Life is all
theafter
choices
oneabout
choice
another.
you make.
Now it’s
time to
make
We make
choosing
your
Medicare
the right
choice
for
easy.
yourplan
health.
Through It All.
SM
H1666_MRK_TMP_TX_FULFILLSWIT13a Approved 08242012
55815.0512
Contact Information
Blue Medicare AdvantageSM
Call
1-877-586-7749 • TTY/TDD 711
8 a.m. - 8 p.m., local time, 7 days a week
rom February 15 - September 30, alternate
F
technologies (for example, voicemail) will be used
on the weekends and holidays.
Web www.mybluemapd.com
Seminars Find a free seminar near you: www.bcbstx.com/medicare/seminars
Write Blue Medicare Advantage • P.O. Box 3897 • Scranton, PA 18505-9947
Medicare
Contact Medicare for more information about Medicare benefits and services, including general
information regarding the health, Medicare Advantage Prescription Drug or Part D benefit.
Call 1-800-MEDICARE (1-800-633-4227) • TTY/TDD 1-877-486-2048
24 hours a day, 7 days a week
Web www.medicare.gov
Call your exclusive licensed Blue Cross and Blue Shield of Texas
authorized agency to schedule an appointment.
Name
Call 1-xxx-xxx-xxxx
Web www.xxxxxx.com
Write Address, City, State
.
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l
A
t
I
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g
u
o
Thr
SM
TY/TDD 711
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1-877-5
mapd.com
www.myblue
2
Experience tells you it’s true. The choices you make
determine the course of your life.
You’ve faced life’s tests and trials through the years and made choices along
the way. Now it’s time to make another important one – for your health.
Start with Blue Medicare Advantage. Whether you are new to Medicare or thinking about switching plans, here
are some important items to consider before choosing Blue Medicare Advantage.
Be sure you are eligible for Medicare and live where
Blue Medicare Advantage is available. Blue Medicare
Advantage is offered in the counties of Bastrop,
Burnet, Caldwell, Collin, Dallas, Denton, Fayette,
Fort Bend, Harris, Hays, Lee, Montgomery, Tarrant,
Travis and Williamson. Your primary residence
must be in one of these counties to enroll.
Are you still working? If you are still working and
planning to retire, ask your benefits administrator
whether you’re eligible for benefits and learn about
your options.
Review how Medicare Advantage works.
Look at the 2013 Blue Medicare Advantage plan
benefits.
•Check the Provider Directory to find
your doctors.
• Have your current prescription drug
information available. You will want to
check the formulary to be sure your drugs
are included.
Enroll in Blue Medicare Advantage. Members may
enroll in the plan only during specific times of the year.
Contact us for more information.
Generations of Americans have
relied on Blue Cross and Blue Shield.
You can count on us, too.
Medicare Advantage Basics
Medicare Advantage Plans*
•
provide all of your Part A
(Hospital Insurance) benefits
•
provide all of your Part B
(Medical Insurance) benefits
•
must cover at least all of the
medically necessary services
that Original Medicare provides
Plans can charge different
•
copays
•
coinsurance
•
deductibles for services
Medicare Advantage Plans
usually offer extra benefits
such as
•
vision
•
hearing
•
health and wellness programs
To help manage costs,
most include
• prescription drug plan
• pharmacy network
• provider network
* Medicare & You, CMS, 2012
3
What is Medicare Advantage?
A Medicare Advantage Plan (like an HMO or PPO*) is another plan choice you may have
as part of Medicare. These plans, sometimes called “Part C” or “MA Plans,” are offered by
private insurance companies approved by Medicare.
Here’s how they work:
• M
edicare pays a fixed amount for your care every month to the company offering Medicare
Advantage (MA) plans.
• T
hese companies must follow rules set by Medicare, including eligibility and enrollment.
• E ach MA plan can charge different out-of-pocket costs, such as deductibles, copays and coinsurance.
• H
MO and PPO plans have networks of providers that help keep the cost of care low. Members
generally must use these network providers to receive non-emergency services.
• M
A plans may have different guidelines for how you get services (like whether you need a referral to
see a specialist or if you have to go to doctors, facilities or suppliers that belong to the plan’s network
for non-emergency or non-urgent care).
Medicare Advantage Plans are not supplement plans. They are different from Medicare
Supplement insurance.
Medicare Advantage Plan
Medicare Supplement Insurance
Part B Premium
Must be paid; is separate from the
Medicare Advantage plan premium.
Must be paid; is separate from the
Medicare Supplement insurance premium.
Monthly Premium
Must be paid; is separate from the
Part B premium.
Must be paid; is separate from the
Part B premium.
Number of Plans
Determined by insurance carrier.
Standardized plans set by Medicare.
Benefits
At least all covered by Medicare Parts
A & B combined, plus those added by
the Medicare Advantage plan.
Must already have Parts A & B;
Medicare Supplement will pay health
care costs that Medicare doesn’t cover,
such as copayments, coinsurance and
deductibles.
Doctors
Members may be required to use
doctors from within the plan’s network.
Members can use any provider that
accepts Medicare.
Hospitals
Members may be required to use
hospitals from within the plan’s network.
Members can use any hospital that
accepts Medicare.
Prescription Drug
Coverage
Prescription drug coverage may be
built into the plan.
Does not include prescription drug
coverage. Enrollment in a separate Part D
plan is recommended.
4
Why choose Blue Medicare Advantage?
Blue Medicare Advantage offers all of the coverage of Original Medicare — plus benefits
not covered by Medicare or most Medicare Supplement insurance plans. Think of it as an
all-in-one plan.
Provider Network
Because Blue Medicare Advantage is a Preferred Provider Organization (PPO) plan, you maximize
your benefits by using providers in our extensive network of doctors. You’ll find doctors from a wide
range of specialties from primary care to cardiology, urology, rheumatology and more. Look for your
providers online at www.mybluemapd.com/providers/tx.
Built-in Prescription Drug Coverage
Our formulary has thousands of drugs on it. You’ll find five tiers of coverage including Generic,
Non-Preferred Generic, Preferred Brand, Non-Preferred Brand and Specialty. Copays for generics are
as low as $3 – that can mean big savings if you have many prescriptions.
Preventive Care and Additional Services
In addition to prescription drug coverage, these services may include routine:
• physical exams
• vision care
• hearing exams
24/7 Nurseline
Staffed by registered nurses, 24/7 Nurseline gives you the professional help you need when you’re not
sure what to do about certain illnesses or injuries, especially at night or on the weekends.
Source: www.medicare.gov/navigation/medicare-basics/medicare-benefits/part-c.aspx
* HMO – Health Maintenance Organization; you must use the doctors, specialists, or hospitals in the plan’s
network of providers. The HMO may require you to get a referral from your primary care physician.
PPO – Preferred Provider Organization; you pay less when you use health care providers in the plan’s network.
You can use providers from outside of the network, but may have to pay more.
5
Saving with Blue Medicare Advantage
With Blue Medicare Advantage you save money.
•Low copay for a visit to your primary care doctor
•Generic prescription drug copays are low
• Discounts for health care products and services
The benefits listed here are a partial description only. Please see the enclosed Summary of Benefits, which
compares Original Medicare benefits with the 2013 Blue Medicare Advantage benefits and includes other
important plan information.
Benefit
Premium
In-Network
Out-of-Network
$69.90
for residents of Bastrop, Burnet, Caldwell, Collin, Dallas, Denton,
Fayette, Fort Bend, Harris, Hays, Lee, Montgomery, Tarrant,
Travis and Williamson counties
$0
Medical Deductible
$3,400
$5,000
$250 per day, days 1-7; $0 per day, days 8-90;
$0 for additional days
$0 per day, days 1-14
$100 per day, days 15-100
$250 per day, days 1-7
$0 per day, days 8-90
$150 per visit
30% coinsurance
$15 Primary Care copay
$45 Specialist copay
30% coinsurance
$65 per visit
$65 per visit
In PCP office, $15 copay for lab and X-ray,
In PCP office, $15 copay for diagnostic
radiology services
$45 copay for therapeutic radiology services
30% coinsurance
$0 copay for training
20% coinsurance for supplies
30% coinsurance
Colorectal Screening Exams
$0 copay
30% coinsurance
Immunizations (Flu, Hepatitis
B and Pneumonia)
$0 copay
30% coinsurance
Mammogram Screening
(for women age 40+)
$0 copay
30% coinsurance
$20 copay per visit
30% coinsurance
$45 copay per exam,
$45 copay for one pair of eyeglasses or
contact lenses after cataract surgery
30% coinsurance
$15 copay per exam
30% coinsurance
Out-of-Pocket Maximum
Hospitalization
Skilled Nursing Facility Care
Outpatient Services/Surgery
Doctor Office Visits
Emergency Care
Diagnostic Tests, X-rays and
Lab Services
Diabetes Self-Monitoring
Training and Supplies
Chiropractic Services
Routine Vision Care
Routine Hearing Care
30% coinsurance
6
Covering your prescription drugs
The added convenience of having your prescription drugs covered is another great reason
to choose all-in-one Blue Medicare Advantage.
Blue Medicare Advantage Drug Coverage
Annual Prescription
Deductible
Amount you pay
before Blue Medicare
Advantage begins
to pay
Initial Coverage
Period Copays
(30-day supply)
Annual drug costs
up to $2,970
$325 for Tiers 3, 4 & 5 only
Tier 1 - Generic Drugs
Tier 2 - Non-Preferred Generic Drugs
Tier 3 - Preferred Brand Drugs
Tier 4 - Non-Preferred Brand Drugs
Tier 5 - Specialty Drugs
$3
$10
$43
$95
25%
Gap Coverage
Annual drug costs
exceeding $2,970
(up to a total of $4,750
out-of-pocket costs)
After the Gap
Copays
After your total
out-of-pocket costs
exceed $4,750
You will receive a discount on Brand Name Drugs and
pay only 79% of the costs of Generic Drugs.
You pay whichever is greater:
Tier 1 - Generic Drugs: $2.65 copay or 5% coinsurance for your drug
Tier 2 - Non-Preferred Generic Drugs: $2.65 copay or 5% coinsurance for your drug
Tier 3 - Preferred Brand Drugs: $6.60 copay or 5% coinsurance for your drug
Tier 4 - Non-Preferred Brand Drugs: $6.60 copay or 5% coinsurance for your drug
Tier 5 - Specialty Drugs: 5% coinsurance for your drug
You must continue to pay your Medicare Part B premium.
The benefit information provided is a brief summary, not a complete description of benefits. For more information
contact the plan.
Limitations, copayments, and restrictions may apply.
Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1 of
each year.
7
Formulary and Pharmacy Facts
Thousands of prescription drugs are in our formulary.
Thousands of pharmacies are in our network.
Blue Medicare Advantage Formulary
•You can save money by switching to a generic. Ask your doctor/pharmacist if this is an option for you.
•Save time and money by using our convenient mail-order service.
•View the most current formulary at www.mybluemapd.com/rxlist/tx.
Blue Medicare Advantage Pharmacies
•Blue Medicare Advantage has pharmacies nationwide, giving you peace of mind while traveling.
•For you to receive benefits, Blue Medicare Advantage network pharmacies or mail-order service must be
used, except in an emergency.
•Blue Medicare Advantage preferred network pharmacies and their affiliates include:
– Brookshire Grocery
–Costco
–CVS
–H-E-B
–Kmart
–Kroger
–Minyard
– Q Pharmacy
–Randalls
– Sam’s Club
– Super 1 Pharmacy
–Target
– Tom Thumb
– United Supermarket Pharmacies
–Walgreens
–Walmart
Other pharmacies are available in our network. Visit www.mybluemapd.com/pharmacies/tx
for a current pharmacy listing.
8
Enroll in Blue Medicare Advantage
Choose one of these easy ways to enroll.
Mail
Web
Call
Fill out the enclosed
enrollment form. To
avoid processing
delays, check that you:
Our secure online form
has simple, step-bystep instructions that
make enrollment easy.
Our product specialist
will walk you through
enrolling in Blue
Medicare Advantage.
Go to:
www.mybluemapd.
com/enroll/tx
Call:
1-877-586-7749
TTY/TDD 711
Select Blue Medicare
Advantage.
Copy your Medicare
number exactly as
printed on your
Medicare ID card.
Sign the form.
Mail the white copy
in the postage-paid
envelope. The blue copy
is for your records.
9
Medicare beneficiaries
may also enroll in
Blue Medicare Advantage
through the CMS Medicare
Online Enrollment
Center located at
http://www.medicare.gov.
After you enroll
Be on the lookout for these communications after you enroll.
Acknowledgement Letter
We will send you a letter within 10 days of receiving your enrollment form.
If you enrolled with an agent or broker, you’ll get a phone call to confirm
your enrollment and to answer any questions you may have.
Confirmation Letter/ID Card
After your enrollment has been approved, we’ll send you a confirmation
letter. It will include your Blue Medicare Advantage ID card and the date
your coverage will be effective.
Welcome Kit
About two weeks after you get your ID card, you’ll receive your
Welcome Kit. It will include your Evidence of Coverage along
with everything you’ll need to know about being a member of
Blue Medicare Advantage.
You’ll discover more benefits as a Blue Medicare Advantage member.
LifeTimes offers news you can use
Watch your mailbox for LifeTimes, our quarterly newsletter filled
with information and articles you’re sure to enjoy, or view it online at
www.bcbstx.com/lifetimes.
10
Important Information
Limitations and Exclusions
There are items and services not covered by Blue
Medicare Advantage. These are called limitations and
exclusions. A full list can be found in the Evidence
of Coverage. Here is a limited list. Blue Medicare
Advantage cannot cover a drug purchased outside the
U.S. and its territories. Blue Medicare Advantage does
not cover:
• Over-the-counter (OTC) drugs
• Drugs when used to aid fertility
• Drugs when used to ease signs of cough or cold
• Drugs when used for cosmetic purposes or to aid
hair growth
• Vitamins and mineral products ordered by a doctor,
except vitamins for pregnant women and fluoride
preparations
• Drugs when used for the care of sexual or erectile
dysfunction, such as Viagra, Cialis, Levitra, and
Caverject
• Drugs when used for care of anorexia, weight loss, or
weight gain
• Outpatient drugs for which the manufacturer calls for
tests or monitoring services to be bought only from
the drug maker as a term of sale
• Barbiturates and Benzodiazepines (starting
January 1, 2013 a limited number of these products
will be covered for specific indications)
Quantity limits, step therapy, and prior authorization
may apply. Look in the Comprehensive Formulary for
more information.
What are my protections under
Blue Medicare Advantage?
Blue Medicare Advantage agrees to stay in the
program for a full year at a time. Each year, the
plan decides whether to carry on for another
year. Even if Blue Medicare Advantage leaves the
program, you will not lose Medicare coverage.
Grievances and Appeals
If you have a problem with our plan, there are two
formal processes in place to address your issue:
appeal and grievance. An appeal is something
you do if you disagree with a decision to deny
a request for prescription drugs or payment
for services or drugs you already received. You
may also make an appeal if you disagree with a
decision to stop services that you are receiving.
For example, you may ask for an appeal if our
plan doesn’t pay for a drug, item, or service you
think you should be able to receive. A grievance
is a type of complaint you make about us or one
of our network pharmacies, including a complaint
concerning the quality of your care. This type of
complaint does not involve coverage or payment
disputes. For more information, please call us.
PLEASE NOTE:
This information is available for free in other
languages. Please contact our Customer Service
number at 1-877-586-7749 for additional
information. (TTY/TDD users should call 711.)
Esta información está disponible en otros idiomas
de forma gratuita. Contacte nuestro número de
Servicio al Cliente en el 1-877-586-7749 para
obtener información adicional. (Los usuarios de
TTY/TDD deberán llamar al 711.)
Make the right choice for your health.
Call Our product specialist will help you.
1-877-586-7749 • TTY/TDD 711
Web Our secure online selection tool has simple, step-by-step instructions that make it easy:
www.mybluemapd.com
Seminars
Find an educational seminar near you: www.bcbstx.com/medicare/seminars
Call your exclusive licensed Blue Cross and Blue Shield of Texas
authorized agency to schedule an appointment.
Name
Call 1-xxx-xxx-xxxx
Web www.xxxxxx.com
Write Address, City, State
For Austin: Premiums apply to residents of Bastrop, Burnet, Caldwell, Fayette, Hays, Lee, Travis and Williamson
counties only.
For Dallas: Premiums apply to residents of Collin, Dallas, Denton and Tarrant counties only.
For Houston: Premiums apply to residents of Fort Bend, Harris and Montgomery counties only.
Blue Cross and Blue Shield of Texas refers to HCSC Insurance Services Company, which is a wholly owned
subsidiary of Health Care Service Corporation, a Mutual Legal Reserve Company. These companies are
independent licensees of the Blue Cross and Blue Shield Association and offer or provide services for Medicare
Advantage under contract H1666 with the Centers for Medicare and Medicaid Services.
HISC is a Medicare Advantage organization with a Medicare contract.