Blue Shield 65 Plus (HMO) benefit overview

Transcription

1 Los Angeles/Orange counties Blue Shield 65 Plus (HMO) benefit overview Medicare Advantage Prescription Drug plan Effective January 1 through December 31, 2013 what s inside 1. why choose Blue Shield 2. summary of 2013 medical benefits 3. summary of 2013 prescription drug coverage 4. SilverSneakers Fitness Program 5. services to help you save money 6. how to enroll 7. what to expect H0504_12_158B CMS Approved blueshieldca.com

2 1. why choose Blue Shield You may be asking yourself what to look for when picking a health plan. Or maybe you re trying to decide between two plans that have similar cost-sharing. Here are some of the things we think you should consider before enrolling. 1. Is your doctor in the plan s network? We have a large network of primary care physicians and specialists, so chances are you can keep seeing your doctor. Or, if you re ready to switch doctors, we can help you find a physician that is convenient for you. 2. Are your prescriptions, or an acceptable alternative, covered? If you currently take medications, be sure you confirm that your medications, or an acceptable alternative, are on our comprehensive formulary (list of drugs). 3. What are the plan s cost-sharing amounts? Use this brochure and our Summary of Benefits to compare what you will pay with our plan versus the other plan. Does the other plan offer these important benefits? ments for primary care physician office visits, basic outpatient tests, and X-rays ment for SilverSneakers Fitness Program 4. Is the plan offered by a reputable, financially sound company that comes recommended by its members? This is where we feel our plan really stands out from the competition. Why? Our members rate us 4.6 out of 5 stars* Members rate our plan online using five categories: customer service, value, easy to use and understand, access to doctors, and access to prescription drugs. We serve California, not shareholders As a not-for-profit corporation, we don t answer to shareholders. Our focus is on our mission to ensure all Californians have access to highquality health care at an affordable price; our members; and our communities. To learn more, visit blueshieldcafoundation.org. We re financially sound As of August 2012, Blue Shield is rated A (excellent) from A.M. Best, Standard & Poor s, and Weiss Ratings. Quality you can trust As of October 28, 2011, our Medicare Advantage plans have earned Commendable accreditation from the National Committee for Quality Assurance (NCQA). Here s the bottom line. Over 100,000 Medicare beneficiaries in California have trusted their healthcare coverage to Blue Shield of California. We know California, and we continue to deliver high-quality health care at an affordable price, a tradition we have been building on for more than 70 years. * Based on 476 reviews by Blue Shield 65 Plus SM and Blue Shield 65 Plus Choice Plan members on Blue Shield s Ratings & Reviews website from September 2009 to December About Blue Shield, Fast Facts at blueshieldca.com. Blue Shield Medicare Advantage HMO and Medicare Supplement plan membership reporting as of June 2012.

3 2. summary of 2013 medical benefits Effective January 1 through December 31, 2013 Available in select areas of Los Angeles County and all of Orange County* Benefit Monthly plan premium (you must continue to pay Medicare Part B premium) Annual out-of-pocket maximum (Medicare Parts A and B covered services) Annual wellness visit (one routine exam per 12-month period) Primary care physician visits Specialist office visits (with primary care physician referral) With Blue Shield 65 Plus, you pay: $0 $3,000 $5 copay Inpatient hospital care $50/day for days 1-5 $250 annual copay maximum Outpatient surgery (when performed at an ambulatory surgical center) Basic outpatient diagnostic tests, basic X-rays, and lab services (according to Medicare guidelines; prior authorization required) Vision care routine eye exam and refraction (once every 12-month period through network providers) Ambulance Basic gym membership/fitness program through SilverSneakers Urgent care (worldwide coverage) Emergency services (worldwide coverage) Skilled nursing facility (100 days per benefit period; no prior hospitalization required if in network) NurseHelp 24/7 SM (offers telephone and online health and medical information, education, and support) $20 copay $250 copay per trip, one way ; see Section 4 of this document $10 copay $65 copay $0/day for days 1 to 10 $85/day for days 11 to 100 * Refer to the Summary of Benefits for a complete description of the service area. $10,000 annual limit for emergency services and urgently needed services outside the U.S. 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.

4 3. Available in select areas of Los Angeles County and all of Orange County* summary of 2013 prescription drug coverage Part D prescription drug benefit (using network pharmacies) Drug limits Deductible $0 With Blue Shield 65 Plus, you pay: No calendar-year limit (see coverage gap limitations below) One-month (30-day) supply from a network preferred or other network pharmacy Tier 1: Preferred Generic Drugs $5 copay $10 copay Tier 2: Preferred Brand Drugs (includes non-preferred generics) $40 copay $80 copay Three-month (90-day) supply from a network preferred pharmacy or through mail service Tier 3: Non-Preferred Brand Drugs $80 copay $160 copay Tier 4: Injectable Drugs (drugs that are generally self-administered by injection) Tier 5: Specialty Tier Drugs Coverage gap (coverage for outpatient prescription drugs after the total yearly drug costs paid by both you and Blue Shield reach $2,970 until your yearly out-of-pocket drug costs reach $4,750) 25% of Blue Shield s contracted rate 33% of Blue Shield s contracted rate 25% of Blue Shield s contracted rate 33% of Blue Shield s contracted rate Tier 1 Preferred Generic Drugs are covered at the copays described above; for all other tiers, you pay 47.5% for brand drugs, and you pay 79% for generic drugs. Whether a drug is considered generic or brand can be determined using the plan formulary. Network retail preferred pharmacies Get a 90-day supply of drugs for only two 30-day copays when you visit one of our network preferred pharmacies! Albertsons/Osco/Sav-on (877) [TTY: 711] CVS Pharmacies (800) [TTY: 711] * Refer to your Summary of Benefits or Evidence of Coverage for a complete description of the service area. Accepts e-prescribing.

5 4. SilverSneakers Fitness Program Exercise, education, and social activities are very important to your health and well-being, which is why Blue Shield of California offers the SilverSneakers Fitness Program at no additional cost! With the SilverSneakers Fitness Program, you ll have a basic health club membership at a participating location in your community where you can get fit, have fun, and make friends. The SilverSneakers Fitness Program includes: Access to a variety of participating locations across the country, including gyms, senior centers, aquatics centers, and Curves (women only) Access to exercise equipment and amenities such as treadmills, swimming pools, indoor walking tracks, and weight machines (amenities may vary by location) Signature SilverSneakers Fitness Program classes, designed specifically for older adults and taught by certified instructors Additional signature classes, such as YogaStretch, SilverSplash, and CardioFit (available at select locations) Fun social activities and events, including health education seminars Visit to view a list of participating locations by ZIP code and choose the most convenient location. Remember, when you travel you can use any participating location in the nation! Enroll today and be one step closer to a healthier lifestyle. Is going to a participating SilverSneakers location inconvenient? We also offer SilverSneakers Steps, a self-directed fitness program designed for members without convenient access to participating locations. Blue Shield 65 Plus members, who live more than 15 miles from a SilverSneakers fitness location, can order a Steps kit with tools and program materials to help you achieve a healthier lifestyle by increasing your level of physical activity. The program helps you to: Set your individual fitness goals Track your progress You can choose to attend a participating fitness center in combination with using the SilverSneakers Steps program, or just use the Steps kit in the convenience of your own home.

6 5. services to help you save money We want to help you feel your best, so we offer many convenient discounts that can help you save money while you get (or stay) healthy. These discounts are available automatically, without any extra cost or paperwork. The products and services described below are neither offered nor guaranteed under our contract with the Medicare program. In addition, they are not subject to the Medicare appeals process. Any disputes regarding these products and services may be subject to the Blue Shield 65 Plus grievance process. Wellness discount programs As a Blue Shield 65 Plus member, you can save on a wide variety of services from participating practitioners to help you manage a healthier lifestyle. Alternative care discount program Acupuncture services* Receive 25% off usual and customary fees for services such as acupuncture and electro-acupuncture. Chiropractic* (for services not covered by Medicare) Receive 25% off usual and customary fees for services such as examinations, manipulative treatment, and adjunctive therapeutic services. Massage therapy* Receive 25% off usual and customary fees for services such as Swedish massage, deep-muscle and deep-tissue massage, trigger-point therapy, shiatsu, acupressure, reflexology, and sports massage. Health and wellness products* Get discounts up to 40% on vitamins, herbal supplements, fitness equipment, and more. Most items ship for free. Hearing-aid discounts Members can save 32% on hearing aids purchased through Newport Audiology, and receive other discounts on products and services. Vision care discounts Members save on a wide range of products and services, including eyeglass frames and lenses, and contact lenses. * Provider networks and products are available through American Specialty Health Systems Inc. using ASH Networks. For more information, go to blueshieldca.com and click on Health & Wellness, then select Wellness Discount Programs. Vision plans administered by EyeMed Vision Care, LLC, First American Administrators.

7 6. how to enroll Apply by mail. Complete, sign, and date the enrollment form, then mail it to us in the enclosed postage-paid envelope. If you have any questions or need help filling out your enrollment form, call your authorized Blue Shield broker. Speak with your authorized Blue Shield broker to enroll in Blue Shield 65 Plus and activate your new benefits for what to expect once you enroll 1. Acknowledgement letter: We will notify you that we received your completed enrollment form and are waiting for Medicare to approve your enrollment. The letter will include a copy of your enrollment form for your records. 2. Confirmation letter: Confirmation that Medicare has approved your enrollment in our plan. 3. New-member verification call: We will call you to verify that you understand that you ve been enrolled in our plan and how the plan works. If we don t reach you by phone, we ll follow up with a letter. 4. Other health insurance survey: Allows us to tell Medicare whether or not you have other insurance in addition to our plan. 5. Welcome Kit: A full explanation of how to use your new plan. Be sure to read the Member Handbook and the Evidence of Coverage. 6. Plan ID card: Present this card every time you receive healthcare services or prescription drugs. 7. Health survey: Your answers can help us provide you and your doctor with information that may better help you effectively manage your health. The Member Handbook in your Welcome Kit will give you more details about what to expect as a member of Blue Shield 65 Plus. We hope to welcome you to our plan!

8 Blue Shield has been dedicated to offering quality healthcare coverage and member service since 1939 an ongoing tradition you can trust. We hope this booklet made our health plan information easy to understand. It s one of the ways we re working to make your health plan selection simple. Need help? Contact your authorized Blue Shield broker. Blue Shield of California is a health plan with a Medicare contract. 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/coinsurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium. Blue Shield and the Shield symbol are registered marks of the BlueCross BlueShield Association, an association of independent Blue Cross and Blue Shield plans. SilverSneakers is a registered mark of Healthways, Inc., and Curves is a registered mark of Curves International, Inc., independent companies that do not provide Blue Shield of California products or services. An independent member of the Blue Shield Association MR15775-PR-LAOR (10/12)