Health insurance coverage for retired educators and other

school district employeesTrue Blue HMO, Blue Cross of Idaho’s Medicare Advantage health

maintenance organization plan, offers coverage with affordable premiums, no deductibles, and predictable costs. In addition,

True Blue HMO for Statewide School Retirees includes enhanced prescription coverage for brand name and generic drugs in the gap.

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3000 East Pine Avenue Meridian, Idaho | 83642-5995 Mailing Address: P.O. Box 8406 Boise, Idaho | 83707-1408

1-888-492-2583 TTY 1-800-377-1363

Customer Service hours are 8:00 a.m. to 8:00 p.m., seven days a week

visit our web site at www.bcidaho.comH1350_MK 11230 File and Use MMDDYYYY 16-106 (11-10)

© 2010 Blue Cross of Idaho. An Independent Licensee of the Blue Cross and Blue Shield Association.

True Blue HMO fOr STaTewide ScHOOl reTireeS

Coverage that offers all your benefits in one plan

True Blue HMO offers benefits beyond Original Medicare, such as vision services and eyewear along with health and wellness education. True Blue HMO also covers annual wellness exams and preventive services to keep you up-to-date.

With True Blue HMO, you choose your primary care physician from a network of more than 2,000 participating providers – and you don’t need a referral to see a specialist. Your primary care provider assists in coordinating care and obtaining prior authorization for some services.

If you recently retired, enrolled in Medicare Parts A and B, and live in one of the select Idaho counties where True Blue HMO is available, you may be eligible for this plan. You may also have the option to use PERSI funds to pay your premiums.

Prescription Drug CoverageTrue Blue HMO prescription drug coverage for statewide school retirees has no Part D deductible and includes coverage for brand name and generic drugs in the gap. Because True Blue HMO has its own drug formulary, check to see if your drugs are included before changing coverage.

ContactIs True Blue HMO for Statewide Schools Retirees right for you? Contact Blue Cross of Idaho at 1-888-492-2583 or TTY 1-800-377-1363, 8 a.m. to 8 p.m., seven days a week to find out more.

Catastrophic Drug CoverageAfter spending an out-of-pocket total of $4,550, you reach the catastrophic level of prescription drug coverage. Your annual out-of-pocket total includes copayments and the costs you pay toward covered Part D medications.

At the catastrophic level, you pay only $2.50 per prescription for generic drugs and $6.30 or 5% coinsurance (which ever is greater) per prescription for all other drugs.

Prescription Drug Copayments or Coinsurance

in-network

retail and mail order copayment or coinsurance

out-of-network copayment or coinsurance

(30 day supply) (90 day supply) (30 day supply) (90 day supply)

tier 1 Generic druGS $ 6 Copayment $ 18 Copayment $ 6 Copayment $18 Copayment

tier 2 Preferred Brand naMe druGS

$31 Copayment $93 Copayment $ 31 Copayment $ 93 Copayment

tier 3 Brand naMe druGS

$41 Copayment $123 Copayment $41 Copayment $123 Copayment

tier 4 SPecialTy druGS

25% Coinsurance 25% Coinsurance 25% Coinsurance 25% Coinsurance

When choosing out-of-network providers you may be responsible for the difference between

in- and out-of-network costs.

Open Enrollment and Continuing your Coverage Each year during Medicare’s open enrollment period, you have the opportunity to review and change your coverage. You can choose between True Blue HMO for Statewide School Retirees or the standard Statewide Schools Retiree plan.

In the event your school district discontinues coverage through Blue Cross of Idaho, you can choose to keep True Blue HMO. When choosing the standard True Blue HMO plan, you no longer get the Statewide Schools Retiree plan enhanced drug coverage. In addition, if you choose to keep standard True Blue HMO coverage, instead of coverage offered by your school district, you may not be eligible for other Statewide Schools Retiree plans in the future.

Statewide School Council member school districts also qualify for True Blue HMO for Statewide School Retirees,regardless of their current health insurance carrier.