member kit medicare + you · learn about your 2021 plan changes dear member, during this time of...

2021 Premera Medicare Advantage (HMO)

Member Kit

MEDICARE + YOU

Table of contents INTRODUCTION .................................................................................................................................. 3

INSTRUCTIONS ................................................................................................................................... 5

ONLINE RESOURCES .......................................................................................................................... 6

Outlines important links on our website and how to find them

PLAN SELECTION FORM .................................................................................................................... 7

Use this form to transfer from your existing Premera Blue Cross Medicare Advantage plan to a new one that better meets your needs

SUPPLEMENTAL BENEFITS GUIDE .................................................................................................. 11

A snapshot of some of the supplemental benefits our plans offer

BENEFIT HIGHLIGHTS ........................................................................................................................17

A snapshot of our most popular plans and how they compare

SUMMARY OF BENEFITS....................................................................................................................37

A comprehensive overview of all Premera Medicare Advantage plan rates, cost shares, and benefits

CVS CAREMARK MAIL ORDER PHARMACY FAQ AND FORM..........................................................76

Have prescriptions mailed directly to your home by ordering them online or filling out the form included here

MEDICARE STAR RATINGS ................................................................................................................80

Star Ratings are assessed annually to help you compare our plans’ performance to other plans

Introduction

Learn about your 2021 Plan Changes

Dear Member,

During this time of ongoing uncertainty, you deserve peace of mind about your Medicare Advantage plan coverage. This kit will help you understand any changes or enhancements made to your current plan. As a reminder, if you’re happy with the plan you’re on, you don’t have to do anything. However, if your needs have changed, this kit includes the other plans we offer that may be a better fit. You can call 888-868-7767 (TTY/TDD: 711) for help in choosing the best option.

continued on next page

And because keeping you healthy is our focus, your plan covers the following benefits to help make care accessible and safe:

• During the COVID-19 public health emergency, shipping costs for mail-order pharmacy is waived for 30-, 60-, and 90-day supplies1

• $0 copay for a 90-day supply of Tier 1 preferred generics through our mail-order pharmacy, with no shipping costs1

• Healthy Rewards program for eligible members who can earn rewards for maintaining their health by getting recommended preventive screenings, managing chronic diseases, participating in a fitness class, and more

• Up to $50 credit per quarter for over-the-counter supplies, shipped to your home2

• Reduced-cost telehealth coverage if offered through your in-network care provider

• Convenient in-home testing kits for cancer screening, diabetes management, and other chronic disease management for eligible members

• No-cost, live, daily workouts on Facebook Live and YouTube through Silver&Fit®

• Enhanced home fitness kits through Silver&Fit, including Garmin and Fitbit options

You can also attend a virtual Member Information Meeting to find out about any changes to your plan firsthand from your local Premera Medicare specialist. They’ll help ensure you’re taking advantage of all the perks available to you as part of your membership. Go to premera.com/member-meeting or call 888-850-8526 (TTY/TDD: 711) to find a meeting and RSVP3.

We appreciate your continued membership.

Sincerely,

Tracy Bos

Vice President and General Manager, Senior Markets

1Not included on the Alpine HMO plan. 2Credit amount depends on the plan. 3Reservations are encouraged, but not required.

On behalf of Premera, The Silver&Fit® program is provided by American Specialty Health Fitness, Inc., a subsidiary of American Specialty Health Incorporated (ASH). Silver&Fit is a federally registered trademark of ASH and used with permission herein. Other names may be trademarks of their respective owners. Kits are subject to change.

http://premera.com/member-meeting

Enrollment Instructions

If you’re happy with the plan you’re on, you don’t have to do anything!

However, if your needs have changed, this kit includes the other plans we offer that may be a better fit. To transfer your membership to a different Premera Blue Cross Medicare Advantage plan:

1

2

3

Print, fill out, and mail the form on pages 7 through 10 to: Premera Blue Cross PO Box 262548 Plano, TX 75026

Call us at 888-868-7767 (TTY/TDD: 711) for help in choosing the best option. Customer Service representatives are ready to assist you in this paperless enrollment process. Our hours of operation are: October 1 – March 31: 8 a.m. – 8 p.m., 7 days a week April 1 – September 30: 8 a.m. – 8 p.m., Monday – Friday

Connect with a local Premera Medicare specialist Our Medicare specialists can answer all of your questions regarding our plans and help you enroll. You can:

• Visit premera.com/member-meeting to find amember meeting and RSVP.

• Or contact the specialist listed who serves your county.

Premera Blue Cross is an HMO plan with a Medicare contract. Enrollment in Premera Blue Cross depends on contract renewal.

Kirsten Keneipp [email protected]

Cowlitz King Kitsap Pierce Lewis Thurston

Darlynn B. Carlson [email protected]

King Snohomish

Lesley Quick [email protected]

Spokane Stevens Walla Walla

Erik Endresen 425-412-0193Erik.Endresen@Premera .com

San Juan Skagit Whatcom

P2020137 Y0134_PBC2796_M 053465 (10-01-2020)

mailto:[email protected]:[email protected]:[email protected]:[email protected]://premera.com/member-meeting

Premera Blue cross in an HMO plan with Medicare conract. Enrollment in Premera Blue Cross

depends on contract renewal. Premera is an Independent Licensee of the Blue Cross Blue Shield

Association.

Y0134_PBC2644_C 047157 (10-01-2020)

Online resources

The Premera Blue Cross Medicare Advantage website contains many resources to help you use your plan. Please see below for commonly requested items available free on our website, premera.com/ma.

Find a doctor, dentist or hospital To find a medical provider or dental provider in your area, go to premera.com/ma and click on Find a doctor.

Find a pharmacy To find a pharmacy in your area, go to premera.com/ma and click on Find a pharmacy.

Formulary (list of covered drugs) To see what drugs are covered, go to premera.com/ma and click on See covered drugs.

Evidence of Coverage To view a copy of the Evidence of Coverage for your plan, go to premera.com/ma. Select Plan documents from the Products & Services tab.

You can also call Premera Blue Cross Medicare Advantage Customer Service at 888-850-8526

(TTY/TDD: 711), April 1 – September 30, Monday – Friday, 8 a.m. - 8 p.m. (October 1 – March

31, 7 days a week, 8 a.m. – 8 p.m.) to receive a paper copy of the above materials.

https://www.premera.com/medicare-advantage/?WT.z_redirect=www.premera.com/ma/https://www.premera.com/medicare-advantage/?WT.z_redirect=www.premera.com/ma/https://premera.sapphirecareselect.com/?ci=medicareadvantage&_ga=2.149038005.228110705.1594766185-1672583937.1578508976https://www.premera.com/medicare-advantage/?WT.z_redirect=www.premera.com/ma/https://www.medicareplanrx.com/PharmacyLocator/?contractId=PremeraPref&lang=en&year=2020&clientId=PremeraPrefhttps://www.premera.com/medicare-advantage/?WT.z_redirect=www.premera.com/ma/https://www.medicareplanrx.com/MedicationPricingTool/planInfo.do?clientId=157&regionId=1&year=2020&contractId=H7245&planId=001&lang=en&formularySearch=true&displayFormularyRegion=false&displayFormularyChangePlan=false&displayPricingRegion=false&displayPricingChangePlan=falsehttps://www.premera.com/medicare-advantage/?WT.z_redirect=www.premera.com/ma/https://www.premera.com/medicare-advantage/products-services/plans/

PREMERA BLUE CROSS MEDICARE ADVANTAGE PLANS

Plan Selection Form To be used by current Premera members only. PO Box 262548

Plano, TX 75026 Please contact us at 888-868-7767 (TTY/TDD: 711) if you need Fax: 800-381-4837 help with your enrollment. Monday–Friday, 8 a.m. to 8 p.m. (or 7 days a week, 8 a.m. to 8 p.m., October 1–March 31).

YOUR INFORMATION

Name: Member number:

Home phone number: Medicare number:

Email address:

Permanent residence (PO box is not allowed)

Street address:

City: State: Zip:

Mailing address (only if different from your permanent address)

Street address:

City: State: Zip:

Name of chosen Primary Care Provider (PCP):

PCP location:

please continue to the next page —

OFFICE USE ONLY: AGENT NAME: WRITING #:

SCOPE OF APPOINTMENT: AGENT RECEIVED DATE:

PAPER APP MAILED TO AGENT EFFECTIVE DATE: SEMINAR (DATE / LOCATION): SEP TYPE: PBP: PLAN #: CONTRACT #: GROUP #:

Y0134_PBC2668_M 042630 (10-05-2020)

CHOOSE YOUR MEDICARE ADVANTAGE PLAN

I am currently a member of the plan in Premera Blue Cross Medicare Advantage, and my current monthly premium is $ . I want to transfer from my current Premera Blue Cross Medicare Advantage plan to the Premera Blue Cross Medicare Advantage plan I have selected below. I agree to allow Premera Blue Cross to use my personal information on file from my current Premera Blue Cross plan to complete my enrollment request. I understand that this plan may have a different provider network and that I must pay the monthly premium (if any) in addition to any Medicare Part A and Part B premiums I may owe. I understand that this plan has different health benefits and a monthly premium of $ . If this form is received by the end of the month, my new plan will generally be effective the 1st of the following month.

KING • PIERCE • SNOHOMISH • THURSTON

LEWIS • KITSAP • COWLITZ

HMO - $0 Classic HMO - $55 Add Optional Dental Plan - $22.50

SPOKANE

HMO - $0 Total Health HMO - $24 Add Optional Dental Plan - $22.50

STEVENS

Total Health HMO - $24

SKAGIT • ISLAND • SAN JUAN • WALLA WALLA

Core HMO - $12 Add Optional Dental Plan - $22.50

Core Plus HMO - $75

WHATCOM

Core HMO - $12 Add Optional Dental Plan - $22.50

Peak + Rx (HMO) - $0 Add Optional Dental Plan - $22.50

Sound + Rx (HMO) - $40

Y0134_PBC2668_M please continue to the next page —

HMO - $0 Add Optional Dental Plan - $22.50

Classic HMO - $55

Classic Plus HMO - $191

Peak + Rx (HMO) - $0 Add Optional Dental Plan - $22.50

Sound + Rx (HMO) - $40

Charter + Rx (HMO) - $151

Alpine (HMO) - $42 (no prescription coverage)

Charter + Rx (HMO) - $151

Alpine (HMO) - $42 (no prescription coverage)

Classic (HMO) - $55

PAYING YOUR PLAN PREMIUM

If we determine that you owe a late enrollment penalty (or if you currently have a late enrollment penalty), we need to know how you would prefer to pay it. You can pay your monthly plan premium, including any late enrollment penalty that you currently have or may owe, by mail or Electronic Funds Transfer (EFT) each month. You can also choose to pay your premium by automatic deduction from your Social Security or Railroad Retirement Board (RRB) benefit check each month. If you are assessed a Part D-Income Related Monthly Adjustment Amount (Part D-IRMAA), you will be notified by the Social Security Administration. You will be responsible for paying this extra amount in addition to your plan premium. You will either have the amount withheld from your Social Security benefit check or be billed directly by Medicare or RRB. DO NOT pay Premera Blue Cross the Part D-IRMAA. People with limited incomes may qualify for extra help to pay for their prescription drug costs. If eligible, Medicare could pay for 75% or more of your drug costs including monthly prescription drug premiums, annual deductibles, and coinsurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don’t even know it. For more information about this extra help, contact your local Social Security office, or call Social Security at 800-772-1213. TTY/TDD users should call 800-325-0778. You can also apply for extra help online at www.socialsecurity.gov/prescriptionhelp. If you qualify for extra help with your Medicare prescription drug coverage costs, Medicare will pay all or part of your plan premium. If Medicare pays only a portion of this premium, we will bill you for the amount that Medicare doesn‘t cover. If you don’t select a payment option, you will get a bill each month.

Please select a premium payment option:

Get a monthly bill

Electronic funds transfer (EFT) from your bank account each month. Please enclose a VOIDED check or provide the following:

Account Holder Name: Account type: Checking Savings

Bank Routing #: Bank Account #:

Automatic deduction from your monthly Social Security or Railroad Retirement Board (RRB)benefit check. Please note: The Social Security/RRB deduction may take two or more months to begin after Social Security or RRB approves the deduction. Before the deduction begins, you may receive invoices for your premium. You will be responsible for paying your monthly premium directly to Premera from your effective date until the date your withholding begins. Invoices will stop once the deduction is approved. If Social Security or RRB does not approve your request for automatic deduction, we will send you a letter and paper bill for your monthly premiums.

I get monthly benefits from: Social Security Railroad Retirement Board

Please check the box if you would prefer us to send you information in a language other than English or in another format: Spanish Braille

Please contact Premera Blue Cross at 888-850-8526 (TTY/TDD: 711) if you need information in another format or language than what is listed above. Our office hours are seven days a week, between 8 a.m. and 8 p.m.

Y0134_PBC2668_M please continue to the next page —

http://www.socialsecurity.gov/prescriptionhelp

STOP — READ THIS IMPORTANT INFORMATION

PLEASE READ AND SIGN BELOW

Premera Blue Cross is a Medicare Advantage plan that has a contract with the Federal government.

I understand that if I am getting assistance from a sales agent, broker, or other individual employed by or contracted with Premera Blue Cross, he/she may be paid based on my enrollment in a Premera Blue Cross Medicare Advantage plan.

Release of Information: By joining this Medicare health plan, I acknowledge that the Medicare health plan will release my information to Medicare and other plans as is necessary for treatment, payment and health care operations. I also acknowledge that Premera Blue Cross will release my information including my prescription drug event data to Medicare, who may release it for research and other purposes which follow all applicable Federal statutes and regulations. The information on this enrollment form is correct to the best of my knowledge. I understand that if I intentionally provide false information on this form, I will be disenrolled from the plan. I understand that people with Medicare aren’t covered under Medicare while out of the country except for limited coverage near the U.S. border.

I understand that beginning on the date my Premera Blue Cross Medicare Advantage coverage begins, I must get all of my health care from Premera Blue Cross, except for emergency or urgently needed services or out-of-area dialysis services. Services authorized by Premera Blue Cross and other services contained in my Premera Blue Cross Medicare Advantage Evidence of Coverage document (also known as a member contract or subscriber agreement) will be covered. WITHOUT AUTHORIZATION, NEITHER MEDICARE NOR PREMERA BLUE CROSS MEDICARE ADVANTAGE PLANS WILL PAY FOR THE SERVICES.

I understand that my signature (or the signature of the person authorized to act on my behalf under the laws of the State where I live) on this application means that I have read and understand the contents of this application. If signed by an authorized individual (as described above), this signature certifies that: 1) this person is authorized under State law to complete this enrollment and 2) documentation of this authority is available upon request from Medicare.

Signature: Today’s date:

If you are the authorized representative, you must sign above and provide the following information:

Name: Address: Phone: Relationship to enrollee:

Once you have completed this form, please mail it to this address:

Premera Blue Cross Medicare Advantage Plans PO Box 262548, Plano, TX 75026 or fax it to 800-390-9656

Premera Blue Cross is an HMO plan with a Medicare contract. Enrollment in Premera depends on contract renewal.

Premera Blue Cross is an Independent Licensee of the Blue Cross Blue Shield Association Y0134_PBC2668_M

Value-added Benefits

MEDICARE ADVANTAGE

your health matters. From the top of your head to the tip of your toes,

The Silver&Fit® Program All Premera Medicare Advantage members can stay active with their no-cost Silver&Fit membership. Membership includes:

• Access to our premium network that includes more than 15,000 local and national fitness centers like YMCA, LA Fitness, Snap Fitness, and others

• Healthy aging coaching – coaches can answer questions related to healthy eating and nutrition, sleep, self-advocacy, coping with isolation, starting a home fitness routine, and other lifestyle questions

• Silver&Fit Home Kits Options – choose one Stay Fit Kit and up to 2 Home Fitness Kits per benefit year to help you stay active without leaving your home

• A Stay Fit Kit – choose a kit with fitness gear designed to help you stay active without leaving your home

• Access over 1,500 digital workout videos available via the Silver&Fit ASHConnect™ mobile app or website

• Access to a national social club network of over 120,000 locations with activities such as walking, chess, bridge, AM radio, cooking, and more

To use this benefit, visit silverandfit.com or call 877-427-4788 (TTY/TDD 711).

24- Hour NurseLine Help is only a call away.

All Premera Medicare Advantage members have access to free confidential help from a registered nurse 24 hours a day, 7 days a week, 365 days a year. Nurses are available through this service to answer questions about medications, help you decide when and where to seek care, or simply provide reassurance when you need it.

To use this benefit, call 855-339-8123.

Call 911 or go to the emergency room in the case of a life-threatening emergency, such as a heart attack or stroke.

http://silverandfit.com

Hearing Services with Hearing Care Solutions (HCS)*

Premera Medicare Advantage plans help you keep your retirement money safe by paying for costs not covered by Original Medicare alone, like hearing aids.

Hearing Care Solutions delivers quality hearing care and hearing instruments at the greatest value to meet your lifestyle needs and includes an annual benefit of $1,000 per ear per year toward hearing aids.

Through Hearing Care Solutions, members receive:

• A hearing aid fitting at no cost

• A 60-day evaluation period to make sure everything feels right

• 1 year of follow-up care at no charge, with the original provider

All instruments purchased through Hearing Care Solutions receive:

• 1 2-month, interest-free financing, available to qualified applicants

• 2-year supply of batteries (up to 64 cells per ear, per year)

• 3-year manufacturer’s warranty, including loss, damage, and repair

To use this benefit, call Hearing Care Solutions at 866-344-7756.

your health matters.From the top of your head to the tip of your toes,

The Silver&Fit program is provided by American Specialty Health Fitness, Inc. (ASH Fitness), a subsidiary of American Specialty Health Incorporated (ASH). Silver&Fit and Silver&Fit Connected! are trademarks of ASH and used with permission herein. The people in this piece are not Silver&Fit members. Kits are subject to change. Participating facilities and fitness chains may vary by location and are subject to change. Other names may be trademarks of their respective owners.

*Not all benefits are included with all plans. Check the Summary of Benefits to see what is included in your plan.

Preventive Dental Benefits*

Keep your mouth looking and feeling young through preventive dental benefits. Premera dental plans include:

• routine oral exams and cleanings

• periodontal maintenance

• $200 to use toward additional dental services

Vision*

Maintain your vision and eye health as you age with Premera vision benefits. Vision plans include:

• a routine eye exam once per calendar year

• a diabetic retinopathy screening once per calendar year

• a $150 hardware allowance (included in most plans)

90-day Prescription Mail Order*

Enjoy the convenience of having long-term drugs delivered right to your home! Through the CVS mail- order pharmacy home delivery service, pay a $0 copay for a 90-day supply of preferred generic drugs. To use this benefit, visit caremark.com, complete the paper form found on premera.com/ma, or call us at the number on your member ID card.

Over the Counter (OTC) Receive up to a $50 quarterly benefit for over-the-counter health and wellness products available through OTC Health Solutions. This benefit provides you with an easy way to get:

• generic personal care items

• bath and safety supplies

• hearing aid batteries and more.

To use this benefit, browse the OTC Health Solutions catalog premera.com/ma. Then, place your order over the phone at 888-628-2770, or online at cvs.com/otchs/premera.

your health matters. From the top of your head to the tip of your toes,

http://caremark.comhttp://premera.com/mahttp://premera.com/mahttp://cvs.com/otchs/premera

Joining a Premera Medicare Advantage plan gives you access to exclusive benefits designed to help improve your life. Use this guide as a quick and simple introduction to what we can offer you.

Visit premera.com/MA/benefits for more information on how to use these benefits as a member.

http://premera.com/MA/benefits

。注意：如果您使用繁體中文，您可以免

費獲得語言援助服務。請致電

Y0134_PBC2672_M053019 (10-01-2020)

To enroll:call 888-868-7767 (TTY/TDD: 711)

visit premera.com/ma

Discrimination is Against the LawPremera Blue Cross Medicare Advantage complies with

applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. ATENCIÓN: si habla español, tiene a su disposición servicios

gratuitos de asistencia lingüística. Llame al 888-850-8526 (TTY: 711).

888-850-8526 (TTY: 711)

Premera Blue Cross is an (HMO) plan with a Medicare contract. Enrollment depends on contract renewal.

http://premera.com/ma

2021 Benefit Highlights

MEDICARE ADVANTAGE

Always in your corner

At Premera Blue Cross, it’s our customers who drive us to innovate and improve with each new day. Our employees work hard to make

healthcare work better—so we are at our best when you need us most.

Enrolling is easy—you can:

ENROLL ONLINE: CONTACT Go to premera.com/ma your producer or local sales representative

ENROLL BY MAIL: ENROLL BY PHONE: Call toll free 888-868-7767 (TTY/TDD: 711) Return your paper application to: October 1–March 31 Premera Blue Cross 7 days a week, 8 a.m. to 8 p.m. PO Box 262548

Plano, TX 75026 April 1–September 30 Monday through Friday, 8 a.m. to 8 p.m.

http://premera.com/ma

Your doctors. Our network. ACCESS WHEN AND WHERE YOU NEED IT

You can find doctors and hospitals across our service area.

This is a partial list of providers in the Medicare Advantage network.

Western Washington • Associates in Family Medicine • Pacific Medical Centers• CHI Franciscan Health • PeaceHealth• The Everett Clinic • Physicians of Southwest Washington (PSW)• EvergreenHealth • The Polyclinic• Family Care Network (FCN) • Providence Health and Services• Morton Medical Center • Skagit Valley Hospital• MultiCare Health System • Swedish Medical Center• Northwest Physicians Network (NPN) • UW Medicine• Overlake Medical Center • Virginia Mason Medical Center

Eastern Washington • The Doctors Clinic • Providence Holy Family Hospital• Multicare Deaconess Hospital • Providence Sacred Heart Medical Center• MultiCare Rockwood Clinic • Vivacity Care Center• MultiCare Valley Hospital • Walla Walla Clinic• Providence Health and Services

As a Premera Medicare Advantage HMO customer, you can receive care from any doctor or hospital in our Medicare Advantage network, even if they are located outside your county. Just ask your primary care physician (PCP) for a referral to the provider you wish to see.

Spokane County Medicare Advantage Total Health (HMO)

MEDICAL SERVICES Premium $24

Maximum out of pocket $5,000Plan Cost

Office Visit

Diagnostic

Outpatient

Physical Therapy

Emergency

Inpatient Care

Retail Pharmacy(Preferred / Standard)

One month supply =30 days

Prescription mail order

Dental

Hearing

Vision

Over The Counter Benefit

Chiropractic

PREVENTIVE

PRESCRIPTION DRUGS

Provider (PCP) visit copay $5 Specialist visit copay $30

Labs $10 X-rays $10

Ambulatory benefits $250 Outpatient surgery $350

$20 Ambulance copay $370(each one-way trip)

Emergency care copay (waived if admitted) $90, worldwide Urgent care (waived if admitted) $45 in US, $50 worldwide

Inpatient hospital Days 1-4 /days 5+ $450/$0 no copay if readmitted within 60 days Days 1-3 /days 4+ NA

Days 1-20 $0 Skilled nursing Days 21-60 $160

(waived 3-day prior hospital) Days 61-100 $0

Drug deductible $180 Deductible waived T1, T2, T3

Tier 1 copay $2/$12 Tier 2 copay $10/$20 Tier 3 copay $40/$47 Tier 4 copay 33% Tier 5 copay 29%

Tier 1 Preferred Generic, 90-day supply $0

Included in plan Yes Copay $0

Coverage includes: routine exams, cleanings, x-rays, fluoride,periodontal maintenance, and emergency exam

Additional coverage $200 Routine hearing exam (1 per year) $0–$30

Hearing aids *$0 copay; $1,000 annual limit (*toward the purchase of hearing aids per earthrough Hearing Care Solutions) Routine eye exam (1 per year) $20

Hardware - reimbursement $150allowance every 12 months Per quarter allowance (mail order only) $50

Routine visit - 6 per year $30 per visit Medicare covered visits $20

Spokane County Medicare Advantage (HMO)


Maximum out of pocket $6,300 Plan Cost

Office Visit

Diagnostic

Outpatient

Physical Therapy

Emergency

Inpatient Care

Retail Pharmacy (Preferred / Standard)

One month supply = 30 days


Dental

Hearing

Vision


Chiropractic

PRESCRIPTION DRUGS

PREVENTIVE


Labs $20 X-rays $20

Ambulatory benefits $250 Outpatient surgery 20%






Drug deductible $180 Deductible waived T1, T2



Included in plan $22.50/mo optional rider Copay $0

Coverage includes: routine exams, cleanings, x-rays, fluoride, periodontal maintenance, and emergency exam

Additional coverage NA Routine hearing exam (1 per year) NA

Hearing aids (*toward the purchase of hearing aids NA

through Hearing Care Solutions) Routine eye exam (1 per year) $20

Hardware - reimbursement NAallowance every 12 months Per quarter allowance (mail order only) $25

Routine visit - 6 per year NA Medicare covered visits $20

Whatcom County Medicare Advantage Core (HMO)



Office Visit

Diagnostic

Outpatient

Physical Therapy

Emergency

Inpatient Care




Dental

Hearing

Vision


Chiropractic

PRESCRIPTION DRUGS

PREVENTIVE


Labs $20 X-rays $20

















Whatcom County Peak + Rx (HMO)



Office Visit

Diagnostic

Outpatient

Physical Therapy

Emergency

Inpatient Care




Dental

Hearing

Vision


Chiropractic

PRESCRIPTION DRUGS

PREVENTIVE


Labs $15 X-rays $20




Inpatient hospital Days 1-4 /days 5+ NA no copay if readmitted within 60 days Days 1-3 /days 4+ $595/$0








Additional coverage NA Routine hearing exam (1 per year) $0-$50




Whatcom County Sound + Rx (HMO)



Office Visit

Diagnostic

Outpatient

Physical Therapy

Emergency

Inpatient Care




Dental

Hearing

Vision


Chiropractic

PRESCRIPTION DRUGS

PREVENTIVE


Labs $15 X-rays $20
















Whatcom County Medicare Advantage Classic (HMO)


Maximum out of pocket $5,000






Plan Cost

Office Visit

Diagnostic

Outpatient

Physical Therapy

Emergency

Inpatient Care




Dental

Hearing

Vision


Chiropractic

PRESCRIPTION DRUGS

PREVENTIVE


Labs $10 X-rays $10







Additional coverage $200 Routine hearing exam (1 per year) $0-$30




Island, San Juan, Skagit and Walla Walla Counties Medicare Advantage Core (HMO)



Office Visit

Diagnostic

Outpatient

Physical Therapy

Emergency

Inpatient Care




Dental

Hearing

Vision


Chiropractic

PRESCRIPTION DRUGS

PREVENTIVE


Labs $20 X-rays $20













Hearing aids (*toward the purchase of hearing aids

through Hearing Care Solutions) NA

Routine eye exam (1 per year) $45 Hardware - reimbursement

allowance every 12 months NA

Per quarter allowance (mail order only) $25 Routine visit - 6 per year Medicare covered visits

NA $20

Island, San Juan, Skagit and Walla Walla Counties Medicare Advantage Core Plus (HMO)



Office Visit

Diagnostic

Outpatient

Physical Therapy

Emergency

Inpatient Care




Dental

Hearing

Vision


Chiropractic

PRESCRIPTION DRUGS

PREVENTIVE


Labs $10 X-rays $10
















King, Pierce, Snohomish and Thurston Counties Medicare Advantage (HMO)



Office Visit

Diagnostic

Outpatient

Physical Therapy

Emergency

Inpatient Care




Dental

Hearing

Vision


Chiropractic

PRESCRIPTION DRUGS

PREVENTIVE


Labs $20 X-rays $20

















King, Pierce, Snohomish and Thurston Counties Medicare Advantage Classic (HMO)



Office Visit

Diagnostic

Outpatient

Physical Therapy

Emergency

Inpatient Care




Dental

Hearing

Vision


Chiropractic

PRESCRIPTION DRUGS

PREVENTIVE


Labs $10 X-rays $10
















King, Pierce, Snohomish and Thurston Counties Peak + Rx (HMO)



Office Visit

Diagnostic

Outpatient

Physical Therapy

Emergency

Inpatient Care




Dental

Hearing

Vision


Chiropractic

PRESCRIPTION DRUGS

PREVENTIVE


Labs $15 X-rays $20
















King, Pierce, Snohomish and Thurston Counties Sound + Rx (HMO)



Office Visit

Diagnostic

Outpatient

Physical Therapy

Emergency

Inpatient Care




Dental

Hearing

Vision


Chiropractic

PRESCRIPTION DRUGS

PREVENTIVE


Labs $15 X-rays $20
















Cowlitz, Kitsap and Lewis Counties Medicare Advantage (HMO)



Office Visit

Diagnostic

Outpatient

Physical Therapy

Emergency

Inpatient Care




Dental

Hearing

Vision


Chiropractic

PRESCRIPTION DRUGS

PREVENTIVE


Labs $20 X-rays $20

















Cowlitz, Kitsap and Lewis Counties Medicare Advantage Classic (HMO)



Office Visit

Diagnostic

Outpatient

Physical Therapy

Emergency

Inpatient Care




Dental

Hearing

Vision


Chiropractic

PRESCRIPTION DRUGS

PREVENTIVE


Labs $10 X-rays $10
















Stevens County Medicare Advantage Total Health (HMO)


Maximum out of pocket $5,000






Plan Cost

Office Visit

Diagnostic

Outpatient

Physical Therapy

Emergency

Inpatient Care




Dental

Hearing

Vision


Chiropractic

PRESCRIPTION DRUGS

PREVENTIVE


Labs $10 X-rays $10







Additional coverage $200 Routine hearing exam (1 per year) $0–$30




Top 5 tips for choosing the plan that’s right for you

Many of our Medicare Advantage plans include extra benefits, like dental, vision, hearing, and fitness. Some even include chiropractic coverage.

Make a list of the medications you’re taking. Then check the list of covered drugs (also called a formulary) to see if all your drugs are covered on the plan you like. Search the Premera Medicare Advantage formulary at premera.com/ma.

Premera has thousands of doctors and hospitals in our Medicare Advantage network. So, chances are your doctor is in our network. You can search our provider directory at premera.com/ma.

A Premera Medicare Advantage plan helps keep your retirement money safe by paying for costs not covered by Original Medicare alone. Plan premiums start as low as $0 per month.

It’s important to be able to call customer service and ask questions about your Medicare Advantage plan. Premera’s customer service team can answer most questions in just one phone call.

http://premera.com/mahttp://premera.com/ma

Premera Blue Cross is an HMO plan with aMedicare contract. Enrollment in Premera Blue Cross depends onrenewal.

H7245_H9302_PBC0985_C 037710 (10-20-2018)

QUESTIONS? Call us today. We’re here to help make

Medicare easy.

CALL TOLL FREE 888-868-7767 (TTY/TDD: 711)

Monday–Friday, 8 a.m.–8 p.m.

(October 1–March 31: 7 days a week, 8 a.m.–8 p.m.)

Premera Blue Cross is an HMO plan with a Medicare contract. Enrollment in Premera Blue Cross depends on contract renewal.

To join a Premera Blue Cross Medicare Advantage Plan, you must have Medicare Part A and Part B and live in the Premera Blue Cross Medicare Advantage service area

(Cowlitz, Island, King, Kitsap, Lewis, Pierce, San Juan, Skagit, Snohomish, Spokane, Stevens, Thurston, Walla Walla, and Whatcom counties in Washington).

Members must select a PCP from the Premera Blue Cross Medicare Advantage Plans provider network.

Statement of Non-Discrimination

Discrimination is Against the Law Premera Blue Cross Medicare Advantage complies with applicable Federal civil rights laws and

does not discriminate on the basis of race, ethnicity, national origin, color, religion, or sex. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística.

Llame al 1-888-850-8526 (TTY: 711). 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-888-850-8526（TTY：711）。

Y0134_PBC2665_M 048849 (10-05-2020)

1

2021 Summary of Benefits PAGES 04-11 PREMERA BLUE CROSS MEDICARE ADVANTAGE CORE (HMO)

PREMERA BLUE CROSS MEDICARE ADVANTAGE CORE PLUS (HMO)

PAGES 12-22 PREMERA BLUE CROSS MEDICARE ADVANTAGE (HMO) PREMERA BLUE CROSS MEDICARE ADVANTAGE CLASSIC (HMO) PREMERA BLUE CROSS MEDICARE ADVANTAGE TOTAL HEALTH (HMO)

PAGES 23-30 PREMERA BLUE CROSS MEDICARE ADVANTAGE PEAK + Rx (HMO) PREMERA BLUE CROSS MEDICARE ADVANTAGE SOUND + Rx (HMO)

PAGES 31-39 PREMERA BLUE CROSS MEDICARE ADVANTAGE ALPINE (HMO) PREMERA BLUE CROSS MEDICARE ADVANTAGE CHARTER + Rx (HMO) PREMERA BLUE CROSS MEDICARE ADVANTAGE CLASSIC PLUS (HMO)

Y0134_PBC2651_M 037040 (10-05-2020)

2021 Summary of Benefits PREMERA BLUE CROSS MEDICARE ADVANTAGE CORE (HMO) H7245-006 PREMERA BLUE CROSS MEDICARE ADVANTAGE CORE PLUS (HMO) H7245-008 PREMERA BLUE CROSS MEDICARE ADVANTAGE (HMO) H7245-001 PREMERA BLUE CROSS MEDICARE ADVANTAGE CLASSIC (HMO) H7245-002 PREMERA BLUE CROSS MEDICARE ADVANTAGE TOTAL HEALTH (HMO) H7245-005 PREMERA BLUE CROSS MEDICARE ADVANTAGE PEAK + Rx (HMO) H9302-011 PREMERA BLUE CROSS MEDICARE ADVANTAGE SOUND + Rx (HMO) H9302-007 PREMERA BLUE CROSS MEDICARE ADVANTAGE ALPINE (HMO) H9302-004 PREMERA BLUE CROSS MEDICARE ADVANTAGE CHARTER + Rx (HMO) H9302-003 PREMERA BLUE CROSS MEDICARE ADVANTAGE CLASSIC PLUS (HMO) H7245-003

This is a summary of drug and health services covered by Premera Blue Cross Medicare Advantage Core (HMO), Premera Blue Cross Medicare Advantage Core Plus (HMO), Premera Blue Cross Medicare Advantage (HMO), Premera Blue Cross Medicare Advantage Classic (HMO), Premera Blue Cross Medicare Advantage Total Health (HMO), Premera Blue Cross Medicare Advantage Peak + Rx (HMO), Premera Blue Cross Medicare Advantage Sound + Rx (HMO), Premera Blue Cross Medicare Advantage Alpine (HMO), Premera Blue Cross Medicare Advantage Charter + Rx (HMO), and Premera Blue Cross Medicare Advantage Classic Plus (HMO) January 1, 2021 to December 31, 2021.

2

Premera Blue Cross Medicare Advantage Core (HMO), Premera Blue Cross Medicare Advantage Core Plus (HMO), Premera Blue Cross Medicare Advantage (HMO), Premera Blue Cross Medicare Advantage Classic (HMO), Premera Blue Cross Medicare Advantage Total Health (HMO), Premera Blue Cross Medicare Advantage Peak + Rx (HMO), Premera Blue Cross Medicare Advantage Sound + Rx (HMO), Premera Blue Cross Medicare Advantage Alpine (HMO), Premera Blue Cross Medicare Advantage Charter + Rx (HMO), and Premera Blue Cross Medicare Advantage Classic Plus (HMO) are plans with a Medicare contract. Enrollment in these plans depends on contract renewal. The benefit information provided does not list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, please request the “Evidence of Coverage” by calling customer service or accessing it on our website: premera.com/ma. To join Premera Blue Cross Medicare Advantage Core (HMO), Premera Blue Cross Medicare Advantage Core Plus (HMO), Premera Blue Cross Medicare Advantage (HMO), Premera Blue Cross Medicare Advantage Classic (HMO), Premera Blue Cross Medicare Advantage Total Health (HMO), Premera Blue Cross Medicare Advantage Peak + Rx (HMO), Premera Blue Cross Medicare Advantage Sound + Rx (HMO), Premera Blue Cross Medicare Advantage Alpine (HMO), Premera Blue Cross Medicare Advantage Charter + Rx (HMO), or Premera Blue Cross Medicare Advantage Classic Plus (HMO), you must be entitled to Medicare Part A, be enrolled in Medicare Part B, and live in our service area. Our service area includes the following counties in Washington: Cowlitz, Island, King, Kitsap, Lewis, Pierce, San Juan, Skagit, Snohomish, Spokane, Stevens, Thurston, Walla Walla, and Whatcom.

If you use providers that are not in our network, we may not pay for these services. For 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). TTY/TDD users should call 1-877-486-2048. This document is available in other formats, including Braille and Spanish. For more information, please call us at 888-850-8526 (TTY/TDD: 711), or visit us at premera.com/ma. Representatives are available: October 1 - March 31, 8 a.m. to 8 p.m., 7 days a week April 1 – Sept 30, 8 a.m. to 8 p.m., Monday through Friday.

3

http://premera.com/mahttp://www.medicare.govhttp://premera.com/ma

Counties: Island, San Juan, Skagit, Walla Walla, Counties: Island, San Juan, Skagit, Walla Walla Whatcom

PREMIUM AND BENEFITS PREMERA BLUE CROSS MEDICARE ADVANTAGE PREMERA BLUE CROSS MEDICARE ADVANTAGE CORE (HM0) CORE PLUS (HM0)

Monthly Plan Premium You pay $12 per month. You must continue to pay your Medicare Part B premium.

You pay $75 per month. You must continue to pay your Medicare Part B premium.

Part C Deductible No deductible. No deductible. Part D Deductible $180 per year for Part D prescription drugs except

for drugs listed on Tier 1 and Tier 2, which are excluded from the deductible.

$180 per year for Part D prescription drugs except for drugs listed on Tier 1, Tier 2, and Tier 3, which are excluded from the deductible.

Maximum Out-of-Pocket Responsibility (does not include prescription drugs)

You pay no more than $6,300 annually. Includes copays and other costs for medical services for the year.


Inpatient Hospital Coverage You pay $450 copay per day for days 1–4. You pay $0 copay per day for days 5 and beyond.

Prior Authorization rules may apply.

You pay $450 copay per day for days 1–4. You pay $0 copay per day for days 5 and beyond.

Prior Authorization rules may apply. Outpatient Hospital Coverage

You pay 20% of the total cost for each Medicare-covered outpatient hospital surgery.


You pay a $350 copay for each Medicare-covered outpatient hospital surgery.

Prior Authorization rules may apply. Ambulatory Surgery Center You pay a $250 copay for each Medicare-covered

ambulatory surgical center visit. You pay a $250 copay for each Medicare-covered ambulatory surgical center visit.

Doctor Visits Primary care providers

Specialists

You pay $15 copay per office visit. You pay a $10 copay per telehealth visit.

You pay $45 per office visit (referral required). You pay a $40 copay per telehealth visit.

You pay $5 copay per office visit. You pay a $0 copay per telehealth visit.

You pay $30 per office visit (referral required). You pay a $25 copay per telehealth visit.

Preventive Care (such as flu vaccine, diabetic screenings)

You pay nothing. Other preventive services are available. There are some covered services that have a cost.

You pay nothing. Other preventive services are available. There are some covered services that have a cost.

4

PREMERA BLUE CROSS MEDICARE ADVANTAGE CORE (HMO) and CORE PLUS (HMO) )



Emergency Care You pay a $90 copay per visit. Waived, if you are admitted to the hospital within 24 hours.

Includes worldwide coverage.

You pay a $90 copay per visit. Waived, if you are admitted to the hospital within 24 hours.

Includes worldwide coverage. Urgently Needed Services You pay a $45 copay per visit.

Includes worldwide coverage with a $50 copay.

You pay a $45 copay per visit.

Includes worldwide coverage with a $50 copay. Diagnostic Services/Labs/ Imaging Diagnostic tests and procedures Lab services Outpatient x-rays Therapeutic radiology services (such as radiation treatment for cancer)

You pay 20% of the total cost.

You pay a $20 copay per day. You pay a $20 copay per day. You pay 20% of the total cost.

If your doctor provides additional services, a separate cost sharing amount may apply.




Prior Authorization rules may apply. Prior Authorization rules may apply. Hearing Services Medicare-covered hearing exam Routine hearing exam

Hearing aid


Not covered.

Not covered.

You pay a $0–$30 copay per visit.

You pay a $0–$30 copay for one routine hearing exam per calendar year.

You pay a $0 copay. There is a $1,000 annual allowance per ear toward the purchase of hearing aids through Hearing Care Solutions.

5



Dental Services Medicare-covered You pay a $45 copay per visit. You pay a $30 copay per visit. dental services Routine dental services For Dental Services (routine), see “Optional

supplemental dental benefit” section later in the booklet.

You pay a $0 copay for routine dental services. • Routine oral exams - two per calendar year. • Comprehensive periodontal exam - one per

calendar year. • Routine cleaning – limited up to two routine

cleaning (prophylaxis) per calendar year OR Periodontal maintenance – limited up to three periodontal maintenance per calendar year.

• Fluoride treatment – twice per calendar year. • Bitewing x-ray – up to one set of four bitewing

x-rays every year. • Panoramic or complete series x-ray – once every

60 months. • Limited emergency exam – limited to once per

calendar year. • Emergency palliative treatment of dental pain. • Periapical x-rays. • $200 toward additional diagnostic, preventive,

basic, and major restorative services.

6



Vision Services Medicare-covered vision exam

Medicare-covered vision hardware

Routine vision exam

Routine vision hardware

You pay a $0 copay for each Medicare-covered diabetic retinopathy screening once per calendar year. You pay a $45 copay for each Medicare-covered exam to diagnose and treat diseases and conditions of the eye.

You pay a $0 copay for one pair of Medicare-covered eyeglasses or contact lenses after each cataract surgery.

You pay a $45 copay for one routine vision exam per calendar year for the purposes of obtaining eyeglasses or contact lenses. No referral is required for routine vision exam.

Not covered.

You pay a $0 copay for each Medicare-covered diabetic retinopathy screening once per calendar year.

You pay a $30 copay for each Medicare-covered exam to diagnose and treat diseases and conditions of the eye. You pay a $0 copay for one pair of Medicare-covered eyeglasses or contact lenses after each cataract surgery.


There is a $150 benefit limit for routine eyeglasses (lenses and frames) or contact lenses per calendar year.

Mental Health Services Inpatient mental health care You pay a $390 copay per day for days 1–4.

You pay a $0 copay per day for days 5–90. You pay a $390 copay per day for days 1–4. You pay a $0 copay per day for days 5–90.

Outpatient mental health care You pay a $40 copay for each Medicare-covered individual or group therapy visit. You pay a $35 copay for each telemental health visit. Prior Authorization rules may apply.

You pay a $40 copay for each Medicare-covered individual or group therapy visit. You pay a $35 copay for each telemental health visit. Prior Authorization rules may apply.

Skilled Nursing Facility You pay a $0 copay per day for days 1–20. You pay a $160 copay per day for days 21–60. You pay a $0 copay per day for days 61–100. Prior Authorization rules may apply.

You pay a $0 copay per day for days 1–20. You pay a $160 copay per day for days 21–60. You pay a $0 copay per day for days 61–100. Prior Authorization rules may apply.

7



Physical Therapy You pay a $40 copay per visit. You pay a $20 copay per visit. Ambulance You pay a $300 copay each way for Medicare-

covered ambulance transport. Prior Authorization rules may apply.

You pay a $310 copay each way for Medicare-covered ambulance transport. Prior Authorization rules may apply.

Transportation Not covered. Not covered. Medicare Part B Drugs You pay 20% of the total cost for Medicare-

covered Part B chemotherapy drugs and other Part B drugs.


You pay 20% of the total cost for Medicare-covered Part B chemotherapy drugs and other Part B drugs.


8

Counties: Island, San Juan, Skagit, Walla Walla, Whatcom Counties: Island, San Juan, Skagit, Walla Walla PREMERA BLUE CROSS MEDICARE ADVANTAGE PREMERA BLUE CROSS MEDICARE ADVANTAGE CORE (HM0) CORE PLUS (HM0) PRESCRIPTION DRUG BENEFITS (PART D) PRESCRIPTION DRUG BENEFITS FOR (PART D) Deductible Phase

During this stage, you pay the full cost of your Tier 3, 4, and 5 drugs. You stay in this stage until you have paid $180 for your Tier 3, 4, and 5 drugs.

Deductible Phase

During this stage, you pay the full cost of your Tier 4 and 5 drugs. You stay in this stage until you have paid $180 for your Tier 4 and 5 drugs.

Initial Coverage Phase - You stay in the Initial Coverage Stage until your total drug costs for the year reach $4,130.

Initial Coverage Phase - You stay in the Initial Coverage Stage until your total drug costs for the year reach $4,130.

Preferred Retail Cost Sharing (in network) (up to a 30-day supply)

Standard Retail Cost Sharing (in network) (up to 30-day supply)

Mail Order Cost Sharing (90-day supply)

Long-Term Care Cost Sharing (up to a 31-day supply)

Preferred Retail Cost Sharing (in network) (up to a 30-day supply)

Standard Retail Cost Sharing (in network) (up to 30-day supply)

Mail Order Cost Sharing (90-day supply)

Long-Term Cost Sharing (up to a 31-day supply)

Tier 1: Preferred Generic

You pay a $4 copay.

You pay a $15 copay.

You pay a $0 copay.


Tier 1: Preferred Generic

You pay a $2 copay.


You pay a $0 copay.


Tier 2: Generic





Tier 2: Generic





Tier 3: Preferred Brand





Tier 3: Preferred Brand





Tier 4: Non-Preferred Drugs

You pay 33% of the cost.




Tier 4: Non-Preferred Drugs





Tier 5: Specialty



Not offered.


Tier 5: Specialty



Not offered.


9

Counties: Island, San Juan, Skagit, Walla Walla, Whatcom Counties: Island, San Juan, Skagit, Walla Walla PREMERA BLUE CROSS MEDICARE ADVANTAGE PREMERA BLUE CROSS MEDICARE ADVANTAGE CORE (HM0) CORE PLUS (HM0) Cost sharing may change depending on the pharmacy you choose and when you enter another of the four phases of the Part D benefit.

Cost sharing may change depending on the pharmacy you choose and when you enter another of the four phases of the Part D benefit.

Coverage Gap Coverage Gap After you enter the Coverage Gap, you pay 25% of the costs of brand name drugs and 25% of the costs of generic drugs until your out-of-pocket costs reach $6,550, which is the end of the Coverage Gap. Not everyone will reach the Coverage Gap.

After you enter the Coverage Gap, you pay 25% of the costs of brand name drugs and 25% of the costs of generic drugs until your out-of-pocket costs reach $6,550, which is the end of the Coverage Gap. Not everyone will reach the Coverage Gap.

Catastrophic Coverage Catastrophic Coverage After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $6,550, you pay the greater of:

• 5% of the cost of the drug, or

• $3.70 copay for a generic drug, or a drug that is treated like a generic, and $9.20 copay for all other drugs.

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $6,550, you pay the greater of:

• 5% of the cost of the drug, or

• $3.70 copay for a generic drug, or a drug that is treated like a generic, and $9.20 copay for all other drugs.

Part D Senior Savings Plan Part D Senior Savings Plan Maximum copay of $35 for 30-day supply for recommended diabetic insulins

Maximum copay of $35 for 30-day supply for recommended diabetic insulins

Over the Counter (OTC) Over the Counter (OTC) Receive a $25 quarterly benefit for over-the-counter health and wellness products available through OTC Health Solutions.

Receive a $50 quarterly benefit for over-the-counter health and wellness products available through OTC Health Solutions.

10

Counties: Island, San Juan, Skagit, Walla Walla, Whatcom Counties: Island, San Juan, Skagit, Walla Walla PREMERA BLUE CROSS MEDICARE ADVANTAGE PREMERA BLUE CROSS MEDICARE ADVANTAGE CORE (HM0) CORE PLUS (HM0) OPTIONAL SUPPLEMENTAL BENEFITS OPTIONAL SUPPLEMENTAL BENEFITS Optional Supplemental Dental Benefit Monthly Premium

Deductible

Annual Benefit Maximum

You pay additional $22.50 per month.

There is no deductible.

There is no annual maximum limit.

Not applicable

You pay a $0 copay for routine dental services.

• Routine oral exams – two per calendar year.

• Comprehensive periodontal exam – one per calendar year.

• Routine cleaning – limited up to two routine cleaning(prophylaxis) per calendar yearOR

• Periodontal maintenance – limited up to three periodontalmaintenance per calendar year.

• Fluoride treatment – twice per calendar year.

• Bitewing x-ray – up to one set of four bitewing x-rays every year.

• Panoramic or complete series x-ray – once every 60 months.

• Limited emergency exam – limited to once per calendar year.

• Emergency palliative treatment of dental pain.

• Periapical x-rays.

11

Counties: Cowlitz, King, Kitsap, Counties: Cowlitz, King, Kitsap, Counties: Spokane and Stevens Lewis, Pierce, Snohomish, Lewis, Pierce, Snohomish, Spokane, and Thurston Thurston, and Whatcom

PREMIUM AND BENEFITS PREMERA BLUE CROSS PREMERA BLUE CROSS PREMERA BLUE CROSS MEDICARE ADVANTAGE (HM0) MEDICARE ADVANTAGE MEDICARE ADVANTAGE

CLASSIC (HM0) TOTAL HEALTH (HM0) Monthly Plan Premium You pay $0 per month.

You must continue to pay your Medicare Part B premium.



Part C Deductible No deductible. No deductible. No deductible. Part D Deductible $180 per year for Part D

prescription drugs except for drugs listed on Tier 1 and Tier 2, which are excluded from the deductible.



Maximum Out-of-Pocket Responsibility (does not include prescription drugs)




Inpatient Hospital Coverage You pay a $450 copay per day for days 1–4. You pay a $0 copay per day for days 5 and beyond.


You pay a $450 copay per day for days 1–4. You pay a $0 copay per day for days 5 and beyond.


You pay a $450 copay per day for days 1–4. You pay a $0 copay per day for days 5 and beyond.


Outpatient Hospital Coverage

You pay 20% of the total cost for each Medicare-covered outpatient hospital surgery.






Ambulatory Surgery Center You pay a $250 copay for each Medicare-covered ambulatory surgical center visit.

You pay a $250 copay for each Medicare-covered ambulatory surgical center visit.

You pay a $250 copay for each Medicare-covered ambulatory surgical center visit.

12

PREMERA BLUE CROSS MEDICARE ADVANTAGE (HMO), CLASSIC (HMO) PREMERA and BLUE CROSS MEDICARE ADVANTAGE TOTAL HEALTH (HMO )



CLASSIC (HM0) TOTAL HEALTH (HM0) Doctor Visits Primary care providers You pay a $15 copay per office

visit. You pay a $10 copay per telehealth visit.

You pay a $5 copay per office visit. You pay a $0 copay per telehealth visit.

You pay a $5 copay per office visit. You pay a $0 copay per telehealth visit.

Specialists You pay a $45 copay per office visit (referral required). You pay a $40 copay per telehealth visit.

You pay a $30 copay per office visit (referral required).

You pay a $25 copay per telehealth visit.

You pay a $30 copay per office visit (referral required).

You pay a $25 copay per telehealth visit.

Preventive Care You pay nothing. You pay nothing. You pay nothing. (such as flu vaccine, Other preventive services are Other preventive services are Other preventive services are diabetic screenings) available. There are some

covered services that have a cost.

available. There are some covered services that have a cost.

available. There are some covered services that have a cost.

Emergency Care You pay a $90 copay per visit. Waived, if you are admitted to the hospital within 24 hours. Includes worldwide coverage.

You pay a $90 copay per visit. Waived, if you are admitted to the hospital within 24 hours. Includes worldwide coverage.

You pay a $90 copay per visit. Waived, if you are admitted to the hospital within 24 hours. Includes worldwide coverage.

Urgently Needed Services You pay a $45 copay per visit.






13



CLASSIC (HM0) TOTAL HEALTH (HM0) Diagnostic Services/Labs/ Imaging Diagnostic tests and procedures Lab services Outpatient x-rays Therapeutic radiology services (such as radiation treatment for cancer)













Hearing Services Medicare-covered You pay a $45 copay per visit. You pay a $0–$30 copay per You pay a $0–$30 copay per hearing exam visit. $0 copay through Hearing

Care Solutions provider; higher copay applies to exams by all other providers.

visit. $0 copay through Hearing Care Solutions provider; higher copay applies to exams by all other providers.

Routine hearing exam Not covered. You pay a $0–$30 copay for one routine hearing exam per calendar year. $0 copay through Hearing Care Solutions provider; higher copay applies to exams by all other providers.

You pay a $0–$30 copay for one routine hearing exam per calendar year. $0 copay through Hearing Care Solutions provider; higher copay applies to exams by all other providers.

Hearing aid Not covered. You pay a $0 copay. There is a $1,000 annual allowance per ear toward the purchase of hearing aids through Hearing Care Solutions.

You pay a $0 copay. There is a $1,000 annual allowance per ear toward the purchase of hearing aids through Hearing Care Solutions.

14



CLASSIC (HM0) TOTAL HEALTH (HM0) Dental Services Medicare-covered You pay a $45 copay per visit. You pay a $30 copay per visit. You pay a $30 copay per visit. dental services

Routine dental services For dental services (routine), see “Optional supplemental dental benefit” section later in the booklet.


• Routine oral exams - two per calendar year.


• Routine oral exams - two per calendar year.

• Comprehensive periodontal exam - one per calendar year.

• Routine cleaning – limited up to two routine cleaning (prophylaxis) per calendar year. OR Periodontal maintenance – limited up to three periodontal maintenance per calendar year.

• Fluoride treatment– twice per calendar year.

• Bitewing x-ray–up to one set of four bitewing x-rays every year.

• Panoramic or complete series x-ray–once every 60 months.

• Limited emergency exam– limited to once per calendar year.


• Comprehensive periodontal exam - one per calendar year.

• Routine cleaning – limited up to two routine cleaning (prophylaxis) per calendar year OR Periodontal maintenance – limited up to three periodontal maintenance per calendar year.

• Fluoride treatment– twice per calendar year.

• Bitewing x-ray–up to one set of four bitewing x-rays every year.

• Panoramic or complete series x-ray–once every 60 months.

• Limited emergency exam– limited to once per calendar year.


15



CLASSIC (HM0) TOTAL HEALTH (HM0) • Periapical x-rays.• $200 toward

additional diagnostic,preventive, basic andmajor restorative services.

• Periapical x-rays.• $200 toward

additional diagnostic,preventive, basic andmajor restorative services.

Vision Services Medicare-covered vision exam

Medicare-covered vision hardware

Routine vision exam

Routine vision hardware




Not covered.




There is a $150 benefit limit for routine eyeglasses (lenses and frames) or contact lenses per calendar year.


You pay a $30 copay for each Medicare

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