SecurityBlue. Link to Specific Guidance Regarding Exceptions and Appeals

Transcription

1 SecurityBlue Conditions and Limitations Potential for Contract Termination Disenrollment Rights and Instructions Exceptions, Prior Authorization, Appeals and Grievances Out-of-Network Coverage Quality Assurance Policies and Procedures 2008 SecurityBlue Benefit Details 2008 Low Income Status Premium Tables Link to Specific Guidance Regarding Exceptions and Appeals

2 SecurityBlue: Conditions and Limitations Network Limitations Enrollees must use network pharmacies or the SecurityBlue mail order pharmacy service to receive covered Part D drugs except under emergency or non-routine circumstances. When obtaining prescriptions from pharmacies outside the network, the coverage by SecurityBlue may be less. In the event that you use a pharmacy outside of SecurityBlue s national pharmacy network, you may need to pay for the drug in full and submit a claim to SecurityBlue for reimbursement. Eligible out-of-network claims will be paid at the rate the drug would have been paid for if you had purchased the drug from a SecurityBlue network pharmacy. You will be responsible for the difference between the amount SecurityBlue would have paid a network pharmacy and the price you paid, in addition to your applicable copayment or coinsurance. Formulary SecurityBlue uses a formulary. A formulary is a list of covered drugs selected by SecurityBlue in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. The plan may periodically make changes to the formulary. If the formulary changes, affected enrollees will be notified in writing at least 60 days before the change is made, except in the case the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market.. SecurityBlue, as with all Medicare prescription drug plans, covers drugs that are listed on a formulary. SecurityBlue covers all Part D drugs allowed by Medicare. You and your prescribing physician may ask for coverage of a non-preferred Part D drug at the preferred cost-sharing level. This is a request for a tiering exception. This would lower the copayment amount you must pay for your drug. You cannot ask that a Part D drug on the specialty tier be covered at a higher level of payment. Brand Drugs vs. Generic Drugs If you choose a brand name drug instead of its generic equivalent, you will be responsible for the applicable brand name copayment plus the difference in cost between the brand name drug and the generic drug. Your cost will not exceed the cost of the brand name drug. Days Supply Prescriptions for 1-34 days will require the same copayment as a 34-day supply and any prescriptions beyond 34 days (35-90 days) will be charged the same copayment as a 90- day supply. Prescriptions obtained at a retail pharmacy for days may have a higher copayment than those received through the SecurityBlue mail order pharmacy service.

3 Eligibility Restrictions Anyone who is entitled to Medicare Part A benefits and enrolled in Medicare Part B is eligible to enroll in a Medicare Advantage plan. However, if you are already enrolled in a Medicare Advantage plan such as an HMO or PPO and then enroll in a SecurityBlue plan, you will be disenrolled from your Medicare Advantage plan. You must also live in the SecurityBlue service area and not be enrolled in any other Medicare-approved prescription drug plan. Individuals with Medicare may enroll in a prescription drug plan during specific times of the year. You may be able to get extra help to pay for your prescription drug premiums and costs. To see if you qualify for getting extra help, contact: MEDICARE ( ) 24 hours a day, seven days a week. TTY/TDD users call , on the Web. The Social Security Administration at (TTY/TDD users call ), 7 a.m. to 7 p.m., Monday through Friday; on the Web. Your state Medicaid office SecurityBlue: Potential for Contract Termination All Medicare Advantage Plan Sponsors agree to offer the program for a full year at a time. Each year, the plans decide whether to continue for another year. Even if a Medicare Advantage Plan leaves the program, you will not lose Medicare coverage. If a sponsor decides not to continue, it must send you a letter at least 90 days before your coverage will end. The letter will explain your options for choosing other Medicare Advantage and Medicare prescription drug coverage in your area. SecurityBlue: Disenrollment Rights and Instructions Voluntary Disenrollment During the Annual Election Period (November 15 through December 31), anyone with Medicare will have an opportunity to switch from one way of getting Medicare to another. From January 1 through March 31, anyone with Medicare has another chance to make one change in the way they get Medicare. With this chance, you are limited in the type of plan you may join. If you have Medicare prescription drug coverage when making your change, you will only be able to join a Medicare Advantage plan that offers Medicare Part D or you will have to go to Original Medicare and join a prescription drug plan. If you do not have Medicare prescription drug coverage when making this change, you will only be able to join a Medicare Advantage plan that does not offer Medicare Part D or go to Original Medicare. Generally, you cannot make any other changes during the year unless you qualify for a Special Election Period. If you wish to leave SecurityBlue, you will need to submit a written and signed disenrollment request to SecurityBlue. You may also call MEDICARE. Medicare Customer Service Representatives are available 24 hours a day, seven days a week. TTY/TDD users should call

4 2048. Until your disenrollment is effective, you must continue getting your health care through SecurityBlue. Involuntary Disenrollment SecurityBlue may end your coverage for any of the following reasons: You lose your entitlement to Medicare Part A hospital insurance and/or fail to pay your Medicare Part B medical insurance SecurityBlue is no longer contracting with Medicare or leaves your service area You permanently move out of the SecurityBlue service area and do not voluntarily disenroll You fail to pay your SecurityBlue premium You engage in disruptive behavior, provided fraudulent information when you enrolled or knowingly permitted abuse or misuse of your enrollment card Please consult the SecurityBlue Evidence of Coverage for complete information on disenrollment rights. SecurityBlue: Part D Exceptions, Prior Authorizations, Appeals and Grievances Exceptions Members of SecurityBlue and their prescribing physicians may ask for coverage of a non-preferred Part D drug at the preferred cost-sharing level. This is a request for a tiering exception. This would lower the copayment amount you must pay for your drug. You cannot ask that a Part D drug on the specialty tier be covered at a higher level of payment. A member s prescribing physician may either contact SecurityBlue directly to request an exception or provide supporting information to SecurityBlue if the request is made by the member. Generally, a request will be approved only if the alternative drugs included in the formulary would not be as effective in treating a condition and/or would result in adverse medical effects. Generally, the Plan must make a decision as expeditiously as the member s health requires, but no later than 72 hours of receiving supporting information from the member s physician for a standard request. If applying the standard timeframe (72 hours) for making the determination seriously jeopardizes the life or health of the member or the member s ability to regain maximum function, an expedited review can be requested. In this instance, the Plan must make a decision as expeditiously as the member s health requires, but no later than 24 hours of receiving supporting information from the member s physician. Prior Authorizations In addition to the exception process addressed above, SecurityBlue requires you to get prior authorization for certain drugs. Even if a drug is on SecurityBlue s formulary, it may still require prior authorization. This means that you will need to get approval from SecurityBlue before you fill your prescription for a drug that requires prior authorization. If you don t obtain approval, SecurityBlue may not cover the drug.

5 Appeals and Grievances Members of SecurityBlue, their physicians, or authorized representatives acting on the member s behalf may request an appeal of an adverse coverage determination made by SecurityBlue. Examples of reasons an appeal or grievance may be filed include: the member believes he or she was denied benefits that the member is entitled to receive, the member believes there has been a delay in providing or approving the drug coverage, or the member disagrees with the amount of cost sharing he or she is required to pay. A request for a Standard Appeal must be made in writing to SecurityBlue. SecurityBlue is required to notify the member in writing of its decision as quickly as the member's health condition requires, but no later than 7 calendar days from the date SecurityBlue receives the request for the Standard Appeal. Members of SecurityBlue and their prescribing physicians may request that an appeal be Expedited for situations in which applying the Standard Appeal process may seriously jeopardize the member's health, life or ability to regain maximum function. (This would not include requests for payment of drugs already furnished.) A request for an Expedited Appeal can be made orally or in writing. SecurityBlue is required to notify the member and the prescribing physician of its decision as quickly as the member's health condition requires, but no later than 72 hours after receiving the request. Members of SecurityBlue may file a Grievance, either orally or in writing, expressing dissatisfaction with the operations, activities or behavior of SecurityBlue or with the quality of care or service received from a SecurityBlue provider. SecurityBlue is required to respond to the member's Grievance as quickly as the case requires, but no later than 30 days after the date SecurityBlue receives the oral or written Grievance. Please refer to the SecurityBlue Evidence of Coverage for details on the Appeals and Grievance process. Obtaining Data on Exceptions, Appeals and Grievances Members of SecurityBlue can receive a description of the number of Exceptions, Appeals and Grievances received and how these cases were resolved by contacting SecurityBlue by phone or in writing. SecurityBlue: Out-of-Network Part D Coverage Obtaining Out-of-Network Coverage To get a complete description of your prescription drug coverage, including how to have your prescriptions filled, please review the Evidence of Coverage. A network pharmacy is a pharmacy that has agreed to provide prescription drug benefits at negotiated prices for SecurityBlue. In most cases, your prescriptions are covered under SecurityBlue only if they are filled at a network pharmacy or through our mail order pharmacy service. We will fill prescriptions at non-network pharmacies under certain circumstances. The

6 following are a few exceptions when we will pay for a prescription filled at a pharmacy outside of our network. Getting coverage when you travel or are away from the plan s service area If you are traveling within the United States and territories and become ill, lose or run out of your prescription drugs, we will cover prescriptions that are filled at an out-of-network pharmacy. In this situation, you will have to pay the full cost (rather than paying just your co-payment) when you fill your prescription. You can ask us to reimburse you for our share of the cost by submitting a claim form. If you go to an out-of-network pharmacy, you may be responsible for paying the difference between what we would pay for a prescription filled at an in-network pharmacy and what the out-of-network pharmacy charged for your prescription. To learn how to submit a paper claim, please refer to the paper claims process described later. We cannot pay for any prescriptions that are filled by pharmacies outside of the United States and territories, even for a medical emergency. What if I need a prescription because of a medical emergency or because I needed urgent care? We will cover prescriptions that are filled at an out-of-network pharmacy if the prescriptions are related to care for a medical emergency or urgent care. In this situation, you will have to pay the full cost (rather than paying just your co-payment) when you fill your prescription. You can ask us to reimburse you for our share of the cost by submitting a paper claim form. If you go to an out-of-network pharmacy, you may be responsible for paying the difference between what we would pay for a prescription filled at an in-network pharmacy and what the out-of-network pharmacy charged for your prescription. To learn how to submit a paper claim, please refer to the paper claims process described later. Other times you can get your prescription covered if you go to an out-of network pharmacy We will cover your prescription at an out-of-network pharmacy if at least one of the following applies: If you are unable to obtain a covered drug in a timely manner within our service area because there is no network pharmacy within a reasonable driving distance that provides 24 hour service. If you are trying to fill a prescription drug that is not regularly stocked at an accessible network retail or mail-order pharmacy (such as high-cost and unique drugs). If you are getting a vaccine that is medically necessary but not covered by Medicare Part B and is administered in your doctor s office. If you are evacuated or displaced from your residence due to a State or Federally declared disaster or health emergency. Before you fill your prescription in any of these situations, call Member Service to see if there is a network pharmacy in your area where you can fill your prescription. If you do go to an out-of-network pharmacy for the reasons listed above, you will have to pay the full cost (rather than paying just your co-payment) when you fill your prescription. You

7 can ask us to reimburse you for our share of the cost by submitting a claim form. If you go to an out-of-network pharmacy, you may be responsible for paying the difference between what we would pay for a prescription filled at an in-network pharmacy and what the out-of-network pharmacy charged for your prescription. To learn how to submit a paper claim, please refer to the paper claims process described next. How do I submit a paper claim? When you go to a network pharmacy your claim is automatically submitted to us by the pharmacy. However, if you go to an out-of-network pharmacy because of the reasons listed above, the pharmacy may not be able to submit the claim directly to us and you will have to pay the full cost of your prescription. When you return home, simply submit your claim and your receipt to the following address: SecurityBlue, PO Box 1068 Pittsburgh, PA Upon receipt, we will make an initial coverage determination on the claim. Please refer to your Evidence of Coverage for more information on coverage determinations. For more information For more detailed information about your SecurityBlue prescription drug coverage, please review the Evidence of Coverage and SecurityBlue s formulary. SecurityBlue: Quality Assurance Policies and Procedures Medication Therapy Management (MTM) Program SecurityBlue offers medication therapy management programs (MTM) at no additional cost for members who have multiple medical conditions, who are taking many prescription drugs, or who have high drug costs. These programs were developed for us by a team of pharmacists and doctors. We use these MTM programs to help up provide better coverage for our members. We offer an MTM program for members who meet specific criteria. We may contact members who qualify for these programs. These programs are voluntary and you do not need to pay anything extra to participate. If you are selected to participate, we will send you information about the specific program, including information about how to access the program. For more information on SecurityBlue MTM programs, please review the Evidence of Coverage or contact member service Prior Authorization SecurityBlue requires you to get prior authorization for certain drugs. This means that you will need to get approval from SecurityBlue before you fill certain prescriptions. If you don t get approval, SecurityBlue may not cover the drug. Quantity Limits For safety purposes, certain drugs are covered in limited amounts per prescription. For example, SecurityBlue provides up to 9 tablets per prescription for the drug Imitrex.

8 Services 2008 SecurityBlue Benefit Details 2008 SecurityBlue Value MA-Only Ambulance $50 co-pay per 1-way trip Chiropractic: $0 co-pay (PCP) Medicare Covered $30 co-pay (specialist) Chiropractic: Not covered Routine Dental (routine) Not covered Diabetic Testing Devices 15% coinsurance/ Diagnostic, Lab, X-Ray (outpatient) $20 co-pay on basic diagnostic services, $50 co-pay for advanced imaging services DME (Oxygen excluded) 15% coinsurance/ Emergency Room $50 co-pay (waived if admitted within 3 (Worldwide Coverage) days for same condition) Gynecological Visits (annual exam) $30 co-pay Hearing (routine): Annual Exam Hearing (routine): Hearing Aid Immunizations (Pneumococcal, influenza, Hepatitis B) Inpatient Services (Acute, Mental Health, Substance Abuse, Rehab) (190 day lifetime max Mental Health) Long Term Acute Care Outpatient Surgery / ASC $30 co-pay $500 allowance / 3 calendar years 100% plan coverage $200 co-pay per inpatient admission/ $400 OOP annual max $50 co-pay per day/ $125 co-pay per visit/per day/per provider Podiatry: Medicare Covered Podiatry: Routine Post-Stabilization Care Preventive Health PCP Office Visits Outpatient Therapy (Per therapy, day, and provider) Rx : Prescription Co-payments (Up to 34 days supply) Rx: Prescription Mail Order Co-payments (Up to 90 days supply) Rx: Initial Coverage Limit (Total Rx expenditures-plan & member) SNF $0 co-pay (PCP) $30 co-pay (specialist) Not covered 100% plan coverage 100% plan coverage $0 co-pay $30 co-pay Not Covered (Discount Applies) Not Covered (Discount Applies) NA $45 co-pay (days 16-50) / $1,575 OOP annual max

9 Specialist Office Visits Urgent Care (Worldwide Coverage) Vision: Annual Routine Exam and Refraction Vision: Eyeglass Frames / 2 years Eyeglass Lenses or Contact Lenses / 2 years $30 co-pay $50 co-pay (hospital) $30 co-pay (non-hospital) $30 co-pay Standard frames 100% coverage Non-standard frames - $60 allowance Standard eyeglass/contact lenses 100% coverage Non-standard eyeglass lenses 90% difference between standard/non-standard charges Specialty contact lenses - $75 allowance Services Ambulance Chiropractic: Medicare Covered Chiropractic: Routine Dental (routine) Diabetic Testing Devices Diagnostic, Lab, X-Ray (outpatient) DME (Oxygen excluded) Emergency Room (Worldwide Coverage) Gynecological Visits (annual exam) 2008 SecurityBlue Basic MA-PD $50 co-pay per 1-way trip $15 co-pay (PCP) $30 co-pay (specialist) 2008 SecurityBlue Standard MA-PD $50 co-pay per 1-way trip $10 co-pay (PCP) $25 co-pay (specialist) 2008 SecurityBlue Deluxe MA-PD $25 co-pay per 1-way trip $10 co-pay (PCP) $20 co-pay (specialist) Not covered Not covered $10 co-pay (PCP) $20 co-pay (specialist) 6 visits/calendar year Not covered Not covered 40% coinsurance 15% coinsurance/ $20 co-pay on basic diagnostic services, $50 co-pay for advanced imaging services 15% coinsurance/ $50 co-pay (waived if admitted within 3 days for same condition) 15% coinsurance/ 15% coinsurance/ 100% plan coverage 100% plan coverage 15% coinsurance/ $50 co-pay (waived if admitted within 3 days for same condition) 15% coinsurance/ $50 co-pay (waived if admitted within 3 days for same condition) $30 co-pay $25 co-pay $20 co-pay

10 Hearing (routine): Annual Exam Hearing (routine): Hearing Aid Immunizations (Pneumococcal, influenza, Hepatitis B) Inpatient Services (Acute, Mental Health, Substance Abuse, Rehab) (190 day lifetime max Mental Health) Long Term Acute Care Outpatient Surgery / ASC Podiatry: Medicare Covered Podiatry: Routine Post- Stabilization Care Preventive Health PCP Office Visits Outpatient Therapy (Per therapy, day, and provider) Rx : Prescription Co-payments (Up to 34 days supply) Rx: Prescription Mail Order Copayments (Up to 90 days supply) $30 co-pay $25 co-pay $20 co-pay $500 allowance / 3 calendar years $500 allowance / 3 calendar years $500 allowance / 3 calendar years 100% plan coverage 100% plan coverage 100% plan coverage $250 co-pay per inpatient admission/ $750 OOP annual max $100 co-pay per day/ $1,000 OOP annual max $100 co-pay per visit/per day/per provider $15 co-pay (PCP) $30 co-pay (specialist) $150 co-pay per inpatient admission/ $300 OOP annual max $50 co-pay per day/ $100 co-pay per visit/per day/per provider $10 co-pay (PCP) $25 co-pay (specialist) $100 co-pay per inpatient admission/ $200 OOP annual max 100% plan coverage 100% plan coverage $10 co-pay (PCP) $20 co-pay (specialist) Not covered Not covered $10 co-pay (PCP) $20 co-pay (specialist) 8 visits/calendar year 100% plan coverage 100% plan coverage 100% plan coverage 100% plan coverage 100% plan coverage 100% plan coverage $15 co-pay $10 co-pay $10 co-pay $30 co-pay $25 co-pay $20 co-pay $5/$38/$68/25% Generic/Preferred Brand/Non-Preferred Brand/Specialty $12.50/$95/$170/25% Generic/Preferred Brand/Non-Preferred Brand/Specialty $5/$36/$66/25% Generic/Preferred Brand/Non-Preferred Brand/Specialty $12.50/$90/$165/25% Generic/Preferred Brand/Non-Preferred Brand/Specialty $4/$29/$60/25% Generic/Preferred Brand/Non-Preferred Brand/Specialty $10/$72.50/$150/25% Generic/Preferred Brand/Non-Preferred Brand/Specialty

11 Rx: Initial Coverage Limit (Total Rx expendituresplan & member) SNF $50 co-pay (days 16-50) / $1,750 OOP annual max Specialist Office Visits Urgent Care (Worldwide Coverage) Vision: Annual Routine Exam and Refraction Vision: Eyeglass Frames / 2 years Eyeglass Lenses or Contact Lenses / 2 years $2,510 $2,510 $2,510 $35 co-pay (days 16-50) / $1,225 OOP annual max $25 co-pay (days 16-50) / $875 OOP annual max $30 co-pay $25 co-pay $20 co-pay $50 co-pay (hospital) $30 co-pay (nonhospital) 50 co-pay (hospital) $25 co-pay (nonhospital) 50 co-pay (hospital) $20 co-pay (nonhospital) $30 co-pay $25 co-pay $20 co-pay Standard frames 100% coverage Non-standard frames - $60 allowance Standard eyeglass/contact lenses 100% coverage Standard frames 100% coverage Non-standard frames - $60 allowance Standard eyeglass/contact lenses 100% coverage Standard frames 100% coverage Non-standard frames - $60 allowance Standard eyeglass/contact lenses 100% coverage Non-standard eyeglass lenses 90% difference between standard/non-standard charges Specialty contact lenses - $75 allowance Non-standard eyeglass lenses 90% difference between standard/non-standard charges Specialty contact lenses - $75 allowance Non-standard eyeglass lenses 90% difference between standard/non-standard charges Specialty contact lenses - $75 allowance

12 2008 SecurityBlue Services Special Needs Plan MA-PD Plan Deductible $131 Coinsurance 20% for Part B Services Maximum OOP N/A Lifetime Maximum Unlimited Allergy Tests & Treatment Ambulance/Wheelchair Vans: Emergent Anesthesia Chemotherapy (Outpatient) Chiropractic Care: Medicare Covered Chiropractic Care: Not covered Routine Clinical Trials Colorectal Screening CORF (Per therapy type / per day / per provider) Dental (routine) Not covered Dental (Comp) Diabetic Education / Training Diabetic Screening Diabetic Testing Devices Diagnostic, Lab, X-Ray (outpatient) Dialysis (Outpatient) DME Emergency Room (Worldwide Coverage) Glaucoma Screening (Annual) Gynecological Visits (Annual exam: Pelvic & breast exam, PAP test) Health & Wellness Education 100% coverage for Medicareapproved clinical laboratory services for all other diagnostic services 100% coverage if you are admitted to the hospital for the same condition within 3 days 80% coverage for pelvic exam 100% coverage for pap test 100% coverage

13 Hearing (routine): Annual Exam Hearing (routine): Hearing Aid Home Health Immunizations (Pneumococcal, influenza, Hepatitis B) Injections Inpatient Services (Acute, Rehab) $1500 allowance / 3 calendar years 100% Coverage Pneumonia and flu vaccines are covered 100% Hepatitis B vaccine is covered 80% after the Part B deductible $992 Initial deductible - Days 1-60 $248/day Days $496/lifetime reserve days Inpatient Psychiatric $992 Initial deductible - and Substance Abuse) Days 1-60 (190 day lifetime $248/day Days maximum) $496/lifetime reserve days Long Term Acute Care $992 Initial deductible - Days 1-60 $248/day Days $496/lifetime reserve days Mammograms 80% coverage Medical Nutrition Therapy Services Mental Health / Substance Abuse: Outpatient Newborn Care (up to 31 days) Obstetrical Care Outpatient Hospital Services Outpatient Surgery / ASC Physical Exams (Annual) Podiatry: Medicare Covered Podiatry: Routine Post-Stabilization Care PCP Office Visits Prosthetics & Orthotics 50% coverage after Part B deductible for Mental Health. 80% coverage after Part B deductible for Substance Abuse. Not Covered

14 Rehab Therapy (cardiac, OT, PT, ST, Respiratory): Outpatient Rx (Part D): Prescription Copayments (Up to 34 days supply) Rx (Part D): Prescription Mail Order Co-payments (Up to 90 days supply) Second Opinion Consult Varies based on your level of Subsidy from the Federal Government Varies based on your level of Subsidy from the Federal Government SNF Days 1-20 $0 Days $124/day Specialist Office Visits Urgent Care (Worldwide Coverage) Vision (routine): 100% Coverage Annual Routine Exam and Refraction Vision (routine): 100% Coverage Contact Lens Exam & Fitting / 2 years Vision (routine): Standard frames 100% Eyeglass Frames / 2 plan coverage years Non-standard frames - $60 allowance Vision (routine): Eyeglass Lenses or Contact Lenses / 2 years Standard eyeglass / contact lenses 100% plan coverage Non-standard eyeglass lenses 90% difference between standard / nonstandard charges Vision (cataract surgery) Vision (cataract surgery): Post Cataract Surgery Eye Exam (Per operated eye) Vision (cataract surgery): Post Cataract Surgery Eyewear (Per operated eye) Specialty contact lenses - $75 allowance 100% coverage for one pair of eyeglasses or contact lenses after cataract surgery

15 SecurityBlue Monthly Plan Premium for People who get Extra Help from Medicare to Help Pay for their Prescription Drug Costs If you get extra help from Medicare to help pay for your Medicare prescription drug plan costs, your monthly plan premium will be lower than what it would be if you did not get extra help form Medicare. The amount of extra help you get will determine your total monthly plan premium as a member of our Plan. The following tables show you what your monthly plan premium will be if you get extra help. Southwest Region Your level of extra help Monthly Premium for Basic Plan* Monthly Premium for Standard Plan* 100% $20.80 $61.90 $ % $23.60 $64.70 $ % $26.40 $67.40 $ % $29.20 $70.20 $ Monthly Premium for Deluxe Plan* Bedford Blair Somerset Region Your level of extra help Monthly Premium for Basic Plan* Monthly Premium for Standard Plan* Monthly Premium for Deluxe Plan* 100% $20.80 $72.90 $ % $23.60 $75.70 $ % $26.40 $78.40 $ % $29.20 $81.20 $ Crawford Erie Mercer Region Your level of extra help Monthly Premium for Basic Plan* Monthly Premium for Standard Plan* Monthly Premium for Deluxe Plan* 100% $20.80 $62.90 $ % $23.60 $65.70 $ % $26.40 $68.40 $ % $29.20 $71.20 $96.90 *This does not include any Medicare Part B premium you may have to pay. SecurityBlue s premium includes coverage for both medical services and prescription drug coverage.

16 If you aren t getting extra help, you can see if you qualify by calling: Medicare of TTY/TDD users call (24 hours a day/7 days a week), Your State Medicaid Office, or The Social Security Administration at TTY/TDD users should call between 7 a.m. and 7 p.m., Monday through Friday.If you have any questions, please call Member Service at , (TTY/TDD: ), from Monday through Sunday from 8:00 a.m. to 8:00 p.m. EST. H3957_70641 (09/2007)