2021 complete blue ppo western pennsylvania plans · 2020. 10. 1. · complete blue ppo distinct...

2021 Complete Blue PPO

Western Pennsylvania Plans

Residents of Allegheny, Armstrong, Beaver, Butler, Cambria, Fayette, Greene, Indiana, Washington, and Westmoreland counties

o Annual Notice of Change (ANOC): • Complete Blue PPO Distinct (PPO), please click here. (H3916_20_5385_M)

o Evidence of Coverage (EOC): • Complete Blue PPO Distinct (PPO), please click here. (H3916_20_5389_C)

Residents of Bedford, Blair, Cameron, Clarion, Clearfield, Elk, Huntingdon, Jefferson, and Somerset counties



Residents of Crawford, Erie, Forest, Lawrence, McKean, Mercer, Potter, Venango, Warren



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Complete Blue PPO Distinct Annual Notice of Changes for 2021

Complete Blue PPO Distinct (PPO) offered by Highmark Senior Health Company

Annual Notice of Changes for 2021 You are currently enrolled as a member of Community Blue Medicare PPO Distinct. Next year, there will be some changes to the plan’s costs and benefits. This booklet tells about the changes.

You have from October 15 until December 7 to make changes to your Medicare coverage for next year.

What to do now

1. ASK: Which changes apply to you

Check the changes to our benefits and costs to see if they affect you.

x It’s important to review your coverage now to make sure it will meet your needs next year.

x Do the changes affect the services you use?

x Look in Sections 2.2 and 2.5 for information about benefit and cost changes for our plan.

Check the changes in the booklet to our prescription drug coverage to see if they affect you.

x Will your drugs be covered?

x Are your drugs in a different tier, with different cost sharing?

x Do any of your drugs have new restrictions, such as needing approval from us before you fill your prescription?

H3916_20_5385_M OMB approval 0938-1051 (Expires: December 31, 2021)

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2 Complete Blue PPO Distinct Annual Notice of Changes for 2021

x Can you keep using the same pharmacies? Are there changes to the cost of using this pharmacy?

x Review the 2021 Drug List and look in Section 2.6 for information about changes to our drug coverage.

x Your drug costs may have risen since last year. Talk to your doctor about lower cost alternatives that may be available for you; this may save you in annual out-of-pocket costs throughout the year. To get additional information on drug prices visit go.medicare.gov/drugprices. These dashboards highlight which manufacturers have been increasing their prices and also show other year-to-year drug price information. Keep in mind that your plan benefits will determine exactly how much your own drug costs may change.

Check to see if your doctors and other providers will be in our network next year.

x Are your doctors, including specialists you see regularly, in our network?

x What about the hospitals or other providers you use?

x Look in Section 2.3 for information about our Provider Directory.

Think about your overall health care costs.

x How much will you spend out-of-pocket for the services and prescription drugs you use regularly?

x How much will you spend on your premium and deductibles?

x How do your total plan costs compare to other Medicare coverage options?

Think about whether you are happy with our plan.

2. COMPARE: Learn about other plan choices

Check coverage and costs of plans in your area.

x Use the personalized search feature on the Medicare Plan Finder at www.medicare.gov/plan-compare website.

x Review the list in the back of your Medicare & You handbook.

x Look in Section 3.2 to learn more about your choices.

Once you narrow your choice to a preferred plan, confirm your costs and coverage on the plan’s website.

3. CHOOSE: Decide whether you want to change your plan

x If you don't join another plan by December 7, 2020, you will be enrolled in Complete Blue PPO Distinct.

x To change to a different plan that may better meet your needs, you can switch plans between October 15 and December 7.

http://www.medicare.gov/plan-comparehttp://go.medicare.gov/drugprices

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4. ENROLL: To change plans, join a plan between October 15 and December 7, 2020

x If you don’t join another plan by December 7, 2020, you will be enrolled in Complete Blue PPO Distinct.

x If you join another plan by December 7, 2020, your new coverage will start on January 1 , 2021. You will be automatically disenrolled from your current plan.

Additional Resources x Please contact our Customer Service number at 1-833-227-9375 for additional information. (TTY users should call 711 National Relay Service). Hours are Monday through Sunday, 8:00 a.m. to 8:00 p.m., Eastern Time.

x This information is available in an alternate format such as large print.

x Coverage under this Plan qualifies as Qualifying Health Coverage (QHC) and satisfies the Patient Protection and Affordable Care Act’s (ACA) individual shared responsibility requirement. Please visit the Internal Revenue Service (IRS) website at www.irs.gov/Affordable-Care-Act/Individuals-and-Families for more information.

About Complete Blue PPO Distinct

x Highmark Senior Health Company is a PPO plan with a Medicare contract. Enrollment in Highmark Senior Health Company depends on contract renewal.

x When this booklet says “we,” “us,” or “our,” it means Highmark Senior Health Company. When it says “plan” or “our plan,” it means Complete Blue PPO Distinct.

http://www.irs.gov/Affordable-Care-Act/Individuals-and-Families

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Summary of Important Costs for 2021

The table below compares the 2020 costs and 2021 costs for Complete Blue PPO Distinct in several important areas. Please note this is only a summary of changes. A copy of the Evidence of Coverage is located on our website at medicare.highmark.com. You may also call Customer Service to ask us to mail you an Evidence of Coverage.

Cost 2020 (this year) 2021 (next year)

Monthly plan premium* $35.00 $35.00

* Your premium may be higher or lower than this amount. See Section 2.1 for details.

Maximum out-of-pocket From network providers: From network providers: amounts $5,900 $6,500 This is the most you will pay out-of-pocket for your covered Part A and Part B services. (See Section 2.2 for details.)

From network and out-of-network providers combined:

From network and out-of-network providers combined:

$10,000 $10,000

Doctor office visits Primary care visits: Primary care visits:

Network: $0 copay per visit


Out-of-Network $0 copay per visit

Out-of-Network: $0 copay per visit

Specialist visits: Specialist visits:



Out-of-Network: $30 copay per visit

Out-of-Network $30 copay per visit

http://medicare.highmark.com

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Cost

Inpatient hospital stays Includes inpatient acute, inpatient rehabilitation, long-term care hospitals, and other types of inpatient hospital services. Inpatient hospital care starts the day you are formally admitted to the hospital with a doctor’s order. The day before you are discharged is your last inpatient day.

Part D prescription drug coverage (See Section 2.6 for details.)

2020 (this year)

Network: $275 copay per admission

Out-of-Network: $350 copay per admission

Deductible: There is no deductible.

Copayment/Coinsurance during the Initial Coverage Stage:

x Drug Tier 1: Standard $7 copay Preferred $0 copay




x Drug Tier 5: Standard 33% coinsurance Preferred 33% coinsurance

2021 (next year)

Network: $325 copay per admission

Out-of-Network: $395 copay per admission

Deductible: There is no deductible.

Copayment/Coinsurance during the Initial Coverage Stage:





x Drug Tier 5: Standard 33% coinsurance Preferred 33% coinsurance

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Annual Notice of Changes for 2021 Table of Contents

Summary of Important Costs for 2021 ........................................................................ 4

SECTION 1 We Are Changing the Plan’s Name.......................................................... 7

SECTION 2 Changes to Benefits and Costs for Next Year ........................................ 7 Section 2.1 – Changes to the Monthly Premium ...................................................................... 7 Section 2.2 – Changes to Your Maximum Out-of-Pocket Amounts ........................................ 7 Section 2.3 – Changes to the Provider Network ....................................................................... 8 Section 2.4 – Changes to the Pharmacy Network..................................................................... 9 Section 2.5 – Changes to Benefits and Costs for Medical Services ......................................... 9 Section 2.6 – Changes to Part D Prescription Drug Coverage ............................................... 13

SECTION 3 Deciding Which Plan to Choose ............................................................ 16 Section 3.1 – If you want to stay in Complete Blue PPO Distinct ......................................... 16 Section 3.2 – If you want to change plans .............................................................................. 16

SECTION 4 Deadline for Changing Plans.................................................................. 17

SECTION 5 Programs That Offer Free Counseling about Medicare ....................... 17

SECTION 6 Programs That Help Pay for Prescription Drugs .................................. 18

SECTION 7 Questions?............................................................................................... 18 Section 7.1 – Getting Help from Complete Blue PPO Distinct.............................................. 19 Section 7.2 – Getting Help from Medicare............................................................................. 19

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SECTION 1 We Are Changing the Plan’s Name

On January 1, 2021, our plan name will change from Community Blue Medicare PPO Distinct to Complete Blue PPO Distinct.

You will be receiving a new identification card by December 20, 2020.

SECTION 2 Changes to Benefits and Costs for Next Year

Section 2.1 – Changes to the Monthly Premium


Monthly premium $35.00 $35.00 (You must also continue to pay your Medicare Part B premium.)

x Your monthly plan premium will be more if you are required to pay a lifetime Part D late enrollment penalty for going without other drug coverage that is at least as good as Medicare drug coverage (also referred to as “creditable coverage”) for 63 days or more.

x If you have a higher income, you may have to pay an additional amount each month directly to the government for your Medicare prescription drug coverage.

x Your monthly premium will be less if you are receiving “Extra Help” with your prescription drug costs. Please see Section 5 regarding “Extra Help” from Medicare.

Section 2.2 – Changes to Your Maximum Out-of-Pocket Amounts

To protect you, Medicare requires all health plans to limit how much you pay “out-of-pocket” during the year. These limits are called the “maximum out-of-pocket amounts.” Once you reach this amount, you generally pay nothing for covered Part A and Part B services for the rest of the year.


In-network maximum out-of-pocket amount

$5,900 $6,500

Once you have paid $6,500 out-of-pocket for covered Part A and Part B services, you will pay nothing for your covered Part A and Part B

Your costs for covered medical services (such as copays) from network providers count toward your in-network maximum out-of-

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pocket amount. Your plan premium and your costs for prescription drugs do not count toward your maximum out-of-pocket amount.

services from network providers for the rest of the calendar year.

Combined maximum out-of-pocket amount

$10,000 $10,000

Your costs for covered medical services (such as copays) from in-network and out-of-network providers count toward your combined maximum out-of-pocket amount. Your plan premium does not count toward your maximum out-of-pocket amount.

Once you have paid $10,000 out-of-pocket for covered Part A and Part B services, you will pay nothing for your covered Part A and Part B services from network or out-of-network providers for the rest of the calendar year.

Section 2.3 – Changes to the Provider Network

There are changes to our network of providers for next year. An updated Provider/Pharmacy Directory is located on our website at medicare.highmark.com. You may also call Customer Service for updated provider information or to ask us to mail you a Provider/Pharmacy Directory. Please review the 2021 Provider/Pharmacy Directory to see if your providers (primary care provider, specialists, hospitals, etc.) are in our network.

It is important that you know that we may make changes to the hospitals, doctors and specialists (providers) that are part of your plan during the year. There are a number of reasons why your provider might leave your plan, but if your doctor or specialist does leave your plan you have certain rights and protections summarized below:

x Even though our network of providers may change during the year, we must furnish you with uninterrupted access to qualified doctors and specialists.

x We will make a good faith effort to provide you with at least 30 days’ notice that your provider is leaving our plan so that you have time to select a new provider.

x We will assist you in selecting a new qualified provider to continue managing your health care needs.

x If you are undergoing medical treatment you have the right to request, and we will work with you to ensure, that the medically necessary treatment you are receiving is not interrupted.


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x If you believe we have not furnished you with a qualified provider to replace your previous provider or that your care is not being appropriately managed, you have the right to file an appeal of our decision.

x If you find out your doctor or specialist is leaving your plan, please contact us so we can assist you in finding a new provider to manage your care.

Section 2.4 – Changes to the Pharmacy Network

Amounts you pay for your prescription drugs may depend on which pharmacy you use. Medicare drug plans have a network of pharmacies. In most cases, your prescriptions are covered only if they are filled at one of our network pharmacies. Our network includes pharmacies with preferred cost sharing, which may offer you lower cost sharing than the standard cost sharing offered by other network pharmacies for some drugs.

There are changes to our network of pharmacies for next year. An updated Provider/Pharmacy Directory is located on our website at medicare.highmark.com. You may also call Customer Service for updated provider information or to ask us to mail you a Provider/Pharmacy Directory. Please review the 2021 Provider/Pharmacy Directory to see which pharmacies are in our network.

Section 2.5 – Changes to Benefits and Costs for Medical Services

We are changing our coverage for certain medical services next year. The information below describes these changes. For details about the coverage and costs for these services, see Chapter 4, Medical Benefits Chart (what is covered and what you pay), in your 2021 Evidence of Coverage.


Acupuncture In-Network: In-Network:

For Medicare-covered chronic low back pain

You pay a $25 copay. You pay a $25 copay.

Out-of-Network: Out-of-Network: You pay a $40 copay. You pay a $35 copay.

Ambulance Network: Network: You pay a $250 per one way trip for emergency and certified medically necessary non-emergency ambulance services.

You pay a $295 per one way trip for emergency and certified medically necessary non-emergency ambulance services.


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Cost

Comprehensive Dental

Inpatient Acute Hospital

Outpatient Diagnostics –

Advanced Imaging

2020 (this year)

Out-of-Network: You pay a $250 per one way trip for emergency ambulance services.

You pay 30% of the total cost per one way trip for certified medically necessary non-emergency ambulance services.

In and Out-of-Network: x Restorative Services -1 every 2 years per tooth/surface

x Prosthodontics and other Oral/Maxillofacial Surgery - 1 set of dentures, partials or bridges / 5 years

x Extractions - 1/year

50% coinsurance with a maximum $750 allowance.

In-Network:

$275 per admission.

Out-of-Network:

$350 per admission.

In-Network: You pay a $225 copay.

Out-of-Network: You pay a $325 copay.

2021 (next year)

Out-of-Network: You pay a $295 per one way trip for emergency ambulance services.

You pay 30% of the total cost per one way trip for certified medically necessary non-emergency ambulance services.

In and Out-of-Network: x Endodontic Therapy/root canals – 1 per tooth per lifetime

x Restorative Services (includes fillings and crowns) -1 every 2 years per tooth/surface

x Prosthodontics and other Oral/Maxillofacial Surgery - 1 set of dentures, partials or bridges / 5 years

x Extractions – 1/year

50% coinsurance with a maximum $750 allowance.

In-Network:

$325 per admission.

Out-of-Network:

$395 per admission.



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Cost

Outpatient Diagnostics –

X-Ray Services

Outpatient Hospital Services

Outpatient Physical and Speech Therapies

Skilled Nursing Facility

2020 (this year)



In-Network: You pay a $250 copay for outpatient surgery at a facility.

You pay a $200 copay for outpatient surgery at an ambulatory surgical center.

Out-of-Network: You pay a $325 copay for outpatient surgery at an ambulatory surgical center or outpatient facility.



In-Network:

You pay a $0 copay for Days 1 – 20.

You pay a $178 copay for Days 21 - 100.

Out-of-Network: You pay 30% coinsurance of the cost per day per admission.

2021 (next year)



In-Network: You pay a $300 copay for outpatient surgery at a facility.


Out-of-Network: You pay a $375 copay for outpatient surgery at a facility.




In-Network:

You pay a $0 copay for Days 1 – 20. You pay a $184 copay for Days 21 - 100.

Out-of-Network: You pay 30% coinsurance of the cost per day per admission.

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Cost

Telehealth –

Physician/Provider

2020 (this year)

In-Network:

You pay a $0 copay for PCP and home health visits.

You pay a $30 copay for specialist visits.

Out-of-Network: You pay a $0 copay for PCP visits.


You pay 30% coinsurance for home health visits.

2021 (next year)

In-Network:

You pay a $0 copay for PCP and home health visits.


You pay a $25 copay physical and speech therapy visits.

You pay a $40 copay for mental health and psychiatric visits.

You pay a $45 copay for opioid treatment and substance abuse visits.

Out-of-Network: You pay a $0 copay for PCP visits.


You pay 30% coinsurance for home health visits.

You pay a $35 copay physical and speech therapy visits.

You pay a $50 copay for mental health, psychiatric visits, opioid treatment and substance abuse visits.

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Section 2.6 – Changes to Part D Prescription Drug Coverage

Changes to Our Drug List

Our list of covered drugs is called a Formulary or “Drug List.” A copy of our Drug List is provided electronically.

We made changes to our Drug List, including changes to the drugs we cover and changes to the restrictions that apply to our coverage for certain drugs. Review the Drug List to make sure your drugs will be covered next year and to see if there will be any restrictions.

If you are affected by a change in drug coverage, you can:

x Work with your doctor (or other prescriber) and ask the plan to make an exception to cover the drug. We encourage current members to ask for an exception before next year.

o To learn what you must do to ask for an exception, see Chapter 9 of your Evidence of Coverage (What to do if you have a problem or complaint (coverage decisions, appeals, complaints)) or call Customer Service.

x Work with your doctor (or other prescriber) to find a different drug that we cover. You can call Customer Service to ask for a list of covered drugs that treat the same medical condition.

In some situations, we are required to cover a temporary supply of a non-formulary drug in the first 90 days of the plan year or the first 90 days of membership to avoid a gap in therapy. (To learn more about when you can get a temporary supply and how to ask for one, see Chapter 5, Section 5.2 of the Evidence of Coverage.) During the time when you are getting a temporary supply of a drug, you should talk with your doctor to decide what to do when your temporary supply runs out. You can either switch to a different drug covered by the plan or ask the plan to make an exception for you and cover your current drug.

If you are currently taking a drug that Highmark Senior Health Company approved as a formulary exception in 2020, you may need to ask for a new formulary exception for the same drug in 2021.

Most of the changes in the Drug List are new for the beginning of each year. However, during the year, we might make other changes that are allowed by Medicare rules.

When we make these changes to the Drug List during the year, you can still work with your doctor (or other prescriber) and ask us to make an exception to cover the drug. We will also continue to update our online Drug List as scheduled and provide other required information to reflect drug changes. (To learn more about changes we may make to the Drug List, see Chapter 5, Section 6 of the Evidence of Coverage.)

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Changes to Prescription Drug Costs

Note: If you are in a program that helps pay for your drugs (“Extra Help”), the information about costs for Part D prescription drugs may not apply to you. We sent you a separate insert, called the “Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs” (also called the “Low Income Subsidy Rider” or the “LIS Rider”), which tells you about your drug costs. If you receive “Extra Help” and haven’t received this insert by September 30, 2020, please call Customer Service and ask for the “LIS Rider.”

There are four “drug payment stages.” How much you pay for a Part D drug depends on which drug payment stage you are in. (You can look in Chapter 6, Section 2 of your Evidence of Coverage for more information about the stages.)

The information below shows the changes for next year to the first two stages – the Yearly Deductible Stage and the Initial Coverage Stage. (Most members do not reach the other two stages – the Coverage Gap Stage or the Catastrophic Coverage Stage. To get information about your costs in these stages, look at Chapter 6, Sections 6 and 7, in the Evidence of Coverage, which is located on our website at medicare.highmark.com. You may also call Customer Service to ask us to mail you an Evidence of Coverage.)

Changes to the Deductible Stage

Stage 2020 (this year) 2021 (next year)

Stage 1: Yearly Deductible Stage Because we have no deductible, this payment stage does not apply to you.

Because we have no deductible, this payment stage does not apply to you.

Changes to Your Cost Sharing in the Initial Coverage Stage

To learn how copayments and coinsurance work, look at Chapter 6, Section 1.2, Types of out-of-pocket costs you may pay for covered drugs in your Evidence of Coverage.

Stage 2020 (this year) 2021 (next year)

Stage 2: Initial Coverage Stage

Your cost for a one-month supply at a network pharmacy:

Your cost for a one-month supply at a network pharmacy:

During this stage, the plan Tier 1 Preferred Generic: Tier 1 Preferred Generic: pays its share of the cost of Standard cost sharing:

You pay $7 per prescription. Standard cost sharing: You pay $7 per prescription.


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______________ ______________


Stage your drugs and you pay your share of the cost.

The costs in this row are for a one-month (31-day) supply when you fill your prescription at a network pharmacy. For information about the costs for a long-term supply or for mail-order prescriptions, look in Chapter 6, Section 5 of your Evidence of Coverage.

We changed the tier for some of the drugs on our Drug List. To see if your drugs will be in a different tier, look them up on the Drug List.

2020 (this year)

Preferred cost sharing: You pay $0 per prescription.

Tier 2 Generic: Standard cost sharing: You pay $20 per prescription.


Tier 3 Preferred Brand: Standard cost sharing: You pay $47 per prescription.


Tier 4 Non-Preferred Drug: Standard cost sharing: You pay $100 per prescription.


Tier 5 Specialty Tier: Standard cost sharing: You pay 33% of the total cost.

Preferred cost sharing: You pay 33% of the total cost.

Once your total drug costs have reached $4,020, you will move to the next stage (the Coverage Gap Stage).

2021 (next year)


Tier 2 Generic: Standard cost sharing: You pay $20 per prescription.


Tier 3 Preferred Brand: Standard cost sharing: You pay $47 per prescription.


Tier 4 Non-Preferred Drug: Standard cost sharing: You pay $100 per prescription.


Tier 5 Specialty Tier: Standard cost sharing: You pay 33% of the total cost.

Preferred cost-sharing: You pay 33% of the total cost.

Once your total drug costs have reached $4,130, you will move to the next stage (the Coverage Gap Stage).

Changes to the Coverage Gap and Catastrophic Coverage Stages

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The other two drug coverage stages – the Coverage Gap Stage and the Catastrophic Coverage Stage – are for people with high drug costs. Most members do not reach the Coverage Gap Stage or the Catastrophic Coverage Stage. For information about your costs in these stages, look at Chapter 6, Sections 6 and 7, in your Evidence of Coverage.

SECTION 3 Deciding Which Plan to Choose

Section 3.1 – If you want to stay in Complete Blue PPO Distinct

To stay in our plan you don’t need to do anything. If you do not sign up for a different plan or change to Original Medicare by December 7, you will automatically be enrolled in our Complete Blue PPO Distinct.

Section 3.2 – If you want to change plans

We hope to keep you as a member next year but if you want to change for 2021 follow these steps:

Step 1: Learn about and compare your choices x You can join a different Medicare health plan timely,

x – OR – You can change to Original Medicare. If you change to Original Medicare, you will need to decide whether to join a Medicare drug plan. If you do not enroll in a Medicare drug plan, please see Section 2.1 regarding a potential Part D late enrollment penalty.

To learn more about Original Medicare and the different types of Medicare plans, read Medicare & You 2021, call your State Health Insurance Assistance Program (see Section 5), or call Medicare (see Section 7.2).

You can also find information about plans in your area by using the Medicare Plan Finder on the Medicare website. Go to www.medicare.gov/plan-compare. Here, you can find information about costs, coverage, and quality ratings for Medicare plans.

As a reminder, Highmark Senior Health Company offers other Medicare health plans and Medicare prescription drug plans. These other plans may differ in coverage, monthly premiums, and cost sharing amounts.

Step 2: Change your coverage x To change to a different Medicare health plan, enroll in the new plan. You will automatically be disenrolled from Complete Blue PPO Distinct.

http://www.medicare.gov/plan-compare

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x To change to Original Medicare with a prescription drug plan, enroll in the new drug plan. You will automatically be disenrolled from Complete Blue PPO Distinct.

x To change to Original Medicare without a prescription drug plan, you must either:

o Send us a written request to disenroll. Contact Customer Service if you need more information on how to do this (phone numbers are in Section 7.1 of this booklet).

o – OR – Contact Medicare, at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week, and ask to be disenrolled. TTY users should call 1-877-486-2048.

SECTION 4 Deadline for Changing Plans

If you want to change to a different plan or to Original Medicare for next year, you can do it from October 15 until December 7. The change will take effect on January 1, 2021.

Are there other times of the year to make a change?

In certain situations, changes are also allowed at other times of the year. For example, people with Medicaid, those who get “Extra Help” paying for their drugs, those who have or are leaving employer coverage, and those who move out of the service area may be allowed to make a change at other times of the year. For more information, see Chapter 10, Section 2.3 of the Evidence of Coverage.

If you enrolled in a Medicare Advantage Plan for January 1, 2021, and don’t like your plan choice, you can switch to another Medicare health plan (either with or without Medicare prescription drug coverage) or switch to Original Medicare (either with or without Medicare prescription drug coverage) between January 1 and March 31, 2021. For more information, see Chapter 10, Section 2.2 of the Evidence of Coverage.

SECTION 5 Programs That Offer Free Counseling about Medicare

The State Health Insurance Assistance Program (SHIP) is a government program with trained counselors in every state. In Pennsylvania, the SHIP is called APPRISE Health Insurance Counseling Program.

APPRISE is independent (not connected with any insurance company or health plan). It is a state program that gets money from the Federal government to give free local health insurance counseling to people with Medicare. APPRISE counselors can help you with your Medicare questions or problems. They can help you understand your Medicare plan choices and answer questions about switching plans. You can call APPRISE at 1-800-783-7067 (TTY users call 711 National Relay Service).You can learn more about APPRISE by visiting their website (www.aging.pa.gov).

http://www.aging.pa.gov

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SECTION 6 Programs That Help Pay for Prescription Drugs

You may qualify for help paying for prescription drugs. Below we list different kinds of help:

x “Extra Help” from Medicare. People with limited incomes may qualify for “Extra Help” to pay for their prescription drug costs. If you qualify, Medicare could pay up to 75 % or more of your drug costs including monthly prescription drug premiums, annual deductibles, and coinsurance. Additionally, those who qualify will not have a coverage gap or late enrollment penalty. Many people are eligible and don’t even know it. To see if you qualify, call:

o 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/7 days a week;

o The Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call 1-800-325-0778 (applications); or

o Your State Medicaid Office (applications). x Help from your state’s pharmaceutical assistance program. Pennsylvania has a program called PACE that helps people pay for prescription drugs based on their financial need,age,or medical condition. To learn more about the program, check with your State Health Insurance Assistance Program (the name and phone numbers for this organization are in Section 5 of this booklet).

x Prescription Cost sharing Assistance for Persons with HIV/AIDS. The AIDS Drug Assistance Program (ADAP) helps ensure that ADAP-eligible individuals living with HIV/AIDS have access to life-saving HIV medications. Individuals must meet certain criteria, including proof of State residence and HIV status, low income as defined by the State, and uninsured/under-insured status. Medicare Part D prescription drugs that are also covered by ADAP qualify for prescription cost sharing assistance through the Pennsylvania Special Pharmaceutical Benefits Program (SPBP). For information on eligibility criteria, covered drugs, or how to enroll in the program, please call the SPBP Customer Service line at 1-800-922-9384 or go to their website at www.health.pa.gov/topics/programs/HIV/Pages/Special-Pharmaceutical-Benefits.aspx.

SECTION 7 Questions?

http://www.health.pa.gov/topics/programs/HIV/Pages/Special-Pharmaceutical-Benefits.aspx

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Section 7.1 – Getting Help from Complete Blue PPO Distinct

Questions? We’re here to help. Please call Customer Service at 1-833-227-9375. (TTY only, call 711 National Relay Service.) We are available for phone calls Monday through Sunday, 8:00 a.m. to 8:00 p.m., Eastern Time. Calls to these numbers are free.

Read your 2021 Evidence of Coverage (it has details about next year's benefits and costs)

This Annual Notice of Changes gives you a summary of changes in your benefits and costs for 2021. For details, look in the 2021 Evidence of Coverage for Complete Blue PPO Distinct. The Evidence of Coverage is the legal, detailed description of your plan benefits. It explains your rights and the rules you need to follow to get covered services and prescription drugs. A copy of the Evidence of Coverage is located on our website at medicare.highmark.com. You may also call Customer Service to ask us to mail you an Evidence of Coverage.

Visit our Website

You can also visit our website at medicare.highmark.com. As a reminder, our website has the most up-to-date information about our provider network (Provider/Pharmacy Directory) and our list of covered drugs (Formulary/Drug List).

Section 7.2 – Getting Help from Medicare

To get information directly from Medicare:

Call 1-800-MEDICARE (1-800-633-4227)

You can call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.

Visit the Medicare Website

You can visit the Medicare website (www.medicare.gov). It has information about cost, coverage, and quality ratings to help you compare Medicare health plans. You can find information about plans available in your area by using the Medicare Plan Finder on the Medicare website. (To view the information about plans, go to www.medicare.gov/plan-compare).

Read Medicare & You 2021

You can read Medicare & You 2021 Handbook. Every year in the fall, this booklet is mailed to people with Medicare. It has a summary of Medicare benefits, rights and protections, and answers to the most frequently asked questions about Medicare. If you don’t have a copy of this

http://www.medicare.govhttp://medicare.highmark.comhttp://medicare.highmark.comhttp://www.medicare.gov/plan-comparehttp://www.medicare.gov/plan-compare

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booklet, you can get it at the Medicare website (www.medicare.gov) or by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.

Highmark Blue Cross Blue Shield and Highmark Senior Health Company are independent licensees of the Blue Cross and Blue Shield Association.

H3916-035/001: Allegheny, Beaver, Butler, Fayette, Greene, Washington, Westmoreland

http://www.medicare.gov

ATENCIÓN: Si usted habla español, servicios de asistencia lingüística, de forma gratuita, están disponibles para usted. Llame al número en la parte posterior de su tarjeta de identificación (TTY: 711).

ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call the number on the back of your ID card (TTY: 711).

Multi-language Interpreter Services

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Discrimination is Against the Law

The Plan complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Plan does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Plan:

• Provides free aids and services to people with disabilities to communicate effectively with us, such as:

– Qualified sign language interpreters

– Written information in other formats (large print, audio, accessible electronic formats, other formats)

• Provides free language services to people whose primary language is not English, such as:

– Qualified interpreters

– Information written in other languages

If you need these services, contact the Civil Rights Coordinator.

If you believe that the Plan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: [email protected]. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/ portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

O65_BCBS_G_M_1Col_12pt_blk

http://www.hhs.gov/ocr/office/file/index.htmlmailto:[email protected]://ocrportal.hhs.gov/ocr/portal/lobby.jsfhttps://ocrportal.hhs.gov/ocr/portal/lobby.jsf

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H3916205385

January 1 – December 31, 2021

Evidence of Coverage:

Your Medicare Health Benefits and Services and Prescription Drug Coverage

as a Member of Complete Blue PPO Distinct (PPO)

This booklet gives you the details about your Medicare health care and prescription drug

coverage from January 1 – December 31, 2021. It explains how to get coverage for the health

care services and prescription drugs you need. This is an important legal document. Please

keep it in a safe place.

This plan, Complete Blue PPO Distinct, is offered by Highmark Senior Health Company. (When

this Evidence of Coverage says “we,” “us,” or “our,” it means Highmark Senior Health

Company. When it says “plan” or “our plan,” it means Complete Blue PPO Distinct.)

Please contact our Customer Service number at 1-833-227-9375 for additional information.

(TTY users should call 711 National Relay Service.) Hours are Monday through Sunday, 8:00

a.m. to 8:00 p.m., Eastern Time.

This information is available in an alternate format such as large print.

Benefits, premium and/or copayments/coinsurance may change on January 1, 2022.

The formulary, pharmacy network, and/or provider network may change at any time. You will

receive notice when necessary.

H3916_20_5389_C OMB Approval 0938-1051 (Expires: December 31, 2021)

2021 Evidence of Coverage for Complete Blue PPO Distinct Table of Contents

1

2021 Evidence of Coverage

Table of Contents

This list of chapters and page numbers is your starting point. For more help in finding

information you need, go to the first page of a chapter. You will find a detailed list of topics at

the beginning of each chapter.

Chapter 1. Getting started as a member ............................................................... 4

Explains what it means to be in a Medicare health plan and how to use this

booklet. Tells about materials we will send you, your plan premium, the Part D

late enrollment penalty, your plan membership card, and keeping your

membership record up to date.

Chapter 2. Important phone numbers and resources ........................................ 22

Tells you how to get in touch with our plan (Complete Blue PPO Distinct) and

with other organizations including Medicare, the State Health Insurance

Assistance Program (SHIP), the Quality Improvement Organization, Social

Security, Medicaid (the state health insurance program for people with low

incomes), programs that help people pay for their prescription drugs, and the

Railroad Retirement Board.

Chapter 3. Using the plan’s coverage for your medical services ..................... 41

Explains important things you need to know about getting your medical care as

a member of our plan. Topics include using the providers in the plan’s network

and how to get care when you have an emergency.

Chapter 4. Medical Benefits Chart (what is covered and what you pay) .......... 56

Gives the details about which types of medical care are covered and not

covered for you as a member of our plan. Explains how much you will pay as

your share of the cost for your covered medical care.

Chapter 5. Using the plan’s coverage for your Part D prescription drugs ..... 101

Explains rules you need to follow when you get your Part D drugs. Tells how to

use the plan’s List of Covered Drugs (Formulary) to find out which drugs are

covered. Tells which kinds of drugs are not covered. Explains several kinds of

restrictions that apply to coverage for certain drugs. Explains where to get your

prescriptions filled. Tells about the plan’s programs for drug safety and

managing medications.

Chapter 6. What you pay for your Part D prescription drugs .......................... 125

2021 Evidence of Coverage for Complete Blue PPO Distinct Table of Contents

2

Tells about the three stages of drug coverage (Initial Coverage Stage, Coverage

Gap Stage, Catastrophic Coverage Stage) and how these stages affect what you

pay for your drugs. Explains the five cost sharing tiers for your Part D drugs

and tells what you must pay for a drug in each cost sharing tier.

Chapter 7. Asking us to pay our share of a bill you have received for covered medical services or drugs ............................................................... 145

Explains when and how to send a bill to us when you want to ask us to pay you

back for our share of the cost for your covered services or drugs.

Chapter 8. Your rights and responsibilities ...................................................... 153

Explains the rights and responsibilities you have as a member of our plan. Tells

what you can do if you think your rights are not being respected.

Chapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) ...................................................... 165

Tells you step-by-step what to do if you are having problems or concerns as a

member of our plan.

Explains how to ask for coverage decisions and make appeals if you are having trouble getting the medical care or prescription drugs you think are

covered by our plan. This includes asking us to make exceptions to the rules

or extra restrictions on your coverage for prescription drugs, and asking us

to keep covering hospital care and certain types of medical services if you

think your coverage is ending too soon.

Explains how to make complaints about quality of care, waiting times, customer service, and other concerns.

Chapter 10. Ending your membership in the plan .............................................. 221

Explains when and how you can end your membership in the plan. Explains

situations in which our plan is required to end your membership.

Chapter 11. Legal notices ..................................................................................... 231

Includes notices about governing law and about nondiscrimination.

Chapter 12. Definitions of important words ........................................................ 236

Explains key terms used in this booklet.

CHAPTER 1 Getting started as a member

2021 Evidence of Coverage for Complete Blue PPO Distinct Chapter 1. Getting started as a member

4

Chapter 1. Getting started as a member

SECTION 1 Introduction ....................................................................................... 6

Section 1.1 You are enrolled in Complete Blue PPO Distinct, which is a Medicare

PPO ...............................................................................................................6

Section 1.2 What is the Evidence of Coverage booklet about? ........................................6

Section 1.3 Legal information about the Evidence of Coverage ......................................6

SECTION 2 What makes you eligible to be a plan member? ............................. 7

Section 2.1 Your eligibility requirements ........................................................................7

Section 2.2 What are Medicare Part A and Medicare Part B? .........................................7

Section 2.3 Here is the plan service area for Complete Blue PPO Distinct .....................7

Section 2.4 U.S. citizen or lawful presence ......................................................................8

SECTION 3 What other materials will you get from us? .................................... 8

Section 3.1 Your plan membership card – Use it to get all covered care and

prescription drugs ..........................................................................................8

Section 3.2 The Provider/Pharmacy Directory: Your guide to all providers and

pharmacies in the plan’s network ..................................................................9

Section 3.3 The plan’s List of Covered Drugs (Formulary) ..........................................10

Section 3.4 The Part D Explanation of Benefits (the “Part D EOB”): Reports with a

summary of payments made for your Part D prescription drugs ................10

SECTION 4 Your monthly premium for Complete Blue PPO Distinct ............. 11

Section 4.1 How much is your plan premium? .............................................................11

SECTION 5 Do you have to pay the Part D “late enrollment penalty”? .......... 12

Section 5.1 What is the Part D “late enrollment penalty”? ............................................12

Section 5.2 How much is the Part D late enrollment penalty? .......................................12

Section 5.3 In some situations, you can enroll late and not have to pay the penalty .....13

Section 5.4 What can you do if you disagree about your Part D late enrollment

penalty? .......................................................................................................14

SECTION 6 Do you have to pay an extra Part D amount because of your income? ............................................................................................ 14

Section 6.1 Who pays an extra Part D amount because of income? ..............................14

Section 6.2 How much is the extra Part D amount? .......................................................14

Section 6.3 What can you do if you disagree about paying an extra Part D amount? ...15

Section 6.4 What happens if you do not pay the extra Part D amount? .........................15

SECTION 7 More information about your monthly premium ........................... 15


5

Section 7.1 There are several ways you can pay your plan premium ............................16

Section 7.2 Can we change your monthly plan premium during the year?....................18

SECTION 8 Please keep your plan membership record up to date ................ 18

Section 8.1 How to help make sure that we have accurate information about you........18

SECTION 9 We protect the privacy of your personal health information ....... 19

Section 9.1 We make sure that your health information is protected ............................19

SECTION 10 How other insurance works with our plan .................................. 19

Section 10.1 Which plan pays first when you have other insurance? .............................19


6

SECTION 1 Introduction

Section 1.1 You are enrolled in Complete Blue PPO Distinct, which is a Medicare PPO

You are covered by Medicare, and you have chosen to get your Medicare health care and your

prescription drug coverage through our plan, Complete Blue PPO Distinct.

There are different types of Medicare health plans. Complete Blue PPO Distinct is a Medicare

Advantage PPO Plan (PPO stands for Preferred Provider Organization). Like all Medicare health

plans, this Medicare PPO is approved by Medicare and run by a private company.

Coverage under this Plan qualifies as Qualifying Health Coverage (QHC) and satisfies the

Patient Protection and Affordable Care Act’s (ACA) individual shared responsibility

requirement. Please visit the Internal Revenue Service (IRS) website at: www.irs.gov/affordable-

care-act/individuals-and-families for more information.

Section 1.2 What is the Evidence of Coverage booklet about?

This Evidence of Coverage booklet tells you how to get your Medicare medical care and

prescription drugs covered through our plan. This booklet explains your rights and

responsibilities, what is covered, and what you pay as a member of the plan.

The word “coverage” and “covered services” refers to the medical care and services and the

prescription drugs available to you as a member of Complete Blue PPO Distinct.

It’s important for you to learn what the plan’s rules are and what services are available to you.

We encourage you to set aside some time to look through this Evidence of Coverage booklet.

If you are confused or concerned or just have a question, please contact our plan’s Customer

Service (phone numbers are printed on the back cover of this booklet).

Section 1.3 Legal information about the Evidence of Coverage

It’s part of our contract with you

This Evidence of Coverage is part of our contract with you about how Complete Blue PPO

Distinct covers your care. Other parts of this contract include your enrollment form, the List of

Covered Drugs (Formulary), and any notices you receive from us about changes to your

coverage or conditions that affect your coverage. These notices are sometimes called “riders” or

“amendments.”

The contract is in effect for months in which you are enrolled in Complete Blue PPO Distinct

between January 1, 2021, and December 31, 2021.

https://www.irs.gov/affordable-care-act/individuals-and-familieshttps://www.irs.gov/affordable-care-act/individuals-and-families


7

Each calendar year, Medicare allows us to make changes to the plans that we offer. This means

we can change the costs and benefits of Complete Blue PPO Distinct after December 31, 2021.

We can also choose to stop offering the plan, or to offer it in a different service area, after

December 31, 2021.

Medicare must approve our plan each year

Medicare (the Centers for Medicare & Medicaid Services) must approve Complete Blue PPO

Distinct each year. You can continue to get Medicare coverage as a member of our plan as long

as we choose to continue to offer the plan and Medicare renews its approval of the plan.

SECTION 2 What makes you eligible to be a plan member?

Section 2.1 Your eligibility requirements

You are eligible for membership in our plan as long as:

You have both Medicare Part A and Medicare Part B (Section 2.2 tells you about Medicare Part A and Medicare Part B)

-- and -- you live in our geographic service area (Section 2.3 below describes our service area).

-- and -- you are a United States citizen or are lawfully present in the United States

Section 2.2 What are Medicare Part A and Medicare Part B?

When you first signed up for Medicare, you received information about what services are

covered under Medicare Part A and Medicare Part B. Remember:

Medicare Part A generally helps cover services provided by hospitals (for inpatient services, skilled nursing facilities, or home health agencies).

Medicare Part B is for most other medical services (such as physician’s services, home infusion therapy, and other outpatient services) and certain items (such as durable

medical equipment (DME) and supplies).

Section 2.3 Here is the plan service area for Complete Blue PPO Distinct

Although Medicare is a Federal program, Complete Blue PPO Distinct is available only to

individuals who live in our plan service area. To remain a member of our plan, you must

continue to reside in the plan service area. The service area is described below.

Our service area includes these counties in Pennsylvania: Allegheny, Armstrong, Beaver,

Bedford, Blair, Butler, Cambria, Cameron, Clarion, Clearfield, Crawford, Elk, Erie, Fayette,


8

Forest, Greene, Huntingdon, Indiana, Jefferson, Lawrence, McKean, Mercer, Potter, Somerset,

Venango, Warren, Washington and Westmoreland.

If you plan to move out of the service area, please contact Customer Service (phone numbers are

printed on the back cover of this booklet). When you move, you will have a Special Enrollment

Period that will allow you to switch to Original Medicare or enroll in a Medicare health or drug

plan that is available in your new location.

It is also important that you call Social Security if you move or change your mailing address.

You can find phone numbers and contact information for Social Security in Chapter 2, Section 5.

Section 2.4 U.S. citizen or lawful presence

A member of a Medicare health plan must be a U.S. citizen or lawfully present in the United

States. Medicare (the Centers for Medicare & Medicaid Services) will notify Complete Blue

PPO Distinct if you are not eligible to remain a member on this basis. Complete Blue PPO

Distinct must disenroll you if you do not meet this requirement.

SECTION 3 What other materials will you get from us?

Section 3.1 Your plan membership card – Use it to get all covered care and prescription drugs

While you are a member of our plan, you must use your membership card for our plan whenever

you get any services covered by this plan and for prescription drugs you get at network

pharmacies. You should also show the provider your Medicaid card, if applicable. Here’s a

sample membership card to show you what yours will look like:

Do NOT use your red, white, and blue Medicare card for covered medical services while you are

a member of this plan. If you use your Medicare card instead of your Complete Blue PPO

Distinct membership card, you may have to pay the full cost of medical services yourself. Keep

your Medicare card in a safe place. You may be asked to show it if you need hospital services,

hospice services, or participate in routine research studies.


9

Here’s why this is so important: If you get covered services using your red, white, and blue

Medicare card instead of using your Complete Blue PPO Distinct membership card while you

are a plan member, you may have to pay the full cost yourself.

If your plan membership card is damaged, lost, or stolen, call Customer Service right away and

we will send you a new card. (Phone numbers for Customer Service are printed on the back

cover of this booklet.)

Section 3.2 The Provider/Pharmacy Directory: Your guide to all providers and pharmacies in the plan’s network

The Provider/Pharmacy Directory lists our network providers, durable medical equipment

suppliers, and pharmacies.

What are “network providers”?

Network providers are the doctors and other health care professionals, medical groups, durable

medical equipment suppliers, hospitals, and other health care facilities that have an agreement

with us to accept our payment and any plan cost sharing as payment in full. We have arranged

for these providers to deliver covered services to members in our plan. The most recent list of

providers and suppliers is available on our website at medicare.highmark.com.

What are “network pharmacies”?

Network pharmacies are all of the pharmacies that have agreed to fill covered prescriptions for

our plan members.

Why do you need to know which providers and pharmacies are part of our network?

As a member of our plan, you can choose to receive care from out-of-network providers. Our

plan will cover services from either in-network or out-of-network providers, as long as the

services are covered benefits and medically necessary. However, if you use an out-of-network

provider, your share of the costs for your covered services may be higher. See Chapter 3 (Using

the plan’s coverage for your medical services) for more specific information.

You can use the Provider/Pharmacy Directory to find the providers and network pharmacy you

want to use. There are changes to our network of providers and pharmacies for next year. An

updated Provider/Pharmacy Directory is located on our website at medicare.highmark.com. You

may also call Customer Service for updated provider information or to ask us to mail you a

Provider/Pharmacy Directory. Please review the 2021 Provider/Pharmacy Directory to see

which providers and pharmacies are in our network.

http://www.medicare.highmark.com/http://www.medicare.highmark.com/


10

The Provider/Pharmacy Directory will also tell you which of the pharmacies in our network

have preferred cost sharing, which may be lower than the standard cost sharing offered by other

network pharmacies for some drugs.

If you don’t have the Provider/Pharmacy Directory, you can get a copy from Customer Service

(phone numbers are printed on the back cover of this booklet). You may ask Customer Service

for more information about our network providers, including their qualifications. You can also

see the Provider/Pharmacy Directory at medicare.highmark.com, or download it from this

website. Both Customer Service and the website can give you the most up-to-date information

about changes in our network providers/pharmacies.

Section 3.3 The plan’s List of Covered Drugs (Formulary)

The plan has a List of Covered Drugs (Formulary). We call it the “Drug List” for short. It tells

which Part D prescription drugs are covered under the Part D benefit included in Complete Blue

PPO Distinct. The drugs on this list are selected by the plan with the help of a team of doctors

and pharmacists. The list must meet requirements set by Medicare. Medicare has approved the

Complete Blue PPO Distinct Drug List.

The Drug List also tells you if there are any rules that restrict coverage for your drugs.

We will provide you a copy of the Drug List. To get the most complete and current information

about which drugs are covered, you can visit the plan’s website (medicare.highmark.com) or call

Customer Service (phone numbers are printed on the back cover of this booklet).

Section 3.4 The Part D Explanation of Benefits (the “Part D EOB”): Reports with a summary of payments made for your Part D prescription drugs

When you use your Part D prescription drug benefits, we will send you a summary report to help

you understand and keep track of payments for your Part D prescription drugs. This summary

report is called the Part D Explanation of Benefits (or the “Part D EOB”).

The Part D Explanation of Benefits tells you the total amount you, or others on your behalf, have

spent on your Part D prescription drugs and the total amount we have paid for each of your Part

D prescription drugs during the month. The Part D EOB provides more information about the

drugs you take, such as increases in price and other drugs with lower cost sharing that may be

available. You should consult with your prescriber about these lower cost options. Chapter 6

(What you pay for your Part D prescription drugs) gives more information about the Part D

Explanation of Benefits and how it can help you keep track of your drug coverage.

A Part D Explanation of Benefits summary is also available upon request. To get a copy, please

contact Customer Service (phone numbers are printed on the back cover of this booklet).

http://www.medicare.highmark.com/http://www.medicare.highmark.com/


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SECTION 4 Your monthly premium for Complete Blue PPO Distinct

Section 4.1 How much is your plan premium?

As a member of our plan, you pay a monthly plan premium. For 2021, the monthly premium for

Complete Blue PPO Distinct is $35.00. In addition, you must continue to pay your Medicare Part

B premium (unless your Part B premium is paid for you by Medicaid or another third party).

In some situations, your plan premium could be less

There are programs to help people with limited resources pay for their drugs. These include

“Extra Help” and State Pharmaceutical Assistance Programs. Chapter 2, Section 7 tells more

about these programs. If you qualify, enrolling in the program might lower your monthly plan

premium.

If you are already enrolled and getting help from one of these programs, the information about

premiums in this Evidence of Coverage may not apply to you. We sent you a separate insert,

called the “Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription

Drugs” (also known as the “Low Income Subsidy Rider” or the “LIS Rider”), which tells you

about your drug coverage. If you don’t have this insert, please call Customer Service and ask for

the “LIS Rider.” (Phone numbers for Customer Service are printed on the back cover of this

booklet.)

In some situations, your plan premium could be more

In some situations, your plan premium could be more than the amount listed above in Section

4.1. This situation is described below.

Some members are required to pay a Part D late enrollment penalty because they did not join a Medicare drug plan when they first became eligible or because they had a

continuous period of 63 days or more when they didn’t have “creditable” prescription

drug coverage. (“Creditable” means the drug coverage is at least as good as Medicare’s

standard drug coverage.) For these members, the Part D late enrollment penalty is added

to the plan’s monthly premium. Their premium amount will be the monthly plan

premium plus the amount of their Part D late enrollment penalty.

o If you are required to pay the Part D late enrollment penalty, the cost of the late enrollment penalty depends on how long you went without Part D or other

creditable prescription drug coverage. Chapter 1, Section 5 explains the Part D

late enrollment penalty.

o If you have a Part D late enrollment penalty and do not pay it, you could be disenrolled from the plan.


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Some members may be required to pay an extra charge, known as the Part D Income Related Monthly Adjustment Amount, also known as IRMAA, because, 2 years ago, they

had a modified adjusted gross income, above a certain amount, on their IRS tax return.

Members subject to an IRMAA will have to pay the standard premium amount and this

extra charge, which will be added to their premium. Chapter 1, Section 6 explains the

IRMAA in further detail.

SECTION 5 Do you have to pay the Part D “late enrollment penalty”?

Section 5.1 What is the Part D “late enrollment penalty”?

Note: If you receive “Extra Help” from Medicare to pay for your prescription drugs, you will not

pay a late enrollment penalty.

The late enrollment penalty is an amount that is added to your Part D premium. You may owe a

Part D late enrollment penalty if, at any time after your initial enrollment period is over, there is

a period of 63 days or more in a row when you did not have Part D or other creditable

prescription drug coverage. (“Creditable prescription drug coverage” is coverage that meets

Medicare’s minimum standards since it is expected to pay, on average, at least as much as

Medicare’s standard prescription drug coverage.) The cost of the late enrollment penalty depends

on how long you went without Part D or other creditable prescription drug coverage. You will

have to pay this penalty for as long as you have Part D coverage.

The Part D late enrollment penalty is added to your monthly premium. (Members who choose to

pay their premium every three months will have the penalty added to their three-month

premium.) When you first enroll in Complete Blue PPO Distinct, we let you know the amount of

the penalty.

Your Part D late enrollment penalty is considered part of your plan premium. If you do not pay

your Part D late enrollment penalty, you could lose your prescription drug benefits for failure to

pay your plan premium.

Section 5.2 How much is the Part D late enrollment penalty?

Medicare determines the amount of the penalty. Here is how it works:

First count the number of full months that you delayed enrolling in a Medicare drug plan after you were eligible to enroll. Or count the number of full months in which you did not

have creditable prescription drug coverage if the break in coverage was 63 days or more.

The penalty is 1% for every month that you didn’t have creditable coverage. For

example, if you go 14 months without coverage, the penalty will be 14%.

Then Medicare determines the amount of the average monthly premium for Medicare drug plans in the nation from the previous year. For 2021, this average premium amount

is $33.06.


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To calculate your monthly penalty, you multiply the penalty percentage and the average monthly premium and then round it to the nearest 10 cents. In the example here it would

be 14% times $33.06, which equals $4.63. This rounds to $4.60. This amount would be

added to the monthly premium for someone with a Part D late enrollment penalty.

There are three important things to note about this monthly Part D late enrollment penalty:

First, the penalty may change each year, because the average monthly premium can change each year. If the national average premium (as determined by Medicare)

increases, your penalty will increase.

Second, you will continue to pay a penalty every month for as long as you are enrolled in a plan that has Medicare Part D drug benefits, even if you change plans.

Third, if you are under 65 and currently receiving Medicare benefits, the Part D late enrollment penalty will reset when you turn 65. After age 65, your Part D late enrollment

penalty will be based only on the months that you don’t have coverage after your initial

enrollment period for aging into Medicare.

Section 5.3 In some situations, you can enroll late and not have to pay the penalty

Even if you have delayed enrolling in a plan offering Medicare Part D coverage when you were

first eligible, sometimes you do not have to pay the Part D late enrollment penalty.

You will not have to pay a penalty for late enrollment if you are in any of these situations:

If you already have prescription drug coverage that is expected to pay, on average, at least as much as Medicare’s standard prescription drug coverage. Medicare calls this

“creditable drug coverage.” Please note:

o Creditable coverage could include drug coverage from a former employer or union, TRICARE, or the Department of Veterans Affairs. Your insurer or your

human resources department will tell you each year if your drug coverage is

creditable coverage. This information may be sent to you in a letter or included in

a newsletter from the plan. Keep this information, because you may need it if you

join a Medicare drug plan later.

Please note: If you receive a “certificate of creditable coverage” when your health coverage ends, it may not mean your prescription drug

coverage was creditable. The notice must state that you had “creditable”

prescription drug coverage that expected to pay as much as Medicare’s

standard prescription drug plan pays.

o The following are not creditable prescription drug coverage: prescription drug discount cards, free clinics, and drug discount websites.

o For additional information about creditable coverage, please look in your Medicare & You 2021 Handbook or call Medicare at 1-800-MEDICARE (1-800-


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633-4227). TTY users call 1-877-486-2048. You can call these numbers for free,

24 hours a day, 7 days a week.

If you were without creditable coverage, but you were without it for less than 63 days in a row.

If you are receiving “Extra Help” from Medicare.

Section 5.4 What can you do if you disagree about your Part D late enrollment penalty?

If you disagree about your Part D late enrollment penalty, you or your representative can ask for

a review of the decision about your late enrollment penalty. Generally, you must request this

review within 60 days from the date on the first letter you receive stating you have to pay a late

enrollment penalty. If you were paying a penalty before joining our plan, you may not have

another chance to request a review of that late enrollment penalty. Call Customer Service to find

out more about how to do this (phone numbers are printed on the back cover of this booklet).

Important: Do not stop paying your Part D late enrollment penalty while you’re waiting for a

review of the decision about your late enrollment penalty. If you do, you could be disenrolled for

failure to pay your plan premiums.

SECTION 6 Do you have to pay an extra Part D amount because of your income?

Section 6.1 Who pays an extra Part D amount because of income?

If your modified adjusted gross income as reported on your IRS tax return from 2 years ago is

above a certain amount, you’ll pay the standard premium amount and an Income Related

Monthly Adjustment Amount, also known as IRMAA. IRMAA is an extra charge added to your

premium.

If you have to pay an extra amount, Social Security, not your Medicare plan, will send you a

letter telling you what that extra amount will be and how to pay it. The extra amount will be

withheld from your Social Security, Railroad Retirement Board, or Office of Personnel

Management benefit check, no matter how you usually pay your plan premium, unless your

monthly benefit isn’t enough to cover the extra amount owed. If your benefit check isn’t enough

to cover the extra amount, you will get a bill from Medicare. You must pay the extra amount

to the government. It cannot be paid with your monthly plan premium.

Section 6.2 How much is the extra Part D amount?

If your modified adjusted gross income (MAGI) as reported on your IRS tax return is above a

certain amount, you will pay an extra amount in addition to your monthly plan premium. For


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more information on the extra amount you may have to pay based on your income, visit

www.medicare.gov/part-d/costs/premiums/drug-plan-premiums.html.

Section 6.3 What can you do if you disagree about paying an extra Part D amount?

If you disagree about paying an extra amount because of your income, you can ask Social

Security to review the decision. To find out more about how to do this, contact Social Security at

1-800-772-1213 (TTY 1-800-325-0778).

Section 6.4 What happens if you do not pay the extra Part D amount?

The extra amount is paid directly to the government (not your Medicare plan) for your Medicare

Part D coverage. If you are required by law to pay the extra amount and you do not pay it, you

will be disenrolled from the plan and lose prescription drug coverage.

SECTION 7 More information about your monthly premium

Many members are required to pay other Medicare premiums

In addition to paying the monthly plan premium, many members are required to pay other

Medicare premiums. As explained in Section 2 above, in order to be eligible for our plan, you

must have both Medicare Part A and Medicare Part B. Some plan members (those who aren’t

eligible for premium-free Part A) pay a premium for Medicare Part A. Most plan members pay a

premium for Medicare Part B. You must continue paying your Medicare premiums to

remain a member of the plan.

If your modified adjusted gross income as reported on your IRS tax return from 2 years ago is

above a certain amount, you’ll pay the standard premium amount and an Income Related

Monthly Adjustment Amount, also known as IRMAA. IRMAA is an extra charge added to your

premium.

If you are required to pay the extra amount and you do not pay it, you will be disenrolled from the plan and lose prescription drug coverage.

If you have to pay an extra amount, Social Security, not your Medicare plan, will send you a letter telling you what that extra amount will be.

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