surgical center: In-network: $225 copay Prosthetic Devices (braces, artificial limbs, etc.) 1 Outpatient hospital observation: In-network: $75 copay Outpatient hospital surgical procedures: In-network: $275 copay Prosthetic devices: In-network: 20% of the cost Renal Dialysis In-network: $10 copay Hospice You pay nothing for hospice care from a Medicare- certified hospice. You may have to pay part of the cost for drugs and respite care. Hospice is covered outside of our plan. Please contact us for more details. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or co-payments/coinsurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium. The provider network may change at any time. You will receive notice when necessary. BlueCross BlueShield of Western New York is a Medicare Advantage plan with a Medicare contract and enrollment depends on contract renewal 9

14 BlueCross BlueShield Senior Blue HMO Select (HMO) Summary of Benefits January 1, December 31, 2017 This booklet gives you a summary of what we cover and what you pay. It doesn't list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, call us and ask for the "Evidence of Coverage." Tips for comparing your Medicare choices This Summary of Benefits booklet gives you a summary of what BlueCross BlueShield Senior Blue HMO Select (HMO) covers and what you pay. If you want to compare our plan with other Medicare health plans, ask the other plans for their Summary of Benefits booklets. Or, use the Medicare Plan Finder on If you want to know more about the coverage and costs of Original Medicare, look in your current "Medicare & You" handbook. View it online at or get a copy by calling MEDICARE ( ), 24 hours a day, 7 days a week. TTY users should call Hours of Operation From October 1 to February 14, you can call us 7 days a week from 8:00 a.m. to 8:00 p.m. Eastern time. From February 15 to September 30, you can call us Monday through Friday from 8:00 a.m. to 8:00 p.m. Eastern time. BlueCross BlueShield Senior Blue HMO Select (HMO) Phone Numbers and Website If you are a member of this plan, call toll-free (TTY 711) If you are not a member of this plan, call toll-free (TTY 711). Our website: Who can join? To join BlueCross BlueShield Senior Blue HMO Select (HMO), you must be entitled to Medicare Part A, be enrolled in Medicare Part B, and live in our service area. Our service area includes the following counties in New York: Allegany, Cattaraugus, Chautauqua, Erie, Genesee, Niagara, Orleans, Wyoming. 1 Y0086_COM417 Accepted

15 Which doctors, hospitals, and pharmacies can I use? BlueCross BlueShield Senior Blue HMO Select (HMO) has a network of doctors, hospitals, pharmacies, and other providers. If you use the providers that are not in our network, the plan may not pay for these services. You must generally use network pharmacies to fill your prescriptions for covered Part D drugs. Some of our network pharmacies have preferred cost-sharing. You may pay less if you use these pharmacies. You can see our plan's provider and pharmacy directory at our website, Or, call us and we will send you a copy of the provider and pharmacy directories. What do we cover? Like all Medicare health plans, we cover everything that Original Medicare covers and more. Our plan members get all of the benefits covered by Original Medicare. For some of these benefits, you may pay more in our plan than you would in Original Medicare. For others, you may pay less. Our plan members also get more than what is covered by Original Medicare. Some of the extra benefits are outlined in this booklet. We cover Part D drugs. In addition, we cover Part B drugs such as chemotherapy and some drugs administered by your provider. You can see the complete plan formulary (list of Part D prescription drugs) and any restrictions on our website, Or, call us and we will send you a copy of the formulary. 2

16 Summary of Benefits Report for Contract H3384, Plan 058 BlueCross BlueShield Senior Blue HMO Select (HMO) January 1, 2017 December 31, 2017 Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services Monthly plan premium $41 per month. In addition, you must keep paying your Medicare Part B premium. Deductible Maximum out-of-pocket responsibility (does not include prescription drugs) Is there a limit on how much the plan will pay? This plan does not have a deductible. Our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care. Your yearly limit(s) in this plan: $6,700 for services you receive from in-network providers. If you reach the limit on out-of-pocket costs, you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year. Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs. No. There are no limits on how much our plan will pay. Covered Medical and Hospital Benefits Note: Services with a 1 may require prior authorization. Inpatient Hospital Care 1 Our plan covers an unlimited number of days for an inpatient hospital stay. In-network: $280 copay per day for days 1 through 7 You pay nothing per day for days 8 through 90 You pay nothing per day for days 91 and beyond Your annual in-network out-of-pocket limit (what you pay) for inpatient hospital care is $1,960. After your limit has been reached, you pay nothing for inpatient hospital care for the remainder of the year. 3

17 Inpatient Mental Health Care Doctor's Office Visits For inpatient mental health care, see the "Mental Health Care" section of this booklet. Primary care physician visit: In-network: $30 copay Specialist visit: In-network: $50 copay Preventive Care In-network: You pay nothing Our plan covers many preventive services, including: Abdominal aortic aneurysm screening Alcohol misuse counseling Bone mass measurement Breast cancer screening (mammogram) Cardiovascular disease (behavioral therapy) Cardiovascular screenings Cervical and vaginal cancer screening Colorectal cancer screenings (Colonoscopy, Fecal occult blood test, Flexible sigmoidoscopy) Depression screening Diabetes screenings HIV screening Medical nutrition therapy services Obesity screening and counseling Prostate cancer screenings (PSA) Sexually transmitted infections screening and counseling Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease) Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots "Welcome to Medicare" preventive visit (one-time) Yearly "Wellness" visit Any additional preventive services approved by Medicare during the contract year will be covered. 4

18 Emergency Care Urgently Needed Services Diagnostic Tests, Lab and Radiology Services, and X-Rays 1 $75 copay If you are admitted to the hospital within 1 day, you do not have to pay your share of the cost for emergency care. See the "Inpatient Hospital Care" section of this booklet for other costs. $65 copay If you are admitted to the hospital within 1 day, you do not have to pay your share of the cost for urgently needed services. See the "Inpatient Hospital Care" section of this booklet for other costs. Diagnostic radiology services (such as MRIs or CT scans): In-network: $175 copay Diagnostic tests and procedures: In-network: $50 copay Lab services: In-network: $5 copay Outpatient x-rays: In-network: $50 copay Hearing Services Therapeutic radiology services (such as radiation treatment for cancer): In-network: $50 copay Exam to diagnose and treat hearing and balance issues: In-network: $50 copay Routine hearing exam (one per year)*: In-network $45 copay Hearing Aids (one per ear per year)*: $699 copayment per aid for Flyte 700 $999 copayment per aid for Flyte 900 *A TruHearing provider must be used. Dental Services Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): In-network: $50 copay 5

19 Vision Services Routine eye exam (up to one every year)**: In-network: $50 copay Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): In-network: $50 copay Annual retinal eye exam for diabetes: In-network: $0 copay Eyeglasses or contact lenses after cataract surgery: In-network: You pay nothing $100 annual allowance for eyewear **An EyeMed provider must be used Mental Health Care 1 Inpatient visit: Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital. In-network: $260 copay per day for days 1 through 6 You pay nothing per day for days 7 through 90 Outpatient group therapy visit: In-network: $40 copay Outpatient individual therapy visit: In-network: $40 copay Your annual in-network out-of-pocket limit (what you pay) for inpatient mental health care is $1,560. After your limit has been reached you pay nothing for the remainder of the year. Skilled Nursing Facility (SNF) 1 Our plan covers up to 100 days in a SNF. In-network: You pay nothing per day for days 1 through 20 $ copay per day for days 21 through 100 6

20 Our plan benefit period applies for any SNF stay. This means that if the member is discharged from the SNF for more than 60 days and readmitted a new benefit period starts. The Plan covers up to 100 days each benefit period. In this situation the members cost sharing applied starts at "day one". If the member is readmitted to the SNF within 60 days from their discharge date, they are still considered to be in the same benefit period. If the member is transferred from one SNF to another within 60 days, they are still considered to be in the same benefit period. In these situations, the member pays the per day copay that was in effect on the last day of the discharge or transfer. Outpatient Rehabilitation Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): In-network: $15 copay Occupational therapy visit: In-network: $35 copay Physical therapy and speech and language therapy visit: In-network: $35 copay Ambulance $200 copay Transportation Not covered Foot Care (podiatry services) Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: In-network: $50 copay Routine foot care (for up to 3 visit(s) every year): In-network: $50 copay Durable Medical Equipment (wheelchairs, oxygen, etc.) 1 Wellness Programs (e.g. fitness) In-network: 20% of the cost, depending on the equipment In-network: $0 copay for compression stockings There is no charge to participate in our Health and Wellness Education Programs. There is no charge for the SilverSneakers Fitness Program 7

21 Prescription Drug Benefits Medicare Part For Part B drugs such as chemotherapy drugs 1 : B Drugs 1 In-network: 20% of the cost Other Part B drugs 1 : In-network: 20% of the cost Part D Drugs Initial Coverage You pay the following until your total yearly drug costs reach $3,700. Total yearly drug costs are the total drug costs paid by both you and our Part D plan. You may get your drugs at network retail pharmacies and mail order pharmacies. Tier Tier 1 (Preferred Generic) Tier 2 (Generic) Tier 3 (Preferred Brand) Tier 4 (Non-Preferred Drug) Tier 5 (Specialty Tier) Onemonth supply Preferred One-month supply Standard Three-month supply Mail-order $10 copay $15 copay $25 copay $15 copay $20 copay $37.50 copay $42 copay $47 copay $105 copay $94 copay $100 copay $235 copay 33% of the cost 33% of the cost 33% of the cost If you reside in a long-term care facility, you pay the same as at a Standard retail pharmacy. Your cost share for a three-month supply at retail is three times the cost for the applicable one-month supply (Preferred or Standard). You may get drugs from an out-of-network pharmacy and pay the same as an innetwork pharmacy, but you will get less of the drug. 8

22 Coverage Gap Most Medicare drug plans have a coverage gap (also called the "donut hole"). This means that there's a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $3,700. After you enter the coverage gap, you pay 40% of the plan's cost for covered brand name drugs and 51% of the plan's cost for covered generic drugs until your costs total $4,950, which is the end of the coverage gap. Not everyone will enter the coverage gap. Catastrophic Coverage After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4,950, you pay the greater of: 5% of the cost, or $3.30 copay for generic (including brand drugs treated as generic) and a $8.25 copayment for all other drugs. 9

23 Optional Supplemental Benefits (you must pay an extra premium each month for these benefits) Package 1: Optional Supplemental Dental Basic How much is the monthly premium? How much is the deductible? Is there a limit on how much the plan will pay? Benefits include: Preventive Dental Comprehensive Dental Additional $17 per month. You must keep paying your Medicare Part B premium and your $41 monthly plan premium. This package does not have a deductible. Our plan pays up to $500 every year. Our plan has additional coverage limits for certain benefits. Optional Supplemental Benefits (you must pay an extra premium each month for these benefits) Package 2: Optional Supplemental Dental Enhanced How much is the monthly premium? How much is the deductible? Is there a limit on how much the plan will pay? Benefits include: Preventive Dental Comprehensive Dental Additional $31 per month. You must keep paying your Medicare Part B premium and your $41 monthly plan premium. This package does not have a deductible. Our plan pays up to $1,000 every year. Our plan has additional coverage limits for certain benefits. 10

24 Additional Benefits Chiropractic Care Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): In-network: $20 copay Diabetes Supplies and Services 1 Diabetes monitoring supplies: In-network: You pay nothing Diabetes self-management training: In-network: You pay nothing Therapeutic shoes or inserts: In-network: You pay nothing Home Health Care Outpatient Substance Abuse 1 Outpatient Hospital Services 1 In-network: You pay nothing Group therapy visit: In-network: 50% of the cost Individual therapy visit: In-network: 50% of the cost Ambulatory surgical center: In-network: $300 copay Outpatient hospital observation: In-network: $75 copay Prosthetic Devices (braces, artificial limbs, etc.) 1 Outpatient hospital surgical procedures: In-network $350 copay Prosthetic devices: In-network: 20% of the cost Renal Dialysis In-network: $30 copay Hospice You pay nothing for hospice care from a Medicare-certified hospice. You may have to pay part of the cost for drugs and respite care. Hospice is covered outside of our plan. Please contact us for more details. 11

25 This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or co-payments/co-insurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium. The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. BlueCross BlueShield of Western New York is a Medicare Advantage plan with a Medicare contract and enrollment depends on contract renewal. You can get prescription drugs shipped to your home through the network mail-order delivery program. You should expect to receive your mail-order prescriptions calendar days after the pharmacy initially receives the order. Please call the Pharmacy Services number located on the back of your member ID card if you do not receive your prescription within the appropriate amount of days. 12

26 BlueCross BlueShield Senior Blue HMO 651 (HMO) Summary of Benefits January 1, December 31, 2017 This booklet gives you a summary of what we cover and what you pay. It doesn't list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, call us and ask for the "Evidence of Coverage." Tips for comparing your Medicare choices This Summary of Benefits booklet gives you a summary of what BlueCross BlueShield Senior Blue HMO 651 (HMO) covers and what you pay. If you want to compare our plan with other Medicare health plans, ask the other plans for their Summary of Benefits booklets. Or, use the Medicare Plan Finder on If you want to know more about the coverage and costs of Original Medicare, look in your current "Medicare & You" handbook. View it online at or get a copy by calling MEDICARE ( ), 24 hours a day, 7 days a week. TTY users should call Hours of Operation From October 1 to February 14, you can call us 7 days a week from 8:00 a.m. to 8:00 p.m. Eastern time. From February 15 to September 30, you can call us Monday through Friday from 8:00 a.m. to 8:00 p.m. Eastern time. BlueCross BlueShield Senior Blue HMO 651 (HMO) Phone Numbers and Website If you are a member of this plan, call toll-free (TTY 711) If you are not a member of this plan, call toll-free (TTY 711). Our website: Who can join? To join BlueCross BlueShield Senior Blue HMO 651 (HMO), you must be entitled to Medicare Part A, be enrolled in Medicare Part B, and live in our service area. Our service area includes the following counties in New York: Allegany, Cattaraugus, Chautauqua, Erie, Genesee, Niagara, Orleans, Wyoming. 1 Y0086_COM418 Accepted

27 Which doctors, hospitals, and pharmacies can I use? BlueCross BlueShield Senior Blue HMO 651 (HMO) has a network of doctors, hospitals, pharmacies, and other providers. If you use the providers that are not in our network, the plan may not pay for these services. You must generally use network pharmacies to fill your prescriptions for covered Part D drugs. Some of our network pharmacies have preferred cost-sharing. You may pay less if you use these pharmacies. You can see our plan's provider and pharmacy directory at our website, Or, call us and we will send you a copy of the provider and pharmacy directories. What do we cover? Like all Medicare health plans, we cover everything that Original Medicare covers and more. Our plan members get all of the benefits covered by Original Medicare. For some of these benefits, you may pay more in our plan than you would in Original Medicare. For others, you may pay less. Our plan members also get more than what is covered by Original Medicare. Some of the extra benefits are outlined in this booklet. We cover Part D drugs. In addition, we cover Part B drugs such as chemotherapy and some drugs administered by your provider. You can see the complete plan formulary (list of Part D prescription drugs) and any restrictions on our website, Or, call us and we will send you a copy of the formulary. 2

28 Summary of Benefits Report for Contract H3384, Plan 019 BlueCross BlueShield Senior Blue HMO 651 (HMO) January 1, 2017 December 31, 2017 Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services Monthly plan premium Deductible Maximum out-ofpocket responsibility (does not include prescription drugs) Is there a limit on how much the plan will pay? $108 per month. In addition, you must keep paying your Medicare Part B premium. This plan does not have a deductible. Our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care. Your yearly limit(s) in this plan: $6,700 for services you receive from in-network providers. If you reach the limit on out-of-pocket costs, you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year. Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs. No. There are no limits on how much our plan will pay. Covered Medical and Hospital Benefits Note: Services with a 1 may require prior authorization. Inpatient Hospital Care 1 Inpatient Mental Health Care Our plan covers an unlimited number of days for an inpatient hospital stay. In-network: $225 copay per day for days 1 through 7 You pay nothing per day for days 8 through 90 You pay nothing per day for days 91 and beyond Your annual in-network out-of-pocket limit (what you pay) for inpatient hospital care is $1,575. After your limit has been reached, you pay nothing for inpatient hospital care for the remainder of the year. For inpatient mental health care, see the "Mental Health Care" section of this booklet. 3

29 Doctor's Office Visits Primary care physician visit: In-network: $20 copay You pay $0 for a follow up visit with your PCP within 14 days following a discharge from a hospital, skilled nursing facility, Community Mental Health Centers stay, outpatient observation, or partial hospitalization that meets the requirements as defined by Medicare. Specialist visit: In-network: $35 copay Preventive Care In-network: You pay nothing Our plan covers many preventive services, including: Abdominal aortic aneurysm screening Alcohol misuse counseling Bone mass measurement Breast cancer screening (mammogram) Cardiovascular disease (behavioral therapy) Cardiovascular screenings Cervical and vaginal cancer screening Colorectal cancer screenings (Colonoscopy, Fecal occult blood test, Flexible sigmoidoscopy) Depression screening Diabetes screenings HIV screening Medical nutrition therapy services Obesity screening and counseling Prostate cancer screenings (PSA) Sexually transmitted infections screening and counseling Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease) Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots "Welcome to Medicare" preventive visit (one-time) Yearly "Wellness" visit Any additional preventive services approved by Medicare during the contract year will be covered. 4

30 Emergency Care Urgently Needed Services Diagnostic Tests, Lab and Radiology Services, and X-Rays 1 $75 copay If you are admitted to the hospital within 1 day, you do not have to pay your share of the cost for emergency care. See the "Inpatient Hospital Care" section of this booklet for other costs. $65 copay If you are admitted to the hospital within 1 day, you do not have to pay your share of the cost for urgently needed services. See the "Inpatient Hospital Care" section of this booklet for other costs. Diagnostic radiology services (such as MRIs or CT scans): In-network: $75 copay Diagnostic tests and procedures: In-network: $40 copay Lab services: In-network: $5 copay Outpatient x-rays: In-network: $40 copay Hearing Services Therapeutic radiology services (such as radiation treatment for cancer): In-network: $40 copay Exam to diagnose and treat hearing and balance issues: In-network: $35 copay Routine hearing exam (one per year)*: In-network $45 copay Hearing Aids (one per ear per year)*: $699 copayment per aid for Flyte 700 $999 copayment per aid for Flyte 900 *A TruHearing provider must be used. Dental Services Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): In-network: $35 copay 5

31 Vision Services Routine eye exam (up to one every year)**: In-network: $35 copay Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): In-network: $35 copay Annual retinal eye exam for diabetes: In-network: $0 copay Eyeglasses or contact lenses after cataract surgery: In-network: You pay nothing $100 annual allowance for eyewear Mental Health Care 1 **An EyeMed provider must be used Inpatient visit: Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital. In-network: $215 copay per day for days 1 through 6 You pay nothing per day for days 7 through 90 Outpatient group therapy visit: In-network: $40 copay Outpatient individual therapy visit: In-network: $40 copay Your annual in-network out-of-pocket limit (what you pay) for inpatient mental health care is $1,290. After your limit has been reached you pay nothing for the remainder of the year. 6

32 Skilled Nursing Facility (SNF) 1 Our plan covers up to 100 days in a SNF. In-network: You pay nothing per day for days 1 through 20 $ copay per day for days 21 through 100 Our plan benefit period applies for any SNF stay. This means that if the member is discharged from the SNF for more than 60 days and readmitted a new benefit period starts. The Plan covers up to 100 days each benefit period. In this situation the members cost sharing applied starts at "day one". If the member is readmitted to the SNF within 60 days from their discharge date, they are still considered to be in the same benefit period. If the member is transferred from one SNF to another within 60 days, they are still considered to be in the same benefit period. In these situations, the member pays the per day copay that was in effect on the last day of the discharge or transfer. Outpatient Rehabilitation Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): In-network: $15 copay Occupational therapy visit: In-network: $15 copay Physical therapy and speech and language therapy visit: In-network: $15 copay Ambulance $125 copay Transportation Not covered Foot Care (podiatry services) Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: In-network: $35 copay Routine foot care (for up to 3 visit(s) every year): In-network: $35 copay 7

33 Durable Medical Equipment (wheelchairs, oxygen, etc.) 1 Wellness Programs (e.g. fitness) In-network: 20% of the cost, depending on the equipment In-network: $0 copay for compression stockings There is no charge to participate in our Health and Wellness Education Programs. There is no charge for the SilverSneakers Fitness Program Prescription Drug Benefits Medicare Part For Part B drugs such as chemotherapy drugs 1 : B Drugs 1 In-network: 20% of the cost Part D Drugs Initial Coverage Other Part B drugs 1 : In-network: $25 copay or 20% of the cost, depending on the drug You pay the following until your total yearly drug costs reach $3,700. Total yearly drug costs are the total drug costs paid by both you and our Part D plan. You may get your drugs at network retail pharmacies and mail order pharmacies. Tier One-month supply Preferred One-month supply Standard Three-month supply Mail-order Tier 1 (Preferred Generic) Tier 2 (Generic) Tier 3 (Preferred Brand) Tier 4 (Non- Preferred Drug) Tier 5 (Specialty Tier) $7 copay $12 copay $17.50 copay $15 copay $20 copay $37.50 copay $42 copay $47 copay $105 copay $94 copay $100 copay $235 copay 33% of the cost 33% of the cost 33% of the cost 8

34 If you reside in a long-term care facility, you pay the same as at a Standard retail pharmacy. Your cost share for a three-month supply at retail is three times the cost for the applicable one-month supply (Preferred or Standard). You may get drugs from an out-of-network pharmacy and pay the same as an innetwork pharmacy, but you will get less of the drug. Coverage Gap Most Medicare drug plans have a coverage gap (also called the "donut hole"). This means that there's a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $3,700. During the coverage gap stage, you will continue to pay your applicable copay for Tier 1 Preferred Generic drugs. For all other covered prescription drugs, you pay 40% of the plan's cost for covered brand name drugs and 51% of the plan's cost for covered generic drugs until your costs total $4,950, which is the end of the coverage gap. Not everyone will enter the coverage gap. Catastrophic Coverage After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4,950, you pay the greater of: 5% of the cost, or $3.30 copay for generic (including brand drugs treated as generic) and a $8.25 copayment for all other drugs. Optional Supplemental Benefits (you must pay an extra premium each month for these benefits) Package 1: Optional Supplemental Dental Basic How much is the monthly premium? How much is the deductible? Benefits include: Preventive Dental Comprehensive Dental Additional $17 per month. You must keep paying your Medicare Part B premium and your $108 monthly plan premium. This package does not have a deductible. 9

35 Is there a limit on how much the plan will pay? Our plan pays up to $500 every year. Our plan has additional coverage limits for certain benefits. 10

36 Optional Supplemental Benefits (you must pay an extra premium each month for these benefits) Package 2: Optional Supplemental Dental Enhanced How much is the monthly premium? How much is the deductible? Is there a limit on how much the plan will pay? Benefits include: Preventive Dental Comprehensive Dental Additional $31 per month. You must keep paying your Medicare Part B premium and your $108 monthly plan premium. This package does not have a deductible. Our plan pays up to $1,000 every year. Our plan has additional coverage limits for certain benefits. 11

37 Additional Benefits Chiropractic Care Diabetes Supplies and Services 1 Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): In-network: $20 copay Diabetes monitoring supplies: In-network: You pay nothing Diabetes self-management training: In-network: You pay nothing Home Health Care Outpatient Substance Abuse 1 Outpatient Hospital Services 1 Prosthetic Devices (braces, artificial limbs, etc.) 1 Therapeutic shoes or inserts: In-network: You pay nothing In-network: You pay nothing Group therapy visit: In-network: 50% of the cost Individual therapy visit: In-network: 50% of the cost Ambulatory surgical center: In-network: $225 copay Outpatient hospital observation: In-network: $75 copay Outpatient hospital surgical procedures: In-network $275 copay Prosthetic devices: In-network: 20% of the cost Renal Dialysis In-network: $10 copay Hospice You pay nothing for hospice care from a Medicare-certified hospice. You may have to pay part of the cost for drugs and respite care. Hospice is covered outside of our plan. Please contact us for more details. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums 12

38 and/or co-payments/co-insurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium. The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. BlueCross BlueShield of Western New York is a Medicare Advantage plan with a Medicare contract and enrollment depends on contract renewal. You can get prescription drugs shipped to your home through the network mail-order delivery program. You should expect to receive your mail-order prescriptions calendar days after the pharmacy initially receives the order. Please call the Pharmacy Services number located on the back of your member ID card if you do not receive your prescription within the appropriate amount of days. 13

39

40 2017 Forever Blue Medicare PPO H5526 Summary of Benefits

41

42 BlueCross BlueShield Forever Blue Medicare PPO Focus (PPO) Summary of Benefits January 1, December 31, 2017 This booklet gives you a summary of what we cover and what you pay. It doesn't list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, call us and ask for the "Evidence of Coverage." Tips for comparing your Medicare choices This Summary of Benefits booklet gives you a summary of what BlueCross BlueShield Forever Blue Medicare PPO Focus (PPO) covers and what you pay. If you want to compare our plan with other Medicare health plans, ask the other plans for their Summary of Benefits booklets. Or, use the Medicare Plan Finder on If you want to know more about the coverage and costs of Original Medicare, look in your current "Medicare & You" handbook. View it online at or get a copy by calling MEDICARE ( ), 24 hours a day, 7 days a week. TTY users should call Hours of Operation From October 1 to February 14, you can call us 7 days a week from 8:00 a.m. to 8:00 p.m. Eastern time. From February 15 to September 30, you can call us Monday through Friday from 8:00 a.m. to 8:00 p.m. Eastern time. BlueCross BlueShield Forever Blue Medicare PPO Focus (PPO) Phone Numbers and Website If you are a member of this plan, call toll-free (TTY 711) If you are not a member of this plan, call toll-free (TTY 711). Our website: Who can join? To join BlueCross BlueShield Forever Blue Medicare PPO Focus (PPO), you must be entitled to Medicare Part A, be enrolled in Medicare Part B, and live in our service area. Our service area includes the following counties in New York: Erie, Niagara. 1 Y0086_COM419 Accepted

43 Which doctors, hospitals, and pharmacies can I use? BlueCross BlueShield Forever Blue Medicare PPO Focus (PPO) has a network of doctors, hospitals, pharmacies, and other providers. If you use the providers in our network, you may pay less for your covered services. But if you want to, you can also use providers that are not in our network. You must generally use network pharmacies to fill your prescriptions for covered Part D drugs. Some of our network pharmacies have preferred cost-sharing. You may pay less if you use these pharmacies. You can see our plan's provider and pharmacy directory at our website, Or, call us and we will send you a copy of the provider and pharmacy directories. What do we cover? Like all Medicare health plans, we cover everything that Original Medicare covers and more. Our plan members get all of the benefits covered by Original Medicare. For some of these benefits, you may pay more in our plan than you would in Original Medicare. For others, you may pay less. Our plan members also get more than what is covered by Original Medicare. Some of the extra benefits are outlined in this booklet. We cover Part D drugs. In addition, we cover Part B drugs such as chemotherapy and some drugs administered by your provider. You can see the complete plan formulary (list of Part D prescription drugs) and any restrictions on our website, Or, call us and we will send you a copy of the formulary. 2

44 Summary of Benefits Report for Contract H5526, Plan 019 BlueCross BlueShield Forever Blue Medicare PPO Focus (PPO) January 1, 2017 December 31, 2017 Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services Monthly plan premium Deductible $78 per month. In addition, you must keep paying your Medicare Part B premium. This plan does not have a deductible. Maximum outof-pocket responsibility (does not include prescription drugs) Our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care. Your yearly limit(s) in this plan: $6,700 for services you receive from in-network providers. $10,000 for services you receive from any provider. Your limit for services received from in-network providers will count toward this limit. If you reach the limit on out-of-pocket costs, you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year. Is there a limit on how much the plan will pay? Please note that you will still need to pay your monthly premiums and costsharing for your Part D prescription drugs. No. There are no limits on how much our plan will pay. Covered Medical and Hospital Benefits Note: Services with a 1 may require prior authorization. Inpatient Hospital Care 1 Our plan covers an unlimited number of days for an inpatient hospital stay. In-network: $270 copay per day for days 1 through 7 You pay nothing per day for days 8 through 90 You pay nothing per day for days 91 and beyond Out-of-network: 35% of the cost per stay Your annual in-network out-of-pocket limit (what you pay) for inpatient hospital care is $1,890. After your limit has been reached, you pay nothing for inpatient hospital care for the remainder of the year. 3

45 Inpatient Mental Health Care Doctor's Office Visits For inpatient mental health care, see the "Mental Health Care" section of this booklet. Primary care physician visit: In-network: $30 copay Specialist visit: In-network: $50 copay Preventive Care In-network: You pay nothing Our plan covers many preventive services, including: Abdominal aortic aneurysm screening Alcohol misuse counseling Bone mass measurement Breast cancer screening (mammogram) Cardiovascular disease (behavioral therapy) Cardiovascular screenings Cervical and vaginal cancer screening Colorectal cancer screenings (Colonoscopy, Fecal occult blood test, Flexible sigmoidoscopy) Depression screening Diabetes screenings HIV screening Medical nutrition therapy services Obesity screening and counseling Prostate cancer screenings (PSA) Sexually transmitted infections screening and counseling Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease) Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots "Welcome to Medicare" preventive visit (one-time) Yearly "Wellness" visit Any additional preventive services approved by Medicare during the contract year will be covered. 4