group medicare advantage ppo plans. group medicare … · 2019. 1. 2. · semana. si usted llama...

Dear IMRF Retiree:

For the past 20 years, IMRF has endorsed Blue Cross and Blue Shield of Illinois health insurance plans administered by Doyle Rowe LTD. IMRF retirees can apply for three additional Group Medicare Advantage PPO plans. Who can benefit For the plan year beginning January 1, 2017, Blue Cross and Blue Shield of Illinois will offer three Group Medicare Advantage PPO plans for IMRF retirees and their spouses who:

x Are age 65 and older x Have Medicare Part A & B x Reside in Cook, DuPage, Kane, or Will Counties x Meet other CMS (Center for Medicare and Medicaid Services) eligibility criteria

Coverage These Group Medicare Advantage PPO plans use a network of doctors and hospitals. You can use doctors and hospitals outside of the PPO network; however, your cost-sharing out-of-network would be greater in most cases. Please review the in- and out-of-network coverage amounts in detail. All plans include:

x Medicare Part D prescription drug coverage, with full coverage through the coverage gap (“donut hole”).

x A preferred pharmacy network that will help you save on prescription copays.

Some of the plans also offer dental, vision, and hearing aid coverage.

To review the directory of Medicare Advantage Network Hospitals and Doctors, please visit http://www.bcbsil.com/medicare/mapd_provider.html. Choose the “Provider Finder (PPO)” option. Rates and copays The three new plans and their monthly premium rates are described on the following pages. Note: The description for Part D Prescription Drug Benefits lists two copays:

x The first copay: What you’ll pay if you use a pharmacy in the preferred pharmacy network. (Preferred pharmacies include Walgreens, CVS, Wal-Mart, Sam’s Club, and Jewel-Osco.) For instance, you can fill a Preferred Generic prescription at any of these pharmacies for a $0 copay.

- over -

http://www.bcbsil.com/medicare/mapd_provider.html

x The second copay: What you’ll pay at a non-preferred pharmacy. For instance, you can fill a Preferred Generic prescription at a non-preferred pharmacy for a $5 copay.

You may choose to have the premium for these plans deducted from your monthly IMRF benefit check. Ask Doyle Rowe LTD about this option. For more information If you want to enroll or have any questions, please contact Doyle Rowe LTD at 1-800-564-7227 or [email protected]. Enrollment in these plans is voluntary. Sincerely,

Louis W. Kosiba Executive Director Important Information from Blue Cross Blue Shield of Illinois The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums, and/or co-payments/co-insurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium. Other pharmacies/physicians/providers are available in our network.

This information is available for free in other languages. Please call our Customer Service number at 1-877-299-1008 (TTY/TDD users should call 711). We are open between 8 AM and 8 PM, local time, seven days a week. If you are calling from February 15 through September 30, alternate technologies (for example, voicemail) will be used on the weekends and holidays.

Esta información está disponible en otros idiomas de forma gratuita. Comuníquese a nuestro número de Servicio al cliente al 1-877-299-1008 (los usuarios de TTY/TDD deben llamar al 711). Nuestro horario es de 8 AM a 8 PM, hora local, los 7 días de la semana. Si usted llama del 15 de febrero al 30 de septiembre, durante los fines de semana y feriados, se usarán tecnologías alternas (por ejemplo, correo de voz).

PPO plans are provided by Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company (HCSC), an Independent Licensee of the Blue Cross and Blue Shield Association. HCSC is a Medicare Advantage organization with a Medicare contract. Enrollment in HCSC’s plans depends on contract renewal.

mailto:[email protected]

BlueCross BlueShieldofIUinois

I Monthly Plan Premium

Annual Deductible: The Annual Deductible appliesto al! coverages that requirecoinsurance. Itdoesnotappiytocoverages that require a copay.

Out-of-pocket Maximum

Includes the Annual Deductible

t|g|%llSI"Mn8((InS%R

I $289.70

In-Network: This plan doesnot have a deductible.

Out-of-Network: This plandoes not have a deductible.

In-Network: $2,500

Out-of-Network: $5,100

I ln-Network:$10copayPrimary Care Office Visit | Out-of-Network: $30 copay

Specialist Office Visit

Inpatienf Hospital Care

Outpatient Hospital Services

Emergency Care

In-Network: $25 copay

Out-of-Network: $45 copay

in-Network:$125/Day(1-7)

Out-of-Network:$400/Day(1-7)

In-Network:$0-$225 ($0 observation)Out-of-Network:40% of the total cost

$90 copay

Emergency Ambulance | $200 copay

|^®Mue|p|us^l?lam?&

$224.50

In-Network: This plan doesnot have a deductible.

Out-of-Network: $250

in-Network: $5,000






in-Network:$250/Day(1-7)

Out-of-Network:$400/Day{1-7)

In-Network:$0-$225 ($0 observation)

Out-of-Network:50% of the total cost

$90 copay

$200 copay

^^Si®Vall^R|aii?|^

$205.70

In-Network: This plan doesnot have a deductibie.

Out-of-Network; $500

In-Network: $6,700


in-Network; $25 copay

Out-of-Network: 40%coinsurance

in-Network: $50 copay

Out-of-Network: 50%comsurance

ln-Network:$250/Day(1-7j

Out-of-Network:

$400/Day(1-7)

In-Network:$0-$225 ($0 observation)

Out-of-Network:50% of the total cost

$90 copay

$200 copay

This information is not a complete description of benefits. Call 1 -877-299-1008 TT/ 71 1 for more information We are open 8:00 a.m. - 8:00 p.m., local time,7 days a week. If you are calling from April 1 through September 30, alternate technologies {for example, voicemail)will be used an weekends and holidays.Out-of-network/non-contracted providers are under no obligation to treat Blue Cross and Blue Shield of Illinois members, except in emergency situations.Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-networkservices.

PPO plans are provided by Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company (HCSC], anIndependent Licensee of the Blue Cross and Blue Shield Association. HCSC is a Medicare Advantage organization with a Medicare contract. Enrollment inHCSC's plans depends on contract renewal.

Y0096_.MRKJL,GRP. IMRFPPOP019NR 851618.1018

PlanOpt ion ; Premuim Plan ValueNusPlan :: VahiePlan

Network

Diabetes Supplies andServices

Medicare-coveredPrevent ive Services

Over-the-Counter Rx

Annual Physica l Exam

Supplementa l Educa t ion /Wellness Programs

Diabetes Self-Management Tra in ing

Prevent ive Denta l

Comprehensive Denta l

Eye Exams

Eye Wear

Hear ing Exams

Hear ing Aids

Travel Benefit

Wor ldwide Emergency

PPO-in-Network

0%-20%(0% Prefer red Test

St r ips;20%aNother

supplies)

$0copay

$20PerMonth

$0 cop ay

PPO-Out-of-Networ l<

40% of the tota l cost


Not Cove red


SilverSneakers F itness Program

$0copay

$5copaySupplementa l;

2exams,2deaningsevery year ;

1 X-ray every 2years

Medicare CoveredSen/ices20%;100%planpay

(Basic Restora t ive,ex. Cava t ies, non-

surgica l ext ract ions,denta l pa in relief);

100%planpay(Major restora t ive,ex. Surgica l toothext ract ions, rootcana ls}, includes

crowns anddentures

$5copaysupp[ementa!;2exams,2deaningsevery 2 years; IX-ray

every year (maybalance bill abovethe

Network a llowablecharge)

Medicare CoveredServices40%;Basic&Major

Restora t ive servicescovered the same as

InNetwork exceptproviders may

ba lance bill above theIn Network a llowabfe

charges.

$1,000 Annual Max

$0copayforMedicare-covered

eye exam; $10copay rout ine eye

exam annua lly

$0copay standardeyeglass lenses; $40

copay Medicarecovered services

$40 a llowance onrout ine eye exams;40% of the tota l

cost for MedicareCovered services

40% of the tota lcost Medicare

covered services

il50 a llowance on eyewear every 2 years

$15copayfor l-out ine hear ing exam

each year ;$15 copay Medicare

covered services

40% of the tota l costout ine hear ing exams0% of the tota l cost for

Medicare-covered

services

$1,000 a llowance on hear ing a ids every3 years

For members tha t a re ou tside of the servicea reforupto6months

Urgent /Emergent Care on ly; No annua l limit ;$75copay

PPCMn-Network


St r ips;20%all other

supplies)

$0copay

$10 Per Month

$0copay

PPO-Out-of-Network



Not Covered


SilverSneakers'* F itness Program

$0cop3y

$5copaySupplementa l;

2exams,2clean ingseveryyear ;

I X-ray every 2 years

Not Covered

$10copay rout ineeye exam

annually; $0Copay MedicareCovered services



$5capay supplementa l;2e>;ams,2deaningsevery2years;lX-ray

every year (maybalance bill abovethe

Network a llowablecharge)

Not Covered




covered services

?100 a llowance on eyewear every 2 years

$15copayfor lrout inehear ingexam

each year ;$15 copay Medicare

covered services

50% of the tota l costrout ine hear ing exams

i0% of the tota l cost forMedicare-covered

services

$500 a llowance on hear ing a ids every 3years

For members tha t a re ou tside of the servicea reforupto6months

Urgent /Emergent Care on ly; Noannual limit ;$75 copay

PPO-ln-Network


St r ips;20%allother

supplies)

$0copay

Not Covered

$0copay

PPO-Out-of-Network



Not Covered


SilverSneakers F itness Program

$0copay

Not Covered

Not Cove red

$10copay rout ineeye exam

annually; $0Copay MedicareCovered services



Not Covered

Not Covered




covered sen /ices

?100 a llowance on eyewear every 2 years

$40 copay Medicarecovered services

Not Covered

i0% of the tota l cost forMedicare-covered

services

Not Covered

For members tha t a re ou tside of the servicea reforuptoSmonths

Urgent /EmergentCare on ly; Noannual limit ;$75copay

2017BlueCross Medicare Advantage

Plan Opt ion

Network

MemberWellnessIncent ives

Ambula torySurgica l Center(ASC) Services

AmbulanceServices

advantage

P remium Plan I ValuePlusPlan i ValuePIan

PPO-ln-Metwork PPO-Out-of-Network

$25 offered a t 4 t imes per year

$125 capay

$200copay


$200copay

PPO-ln-Network PPO-Out-of-Network

$25 offered a t4t imes per year

$125 copay

$200copay


$200copay

PPO-in-Network PPO-Out-of-Network

$25 offered a t 4 t imes per year

$125 copay

$200copay


$200 co pay

TheSilverSneakers® Fitness Program is a wellness program owned and opera ted by Hea lthways, Inc, an independent company. Hea lthwaysandSj[verSneakers(sa reregistered t rademarksofHealthwaysJ nc.and/or it s subsidia r ies.

Blue Cross®, Blue Shield6 and the Cross and Shield Symbols a re registered service marks of the Blue Cross and Blue Shield Associa t ion , an associa t ion ofindependent Blue Cross and Blue Shield P lans.

This in format ion is ava ilable for free in other languages. P lease ca ll our Customer Service number a t 1-877-299-1008. (TT//TDD users should ca ll 711). Weare open between 8 a .m. " 8 p.m., loca l t ime, 7 days a week. If you a re ca lling from February 15 through September 30, a lterna te technologies (forexample, voicemail) will be used on the weekends and holidays.

Esta in formacion esta disponible en ot ros idiomas de forma gra tu ita . Comuni'quese a nuest ro numero de Servicio a l clie'n te a i 1-877-299-1008 (los usuar iosde TT//TDD deben llamar a l 711). Nuest ro horar io es de 8 a .m. a 8 p.m., hora loca l, los 7 dfas de la semana . Si usted llama del 15 de febrero a l 30 desept iembre, duran te los fines de semana y fer iados, se usaran tecnologi'as a lternas (por ejemplo, cor reo de voz).

This in format ion is not a complete descr ipt ion of benefit s. Contact the plan for more in format ion . Limita t ions, copayments, and rest r ict ions may apply.Benefit s, premiums and/or co-payments/co-insurance may change on J anuary 1 of each year . The formulary, pharmacy network, and/or provider networkmay change a t any t ime. You will receive not ice when necessary.

Out -of-network/non-cont racted providers a re under no obliga t ion to t rea t Blue Cross and Blue Shield of Illinois members, except in emergencysitua t ions. For a decision about whether we will cover an ou t -of-network service, we encourage you or your provider to ask us for a pre-serviceorganiza t ion determina t ion before you receive the sen /ice. P lease ca ll our customer service number or see your Evidence of Coverage for moreinformat ion , including the cost -shar ing tha t applies to ou t -of-network services.

You must cont inue to pay your Medicare Par t B premium

PPO plans a re provided by Blue Cross and Blue Shield of Illinois, a Division of Hea lth Care Sen/ice Corpora t ion , a Mutua l Lega l Reserve Company (HCSC), an IndependentLicensee of the Blue Cross and Blue Shield Associa t ion . HCSC is a Medicare Advantage organiza t ion with a Medicare cont ract . Enrollment in HCSC's plans depends on cont ractrenewal

17

Blue Cross Medicare Advantage (PPO)SM

Initial Coverage (continued)

Standard Retail Cost-Sharing

Tier One-month supply Three-month supply

Tier 1 (Preferred Generic) $5 copay $15 copay

Tier 2 (Generic) $11 copay $33 copay

Tier 3 (Preferred Brand) $44 copay $132 copay

Tier 4 (Non- Preferred Brand) $95 copay $285 copay

Tier 5 (Specialty Tier) 33% of the total cost 33% of the total cost

Preferred Retail Cost-Sharing







Standard Mail Order Cost-Sharing







18


Initial Coverage (continued)

Preferred Mail Cost-Sharing







If you reside in a long-term care facility, you pay the same as at a retail pharmacy.

19


Coverage Gap Your plan provides additional coverage through the gap. You continue to pay similar amounts as you did in the Initial Coveragestage. You stay in this stage until your total yearly out-of-pocket drug costs reach $5,000.Under this plan, you may pay even less for the brand and generic drugs on the formulary. Your cost varies by tier. You will need to use your formulary to locate your drug’s tier. See the chart that follows to find out how much it will cost you.

20


Coverage Gap (Continued)

Standard Retail Cost-Sharing





Tier 4 (Non-Preferred Brand) $95 copay $285 copay


Preferred Retail Cost-Sharing







Standard Mail Order Cost-Sharing







21


Coverage Gap (Continued)

Preferred Mail Order Cost-Sharing







group medicare advantage ppo plans. group medicare … · 2019. 1. 2. · semana. si usted llama...

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