Medicare Plus Blue SM PPO Confidence comes with every card. 2017 Summary of Benefits Essential, Vitality, Signature, and Assure January 1, 2017 December 31, 2017 This information is not a complete description of benefits. Contact the plan for more information. To get a complete list of services we cover, call Customer Service and ask for the Evidence of Coverage (phone numbers are printed on the back cover of this booklet). To join Medicare Plus Blue PPO Essential, Vitality, Signature or Assure, you must be entitled to Medicare Part A, and/or be enrolled in Medicare Part B, and live in our service area. Our service area includes the state of Michigan. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or copayments/coinsurance may change on January 1 of each year. Medicare Plus Blue is a PPO plan with a Medicare contract. Enrollment in Medicare Plus Blue depends on contract renewal. bcbsm.com/medicare
Medicare Plus Blue PPO Essential, Vitality, Signature and Assure have a network of doctors, hospitals, pharmacies, and other providers. If you use the providers in our network, you may pay less for your covered But if you want to, you can also use providers that are not in our network. For more detailed information about our providers, you can call Customer Service (phone numbers are printed on the back cover of this booklet) or visit our website at www.bcbsm.com/medicare. Out of network/non contracted providers are under no obligation to treat Medicare Plus Blue PPO Essential, Vitality, Signature and Assure members, except in emergency situations. For a decision about whether we will cover an out of network service, we encourage you or your provider to ask us for a pre service organization determination before you receive the service. Please call our customer service number or see your Evidence of Coverage for more information, including the cost sharing that applies to out of network You can see the complete plan formulary (list of Part D prescription drugs) and any restrictions on our website at www.bcbsm.com/formularymedicare. The Formulary, pharmacy network and/or provider network may change at any time. You will receive notice when necessary.
Premium/Cost-sharing Table for Medicare Plus Blue PPO Premiums vary by county in which you permanently reside (rates are based on the use and cost of health care services in each regional segment). You must continue to pay your Medicare Part B premium. 1) Find the county and region that you live in. 2) Look across the plan option columns to find your monthly premium rate. Regions with counties Region 1 Allegan, Barry, Ionia, Kalamazoo, Mason, Muskegon, Newaygo, Oceana and Ottawa counties Region 2 Berrien, Branch, Calhoun, Eaton, Gratiot, Hillsdale, Ingham, Jackson, Monroe, Montcalm, St. Joseph and Van Buren counties Region 3 Alcona, Alger, Alpena, Arenac, Baraga, Bay, Charlevoix, Cheboygan, Chippewa, Clare, Crawford, Gladwin, Huron, Iosco, Kalkaska, Keweenaw, Luce, Mackinac, Montmorency, Ogemaw, Ontonagon, Oscoda, Presque Isle, Roscommon, Saginaw, Sanilac, Schoolcraft, Shiawassee and Tuscola counties Region 4 Antrim, Benzie, Cass, Clinton, Delta, Dickinson, Emmet, Genesee, Gogebic, Grand Traverse, Houghton, Iron, Isabella, Kent, Lake, Lapeer, Leelanau, Lenawee, Livingston, Manistee, Marquette, Mecosta, Menominee, Midland, Missaukee, Osceola, Otsego, St. Clair and Wexford counties Region 6 Macomb, Oakland, Washtenaw and Wayne counties Medicare Plus Blue premium rates per month Essential Vitality Signature Assure $21 $46 $131 $211 $25.50 $88 $181 $271 $30.50 $106 $181 $314 $30.50 $86 $181 $264 $25.50 $111 $174 $314 Region 5 is not being used at this time. 1
Deductible This plan has deductibles for some hospital and medical services, and Part D prescription drugs. This plan has deductibles for some hospital and medical services, and Part D prescription drugs. This plan has deductibles for some hospital and medical services, and Part D prescription drugs. This plan has deductibles for some hospital and medical You pay $160 per year for most innetwork and out-ofnetwork You pay $100 per year for most innetwork and out-ofnetwork services You pay $750 per year for most out-ofnetwork You pay $250 per year for most out-ofnetwork You pay $400 per year for Part D prescription drugs You pay $400 per year for Part D prescription drugs. You pay $105 per year for Part D prescription drugs except for drugs listed on Tier 1 and Tier 2 which are excluded from the deductible. This plan does not have a deductible for Part D prescription drugs. Maximum You pay $6,400 for You pay $5,400 for You pay $4,700 for You pay $4,000 for The most you pay for Out-of-Pocket services you services you receive services you receive services you receive copays, coinsurance Responsibility receive from in- from in-network from in-network from in-network and other costs for (does not include network providers. providers. providers. providers. medical services for the prescription drugs) You pay $8,100 for services you receive from any provider. Your limit for services received from innetwork providers will count toward this limit. You pay $7,100 for services you receive from any provider. Your limit for services received from innetwork providers will count toward this limit. You pay $6,500 for services you receive from any provider. Your limit for services received from innetwork providers will count toward this limit. You pay $6,000 for services you receive from any provider. Your limit for services received from innetwork providers will count toward this limit. year. Please note that you will still need to pay your monthly premiums and cost sharing for your Part D prescription drugs. 2
Note: Inpatient Hospital Coverage 1 Services with a 1 may require prior authorization The copays for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you re admitted as an inpatient and ends when you haven t received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There s no limit to the number of benefit periods. Our plan covers an unlimited number of days for an inpatient hospital stay. You pay $260 You pay $250 You pay $175 You pay $125 copay per day for copay per day for copay per day for copay per day for days 1 through 6 days 1 through 6 days 1 through 6 days 1 through 6 per day per day per day per day for days 7 through for days 7 through for days 7 through for days 7 through 90 90 90 90 per day per day per day per day for days 91 and for days 91 and for days 91 and for days 91 and beyond beyond beyond beyond per stay per stay per stay per stay 3
Doctor Visits o Primary o Specialists You pay $25 copay You pay $20 copay You pay $15 copay You pay $10 copay Preventive Care.. 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 Medical nutrition therapy services Obesity screening and counseling Prostate cancer screenings (PSA) Screening for lung cancer with low dose computed tomography (LDCT) Sexually transmitted infections screening and counseling Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease) 4
Preventive Care, continued Colorectal cancer screenings (Colonoscopy, Fecal occult blood test, Flexible sigmoidoscopy) Depression screening Diabetes screenings HIV screening 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. Emergency Care In- and You pay $75 copay If you are admitted to the hospital within 3 days, you do not have to pay your share of for emergency care. Urgently Needed Services In- and Out-ofnetwork: In- and Out-ofnetwork: In- and Out-ofnetwork: In- and Out-ofnetwork: 5
Diagnostic Services/Labs/ Imaging 1 o Diagnostic radiology service (e.g., MRI, hightech 1 You pay $100 copay You pay $100 copay You pay $100 copay You pay $75 copay Only high-tech X-rays require preauthorization. o Lab services -$40 -$40 -$30 -$20 o Diagnostic tests and procedures 6
Diagnostic Services/Labs/ Imaging 1,continued o Outpatient X-rays You pay $35 copay You pay $35 copay You pay $35 copay You pay $35 copay Only high-tech X-rays require preauthorization. o Therapeutic radiology services You pay $35 copay You pay $35 copay You pay $35 copay You pay $35 copay Hearing Services o Hearing exam to diagnose and treat hearing and balance issues You pay $25-$50 You pay $20-$50 You pay $15-$50 You pay $10-$40 7
Hearing Services, continued o Routine hearing exam (for up to 1 every year) This is not a covered benefit. You pay $20-$50 You pay $15-$50 You pay $10-$40 o Hearing aid fitting/ evaluation (for up to 1 every three years) This is not a covered benefit. o Hearing aid This is not a covered benefit. Plans with this benefit pay up to a $500 allowance toward one new standard hearing aid for each ear every 3 years from any provider. 8
Dental Services Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth) Preventive dental services o Cleaning (for up to 2 every year) o Dental X-rays (for up to 1 every two years) o Oral exam (for up to 2 every year) You pay $25-$50 copay Preventive dental services are not a covered benefit. You pay $20-$50 copay You pay $15-$50 copay You pay $10-$40 copay Vision Services o Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening) -$50 for services -$50 for services -$50 for services -$40 for services Essential &Vitality: services 9
Vision Services, continued Eyeglasses or contact lenses after cataract surgery o Lasik and RK surgery Essential &Vitality: o Routine eye exam You pay $10 copay You pay $20 copay You pay $10 copay You pay $10 copay You pay $10 copay o Contact lenses in lieu of eyeglasses and/or frames up to 1 pair every two years This is not a covered benefit. In- and Out-ofnetwork: In- and Out-ofnetwork: In- and Out-ofnetwork: Our plan pays up to $100 every two years for eyewear from any provider 10
Mental Health Services 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. The copays for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you re admitted as an inpatient and ends when you haven t received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There s no limit to the number of benefit periods. 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 o Inpatient visit 1 You pay $260 copay per day for days 1 through 6 per day for days 7 through 90 per day for days 91 190 until lifetime limit is exhausted You pay $250 copay per day for days 1 through 6 per day for days 7 through 90 per day for days 91 190 until lifetime limit is exhausted You pay $175 copay per day for days 1 through 6 per day for days 7 through 90 per day for days 91 190 until lifetime limit is exhausted You pay $125 copay per day for days 1 through 6 per day for days 7 through 90 per day for days 91 190 until lifetime limit is exhausted 11
Mental Health Services, continued o Inpatient visit per stay per stay per stay per stay o Outpatient group or individual therapy visit Skilled Nursing Facility (SNF) 1 per day for days 1 through 20 You pay $160 copay per day for days 21 through 100 per stay per day for days 1 through 20 You pay $160 copay per day for days 21 through 100 per stay per day for days 1 through 20 You pay $160 copay per day for days 21 through 100 per stay per day for days 1 through 20 You pay $160 copay per day for days 21 through 100 per stay Our plan covers up to 100 days in a SNF. 12
Rehabilitation Services o Cardiac (heart) rehab services (for a maximum of 2 onehour sessions per day for up to 36 sessions up to 36 weeks) o Occupational therapy visit 1 You pay $45 copay You pay $35 copay You pay $30 copay o Physical therapy 1 and speech and language therapy visit You pay $35 copay You pay $30 copay o Pulmonary rehabilitation You pay $30 copay You pay $30 copay You pay $30 copay You pay $30 copay 13
Ambulance You pay $200 copay You pay $200 copay or 50% of, depending on the service You pay $200 copay You pay $200 copay or 40% of, depending on the service You pay $200 copay You pay $200 copay or 40% of, depending on the service You pay $200 copay You pay $200 copay or 30% of, depending on the service Vitality, Signature & Assure: Transportation Not covered Foot Care (podiatry services) o Foot exams and treatment if you have diabetesrelated nerve damage and/or meet certain conditions Medical Equipment/Supplies o Durable Medical Equipment (e.g., wheelchairs, oxygen) 14
Medical Equipment/Supplies, continued o Prosthetics (e.g., braces, artificial limbs) o Diabetes supplies (e.g., monitoring, shoes or inserts) Wellness Programs (e.g., fitness) All members can join the SilverSneakers Fitness program at no cost. SilverSneakers is a leading fitness program for people with Medicare. Locations nationwide Low-impact classes to improve strength and balance Health education events SilverSneakers Steps at-home program You must use network facilities to obtain this benefit. Healthways is an independent company not associated with the Blue Cross Blue Shield Association. Blue Cross Blue Shield of Michigan and Medicare Plus Blue PPO contract with Healthways to offer the SilverSneakers fitness program benefit. SilverSneakers is a registered mark of Healthways, Inc. 15
Medicare Part B Drugs 1 o Part B drugs such as chemotherapy drugs o Other Part B drugs o Part B Immunizations copay copay copay copay 16
Chiropractic Care o Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position) o Routine care/other You pay $20 copay You pay $35 copay You pay $20 copay You pay $35 copay You pay $20 copay You pay $35 copay You pay $20 copay You pay $35 copay Routine chiropractic visits give members coverage for one set of X-rays (up to 3 views) per year performed by a chiropractor. Cost share is the same as diagnostic X- rays. Home Health Care 17
Hospice 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 (phone numbers are on the back of this booklet). Outpatient Substance Abuse 1 o Group therapy visit o Individual therapy visit services services 18
Outpatient Surgery o Ambulatory surgical center o Outpatient hospital You pay $100-$125 You pay $150-$200 You pay $100-$125 You pay $150-$175 You pay $75-$100 You pay $125-$150 You pay $50-$75 You pay $75-$100 Renal dialysis You pay $30 copay You pay $30 copay You pay $30 copay You pay $30 copay 19
Outpatient Prescription Drugs Phase 1: Deductible Stage Essential & Vitality You pay $400 per year for Part D prescription drugs. Phase 2: Initial Coverage Stage After you pay your yearly deductible, 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. Tier 1: Preferred Generic Preferred Retail, Mail Order, Standard Retail, and Longterm care Rx 31-day supply Standard Retail Rx 90-day supply Preferred Retail and Mail Order Rx 90-day supply 25% 25% 25% Tier 2: Generic 25% 25% 25% Tier 3: Preferred Brand Tier 4: Non-Preferred Drugs 25% 25% 25% 25% 25% 25% Tier 5: Specialty 25% Not Offered Not Offered Phase 3 & 4: Coverage Gap and Catastrophic Coverage Stages Cost sharing may change depending on the pharmacy you choose and when you enter another phase of the Part D benefit. For more information on the additional pharmacy-specific cost sharing and the phases of the benefit, please call us or access our Evidence of Coverage online at www.bcbsm.com/medicare. Most members do not reach the Coverage Gap stage or the Catastrophic Coverage stage. For information about your costs in these stages, look at Chapter 6, Sections 6 and 7, in the Evidence of Coverage online at www.bcbsm.com/medicare. Your plan requires prior authorization and has step therapy and quantity limit restrictions for certain drugs. Please refer to your formulary to determine if your drugs are subject to any limitations. 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 pharmacy directory at our website (www.bcbsm.com/pharmaciesmedicare). You can see the most complete and current information about which drugs are covered on our website (www.bcbsm.com/formularymedicare). 20
Signature Outpatient Prescription Drugs Phase 1: Deductible You pay $105 except for drugs listed on Tier 1 and Tier 2 which are excluded from the deductible. Stage Phase 2: Initial Coverage Stage Tier 1: Preferred Generic 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. Preferred Retail, Mail Order, Standard Retail, and Longterm care Rx 31-day supply Standard Retail Rx 90-day supply Preferred Retail and Mail Order Rx 90-day supply $3 $9 $7.50 Tier 2: Generic $15 $45 $37.50 Tier 3: Preferred Brand $45 $135 $112.50 Tier 4: Non-Preferred Drugs 45% 45% 42% Tier 5: Specialty 30% Not Offered Not Offered Phase 3 & 4: Coverage Gap and Catastrophic Coverage Stages Cost sharing may change depending on the pharmacy you choose and when you enter another phase of the Part D benefit. For more information on the additional pharmacy-specific cost sharing and the phases of the benefit, please call us or access our Evidence of Coverage online at www.bcbsm.com/medicare. Most members do not reach the Coverage Gap stage or the Catastrophic Coverage stage. For information about your costs in these stages, look at Chapter 6, Sections 6 and 7, in the Evidence of Coverage online at www.bcbsm.com/medicare. Your plan requires prior authorization and has step therapy and quantity limit restrictions for certain drugs. Please refer to your formulary to determine if your drugs are subject to any limitations. 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 pharmacy directory at our website (www.bcbsm.com/pharmaciesmedicare). You can see the most complete and current information about which drugs are covered on our website (www.bcbsm.com/formularymedicare). 21
Outpatient Prescription Drugs Phase 1: Deductible Stage Phase 2: Initial Coverage Stage Tier 1: Preferred Generic Assure 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. Preferred Retail, Mail Order, Standard Retail, and Longterm care Rx 31-day supply Standard Retail Rx 90-day supply Preferred Retail and Mail Order Rx 90-day supply $3 $9 $7.50 Tier 2: Generic $14 $42 $35 Tier 3: Preferred Brand $40 $120 $100 Tier 4: Non-Preferred Drugs 45% 45% 42% Tier 5: Specialty 33% Not Offered Not Offered Phase 3 & 4: Coverage Gap and Catastrophic Coverage Stages Cost sharing may change depending on the pharmacy you choose and when you enter another phase of the Part D benefit. For more information on the additional pharmacy-specific cost sharing and the phases of the benefit, please call us or access our Evidence of Coverage online at www.bcbsm.com/medicare. Most members do not reach the Coverage Gap stage or the Catastrophic Coverage stage. For information about your costs in these stages, look at Chapter 6, Sections 6 and 7, in the Evidence of Coverage online at www.bcbsm.com/medicare. Your plan requires prior authorization and has step therapy and quantity limit restrictions for certain drugs. Please refer to your formulary to determine if your drugs are subject to any limitations. 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 pharmacy directory at our website (www.bcbsm.com/pharmaciesmedicare). You can see the most complete and current information about which drugs are covered on our website (www.bcbsm.com/formularymedicare). 22
For more information, please call us at the phone number below or visit us at www.bcbsm.com/medicare. If you are a member of this plan, call toll free 1 877 241 2583. TTY users should call 711. If you are not a member of this plan, call toll free 1 888 563 3307. TTY users should call 711. From October 1 to February 14, you can call us 7 days a week from 8 a.m. to 9 p.m. Eastern time. From February 15 to September 30, you can call us Monday through Friday from 8 a.m. to 9 p.m. Eastern time. If you want to more about the coverage and costs of Original Medicare, look in your current Medicare & You handbook. View it online at www.medicare.gov or get a copy by calling 1 800 MEDICARE (1 800 633 4227), 24 hours a day, 7 days a week. TTY users should call 1 877 486 2048. This document is available in other formats such as Braille and large print. This document may be available in a non English language. H9572_C_17PPOSB CMS Accepted 09112016 DB 14959 SEP 16 R056910