sm summary of benefits - christian reformed church group ppo...summary of benefits consolidated...
TRANSCRIPT
-
2012
Medic
are
PLU
SG
roup P
PO
Blu
e C
ross
Blu
e S
hiel
d o
f Mic
higa
n is
a n
onp
rofit
co
rpor
atio
n an
d in
dep
end
ent l
icen
see
of th
e B
lue
Cro
ss a
nd B
lue
Shi
eld
Ass
ocia
tion. Su
mm
ary
of B
enef
its
Con
solid
ated
Gro
up In
sura
nce
(CG
I)
Janu
ary
1, 2
012
- Dec
embe
r 31,
201
2
A h
ealth
pla
n w
ith a
Med
icar
e co
ntra
ct.
Fo
rmul
ary(
Ope
n)
H95
72_C
_12G
rpM
APD
FVN
R 0
911
9/11
80
306-
601
Med
icar
e P
lus
Blu
e G
roup
PP
OS
M
-
2
Plea
se re
ad th
is Im
port
ant I
nfor
mat
ion
abou
t M
edic
are
Plus
Blu
e G
roup
PPO
SM
I und
erst
and
that
:
M
edic
are
Plu
s B
lue
Gro
up P
PO
SM is
a M
edic
are
Adv
anta
ge p
lan
that
re
quire
s th
at I
keep
my
Med
icar
e P
art A
and
Par
t B.
I c
an o
nly
be in
one
Med
icar
e A
dvan
tage
pla
n at
a ti
me.
My
enro
llmen
t in
this
pla
n w
ill a
utom
atic
ally
end
my
enro
llmen
t in
any
othe
r Med
icar
e A
dvan
tage
pla
n or
Med
icar
e P
art D
sta
nd-a
lone
pr
escr
iptio
n dr
ug p
lan.
I und
erst
and
that
if I
do n
ot h
ave
Med
icar
e pr
escr
iptio
n dr
ug c
over
age
or c
redi
tabl
e pr
escr
iptio
n dr
ug c
over
age
(as
good
as
Med
icar
e’s)
,
I may
hav
e to
pay
a la
te e
nrol
lmen
t pen
alty
if I
enro
ll in
Med
icar
e pr
escr
iptio
n dr
ug c
over
age
in th
e fu
ture
.
Onc
e I a
m a
mem
ber o
f Med
icar
e P
lus
Blu
e G
roup
PP
O, I
hav
e th
e rig
ht to
app
eal p
lan
deci
sion
s ab
out p
aym
ent o
r ser
vice
s if
I dis
agre
e.
O
nce
I am
enr
olle
d, I
will
read
the
Evi
denc
e of
Cov
erag
e do
cum
ent
from
Med
icar
e P
lus
Blu
e G
roup
PP
O th
at w
ill p
rovi
de d
etai
led
guid
elin
es I
mus
t fol
low
in o
rder
to re
ceiv
e co
vera
ge u
nder
Med
icar
e A
dvan
tage
pla
ns.
B
y jo
inin
g th
e M
edic
are
Plu
s B
lue
Gro
up P
PO
, I a
ckno
wle
dge
that
th
is M
edic
are
heal
th p
lan
will
rele
ase
my
info
rmat
ion
to M
edic
are
and
othe
r pla
ns a
s is
nec
essa
ry fo
r tre
atm
ent,
paym
ent a
nd h
ealth
car
e op
erat
ions
.
For m
ore
info
rmat
ion
abou
t thi
s pl
an:
V
isit
us a
t ww
w.b
cbsm
.com
or c
all M
edic
are
Plu
s B
lue
Gro
up P
PO
Mem
ber S
ervi
ces
at
1-8
66-6
84-8
216.
W
e’re
ava
ilabl
e M
onda
y th
roug
h Fr
iday
, fro
m 8
:30
a.m
. to
5 p.
m. E
ST.
(T
TY/T
DD
use
rs c
all 1
-800
-579
-023
5)
For m
ore
info
rmat
ion
abou
t Med
icar
e, p
leas
e ca
ll 1-
800-
ME
DIC
AR
E (1
-800
-633
-422
7).
TTY
use
rs s
houl
d ca
ll 1-
877-
486-
2048
. You
can
cal
l 24
hour
s a
day,
7 d
ays
a w
eek.
O
r, vi
sit w
ww
.med
icar
e.go
v on
the
Web
. If
you
have
spe
cial
nee
ds, t
his
docu
men
t may
be
avai
labl
e in
oth
er fo
rmat
s.
-
B
3
Than
k yo
u fo
r you
r int
eres
t in
Med
icar
e Pl
us B
lue
Gro
up P
POSM
. Our
pl
an is
offe
red
by B
lue
Cro
ss B
lue
Shi
eld
of M
ichi
gan,
a M
edic
are
Adv
anta
ge P
refe
rred
Pro
vide
r Org
aniz
atio
n (P
PO).
This
Sum
mar
y of
B
enef
its te
lls y
ou s
ome
feat
ures
of t
he p
lan.
It d
oesn
’t lis
t eve
ry s
ervi
ce
we
cove
r or l
ist e
very
lim
itatio
n or
exc
lusi
on. T
o ge
t a c
ompl
ete
list o
f our
be
nefit
s, p
leas
e ca
ll M
edic
are
Plus
Blu
e G
roup
PPO
Mem
ber S
ervi
ces
and
ask
for t
he E
vide
nce
of C
over
age.
You
have
cho
ices
in y
our h
ealth
car
e A
s a
Med
icar
e be
nefic
iary
, you
can
cho
ose
from
diff
eren
t Med
icar
e op
tions
. One
opt
ion
is th
e O
rigin
al (f
ee-fo
r-se
rvic
e) M
edic
are
plan
. A
noth
er o
ptio
n is
this
Med
icar
e A
dvan
tage
pla
n of
fere
d th
roug
h yo
ur
empl
oyer
or u
nion
gro
up: M
edic
are
Plus
Blu
e G
roup
PPO
. For
mor
e in
form
atio
n ab
out y
our M
edic
are
optio
ns, c
all
1-80
0-M
ED
ICA
RE
(1-8
00-6
33-4
227)
24
hour
s a
day,
7 d
ays
a w
eek.
TTY
us
ers
may
cal
l 1-8
77-4
86-2
048.
You
may
leav
e th
is p
lan
at a
ny ti
me
but t
he ti
mef
ram
e in
whi
ch y
ou c
an
enro
ll in
ano
ther
Med
icar
e A
dvan
tage
pla
n m
ay b
e lim
ited.
Ple
ase
call
Med
icar
e Pl
us B
lue
Gro
up P
PO M
embe
r Ser
vice
s at
the
tele
phon
e nu
mbe
r lis
ted
on th
e in
side
fron
t cov
er o
f thi
s bo
okle
t for
mor
e in
form
atio
n.
How
can
I co
mpa
re m
y op
tions
?
You
can
com
pare
Med
icar
e Pl
us B
lue
Gro
up P
PO a
nd th
e O
rigin
al
Med
icar
e pl
an u
sing
this
Sum
mar
y of
Ben
efits
. The
cha
rts in
this
boo
klet
lis
t som
e im
porta
nt h
ealth
ben
efits
. For
eac
h be
nefit
, you
can
see
wha
t ou
r pla
n co
vers
and
wha
t the
Orig
inal
Med
icar
e pl
an c
over
s. Y
ou w
ill
rece
ive
all o
f the
ben
efits
that
Orig
inal
Med
icar
e pl
an o
ffers
. You
r gro
up
heal
th p
lan
may
als
o of
fer m
ore
bene
fits,
whi
ch m
ay c
hang
e fro
m y
ear t
o ye
ar.
Whe
re is
Med
icar
e Pl
us B
lue
Gro
up P
PO a
vaila
ble?
M
edic
are
Plus
Blu
e G
roup
PPO
is a
vaila
ble
to e
mpl
oyer
and
uni
on
grou
p m
embe
rs w
ho li
ve in
our
pla
n se
rvic
e ar
ea, w
hich
is th
e en
tire
50
stat
es a
nd te
rrito
ries
of th
e U
nite
d S
tate
s. T
o st
ay a
mem
ber o
f our
pla
n,
you
mus
t kee
p liv
ing
in th
is s
ervi
ce a
rea.
If y
ou p
lan
to m
ove
out o
f the
se
rvic
e ar
ea, p
leas
e co
ntac
t Mem
ber S
ervi
ces.
Who
is e
ligib
le to
join
Med
icar
e Pl
us B
lue
Gro
up P
PO?
You
can
join
Med
icar
e Pl
us B
lue
Gro
up P
PO if
you
are
ent
itled
to
Med
icar
e P
art A
and
enr
olle
d in
Med
icar
e P
art B
and
live
in th
e U
nite
d S
tate
s or
its
terr
itorie
s.
Can
I ch
oose
my
doct
ors?
M
edic
are
Plus
Blu
e G
roup
PPO
has
a n
etw
ork
of d
octo
rs, s
peci
alis
ts
and
hosp
itals
. You
can
use
any
doc
tor w
ho is
par
t of o
ur n
etw
ork.
You
m
ay a
lso
go to
doc
tors
out
side
of o
ur n
etw
ork
but y
ou m
ay p
ay m
ore.
Th
e he
alth
pro
vide
rs in
our
net
wor
k ca
n ch
ange
at a
ny ti
me.
Vis
it ou
r web
site
at w
ww
.bcb
sm.c
om/m
edic
are
for t
he m
ost u
p-to
-dat
e pr
ovid
er n
etw
ork
info
rmat
ion.
You
can
als
o ca
ll M
embe
r Ser
vice
s to
ask
fo
r a P
rovi
der D
irect
ory
book
. If y
ou a
re o
utsi
de th
e st
ate
of M
ichi
gan,
yo
u ca
n re
ceiv
e ca
re fr
om a
ny p
rovi
der w
ho a
ccep
ts M
edic
are.
Wha
t hap
pens
if I
go to
a d
octo
r who
is n
ot in
you
r net
wor
k?
In M
ichi
gan,
you
may
hav
e to
pay
mor
e fo
r ser
vice
s yo
u re
ceiv
e ou
tsid
e th
e ne
twor
k, a
nd y
ou m
ay h
ave
to fo
llow
spe
cial
rule
s pr
ior t
o ge
tting
se
rvic
es in
- or o
ut-o
f-net
wor
k. O
utsi
de M
ichi
gan,
you
r cos
ts a
re th
e sa
me
as s
ervi
ces
whe
n yo
u us
e pr
ovid
ers
that
acc
ept M
edic
are.
Usi
ng
prov
ider
s th
at d
o no
t acc
ept M
edic
are
may
cos
t you
mor
e. C
all M
embe
r S
ervi
ces
for m
ore
info
rmat
ion.
Doe
s m
y pl
an c
over
Med
icar
e Pa
rt B
or P
art D
dru
gs?
M
edic
are
Plus
Blu
e G
roup
PPO
incl
udes
Med
icar
e P
art B
and
Par
t D
pres
crip
tion
drug
cov
erag
e.
Wha
t is
a pr
escr
iptio
n dr
ug fo
rmul
ary?
M
edic
are
Plus
Blu
e G
roup
PPO
use
s a
form
ular
y. A
form
ular
y is
a li
st
of d
rugs
cov
ered
by
your
pla
n to
mee
t pat
ient
nee
ds. W
e m
ay
perio
dica
lly a
dd, r
emov
e, m
ake
chan
ges
to c
over
age
limita
tions
on
certa
in d
rugs
or c
hang
e ho
w m
uch
you
pay
for a
dru
g. If
we
mak
e an
y fo
rmul
ary
chan
ge th
at li
mits
our
mem
bers
’ abi
lity
to fi
ll th
eir p
resc
riptio
ns,
we
will
not
ify th
e af
fect
ed e
nrol
lees
bef
ore
the
chan
ge is
mad
e. W
e w
ill
send
you
a c
opy
of th
e fo
rmul
ary
and
you
can
see
the
com
plet
e fo
rmul
ary
on o
ur w
ebsi
te a
t ww
w.b
cbsm
.com
/med
icar
e .
-
4
If yo
u ar
e cu
rren
tly ta
king
a d
rug
that
is n
ot o
n ou
r for
mul
ary
or s
ubje
ct to
ad
ditio
nal r
equi
rem
ents
or l
imits
, you
may
be
able
to g
et a
tem
pora
ry
supp
ly o
f the
dru
g. Y
ou c
an c
onta
ct u
s to
requ
est a
n ex
cept
ion
or s
witc
h to
an
alte
rnat
ive
drug
list
ed o
n ou
r for
mul
ary
with
you
r phy
sici
an’s
hel
p.
Cal
l us
to s
ee if
you
can
get
a te
mpo
rary
sup
ply
of a
dru
g or
for m
ore
deta
ils a
bout
our
dru
g tra
nsiti
on p
olic
y.
Whe
re c
an I
get m
y pr
escr
iptio
ns if
I jo
in th
is p
lan?
M
edic
are
Plus
Blu
e G
roup
PPO
has
a n
etw
ork
of p
harm
acie
s. Y
ou
mus
t use
a n
etw
ork
phar
mac
y to
rece
ive
plan
ben
efits
. We
may
not
pay
fo
r you
r pre
scrip
tions
if y
ou u
se a
n ou
t-of-n
etw
ork
phar
mac
y, e
xcep
t in
certa
in c
ases
. The
pha
rmac
ies
in o
ur n
etw
ork
can
chan
ge a
t any
tim
e.
You
can
ask
for a
pha
rmac
y di
rect
ory
by c
allin
g M
embe
r Ser
vice
s or
vi
sitin
g w
ww
.bcb
sm.c
om/m
edic
are .
Med
icar
e Pl
us B
lue
Gro
up P
PO h
as a
list
of p
refe
rred
pha
rmac
ies.
At
thes
e ph
arm
acie
s, y
ou m
ay g
et y
our d
rugs
at a
low
er c
opay
or
coin
sura
nce.
You
may
go
to a
non
-pre
ferr
ed p
harm
acy,
but
you
may
ha
ve to
pay
mor
e fo
r you
r pre
scrip
tion
drug
s.
How
can
I ge
t Ext
ra H
elp
with
pre
scrip
tion
drug
pla
n co
sts?
Y
ou m
ay b
e ab
le to
get
ext
ra h
elp
to p
ay fo
r you
r pre
scrip
tion
drug
pr
emiu
ms
and
cost
s as
wel
l as
get h
elp
with
oth
er M
edic
are
cost
s. T
o se
e if
you
qual
ify fo
r get
ting
extra
hel
p, c
all:
1-
800-
ME
DIC
AR
E (1
-800
-633
-422
7) 2
4 ho
urs
a da
y, 7
day
s a
wee
k;
TTY
/TD
D u
sers
sho
uld
call
1-87
7-48
6-20
48
Th
e S
ocia
l Sec
urity
Adm
inis
tratio
n at
1-8
00-7
72-1
213,
Mon
day
thro
ugh
Frid
ay fr
om 7
a.m
. to
7 p.
m. T
TY/T
DD
use
rs s
houl
d ca
ll 1-
800-
325-
0778
You
r Sta
te M
edic
aid
Offi
ce
Wha
t are
my
prot
ectio
ns in
this
pla
n?
All
Med
icar
e A
dvan
tage
pla
ns m
ust a
gree
to s
tay
in th
e pr
ogra
m fo
r a fu
ll ca
lend
ar y
ear a
t a ti
me.
Eac
h ye
ar, t
he p
lans
dec
ide
whe
ther
to c
ontin
ue
to p
artic
ipat
e w
ith M
edic
are
Adv
anta
ge. A
lso,
Med
icar
e m
ay d
ecid
e to
en
d a
cont
ract
with
a p
lan.
Eve
n yo
ur M
edic
are
Adv
anta
ge p
lan
leav
es
the
prog
ram
, you
will
not
lose
Med
icar
e co
vera
ge. I
f a p
lan
deci
des
not t
o co
ntin
ue fo
r an
addi
tiona
l cal
enda
r yea
r, it
mus
t sen
d yo
u a
lette
r at l
east
90
day
s be
fore
you
r cov
erag
e w
ill e
nd. T
he le
tter w
ill e
xpla
in y
our o
ptio
ns
for M
edic
are
cove
rage
in y
our a
rea.
As
a m
embe
r of M
edic
are
Plus
Blu
e G
roup
PPO
, you
hav
e th
e rig
ht to
re
ques
t an
orga
niza
tion
dete
rmin
atio
n, w
hich
incl
udes
the
right
to fi
le a
n ap
peal
if w
e de
ny c
over
age
for a
n ite
m o
r ser
vice
, and
the
right
to fi
le a
gr
ieva
nce.
You
hav
e th
e rig
ht to
requ
est a
n or
gani
zatio
n de
term
inat
ion
if yo
u w
ant u
s to
pro
vide
or p
ay fo
r an
item
or s
ervi
ce th
at y
ou b
elie
ve
shou
ld b
e co
vere
d. If
we
deny
cov
erag
e fo
r you
r req
uest
ed it
em o
r se
rvic
e, y
ou h
ave
the
right
to a
ppea
l and
ask
us
to re
view
our
dec
isio
n.
You
may
ask
us
for a
n ex
pedi
ted
(fast
) cov
erag
e de
term
inat
ion
or a
ppea
l if
you
belie
ve th
at w
aitin
g fo
r a d
ecis
ion
coul
d se
rious
ly p
ut y
our l
ife o
r he
alth
at r
isk,
or a
ffect
you
r abi
lity
to re
gain
max
imum
func
tion.
If y
our
doct
or m
akes
or s
uppo
rts th
e ex
pedi
ted
requ
est,
we
mus
t exp
edite
our
de
cisi
on. F
inal
ly, y
ou h
ave
the
right
to fi
le a
grie
vanc
e if
you
have
any
ty
pe o
f pro
blem
with
us
or o
ne o
f our
pro
vide
rs th
at d
oes
not i
nvol
ve
cove
rage
for a
n ite
m o
r ser
vice
. If y
our p
robl
em in
volv
es q
ualit
y of
car
e,
you
also
hav
e th
e rig
ht to
file
a g
rieva
nce
with
the
Qua
lity
Impr
ovem
ent
Org
aniz
atio
n (Q
IO) f
or y
our s
tate
. Ref
er to
the
Evi
denc
e of
Cov
erag
e fo
r th
e Q
IO c
onta
ct in
form
atio
n.
As
a m
embe
r of M
edic
are
Plus
Blu
e G
roup
PPO
, you
hav
e th
e rig
ht to
re
ques
t a c
over
age
dete
rmin
atio
n, w
hich
incl
udes
the
right
to re
ques
t an
exce
ptio
n, th
e rig
ht to
file
an
appe
al if
we
deny
cov
erag
e fo
r a
pres
crip
tion
drug
, and
the
right
to fi
le a
grie
vanc
e. Y
ou h
ave
the
right
to
requ
est a
cov
erag
e de
term
inat
ion
if yo
u w
ant u
s to
cov
er a
Par
t D d
rug
that
you
bel
ieve
sho
uld
be c
over
ed. A
n ex
cept
ion
is a
type
of c
over
age
dete
rmin
atio
n. Y
ou m
ay a
sk u
s fo
r an
exce
ptio
n if
you
belie
ve y
ou n
eed
a dr
ug th
at is
not
on
our l
ist o
f cov
ered
dru
gs o
r bel
ieve
you
sho
uld
get a
no
n-pr
efer
red
drug
at a
low
er o
ut-o
f-poc
ket c
ost.
You
can
als
o as
k fo
r an
exce
ptio
n to
cos
t-util
izat
ion
rule
s, s
uch
as a
lim
it on
the
quan
tity
of a
dr
ug. I
f you
thin
k yo
u ne
ed a
n ex
cept
ion,
you
sho
uld
cont
act u
s be
fore
yo
u try
to fi
ll yo
ur p
resc
riptio
n at
a p
harm
acy.
You
r doc
tor m
ust p
rovi
de a
st
atem
ent t
o su
ppor
t you
r exc
eptio
n re
ques
t. If
we
deny
cov
erag
e fo
r yo
ur p
resc
riptio
n dr
ug(s
), yo
u ha
ve th
e rig
ht to
app
eal a
nd a
sk u
s to
re
view
our
dec
isio
n.
Fina
lly, y
ou h
ave
the
right
to fi
le a
grie
vanc
e if
you
have
any
type
of
prob
lem
with
us
or o
ne o
f our
net
wor
k ph
arm
acie
s th
at d
oes
not i
nvol
ve
cove
rage
for a
pre
scrip
tion
drug
. If y
our p
robl
em in
volv
es q
ualit
y of
car
e,
you
also
hav
e th
e rig
ht to
file
a g
rieva
nce
with
the
Qua
lity
Impr
ovem
ent
Org
aniz
atio
n (Q
IO) f
or y
our s
tate
. Ref
er to
the
Evi
denc
e of
Cov
erag
e fo
r th
e Q
IO c
onta
ct in
form
atio
n.
-
B
5
Wha
t is
a M
edic
atio
n Th
erap
y M
anag
emen
t (M
TM) P
rogr
am?
A M
edic
atio
n Th
erap
y M
anag
emen
t (M
TM) P
rogr
am is
a fr
ee s
ervi
ce w
e of
fer.
You
may
be
invi
ted
to p
artic
ipat
e in
a p
rogr
am d
esig
ned
for y
our
spec
ific
heal
th a
nd p
harm
acy
need
s. Y
ou m
ay d
ecid
e no
t to
parti
cipa
te
but i
t is
reco
mm
ende
d th
at y
ou ta
ke fu
ll ad
vant
age
of th
is c
over
ed
serv
ice
if yo
u ar
e se
lect
ed. C
onta
ct M
edic
are
Plus
Blu
e G
roup
PPO
, 1-
866-
684-
8216
(TTY
use
rs c
all 1
-800
-579
-023
5) fo
r mor
e de
tails
. Hou
rs
are
8:30
a.m
. to
5 p.
m. M
onda
y th
roug
h Fr
iday
.
Wha
t typ
es o
f dru
gs m
ay b
e co
vere
d un
der M
edic
are
Part
B?
S
ome
outp
atie
nt p
resc
riptio
n dr
ugs
may
be
cove
red
unde
r Med
icar
e P
art
B. T
hese
may
incl
ude,
but
are
not
lim
ited
to, t
he fo
llow
ing
type
s of
dru
gs:
Som
e an
tigen
s: if
they
are
pre
pare
d by
a d
octo
r and
adm
inis
tere
d by
a
prop
erly
inst
ruct
ed p
erso
n (w
ho c
ould
be
the
patie
nt) u
nder
doc
tor
supe
rvis
ion.
O
steo
poro
sis
drug
s: in
ject
able
dru
gs fo
r ost
eopo
rosi
s fo
r cer
tain
w
omen
with
Med
icar
e.
E
ryth
ropo
ietin
(epo
etin
alfa
or E
poge
n®):
by in
ject
ion
if yo
u ha
ve e
nd-
stag
e re
nal d
isea
se (p
erm
anen
t kid
ney
failu
re re
quiri
ng e
ither
dia
lysi
s or
tran
spla
ntat
ion)
and
nee
d th
is d
rug
to tr
eat a
nem
ia.
H
emop
hilia
clo
tting
fact
ors:
sel
f-adm
inis
tere
d cl
ottin
g fa
ctor
s if
you
have
hem
ophi
lia.
In
ject
able
dru
gs: m
ost i
njec
tabl
e dr
ugs
adm
inis
tere
d in
cide
nt to
a
phys
icia
n’s
serv
ice.
Im
mun
osup
pres
sive
dru
gs: i
mm
unos
uppr
essi
ve d
rug
ther
apy
for
trans
plan
t pat
ient
s if
the
trans
plan
t was
pai
d fo
r by
Med
icar
e or
pai
d by
priv
ate
insu
ranc
e th
at p
aid
as a
prim
ary
paye
r to
your
Med
icar
e P
art A
cov
erag
e, in
a M
edic
are-
certi
fied
faci
lity.
Som
e or
al c
ance
r dru
gs: i
f the
sam
e dr
ug is
ava
ilabl
e in
inje
ctab
le
form
.
Ora
l ant
i-nau
sea
drug
s: if
you
are
par
t of a
n an
ti-ca
ncer
ch
emot
hera
peut
ic re
gim
en.
In
hala
tion
and
infu
sion
dru
gs a
dmin
iste
red
thro
ugh
DM
E.
Con
tact
Med
icar
e P
lus
Blu
e G
roup
PP
O fo
r mor
e de
tails
.
Whe
re c
an I
find
info
rmat
ion
on p
lan
ratin
gs?
Th
e M
edic
are
prog
ram
rate
s ho
w w
ell p
lans
per
form
in d
iffer
ent
cate
gorie
s (fo
r exa
mpl
e, d
etec
ting
and
prev
entin
g ill
ness
ratin
gs fr
om
patie
nts
and
cust
omer
ser
vice
). If
you
have
acc
ess
to th
e W
eb, y
ou m
ay
use
the
web
tool
s on
ww
w.m
edic
are.
gov
and
sele
ct “H
ealth
and
Dru
g P
lan”
then
“Com
pare
Dru
g an
d H
ealth
Pla
ns” t
o co
mpa
re th
e pl
an ra
tings
fo
r Med
icar
e pl
ans
in y
our a
rea.
You
can
als
o ca
ll M
embe
r Ser
vice
s at
1-
866-
684-
8216
(TTY
use
rs c
all 1
-800
-579
-023
5) fo
r mor
e de
tails
. Cal
l M
onda
y th
roug
h Fr
iday
from
8:3
0 a.
m. t
o 5
p.m
. Eas
tern
tim
e, to
obt
ain
a co
py o
f the
pla
n ra
tings
for t
his
plan
.
-
6
Your
ser
vice
s m
ust b
e m
edic
ally
nec
essa
ry w
ith th
e ex
cept
ion
of th
ose
liste
d as
pre
vent
ive
care
. If y
ou h
ave
any
ques
tions
abo
ut th
is p
lan’
s be
nefit
s or
co
sts,
ple
ase
call
Med
icar
e Pl
us B
lue
Gro
up P
PO M
embe
r Ser
vice
s at
1-8
66-6
84-8
216,
Mon
day
thro
ugh
Frid
ay fr
om 8
:30
a.m
. to
5 p.
m. E
aste
rn ti
me.
(T
TY u
sers
cal
l 1-8
00-5
79-0
235)
. M
edic
are
Plus
Blu
e G
roup
PPO
B
enef
it O
rigin
al M
edic
are
In-n
etw
ork
and
Out
-of-n
etw
ork
IMPO
RTA
NT
INFO
RM
ATI
ON
Prem
ium
and
Oth
er
Impo
rtan
t Inf
orm
atio
n
In 2
011
the
mon
thly
Par
t B P
rem
ium
was
$96
.40
and
may
cha
nge
for 2
012
and
the
year
ly P
art B
ded
uctib
le
amou
nt w
as $
162
and
may
cha
nge
for 2
012.
If
a do
ctor
or s
uppl
ier d
oes
not a
ccep
t ass
ignm
ent,
thei
r cos
ts a
re o
ften
high
er, w
hich
mea
ns y
ou p
ay
mor
e.
Gen
eral
M
ost p
eopl
e w
ill p
ay th
e st
anda
rd m
onth
ly P
art B
pr
emiu
m. H
owev
er, s
ome
peop
le w
ill p
ay a
hig
her
prem
ium
bec
ause
of t
heir
year
ly in
com
e (o
ver $
85,0
00
for s
ingl
es, $
170,
000
for m
arrie
d co
uple
s). F
or m
ore
info
rmat
ion
abou
t Par
t B p
rem
ium
s ba
sed
on in
com
e,
call
Med
icar
e at
1-8
00-M
ED
ICA
RE
(1-8
00-6
33-4
227)
. TT
Y u
sers
sho
uld
call
1-87
7-48
6-20
48. Y
ou m
ay a
lso
call
Soc
ial S
ecur
ity a
t 1-
800-
772-
1213
. TTY
use
rs s
houl
d ca
ll 1-
800-
325-
0778
.
In a
dditi
on to
the
Med
icar
e P
art B
pre
miu
m y
ou m
ay a
lso
be
requ
ired
to p
ay a
pre
miu
m c
ontri
butio
n as
def
ined
by
your
em
ploy
er o
r uni
on g
roup
. Fo
r man
y co
vere
d se
rvic
es d
escr
ibed
bel
ow, t
he fo
llow
ing
cost
sha
re a
pplie
s:
Ser
vice
s ar
e su
bjec
t to
the
annu
al d
educ
tible
of $
250.
Th
ere
is a
n an
nual
out
-of-p
ocke
t max
imum
of $
1000
. Onc
e yo
ur c
oins
uran
ce p
aym
ents
, cop
aym
ents
and
ded
uctib
le
equa
l $10
00, a
ll co
vere
d se
rvic
es w
ill b
e pa
id a
t 100
% o
f the
ap
prov
ed a
mou
nt fo
r the
rem
aind
er o
f the
yea
r.
D
octo
r and
H
ospi
tal C
hoic
e (S
ee “E
mer
genc
y C
are”
(#
15) a
nd “U
rgen
tly
Nee
ded
Car
e” (#
16)
You
may
go
to a
ny d
octo
r, sp
ecia
list o
r hos
pita
l tha
t ac
cept
s M
edic
are.
N
o re
ferr
al re
quire
d fo
r net
wor
k do
ctor
s, s
peci
alis
ts a
nd
hosp
itals
. O
ut-o
f-ser
vice
Are
a P
lan
cove
rs y
ou w
hen
you
trave
l in
the
U.S
.
SEC
TIO
N 2
–Su
mm
ary
of B
enef
its
1 2
-
B
7
Med
icar
e Pl
us B
lue
Gro
up P
PO
Ben
efit
Orig
inal
Med
icar
e In
-net
wor
k an
d O
ut-o
f-net
wor
k IN
PATI
ENT
CA
RE
Inpa
tient
Hos
pita
l C
are
(In
clud
es S
ubst
ance
Abu
se
and
Reh
abili
tatio
n S
ervi
ces)
In 2
011
the
amou
nts
for e
ach
bene
fit p
erio
d w
ere:
D
ays
1 - 6
0: $
1132
ded
uctib
le
Day
s 61
- 90
: $28
3 pe
r day
D
ays
91 -
150:
$56
6 pe
r life
time
rese
rve
day
Thes
e am
ount
s m
ay c
hang
e fo
r 201
2.
Cal
l 1-8
00-M
ED
ICA
RE
(1-8
00-6
33-4
227)
for
info
rmat
ion
abou
t life
time
rese
rve
days
.
Life
time
rese
rve
days
can
onl
y be
use
d on
ce.
A "b
enef
it pe
riod"
sta
rts th
e da
y yo
u go
into
a h
ospi
tal
or s
kille
d nu
rsin
g fa
cilit
y. It
end
s w
hen
you
go fo
r 60
days
in a
row
with
out h
ospi
tal o
r ski
lled
nurs
ing
care
. If
you
go in
to th
e ho
spita
l afte
r one
ben
efit
perio
d ha
s en
ded,
a n
ew b
enef
it pe
riod
begi
ns. Y
ou m
ust p
ay th
e in
patie
nt h
ospi
tal d
educ
tible
for e
ach
bene
fit p
erio
d.
Ther
e is
no
limit
to th
e nu
mbe
r of b
enef
it pe
riods
you
ca
n ha
ve.
For f
acili
ty e
valu
atio
n an
d m
anag
emen
t ser
vice
s, y
our
coin
sura
nce
is 1
0% o
f the
app
rove
d am
ount
, afte
r you
mee
t yo
ur a
nnua
l ded
uctib
le. T
hese
ser
vice
s ap
ply
to th
e an
nual
ou
t-of-p
ocke
t max
imum
. A
ll ot
her s
ervi
ces
are
cove
red
at 1
00%
of t
he a
ppro
ved
amou
nt.
You
hav
e un
limite
d da
ys o
f inp
atie
nt c
are
cove
rage
.
3
-
8
Med
icar
e Pl
us B
lue
Gro
up P
PO
Ben
efit
Orig
inal
Med
icar
e In
-net
wor
k an
d O
ut-o
f-net
wor
k In
patie
nt m
enta
l he
alth
car
e
In 2
011
the
amou
nts
for e
ach
bene
fit p
erio
d w
ere:
D
ays
1 - 6
0: $
1132
ded
uctib
le
Day
s 61
- 90
: $28
3 pe
r day
D
ays
91 -
150:
$56
6 pe
r life
time
rese
rve
day
Thes
e am
ount
s m
ay c
hang
e fo
r 201
2.
You
get
up
to 1
90 d
ays
of in
patie
nt p
sych
iatri
c ho
spita
l ca
re in
a li
fetim
e. In
patie
nt p
sych
iatri
c ho
spita
l ser
vice
s co
unt t
owar
d th
e 19
0-da
y lif
etim
e lim
itatio
n on
ly if
ce
rtain
con
ditio
ns a
re m
et. T
his
limita
tion
does
not
ap
ply
to in
patie
nt p
sych
iatri
c se
rvic
es fu
rnis
hed
in a
ge
nera
l hos
pita
l.
For f
acili
ty e
valu
atio
n an
d m
anag
emen
t ser
vice
s, y
our
coin
sura
nce
is 1
0% o
f the
app
rove
d am
ount
, afte
r you
mee
t yo
ur a
nnua
l ded
uctib
le. T
hese
ser
vice
s ap
ply
to th
e in
-ne
twor
k an
nual
out
-of-p
ocke
t max
imum
. A
ll ot
her s
ervi
ces
are
cove
red
at 1
00%
of t
he a
ppro
ved
amou
nt.
You
hav
e un
limite
d da
ys o
f inp
atie
nt c
over
age.
Skill
ed n
ursi
ng
faci
lity
Y
ou m
ust r
ecei
ve c
are
in a
M
edic
are-
certi
fied
skill
ed
nurs
ing
faci
lity.
In 2
011
the
amou
nts
for e
ach
bene
fit p
erio
d af
ter a
t le
ast a
3-d
ay c
over
ed h
ospi
tal s
tay
wer
e:
Day
s 1
- 20:
$0
per d
ay.
Day
s 21
- 10
0: $
141.
50 p
er d
ay.
Thes
e am
ount
s m
ay c
hang
e fo
r 201
2.
100
days
for e
ach
bene
fit p
erio
d A
"ben
efit
perio
d" s
tarts
the
day
you
go in
to a
hos
pita
l or
SN
F. It
end
s w
hen
you
go fo
r 60
days
in a
row
w
ithou
t hos
pita
l or s
kille
d nu
rsin
g ca
re. I
f you
go
into
th
e ho
spita
l afte
r one
ben
efit
perio
d ha
s en
ded,
a n
ew
bene
fit p
erio
d be
gins
. You
mus
t pay
the
inpa
tient
ho
spita
l ded
uctib
le fo
r eac
h be
nefit
per
iod.
The
re is
no
limit
to th
e nu
mbe
r of b
enef
it pe
riods
you
can
hav
e.
For f
acili
ty e
valu
atio
n an
d m
anag
emen
t ser
vice
s, y
our
coin
sura
nce
is 1
0% o
f the
app
rove
d am
ount
, afte
r you
mee
t yo
ur a
nnua
l ded
uctib
le. T
hese
ser
vice
s ap
ply
to th
e an
nual
ou
t-of-p
ocke
t max
imum
. Al
l oth
er s
ervi
ces
are
cove
red
at 1
00%
of t
he a
ppro
ved
amou
nt.
Pla
n co
vers
up
to 1
00 d
ays
for e
ach
bene
fit p
erio
d.
4 5
-
B
9
Med
icar
e Pl
us B
lue
Gro
up P
PO
Ben
efit
Orig
inal
Med
icar
e In
-net
wor
k an
d O
ut-o
f-net
wor
k H
ome
Hea
lth C
are
(In
clud
es m
edic
ally
ne
cess
ary
inte
rmitt
ent
skill
ed n
ursi
ng c
are,
hom
e he
alth
aid
e se
rvic
es, h
ome
infu
sion
, reh
abili
tatio
n se
rvic
es, e
tc.)
$0 c
opay
S
ervi
ces
are
cove
red
at 1
00%
of t
he a
ppro
ved
amou
nt.
Hos
pice
You
mus
t rec
eive
car
e fro
m
a M
edic
are-
certi
fied
hosp
ice.
You
pay
par
t of t
he c
ost f
or o
utpa
tient
dru
gs a
nd
inpa
tient
resp
ite c
are.
Y
ou m
ust g
et c
are
from
a M
edic
are-
certi
fied
hosp
ice.
Whe
n yo
u en
roll
in a
Med
icar
e-ce
rtifie
d ho
spic
e pr
ogra
m, y
our
hosp
ice
serv
ices
are
pai
d fo
r by
Orig
inal
Med
icar
e, n
ot
Med
icar
e P
lus
Blu
e G
roup
PP
O.
6 7
-
10
M
edic
are
Plus
Blu
e G
roup
PPO
B
enef
it O
rigin
al M
edic
are
In-n
etw
ork
and
Out
-of-n
etw
ork
OU
TPA
TIEN
T C
AR
E
Doc
tor O
ffice
Vis
its
20%
coi
nsur
ance
For o
ffice
vis
its, y
ou p
ay a
cop
aym
ent o
f $25
. Not
sub
ject
to a
de
duct
ible
. The
se s
ervi
ces
appl
y to
the
annu
al o
ut-o
f-poc
ket
max
imum
.
Chi
ropr
actic
Ser
vice
s
(F
or m
anua
l man
ipul
atio
n of
th
e sp
ine
to c
orre
ct
subl
uxat
ion
if yo
u re
ceiv
e se
rvic
es fr
om a
chi
ropr
acto
r or
oth
er q
ualif
ied
prov
ider
.)
Sup
plem
enta
l rou
tine
care
not
cov
ered
20%
coi
nsur
ance
for m
anua
l man
ipul
atio
n of
the
spin
e to
cor
rect
sub
luxa
tion
(a d
ispl
acem
ent o
r m
isal
ignm
ent o
f a jo
int o
r bod
y pa
rt) if
you
get
it
from
a c
hiro
prac
tor o
r oth
er q
ualif
ied
prov
ider
s
For o
ffice
vis
its, y
ou p
ay a
cop
aym
ent o
f $20
. Not
sub
ject
to
a de
duct
ible
. The
se s
ervi
ces
appl
y to
the
annu
al o
ut-o
f-po
cket
max
imum
.
Podi
atry
Ser
vice
s
Sup
plem
enta
l rou
tine
care
not
cov
ered
20
% c
oins
uran
ce fo
r med
ical
ly n
eces
sary
foot
car
e,
incl
udin
g ca
re fo
r med
ical
con
ditio
ns a
ffect
ing
the
low
er li
mbs
For o
ffice
vis
its, y
ou p
ay a
cop
aym
ent o
f $25
. Not
sub
ject
to a
de
duct
ible
. The
se s
ervi
ces
appl
y to
the
annu
al o
ut-o
f-poc
ket
max
imum
. Fo
r som
e m
edic
ally
nec
essa
ry fo
ot c
are
serv
ices
oth
er th
an
offic
e vi
sits
, you
r coi
nsur
ance
is 1
0% o
f the
app
rove
d am
ount
, af
ter y
ou m
eet y
our a
nnua
l ded
uctib
le.
Thes
e se
rvic
es a
pply
to
the
annu
al o
ut-o
f-poc
ket m
axim
um.
Out
patie
nt M
enta
l H
ealth
Car
e 40
% c
oins
uran
ce fo
r mos
t out
patie
nt m
enta
l hea
lth
serv
ices
S
peci
fied
copa
ymen
t for
out
patie
nt p
artia
l ho
spita
lizat
ion
prog
ram
ser
vice
s fu
rnis
hed
by a
ho
spita
l or c
omm
unity
men
tal h
ealth
cen
ter
(CM
HC
). C
opay
can
not e
xcee
d th
e P
art A
inpa
tient
ho
spita
l ded
uctib
le.
“Par
tial h
ospi
taliz
atio
n pr
ogra
m” i
s a
stru
ctur
ed
prog
ram
of a
ctiv
e ou
tpat
ient
psy
chia
tric
treat
men
t th
at is
mor
e in
tens
e th
an th
e ca
re re
ceiv
ed in
you
r do
ctor
’s o
r the
rapi
st’s
offi
ce a
nd is
an
alte
rnat
ive
to
inpa
tient
hos
pita
lizat
ion.
For m
enta
l hea
lth s
ervi
ces
rend
ered
at a
men
tal h
ealth
faci
lity,
yo
ur c
oins
uran
ce is
10%
of t
he a
ppro
ved
amou
nt, a
fter y
ou
mee
t you
r ann
ual d
educ
tible
. The
se s
ervi
ces
appl
y to
the
annu
al o
ut-o
f-poc
ket m
axim
um.
For m
enta
l hea
lth s
ervi
ces
in a
n of
fice
setti
ng, y
ou p
ay a
co
paym
ent o
f $25
for e
ach
visi
t. N
ot s
ubje
ct to
a d
educ
tible
. Th
ese
serv
ices
app
ly to
the
annu
al o
ut-o
f-poc
ket m
axim
um.
8 9 10
11
-
B
11
Med
icar
e Pl
us B
lue
Gro
up P
PO
Ben
efit
Orig
inal
Med
icar
e In
-net
wor
k an
d O
ut-o
f-net
wor
k O
utpa
tient
Su
bsta
nce
Abu
se
Car
e
20%
coi
nsur
ance
For s
ubst
ance
abu
se tr
eatm
ent s
ervi
ces
rend
ered
at a
faci
lity,
yo
ur c
oins
uran
ce is
10%
of t
he a
ppro
ved
amou
nt, a
fter y
ou
mee
t you
r ann
ual d
educ
tible
. The
se s
ervi
ces
appl
y to
the
annu
al o
ut-o
f-poc
ket m
axim
um.
For s
ubst
ance
abu
se tr
eatm
ent s
ervi
ces
in a
n of
fice
setti
ng, y
ou
pay
a co
paym
ent o
f $25
. Not
sub
ject
to a
ded
uctib
le. T
hese
se
rvic
es a
pply
to th
e an
nual
out
-of-p
ocke
t max
imum
. O
utpa
tient
Ser
vice
s 20
% c
oins
uran
ce fo
r the
doc
tor’s
ser
vice
s S
peci
fied
copa
ymen
t for
out
patie
nt h
ospi
tal f
acili
ty
serv
ices
C
opay
can
not e
xcee
d th
e P
art A
inpa
tient
hos
pita
l de
duct
ible
.
You
r coi
nsur
ance
is 1
0% o
f the
app
rove
d am
ount
, afte
r you
m
eet y
our a
nnua
l ded
uctib
le. T
hese
ser
vice
s ap
ply
to th
e an
nual
out
-of-p
ocke
t max
imum
.
Out
patie
nt S
urge
ry
prov
ided
at h
ospi
tal
outp
atie
nt fa
cilit
ies
and
ambu
lato
ry
surg
ical
cen
ters
20%
coi
nsur
ance
Fo
r out
patie
nt s
urge
ry, y
our c
oins
uran
ce is
10%
of t
he
appr
oved
am
ount
, afte
r you
mee
t you
r ann
ual d
educ
tible
. The
se
serv
ices
app
ly to
the
annu
al o
ut-o
f-poc
ket m
axim
um.
A
mbu
lanc
e Se
rvic
es
(M
edic
ally
nec
essa
ry
ambu
lanc
e se
rvic
es)
20%
coi
nsur
ance
Y
our c
oins
uran
ce is
10%
of t
he a
ppro
ved
amou
nt, a
fter y
ou
mee
t you
r ann
ual d
educ
tible
, for
Med
icar
e-co
vere
d am
bula
nce
serv
ices
. Cos
t-sha
ring
appl
ies
for e
ach
one-
way
trip
. The
se
serv
ices
app
ly to
the
annu
al o
ut-o
f-poc
ket m
axim
um.
Emer
genc
y C
are
(Y
ou m
ay g
o to
any
em
erge
ncy
room
if y
ou
reas
onab
ly b
elie
ve y
ou
need
em
erge
ncy
care
.)
20%
coi
nsur
ance
for t
he d
octo
r’s s
ervi
ces
Spe
cifie
d co
paym
ent f
or o
utpa
tient
hos
pita
l fac
ility
em
erge
ncy
serv
ices
E
mer
genc
y se
rvic
es c
opay
can
not e
xcee
d P
art A
in
patie
nt h
ospi
tal d
educ
tible
for e
ach
serv
ice
prov
ided
by
the
hosp
ital.
You
pay
a $
50 c
opay
men
t for
Med
icar
e-co
vere
d em
erge
ncy
room
vis
its (w
aive
d if
adm
itted
with
in 3
day
s). N
ot s
ubje
ct to
the
dedu
ctib
le. T
hese
ser
vice
s ap
ply
to th
e an
nual
out
-of-p
ocke
t m
axim
um.
12
13
14
15
16
-
12
Med
icar
e Pl
us B
lue
Gro
up P
PO
Ben
efit
Orig
inal
Med
icar
e In
-net
wor
k an
d O
ut-o
f-net
wor
k Y
ou d
on't
have
to p
ay th
e em
erge
ncy
room
cop
ay if
yo
u ar
e ad
mitt
ed to
the
hosp
ital a
s an
inpa
tient
for
the
sam
e co
nditi
on w
ithin
3 d
ays
of th
e em
erge
ncy
room
vis
it.
Not
cov
ered
out
side
the
U.S
. exc
ept u
nder
lim
ited
circ
umst
ance
s
Urg
ently
Nee
ded
Car
e
(Thi
s is
NO
T em
erge
ncy
care
.)
20%
coi
nsur
ance
or a
set
cop
ay
NO
T co
vere
d ou
tsid
e th
e U
.S. e
xcep
t und
er li
mite
d ci
rcum
stan
ces
You
pay
a c
opay
men
t of $
25. N
ot s
ubje
ct to
the
dedu
ctib
le.
Thes
e se
rvic
es a
pply
to th
e an
nual
out
-of-p
ocke
t max
imum
.
Out
patie
nt
Reh
abili
tatio
n Se
rvic
es
(Occ
upat
iona
l the
rapy
, ph
ysic
al th
erap
y, s
peec
h,
and
lang
uage
ther
apy)
20%
coi
nsur
ance
Y
our c
oins
uran
ce is
10%
of t
he a
ppro
ved
amou
nt, a
fter y
ou
mee
t you
r ann
ual d
educ
tible
. The
se s
ervi
ces
appl
y to
the
annu
al o
ut-o
f-poc
ket m
axim
um.
Med
icar
e th
erap
y lim
its a
pply
to re
habi
litat
ion
serv
ices
pro
vide
d.
17
18
-
B
13
Med
icar
e Pl
us B
lue
Gro
up P
PO
Ben
efit
Orig
inal
Med
icar
e In
-net
wor
k an
d O
ut-o
f-net
wor
k O
UTP
ATI
ENT
MED
ICA
L SE
RVI
CES
AN
D S
UPP
LIES
Dur
able
Med
ical
Eq
uipm
ent
(In
clud
es w
heel
chai
rs,
oxyg
en, e
tc.)
20%
coi
nsur
ance
Y
our c
oins
uran
ce is
10%
of t
he a
ppro
ved
amou
nt. N
ot s
ubje
ct
to a
ded
uctib
le. T
hese
ser
vice
s ap
ply
to th
e $5
00 a
nnua
l out
-of-
pock
et m
axim
um fo
r dur
able
med
ical
equ
ipm
ent,
pros
thet
ics,
or
thot
ics
and
rela
ted
supp
lies.
Pros
thet
ic a
nd
Ort
hotic
Dev
ices
(Bra
ces,
arti
ficia
l lim
bs a
nd
eyes
, etc
.)
20%
coi
nsur
ance
Y
our c
oins
uran
ce is
10%
of t
he a
ppro
ved
amou
nt. N
ot s
ubje
ct
to a
ded
uctib
le. T
hese
ser
vice
s ap
ply
to th
e $5
00 a
nnua
l out
-of-
pock
et m
axim
um fo
r dur
able
med
ical
equ
ipm
ent,
pros
thet
ics,
or
thot
ics
and
rela
ted
supp
lies.
Dia
bete
s Pr
ogra
ms
and
Supp
lies
(Incl
udes
cov
erag
e fo
r gl
ucos
e m
onito
rs, t
est
strip
s, la
ncet
s, s
cree
ning
te
sts
and
self-
man
agem
ent
train
ing.
)
20%
coi
nsur
ance
for d
iabe
tes
self-
man
agem
ent
train
ing
20%
coi
nsur
ance
for d
iabe
tes
supp
lies
20%
coi
nsur
ance
for d
iabe
tic th
erap
eutic
sho
es o
r in
serts
Ser
vice
s ar
e co
vere
d at
100
% o
f the
app
rove
d am
ount
for
diab
etes
scr
eeni
ngs,
dia
bete
s-re
late
d du
rabl
e m
edic
al
equi
pmen
t or s
uppl
ies,
and
sel
f-man
agem
ent t
rain
ing.
19
20
21
-
14
Med
icar
e Pl
us B
lue
Gro
up P
PO
Ben
efit
Orig
inal
Med
icar
e In
-net
wor
k an
d O
ut-o
f-net
wor
k D
iagn
ostic
Tes
ts,
X-ra
ys, L
ab
Serv
ices
and
R
adio
logy
Se
rvic
es
20%
coi
nsur
ance
for d
iagn
ostic
test
s an
d X-
rays
$0 c
opay
for M
edic
are-
cove
red
lab
serv
ices
Lab
Ser
vice
s: M
edic
are
cove
rs m
edic
ally
nec
essa
ry
diag
nost
ic la
b se
rvic
es th
at a
re o
rder
ed b
y yo
ur
treat
ing
doct
or w
hen
they
are
pro
vide
d by
a C
linic
al
Labo
rato
ry Im
prov
emen
t Am
endm
ents
(CLI
A)
certi
fied
labo
rato
ry th
at p
artic
ipat
es in
Med
icar
e.
Dia
gnos
tic la
b se
rvic
es a
re d
one
to h
elp
your
doc
tor
diag
nose
or r
ule
out a
sus
pect
ed il
lnes
s or
co
nditi
on. M
edic
are
does
not
cov
er m
ost
supp
lem
enta
l rou
tine
scre
enin
g te
sts,
like
che
ckin
g yo
ur c
hole
ster
ol.
20%
coi
nsur
ance
for d
igita
l rec
tal e
xam
and
oth
er
rela
ted
serv
ices
Cov
ered
onc
e a
year
for a
ll m
en w
ith M
edic
are
over
ag
e 50
You
r coi
nsur
ance
is 1
0% o
f the
app
rove
d am
ount
, afte
r you
m
eet y
our a
nnua
l ded
uctib
le. T
hese
ser
vice
s ap
ply
to th
e an
nual
out
-of-p
ocke
t max
imum
.
Car
diac
and
Pu
lmon
ary
Reh
abili
tatio
n Se
rvic
es
20%
coi
nsur
ance
for c
ardi
ac re
habi
litat
ion
serv
ices
20%
coi
nsur
ance
for p
ulm
onar
y re
habi
litat
ion
serv
ices
20%
coi
nsur
ance
for i
nten
sive
car
diac
reha
bilit
atio
n se
rvic
es
This
app
lies
to p
rogr
am s
ervi
ces
prov
ided
in a
do
ctor
’s o
ffice
. Spe
cifie
d co
st s
harin
g fo
r pro
gram
se
rvic
es p
rovi
ded
by h
ospi
tal o
utpa
tient
de
partm
ents
.
You
r coi
nsur
ance
is 1
0% o
f the
app
rove
d am
ount
, afte
r you
m
eet y
our a
nnua
l ded
uctib
le. T
hese
ser
vice
s ap
ply
to th
e an
nual
out
-of-p
ocke
t max
imum
.
22
23
-
B
15
Med
icar
e Pl
us B
lue
Gro
up P
PO
Ben
efit
Orig
inal
Med
icar
e In
-net
wor
k an
d O
ut-o
f-net
wor
k K
idne
y D
isea
se
and
Con
ditio
ns
20%
coi
nsur
ance
for r
enal
dia
lysi
s 20
% c
oins
uran
ce fo
r kid
ney
dise
ase
educ
atio
n se
rvic
es
You
r coi
nsur
ance
is 1
0% o
f the
app
rove
d am
ount
, afte
r you
m
eet y
our a
nnua
l ded
uctib
le. T
hese
ser
vice
s ap
ply
to th
e an
nual
out
-of-p
ocke
t max
imum
. H
ome
dial
ysis
equ
ipm
ent a
nd s
uppl
ies
are
cove
red
at 1
00%
of
the
appr
oved
am
ount
. K
idne
y di
seas
e ed
ucat
ion
is c
over
ed a
t 100
% o
f the
ap
prov
ed a
mou
nt.
24
-
16
M
edic
are
Plus
Blu
e G
roup
PPO
B
enef
it O
rigin
al M
edic
are
In-n
etw
ork
and
Out
-of-n
etw
ork
PREV
ENTI
VE S
ERVI
CES
Prev
entiv
e Se
rvic
es a
nd
Wel
lnes
s/
Educ
atio
n Pr
ogra
ms
No
coin
sura
nce,
cop
aym
ent o
r ded
uctib
le fo
r the
fo
llow
ing:
-
Abd
omin
al A
ortic
Ane
urys
m S
cree
ning
-
Bon
e M
ass
Mea
sure
men
t C
over
ed o
nce
ever
y 24
mon
ths
(mor
e of
ten
if m
edic
ally
nec
essa
ry) i
f you
mee
t cer
tain
med
ical
co
nditi
ons
- C
ardi
ovas
cula
r Scr
eeni
ng
- C
ervi
cal a
nd V
agin
al C
ance
r Scr
eeni
ng
Cov
ered
onc
e ev
ery
2 ye
ars
Cov
ered
onc
e a
year
for w
omen
with
Med
icar
e at
hi
gh ri
sk
- C
olor
ecta
l Can
cer S
cree
ning
-
Dia
bete
s S
cree
ning
-
Influ
enza
Vac
cine
-
Hep
atiti
s B
Vac
cine
fo
r peo
ple
with
Med
icar
e at
risk
-
HIV
Scr
eeni
ng
$0 c
opay
for t
he H
IV s
cree
ning
, but
you
gen
eral
ly
pay
20%
of t
he M
edic
are-
appr
oved
am
ount
for t
he
doct
or’s
vis
it. H
IV s
cree
ning
is c
over
ed fo
r peo
ple
with
Med
icar
e w
ho a
re p
regn
ant a
nd p
eopl
e at
in
crea
sed
risk
for t
he in
fect
ion,
incl
udin
g an
yone
w
ho a
sks
for t
he te
st. M
edic
are
cove
rs th
is te
st
once
eve
ry 1
2 m
onth
s or
up
to th
ree
times
dur
ing
a pr
egna
ncy.
-
Bre
ast C
ance
r Scr
eeni
ng (M
amm
ogra
m)
Med
icar
e co
vers
scr
eeni
ng m
amm
ogra
ms
once
ev
ery
12 m
onth
s fo
r all
wom
en w
ith M
edic
are,
age
40
and
old
er. M
edic
are
cove
rs o
ne b
asel
ine
mam
mog
ram
for w
omen
bet
wee
n ag
es 3
5-39
.
Ser
vice
s ar
e co
vere
d at
100
% o
f the
app
rove
d am
ount
.
25
-
B
17
Med
icar
e Pl
us B
lue
Gro
up P
PO
Ben
efit
Orig
inal
Med
icar
e In
-net
wor
k an
d O
ut-o
f-net
wor
k Pr
even
tive
Serv
ices
and
W
elln
ess/
Ed
ucat
ion
Prog
ram
s (c
ontin
ued)
- M
edic
al N
utrit
ion
Ther
apy
Ser
vice
s
Nut
ritio
n th
erap
y is
for p
eopl
e w
ho h
ave
diab
etes
or
kidn
ey d
isea
se (b
ut a
ren’
t on
dial
ysis
or h
aven
’t ha
d a
kidn
ey tr
ansp
lant
) whe
n re
ferr
ed b
y a
doct
or.
Thes
e se
rvic
es c
an b
e gi
ven
by a
regi
ster
ed
diet
icia
n an
d m
ay in
clud
e a
nutri
tiona
l ass
essm
ent
and
coun
selin
g to
hel
p yo
u m
anag
e yo
ur d
iabe
tes
or k
idne
y di
seas
e.
- P
erso
naliz
ed P
reve
ntio
n P
lan
Ser
vice
s (A
nnua
l W
elln
ess
Vis
its)
- P
neum
ococ
cal V
acci
ne
You
may
onl
y ne
ed th
e P
neum
onia
vac
cine
onc
e in
yo
ur li
fetim
e. C
all y
our d
octo
r for
mor
e in
form
atio
n.
- P
rost
ate
Can
cer S
cree
ning
(Pro
stat
e S
peci
fic
Ant
igen
[PS
A] t
est o
nly)
C
over
ed o
nce
a ye
ar fo
r all
men
with
Med
icar
e ov
er
age
50
- S
mok
ing
Ces
satio
n (c
ouns
elin
g to
sto
p sm
okin
g)
Cov
ered
if o
rder
ed b
y yo
ur d
octo
r In
clud
es tw
o co
unse
ling
atte
mpt
s w
ithin
a 1
2-m
onth
pe
riod.
Eac
h co
unse
ling
atte
mpt
incl
udes
up
to fo
ur
face
-to-fa
ce v
isits
. -
Wel
com
e to
Med
icar
e P
hysi
cal E
xam
(ini
tial
prev
entiv
e ph
ysic
al e
xam
) W
hen
you
join
Med
icar
e P
art B
, the
n yo
u ar
e el
igib
le a
s fo
llow
s: D
urin
g th
e fir
st 1
2 m
onth
s of
yo
ur n
ew P
art B
cov
erag
e, y
ou c
an g
et e
ither
a
Wel
com
e to
Med
icar
e P
hysi
cal E
xam
or a
n A
nnua
l W
elln
ess
Vis
it. A
fter y
our f
irst 1
2 m
onth
s, y
ou c
an
get o
ne A
nnua
l Wel
lnes
s V
isit
ever
y 12
mon
ths.
25
-
18
Med
icar
e Pl
us B
lue
Gro
up P
PO
Ben
efit
Orig
inal
Med
icar
e In
-net
wor
k an
d O
ut-o
f-net
wor
k O
THER
SER
VIC
ES
D
enta
l Ser
vice
s
Pre
vent
ive
dent
al s
ervi
ces
(suc
h as
cle
anin
g) n
ot
cove
red
Orig
inal
Med
icar
e co
vers
ver
y lim
ited
med
ical
ly n
eces
sary
de
ntal
ser
vice
s. Y
our M
edic
are
Adv
anta
ge p
lan
will
cov
er
thos
e sa
me
med
ical
ly n
eces
sary
ser
vice
s. T
he c
ost-s
harin
g fo
r tho
se s
ervi
ces
(e.g
. sur
gery
, offi
ce v
isits
, X-r
ays)
is
refe
renc
ed in
oth
er a
reas
of t
he b
enef
it ch
art.
For m
ore
info
rmat
ion,
con
tact
Mem
ber S
ervi
ces.
H
earin
g Se
rvic
es
S
uppl
emen
tal r
outin
e he
arin
g ex
ams
and
hear
ing
aids
not
cov
ered
20
% c
oins
uran
ce fo
r dia
gnos
tic h
earin
g ex
ams
Rou
tine
hear
ing
exam
s ar
e no
t cov
ered
.
For d
iagn
ostic
test
ing
serv
ices
, you
r coi
nsur
ance
is 1
0% o
f th
e ap
prov
ed a
mou
nt, a
fter y
ou m
eet y
our a
nnua
l de
duct
ible
. The
se s
ervi
ces
appl
y to
the
annu
al o
ut-o
f-po
cket
max
imum
. Fo
r dia
gnos
tic h
earin
g of
fice
visi
ts, y
ou p
ay a
cop
aym
ent o
f $2
5. N
ot s
ubje
ct to
a d
educ
tible
. The
se s
ervi
ces
appl
y to
th
e an
nual
out
-of-p
ocke
t max
imum
.
Visi
on S
ervi
ces
20%
coi
nsur
ance
for d
iagn
osis
and
trea
tmen
t of
dise
ases
and
con
ditio
ns o
f the
eye
Sup
plem
enta
l rou
tine
eye
exam
s an
d gl
asse
s no
t co
vere
d
Med
icar
e pa
ys fo
r one
pai
r of e
yegl
asse
s or
con
tact
le
nses
afte
r cat
arac
t sur
gery
. Ann
ual g
lauc
oma
scre
enin
gs c
over
ed fo
r peo
ple
at
risk
For d
iagn
osis
and
trea
tmen
t of d
isea
ses
and
cond
ition
s of
th
e ey
e, y
our c
oins
uran
ce is
10%
of t
he a
ppro
ved
amou
nt,
afte
r you
mee
t you
r ann
ual d
educ
tible
. The
se s
ervi
ces
appl
y to
the
annu
al o
ut-o
f-poc
ket m
axim
um.
For m
edic
al v
isio
n of
fice
visi
ts, y
ou p
ay a
cop
aym
ent o
f $2
5. N
ot s
ubje
ct to
a d
educ
tible
. The
se s
ervi
ces
appl
y to
th
e an
nual
out
-of-p
ocke
t max
imum
. S
ervi
ces
are
cove
red
at 1
00%
of t
he a
ppro
ved
amou
nt fo
r co
rrec
tive
lens
es fo
llow
ing
cata
ract
sur
gery
. S
ervi
ces
are
cove
red
at 1
00%
of t
he a
ppro
ved
amou
nt fo
r an
nual
gla
ucom
a sc
reen
ings
for t
hose
mem
bers
at r
isk.
R
outin
e ey
e ex
ams
and
glas
ses
are
not c
over
ed b
y th
is
plan
.
26
27
28
-
B
19
A
DD
ITIO
NA
L SE
RVI
CES
Non
-med
ical
ly n
eces
sary
st
erili
zatio
n Th
ese
serv
ices
are
not
cov
ered
. Y
our c
oins
uran
ce is
10%
of t
he a
ppro
ved
amou
nt, a
fter y
ou
mee
t you
r ann
ual d
educ
tible
. The
se s
ervi
ces
appl
y to
the
annu
al o
ut-o
f-poc
ket m
axim
um.
Con
trace
ptiv
e de
vice
s Th
ese
serv
ices
are
not
cov
ered
. Y
our c
oins
uran
ce is
10%
of t
he a
ppro
ved
amou
nt, a
fter y
ou
mee
t you
r ann
ual d
educ
tible
. The
se s
ervi
ces
appl
y to
the
annu
al o
ut-o
f-poc
ket m
axim
um.
Hom
e in
fusi
on th
erap
y Th
ese
serv
ices
are
not
cov
ered
. S
ervi
ces
are
cove
red
at 1
00%
of t
he a
ppro
ved
amou
nt.
-
20
PR
ESC
RIP
TIO
N D
RU
GS
Dru
gs c
over
ed u
nder
Med
icar
e P
art D
— G
ener
al
This
pla
n us
es a
form
ular
y. T
he p
lan
will
send
you
the
form
ular
y. Y
ou c
an a
lso
see
the
form
ular
y at
ww
w.b
cbsm
.com
/med
icar
e.
Diff
eren
t out
-of-p
ocke
t cos
ts m
ay a
pply
for p
eopl
e w
ho h
ave
limite
d in
com
es, l
ive
in lo
ng-te
rm c
are
faci
litie
s or