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

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1 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 Shield Association. Y0011_ EGWP C: 08/2016

2 (Employer PPO) Summary of Benefits Plan Year 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." Things to Know About Eligibility requirements You and your dependent(s) can join this plan if you are a retired employee of the group and the following conditions are met: You and your dependent(s) are entitled to Medicare Part A and enrolled in Medicare Part B You and your dependent(s) live in the plan service area, and You are identified as an eligible participant by your former employer. Neither you nor your dependent(s) are eligible for this plan if: You are an active employee of the group, or You are a retired employee of the group with a dependent who is an active employee of the group and has coverage through the group's plan for active employees. Our service are includes all fifty states and the District of Columbia. Which doctors, hospitals, and pharmacies can I use? has a network of doctors, hospitals and other providers. You can use both in-network and out-of-network providers, but in most cases you will pay less for your covered services if you use in-network providers. However, if you need emergency care, urgent care, or dialysis while you are temporarily outside our plan s service area, you will pay in-network costsharing for services you receive from out-of-network providers. In most situations, you must use our network pharmacies to fill your prescriptions for covered Part D drugs. You can see our plan's provider directory on our website, You can see our plan's pharmacy directory on our website, You can see our plan's comprehensive formulary (list of covered Part D drugs) at our website, Or call us and we will send you a copy of the provider and pharmacy directories and the formulary. How will I determine my drug costs? Our plan groups each medication into one of five tiers. You will need to use your formulary to locate what tier your drug is on to determine how much it will cost you. The amount you pay depends on the drug's tier and what stage of the benefit you have reached. Later in this document we discuss the benefit stages that occur: Initial Coverage and Catastrophic Coverage. What do we cover? Our plan includes 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. Page 1

3 Hours of Operation From October 1 to February14: 8:00 a.m. 8:00 p.m. local time, 7 days a week. From February 15 to September 30: 8:00 a.m. 8:00 p.m. local time, Monday through Friday. Phone Numbers and Website If you are a current member of : If you are not currently a member of one of these plans, call TTY users: Call Our website: 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 This document is available in other formats such as Braille and large print. This information is available for free in other languages. Please call our Member Services number at (TTY users should call ) Hours are 8:00 a.m. 8:00 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, 8:00 a.m. 8:00 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 8:00 a.m. a 8:00 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. Florida Blue is a PPO plan with a Medicare contract. Enrollment in Florida Blue depends on contract renewal. 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 copayments/coinsurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium. The formulary and/or pharmacy network may change at any time. You will receive notice when necessary. Out-of-network/non-contracted providers are under no obligation to treat BlueMedicare PPO 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 Member Services number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services. Page 2

4 Monthly Plan Premium Please contact your former employer's benefits administrator for premium information. You must continue to pay your Medicare Part B premium. Deductible : $0 : $1,000 Maximum Out-of-Pocket Responsibility (does not include prescription drugs) Inpatient Hospital Coverage Doctor Visits Preventive Care Your yearly limit(s) in this plan: $1,000 for services from in-network providers. $3,000 for services from out-of-network providers. $3,000 for services combined from in- and out-of-network providers. Your limit for services received from in-network providers and your limit for services received from out-of-network providers will count toward this limit. If you reach the limit on out-of-pocket costs, and you keep getting covered hospital and medical services, 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 costsharing for your Part D prescription drugs. Prior Authorization is required for non-emergency Inpatient Hospital stays. Days 1-7: $150 copay per day After day 7: You pay nothing 20% of the Medicare-allowed amount, after the plan year $10 copay per primary care visit $30 copay per specialist visit 20% of the Medicare-allowed amount for primary care and specialist visits, after the plan year You pay nothing. 20% of the Medicare-allowed amount Covered preventive services include: Abdominal aortic aneurysm screening Page 3

5 Preventive Care (continued) Emergency Care Urgently Needed Services Alcohol misuse counseling Annual Wellness visit Bone mass measurement Breast cancer screening (mammograms) Cardiovascular disease risk reduction visit (yearly) Cardiovascular disease testing Cervical and vaginal cancer screening Colorectal cancer screening (Colonoscopy, Fecal occult blood test, Flexible sigmoidoscopy or barium enema, Cologuard test) Depression screening Diabetes screening Diabetes self-management training HIV screening Medical nutrition therapy services Obesity screening and therapy to promote sustained weight loss Prostate cancer screening exams Screening for sexually transmitted infections (STIs) and screening and counseling to prevent STIs Smoking and tobacco use cessation counseling Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots "Welcome to Medicare" preventive visit (one-time) Lung Cancer Screening Any additional preventive services approved by Medicare during the contract year will be covered. In- and $75 copay per visit If you are immediately admitted to the hospital, you do not have to pay your share of the cost for emergency care. Emergency coverage is provided worldwide. Worldwide emergency coverage does not include emergency transportation. Worldwide Emergency Care $75 copay per visit In- and $30 copay at a Convenient Care Center $30 copay at an Urgent Care Center Page 4

6 Diagnostic Services/Labs/Imaging Hearing Services Prior Authorization is required for certain services. Call Member Services for additional information. Laboratory Services You pay nothing at an Independent Clinical Laboratory. $15 copay at an outpatient hospital facility 20% of the Medicare-allowed amount, after the plan year X-Rays $50 copay at an Independent Diagnostic Testing Facility (IDTF) $150 copay at an outpatient hospital facility 20% of the Medicare-allowed amount, after the plan year Advanced Imaging Services (e.g., Magnetic Resonance Imaging [MRI], Positron Emission Tomography [PET], Computer Tomography [CT] Scan) $125 copay at a specialist s office $125 copay at an IDTF $150 copay at an outpatient hospital facility 20% of the Medicare-allowed amount, after the plan year Radiation Therapy $50 copay 20% of the Medicare-allowed amount, after the plan year Prior authorization is required for Medicare-covered hearing services. Exams to diagnose and treat hearing and balance issues: $30 copay 20% of the Medicare-allowed amount, after the plan year Page 5

7 Hearing Services (continued) Dental Services Vision Services Additional Hearing Services Routine hearing exam (for up to 1 every year): $45 copay Evaluation and Fitting: $45 copay Hearing aids: $699 copay for Flyte 700 $999 copay for Flyte 900 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. You must see a TruHearing provider to use this benefit. Call (844) to schedule an appointment. Note: See the Hearing Benefits Schedule for complete information about additional hearing services covered by the plan. Prior authorization is required for Medicare-covered comprehensive dental services. Medicare-Covered Dental Services Non-routine dental care such as setting fractures of the jaw or facial bones, jaw surgery, extraction of teeth to prepare for radiation therapy, services covered when provided by a physician: : $30 copay : 20% of the Medicare-allowed amount for Medicarecovered dental benefits, after the plan year. Additional Dental Services Cleanings, oral exams, X-rays, extraction of erupted tooth or exposed root, adjustment of complete or partial denture: You pay nothing. Note: See the Dental Benefits Schedule for complete information about additional dental services covered by the plan. Prior authorization is required for Medicare-covered vision services. Medicare-Covered Vision Services Exams to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screenings and diabetic retinal exam): : $0-$30 copay, depending on the service : 20% of the Medicare-allowed amount, after the plan year. Eyewear after cataract surgery: : You pay nothing : 20% of the Medicare-allowed amount, after the plan year. Page 6

8 Vision Services (continued) Mental Health Services Additional Vision Services Routine eye exam (for up to 1 every year): : You pay noting : Reimbursed up to $25 Elective contact lenses (for up to 1 every year): : $0 copay, up to a $100 allowance : Reimbursed up to $55 Eyeglass frames (for up to 1 every two years) : $0-40 copay, depending on the service, up to a $100 allowance : Reimbursed up to $35 Eyeglass lenses (for up to 1 every year): : $20-$65 copy, depending on the service : Reimbursed $20-$40, depending on service Note: See the Vision Benefits Schedule for complete information about additional vision services covered by the plan. Inpatient Mental Health Services Prior authorization is required for non-emergency services. All Mental Health Services are coordinated through a vendor. Contact Member Services for more information. Our plan covers up to 190 days per lifetime for inpatient mental health care in a psychiatric hospital. This limit does not apply to inpatient mental health services provided in a general hospital. Days 1-7: $200 copay per day Days 8-90: You pay nothing. Out-of-network 20% of the Medicare-allowed amount, after the plan year Outpatient Mental Health Services Prior authorization is required for certain services. All Mental Health Services are coordinated through a vendor. Contact Member Services for more information. $35 copay 20% of the Medicare-allowed amount, after the plan year Page 7

9 Skilled Nursing Facility (SNF) Rehabilitation Services Ambulance Transportation (Routine) Foot Care (podiatry services) Prior authorization is required for SNF stays. Our plan covers up to 100 days in a SNF per benefit period. Days 1-20: You pay nothing Days : $75 copay per day 20% of the Medicare-allowed amount, after the plan year Prior authorization is required for all therapy services. Occupational therapy visits Physical therapy and speech and language therapy visits A $1,960 yearly Medicare limit applies to outpatient physical and speech therapy services. This limit is for 2016 and may change in A separate $1,960 yearly Medicare limit applies to outpatient occupational therapy services. This limit is for 2016 and may change in $30 copay 20% of the Medicare-allowed amount, after the plan year Prior authorization is required for non-emergency ambulance services. In- and $150 copay for each Medicare-covered trip (one-way) Not covered Diagnosis and treatment of injuries and diseases of the feet. Routine care for members with certain conditions affecting the lower limbs. $30 copay 20% of the Medicare-allowed amount, after the plan year Page 8

10 Medical Equipment/Supplies Wellness Programs Medicare Part B Drugs Prior authorization is required for certain equipment/supplies. Call Member Services for additional information. Durable Medical Equipment You pay nothing for equipment except motorized wheelchairs and electric scooters. 20% of the Medicare-allowed amount for motorized wheelchairs and electric scooters 20% of the Medicare-allowed amount, after the plan year Prosthetics You pay nothing 20% of the Medicare-allowed amount, after the plan year Diabetic Supplies You pay nothing 20% of the Medicare-allowed amount, after the plan year Healthways SilverSneakers Fitness Program - For more information, visit silversneakers.com or call (TTY: 711), Monday through Friday, 8:00 a.m. to 8:00 p.m. ET. Diabetes Prevention Program - An evidence-based program designed to delay or prevent participants progression to type 2 diabetes. In- and You pay nothing to participate in these programs. Prior authorization is required for Medicare Part B-covered prescription drugs except for allergy injections. $5 copay for allergy injections 20% of the Medicare-allowed amount for chemotherapy drugs and other Medicare Part B-covered drugs 20% of the Medicare-allowed amount, after the plan year Page 9

11 Part D Prescription Drug Benefits Initial Coverage Stage During this stage, the plan pays its share of the cost of your generic drugs and you pay your share of the cost. After you (or others on your behalf) have met your brand name, the plan pays its share of the costs of your brand name drugs and you pay your share. You stay in this stage until your year-to-date out-ofpocket costs (your payments) reach $4,950. Cost-Sharing for a one-month supply (up to 31 days) of a covered Part D prescription drug) Tier Retail Mail Order Tier 1 (Preferred Generic) $10 Copay $0 Copay Tier 2 (Generic) $10 Copay $0 Copay Tier 3 (Preferred Brand) Tier 4 (Non- Preferred Brand) Tier 5 (Specialty Drugs) $40 Copay $40 Copay $70 Copay $70 Copay 25% of the cost 25% of the cost If you reside in a long-term care facility, you pay the standard retail cost-sharing amount. If you purchase drugs from an out-of-network pharmacy, you pay the standard retail cost-sharing amount. Catastrophic Coverage Stage After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4,950, you pay: $3.30 copay for generic drugs (including brand drugs treated as generic) and an $8.25 copay for all other drugs. Page 10