Y0079_XXX CMS Approved MMDDYYYY

2014 Blue Medicare Rx (PDP)

Prescription drug coverage for Medicare beneficiaries

(PDP)

Y0079_6354 CMS Accepted 08272013U5073a 813

ContentsYour guide to Blue Medicare Rx 3

Important information 9

Summary of benefits 19

What You Get + Extensive list of covered drugs ndash more than 1800 in our Blue

Medicare Enhanced Plan

+ Additional savings with our Preferred Pharmacy Network

+ Virtually no paperwork when you use a network pharmacy

+ Enhanced Plan has no deductible and has gap coverage when you purchase preferred generic drugs

PAGE 2 of 4 0

Medicare prescription drug coverage helps cover your drug costs

Filling your PrescriptionsOur pharmacy network includes most national chains as well as local pharmacies around the state You can save even more time and avoid the line by using our mail order pharmacy services Your prescriptions will be mailed to your door and we handle the paperwork for you When you enroll in one of our Medicare Prescription Drug (Part D) Plans we verify enrollment with Medicare and Medicare helps pay your prescription costs Please review the preferred and non-preferred charts to understand our Part D benefits

Eligibility and types of coverage for beneficiariesEveryone who is entitled to Medicare benefits under Part A or enrolled in Part B is eligible for this coverage however you are not enrolled automatically You must join a plan to receive the coverage2 This voluntary program is coverage that you may choose to purchase annually

Unlike Medicare Part A and Part B this coverage is available solely through private companies like BCBSNC Medicare requires that all companies that provide Medicare Part D coverage offer the Medicare standard coverage Companies may also choose to provide enhanced coverage like the Blue Medicare Rx Enhanced Plan

Designed to make prescriptions more affordableBlue Cross and Blue Shield of North Carolina (BCBSNC) offers Medicare prescription drug coverage with more than 1800 drugs covered in our Blue Medicare Enhanced Plan and more than 1000 drugs covered in our Blue Medicare Standard Plan to help you pay for prescription drugs at local and network pharmacies and through mail order Sometimes referred to as Medicare Part D Medicare prescription drug coverage must be approved by Medicare and provided through private companies like BCBSNC Coverage is designed to make filling prescriptions more affordable

Preferred Pharmacy NetworkAt BCBSNC we offer two Medicare Prescription Drug Plans Blue Medicare RxSM Standard and Blue Medicare RxSM Enhanced BCBSNCrsquos Preferred Pharmacy Network is designed to help save you money on your prescription copays This select network of national and local independent pharmacies has worked with BCBSNC to get you the savings and value that you looking for by offering lower costs and better value from your prescription plan without sacrificing convenience

Footnotes 1 Blue Cross and Blue Shield of North Carolina is a PDP plan with a Medicare contract Enrollment in Blue

Cross and Blue Shield of North Carolina depends on contract renewal 2 You must join a plan to receive the coverage unless you are eligible for both Medicare and Medicaid

Contact your State Medicaid or medical assistance office if you have questions about your eligibility

PAG E 3 of 40

Cat

astr

ophi

c

Cov

erag

e G

ap

Compare Part D benefitsPlease refer to the charts to review our Blue Medicare Rx plans The total amount you spendon prescription drugs increases during the calendar year as you move through some or all of thephases of coverage Remember you must always present your planrsquos member ID card to fill yourprescriptions Note For members who qualify for low-income assistance benefits may vary

PREFERRED PHARMACY NETWORK BENEFITS

Our preferred network includes CVS Walmart Kerr and Epic pharmacies

Plan Feature Standard $4100month Enhanced $7860month

Drug list (Formulary) We cover a comprehensive list of Medicare Part D covered drugs

Tier 1 Preferred Generic $4 $3

Tier 2 Non-preferred generic $10 $6

Tier 3 Preferred brand $40 $30

Tier 4 Non-preferred brand $85 $70 Tier 5 Specialty You pay 29 coinsurance You pay 33 coinsurance

Annual deductible You pay a $145 annual deductible You pay $0You pay no annual deductible

Init

ial

Retail You + Plan = $2850 You pay the copayment per 30-day supply orcoinsurance for your drugs and the plan pays the remainder untiltotal drug costs reach $2850

Preferred Mail Order

You pay $4 for a 30-day supply ofpreferred generic drugs

You pay $3 for a 30-day supply ofpreferred generic drugs

You pay $0 copay for a 60- or 90-day supply of preferred genericdrugs at our preferred mail-order pharmacy through the initial phase

Cov

erag

e G

ap Retail

You pay 72 on all genericdrugs You receive a discountfor brand-name drugs

You pay a $3 copayment for Tier 1preferred generic drugs You pay72 for all other generic drugs

Preferred Mail Order

You pay 72 for all generic drugs You pay a $3 copayment for Tier 1preferred generic drugs You pay72 for all other generic drugs

You receive a discount for brand-name drugs You remain in thecoverage gap until your yearly out-of-pocket drug costs (not includingpremiums) equal $4550

Cat

astr

ophi

c

Catastrophic coverage

You pay 5 After you reach $4550 in out-of-pocket costs the plan pays the majority of the drug costs until the end of the year You pay the greater of $255 for generic $635 for brand name or 5 of the total drug cost

PAGE 4 of 40

NON-PREFERRED PHARMACY NETWORK BENEFITS

Plan Feature Standard $4100month Enhanced $7860month

Drug list (Formulary) Includes nearly 100 of the drugs covered by Medicare Part D

Tier 1 Preferred Generic $10 $8

Tier 2 Non-preferred generic $33 $20

Tier 3 Preferred brand $45 $45

Tier 4 Non-preferred brand $95 $95

Tier 5 Specialty You pay 29 coinsurance You pay 33 coinsurance

Init

ial

Retail You + Plan = $2850 You pay the copayment per 30-day supply orcoinsurance for your drugs and the plan pays the remainder untiltotal drug costs reach $2850

Non-preferred Mail Order

You pay $10 for a 30-day supply ofpreferred generic drugs

You pay $8 for a 30-day supply ofpreferred generic drugs

You pay 3 times the copay for a 90-day supply of preferred generic andbrand-name drugs at a non-preferred mail-order pharmacy throughthe initial phase

Cov

erag

e G

ap

Retail You pay 72 on all generic drugsYou receive a discount for brand-name drugs

You pay a $8 copayment for Tier 1 preferred generic drugs You pay 72 for all other generic drugs

Non-preferred Mail Order

You pay 72 on all generic drugs You pay $8 for Tier 1 preferred generic drugs and you pay 72 for all other generic drugs

You receive a discount for brand-name drugs You remain in the coverage gap until your yearly out-of-pocket drug costs (not including premiums) equal $4550

Cat

astr

ophi

c

Catastrophic coverage

You pay 5 After you reach $4550 in out-of-pocket costs the plan pays the majority of the drug costs until the end of the year You pay the greater of $255 for generic $635 for brand-name or 5 of the total drug cost

Compare Part D benefits (continued)

PAGE 5 of 40 Y0079_6534 CMS Accepted 11262013

Prescription drugs covered by the plans

Here are three ways to find out if your prescriptions are

covered by our formulary

Search online for specific drugs by visiting the Blue Medicare Rx section of bcbsnccommedicare (You may also download the complete formulary in PDF format)

Call or visit your local Authorized Sales Representative

Call 1-800-478-0583 7 days a week 8 amndash8 pm and speak to an authorized agent Hearing and speech impaired (TTYTDD) users call 1-800-922-3140Representatives can help you determine whether or not a specific drug is covered

Extensive network of pharmacies makes getting your medications easyExcept under certain non-routine circumstances you need to use a network pharmacy to obtain the full benefit of your Medicare Part D plan Quantity limitations and restrictions may apply BCBSNC offers an extensive network of pharmacies of the following types retail national chain mail-order extended supply home infusion long-term care or Indian Health ServiceTribalUrban Indian Health Program (ITU) pharmacies

You can use our mail-order pharmacyOur plans also offer the convenience of using preferred mail-order pharmacy at a reduced cost to you Pay a reduced copayment for a 90-day

supply of covered brand drugs up to $2850 of total drug costs You pay $3 copayment for Enhanced and $4 for Standard plans for a 30-day supply of all preferred generic drugs ordered through mail-order

Many of the most commonly used drugs are coveredThe Blue Medicare Rx Enhanced Plan and the Blue Medicare Rx Standard Plan have a formulary that lists the generic brand-name and specialty drugs covered by the plans The formulary covers many drugs eligible for coverage under Medicare Part D ndash more than 1800 drugs on our Enhanced Plan and more than 1000 drugs on our Standard Plan

Medicare Part D plans do not cover certain drugs or classes of drugs that are excluded by law such as over-the-counter medications and prescription vitamins

Compare Medicare drug plans+ Find out which Medicare drug plans

are available in your area+ Learn about plan benefits and costs+ Compare ratings by quality premium

estimated annual costs and more+ Compare BCBSNC plan ratings

included in the Enrollment kit or visit wwwmedicaregov Plan ratings are available upon request for this plan by calling BCBSNC directly at 1-800-478-0583 7 days a week 8 amndash8 pm For the hearing and speech impaired (TTYTDD) call 1-800-922-3104

Medicare evaluates plans based on a 5-Star ratingsystem Star Ratings are calculated each year and may change from one year to the next

1

2

3

PAGE 6 of 40

Call your State Medicaid Office

Hearing and speech impairedMon through Fri 1-800-772-1213

40 of 7 PAGE

2

3

Security Administrationrsquos postage-paid envelope assistance fill it out and return it in the Social If you receive an application for financial

3 for financial assistance$26580 (for a married couple) you may qualify under $13300 (for a single person) or under stocks but not counting your home or car) are If your resources (including your savings and +

3 with youhalf support to other family members living

Paying for Medicare Part D coverage

Footnotes 3 Medicaregov website June 2013

Here are three ways to find out if you qualify to receive

financial assistance

Call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day 7 days a week Hearing and speech impaired(TTYTDD) users call 1-877-486-2048 Or visit Medicarersquos Web sitewwwmedicaregov and click the

rdquoPrescription Drug Planrdquo link

Call the Social Security Administration atbetween 7 am and 7 pm

(TTYTDD users) call 1-800-325-0778

1

Premiums for Medicare Part D plans vary based on the plan that you choose If you have Medicare Part B you must continueto pay your Medicare Part B premium if nototherwise paid for under Medicaid or byanother third party

You may qualify for extra help to pay for plan premiums and prescription drug costs If you have Medicare and have limited incomeand resources you may qualify for specialfinancial assistance to help you pay for yourMedicare Part D plan premiums and prescriptiondrug costs The amount of assistance you qualifyfor will depend on your income and resources

+If your annual income is below $17235 for asingle person (or $23265 if you are marriedand living with your spouse) for 2013 youmay qualify for financial assistance Slightlyhigher income levels may apply if you provide

Prescription drugs coveredby the plans

Here are three ways to enroll in Medicare Part D

Enroll directly with the Medicare Part Dplan you choose via paper or onlineapplication at bcbsnccommedicare

Visit the Centers for Medicare amp Medicaid Services (CMS) Online Enrollment Center at wwwmedicaregov

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

+ Generally you can join or change Medicare Part D plans during the annual enrollment period ndash any time between October 15 and December 7 with an effective date of January 1 of the following year

+ If you are enrolling at a different time of year the effective date of your coverage will depend on your situation and whether or not you qualify for a special election period

+ You may only be enrolled in one Medicare Part D plan at a time

+ If you enroll in a stand-alone Medicare Part D plan while enrolled in a Medicare Advantage plan you will be disenrolled automatically from the Medicare Advantage plan and returned to Original Medicare

PAGE 8 of 40

How to join

Choose a plan Before you select a plan gather anydocumentation you may have on yourprescription drug purchases over thepast year This information will helpyou determine how much you mightsave with a Medicare Part D plan Thenyou can choose a plan that best fits yourneeds and your budget

Enroll in a plan Then you must fill out an enrollment formYou will be enrolled in the Medicare Part D plan you select and Medicare will beinformed that you have enrolled Inaddition to the paper enrollment formBlue Medicare Rx applicants can enrollonline at bcbsnccommedicare

Changing Medicare Part D plans Congress designed Medicare prescriptiondrug coverage to work on an annualenrollment cycle This means that each yearyou will have the option to remain with yourexisting Medicare Part D plan or change plansbetween October 15 and December 7

You may also have another opportunityduring the year to switch plans underlimited circumstances For example if youmove out of your planrsquos service area you willhave an opportunity to choose another planthat serves your new area Please contactBCBSNC if you would like more informationabout other situations in which you mayqualify for coverage or changes in coverageoutside the annual enrollment cycle

Important enrollment information

1

2

3

PAGE 9 of 40

You can join a Medicare Part D plan any time during your initial enrollment period for Medicare Generally a Medicare beneficiaryrsquos initial enrollment is a seven-month period three months prior to becoming Medicare eligible the month you become Medicare eligible and three months following the month you become Medicare eligible

If you were eligible for Medicare on or prior to January 1 2006 and did not enroll in a Medicare Part D plan or Medicare Advantage Prescription Drug Plan by May 15 2006 you may have to pay a penalty for late enrollment This penalty will not apply to Medicare beneficiaries who have equal or better prescription drug benefits through their

employer or another plan As of January 1 2009 these penalties no longer apply to Medicare individuals with Low Income Subsidy (LIS)

The penalty was designed to help hold down the overall costs of the drug program and is similar to the penalty imposed for late enrollment in Medicare Part B The late penalty equals one percent of the national base benchmark premium amount for each month that enrollment is delayed beyond your initial enrollment period For example if you delay enrollment in a Medicare Part D plan for two years you will pay the regular monthly plan premium plus 24 percent of the national base benchmark premium each month

Penalties for late enrollment

Important dates+ October 15 2013

First day you can enroll in a Medicare Part D plan for 2014 or the first day you can elect to switch to a different Medicare Part D plan (unless you qualify for a special election period)

+ December 7 2013 Last day you can enroll in a Medicare Part D plan for 2014 or the last day you can elect to switch to a different Medicare Part D plan (unless you qualify for a special election period)

+ January 1 2014 First day coverage begins (if you join a plan or switch plans by December 7 2013)

PAGE 10 of 40

(PDP)

Important information about our Medicare prescription drug plans

U5073b 813

Y0079_6248 CMS Accepted 08102013 PAGE 11 of 40

Important information

Eligibility for beneficiaries

Eligibility for beneficiaries Everyone who is entitled to Medicare benefitsunder Part A or enrolled in Part B is eligible forthis coverage however you are not enrolledautomatically You must join a plan to receivethe coverage6 This voluntary program is coveragethat you may choose to purchase annually Thisproduct is available to Medicare beneficiariesliving in North Carolina

Additional enrollment criteria You may enroll in only one Part D plan at a timeIf you are enrolled in a Medicare Advantage planyour enrollment in either of the PDP plans fromBlue Cross and Blue Shield of North Carolina (BCBSNC) may automatically disenroll you fromyour Medicare Advantage Plan and re-enroll youin Original Medicare for medical coverage Checkwith your plan for more information

Financial assistance

Financial assistance available People with limited incomes may qualify forExtra Help to pay for their prescription drugcosts If you qualify Medicare could pay for upto seventy-five (75) percent or more of your drugcosts including monthly prescriptiondrug premiums annual deductibles andco-insurance Additionally those who qualifywill not be subject to the coverage gap or a lateenrollment penalty Many people are eligiblefor these savings and donrsquot even know itFor more information about this Extra Helpcontact your local Social Security office or call1-800-MEDICARE (1-800-633-4227) 24 hours perday 7 days per week TTYTDD users shouldcall 1-877-486-2048

This document may be available in alternate formats upon request

Footnote 6 You must join a plan to receive the coverage unless

you are eligible for both Medicare and Medicaid Contact your State Medicaid or medical assistance office if you have questions about your eligibility

Social Security Administration

Phone 1-800-772-1213

TTYTDD 1-800-325-0778

Hours MondayndashFriday7 amndash7 pm

PAGE 12 of 40

Medicare

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

TTYTDD 1-877-486-2048

Hours 24 hours a day7 days a week

Important information

Pharmacy network

Pharmacy network information Our network includes a variety of pharmaciesincluding retail home infusion IndianTribalUrban organizations extended supply and long-term care pharmacies In order to obtain thegreatest savings on your prescription medicationsplease visit one of our preferred network providers(CVS WalMart Kerr and Epic Pharmacies) Formore information about our pharmacy networkand out-of-network policies please see our contactinformation below

Mail order contact information For information on our mail order service or to obtain forms please contact us at

Coverage determination

What is a coverage determination When we make a coverage determination weare making a decision about whether or not toprovide or pay for a Part D drug and what yourshare of the cost is for the drug (also see thedescription of the exceptions process) You mustcontact us if you would like to request a coveragedetermination including an exception Youcannot request an appeal if we have not issueda coverage determination

Mail order contact information

Phone 1-888-247-4142

TTYTDD 1-888-247-4145

Hours 7 days a week8 amndash8 pm

Mail BCBSNC Customer Service PO Box 17509 Winston-Salem NC 27116-7509

Online For a comprehensive list ofall pharmacies please visitbcbsnccommedicare

Examples of when you may ask us for a coverage determination

If you are not getting a prescription drug thatyou believe may be covered by us

If you have received a Part D prescription drugthat you believe may be covered by us while youwere a member but we have refused to pay forthe drug

If you are being told that coverage for a Part Dprescription drug that you have been gettingwill be reduced or stopped and you believe youhave special circumstances that should excludeyou from the reductionnon-coverage

If there is a limit on the quantity (or dose) of thedrug and you disagree with the requirement ordosage limitation

If you bought a drug at a pharmacy that isnot in our network and you want to requestreimbursement for the expense

PAGE 13 of 40

Important information

Coverage determination (continued)

How do I make a request for coverage determination Standard To ask for a standard decision you oryour appointed representative may call ourCustomer Service Department at the numberslisted on the back cover You can also mail a written request to the below address

Fast To ask for a fast decision you your physicianor your appointed representative may call theCustomer Service Department at the numbers listedon the back cover You can also mail a written request to the below address

Standard Generally we must give you our decisionno later than 72 hours after we have received yourrequest but we will make it sooner if your healthcondition requires

Fast If you get a fast review we will give you ourdecision within 24 hours after you or your doctor askfor a fast review mdash sooner if your health requires

PAGE 14 of 40

Contact information

Mail BCBSNC PO Box 17509 Winston-Salem NC 27116-7509

Fax Request 1-888-446-8440

Hours MondayndashFriday8 amndash5 pm

Note You cannot ask for a fast decision on a requestfor coverage of a drug already purchased

For some reviews we may require a supportingstatement from your doctor that explains why the drugyou are asking coverage for is medically necessary

After regular business hours you should consultwith a network pharmacy regarding your need for anemergency or temporary supply of medication untilyou can contact the Plan the next business day Youmay also call our Customer Service Department andleave a message on the Part D After Hours ExceptionRequest voicemail Be sure to ask for a ldquofastrdquoldquoexpeditedrdquo or ldquo24-hourrdquo review

When will I hear back with a decision

Important information

Exceptions process

What is an exception request Exception requests are a kind of coveragedetermination You your authorized representativeor your prescribing physician may request anexception to seek coverage of a drug that

+ Is not on the formulary (list of drugsthe plan covers)

+ Requires prior authorization + Has quantity limitations

Example of an exception request If the Planrsquos formulary does not include a drug thatyou or your prescribing physician feel is necessarythen you or your prescribing physician may requestan exception so that you may obtain coverage ofthis drug If the Plan does not grant the requestedexception then you or your prescribing physicianmay file an appeal

How do I make an exception request You or your prescribing physician may request anexception to the coverage rules for your MedicarePrescription Drug Plan A specific form is notrequired for you to make an exception requestThe request must include your prescribingphysicianrsquos statement that heshe has determinedthat the preferred drug either would not be aseffective or would have adverse effects for you

For your convenience forms are available at bcbsnccomcontentmedicarememberindexhtm

Contact information

Mail BCBSNC Attn PDP Exception RequestsPO Box 17509 Winston-Salem NC 27116-7509

Phone 1-888-247-4142

Physicians call 1-888-298-7552

TTYTDD 1-888-247-4145

Hours 7 days a week8 amndash8 pm

When will I receive a decision on my exception request If your exception request includes a formularyexception or an exception from utilizationmanagement rules such as dosage or quantitylimits we must make our decision no later than 72 hours after we have received your doctorrsquossupporting statement which explains why thedrug you are asking for is medically necessary

If you have asked for a fast or expedited exceptionrequest we must make our decision no later than24 hours after we get your doctorrsquos supporting statement

You will be notified by phone followed by awritten notice of our decision If the decision is not in your favor you have the right to appeal

PAGE 15 of 40

Important informationAppeals process

What is an appeal An appeal is your opportunity to requesta redetermination of an adverse coveragedetermination which includes denied exception requests

Example of an appeal If we deny your request for an exception to covera non-formulary drug then you may file an appealof the denial An appeal can only be filed afteran exception has been requested and denied bythe Plan

How do I file an appeal If you receive a coverage determination denial youor your appointed representative or your doctor orother prescriber may file an appeal A specific formis not required for you to file an appeal An appealmust be filed within 60 calendar days of the date ofa denial notice and must be in writing unless youare filing an expedited or fast appeal You mustsubmit it via mail fax or in person

When will I receive a decision on my appeal

We will perform a standard review of your appealwithin seven calendar days of receipt of your appealor sooner if your health requires We will reviewrequests for an expedited or fast appeal as soon aspossible but no later than 72 hours following ourreceipt of the request An individual who was notinvolved with your original coverage determinationwill make a decision on your appeal

You will receive a written response to your appealThe decision on an expedited appeal will beprovided by phone followed by the written noticeIf our decision is to deny the appeal the notice willadvise you of your right to submit your appeal to the Independent Review Entity (IRE) with instructionson how to do so If we miss our time frames for claims adjudication or review of the appeal wewill automatically forward the appeal to the IREfor a decision There may be additional levels ofappeal available to you We will inform you of youradditional rights in the notice or you may refer toyour Evidence of Coverage for further details

Contact information

Mail BCBSNC Attn Medicare Appeals amp GrievancesPO Box 17509 Winston-Salem NC 27116-7509

Fax 1-888-375-8836 or 1-336-794-8836

In Person

BCBSNC 5660 University PkwyWinston-Salem NC 27105

PAGE 16 of 40

Important information

Grievance process

What is a grievance A grievance is a complaint that you may file ifyou are dissatisfied with the Plan or a contractedprovider for reasons other than a decision ona coverage determination Grievances alsoinclude complaints regarding the timelinessappropriateness access to or setting of a coveredprescription drug

Example of a grievance If you are dissatisfied with the service you receivedfrom a pharmacist or plan representative then youcould file a grievance

How do I file a grievance The grievance must be filed within 60 days after theevent or incident that caused you to be dissatisfiedA specific form is not required for you to file agrievance You or your appointed representativemay file a grievance via the phone by mail faxor in person

When will I receive a decision on my grievance The resolution of a grievance will be made asquickly as your concern requires but no more than30 calendar days after our receipt of the grievanceWe may extend the time frame by up to 14 calendardays if you request the extension or if we justify aneed for additional information and the delay is inyour best interest

If you request a written response to an oralgrievance one will be provided within 30 days afterreceipt of the grievance A written response will beprovided to all written grievances Our decision ona grievance is final and is not subject to an appeal

You have the right to an expedited review ofa grievance concerning our refusal to grant anexpedited coverage determination or expeditedappeal This type of grievance will be responded towithin 24 hours after our receipt of the grievance

Contact information

Phone 1-888-247-4142

Fax 1-888-375-8836 or 1-336-794-8836

Hours 7 days a week8 amndash8 pm

Mail BCBSNC Attn Medicare Appeals amp GrievancesPO Box 17509 Winston-Salem NC 27116-7509

In Person

BCBSNC 5660 University PkwyWinston-Salem NC 27105

PAGE 17 of 40

Important information

Quality improvement

What if I have a concern about the quality of services I received If you have a concern relating to the quality of services that you received under the Medicare Part D planthen in addition to our review you can also request review by the following organizations

The Carolinas Center for Medical Excellence (CCME) Quality Improvement Organization (QIO) in North Carolina CCME formerly known as Medical Review ofNorth Carolina Inc is a nonprofit medical carequality improvement organization CCME has beendesignated by the Centers for Medicare amp MedicaidServices as the Quality Improvement Organization(QIO) for North Carolina The QIO conducts casereviews to ensure that Medicare beneficiaries receive the quality of medical care that they expect andare entitled to CCME serves as an independentimpartial third party to review Medicare beneficiarycomplaints

Quality of care complaints filed with the QIO mustbe made in writing to the address below Assistanceis available via phone or online

The Carolinas Center for Medical Excellence (CCME)

Mail CCME 100 Regency Forest DriveSuite 200 Cary NC 27518-8598

Phone 1-919-380-9860 or 1-800-682-2650

TTYTDD 1-800-735-2962

Hours MondayndashFriday8 amndash5 pm

Web inquiries wwwccmemedicareorg

Seniorsrsquo Health Insurance Information Program (SHIIP) SHIIP is a state consumer division of the North Carolina Department of Insurance SHIIP assistssenior citizens with Medicare Medicare Part D Medicare Advantage Medicare supplementsMedicare fraud and abuse and long-term careinsurance questions Assistance is available viaphone or online

Seniorsrsquo Health Insurance Information Program (SHIIP)

Phone 1-800-443-9354

TYYTDD 1-800-735-2962

Hours MondayndashFriday8 amndash5 pm

Email ncshiipncdoigov

Online wwwncshiipcom

PAGE 18 of 40

Important information

Additional information

Notice of possible contract termination BCBSNC has a contract with the Centers for Medicare amp Medicaid Services (CMS) the government agencythat runs Medicare to provide a Medicare PrescriptionDrug Plan (PDP) This contract renews each year At theend of each year the contract is reviewed and eitherBCBSNC or CMS can decide to end it Members will get 90 days advance written notice in this situationIt is also possible for our contract to end at some othertime If the contract is going to end we will generallytell members 90 days in advance Advance notice maybe as little as 30 days or even fewer days if CMS endsour contract in the middle of the year In this noticewe would provide a written description of alternativesavailable for obtaining qualified prescription drugcoverage in North Carolina We are also required tonotify the general public of a contract termination vialocal newspapers

If BCBSNC decides to stop offering the Medicare PDPor change our service area so that it no longer includesthe area where you live membership in BCBSNCrsquosMedicare PDP will end for everyone in that servicearea and members will have to change to a differentprescription drug plan Members will continue to getprescription drugs through BCBSNCrsquos Medicare PDPuntil the contract ends

PAGE 19 of 40

Important information

For more information

Blue Cross and Blue Shield of North Carolina

Phone 1-800-478-0583

TTYTDD 1-800-922-3140

Hours 7 days a week8 amndash8 pm

Online bcbsnccommedicare

Medicare

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

TTYTDD 1-877-486-2048

Hours 7 days a week24 hours a day

Online wwwmedicaregovClick the ldquoPrescription Drug Planrdquo link

Blue Cross and Blue Shield of North Carolina is a PDP plan with a Medicare contract Enrollment in Blue Cross and Blue Shield of North Carolina depends on contract renewal Benefits formulary pharmacy network premium andor copaymentscoinsurance may change on January 1 2015 Please contact BCBSNC for details

An independent licensee of the Blue Cross and Blue Shield Association

PAGE 20 of 40

(PDP)

2014 Summary of benefits for our Medicare prescription drug plans (Enhanced and Standard)

Contract S5540 Plans 004 and 002 January 1 2014 ndash December 31 2014

U5073c 813

PAGE 21 of 40Y0079_6249 CMS Accepted 09112013

Introduction to the

Summary of benefits for (PDP)

Thank you for your interest in Blue Medicare Rx(PDP) plans Our plans are offered by Blue Crossand Blue Shield of North Carolina a MedicarePrescription Drug Plan that contracts with theFederal government This Summary of Benefits tellsyou some features of our plans It doesnrsquot list everydrug we cover every limitation or exclusionTo get a complete list of our benefits please callBlue Medicare Rx and ask for the ldquoEvidence of Coveragerdquo You have choices in your Medicare prescription drug coverage As a Medicare beneficiary you can choose fromdifferent Medicare prescription drug coverageoptions One option is to get prescription drugcoverage through a Medicare Prescription DrugPlan like Blue Medicare Rx plans Another optionis to get your prescription drug coverage througha Medicare Advantage Plan that offers prescriptiondrug coverage You make the choice How can I compare my options The charts in this booklet list some important drugbenefits You can use this Summary of Benefitsto compare the benefits offered by Blue MedicareRx plans to the benefits offered by other MedicarePrescription Drug Plans or Medicare AdvantagePlans with prescription drug coverage Where are Blue Medicare Rx Plans available The service area for these plans includesNorth Carolina You must live in one of these areas to join one of these plans Who is eligible to join You can join one of these plans if you are entitled toMedicare Part A andor enrolled in Medicare Part Band live in the service area If you are enrolled in an MA coordinated care(HMO or PPO) plan or an MA PFFS plan thatincludes Medicare prescription drugs you maynot enroll in a PDP unless you disenroll from theHMO PPO or MA PFFS plan Enrollees in a private Fee-for-Service plan (PFFS)that does not provide Medicare prescription drugcoverage or an MA Medical Savings Account (MSA)plan may enroll in a PDP Enrollees in an 1876 Costplan may enroll in a PDP

Where can I get my prescriptions Blue Medicare Rx plans have formed a network ofpharmacies You must use a network pharmacyto receive plan benefits We will not pay foryour prescriptions if you use an out-of-networkpharmacy except in certain cases Blue Medicare Rx plans have a list of preferredpharmacies At these pharmacies you may getyour drugs at a lower co-pay or coinsuranceYou may go to a non-preferred pharmacy but youmay have to pay more for your prescription drugs The pharmacies in our network can change at anytime You can ask for a Pharmacy Directory or visit usat wwwmyprimecomMyRxMyPrimeMedicareDpharmacyBCBSNC Our customer service number is listed at the end of this introduction What if my doctor prescribes less than a monthrsquos supply In consultation with your doctor or pharmacist youmay receive less than a monthrsquos supply of certaindrugs Also if you live in a long-term care facilityyou will receive less than a monthrsquos supply of certainbrand [and generic] drugs Dispensing fewer drugs ata time can help reduce cost and waste in the MedicarePart D program when this is medically appropriate The amount you pay in these circumstances willdepend on whether you are responsible for payingcoinsurance (a percentage of the cost of the drug) ora copay (a flat dollar amount for the drug) If youare responsible for coinsurance for the drug youwill continue to pay the applicable percentage ofthe drug cost If you are responsible for a copay forthe drug a ldquodaily cost-sharing raterdquo will be appliedIf your doctor decides to continue the drug after atrial period you should not pay more for a monthrsquossupply than you otherwise would have paid Contactyour plan if you have questions about cost-sharingwhen less than a one-month supply is dispensed Does my plan cover Medicare Part B or Part D drugs Blue Medicare Rx Standard and Enhanced plans donot cover drugs that are covered under Medicare PartB as prescribed and dispensed Generally we onlycover drugs vaccines biological products and medicalsupplies associated with the delivery of insulin thatare covered under the Medicare Prescription DrugBenefit (Part D) and that are on our formulary

PAG E 22 of 40

Introduction to the

Summary of benefits (continued)

What is a prescription drug formulary Blue Medicare Rx plans use a formularyA formulary is a list of drugs covered by your planto meet patient needs We may periodically addremove or make changes to coverage limitationson certain drugs or change how much you pay for adrug If we make any formulary change that limitsour membersrsquo ability to fill their prescriptions wewill notify the affected members before the changeis made We will send a formulary to you andyou can see our complete formulary on our Website at httpwwwbcbsnccomcontentmedicareformulary-homehtm If you are currently taking a drug that is not on ourformulary or subject to additional requirements orlimits you may be able to get a temporary supply ofthe drug You can contact us to request an exceptionor switch to an alternative drug listed on ourformulary with your physicianrsquos help Call us to seeif you can get a temporary supply of the drug or formore details about our drug transition policy What should I do if I have other insurance in addition to Medicare If you have a Medigap (Medicare Supplement)policy that includes prescription drug coverage youmust contact your Medigap Issuer to let them knowthat you have joined a Medicare Prescription DrugPlan If you decide to keep your current Medigapsupplement policy your Medigap Issuer willremove the prescription drug coverage portion ofyour policy Call your Medigap Issuer for details If you or your spouse has or is able to get employergroup coverage you should talk to your employerto find out how your benefits will be affected if youjoin a Blue Medicare Rx plan Get this informationbefore you decide to enroll in this plan

How can I get extra help with my prescription drug plan costs or get extra help with other Medicare costs You may be able to get extra help to pay for yourprescription drug premiums and costs as well as gethelp with other Medicare costs To see if you qualifyfor getting extra help call +1-800-MEDICARE (1-800-633-4227)

TTYTDD users should call 1-877-486-204824 hours a day7 days a week and seehttpwwwmedicaregov lsquoPrograms for Peoplewith Limited Income and Resourcesrsquo in the publication Medicare amp You

+The Social Security Administration at1-800-772-1213 between 7 am and 7 pmMonday through Friday TTYTDD usersshould call 1-800-325-0778 or

+Your State Medicaid Office What are my protections in this plan All Medicare Prescription Drug Plans agree to stayin the program for a full calendar year at a timePlan benefits and cost-sharing may change fromcalendar year to calendar year Each year plans candecide whether to continue to participate with theMedicare Prescription Drug Program A plan maycontinue in their entire service area (geographicarea where the plan accepts members) or choose tocontinue only in certain areas Also Medicare maydecide to end a contract with a plan Even if yourMedicare Prescription Plan leaves the program youwill not lose Medicare coverage If a plan decidesnot to continue for an additional calendar year itmust send you a letter at least 90 days before yourcoverage will end The letter will explain youroptions for Medicare coverage in your area As a member of a Blue Medicare Rx plan you havethe right to request a coverage determination whichincludes the right to request an exception the right tofile an appeal if we deny coverage for a prescriptiondrug and the right to file a grievance You havethe right to request a coverage determination if youwant us to cover a Part D drug that you believeshould be covered An exception is a type of coveragedetermination You may ask us for an exception ifyou believe you need a drug that is not on our list

PAG E 23 of 40

ContentsYour guide to Blue Medicare Rx 3

Important information 9

Summary of benefits 19

What You Get + Extensive list of covered drugs ndash more than 1800 in our Blue

Medicare Enhanced Plan

+ Additional savings with our Preferred Pharmacy Network

+ Virtually no paperwork when you use a network pharmacy

+ Enhanced Plan has no deductible and has gap coverage when you purchase preferred generic drugs

PAGE 2 of 4 0

Medicare prescription drug coverage helps cover your drug costs

Filling your PrescriptionsOur pharmacy network includes most national chains as well as local pharmacies around the state You can save even more time and avoid the line by using our mail order pharmacy services Your prescriptions will be mailed to your door and we handle the paperwork for you When you enroll in one of our Medicare Prescription Drug (Part D) Plans we verify enrollment with Medicare and Medicare helps pay your prescription costs Please review the preferred and non-preferred charts to understand our Part D benefits

Eligibility and types of coverage for beneficiariesEveryone who is entitled to Medicare benefits under Part A or enrolled in Part B is eligible for this coverage however you are not enrolled automatically You must join a plan to receive the coverage2 This voluntary program is coverage that you may choose to purchase annually

Unlike Medicare Part A and Part B this coverage is available solely through private companies like BCBSNC Medicare requires that all companies that provide Medicare Part D coverage offer the Medicare standard coverage Companies may also choose to provide enhanced coverage like the Blue Medicare Rx Enhanced Plan

Designed to make prescriptions more affordableBlue Cross and Blue Shield of North Carolina (BCBSNC) offers Medicare prescription drug coverage with more than 1800 drugs covered in our Blue Medicare Enhanced Plan and more than 1000 drugs covered in our Blue Medicare Standard Plan to help you pay for prescription drugs at local and network pharmacies and through mail order Sometimes referred to as Medicare Part D Medicare prescription drug coverage must be approved by Medicare and provided through private companies like BCBSNC Coverage is designed to make filling prescriptions more affordable

Preferred Pharmacy NetworkAt BCBSNC we offer two Medicare Prescription Drug Plans Blue Medicare RxSM Standard and Blue Medicare RxSM Enhanced BCBSNCrsquos Preferred Pharmacy Network is designed to help save you money on your prescription copays This select network of national and local independent pharmacies has worked with BCBSNC to get you the savings and value that you looking for by offering lower costs and better value from your prescription plan without sacrificing convenience

Footnotes 1 Blue Cross and Blue Shield of North Carolina is a PDP plan with a Medicare contract Enrollment in Blue

Cross and Blue Shield of North Carolina depends on contract renewal 2 You must join a plan to receive the coverage unless you are eligible for both Medicare and Medicaid

Contact your State Medicaid or medical assistance office if you have questions about your eligibility

PAG E 3 of 40

Cat

astr

ophi

c

Cov

erag

e G

ap

Compare Part D benefitsPlease refer to the charts to review our Blue Medicare Rx plans The total amount you spendon prescription drugs increases during the calendar year as you move through some or all of thephases of coverage Remember you must always present your planrsquos member ID card to fill yourprescriptions Note For members who qualify for low-income assistance benefits may vary

PREFERRED PHARMACY NETWORK BENEFITS

Our preferred network includes CVS Walmart Kerr and Epic pharmacies

Plan Feature Standard $4100month Enhanced $7860month

Drug list (Formulary) We cover a comprehensive list of Medicare Part D covered drugs

Tier 1 Preferred Generic $4 $3

Tier 2 Non-preferred generic $10 $6

Tier 3 Preferred brand $40 $30

Tier 4 Non-preferred brand $85 $70 Tier 5 Specialty You pay 29 coinsurance You pay 33 coinsurance

Annual deductible You pay a $145 annual deductible You pay $0You pay no annual deductible

Init

ial

Retail You + Plan = $2850 You pay the copayment per 30-day supply orcoinsurance for your drugs and the plan pays the remainder untiltotal drug costs reach $2850

Preferred Mail Order

You pay $4 for a 30-day supply ofpreferred generic drugs

You pay $3 for a 30-day supply ofpreferred generic drugs

You pay $0 copay for a 60- or 90-day supply of preferred genericdrugs at our preferred mail-order pharmacy through the initial phase

Cov

erag

e G

ap Retail

You pay 72 on all genericdrugs You receive a discountfor brand-name drugs

You pay a $3 copayment for Tier 1preferred generic drugs You pay72 for all other generic drugs

Preferred Mail Order

You pay 72 for all generic drugs You pay a $3 copayment for Tier 1preferred generic drugs You pay72 for all other generic drugs

You receive a discount for brand-name drugs You remain in thecoverage gap until your yearly out-of-pocket drug costs (not includingpremiums) equal $4550

Cat

astr

ophi

c

Catastrophic coverage

You pay 5 After you reach $4550 in out-of-pocket costs the plan pays the majority of the drug costs until the end of the year You pay the greater of $255 for generic $635 for brand name or 5 of the total drug cost

PAGE 4 of 40

NON-PREFERRED PHARMACY NETWORK BENEFITS

Plan Feature Standard $4100month Enhanced $7860month

Drug list (Formulary) Includes nearly 100 of the drugs covered by Medicare Part D

Tier 1 Preferred Generic $10 $8

Tier 2 Non-preferred generic $33 $20

Tier 3 Preferred brand $45 $45

Tier 4 Non-preferred brand $95 $95

Tier 5 Specialty You pay 29 coinsurance You pay 33 coinsurance

Init

ial

Retail You + Plan = $2850 You pay the copayment per 30-day supply orcoinsurance for your drugs and the plan pays the remainder untiltotal drug costs reach $2850

Non-preferred Mail Order

You pay $10 for a 30-day supply ofpreferred generic drugs

You pay $8 for a 30-day supply ofpreferred generic drugs

You pay 3 times the copay for a 90-day supply of preferred generic andbrand-name drugs at a non-preferred mail-order pharmacy throughthe initial phase

Cov

erag

e G

ap

Retail You pay 72 on all generic drugsYou receive a discount for brand-name drugs

You pay a $8 copayment for Tier 1 preferred generic drugs You pay 72 for all other generic drugs

Non-preferred Mail Order

You pay 72 on all generic drugs You pay $8 for Tier 1 preferred generic drugs and you pay 72 for all other generic drugs

You receive a discount for brand-name drugs You remain in the coverage gap until your yearly out-of-pocket drug costs (not including premiums) equal $4550

Cat

astr

ophi

c

Catastrophic coverage

You pay 5 After you reach $4550 in out-of-pocket costs the plan pays the majority of the drug costs until the end of the year You pay the greater of $255 for generic $635 for brand-name or 5 of the total drug cost

Compare Part D benefits (continued)

PAGE 5 of 40 Y0079_6534 CMS Accepted 11262013

Prescription drugs covered by the plans

Here are three ways to find out if your prescriptions are

covered by our formulary

Search online for specific drugs by visiting the Blue Medicare Rx section of bcbsnccommedicare (You may also download the complete formulary in PDF format)

Call or visit your local Authorized Sales Representative

Call 1-800-478-0583 7 days a week 8 amndash8 pm and speak to an authorized agent Hearing and speech impaired (TTYTDD) users call 1-800-922-3140Representatives can help you determine whether or not a specific drug is covered

Extensive network of pharmacies makes getting your medications easyExcept under certain non-routine circumstances you need to use a network pharmacy to obtain the full benefit of your Medicare Part D plan Quantity limitations and restrictions may apply BCBSNC offers an extensive network of pharmacies of the following types retail national chain mail-order extended supply home infusion long-term care or Indian Health ServiceTribalUrban Indian Health Program (ITU) pharmacies

You can use our mail-order pharmacyOur plans also offer the convenience of using preferred mail-order pharmacy at a reduced cost to you Pay a reduced copayment for a 90-day

supply of covered brand drugs up to $2850 of total drug costs You pay $3 copayment for Enhanced and $4 for Standard plans for a 30-day supply of all preferred generic drugs ordered through mail-order

Many of the most commonly used drugs are coveredThe Blue Medicare Rx Enhanced Plan and the Blue Medicare Rx Standard Plan have a formulary that lists the generic brand-name and specialty drugs covered by the plans The formulary covers many drugs eligible for coverage under Medicare Part D ndash more than 1800 drugs on our Enhanced Plan and more than 1000 drugs on our Standard Plan

Medicare Part D plans do not cover certain drugs or classes of drugs that are excluded by law such as over-the-counter medications and prescription vitamins

Compare Medicare drug plans+ Find out which Medicare drug plans

are available in your area+ Learn about plan benefits and costs+ Compare ratings by quality premium

estimated annual costs and more+ Compare BCBSNC plan ratings

included in the Enrollment kit or visit wwwmedicaregov Plan ratings are available upon request for this plan by calling BCBSNC directly at 1-800-478-0583 7 days a week 8 amndash8 pm For the hearing and speech impaired (TTYTDD) call 1-800-922-3104

Medicare evaluates plans based on a 5-Star ratingsystem Star Ratings are calculated each year and may change from one year to the next

1

2

3

PAGE 6 of 40

Call your State Medicaid Office

Hearing and speech impairedMon through Fri 1-800-772-1213

40 of 7 PAGE

2

3

Security Administrationrsquos postage-paid envelope assistance fill it out and return it in the Social If you receive an application for financial

3 for financial assistance$26580 (for a married couple) you may qualify under $13300 (for a single person) or under stocks but not counting your home or car) are If your resources (including your savings and +

3 with youhalf support to other family members living

Paying for Medicare Part D coverage

Footnotes 3 Medicaregov website June 2013

Here are three ways to find out if you qualify to receive

financial assistance

Call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day 7 days a week Hearing and speech impaired(TTYTDD) users call 1-877-486-2048 Or visit Medicarersquos Web sitewwwmedicaregov and click the

rdquoPrescription Drug Planrdquo link

Call the Social Security Administration atbetween 7 am and 7 pm

(TTYTDD users) call 1-800-325-0778

1

Premiums for Medicare Part D plans vary based on the plan that you choose If you have Medicare Part B you must continueto pay your Medicare Part B premium if nototherwise paid for under Medicaid or byanother third party

You may qualify for extra help to pay for plan premiums and prescription drug costs If you have Medicare and have limited incomeand resources you may qualify for specialfinancial assistance to help you pay for yourMedicare Part D plan premiums and prescriptiondrug costs The amount of assistance you qualifyfor will depend on your income and resources

+If your annual income is below $17235 for asingle person (or $23265 if you are marriedand living with your spouse) for 2013 youmay qualify for financial assistance Slightlyhigher income levels may apply if you provide

Prescription drugs coveredby the plans

Here are three ways to enroll in Medicare Part D

Enroll directly with the Medicare Part Dplan you choose via paper or onlineapplication at bcbsnccommedicare

Visit the Centers for Medicare amp Medicaid Services (CMS) Online Enrollment Center at wwwmedicaregov

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

+ Generally you can join or change Medicare Part D plans during the annual enrollment period ndash any time between October 15 and December 7 with an effective date of January 1 of the following year

+ If you are enrolling at a different time of year the effective date of your coverage will depend on your situation and whether or not you qualify for a special election period

+ You may only be enrolled in one Medicare Part D plan at a time

+ If you enroll in a stand-alone Medicare Part D plan while enrolled in a Medicare Advantage plan you will be disenrolled automatically from the Medicare Advantage plan and returned to Original Medicare

PAGE 8 of 40

How to join

Choose a plan Before you select a plan gather anydocumentation you may have on yourprescription drug purchases over thepast year This information will helpyou determine how much you mightsave with a Medicare Part D plan Thenyou can choose a plan that best fits yourneeds and your budget

Enroll in a plan Then you must fill out an enrollment formYou will be enrolled in the Medicare Part D plan you select and Medicare will beinformed that you have enrolled Inaddition to the paper enrollment formBlue Medicare Rx applicants can enrollonline at bcbsnccommedicare

Changing Medicare Part D plans Congress designed Medicare prescriptiondrug coverage to work on an annualenrollment cycle This means that each yearyou will have the option to remain with yourexisting Medicare Part D plan or change plansbetween October 15 and December 7

You may also have another opportunityduring the year to switch plans underlimited circumstances For example if youmove out of your planrsquos service area you willhave an opportunity to choose another planthat serves your new area Please contactBCBSNC if you would like more informationabout other situations in which you mayqualify for coverage or changes in coverageoutside the annual enrollment cycle

Important enrollment information

1

2

3

PAGE 9 of 40

You can join a Medicare Part D plan any time during your initial enrollment period for Medicare Generally a Medicare beneficiaryrsquos initial enrollment is a seven-month period three months prior to becoming Medicare eligible the month you become Medicare eligible and three months following the month you become Medicare eligible

If you were eligible for Medicare on or prior to January 1 2006 and did not enroll in a Medicare Part D plan or Medicare Advantage Prescription Drug Plan by May 15 2006 you may have to pay a penalty for late enrollment This penalty will not apply to Medicare beneficiaries who have equal or better prescription drug benefits through their

employer or another plan As of January 1 2009 these penalties no longer apply to Medicare individuals with Low Income Subsidy (LIS)

The penalty was designed to help hold down the overall costs of the drug program and is similar to the penalty imposed for late enrollment in Medicare Part B The late penalty equals one percent of the national base benchmark premium amount for each month that enrollment is delayed beyond your initial enrollment period For example if you delay enrollment in a Medicare Part D plan for two years you will pay the regular monthly plan premium plus 24 percent of the national base benchmark premium each month

Penalties for late enrollment

Important dates+ October 15 2013

First day you can enroll in a Medicare Part D plan for 2014 or the first day you can elect to switch to a different Medicare Part D plan (unless you qualify for a special election period)

+ December 7 2013 Last day you can enroll in a Medicare Part D plan for 2014 or the last day you can elect to switch to a different Medicare Part D plan (unless you qualify for a special election period)

+ January 1 2014 First day coverage begins (if you join a plan or switch plans by December 7 2013)

PAGE 10 of 40

(PDP)

Important information about our Medicare prescription drug plans

U5073b 813

Y0079_6248 CMS Accepted 08102013 PAGE 11 of 40

Important information

Eligibility for beneficiaries

Eligibility for beneficiaries Everyone who is entitled to Medicare benefitsunder Part A or enrolled in Part B is eligible forthis coverage however you are not enrolledautomatically You must join a plan to receivethe coverage6 This voluntary program is coveragethat you may choose to purchase annually Thisproduct is available to Medicare beneficiariesliving in North Carolina

Additional enrollment criteria You may enroll in only one Part D plan at a timeIf you are enrolled in a Medicare Advantage planyour enrollment in either of the PDP plans fromBlue Cross and Blue Shield of North Carolina (BCBSNC) may automatically disenroll you fromyour Medicare Advantage Plan and re-enroll youin Original Medicare for medical coverage Checkwith your plan for more information

Financial assistance

Financial assistance available People with limited incomes may qualify forExtra Help to pay for their prescription drugcosts If you qualify Medicare could pay for upto seventy-five (75) percent or more of your drugcosts including monthly prescriptiondrug premiums annual deductibles andco-insurance Additionally those who qualifywill not be subject to the coverage gap or a lateenrollment penalty Many people are eligiblefor these savings and donrsquot even know itFor more information about this Extra Helpcontact your local Social Security office or call1-800-MEDICARE (1-800-633-4227) 24 hours perday 7 days per week TTYTDD users shouldcall 1-877-486-2048

This document may be available in alternate formats upon request

Footnote 6 You must join a plan to receive the coverage unless

you are eligible for both Medicare and Medicaid Contact your State Medicaid or medical assistance office if you have questions about your eligibility

Social Security Administration

Phone 1-800-772-1213

TTYTDD 1-800-325-0778

Hours MondayndashFriday7 amndash7 pm

PAGE 12 of 40

Medicare

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

TTYTDD 1-877-486-2048

Hours 24 hours a day7 days a week

Important information

Pharmacy network

Pharmacy network information Our network includes a variety of pharmaciesincluding retail home infusion IndianTribalUrban organizations extended supply and long-term care pharmacies In order to obtain thegreatest savings on your prescription medicationsplease visit one of our preferred network providers(CVS WalMart Kerr and Epic Pharmacies) Formore information about our pharmacy networkand out-of-network policies please see our contactinformation below

Mail order contact information For information on our mail order service or to obtain forms please contact us at

Coverage determination

What is a coverage determination When we make a coverage determination weare making a decision about whether or not toprovide or pay for a Part D drug and what yourshare of the cost is for the drug (also see thedescription of the exceptions process) You mustcontact us if you would like to request a coveragedetermination including an exception Youcannot request an appeal if we have not issueda coverage determination

Mail order contact information

Phone 1-888-247-4142

TTYTDD 1-888-247-4145

Hours 7 days a week8 amndash8 pm

Mail BCBSNC Customer Service PO Box 17509 Winston-Salem NC 27116-7509

Online For a comprehensive list ofall pharmacies please visitbcbsnccommedicare

Examples of when you may ask us for a coverage determination

If you are not getting a prescription drug thatyou believe may be covered by us

If you have received a Part D prescription drugthat you believe may be covered by us while youwere a member but we have refused to pay forthe drug

If you are being told that coverage for a Part Dprescription drug that you have been gettingwill be reduced or stopped and you believe youhave special circumstances that should excludeyou from the reductionnon-coverage

If there is a limit on the quantity (or dose) of thedrug and you disagree with the requirement ordosage limitation

If you bought a drug at a pharmacy that isnot in our network and you want to requestreimbursement for the expense

PAGE 13 of 40

Important information

Coverage determination (continued)

How do I make a request for coverage determination Standard To ask for a standard decision you oryour appointed representative may call ourCustomer Service Department at the numberslisted on the back cover You can also mail a written request to the below address

Fast To ask for a fast decision you your physicianor your appointed representative may call theCustomer Service Department at the numbers listedon the back cover You can also mail a written request to the below address

Standard Generally we must give you our decisionno later than 72 hours after we have received yourrequest but we will make it sooner if your healthcondition requires

Fast If you get a fast review we will give you ourdecision within 24 hours after you or your doctor askfor a fast review mdash sooner if your health requires

PAGE 14 of 40

Contact information

Mail BCBSNC PO Box 17509 Winston-Salem NC 27116-7509

Fax Request 1-888-446-8440

Hours MondayndashFriday8 amndash5 pm

Note You cannot ask for a fast decision on a requestfor coverage of a drug already purchased

For some reviews we may require a supportingstatement from your doctor that explains why the drugyou are asking coverage for is medically necessary

After regular business hours you should consultwith a network pharmacy regarding your need for anemergency or temporary supply of medication untilyou can contact the Plan the next business day Youmay also call our Customer Service Department andleave a message on the Part D After Hours ExceptionRequest voicemail Be sure to ask for a ldquofastrdquoldquoexpeditedrdquo or ldquo24-hourrdquo review

When will I hear back with a decision

Important information

Exceptions process

What is an exception request Exception requests are a kind of coveragedetermination You your authorized representativeor your prescribing physician may request anexception to seek coverage of a drug that

+ Is not on the formulary (list of drugsthe plan covers)

+ Requires prior authorization + Has quantity limitations

Example of an exception request If the Planrsquos formulary does not include a drug thatyou or your prescribing physician feel is necessarythen you or your prescribing physician may requestan exception so that you may obtain coverage ofthis drug If the Plan does not grant the requestedexception then you or your prescribing physicianmay file an appeal

How do I make an exception request You or your prescribing physician may request anexception to the coverage rules for your MedicarePrescription Drug Plan A specific form is notrequired for you to make an exception requestThe request must include your prescribingphysicianrsquos statement that heshe has determinedthat the preferred drug either would not be aseffective or would have adverse effects for you

For your convenience forms are available at bcbsnccomcontentmedicarememberindexhtm

Contact information

Mail BCBSNC Attn PDP Exception RequestsPO Box 17509 Winston-Salem NC 27116-7509

Phone 1-888-247-4142

Physicians call 1-888-298-7552

TTYTDD 1-888-247-4145

Hours 7 days a week8 amndash8 pm

When will I receive a decision on my exception request If your exception request includes a formularyexception or an exception from utilizationmanagement rules such as dosage or quantitylimits we must make our decision no later than 72 hours after we have received your doctorrsquossupporting statement which explains why thedrug you are asking for is medically necessary

If you have asked for a fast or expedited exceptionrequest we must make our decision no later than24 hours after we get your doctorrsquos supporting statement

You will be notified by phone followed by awritten notice of our decision If the decision is not in your favor you have the right to appeal

PAGE 15 of 40

Important informationAppeals process

What is an appeal An appeal is your opportunity to requesta redetermination of an adverse coveragedetermination which includes denied exception requests

Example of an appeal If we deny your request for an exception to covera non-formulary drug then you may file an appealof the denial An appeal can only be filed afteran exception has been requested and denied bythe Plan

How do I file an appeal If you receive a coverage determination denial youor your appointed representative or your doctor orother prescriber may file an appeal A specific formis not required for you to file an appeal An appealmust be filed within 60 calendar days of the date ofa denial notice and must be in writing unless youare filing an expedited or fast appeal You mustsubmit it via mail fax or in person

When will I receive a decision on my appeal

We will perform a standard review of your appealwithin seven calendar days of receipt of your appealor sooner if your health requires We will reviewrequests for an expedited or fast appeal as soon aspossible but no later than 72 hours following ourreceipt of the request An individual who was notinvolved with your original coverage determinationwill make a decision on your appeal

You will receive a written response to your appealThe decision on an expedited appeal will beprovided by phone followed by the written noticeIf our decision is to deny the appeal the notice willadvise you of your right to submit your appeal to the Independent Review Entity (IRE) with instructionson how to do so If we miss our time frames for claims adjudication or review of the appeal wewill automatically forward the appeal to the IREfor a decision There may be additional levels ofappeal available to you We will inform you of youradditional rights in the notice or you may refer toyour Evidence of Coverage for further details

Contact information

Mail BCBSNC Attn Medicare Appeals amp GrievancesPO Box 17509 Winston-Salem NC 27116-7509

Fax 1-888-375-8836 or 1-336-794-8836

In Person

BCBSNC 5660 University PkwyWinston-Salem NC 27105

PAGE 16 of 40

Important information

Grievance process

What is a grievance A grievance is a complaint that you may file ifyou are dissatisfied with the Plan or a contractedprovider for reasons other than a decision ona coverage determination Grievances alsoinclude complaints regarding the timelinessappropriateness access to or setting of a coveredprescription drug

Example of a grievance If you are dissatisfied with the service you receivedfrom a pharmacist or plan representative then youcould file a grievance

How do I file a grievance The grievance must be filed within 60 days after theevent or incident that caused you to be dissatisfiedA specific form is not required for you to file agrievance You or your appointed representativemay file a grievance via the phone by mail faxor in person

When will I receive a decision on my grievance The resolution of a grievance will be made asquickly as your concern requires but no more than30 calendar days after our receipt of the grievanceWe may extend the time frame by up to 14 calendardays if you request the extension or if we justify aneed for additional information and the delay is inyour best interest

If you request a written response to an oralgrievance one will be provided within 30 days afterreceipt of the grievance A written response will beprovided to all written grievances Our decision ona grievance is final and is not subject to an appeal

You have the right to an expedited review ofa grievance concerning our refusal to grant anexpedited coverage determination or expeditedappeal This type of grievance will be responded towithin 24 hours after our receipt of the grievance

Contact information

Phone 1-888-247-4142

Fax 1-888-375-8836 or 1-336-794-8836

Hours 7 days a week8 amndash8 pm

Mail BCBSNC Attn Medicare Appeals amp GrievancesPO Box 17509 Winston-Salem NC 27116-7509

In Person

BCBSNC 5660 University PkwyWinston-Salem NC 27105

PAGE 17 of 40

Important information

Quality improvement

What if I have a concern about the quality of services I received If you have a concern relating to the quality of services that you received under the Medicare Part D planthen in addition to our review you can also request review by the following organizations

The Carolinas Center for Medical Excellence (CCME) Quality Improvement Organization (QIO) in North Carolina CCME formerly known as Medical Review ofNorth Carolina Inc is a nonprofit medical carequality improvement organization CCME has beendesignated by the Centers for Medicare amp MedicaidServices as the Quality Improvement Organization(QIO) for North Carolina The QIO conducts casereviews to ensure that Medicare beneficiaries receive the quality of medical care that they expect andare entitled to CCME serves as an independentimpartial third party to review Medicare beneficiarycomplaints

Quality of care complaints filed with the QIO mustbe made in writing to the address below Assistanceis available via phone or online

The Carolinas Center for Medical Excellence (CCME)

Mail CCME 100 Regency Forest DriveSuite 200 Cary NC 27518-8598

Phone 1-919-380-9860 or 1-800-682-2650

TTYTDD 1-800-735-2962

Hours MondayndashFriday8 amndash5 pm

Web inquiries wwwccmemedicareorg

Seniorsrsquo Health Insurance Information Program (SHIIP) SHIIP is a state consumer division of the North Carolina Department of Insurance SHIIP assistssenior citizens with Medicare Medicare Part D Medicare Advantage Medicare supplementsMedicare fraud and abuse and long-term careinsurance questions Assistance is available viaphone or online

Seniorsrsquo Health Insurance Information Program (SHIIP)

Phone 1-800-443-9354

TYYTDD 1-800-735-2962

Hours MondayndashFriday8 amndash5 pm

Email ncshiipncdoigov

Online wwwncshiipcom

PAGE 18 of 40

Important information

Additional information

Notice of possible contract termination BCBSNC has a contract with the Centers for Medicare amp Medicaid Services (CMS) the government agencythat runs Medicare to provide a Medicare PrescriptionDrug Plan (PDP) This contract renews each year At theend of each year the contract is reviewed and eitherBCBSNC or CMS can decide to end it Members will get 90 days advance written notice in this situationIt is also possible for our contract to end at some othertime If the contract is going to end we will generallytell members 90 days in advance Advance notice maybe as little as 30 days or even fewer days if CMS endsour contract in the middle of the year In this noticewe would provide a written description of alternativesavailable for obtaining qualified prescription drugcoverage in North Carolina We are also required tonotify the general public of a contract termination vialocal newspapers

If BCBSNC decides to stop offering the Medicare PDPor change our service area so that it no longer includesthe area where you live membership in BCBSNCrsquosMedicare PDP will end for everyone in that servicearea and members will have to change to a differentprescription drug plan Members will continue to getprescription drugs through BCBSNCrsquos Medicare PDPuntil the contract ends

PAGE 19 of 40

Important information

For more information

Blue Cross and Blue Shield of North Carolina

Phone 1-800-478-0583

TTYTDD 1-800-922-3140

Hours 7 days a week8 amndash8 pm

Online bcbsnccommedicare

Medicare

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

TTYTDD 1-877-486-2048

Hours 7 days a week24 hours a day

Online wwwmedicaregovClick the ldquoPrescription Drug Planrdquo link

Blue Cross and Blue Shield of North Carolina is a PDP plan with a Medicare contract Enrollment in Blue Cross and Blue Shield of North Carolina depends on contract renewal Benefits formulary pharmacy network premium andor copaymentscoinsurance may change on January 1 2015 Please contact BCBSNC for details

An independent licensee of the Blue Cross and Blue Shield Association

PAGE 20 of 40

(PDP)

2014 Summary of benefits for our Medicare prescription drug plans (Enhanced and Standard)

Contract S5540 Plans 004 and 002 January 1 2014 ndash December 31 2014

U5073c 813

PAGE 21 of 40Y0079_6249 CMS Accepted 09112013

Introduction to the

Summary of benefits for (PDP)

Thank you for your interest in Blue Medicare Rx(PDP) plans Our plans are offered by Blue Crossand Blue Shield of North Carolina a MedicarePrescription Drug Plan that contracts with theFederal government This Summary of Benefits tellsyou some features of our plans It doesnrsquot list everydrug we cover every limitation or exclusionTo get a complete list of our benefits please callBlue Medicare Rx and ask for the ldquoEvidence of Coveragerdquo You have choices in your Medicare prescription drug coverage As a Medicare beneficiary you can choose fromdifferent Medicare prescription drug coverageoptions One option is to get prescription drugcoverage through a Medicare Prescription DrugPlan like Blue Medicare Rx plans Another optionis to get your prescription drug coverage througha Medicare Advantage Plan that offers prescriptiondrug coverage You make the choice How can I compare my options The charts in this booklet list some important drugbenefits You can use this Summary of Benefitsto compare the benefits offered by Blue MedicareRx plans to the benefits offered by other MedicarePrescription Drug Plans or Medicare AdvantagePlans with prescription drug coverage Where are Blue Medicare Rx Plans available The service area for these plans includesNorth Carolina You must live in one of these areas to join one of these plans Who is eligible to join You can join one of these plans if you are entitled toMedicare Part A andor enrolled in Medicare Part Band live in the service area If you are enrolled in an MA coordinated care(HMO or PPO) plan or an MA PFFS plan thatincludes Medicare prescription drugs you maynot enroll in a PDP unless you disenroll from theHMO PPO or MA PFFS plan Enrollees in a private Fee-for-Service plan (PFFS)that does not provide Medicare prescription drugcoverage or an MA Medical Savings Account (MSA)plan may enroll in a PDP Enrollees in an 1876 Costplan may enroll in a PDP

Where can I get my prescriptions Blue Medicare Rx plans have formed a network ofpharmacies You must use a network pharmacyto receive plan benefits We will not pay foryour prescriptions if you use an out-of-networkpharmacy except in certain cases Blue Medicare Rx plans have a list of preferredpharmacies At these pharmacies you may getyour drugs at a lower co-pay or coinsuranceYou may go to a non-preferred pharmacy but youmay have to pay more for your prescription drugs The pharmacies in our network can change at anytime You can ask for a Pharmacy Directory or visit usat wwwmyprimecomMyRxMyPrimeMedicareDpharmacyBCBSNC Our customer service number is listed at the end of this introduction What if my doctor prescribes less than a monthrsquos supply In consultation with your doctor or pharmacist youmay receive less than a monthrsquos supply of certaindrugs Also if you live in a long-term care facilityyou will receive less than a monthrsquos supply of certainbrand [and generic] drugs Dispensing fewer drugs ata time can help reduce cost and waste in the MedicarePart D program when this is medically appropriate The amount you pay in these circumstances willdepend on whether you are responsible for payingcoinsurance (a percentage of the cost of the drug) ora copay (a flat dollar amount for the drug) If youare responsible for coinsurance for the drug youwill continue to pay the applicable percentage ofthe drug cost If you are responsible for a copay forthe drug a ldquodaily cost-sharing raterdquo will be appliedIf your doctor decides to continue the drug after atrial period you should not pay more for a monthrsquossupply than you otherwise would have paid Contactyour plan if you have questions about cost-sharingwhen less than a one-month supply is dispensed Does my plan cover Medicare Part B or Part D drugs Blue Medicare Rx Standard and Enhanced plans donot cover drugs that are covered under Medicare PartB as prescribed and dispensed Generally we onlycover drugs vaccines biological products and medicalsupplies associated with the delivery of insulin thatare covered under the Medicare Prescription DrugBenefit (Part D) and that are on our formulary

PAG E 22 of 40

Introduction to the

Summary of benefits (continued)

What is a prescription drug formulary Blue Medicare Rx plans use a formularyA formulary is a list of drugs covered by your planto meet patient needs We may periodically addremove or make changes to coverage limitationson certain drugs or change how much you pay for adrug If we make any formulary change that limitsour membersrsquo ability to fill their prescriptions wewill notify the affected members before the changeis made We will send a formulary to you andyou can see our complete formulary on our Website at httpwwwbcbsnccomcontentmedicareformulary-homehtm If you are currently taking a drug that is not on ourformulary or subject to additional requirements orlimits you may be able to get a temporary supply ofthe drug You can contact us to request an exceptionor switch to an alternative drug listed on ourformulary with your physicianrsquos help Call us to seeif you can get a temporary supply of the drug or formore details about our drug transition policy What should I do if I have other insurance in addition to Medicare If you have a Medigap (Medicare Supplement)policy that includes prescription drug coverage youmust contact your Medigap Issuer to let them knowthat you have joined a Medicare Prescription DrugPlan If you decide to keep your current Medigapsupplement policy your Medigap Issuer willremove the prescription drug coverage portion ofyour policy Call your Medigap Issuer for details If you or your spouse has or is able to get employergroup coverage you should talk to your employerto find out how your benefits will be affected if youjoin a Blue Medicare Rx plan Get this informationbefore you decide to enroll in this plan

How can I get extra help with my prescription drug plan costs or get extra help with other Medicare costs You may be able to get extra help to pay for yourprescription drug premiums and costs as well as gethelp with other Medicare costs To see if you qualifyfor getting extra help call +1-800-MEDICARE (1-800-633-4227)

TTYTDD users should call 1-877-486-204824 hours a day7 days a week and seehttpwwwmedicaregov lsquoPrograms for Peoplewith Limited Income and Resourcesrsquo in the publication Medicare amp You

+The Social Security Administration at1-800-772-1213 between 7 am and 7 pmMonday through Friday TTYTDD usersshould call 1-800-325-0778 or

+Your State Medicaid Office What are my protections in this plan All Medicare Prescription Drug Plans agree to stayin the program for a full calendar year at a timePlan benefits and cost-sharing may change fromcalendar year to calendar year Each year plans candecide whether to continue to participate with theMedicare Prescription Drug Program A plan maycontinue in their entire service area (geographicarea where the plan accepts members) or choose tocontinue only in certain areas Also Medicare maydecide to end a contract with a plan Even if yourMedicare Prescription Plan leaves the program youwill not lose Medicare coverage If a plan decidesnot to continue for an additional calendar year itmust send you a letter at least 90 days before yourcoverage will end The letter will explain youroptions for Medicare coverage in your area As a member of a Blue Medicare Rx plan you havethe right to request a coverage determination whichincludes the right to request an exception the right tofile an appeal if we deny coverage for a prescriptiondrug and the right to file a grievance You havethe right to request a coverage determination if youwant us to cover a Part D drug that you believeshould be covered An exception is a type of coveragedetermination You may ask us for an exception ifyou believe you need a drug that is not on our list

PAG E 23 of 40

Medicare prescription drug coverage helps cover your drug costs

Filling your PrescriptionsOur pharmacy network includes most national chains as well as local pharmacies around the state You can save even more time and avoid the line by using our mail order pharmacy services Your prescriptions will be mailed to your door and we handle the paperwork for you When you enroll in one of our Medicare Prescription Drug (Part D) Plans we verify enrollment with Medicare and Medicare helps pay your prescription costs Please review the preferred and non-preferred charts to understand our Part D benefits

Eligibility and types of coverage for beneficiariesEveryone who is entitled to Medicare benefits under Part A or enrolled in Part B is eligible for this coverage however you are not enrolled automatically You must join a plan to receive the coverage2 This voluntary program is coverage that you may choose to purchase annually

Unlike Medicare Part A and Part B this coverage is available solely through private companies like BCBSNC Medicare requires that all companies that provide Medicare Part D coverage offer the Medicare standard coverage Companies may also choose to provide enhanced coverage like the Blue Medicare Rx Enhanced Plan

Designed to make prescriptions more affordableBlue Cross and Blue Shield of North Carolina (BCBSNC) offers Medicare prescription drug coverage with more than 1800 drugs covered in our Blue Medicare Enhanced Plan and more than 1000 drugs covered in our Blue Medicare Standard Plan to help you pay for prescription drugs at local and network pharmacies and through mail order Sometimes referred to as Medicare Part D Medicare prescription drug coverage must be approved by Medicare and provided through private companies like BCBSNC Coverage is designed to make filling prescriptions more affordable

Preferred Pharmacy NetworkAt BCBSNC we offer two Medicare Prescription Drug Plans Blue Medicare RxSM Standard and Blue Medicare RxSM Enhanced BCBSNCrsquos Preferred Pharmacy Network is designed to help save you money on your prescription copays This select network of national and local independent pharmacies has worked with BCBSNC to get you the savings and value that you looking for by offering lower costs and better value from your prescription plan without sacrificing convenience

Footnotes 1 Blue Cross and Blue Shield of North Carolina is a PDP plan with a Medicare contract Enrollment in Blue

Cross and Blue Shield of North Carolina depends on contract renewal 2 You must join a plan to receive the coverage unless you are eligible for both Medicare and Medicaid

Contact your State Medicaid or medical assistance office if you have questions about your eligibility

PAG E 3 of 40

Cat

astr

ophi

c

Cov

erag

e G

ap

Compare Part D benefitsPlease refer to the charts to review our Blue Medicare Rx plans The total amount you spendon prescription drugs increases during the calendar year as you move through some or all of thephases of coverage Remember you must always present your planrsquos member ID card to fill yourprescriptions Note For members who qualify for low-income assistance benefits may vary

PREFERRED PHARMACY NETWORK BENEFITS

Our preferred network includes CVS Walmart Kerr and Epic pharmacies

Plan Feature Standard $4100month Enhanced $7860month

Drug list (Formulary) We cover a comprehensive list of Medicare Part D covered drugs

Tier 1 Preferred Generic $4 $3

Tier 2 Non-preferred generic $10 $6

Tier 3 Preferred brand $40 $30

Tier 4 Non-preferred brand $85 $70 Tier 5 Specialty You pay 29 coinsurance You pay 33 coinsurance

Annual deductible You pay a $145 annual deductible You pay $0You pay no annual deductible

Init

ial

Retail You + Plan = $2850 You pay the copayment per 30-day supply orcoinsurance for your drugs and the plan pays the remainder untiltotal drug costs reach $2850

Preferred Mail Order

You pay $4 for a 30-day supply ofpreferred generic drugs

You pay $3 for a 30-day supply ofpreferred generic drugs

You pay $0 copay for a 60- or 90-day supply of preferred genericdrugs at our preferred mail-order pharmacy through the initial phase

Cov

erag

e G

ap Retail

You pay 72 on all genericdrugs You receive a discountfor brand-name drugs

You pay a $3 copayment for Tier 1preferred generic drugs You pay72 for all other generic drugs

Preferred Mail Order

You pay 72 for all generic drugs You pay a $3 copayment for Tier 1preferred generic drugs You pay72 for all other generic drugs

You receive a discount for brand-name drugs You remain in thecoverage gap until your yearly out-of-pocket drug costs (not includingpremiums) equal $4550

Cat

astr

ophi

c

Catastrophic coverage

You pay 5 After you reach $4550 in out-of-pocket costs the plan pays the majority of the drug costs until the end of the year You pay the greater of $255 for generic $635 for brand name or 5 of the total drug cost

PAGE 4 of 40

NON-PREFERRED PHARMACY NETWORK BENEFITS

Plan Feature Standard $4100month Enhanced $7860month

Drug list (Formulary) Includes nearly 100 of the drugs covered by Medicare Part D

Tier 1 Preferred Generic $10 $8

Tier 2 Non-preferred generic $33 $20

Tier 3 Preferred brand $45 $45

Tier 4 Non-preferred brand $95 $95

Tier 5 Specialty You pay 29 coinsurance You pay 33 coinsurance

Init

ial

Retail You + Plan = $2850 You pay the copayment per 30-day supply orcoinsurance for your drugs and the plan pays the remainder untiltotal drug costs reach $2850

Non-preferred Mail Order

You pay $10 for a 30-day supply ofpreferred generic drugs

You pay $8 for a 30-day supply ofpreferred generic drugs

You pay 3 times the copay for a 90-day supply of preferred generic andbrand-name drugs at a non-preferred mail-order pharmacy throughthe initial phase

Cov

erag

e G

ap

Retail You pay 72 on all generic drugsYou receive a discount for brand-name drugs

You pay a $8 copayment for Tier 1 preferred generic drugs You pay 72 for all other generic drugs

Non-preferred Mail Order

You pay 72 on all generic drugs You pay $8 for Tier 1 preferred generic drugs and you pay 72 for all other generic drugs

You receive a discount for brand-name drugs You remain in the coverage gap until your yearly out-of-pocket drug costs (not including premiums) equal $4550

Cat

astr

ophi

c

Catastrophic coverage

You pay 5 After you reach $4550 in out-of-pocket costs the plan pays the majority of the drug costs until the end of the year You pay the greater of $255 for generic $635 for brand-name or 5 of the total drug cost

Compare Part D benefits (continued)

PAGE 5 of 40 Y0079_6534 CMS Accepted 11262013

Prescription drugs covered by the plans

Here are three ways to find out if your prescriptions are

covered by our formulary

Search online for specific drugs by visiting the Blue Medicare Rx section of bcbsnccommedicare (You may also download the complete formulary in PDF format)

Call or visit your local Authorized Sales Representative

Call 1-800-478-0583 7 days a week 8 amndash8 pm and speak to an authorized agent Hearing and speech impaired (TTYTDD) users call 1-800-922-3140Representatives can help you determine whether or not a specific drug is covered

Extensive network of pharmacies makes getting your medications easyExcept under certain non-routine circumstances you need to use a network pharmacy to obtain the full benefit of your Medicare Part D plan Quantity limitations and restrictions may apply BCBSNC offers an extensive network of pharmacies of the following types retail national chain mail-order extended supply home infusion long-term care or Indian Health ServiceTribalUrban Indian Health Program (ITU) pharmacies

You can use our mail-order pharmacyOur plans also offer the convenience of using preferred mail-order pharmacy at a reduced cost to you Pay a reduced copayment for a 90-day

supply of covered brand drugs up to $2850 of total drug costs You pay $3 copayment for Enhanced and $4 for Standard plans for a 30-day supply of all preferred generic drugs ordered through mail-order

Many of the most commonly used drugs are coveredThe Blue Medicare Rx Enhanced Plan and the Blue Medicare Rx Standard Plan have a formulary that lists the generic brand-name and specialty drugs covered by the plans The formulary covers many drugs eligible for coverage under Medicare Part D ndash more than 1800 drugs on our Enhanced Plan and more than 1000 drugs on our Standard Plan

Medicare Part D plans do not cover certain drugs or classes of drugs that are excluded by law such as over-the-counter medications and prescription vitamins

Compare Medicare drug plans+ Find out which Medicare drug plans

are available in your area+ Learn about plan benefits and costs+ Compare ratings by quality premium

estimated annual costs and more+ Compare BCBSNC plan ratings

included in the Enrollment kit or visit wwwmedicaregov Plan ratings are available upon request for this plan by calling BCBSNC directly at 1-800-478-0583 7 days a week 8 amndash8 pm For the hearing and speech impaired (TTYTDD) call 1-800-922-3104

Medicare evaluates plans based on a 5-Star ratingsystem Star Ratings are calculated each year and may change from one year to the next

1

2

3

PAGE 6 of 40

Call your State Medicaid Office

Hearing and speech impairedMon through Fri 1-800-772-1213

40 of 7 PAGE

2

3

Security Administrationrsquos postage-paid envelope assistance fill it out and return it in the Social If you receive an application for financial

3 for financial assistance$26580 (for a married couple) you may qualify under $13300 (for a single person) or under stocks but not counting your home or car) are If your resources (including your savings and +

3 with youhalf support to other family members living

Paying for Medicare Part D coverage

Footnotes 3 Medicaregov website June 2013

Here are three ways to find out if you qualify to receive

financial assistance

Call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day 7 days a week Hearing and speech impaired(TTYTDD) users call 1-877-486-2048 Or visit Medicarersquos Web sitewwwmedicaregov and click the

rdquoPrescription Drug Planrdquo link

Call the Social Security Administration atbetween 7 am and 7 pm

(TTYTDD users) call 1-800-325-0778

1

Premiums for Medicare Part D plans vary based on the plan that you choose If you have Medicare Part B you must continueto pay your Medicare Part B premium if nototherwise paid for under Medicaid or byanother third party

You may qualify for extra help to pay for plan premiums and prescription drug costs If you have Medicare and have limited incomeand resources you may qualify for specialfinancial assistance to help you pay for yourMedicare Part D plan premiums and prescriptiondrug costs The amount of assistance you qualifyfor will depend on your income and resources

+If your annual income is below $17235 for asingle person (or $23265 if you are marriedand living with your spouse) for 2013 youmay qualify for financial assistance Slightlyhigher income levels may apply if you provide

Prescription drugs coveredby the plans

Here are three ways to enroll in Medicare Part D

Enroll directly with the Medicare Part Dplan you choose via paper or onlineapplication at bcbsnccommedicare

Visit the Centers for Medicare amp Medicaid Services (CMS) Online Enrollment Center at wwwmedicaregov

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

+ Generally you can join or change Medicare Part D plans during the annual enrollment period ndash any time between October 15 and December 7 with an effective date of January 1 of the following year

+ If you are enrolling at a different time of year the effective date of your coverage will depend on your situation and whether or not you qualify for a special election period

+ You may only be enrolled in one Medicare Part D plan at a time

+ If you enroll in a stand-alone Medicare Part D plan while enrolled in a Medicare Advantage plan you will be disenrolled automatically from the Medicare Advantage plan and returned to Original Medicare

PAGE 8 of 40

How to join

Choose a plan Before you select a plan gather anydocumentation you may have on yourprescription drug purchases over thepast year This information will helpyou determine how much you mightsave with a Medicare Part D plan Thenyou can choose a plan that best fits yourneeds and your budget

Enroll in a plan Then you must fill out an enrollment formYou will be enrolled in the Medicare Part D plan you select and Medicare will beinformed that you have enrolled Inaddition to the paper enrollment formBlue Medicare Rx applicants can enrollonline at bcbsnccommedicare

Changing Medicare Part D plans Congress designed Medicare prescriptiondrug coverage to work on an annualenrollment cycle This means that each yearyou will have the option to remain with yourexisting Medicare Part D plan or change plansbetween October 15 and December 7

You may also have another opportunityduring the year to switch plans underlimited circumstances For example if youmove out of your planrsquos service area you willhave an opportunity to choose another planthat serves your new area Please contactBCBSNC if you would like more informationabout other situations in which you mayqualify for coverage or changes in coverageoutside the annual enrollment cycle

Important enrollment information

1

2

3

PAGE 9 of 40

You can join a Medicare Part D plan any time during your initial enrollment period for Medicare Generally a Medicare beneficiaryrsquos initial enrollment is a seven-month period three months prior to becoming Medicare eligible the month you become Medicare eligible and three months following the month you become Medicare eligible

If you were eligible for Medicare on or prior to January 1 2006 and did not enroll in a Medicare Part D plan or Medicare Advantage Prescription Drug Plan by May 15 2006 you may have to pay a penalty for late enrollment This penalty will not apply to Medicare beneficiaries who have equal or better prescription drug benefits through their

employer or another plan As of January 1 2009 these penalties no longer apply to Medicare individuals with Low Income Subsidy (LIS)

The penalty was designed to help hold down the overall costs of the drug program and is similar to the penalty imposed for late enrollment in Medicare Part B The late penalty equals one percent of the national base benchmark premium amount for each month that enrollment is delayed beyond your initial enrollment period For example if you delay enrollment in a Medicare Part D plan for two years you will pay the regular monthly plan premium plus 24 percent of the national base benchmark premium each month

Penalties for late enrollment

Important dates+ October 15 2013

First day you can enroll in a Medicare Part D plan for 2014 or the first day you can elect to switch to a different Medicare Part D plan (unless you qualify for a special election period)

+ December 7 2013 Last day you can enroll in a Medicare Part D plan for 2014 or the last day you can elect to switch to a different Medicare Part D plan (unless you qualify for a special election period)

+ January 1 2014 First day coverage begins (if you join a plan or switch plans by December 7 2013)

PAGE 10 of 40

(PDP)

Important information about our Medicare prescription drug plans

U5073b 813

Y0079_6248 CMS Accepted 08102013 PAGE 11 of 40

Important information

Eligibility for beneficiaries

Eligibility for beneficiaries Everyone who is entitled to Medicare benefitsunder Part A or enrolled in Part B is eligible forthis coverage however you are not enrolledautomatically You must join a plan to receivethe coverage6 This voluntary program is coveragethat you may choose to purchase annually Thisproduct is available to Medicare beneficiariesliving in North Carolina

Additional enrollment criteria You may enroll in only one Part D plan at a timeIf you are enrolled in a Medicare Advantage planyour enrollment in either of the PDP plans fromBlue Cross and Blue Shield of North Carolina (BCBSNC) may automatically disenroll you fromyour Medicare Advantage Plan and re-enroll youin Original Medicare for medical coverage Checkwith your plan for more information

Financial assistance

Financial assistance available People with limited incomes may qualify forExtra Help to pay for their prescription drugcosts If you qualify Medicare could pay for upto seventy-five (75) percent or more of your drugcosts including monthly prescriptiondrug premiums annual deductibles andco-insurance Additionally those who qualifywill not be subject to the coverage gap or a lateenrollment penalty Many people are eligiblefor these savings and donrsquot even know itFor more information about this Extra Helpcontact your local Social Security office or call1-800-MEDICARE (1-800-633-4227) 24 hours perday 7 days per week TTYTDD users shouldcall 1-877-486-2048

This document may be available in alternate formats upon request

Footnote 6 You must join a plan to receive the coverage unless

you are eligible for both Medicare and Medicaid Contact your State Medicaid or medical assistance office if you have questions about your eligibility

Social Security Administration

Phone 1-800-772-1213

TTYTDD 1-800-325-0778

Hours MondayndashFriday7 amndash7 pm

PAGE 12 of 40

Medicare

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

TTYTDD 1-877-486-2048

Hours 24 hours a day7 days a week

Important information

Pharmacy network

Pharmacy network information Our network includes a variety of pharmaciesincluding retail home infusion IndianTribalUrban organizations extended supply and long-term care pharmacies In order to obtain thegreatest savings on your prescription medicationsplease visit one of our preferred network providers(CVS WalMart Kerr and Epic Pharmacies) Formore information about our pharmacy networkand out-of-network policies please see our contactinformation below

Mail order contact information For information on our mail order service or to obtain forms please contact us at

Coverage determination

What is a coverage determination When we make a coverage determination weare making a decision about whether or not toprovide or pay for a Part D drug and what yourshare of the cost is for the drug (also see thedescription of the exceptions process) You mustcontact us if you would like to request a coveragedetermination including an exception Youcannot request an appeal if we have not issueda coverage determination

Mail order contact information

Phone 1-888-247-4142

TTYTDD 1-888-247-4145

Hours 7 days a week8 amndash8 pm

Mail BCBSNC Customer Service PO Box 17509 Winston-Salem NC 27116-7509

Online For a comprehensive list ofall pharmacies please visitbcbsnccommedicare

Examples of when you may ask us for a coverage determination

If you are not getting a prescription drug thatyou believe may be covered by us

If you have received a Part D prescription drugthat you believe may be covered by us while youwere a member but we have refused to pay forthe drug

If you are being told that coverage for a Part Dprescription drug that you have been gettingwill be reduced or stopped and you believe youhave special circumstances that should excludeyou from the reductionnon-coverage

If there is a limit on the quantity (or dose) of thedrug and you disagree with the requirement ordosage limitation

If you bought a drug at a pharmacy that isnot in our network and you want to requestreimbursement for the expense

PAGE 13 of 40

Important information

Coverage determination (continued)

How do I make a request for coverage determination Standard To ask for a standard decision you oryour appointed representative may call ourCustomer Service Department at the numberslisted on the back cover You can also mail a written request to the below address

Fast To ask for a fast decision you your physicianor your appointed representative may call theCustomer Service Department at the numbers listedon the back cover You can also mail a written request to the below address

Standard Generally we must give you our decisionno later than 72 hours after we have received yourrequest but we will make it sooner if your healthcondition requires

Fast If you get a fast review we will give you ourdecision within 24 hours after you or your doctor askfor a fast review mdash sooner if your health requires

PAGE 14 of 40

Contact information

Mail BCBSNC PO Box 17509 Winston-Salem NC 27116-7509

Fax Request 1-888-446-8440

Hours MondayndashFriday8 amndash5 pm

Note You cannot ask for a fast decision on a requestfor coverage of a drug already purchased

For some reviews we may require a supportingstatement from your doctor that explains why the drugyou are asking coverage for is medically necessary

After regular business hours you should consultwith a network pharmacy regarding your need for anemergency or temporary supply of medication untilyou can contact the Plan the next business day Youmay also call our Customer Service Department andleave a message on the Part D After Hours ExceptionRequest voicemail Be sure to ask for a ldquofastrdquoldquoexpeditedrdquo or ldquo24-hourrdquo review

When will I hear back with a decision

Important information

Exceptions process

What is an exception request Exception requests are a kind of coveragedetermination You your authorized representativeor your prescribing physician may request anexception to seek coverage of a drug that

+ Is not on the formulary (list of drugsthe plan covers)

+ Requires prior authorization + Has quantity limitations

Example of an exception request If the Planrsquos formulary does not include a drug thatyou or your prescribing physician feel is necessarythen you or your prescribing physician may requestan exception so that you may obtain coverage ofthis drug If the Plan does not grant the requestedexception then you or your prescribing physicianmay file an appeal

How do I make an exception request You or your prescribing physician may request anexception to the coverage rules for your MedicarePrescription Drug Plan A specific form is notrequired for you to make an exception requestThe request must include your prescribingphysicianrsquos statement that heshe has determinedthat the preferred drug either would not be aseffective or would have adverse effects for you

For your convenience forms are available at bcbsnccomcontentmedicarememberindexhtm

Contact information

Mail BCBSNC Attn PDP Exception RequestsPO Box 17509 Winston-Salem NC 27116-7509

Phone 1-888-247-4142

Physicians call 1-888-298-7552

TTYTDD 1-888-247-4145

Hours 7 days a week8 amndash8 pm

When will I receive a decision on my exception request If your exception request includes a formularyexception or an exception from utilizationmanagement rules such as dosage or quantitylimits we must make our decision no later than 72 hours after we have received your doctorrsquossupporting statement which explains why thedrug you are asking for is medically necessary

If you have asked for a fast or expedited exceptionrequest we must make our decision no later than24 hours after we get your doctorrsquos supporting statement

You will be notified by phone followed by awritten notice of our decision If the decision is not in your favor you have the right to appeal

PAGE 15 of 40

Important informationAppeals process

What is an appeal An appeal is your opportunity to requesta redetermination of an adverse coveragedetermination which includes denied exception requests

Example of an appeal If we deny your request for an exception to covera non-formulary drug then you may file an appealof the denial An appeal can only be filed afteran exception has been requested and denied bythe Plan

How do I file an appeal If you receive a coverage determination denial youor your appointed representative or your doctor orother prescriber may file an appeal A specific formis not required for you to file an appeal An appealmust be filed within 60 calendar days of the date ofa denial notice and must be in writing unless youare filing an expedited or fast appeal You mustsubmit it via mail fax or in person

When will I receive a decision on my appeal

We will perform a standard review of your appealwithin seven calendar days of receipt of your appealor sooner if your health requires We will reviewrequests for an expedited or fast appeal as soon aspossible but no later than 72 hours following ourreceipt of the request An individual who was notinvolved with your original coverage determinationwill make a decision on your appeal

You will receive a written response to your appealThe decision on an expedited appeal will beprovided by phone followed by the written noticeIf our decision is to deny the appeal the notice willadvise you of your right to submit your appeal to the Independent Review Entity (IRE) with instructionson how to do so If we miss our time frames for claims adjudication or review of the appeal wewill automatically forward the appeal to the IREfor a decision There may be additional levels ofappeal available to you We will inform you of youradditional rights in the notice or you may refer toyour Evidence of Coverage for further details

Contact information

Mail BCBSNC Attn Medicare Appeals amp GrievancesPO Box 17509 Winston-Salem NC 27116-7509

Fax 1-888-375-8836 or 1-336-794-8836

In Person

BCBSNC 5660 University PkwyWinston-Salem NC 27105

PAGE 16 of 40

Important information

Grievance process

What is a grievance A grievance is a complaint that you may file ifyou are dissatisfied with the Plan or a contractedprovider for reasons other than a decision ona coverage determination Grievances alsoinclude complaints regarding the timelinessappropriateness access to or setting of a coveredprescription drug

Example of a grievance If you are dissatisfied with the service you receivedfrom a pharmacist or plan representative then youcould file a grievance

How do I file a grievance The grievance must be filed within 60 days after theevent or incident that caused you to be dissatisfiedA specific form is not required for you to file agrievance You or your appointed representativemay file a grievance via the phone by mail faxor in person

When will I receive a decision on my grievance The resolution of a grievance will be made asquickly as your concern requires but no more than30 calendar days after our receipt of the grievanceWe may extend the time frame by up to 14 calendardays if you request the extension or if we justify aneed for additional information and the delay is inyour best interest

If you request a written response to an oralgrievance one will be provided within 30 days afterreceipt of the grievance A written response will beprovided to all written grievances Our decision ona grievance is final and is not subject to an appeal

You have the right to an expedited review ofa grievance concerning our refusal to grant anexpedited coverage determination or expeditedappeal This type of grievance will be responded towithin 24 hours after our receipt of the grievance

Contact information

Phone 1-888-247-4142

Fax 1-888-375-8836 or 1-336-794-8836

Hours 7 days a week8 amndash8 pm

Mail BCBSNC Attn Medicare Appeals amp GrievancesPO Box 17509 Winston-Salem NC 27116-7509

In Person

BCBSNC 5660 University PkwyWinston-Salem NC 27105

PAGE 17 of 40

Important information

Quality improvement

What if I have a concern about the quality of services I received If you have a concern relating to the quality of services that you received under the Medicare Part D planthen in addition to our review you can also request review by the following organizations

The Carolinas Center for Medical Excellence (CCME) Quality Improvement Organization (QIO) in North Carolina CCME formerly known as Medical Review ofNorth Carolina Inc is a nonprofit medical carequality improvement organization CCME has beendesignated by the Centers for Medicare amp MedicaidServices as the Quality Improvement Organization(QIO) for North Carolina The QIO conducts casereviews to ensure that Medicare beneficiaries receive the quality of medical care that they expect andare entitled to CCME serves as an independentimpartial third party to review Medicare beneficiarycomplaints

Quality of care complaints filed with the QIO mustbe made in writing to the address below Assistanceis available via phone or online

The Carolinas Center for Medical Excellence (CCME)

Mail CCME 100 Regency Forest DriveSuite 200 Cary NC 27518-8598

Phone 1-919-380-9860 or 1-800-682-2650

TTYTDD 1-800-735-2962

Hours MondayndashFriday8 amndash5 pm

Web inquiries wwwccmemedicareorg

Seniorsrsquo Health Insurance Information Program (SHIIP) SHIIP is a state consumer division of the North Carolina Department of Insurance SHIIP assistssenior citizens with Medicare Medicare Part D Medicare Advantage Medicare supplementsMedicare fraud and abuse and long-term careinsurance questions Assistance is available viaphone or online

Seniorsrsquo Health Insurance Information Program (SHIIP)

Phone 1-800-443-9354

TYYTDD 1-800-735-2962

Hours MondayndashFriday8 amndash5 pm

Email ncshiipncdoigov

Online wwwncshiipcom

PAGE 18 of 40

Important information

Additional information

Notice of possible contract termination BCBSNC has a contract with the Centers for Medicare amp Medicaid Services (CMS) the government agencythat runs Medicare to provide a Medicare PrescriptionDrug Plan (PDP) This contract renews each year At theend of each year the contract is reviewed and eitherBCBSNC or CMS can decide to end it Members will get 90 days advance written notice in this situationIt is also possible for our contract to end at some othertime If the contract is going to end we will generallytell members 90 days in advance Advance notice maybe as little as 30 days or even fewer days if CMS endsour contract in the middle of the year In this noticewe would provide a written description of alternativesavailable for obtaining qualified prescription drugcoverage in North Carolina We are also required tonotify the general public of a contract termination vialocal newspapers

If BCBSNC decides to stop offering the Medicare PDPor change our service area so that it no longer includesthe area where you live membership in BCBSNCrsquosMedicare PDP will end for everyone in that servicearea and members will have to change to a differentprescription drug plan Members will continue to getprescription drugs through BCBSNCrsquos Medicare PDPuntil the contract ends

PAGE 19 of 40

Important information

For more information

Blue Cross and Blue Shield of North Carolina

Phone 1-800-478-0583

TTYTDD 1-800-922-3140

Hours 7 days a week8 amndash8 pm

Online bcbsnccommedicare

Medicare

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

TTYTDD 1-877-486-2048

Hours 7 days a week24 hours a day

Online wwwmedicaregovClick the ldquoPrescription Drug Planrdquo link

Blue Cross and Blue Shield of North Carolina is a PDP plan with a Medicare contract Enrollment in Blue Cross and Blue Shield of North Carolina depends on contract renewal Benefits formulary pharmacy network premium andor copaymentscoinsurance may change on January 1 2015 Please contact BCBSNC for details

An independent licensee of the Blue Cross and Blue Shield Association

PAGE 20 of 40

(PDP)

2014 Summary of benefits for our Medicare prescription drug plans (Enhanced and Standard)

Contract S5540 Plans 004 and 002 January 1 2014 ndash December 31 2014

U5073c 813

PAGE 21 of 40Y0079_6249 CMS Accepted 09112013

Introduction to the

Summary of benefits for (PDP)

Thank you for your interest in Blue Medicare Rx(PDP) plans Our plans are offered by Blue Crossand Blue Shield of North Carolina a MedicarePrescription Drug Plan that contracts with theFederal government This Summary of Benefits tellsyou some features of our plans It doesnrsquot list everydrug we cover every limitation or exclusionTo get a complete list of our benefits please callBlue Medicare Rx and ask for the ldquoEvidence of Coveragerdquo You have choices in your Medicare prescription drug coverage As a Medicare beneficiary you can choose fromdifferent Medicare prescription drug coverageoptions One option is to get prescription drugcoverage through a Medicare Prescription DrugPlan like Blue Medicare Rx plans Another optionis to get your prescription drug coverage througha Medicare Advantage Plan that offers prescriptiondrug coverage You make the choice How can I compare my options The charts in this booklet list some important drugbenefits You can use this Summary of Benefitsto compare the benefits offered by Blue MedicareRx plans to the benefits offered by other MedicarePrescription Drug Plans or Medicare AdvantagePlans with prescription drug coverage Where are Blue Medicare Rx Plans available The service area for these plans includesNorth Carolina You must live in one of these areas to join one of these plans Who is eligible to join You can join one of these plans if you are entitled toMedicare Part A andor enrolled in Medicare Part Band live in the service area If you are enrolled in an MA coordinated care(HMO or PPO) plan or an MA PFFS plan thatincludes Medicare prescription drugs you maynot enroll in a PDP unless you disenroll from theHMO PPO or MA PFFS plan Enrollees in a private Fee-for-Service plan (PFFS)that does not provide Medicare prescription drugcoverage or an MA Medical Savings Account (MSA)plan may enroll in a PDP Enrollees in an 1876 Costplan may enroll in a PDP

Where can I get my prescriptions Blue Medicare Rx plans have formed a network ofpharmacies You must use a network pharmacyto receive plan benefits We will not pay foryour prescriptions if you use an out-of-networkpharmacy except in certain cases Blue Medicare Rx plans have a list of preferredpharmacies At these pharmacies you may getyour drugs at a lower co-pay or coinsuranceYou may go to a non-preferred pharmacy but youmay have to pay more for your prescription drugs The pharmacies in our network can change at anytime You can ask for a Pharmacy Directory or visit usat wwwmyprimecomMyRxMyPrimeMedicareDpharmacyBCBSNC Our customer service number is listed at the end of this introduction What if my doctor prescribes less than a monthrsquos supply In consultation with your doctor or pharmacist youmay receive less than a monthrsquos supply of certaindrugs Also if you live in a long-term care facilityyou will receive less than a monthrsquos supply of certainbrand [and generic] drugs Dispensing fewer drugs ata time can help reduce cost and waste in the MedicarePart D program when this is medically appropriate The amount you pay in these circumstances willdepend on whether you are responsible for payingcoinsurance (a percentage of the cost of the drug) ora copay (a flat dollar amount for the drug) If youare responsible for coinsurance for the drug youwill continue to pay the applicable percentage ofthe drug cost If you are responsible for a copay forthe drug a ldquodaily cost-sharing raterdquo will be appliedIf your doctor decides to continue the drug after atrial period you should not pay more for a monthrsquossupply than you otherwise would have paid Contactyour plan if you have questions about cost-sharingwhen less than a one-month supply is dispensed Does my plan cover Medicare Part B or Part D drugs Blue Medicare Rx Standard and Enhanced plans donot cover drugs that are covered under Medicare PartB as prescribed and dispensed Generally we onlycover drugs vaccines biological products and medicalsupplies associated with the delivery of insulin thatare covered under the Medicare Prescription DrugBenefit (Part D) and that are on our formulary

PAG E 22 of 40

Introduction to the

Summary of benefits (continued)

What is a prescription drug formulary Blue Medicare Rx plans use a formularyA formulary is a list of drugs covered by your planto meet patient needs We may periodically addremove or make changes to coverage limitationson certain drugs or change how much you pay for adrug If we make any formulary change that limitsour membersrsquo ability to fill their prescriptions wewill notify the affected members before the changeis made We will send a formulary to you andyou can see our complete formulary on our Website at httpwwwbcbsnccomcontentmedicareformulary-homehtm If you are currently taking a drug that is not on ourformulary or subject to additional requirements orlimits you may be able to get a temporary supply ofthe drug You can contact us to request an exceptionor switch to an alternative drug listed on ourformulary with your physicianrsquos help Call us to seeif you can get a temporary supply of the drug or formore details about our drug transition policy What should I do if I have other insurance in addition to Medicare If you have a Medigap (Medicare Supplement)policy that includes prescription drug coverage youmust contact your Medigap Issuer to let them knowthat you have joined a Medicare Prescription DrugPlan If you decide to keep your current Medigapsupplement policy your Medigap Issuer willremove the prescription drug coverage portion ofyour policy Call your Medigap Issuer for details If you or your spouse has or is able to get employergroup coverage you should talk to your employerto find out how your benefits will be affected if youjoin a Blue Medicare Rx plan Get this informationbefore you decide to enroll in this plan

How can I get extra help with my prescription drug plan costs or get extra help with other Medicare costs You may be able to get extra help to pay for yourprescription drug premiums and costs as well as gethelp with other Medicare costs To see if you qualifyfor getting extra help call +1-800-MEDICARE (1-800-633-4227)

TTYTDD users should call 1-877-486-204824 hours a day7 days a week and seehttpwwwmedicaregov lsquoPrograms for Peoplewith Limited Income and Resourcesrsquo in the publication Medicare amp You

+The Social Security Administration at1-800-772-1213 between 7 am and 7 pmMonday through Friday TTYTDD usersshould call 1-800-325-0778 or

+Your State Medicaid Office What are my protections in this plan All Medicare Prescription Drug Plans agree to stayin the program for a full calendar year at a timePlan benefits and cost-sharing may change fromcalendar year to calendar year Each year plans candecide whether to continue to participate with theMedicare Prescription Drug Program A plan maycontinue in their entire service area (geographicarea where the plan accepts members) or choose tocontinue only in certain areas Also Medicare maydecide to end a contract with a plan Even if yourMedicare Prescription Plan leaves the program youwill not lose Medicare coverage If a plan decidesnot to continue for an additional calendar year itmust send you a letter at least 90 days before yourcoverage will end The letter will explain youroptions for Medicare coverage in your area As a member of a Blue Medicare Rx plan you havethe right to request a coverage determination whichincludes the right to request an exception the right tofile an appeal if we deny coverage for a prescriptiondrug and the right to file a grievance You havethe right to request a coverage determination if youwant us to cover a Part D drug that you believeshould be covered An exception is a type of coveragedetermination You may ask us for an exception ifyou believe you need a drug that is not on our list

PAG E 23 of 40

Cat

astr

ophi

c

Cov

erag

e G

ap

Compare Part D benefitsPlease refer to the charts to review our Blue Medicare Rx plans The total amount you spendon prescription drugs increases during the calendar year as you move through some or all of thephases of coverage Remember you must always present your planrsquos member ID card to fill yourprescriptions Note For members who qualify for low-income assistance benefits may vary

PREFERRED PHARMACY NETWORK BENEFITS

Our preferred network includes CVS Walmart Kerr and Epic pharmacies

Plan Feature Standard $4100month Enhanced $7860month

Drug list (Formulary) We cover a comprehensive list of Medicare Part D covered drugs

Tier 1 Preferred Generic $4 $3

Tier 2 Non-preferred generic $10 $6

Tier 3 Preferred brand $40 $30

Tier 4 Non-preferred brand $85 $70 Tier 5 Specialty You pay 29 coinsurance You pay 33 coinsurance

Annual deductible You pay a $145 annual deductible You pay $0You pay no annual deductible

Init

ial

Retail You + Plan = $2850 You pay the copayment per 30-day supply orcoinsurance for your drugs and the plan pays the remainder untiltotal drug costs reach $2850

Preferred Mail Order

You pay $4 for a 30-day supply ofpreferred generic drugs

You pay $3 for a 30-day supply ofpreferred generic drugs

You pay $0 copay for a 60- or 90-day supply of preferred genericdrugs at our preferred mail-order pharmacy through the initial phase

Cov

erag

e G

ap Retail

You pay 72 on all genericdrugs You receive a discountfor brand-name drugs

You pay a $3 copayment for Tier 1preferred generic drugs You pay72 for all other generic drugs

Preferred Mail Order

You pay 72 for all generic drugs You pay a $3 copayment for Tier 1preferred generic drugs You pay72 for all other generic drugs

You receive a discount for brand-name drugs You remain in thecoverage gap until your yearly out-of-pocket drug costs (not includingpremiums) equal $4550

Cat

astr

ophi

c

Catastrophic coverage

You pay 5 After you reach $4550 in out-of-pocket costs the plan pays the majority of the drug costs until the end of the year You pay the greater of $255 for generic $635 for brand name or 5 of the total drug cost

PAGE 4 of 40

NON-PREFERRED PHARMACY NETWORK BENEFITS

Plan Feature Standard $4100month Enhanced $7860month

Drug list (Formulary) Includes nearly 100 of the drugs covered by Medicare Part D

Tier 1 Preferred Generic $10 $8

Tier 2 Non-preferred generic $33 $20

Tier 3 Preferred brand $45 $45

Tier 4 Non-preferred brand $95 $95

Tier 5 Specialty You pay 29 coinsurance You pay 33 coinsurance

Init

ial

Retail You + Plan = $2850 You pay the copayment per 30-day supply orcoinsurance for your drugs and the plan pays the remainder untiltotal drug costs reach $2850

Non-preferred Mail Order

You pay $10 for a 30-day supply ofpreferred generic drugs

You pay $8 for a 30-day supply ofpreferred generic drugs

You pay 3 times the copay for a 90-day supply of preferred generic andbrand-name drugs at a non-preferred mail-order pharmacy throughthe initial phase

Cov

erag

e G

ap

Retail You pay 72 on all generic drugsYou receive a discount for brand-name drugs

You pay a $8 copayment for Tier 1 preferred generic drugs You pay 72 for all other generic drugs

Non-preferred Mail Order

You pay 72 on all generic drugs You pay $8 for Tier 1 preferred generic drugs and you pay 72 for all other generic drugs

You receive a discount for brand-name drugs You remain in the coverage gap until your yearly out-of-pocket drug costs (not including premiums) equal $4550

Cat

astr

ophi

c

Catastrophic coverage

You pay 5 After you reach $4550 in out-of-pocket costs the plan pays the majority of the drug costs until the end of the year You pay the greater of $255 for generic $635 for brand-name or 5 of the total drug cost

Compare Part D benefits (continued)

PAGE 5 of 40 Y0079_6534 CMS Accepted 11262013

Prescription drugs covered by the plans

Here are three ways to find out if your prescriptions are

covered by our formulary

Search online for specific drugs by visiting the Blue Medicare Rx section of bcbsnccommedicare (You may also download the complete formulary in PDF format)

Call or visit your local Authorized Sales Representative

Call 1-800-478-0583 7 days a week 8 amndash8 pm and speak to an authorized agent Hearing and speech impaired (TTYTDD) users call 1-800-922-3140Representatives can help you determine whether or not a specific drug is covered

Extensive network of pharmacies makes getting your medications easyExcept under certain non-routine circumstances you need to use a network pharmacy to obtain the full benefit of your Medicare Part D plan Quantity limitations and restrictions may apply BCBSNC offers an extensive network of pharmacies of the following types retail national chain mail-order extended supply home infusion long-term care or Indian Health ServiceTribalUrban Indian Health Program (ITU) pharmacies

You can use our mail-order pharmacyOur plans also offer the convenience of using preferred mail-order pharmacy at a reduced cost to you Pay a reduced copayment for a 90-day

supply of covered brand drugs up to $2850 of total drug costs You pay $3 copayment for Enhanced and $4 for Standard plans for a 30-day supply of all preferred generic drugs ordered through mail-order

Many of the most commonly used drugs are coveredThe Blue Medicare Rx Enhanced Plan and the Blue Medicare Rx Standard Plan have a formulary that lists the generic brand-name and specialty drugs covered by the plans The formulary covers many drugs eligible for coverage under Medicare Part D ndash more than 1800 drugs on our Enhanced Plan and more than 1000 drugs on our Standard Plan

Medicare Part D plans do not cover certain drugs or classes of drugs that are excluded by law such as over-the-counter medications and prescription vitamins

Compare Medicare drug plans+ Find out which Medicare drug plans

are available in your area+ Learn about plan benefits and costs+ Compare ratings by quality premium

estimated annual costs and more+ Compare BCBSNC plan ratings

included in the Enrollment kit or visit wwwmedicaregov Plan ratings are available upon request for this plan by calling BCBSNC directly at 1-800-478-0583 7 days a week 8 amndash8 pm For the hearing and speech impaired (TTYTDD) call 1-800-922-3104

Medicare evaluates plans based on a 5-Star ratingsystem Star Ratings are calculated each year and may change from one year to the next

1

2

3

PAGE 6 of 40

Call your State Medicaid Office

Hearing and speech impairedMon through Fri 1-800-772-1213

40 of 7 PAGE

2

3

Security Administrationrsquos postage-paid envelope assistance fill it out and return it in the Social If you receive an application for financial

3 for financial assistance$26580 (for a married couple) you may qualify under $13300 (for a single person) or under stocks but not counting your home or car) are If your resources (including your savings and +

3 with youhalf support to other family members living

Paying for Medicare Part D coverage

Footnotes 3 Medicaregov website June 2013

Here are three ways to find out if you qualify to receive

financial assistance

Call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day 7 days a week Hearing and speech impaired(TTYTDD) users call 1-877-486-2048 Or visit Medicarersquos Web sitewwwmedicaregov and click the

rdquoPrescription Drug Planrdquo link

Call the Social Security Administration atbetween 7 am and 7 pm

(TTYTDD users) call 1-800-325-0778

1

Premiums for Medicare Part D plans vary based on the plan that you choose If you have Medicare Part B you must continueto pay your Medicare Part B premium if nototherwise paid for under Medicaid or byanother third party

You may qualify for extra help to pay for plan premiums and prescription drug costs If you have Medicare and have limited incomeand resources you may qualify for specialfinancial assistance to help you pay for yourMedicare Part D plan premiums and prescriptiondrug costs The amount of assistance you qualifyfor will depend on your income and resources

+If your annual income is below $17235 for asingle person (or $23265 if you are marriedand living with your spouse) for 2013 youmay qualify for financial assistance Slightlyhigher income levels may apply if you provide

Prescription drugs coveredby the plans

Here are three ways to enroll in Medicare Part D

Enroll directly with the Medicare Part Dplan you choose via paper or onlineapplication at bcbsnccommedicare

Visit the Centers for Medicare amp Medicaid Services (CMS) Online Enrollment Center at wwwmedicaregov

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

+ Generally you can join or change Medicare Part D plans during the annual enrollment period ndash any time between October 15 and December 7 with an effective date of January 1 of the following year

+ If you are enrolling at a different time of year the effective date of your coverage will depend on your situation and whether or not you qualify for a special election period

+ You may only be enrolled in one Medicare Part D plan at a time

+ If you enroll in a stand-alone Medicare Part D plan while enrolled in a Medicare Advantage plan you will be disenrolled automatically from the Medicare Advantage plan and returned to Original Medicare

PAGE 8 of 40

How to join

Choose a plan Before you select a plan gather anydocumentation you may have on yourprescription drug purchases over thepast year This information will helpyou determine how much you mightsave with a Medicare Part D plan Thenyou can choose a plan that best fits yourneeds and your budget

Enroll in a plan Then you must fill out an enrollment formYou will be enrolled in the Medicare Part D plan you select and Medicare will beinformed that you have enrolled Inaddition to the paper enrollment formBlue Medicare Rx applicants can enrollonline at bcbsnccommedicare

Changing Medicare Part D plans Congress designed Medicare prescriptiondrug coverage to work on an annualenrollment cycle This means that each yearyou will have the option to remain with yourexisting Medicare Part D plan or change plansbetween October 15 and December 7

You may also have another opportunityduring the year to switch plans underlimited circumstances For example if youmove out of your planrsquos service area you willhave an opportunity to choose another planthat serves your new area Please contactBCBSNC if you would like more informationabout other situations in which you mayqualify for coverage or changes in coverageoutside the annual enrollment cycle

Important enrollment information

1

2

3

PAGE 9 of 40

You can join a Medicare Part D plan any time during your initial enrollment period for Medicare Generally a Medicare beneficiaryrsquos initial enrollment is a seven-month period three months prior to becoming Medicare eligible the month you become Medicare eligible and three months following the month you become Medicare eligible

If you were eligible for Medicare on or prior to January 1 2006 and did not enroll in a Medicare Part D plan or Medicare Advantage Prescription Drug Plan by May 15 2006 you may have to pay a penalty for late enrollment This penalty will not apply to Medicare beneficiaries who have equal or better prescription drug benefits through their

employer or another plan As of January 1 2009 these penalties no longer apply to Medicare individuals with Low Income Subsidy (LIS)

The penalty was designed to help hold down the overall costs of the drug program and is similar to the penalty imposed for late enrollment in Medicare Part B The late penalty equals one percent of the national base benchmark premium amount for each month that enrollment is delayed beyond your initial enrollment period For example if you delay enrollment in a Medicare Part D plan for two years you will pay the regular monthly plan premium plus 24 percent of the national base benchmark premium each month

Penalties for late enrollment

Important dates+ October 15 2013

First day you can enroll in a Medicare Part D plan for 2014 or the first day you can elect to switch to a different Medicare Part D plan (unless you qualify for a special election period)

+ December 7 2013 Last day you can enroll in a Medicare Part D plan for 2014 or the last day you can elect to switch to a different Medicare Part D plan (unless you qualify for a special election period)

+ January 1 2014 First day coverage begins (if you join a plan or switch plans by December 7 2013)

PAGE 10 of 40

(PDP)

Important information about our Medicare prescription drug plans

U5073b 813

Y0079_6248 CMS Accepted 08102013 PAGE 11 of 40

Important information

Eligibility for beneficiaries

Eligibility for beneficiaries Everyone who is entitled to Medicare benefitsunder Part A or enrolled in Part B is eligible forthis coverage however you are not enrolledautomatically You must join a plan to receivethe coverage6 This voluntary program is coveragethat you may choose to purchase annually Thisproduct is available to Medicare beneficiariesliving in North Carolina

Additional enrollment criteria You may enroll in only one Part D plan at a timeIf you are enrolled in a Medicare Advantage planyour enrollment in either of the PDP plans fromBlue Cross and Blue Shield of North Carolina (BCBSNC) may automatically disenroll you fromyour Medicare Advantage Plan and re-enroll youin Original Medicare for medical coverage Checkwith your plan for more information

Financial assistance

Financial assistance available People with limited incomes may qualify forExtra Help to pay for their prescription drugcosts If you qualify Medicare could pay for upto seventy-five (75) percent or more of your drugcosts including monthly prescriptiondrug premiums annual deductibles andco-insurance Additionally those who qualifywill not be subject to the coverage gap or a lateenrollment penalty Many people are eligiblefor these savings and donrsquot even know itFor more information about this Extra Helpcontact your local Social Security office or call1-800-MEDICARE (1-800-633-4227) 24 hours perday 7 days per week TTYTDD users shouldcall 1-877-486-2048

This document may be available in alternate formats upon request

Footnote 6 You must join a plan to receive the coverage unless

you are eligible for both Medicare and Medicaid Contact your State Medicaid or medical assistance office if you have questions about your eligibility

Social Security Administration

Phone 1-800-772-1213

TTYTDD 1-800-325-0778

Hours MondayndashFriday7 amndash7 pm

PAGE 12 of 40

Medicare

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

TTYTDD 1-877-486-2048

Hours 24 hours a day7 days a week

Important information

Pharmacy network

Pharmacy network information Our network includes a variety of pharmaciesincluding retail home infusion IndianTribalUrban organizations extended supply and long-term care pharmacies In order to obtain thegreatest savings on your prescription medicationsplease visit one of our preferred network providers(CVS WalMart Kerr and Epic Pharmacies) Formore information about our pharmacy networkand out-of-network policies please see our contactinformation below

Mail order contact information For information on our mail order service or to obtain forms please contact us at

Coverage determination

What is a coverage determination When we make a coverage determination weare making a decision about whether or not toprovide or pay for a Part D drug and what yourshare of the cost is for the drug (also see thedescription of the exceptions process) You mustcontact us if you would like to request a coveragedetermination including an exception Youcannot request an appeal if we have not issueda coverage determination

Mail order contact information

Phone 1-888-247-4142

TTYTDD 1-888-247-4145

Hours 7 days a week8 amndash8 pm

Mail BCBSNC Customer Service PO Box 17509 Winston-Salem NC 27116-7509

Online For a comprehensive list ofall pharmacies please visitbcbsnccommedicare

Examples of when you may ask us for a coverage determination

If you are not getting a prescription drug thatyou believe may be covered by us

If you have received a Part D prescription drugthat you believe may be covered by us while youwere a member but we have refused to pay forthe drug

If you are being told that coverage for a Part Dprescription drug that you have been gettingwill be reduced or stopped and you believe youhave special circumstances that should excludeyou from the reductionnon-coverage

If there is a limit on the quantity (or dose) of thedrug and you disagree with the requirement ordosage limitation

If you bought a drug at a pharmacy that isnot in our network and you want to requestreimbursement for the expense

PAGE 13 of 40

Important information

Coverage determination (continued)

How do I make a request for coverage determination Standard To ask for a standard decision you oryour appointed representative may call ourCustomer Service Department at the numberslisted on the back cover You can also mail a written request to the below address

Fast To ask for a fast decision you your physicianor your appointed representative may call theCustomer Service Department at the numbers listedon the back cover You can also mail a written request to the below address

Standard Generally we must give you our decisionno later than 72 hours after we have received yourrequest but we will make it sooner if your healthcondition requires

Fast If you get a fast review we will give you ourdecision within 24 hours after you or your doctor askfor a fast review mdash sooner if your health requires

PAGE 14 of 40

Contact information

Mail BCBSNC PO Box 17509 Winston-Salem NC 27116-7509

Fax Request 1-888-446-8440

Hours MondayndashFriday8 amndash5 pm

Note You cannot ask for a fast decision on a requestfor coverage of a drug already purchased

For some reviews we may require a supportingstatement from your doctor that explains why the drugyou are asking coverage for is medically necessary

After regular business hours you should consultwith a network pharmacy regarding your need for anemergency or temporary supply of medication untilyou can contact the Plan the next business day Youmay also call our Customer Service Department andleave a message on the Part D After Hours ExceptionRequest voicemail Be sure to ask for a ldquofastrdquoldquoexpeditedrdquo or ldquo24-hourrdquo review

When will I hear back with a decision

Important information

Exceptions process

What is an exception request Exception requests are a kind of coveragedetermination You your authorized representativeor your prescribing physician may request anexception to seek coverage of a drug that

+ Is not on the formulary (list of drugsthe plan covers)

+ Requires prior authorization + Has quantity limitations

Example of an exception request If the Planrsquos formulary does not include a drug thatyou or your prescribing physician feel is necessarythen you or your prescribing physician may requestan exception so that you may obtain coverage ofthis drug If the Plan does not grant the requestedexception then you or your prescribing physicianmay file an appeal

How do I make an exception request You or your prescribing physician may request anexception to the coverage rules for your MedicarePrescription Drug Plan A specific form is notrequired for you to make an exception requestThe request must include your prescribingphysicianrsquos statement that heshe has determinedthat the preferred drug either would not be aseffective or would have adverse effects for you

For your convenience forms are available at bcbsnccomcontentmedicarememberindexhtm

Contact information

Mail BCBSNC Attn PDP Exception RequestsPO Box 17509 Winston-Salem NC 27116-7509

Phone 1-888-247-4142

Physicians call 1-888-298-7552

TTYTDD 1-888-247-4145

Hours 7 days a week8 amndash8 pm

When will I receive a decision on my exception request If your exception request includes a formularyexception or an exception from utilizationmanagement rules such as dosage or quantitylimits we must make our decision no later than 72 hours after we have received your doctorrsquossupporting statement which explains why thedrug you are asking for is medically necessary

If you have asked for a fast or expedited exceptionrequest we must make our decision no later than24 hours after we get your doctorrsquos supporting statement

You will be notified by phone followed by awritten notice of our decision If the decision is not in your favor you have the right to appeal

PAGE 15 of 40

Important informationAppeals process

What is an appeal An appeal is your opportunity to requesta redetermination of an adverse coveragedetermination which includes denied exception requests

Example of an appeal If we deny your request for an exception to covera non-formulary drug then you may file an appealof the denial An appeal can only be filed afteran exception has been requested and denied bythe Plan

How do I file an appeal If you receive a coverage determination denial youor your appointed representative or your doctor orother prescriber may file an appeal A specific formis not required for you to file an appeal An appealmust be filed within 60 calendar days of the date ofa denial notice and must be in writing unless youare filing an expedited or fast appeal You mustsubmit it via mail fax or in person

When will I receive a decision on my appeal

We will perform a standard review of your appealwithin seven calendar days of receipt of your appealor sooner if your health requires We will reviewrequests for an expedited or fast appeal as soon aspossible but no later than 72 hours following ourreceipt of the request An individual who was notinvolved with your original coverage determinationwill make a decision on your appeal

You will receive a written response to your appealThe decision on an expedited appeal will beprovided by phone followed by the written noticeIf our decision is to deny the appeal the notice willadvise you of your right to submit your appeal to the Independent Review Entity (IRE) with instructionson how to do so If we miss our time frames for claims adjudication or review of the appeal wewill automatically forward the appeal to the IREfor a decision There may be additional levels ofappeal available to you We will inform you of youradditional rights in the notice or you may refer toyour Evidence of Coverage for further details

Contact information

Mail BCBSNC Attn Medicare Appeals amp GrievancesPO Box 17509 Winston-Salem NC 27116-7509

Fax 1-888-375-8836 or 1-336-794-8836

In Person

BCBSNC 5660 University PkwyWinston-Salem NC 27105

PAGE 16 of 40

Important information

Grievance process

What is a grievance A grievance is a complaint that you may file ifyou are dissatisfied with the Plan or a contractedprovider for reasons other than a decision ona coverage determination Grievances alsoinclude complaints regarding the timelinessappropriateness access to or setting of a coveredprescription drug

Example of a grievance If you are dissatisfied with the service you receivedfrom a pharmacist or plan representative then youcould file a grievance

How do I file a grievance The grievance must be filed within 60 days after theevent or incident that caused you to be dissatisfiedA specific form is not required for you to file agrievance You or your appointed representativemay file a grievance via the phone by mail faxor in person

When will I receive a decision on my grievance The resolution of a grievance will be made asquickly as your concern requires but no more than30 calendar days after our receipt of the grievanceWe may extend the time frame by up to 14 calendardays if you request the extension or if we justify aneed for additional information and the delay is inyour best interest

If you request a written response to an oralgrievance one will be provided within 30 days afterreceipt of the grievance A written response will beprovided to all written grievances Our decision ona grievance is final and is not subject to an appeal

You have the right to an expedited review ofa grievance concerning our refusal to grant anexpedited coverage determination or expeditedappeal This type of grievance will be responded towithin 24 hours after our receipt of the grievance

Contact information

Phone 1-888-247-4142

Fax 1-888-375-8836 or 1-336-794-8836

Hours 7 days a week8 amndash8 pm

Mail BCBSNC Attn Medicare Appeals amp GrievancesPO Box 17509 Winston-Salem NC 27116-7509

In Person

BCBSNC 5660 University PkwyWinston-Salem NC 27105

PAGE 17 of 40

Important information

Quality improvement

What if I have a concern about the quality of services I received If you have a concern relating to the quality of services that you received under the Medicare Part D planthen in addition to our review you can also request review by the following organizations

The Carolinas Center for Medical Excellence (CCME) Quality Improvement Organization (QIO) in North Carolina CCME formerly known as Medical Review ofNorth Carolina Inc is a nonprofit medical carequality improvement organization CCME has beendesignated by the Centers for Medicare amp MedicaidServices as the Quality Improvement Organization(QIO) for North Carolina The QIO conducts casereviews to ensure that Medicare beneficiaries receive the quality of medical care that they expect andare entitled to CCME serves as an independentimpartial third party to review Medicare beneficiarycomplaints

Quality of care complaints filed with the QIO mustbe made in writing to the address below Assistanceis available via phone or online

The Carolinas Center for Medical Excellence (CCME)

Mail CCME 100 Regency Forest DriveSuite 200 Cary NC 27518-8598

Phone 1-919-380-9860 or 1-800-682-2650

TTYTDD 1-800-735-2962

Hours MondayndashFriday8 amndash5 pm

Web inquiries wwwccmemedicareorg

Seniorsrsquo Health Insurance Information Program (SHIIP) SHIIP is a state consumer division of the North Carolina Department of Insurance SHIIP assistssenior citizens with Medicare Medicare Part D Medicare Advantage Medicare supplementsMedicare fraud and abuse and long-term careinsurance questions Assistance is available viaphone or online

Seniorsrsquo Health Insurance Information Program (SHIIP)

Phone 1-800-443-9354

TYYTDD 1-800-735-2962

Hours MondayndashFriday8 amndash5 pm

Email ncshiipncdoigov

Online wwwncshiipcom

PAGE 18 of 40

Important information

Additional information

Notice of possible contract termination BCBSNC has a contract with the Centers for Medicare amp Medicaid Services (CMS) the government agencythat runs Medicare to provide a Medicare PrescriptionDrug Plan (PDP) This contract renews each year At theend of each year the contract is reviewed and eitherBCBSNC or CMS can decide to end it Members will get 90 days advance written notice in this situationIt is also possible for our contract to end at some othertime If the contract is going to end we will generallytell members 90 days in advance Advance notice maybe as little as 30 days or even fewer days if CMS endsour contract in the middle of the year In this noticewe would provide a written description of alternativesavailable for obtaining qualified prescription drugcoverage in North Carolina We are also required tonotify the general public of a contract termination vialocal newspapers

If BCBSNC decides to stop offering the Medicare PDPor change our service area so that it no longer includesthe area where you live membership in BCBSNCrsquosMedicare PDP will end for everyone in that servicearea and members will have to change to a differentprescription drug plan Members will continue to getprescription drugs through BCBSNCrsquos Medicare PDPuntil the contract ends

PAGE 19 of 40

Important information

For more information

Blue Cross and Blue Shield of North Carolina

Phone 1-800-478-0583

TTYTDD 1-800-922-3140

Hours 7 days a week8 amndash8 pm

Online bcbsnccommedicare

Medicare

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

TTYTDD 1-877-486-2048

Hours 7 days a week24 hours a day

Online wwwmedicaregovClick the ldquoPrescription Drug Planrdquo link

Blue Cross and Blue Shield of North Carolina is a PDP plan with a Medicare contract Enrollment in Blue Cross and Blue Shield of North Carolina depends on contract renewal Benefits formulary pharmacy network premium andor copaymentscoinsurance may change on January 1 2015 Please contact BCBSNC for details

An independent licensee of the Blue Cross and Blue Shield Association

PAGE 20 of 40

(PDP)

2014 Summary of benefits for our Medicare prescription drug plans (Enhanced and Standard)

Contract S5540 Plans 004 and 002 January 1 2014 ndash December 31 2014

U5073c 813

PAGE 21 of 40Y0079_6249 CMS Accepted 09112013

Introduction to the

Summary of benefits for (PDP)

Thank you for your interest in Blue Medicare Rx(PDP) plans Our plans are offered by Blue Crossand Blue Shield of North Carolina a MedicarePrescription Drug Plan that contracts with theFederal government This Summary of Benefits tellsyou some features of our plans It doesnrsquot list everydrug we cover every limitation or exclusionTo get a complete list of our benefits please callBlue Medicare Rx and ask for the ldquoEvidence of Coveragerdquo You have choices in your Medicare prescription drug coverage As a Medicare beneficiary you can choose fromdifferent Medicare prescription drug coverageoptions One option is to get prescription drugcoverage through a Medicare Prescription DrugPlan like Blue Medicare Rx plans Another optionis to get your prescription drug coverage througha Medicare Advantage Plan that offers prescriptiondrug coverage You make the choice How can I compare my options The charts in this booklet list some important drugbenefits You can use this Summary of Benefitsto compare the benefits offered by Blue MedicareRx plans to the benefits offered by other MedicarePrescription Drug Plans or Medicare AdvantagePlans with prescription drug coverage Where are Blue Medicare Rx Plans available The service area for these plans includesNorth Carolina You must live in one of these areas to join one of these plans Who is eligible to join You can join one of these plans if you are entitled toMedicare Part A andor enrolled in Medicare Part Band live in the service area If you are enrolled in an MA coordinated care(HMO or PPO) plan or an MA PFFS plan thatincludes Medicare prescription drugs you maynot enroll in a PDP unless you disenroll from theHMO PPO or MA PFFS plan Enrollees in a private Fee-for-Service plan (PFFS)that does not provide Medicare prescription drugcoverage or an MA Medical Savings Account (MSA)plan may enroll in a PDP Enrollees in an 1876 Costplan may enroll in a PDP

Where can I get my prescriptions Blue Medicare Rx plans have formed a network ofpharmacies You must use a network pharmacyto receive plan benefits We will not pay foryour prescriptions if you use an out-of-networkpharmacy except in certain cases Blue Medicare Rx plans have a list of preferredpharmacies At these pharmacies you may getyour drugs at a lower co-pay or coinsuranceYou may go to a non-preferred pharmacy but youmay have to pay more for your prescription drugs The pharmacies in our network can change at anytime You can ask for a Pharmacy Directory or visit usat wwwmyprimecomMyRxMyPrimeMedicareDpharmacyBCBSNC Our customer service number is listed at the end of this introduction What if my doctor prescribes less than a monthrsquos supply In consultation with your doctor or pharmacist youmay receive less than a monthrsquos supply of certaindrugs Also if you live in a long-term care facilityyou will receive less than a monthrsquos supply of certainbrand [and generic] drugs Dispensing fewer drugs ata time can help reduce cost and waste in the MedicarePart D program when this is medically appropriate The amount you pay in these circumstances willdepend on whether you are responsible for payingcoinsurance (a percentage of the cost of the drug) ora copay (a flat dollar amount for the drug) If youare responsible for coinsurance for the drug youwill continue to pay the applicable percentage ofthe drug cost If you are responsible for a copay forthe drug a ldquodaily cost-sharing raterdquo will be appliedIf your doctor decides to continue the drug after atrial period you should not pay more for a monthrsquossupply than you otherwise would have paid Contactyour plan if you have questions about cost-sharingwhen less than a one-month supply is dispensed Does my plan cover Medicare Part B or Part D drugs Blue Medicare Rx Standard and Enhanced plans donot cover drugs that are covered under Medicare PartB as prescribed and dispensed Generally we onlycover drugs vaccines biological products and medicalsupplies associated with the delivery of insulin thatare covered under the Medicare Prescription DrugBenefit (Part D) and that are on our formulary

PAG E 22 of 40

Introduction to the

Summary of benefits (continued)

What is a prescription drug formulary Blue Medicare Rx plans use a formularyA formulary is a list of drugs covered by your planto meet patient needs We may periodically addremove or make changes to coverage limitationson certain drugs or change how much you pay for adrug If we make any formulary change that limitsour membersrsquo ability to fill their prescriptions wewill notify the affected members before the changeis made We will send a formulary to you andyou can see our complete formulary on our Website at httpwwwbcbsnccomcontentmedicareformulary-homehtm If you are currently taking a drug that is not on ourformulary or subject to additional requirements orlimits you may be able to get a temporary supply ofthe drug You can contact us to request an exceptionor switch to an alternative drug listed on ourformulary with your physicianrsquos help Call us to seeif you can get a temporary supply of the drug or formore details about our drug transition policy What should I do if I have other insurance in addition to Medicare If you have a Medigap (Medicare Supplement)policy that includes prescription drug coverage youmust contact your Medigap Issuer to let them knowthat you have joined a Medicare Prescription DrugPlan If you decide to keep your current Medigapsupplement policy your Medigap Issuer willremove the prescription drug coverage portion ofyour policy Call your Medigap Issuer for details If you or your spouse has or is able to get employergroup coverage you should talk to your employerto find out how your benefits will be affected if youjoin a Blue Medicare Rx plan Get this informationbefore you decide to enroll in this plan

How can I get extra help with my prescription drug plan costs or get extra help with other Medicare costs You may be able to get extra help to pay for yourprescription drug premiums and costs as well as gethelp with other Medicare costs To see if you qualifyfor getting extra help call +1-800-MEDICARE (1-800-633-4227)

TTYTDD users should call 1-877-486-204824 hours a day7 days a week and seehttpwwwmedicaregov lsquoPrograms for Peoplewith Limited Income and Resourcesrsquo in the publication Medicare amp You

+The Social Security Administration at1-800-772-1213 between 7 am and 7 pmMonday through Friday TTYTDD usersshould call 1-800-325-0778 or

+Your State Medicaid Office What are my protections in this plan All Medicare Prescription Drug Plans agree to stayin the program for a full calendar year at a timePlan benefits and cost-sharing may change fromcalendar year to calendar year Each year plans candecide whether to continue to participate with theMedicare Prescription Drug Program A plan maycontinue in their entire service area (geographicarea where the plan accepts members) or choose tocontinue only in certain areas Also Medicare maydecide to end a contract with a plan Even if yourMedicare Prescription Plan leaves the program youwill not lose Medicare coverage If a plan decidesnot to continue for an additional calendar year itmust send you a letter at least 90 days before yourcoverage will end The letter will explain youroptions for Medicare coverage in your area As a member of a Blue Medicare Rx plan you havethe right to request a coverage determination whichincludes the right to request an exception the right tofile an appeal if we deny coverage for a prescriptiondrug and the right to file a grievance You havethe right to request a coverage determination if youwant us to cover a Part D drug that you believeshould be covered An exception is a type of coveragedetermination You may ask us for an exception ifyou believe you need a drug that is not on our list

PAG E 23 of 40

NON-PREFERRED PHARMACY NETWORK BENEFITS

Plan Feature Standard $4100month Enhanced $7860month

Drug list (Formulary) Includes nearly 100 of the drugs covered by Medicare Part D

Tier 1 Preferred Generic $10 $8

Tier 2 Non-preferred generic $33 $20

Tier 3 Preferred brand $45 $45

Tier 4 Non-preferred brand $95 $95

Tier 5 Specialty You pay 29 coinsurance You pay 33 coinsurance

Init

ial

Retail You + Plan = $2850 You pay the copayment per 30-day supply orcoinsurance for your drugs and the plan pays the remainder untiltotal drug costs reach $2850

Non-preferred Mail Order

You pay $10 for a 30-day supply ofpreferred generic drugs

You pay $8 for a 30-day supply ofpreferred generic drugs

You pay 3 times the copay for a 90-day supply of preferred generic andbrand-name drugs at a non-preferred mail-order pharmacy throughthe initial phase

Cov

erag

e G

ap

Retail You pay 72 on all generic drugsYou receive a discount for brand-name drugs

You pay a $8 copayment for Tier 1 preferred generic drugs You pay 72 for all other generic drugs

Non-preferred Mail Order

You pay 72 on all generic drugs You pay $8 for Tier 1 preferred generic drugs and you pay 72 for all other generic drugs

You receive a discount for brand-name drugs You remain in the coverage gap until your yearly out-of-pocket drug costs (not including premiums) equal $4550

Cat

astr

ophi

c

Catastrophic coverage

You pay 5 After you reach $4550 in out-of-pocket costs the plan pays the majority of the drug costs until the end of the year You pay the greater of $255 for generic $635 for brand-name or 5 of the total drug cost

Compare Part D benefits (continued)

PAGE 5 of 40 Y0079_6534 CMS Accepted 11262013

Prescription drugs covered by the plans

Here are three ways to find out if your prescriptions are

covered by our formulary

Search online for specific drugs by visiting the Blue Medicare Rx section of bcbsnccommedicare (You may also download the complete formulary in PDF format)

Call or visit your local Authorized Sales Representative

Call 1-800-478-0583 7 days a week 8 amndash8 pm and speak to an authorized agent Hearing and speech impaired (TTYTDD) users call 1-800-922-3140Representatives can help you determine whether or not a specific drug is covered

Extensive network of pharmacies makes getting your medications easyExcept under certain non-routine circumstances you need to use a network pharmacy to obtain the full benefit of your Medicare Part D plan Quantity limitations and restrictions may apply BCBSNC offers an extensive network of pharmacies of the following types retail national chain mail-order extended supply home infusion long-term care or Indian Health ServiceTribalUrban Indian Health Program (ITU) pharmacies

You can use our mail-order pharmacyOur plans also offer the convenience of using preferred mail-order pharmacy at a reduced cost to you Pay a reduced copayment for a 90-day

supply of covered brand drugs up to $2850 of total drug costs You pay $3 copayment for Enhanced and $4 for Standard plans for a 30-day supply of all preferred generic drugs ordered through mail-order

Many of the most commonly used drugs are coveredThe Blue Medicare Rx Enhanced Plan and the Blue Medicare Rx Standard Plan have a formulary that lists the generic brand-name and specialty drugs covered by the plans The formulary covers many drugs eligible for coverage under Medicare Part D ndash more than 1800 drugs on our Enhanced Plan and more than 1000 drugs on our Standard Plan

Medicare Part D plans do not cover certain drugs or classes of drugs that are excluded by law such as over-the-counter medications and prescription vitamins

Compare Medicare drug plans+ Find out which Medicare drug plans

are available in your area+ Learn about plan benefits and costs+ Compare ratings by quality premium

estimated annual costs and more+ Compare BCBSNC plan ratings

included in the Enrollment kit or visit wwwmedicaregov Plan ratings are available upon request for this plan by calling BCBSNC directly at 1-800-478-0583 7 days a week 8 amndash8 pm For the hearing and speech impaired (TTYTDD) call 1-800-922-3104

Medicare evaluates plans based on a 5-Star ratingsystem Star Ratings are calculated each year and may change from one year to the next

1

2

3

PAGE 6 of 40

Call your State Medicaid Office

Hearing and speech impairedMon through Fri 1-800-772-1213

40 of 7 PAGE

2

3

Security Administrationrsquos postage-paid envelope assistance fill it out and return it in the Social If you receive an application for financial

3 for financial assistance$26580 (for a married couple) you may qualify under $13300 (for a single person) or under stocks but not counting your home or car) are If your resources (including your savings and +

3 with youhalf support to other family members living

Paying for Medicare Part D coverage

Footnotes 3 Medicaregov website June 2013

Here are three ways to find out if you qualify to receive

financial assistance

Call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day 7 days a week Hearing and speech impaired(TTYTDD) users call 1-877-486-2048 Or visit Medicarersquos Web sitewwwmedicaregov and click the

rdquoPrescription Drug Planrdquo link

Call the Social Security Administration atbetween 7 am and 7 pm

(TTYTDD users) call 1-800-325-0778

1

Premiums for Medicare Part D plans vary based on the plan that you choose If you have Medicare Part B you must continueto pay your Medicare Part B premium if nototherwise paid for under Medicaid or byanother third party

You may qualify for extra help to pay for plan premiums and prescription drug costs If you have Medicare and have limited incomeand resources you may qualify for specialfinancial assistance to help you pay for yourMedicare Part D plan premiums and prescriptiondrug costs The amount of assistance you qualifyfor will depend on your income and resources

+If your annual income is below $17235 for asingle person (or $23265 if you are marriedand living with your spouse) for 2013 youmay qualify for financial assistance Slightlyhigher income levels may apply if you provide

Prescription drugs coveredby the plans

Here are three ways to enroll in Medicare Part D

Enroll directly with the Medicare Part Dplan you choose via paper or onlineapplication at bcbsnccommedicare

Visit the Centers for Medicare amp Medicaid Services (CMS) Online Enrollment Center at wwwmedicaregov

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

+ Generally you can join or change Medicare Part D plans during the annual enrollment period ndash any time between October 15 and December 7 with an effective date of January 1 of the following year

+ If you are enrolling at a different time of year the effective date of your coverage will depend on your situation and whether or not you qualify for a special election period

+ You may only be enrolled in one Medicare Part D plan at a time

+ If you enroll in a stand-alone Medicare Part D plan while enrolled in a Medicare Advantage plan you will be disenrolled automatically from the Medicare Advantage plan and returned to Original Medicare

PAGE 8 of 40

How to join

Choose a plan Before you select a plan gather anydocumentation you may have on yourprescription drug purchases over thepast year This information will helpyou determine how much you mightsave with a Medicare Part D plan Thenyou can choose a plan that best fits yourneeds and your budget

Enroll in a plan Then you must fill out an enrollment formYou will be enrolled in the Medicare Part D plan you select and Medicare will beinformed that you have enrolled Inaddition to the paper enrollment formBlue Medicare Rx applicants can enrollonline at bcbsnccommedicare

Changing Medicare Part D plans Congress designed Medicare prescriptiondrug coverage to work on an annualenrollment cycle This means that each yearyou will have the option to remain with yourexisting Medicare Part D plan or change plansbetween October 15 and December 7

You may also have another opportunityduring the year to switch plans underlimited circumstances For example if youmove out of your planrsquos service area you willhave an opportunity to choose another planthat serves your new area Please contactBCBSNC if you would like more informationabout other situations in which you mayqualify for coverage or changes in coverageoutside the annual enrollment cycle

Important enrollment information

1

2

3

PAGE 9 of 40

You can join a Medicare Part D plan any time during your initial enrollment period for Medicare Generally a Medicare beneficiaryrsquos initial enrollment is a seven-month period three months prior to becoming Medicare eligible the month you become Medicare eligible and three months following the month you become Medicare eligible

If you were eligible for Medicare on or prior to January 1 2006 and did not enroll in a Medicare Part D plan or Medicare Advantage Prescription Drug Plan by May 15 2006 you may have to pay a penalty for late enrollment This penalty will not apply to Medicare beneficiaries who have equal or better prescription drug benefits through their

employer or another plan As of January 1 2009 these penalties no longer apply to Medicare individuals with Low Income Subsidy (LIS)

The penalty was designed to help hold down the overall costs of the drug program and is similar to the penalty imposed for late enrollment in Medicare Part B The late penalty equals one percent of the national base benchmark premium amount for each month that enrollment is delayed beyond your initial enrollment period For example if you delay enrollment in a Medicare Part D plan for two years you will pay the regular monthly plan premium plus 24 percent of the national base benchmark premium each month

Penalties for late enrollment

Important dates+ October 15 2013

First day you can enroll in a Medicare Part D plan for 2014 or the first day you can elect to switch to a different Medicare Part D plan (unless you qualify for a special election period)

+ December 7 2013 Last day you can enroll in a Medicare Part D plan for 2014 or the last day you can elect to switch to a different Medicare Part D plan (unless you qualify for a special election period)

+ January 1 2014 First day coverage begins (if you join a plan or switch plans by December 7 2013)

PAGE 10 of 40

(PDP)

Important information about our Medicare prescription drug plans

U5073b 813

Y0079_6248 CMS Accepted 08102013 PAGE 11 of 40

Important information

Eligibility for beneficiaries

Eligibility for beneficiaries Everyone who is entitled to Medicare benefitsunder Part A or enrolled in Part B is eligible forthis coverage however you are not enrolledautomatically You must join a plan to receivethe coverage6 This voluntary program is coveragethat you may choose to purchase annually Thisproduct is available to Medicare beneficiariesliving in North Carolina

Additional enrollment criteria You may enroll in only one Part D plan at a timeIf you are enrolled in a Medicare Advantage planyour enrollment in either of the PDP plans fromBlue Cross and Blue Shield of North Carolina (BCBSNC) may automatically disenroll you fromyour Medicare Advantage Plan and re-enroll youin Original Medicare for medical coverage Checkwith your plan for more information

Financial assistance

Financial assistance available People with limited incomes may qualify forExtra Help to pay for their prescription drugcosts If you qualify Medicare could pay for upto seventy-five (75) percent or more of your drugcosts including monthly prescriptiondrug premiums annual deductibles andco-insurance Additionally those who qualifywill not be subject to the coverage gap or a lateenrollment penalty Many people are eligiblefor these savings and donrsquot even know itFor more information about this Extra Helpcontact your local Social Security office or call1-800-MEDICARE (1-800-633-4227) 24 hours perday 7 days per week TTYTDD users shouldcall 1-877-486-2048

This document may be available in alternate formats upon request

Footnote 6 You must join a plan to receive the coverage unless

you are eligible for both Medicare and Medicaid Contact your State Medicaid or medical assistance office if you have questions about your eligibility

Social Security Administration

Phone 1-800-772-1213

TTYTDD 1-800-325-0778

Hours MondayndashFriday7 amndash7 pm

PAGE 12 of 40

Medicare

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

TTYTDD 1-877-486-2048

Hours 24 hours a day7 days a week

Important information

Pharmacy network

Pharmacy network information Our network includes a variety of pharmaciesincluding retail home infusion IndianTribalUrban organizations extended supply and long-term care pharmacies In order to obtain thegreatest savings on your prescription medicationsplease visit one of our preferred network providers(CVS WalMart Kerr and Epic Pharmacies) Formore information about our pharmacy networkand out-of-network policies please see our contactinformation below

Mail order contact information For information on our mail order service or to obtain forms please contact us at

Coverage determination

What is a coverage determination When we make a coverage determination weare making a decision about whether or not toprovide or pay for a Part D drug and what yourshare of the cost is for the drug (also see thedescription of the exceptions process) You mustcontact us if you would like to request a coveragedetermination including an exception Youcannot request an appeal if we have not issueda coverage determination

Mail order contact information

Phone 1-888-247-4142

TTYTDD 1-888-247-4145

Hours 7 days a week8 amndash8 pm

Mail BCBSNC Customer Service PO Box 17509 Winston-Salem NC 27116-7509

Online For a comprehensive list ofall pharmacies please visitbcbsnccommedicare

Examples of when you may ask us for a coverage determination

If you are not getting a prescription drug thatyou believe may be covered by us

If you have received a Part D prescription drugthat you believe may be covered by us while youwere a member but we have refused to pay forthe drug

If you are being told that coverage for a Part Dprescription drug that you have been gettingwill be reduced or stopped and you believe youhave special circumstances that should excludeyou from the reductionnon-coverage

If there is a limit on the quantity (or dose) of thedrug and you disagree with the requirement ordosage limitation

If you bought a drug at a pharmacy that isnot in our network and you want to requestreimbursement for the expense

PAGE 13 of 40

Important information

Coverage determination (continued)

How do I make a request for coverage determination Standard To ask for a standard decision you oryour appointed representative may call ourCustomer Service Department at the numberslisted on the back cover You can also mail a written request to the below address

Fast To ask for a fast decision you your physicianor your appointed representative may call theCustomer Service Department at the numbers listedon the back cover You can also mail a written request to the below address

Standard Generally we must give you our decisionno later than 72 hours after we have received yourrequest but we will make it sooner if your healthcondition requires

Fast If you get a fast review we will give you ourdecision within 24 hours after you or your doctor askfor a fast review mdash sooner if your health requires

PAGE 14 of 40

Contact information

Mail BCBSNC PO Box 17509 Winston-Salem NC 27116-7509

Fax Request 1-888-446-8440

Hours MondayndashFriday8 amndash5 pm

Note You cannot ask for a fast decision on a requestfor coverage of a drug already purchased

For some reviews we may require a supportingstatement from your doctor that explains why the drugyou are asking coverage for is medically necessary

After regular business hours you should consultwith a network pharmacy regarding your need for anemergency or temporary supply of medication untilyou can contact the Plan the next business day Youmay also call our Customer Service Department andleave a message on the Part D After Hours ExceptionRequest voicemail Be sure to ask for a ldquofastrdquoldquoexpeditedrdquo or ldquo24-hourrdquo review

When will I hear back with a decision

Important information

Exceptions process

What is an exception request Exception requests are a kind of coveragedetermination You your authorized representativeor your prescribing physician may request anexception to seek coverage of a drug that

+ Is not on the formulary (list of drugsthe plan covers)

+ Requires prior authorization + Has quantity limitations

Example of an exception request If the Planrsquos formulary does not include a drug thatyou or your prescribing physician feel is necessarythen you or your prescribing physician may requestan exception so that you may obtain coverage ofthis drug If the Plan does not grant the requestedexception then you or your prescribing physicianmay file an appeal

How do I make an exception request You or your prescribing physician may request anexception to the coverage rules for your MedicarePrescription Drug Plan A specific form is notrequired for you to make an exception requestThe request must include your prescribingphysicianrsquos statement that heshe has determinedthat the preferred drug either would not be aseffective or would have adverse effects for you

For your convenience forms are available at bcbsnccomcontentmedicarememberindexhtm

Contact information

Mail BCBSNC Attn PDP Exception RequestsPO Box 17509 Winston-Salem NC 27116-7509

Phone 1-888-247-4142

Physicians call 1-888-298-7552

TTYTDD 1-888-247-4145

Hours 7 days a week8 amndash8 pm

When will I receive a decision on my exception request If your exception request includes a formularyexception or an exception from utilizationmanagement rules such as dosage or quantitylimits we must make our decision no later than 72 hours after we have received your doctorrsquossupporting statement which explains why thedrug you are asking for is medically necessary

If you have asked for a fast or expedited exceptionrequest we must make our decision no later than24 hours after we get your doctorrsquos supporting statement

You will be notified by phone followed by awritten notice of our decision If the decision is not in your favor you have the right to appeal

PAGE 15 of 40

Important informationAppeals process

What is an appeal An appeal is your opportunity to requesta redetermination of an adverse coveragedetermination which includes denied exception requests

Example of an appeal If we deny your request for an exception to covera non-formulary drug then you may file an appealof the denial An appeal can only be filed afteran exception has been requested and denied bythe Plan

How do I file an appeal If you receive a coverage determination denial youor your appointed representative or your doctor orother prescriber may file an appeal A specific formis not required for you to file an appeal An appealmust be filed within 60 calendar days of the date ofa denial notice and must be in writing unless youare filing an expedited or fast appeal You mustsubmit it via mail fax or in person

When will I receive a decision on my appeal

We will perform a standard review of your appealwithin seven calendar days of receipt of your appealor sooner if your health requires We will reviewrequests for an expedited or fast appeal as soon aspossible but no later than 72 hours following ourreceipt of the request An individual who was notinvolved with your original coverage determinationwill make a decision on your appeal

You will receive a written response to your appealThe decision on an expedited appeal will beprovided by phone followed by the written noticeIf our decision is to deny the appeal the notice willadvise you of your right to submit your appeal to the Independent Review Entity (IRE) with instructionson how to do so If we miss our time frames for claims adjudication or review of the appeal wewill automatically forward the appeal to the IREfor a decision There may be additional levels ofappeal available to you We will inform you of youradditional rights in the notice or you may refer toyour Evidence of Coverage for further details

Contact information

Mail BCBSNC Attn Medicare Appeals amp GrievancesPO Box 17509 Winston-Salem NC 27116-7509

Fax 1-888-375-8836 or 1-336-794-8836

In Person

BCBSNC 5660 University PkwyWinston-Salem NC 27105

PAGE 16 of 40

Important information

Grievance process

What is a grievance A grievance is a complaint that you may file ifyou are dissatisfied with the Plan or a contractedprovider for reasons other than a decision ona coverage determination Grievances alsoinclude complaints regarding the timelinessappropriateness access to or setting of a coveredprescription drug

Example of a grievance If you are dissatisfied with the service you receivedfrom a pharmacist or plan representative then youcould file a grievance

How do I file a grievance The grievance must be filed within 60 days after theevent or incident that caused you to be dissatisfiedA specific form is not required for you to file agrievance You or your appointed representativemay file a grievance via the phone by mail faxor in person

When will I receive a decision on my grievance The resolution of a grievance will be made asquickly as your concern requires but no more than30 calendar days after our receipt of the grievanceWe may extend the time frame by up to 14 calendardays if you request the extension or if we justify aneed for additional information and the delay is inyour best interest

If you request a written response to an oralgrievance one will be provided within 30 days afterreceipt of the grievance A written response will beprovided to all written grievances Our decision ona grievance is final and is not subject to an appeal

You have the right to an expedited review ofa grievance concerning our refusal to grant anexpedited coverage determination or expeditedappeal This type of grievance will be responded towithin 24 hours after our receipt of the grievance

Contact information

Phone 1-888-247-4142

Fax 1-888-375-8836 or 1-336-794-8836

Hours 7 days a week8 amndash8 pm

Mail BCBSNC Attn Medicare Appeals amp GrievancesPO Box 17509 Winston-Salem NC 27116-7509

In Person

BCBSNC 5660 University PkwyWinston-Salem NC 27105

PAGE 17 of 40

Important information

Quality improvement

What if I have a concern about the quality of services I received If you have a concern relating to the quality of services that you received under the Medicare Part D planthen in addition to our review you can also request review by the following organizations

The Carolinas Center for Medical Excellence (CCME) Quality Improvement Organization (QIO) in North Carolina CCME formerly known as Medical Review ofNorth Carolina Inc is a nonprofit medical carequality improvement organization CCME has beendesignated by the Centers for Medicare amp MedicaidServices as the Quality Improvement Organization(QIO) for North Carolina The QIO conducts casereviews to ensure that Medicare beneficiaries receive the quality of medical care that they expect andare entitled to CCME serves as an independentimpartial third party to review Medicare beneficiarycomplaints

Quality of care complaints filed with the QIO mustbe made in writing to the address below Assistanceis available via phone or online

The Carolinas Center for Medical Excellence (CCME)

Mail CCME 100 Regency Forest DriveSuite 200 Cary NC 27518-8598

Phone 1-919-380-9860 or 1-800-682-2650

TTYTDD 1-800-735-2962

Hours MondayndashFriday8 amndash5 pm

Web inquiries wwwccmemedicareorg

Seniorsrsquo Health Insurance Information Program (SHIIP) SHIIP is a state consumer division of the North Carolina Department of Insurance SHIIP assistssenior citizens with Medicare Medicare Part D Medicare Advantage Medicare supplementsMedicare fraud and abuse and long-term careinsurance questions Assistance is available viaphone or online

Seniorsrsquo Health Insurance Information Program (SHIIP)

Phone 1-800-443-9354

TYYTDD 1-800-735-2962

Hours MondayndashFriday8 amndash5 pm

Email ncshiipncdoigov

Online wwwncshiipcom

PAGE 18 of 40

Important information

Additional information

Notice of possible contract termination BCBSNC has a contract with the Centers for Medicare amp Medicaid Services (CMS) the government agencythat runs Medicare to provide a Medicare PrescriptionDrug Plan (PDP) This contract renews each year At theend of each year the contract is reviewed and eitherBCBSNC or CMS can decide to end it Members will get 90 days advance written notice in this situationIt is also possible for our contract to end at some othertime If the contract is going to end we will generallytell members 90 days in advance Advance notice maybe as little as 30 days or even fewer days if CMS endsour contract in the middle of the year In this noticewe would provide a written description of alternativesavailable for obtaining qualified prescription drugcoverage in North Carolina We are also required tonotify the general public of a contract termination vialocal newspapers

If BCBSNC decides to stop offering the Medicare PDPor change our service area so that it no longer includesthe area where you live membership in BCBSNCrsquosMedicare PDP will end for everyone in that servicearea and members will have to change to a differentprescription drug plan Members will continue to getprescription drugs through BCBSNCrsquos Medicare PDPuntil the contract ends

PAGE 19 of 40

Important information

For more information

Blue Cross and Blue Shield of North Carolina

Phone 1-800-478-0583

TTYTDD 1-800-922-3140

Hours 7 days a week8 amndash8 pm

Online bcbsnccommedicare

Medicare

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

TTYTDD 1-877-486-2048

Hours 7 days a week24 hours a day

Online wwwmedicaregovClick the ldquoPrescription Drug Planrdquo link

Blue Cross and Blue Shield of North Carolina is a PDP plan with a Medicare contract Enrollment in Blue Cross and Blue Shield of North Carolina depends on contract renewal Benefits formulary pharmacy network premium andor copaymentscoinsurance may change on January 1 2015 Please contact BCBSNC for details

An independent licensee of the Blue Cross and Blue Shield Association

PAGE 20 of 40

(PDP)

2014 Summary of benefits for our Medicare prescription drug plans (Enhanced and Standard)

Contract S5540 Plans 004 and 002 January 1 2014 ndash December 31 2014

U5073c 813

PAGE 21 of 40Y0079_6249 CMS Accepted 09112013

Introduction to the

Summary of benefits for (PDP)

Thank you for your interest in Blue Medicare Rx(PDP) plans Our plans are offered by Blue Crossand Blue Shield of North Carolina a MedicarePrescription Drug Plan that contracts with theFederal government This Summary of Benefits tellsyou some features of our plans It doesnrsquot list everydrug we cover every limitation or exclusionTo get a complete list of our benefits please callBlue Medicare Rx and ask for the ldquoEvidence of Coveragerdquo You have choices in your Medicare prescription drug coverage As a Medicare beneficiary you can choose fromdifferent Medicare prescription drug coverageoptions One option is to get prescription drugcoverage through a Medicare Prescription DrugPlan like Blue Medicare Rx plans Another optionis to get your prescription drug coverage througha Medicare Advantage Plan that offers prescriptiondrug coverage You make the choice How can I compare my options The charts in this booklet list some important drugbenefits You can use this Summary of Benefitsto compare the benefits offered by Blue MedicareRx plans to the benefits offered by other MedicarePrescription Drug Plans or Medicare AdvantagePlans with prescription drug coverage Where are Blue Medicare Rx Plans available The service area for these plans includesNorth Carolina You must live in one of these areas to join one of these plans Who is eligible to join You can join one of these plans if you are entitled toMedicare Part A andor enrolled in Medicare Part Band live in the service area If you are enrolled in an MA coordinated care(HMO or PPO) plan or an MA PFFS plan thatincludes Medicare prescription drugs you maynot enroll in a PDP unless you disenroll from theHMO PPO or MA PFFS plan Enrollees in a private Fee-for-Service plan (PFFS)that does not provide Medicare prescription drugcoverage or an MA Medical Savings Account (MSA)plan may enroll in a PDP Enrollees in an 1876 Costplan may enroll in a PDP

Where can I get my prescriptions Blue Medicare Rx plans have formed a network ofpharmacies You must use a network pharmacyto receive plan benefits We will not pay foryour prescriptions if you use an out-of-networkpharmacy except in certain cases Blue Medicare Rx plans have a list of preferredpharmacies At these pharmacies you may getyour drugs at a lower co-pay or coinsuranceYou may go to a non-preferred pharmacy but youmay have to pay more for your prescription drugs The pharmacies in our network can change at anytime You can ask for a Pharmacy Directory or visit usat wwwmyprimecomMyRxMyPrimeMedicareDpharmacyBCBSNC Our customer service number is listed at the end of this introduction What if my doctor prescribes less than a monthrsquos supply In consultation with your doctor or pharmacist youmay receive less than a monthrsquos supply of certaindrugs Also if you live in a long-term care facilityyou will receive less than a monthrsquos supply of certainbrand [and generic] drugs Dispensing fewer drugs ata time can help reduce cost and waste in the MedicarePart D program when this is medically appropriate The amount you pay in these circumstances willdepend on whether you are responsible for payingcoinsurance (a percentage of the cost of the drug) ora copay (a flat dollar amount for the drug) If youare responsible for coinsurance for the drug youwill continue to pay the applicable percentage ofthe drug cost If you are responsible for a copay forthe drug a ldquodaily cost-sharing raterdquo will be appliedIf your doctor decides to continue the drug after atrial period you should not pay more for a monthrsquossupply than you otherwise would have paid Contactyour plan if you have questions about cost-sharingwhen less than a one-month supply is dispensed Does my plan cover Medicare Part B or Part D drugs Blue Medicare Rx Standard and Enhanced plans donot cover drugs that are covered under Medicare PartB as prescribed and dispensed Generally we onlycover drugs vaccines biological products and medicalsupplies associated with the delivery of insulin thatare covered under the Medicare Prescription DrugBenefit (Part D) and that are on our formulary

PAG E 22 of 40

Introduction to the

Summary of benefits (continued)

What is a prescription drug formulary Blue Medicare Rx plans use a formularyA formulary is a list of drugs covered by your planto meet patient needs We may periodically addremove or make changes to coverage limitationson certain drugs or change how much you pay for adrug If we make any formulary change that limitsour membersrsquo ability to fill their prescriptions wewill notify the affected members before the changeis made We will send a formulary to you andyou can see our complete formulary on our Website at httpwwwbcbsnccomcontentmedicareformulary-homehtm If you are currently taking a drug that is not on ourformulary or subject to additional requirements orlimits you may be able to get a temporary supply ofthe drug You can contact us to request an exceptionor switch to an alternative drug listed on ourformulary with your physicianrsquos help Call us to seeif you can get a temporary supply of the drug or formore details about our drug transition policy What should I do if I have other insurance in addition to Medicare If you have a Medigap (Medicare Supplement)policy that includes prescription drug coverage youmust contact your Medigap Issuer to let them knowthat you have joined a Medicare Prescription DrugPlan If you decide to keep your current Medigapsupplement policy your Medigap Issuer willremove the prescription drug coverage portion ofyour policy Call your Medigap Issuer for details If you or your spouse has or is able to get employergroup coverage you should talk to your employerto find out how your benefits will be affected if youjoin a Blue Medicare Rx plan Get this informationbefore you decide to enroll in this plan

How can I get extra help with my prescription drug plan costs or get extra help with other Medicare costs You may be able to get extra help to pay for yourprescription drug premiums and costs as well as gethelp with other Medicare costs To see if you qualifyfor getting extra help call +1-800-MEDICARE (1-800-633-4227)

TTYTDD users should call 1-877-486-204824 hours a day7 days a week and seehttpwwwmedicaregov lsquoPrograms for Peoplewith Limited Income and Resourcesrsquo in the publication Medicare amp You

+The Social Security Administration at1-800-772-1213 between 7 am and 7 pmMonday through Friday TTYTDD usersshould call 1-800-325-0778 or

+Your State Medicaid Office What are my protections in this plan All Medicare Prescription Drug Plans agree to stayin the program for a full calendar year at a timePlan benefits and cost-sharing may change fromcalendar year to calendar year Each year plans candecide whether to continue to participate with theMedicare Prescription Drug Program A plan maycontinue in their entire service area (geographicarea where the plan accepts members) or choose tocontinue only in certain areas Also Medicare maydecide to end a contract with a plan Even if yourMedicare Prescription Plan leaves the program youwill not lose Medicare coverage If a plan decidesnot to continue for an additional calendar year itmust send you a letter at least 90 days before yourcoverage will end The letter will explain youroptions for Medicare coverage in your area As a member of a Blue Medicare Rx plan you havethe right to request a coverage determination whichincludes the right to request an exception the right tofile an appeal if we deny coverage for a prescriptiondrug and the right to file a grievance You havethe right to request a coverage determination if youwant us to cover a Part D drug that you believeshould be covered An exception is a type of coveragedetermination You may ask us for an exception ifyou believe you need a drug that is not on our list

PAG E 23 of 40

Prescription drugs covered by the plans

Here are three ways to find out if your prescriptions are

covered by our formulary

Search online for specific drugs by visiting the Blue Medicare Rx section of bcbsnccommedicare (You may also download the complete formulary in PDF format)

Call or visit your local Authorized Sales Representative

Call 1-800-478-0583 7 days a week 8 amndash8 pm and speak to an authorized agent Hearing and speech impaired (TTYTDD) users call 1-800-922-3140Representatives can help you determine whether or not a specific drug is covered

Extensive network of pharmacies makes getting your medications easyExcept under certain non-routine circumstances you need to use a network pharmacy to obtain the full benefit of your Medicare Part D plan Quantity limitations and restrictions may apply BCBSNC offers an extensive network of pharmacies of the following types retail national chain mail-order extended supply home infusion long-term care or Indian Health ServiceTribalUrban Indian Health Program (ITU) pharmacies

You can use our mail-order pharmacyOur plans also offer the convenience of using preferred mail-order pharmacy at a reduced cost to you Pay a reduced copayment for a 90-day

supply of covered brand drugs up to $2850 of total drug costs You pay $3 copayment for Enhanced and $4 for Standard plans for a 30-day supply of all preferred generic drugs ordered through mail-order

Many of the most commonly used drugs are coveredThe Blue Medicare Rx Enhanced Plan and the Blue Medicare Rx Standard Plan have a formulary that lists the generic brand-name and specialty drugs covered by the plans The formulary covers many drugs eligible for coverage under Medicare Part D ndash more than 1800 drugs on our Enhanced Plan and more than 1000 drugs on our Standard Plan

Medicare Part D plans do not cover certain drugs or classes of drugs that are excluded by law such as over-the-counter medications and prescription vitamins

Compare Medicare drug plans+ Find out which Medicare drug plans

are available in your area+ Learn about plan benefits and costs+ Compare ratings by quality premium

estimated annual costs and more+ Compare BCBSNC plan ratings

included in the Enrollment kit or visit wwwmedicaregov Plan ratings are available upon request for this plan by calling BCBSNC directly at 1-800-478-0583 7 days a week 8 amndash8 pm For the hearing and speech impaired (TTYTDD) call 1-800-922-3104

Medicare evaluates plans based on a 5-Star ratingsystem Star Ratings are calculated each year and may change from one year to the next

1

2

3

PAGE 6 of 40

Call your State Medicaid Office

Hearing and speech impairedMon through Fri 1-800-772-1213

40 of 7 PAGE

2

3

Security Administrationrsquos postage-paid envelope assistance fill it out and return it in the Social If you receive an application for financial

3 for financial assistance$26580 (for a married couple) you may qualify under $13300 (for a single person) or under stocks but not counting your home or car) are If your resources (including your savings and +

3 with youhalf support to other family members living

Paying for Medicare Part D coverage

Footnotes 3 Medicaregov website June 2013

Here are three ways to find out if you qualify to receive

financial assistance

Call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day 7 days a week Hearing and speech impaired(TTYTDD) users call 1-877-486-2048 Or visit Medicarersquos Web sitewwwmedicaregov and click the

rdquoPrescription Drug Planrdquo link

Call the Social Security Administration atbetween 7 am and 7 pm

(TTYTDD users) call 1-800-325-0778

1

Premiums for Medicare Part D plans vary based on the plan that you choose If you have Medicare Part B you must continueto pay your Medicare Part B premium if nototherwise paid for under Medicaid or byanother third party

You may qualify for extra help to pay for plan premiums and prescription drug costs If you have Medicare and have limited incomeand resources you may qualify for specialfinancial assistance to help you pay for yourMedicare Part D plan premiums and prescriptiondrug costs The amount of assistance you qualifyfor will depend on your income and resources

+If your annual income is below $17235 for asingle person (or $23265 if you are marriedand living with your spouse) for 2013 youmay qualify for financial assistance Slightlyhigher income levels may apply if you provide

Prescription drugs coveredby the plans

Here are three ways to enroll in Medicare Part D

Enroll directly with the Medicare Part Dplan you choose via paper or onlineapplication at bcbsnccommedicare

Visit the Centers for Medicare amp Medicaid Services (CMS) Online Enrollment Center at wwwmedicaregov

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

+ Generally you can join or change Medicare Part D plans during the annual enrollment period ndash any time between October 15 and December 7 with an effective date of January 1 of the following year

+ If you are enrolling at a different time of year the effective date of your coverage will depend on your situation and whether or not you qualify for a special election period

+ You may only be enrolled in one Medicare Part D plan at a time

+ If you enroll in a stand-alone Medicare Part D plan while enrolled in a Medicare Advantage plan you will be disenrolled automatically from the Medicare Advantage plan and returned to Original Medicare

PAGE 8 of 40

How to join

Choose a plan Before you select a plan gather anydocumentation you may have on yourprescription drug purchases over thepast year This information will helpyou determine how much you mightsave with a Medicare Part D plan Thenyou can choose a plan that best fits yourneeds and your budget

Enroll in a plan Then you must fill out an enrollment formYou will be enrolled in the Medicare Part D plan you select and Medicare will beinformed that you have enrolled Inaddition to the paper enrollment formBlue Medicare Rx applicants can enrollonline at bcbsnccommedicare

Changing Medicare Part D plans Congress designed Medicare prescriptiondrug coverage to work on an annualenrollment cycle This means that each yearyou will have the option to remain with yourexisting Medicare Part D plan or change plansbetween October 15 and December 7

You may also have another opportunityduring the year to switch plans underlimited circumstances For example if youmove out of your planrsquos service area you willhave an opportunity to choose another planthat serves your new area Please contactBCBSNC if you would like more informationabout other situations in which you mayqualify for coverage or changes in coverageoutside the annual enrollment cycle

Important enrollment information

1

2

3

PAGE 9 of 40

You can join a Medicare Part D plan any time during your initial enrollment period for Medicare Generally a Medicare beneficiaryrsquos initial enrollment is a seven-month period three months prior to becoming Medicare eligible the month you become Medicare eligible and three months following the month you become Medicare eligible

If you were eligible for Medicare on or prior to January 1 2006 and did not enroll in a Medicare Part D plan or Medicare Advantage Prescription Drug Plan by May 15 2006 you may have to pay a penalty for late enrollment This penalty will not apply to Medicare beneficiaries who have equal or better prescription drug benefits through their

employer or another plan As of January 1 2009 these penalties no longer apply to Medicare individuals with Low Income Subsidy (LIS)

The penalty was designed to help hold down the overall costs of the drug program and is similar to the penalty imposed for late enrollment in Medicare Part B The late penalty equals one percent of the national base benchmark premium amount for each month that enrollment is delayed beyond your initial enrollment period For example if you delay enrollment in a Medicare Part D plan for two years you will pay the regular monthly plan premium plus 24 percent of the national base benchmark premium each month

Penalties for late enrollment

Important dates+ October 15 2013

First day you can enroll in a Medicare Part D plan for 2014 or the first day you can elect to switch to a different Medicare Part D plan (unless you qualify for a special election period)

+ December 7 2013 Last day you can enroll in a Medicare Part D plan for 2014 or the last day you can elect to switch to a different Medicare Part D plan (unless you qualify for a special election period)

+ January 1 2014 First day coverage begins (if you join a plan or switch plans by December 7 2013)

PAGE 10 of 40

(PDP)

Important information about our Medicare prescription drug plans

U5073b 813

Y0079_6248 CMS Accepted 08102013 PAGE 11 of 40

Important information

Eligibility for beneficiaries

Eligibility for beneficiaries Everyone who is entitled to Medicare benefitsunder Part A or enrolled in Part B is eligible forthis coverage however you are not enrolledautomatically You must join a plan to receivethe coverage6 This voluntary program is coveragethat you may choose to purchase annually Thisproduct is available to Medicare beneficiariesliving in North Carolina

Additional enrollment criteria You may enroll in only one Part D plan at a timeIf you are enrolled in a Medicare Advantage planyour enrollment in either of the PDP plans fromBlue Cross and Blue Shield of North Carolina (BCBSNC) may automatically disenroll you fromyour Medicare Advantage Plan and re-enroll youin Original Medicare for medical coverage Checkwith your plan for more information

Financial assistance

Financial assistance available People with limited incomes may qualify forExtra Help to pay for their prescription drugcosts If you qualify Medicare could pay for upto seventy-five (75) percent or more of your drugcosts including monthly prescriptiondrug premiums annual deductibles andco-insurance Additionally those who qualifywill not be subject to the coverage gap or a lateenrollment penalty Many people are eligiblefor these savings and donrsquot even know itFor more information about this Extra Helpcontact your local Social Security office or call1-800-MEDICARE (1-800-633-4227) 24 hours perday 7 days per week TTYTDD users shouldcall 1-877-486-2048

This document may be available in alternate formats upon request

Footnote 6 You must join a plan to receive the coverage unless

you are eligible for both Medicare and Medicaid Contact your State Medicaid or medical assistance office if you have questions about your eligibility

Social Security Administration

Phone 1-800-772-1213

TTYTDD 1-800-325-0778

Hours MondayndashFriday7 amndash7 pm

PAGE 12 of 40

Medicare

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

TTYTDD 1-877-486-2048

Hours 24 hours a day7 days a week

Important information

Pharmacy network

Pharmacy network information Our network includes a variety of pharmaciesincluding retail home infusion IndianTribalUrban organizations extended supply and long-term care pharmacies In order to obtain thegreatest savings on your prescription medicationsplease visit one of our preferred network providers(CVS WalMart Kerr and Epic Pharmacies) Formore information about our pharmacy networkand out-of-network policies please see our contactinformation below

Mail order contact information For information on our mail order service or to obtain forms please contact us at

Coverage determination

What is a coverage determination When we make a coverage determination weare making a decision about whether or not toprovide or pay for a Part D drug and what yourshare of the cost is for the drug (also see thedescription of the exceptions process) You mustcontact us if you would like to request a coveragedetermination including an exception Youcannot request an appeal if we have not issueda coverage determination

Mail order contact information

Phone 1-888-247-4142

TTYTDD 1-888-247-4145

Hours 7 days a week8 amndash8 pm

Mail BCBSNC Customer Service PO Box 17509 Winston-Salem NC 27116-7509

Online For a comprehensive list ofall pharmacies please visitbcbsnccommedicare

Examples of when you may ask us for a coverage determination

If you are not getting a prescription drug thatyou believe may be covered by us

If you have received a Part D prescription drugthat you believe may be covered by us while youwere a member but we have refused to pay forthe drug

If you are being told that coverage for a Part Dprescription drug that you have been gettingwill be reduced or stopped and you believe youhave special circumstances that should excludeyou from the reductionnon-coverage

If there is a limit on the quantity (or dose) of thedrug and you disagree with the requirement ordosage limitation

If you bought a drug at a pharmacy that isnot in our network and you want to requestreimbursement for the expense

PAGE 13 of 40

Important information

Coverage determination (continued)

How do I make a request for coverage determination Standard To ask for a standard decision you oryour appointed representative may call ourCustomer Service Department at the numberslisted on the back cover You can also mail a written request to the below address

Fast To ask for a fast decision you your physicianor your appointed representative may call theCustomer Service Department at the numbers listedon the back cover You can also mail a written request to the below address

Standard Generally we must give you our decisionno later than 72 hours after we have received yourrequest but we will make it sooner if your healthcondition requires

Fast If you get a fast review we will give you ourdecision within 24 hours after you or your doctor askfor a fast review mdash sooner if your health requires

PAGE 14 of 40

Contact information

Mail BCBSNC PO Box 17509 Winston-Salem NC 27116-7509

Fax Request 1-888-446-8440

Hours MondayndashFriday8 amndash5 pm

Note You cannot ask for a fast decision on a requestfor coverage of a drug already purchased

For some reviews we may require a supportingstatement from your doctor that explains why the drugyou are asking coverage for is medically necessary

After regular business hours you should consultwith a network pharmacy regarding your need for anemergency or temporary supply of medication untilyou can contact the Plan the next business day Youmay also call our Customer Service Department andleave a message on the Part D After Hours ExceptionRequest voicemail Be sure to ask for a ldquofastrdquoldquoexpeditedrdquo or ldquo24-hourrdquo review

When will I hear back with a decision

Important information

Exceptions process

What is an exception request Exception requests are a kind of coveragedetermination You your authorized representativeor your prescribing physician may request anexception to seek coverage of a drug that

+ Is not on the formulary (list of drugsthe plan covers)

+ Requires prior authorization + Has quantity limitations

Example of an exception request If the Planrsquos formulary does not include a drug thatyou or your prescribing physician feel is necessarythen you or your prescribing physician may requestan exception so that you may obtain coverage ofthis drug If the Plan does not grant the requestedexception then you or your prescribing physicianmay file an appeal

How do I make an exception request You or your prescribing physician may request anexception to the coverage rules for your MedicarePrescription Drug Plan A specific form is notrequired for you to make an exception requestThe request must include your prescribingphysicianrsquos statement that heshe has determinedthat the preferred drug either would not be aseffective or would have adverse effects for you

For your convenience forms are available at bcbsnccomcontentmedicarememberindexhtm

Contact information

Mail BCBSNC Attn PDP Exception RequestsPO Box 17509 Winston-Salem NC 27116-7509

Phone 1-888-247-4142

Physicians call 1-888-298-7552

TTYTDD 1-888-247-4145

Hours 7 days a week8 amndash8 pm

When will I receive a decision on my exception request If your exception request includes a formularyexception or an exception from utilizationmanagement rules such as dosage or quantitylimits we must make our decision no later than 72 hours after we have received your doctorrsquossupporting statement which explains why thedrug you are asking for is medically necessary

If you have asked for a fast or expedited exceptionrequest we must make our decision no later than24 hours after we get your doctorrsquos supporting statement

You will be notified by phone followed by awritten notice of our decision If the decision is not in your favor you have the right to appeal

PAGE 15 of 40

Important informationAppeals process

What is an appeal An appeal is your opportunity to requesta redetermination of an adverse coveragedetermination which includes denied exception requests

Example of an appeal If we deny your request for an exception to covera non-formulary drug then you may file an appealof the denial An appeal can only be filed afteran exception has been requested and denied bythe Plan

How do I file an appeal If you receive a coverage determination denial youor your appointed representative or your doctor orother prescriber may file an appeal A specific formis not required for you to file an appeal An appealmust be filed within 60 calendar days of the date ofa denial notice and must be in writing unless youare filing an expedited or fast appeal You mustsubmit it via mail fax or in person

When will I receive a decision on my appeal

We will perform a standard review of your appealwithin seven calendar days of receipt of your appealor sooner if your health requires We will reviewrequests for an expedited or fast appeal as soon aspossible but no later than 72 hours following ourreceipt of the request An individual who was notinvolved with your original coverage determinationwill make a decision on your appeal

You will receive a written response to your appealThe decision on an expedited appeal will beprovided by phone followed by the written noticeIf our decision is to deny the appeal the notice willadvise you of your right to submit your appeal to the Independent Review Entity (IRE) with instructionson how to do so If we miss our time frames for claims adjudication or review of the appeal wewill automatically forward the appeal to the IREfor a decision There may be additional levels ofappeal available to you We will inform you of youradditional rights in the notice or you may refer toyour Evidence of Coverage for further details

Contact information

Mail BCBSNC Attn Medicare Appeals amp GrievancesPO Box 17509 Winston-Salem NC 27116-7509

Fax 1-888-375-8836 or 1-336-794-8836

In Person

BCBSNC 5660 University PkwyWinston-Salem NC 27105

PAGE 16 of 40

Important information

Grievance process

What is a grievance A grievance is a complaint that you may file ifyou are dissatisfied with the Plan or a contractedprovider for reasons other than a decision ona coverage determination Grievances alsoinclude complaints regarding the timelinessappropriateness access to or setting of a coveredprescription drug

Example of a grievance If you are dissatisfied with the service you receivedfrom a pharmacist or plan representative then youcould file a grievance

How do I file a grievance The grievance must be filed within 60 days after theevent or incident that caused you to be dissatisfiedA specific form is not required for you to file agrievance You or your appointed representativemay file a grievance via the phone by mail faxor in person

When will I receive a decision on my grievance The resolution of a grievance will be made asquickly as your concern requires but no more than30 calendar days after our receipt of the grievanceWe may extend the time frame by up to 14 calendardays if you request the extension or if we justify aneed for additional information and the delay is inyour best interest

If you request a written response to an oralgrievance one will be provided within 30 days afterreceipt of the grievance A written response will beprovided to all written grievances Our decision ona grievance is final and is not subject to an appeal

You have the right to an expedited review ofa grievance concerning our refusal to grant anexpedited coverage determination or expeditedappeal This type of grievance will be responded towithin 24 hours after our receipt of the grievance

Contact information

Phone 1-888-247-4142

Fax 1-888-375-8836 or 1-336-794-8836

Hours 7 days a week8 amndash8 pm

Mail BCBSNC Attn Medicare Appeals amp GrievancesPO Box 17509 Winston-Salem NC 27116-7509

In Person

BCBSNC 5660 University PkwyWinston-Salem NC 27105

PAGE 17 of 40

Important information

Quality improvement

What if I have a concern about the quality of services I received If you have a concern relating to the quality of services that you received under the Medicare Part D planthen in addition to our review you can also request review by the following organizations

The Carolinas Center for Medical Excellence (CCME) Quality Improvement Organization (QIO) in North Carolina CCME formerly known as Medical Review ofNorth Carolina Inc is a nonprofit medical carequality improvement organization CCME has beendesignated by the Centers for Medicare amp MedicaidServices as the Quality Improvement Organization(QIO) for North Carolina The QIO conducts casereviews to ensure that Medicare beneficiaries receive the quality of medical care that they expect andare entitled to CCME serves as an independentimpartial third party to review Medicare beneficiarycomplaints

Quality of care complaints filed with the QIO mustbe made in writing to the address below Assistanceis available via phone or online

The Carolinas Center for Medical Excellence (CCME)

Mail CCME 100 Regency Forest DriveSuite 200 Cary NC 27518-8598

Phone 1-919-380-9860 or 1-800-682-2650

TTYTDD 1-800-735-2962

Hours MondayndashFriday8 amndash5 pm

Web inquiries wwwccmemedicareorg

Seniorsrsquo Health Insurance Information Program (SHIIP) SHIIP is a state consumer division of the North Carolina Department of Insurance SHIIP assistssenior citizens with Medicare Medicare Part D Medicare Advantage Medicare supplementsMedicare fraud and abuse and long-term careinsurance questions Assistance is available viaphone or online

Seniorsrsquo Health Insurance Information Program (SHIIP)

Phone 1-800-443-9354

TYYTDD 1-800-735-2962

Hours MondayndashFriday8 amndash5 pm

Email ncshiipncdoigov

Online wwwncshiipcom

PAGE 18 of 40

Important information

Additional information

Notice of possible contract termination BCBSNC has a contract with the Centers for Medicare amp Medicaid Services (CMS) the government agencythat runs Medicare to provide a Medicare PrescriptionDrug Plan (PDP) This contract renews each year At theend of each year the contract is reviewed and eitherBCBSNC or CMS can decide to end it Members will get 90 days advance written notice in this situationIt is also possible for our contract to end at some othertime If the contract is going to end we will generallytell members 90 days in advance Advance notice maybe as little as 30 days or even fewer days if CMS endsour contract in the middle of the year In this noticewe would provide a written description of alternativesavailable for obtaining qualified prescription drugcoverage in North Carolina We are also required tonotify the general public of a contract termination vialocal newspapers

If BCBSNC decides to stop offering the Medicare PDPor change our service area so that it no longer includesthe area where you live membership in BCBSNCrsquosMedicare PDP will end for everyone in that servicearea and members will have to change to a differentprescription drug plan Members will continue to getprescription drugs through BCBSNCrsquos Medicare PDPuntil the contract ends

PAGE 19 of 40

Important information

For more information

Blue Cross and Blue Shield of North Carolina

Phone 1-800-478-0583

TTYTDD 1-800-922-3140

Hours 7 days a week8 amndash8 pm

Online bcbsnccommedicare

Medicare

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

TTYTDD 1-877-486-2048

Hours 7 days a week24 hours a day

Online wwwmedicaregovClick the ldquoPrescription Drug Planrdquo link

Blue Cross and Blue Shield of North Carolina is a PDP plan with a Medicare contract Enrollment in Blue Cross and Blue Shield of North Carolina depends on contract renewal Benefits formulary pharmacy network premium andor copaymentscoinsurance may change on January 1 2015 Please contact BCBSNC for details

An independent licensee of the Blue Cross and Blue Shield Association

PAGE 20 of 40

(PDP)

2014 Summary of benefits for our Medicare prescription drug plans (Enhanced and Standard)

Contract S5540 Plans 004 and 002 January 1 2014 ndash December 31 2014

U5073c 813

PAGE 21 of 40Y0079_6249 CMS Accepted 09112013

Introduction to the

Summary of benefits for (PDP)

Thank you for your interest in Blue Medicare Rx(PDP) plans Our plans are offered by Blue Crossand Blue Shield of North Carolina a MedicarePrescription Drug Plan that contracts with theFederal government This Summary of Benefits tellsyou some features of our plans It doesnrsquot list everydrug we cover every limitation or exclusionTo get a complete list of our benefits please callBlue Medicare Rx and ask for the ldquoEvidence of Coveragerdquo You have choices in your Medicare prescription drug coverage As a Medicare beneficiary you can choose fromdifferent Medicare prescription drug coverageoptions One option is to get prescription drugcoverage through a Medicare Prescription DrugPlan like Blue Medicare Rx plans Another optionis to get your prescription drug coverage througha Medicare Advantage Plan that offers prescriptiondrug coverage You make the choice How can I compare my options The charts in this booklet list some important drugbenefits You can use this Summary of Benefitsto compare the benefits offered by Blue MedicareRx plans to the benefits offered by other MedicarePrescription Drug Plans or Medicare AdvantagePlans with prescription drug coverage Where are Blue Medicare Rx Plans available The service area for these plans includesNorth Carolina You must live in one of these areas to join one of these plans Who is eligible to join You can join one of these plans if you are entitled toMedicare Part A andor enrolled in Medicare Part Band live in the service area If you are enrolled in an MA coordinated care(HMO or PPO) plan or an MA PFFS plan thatincludes Medicare prescription drugs you maynot enroll in a PDP unless you disenroll from theHMO PPO or MA PFFS plan Enrollees in a private Fee-for-Service plan (PFFS)that does not provide Medicare prescription drugcoverage or an MA Medical Savings Account (MSA)plan may enroll in a PDP Enrollees in an 1876 Costplan may enroll in a PDP

Where can I get my prescriptions Blue Medicare Rx plans have formed a network ofpharmacies You must use a network pharmacyto receive plan benefits We will not pay foryour prescriptions if you use an out-of-networkpharmacy except in certain cases Blue Medicare Rx plans have a list of preferredpharmacies At these pharmacies you may getyour drugs at a lower co-pay or coinsuranceYou may go to a non-preferred pharmacy but youmay have to pay more for your prescription drugs The pharmacies in our network can change at anytime You can ask for a Pharmacy Directory or visit usat wwwmyprimecomMyRxMyPrimeMedicareDpharmacyBCBSNC Our customer service number is listed at the end of this introduction What if my doctor prescribes less than a monthrsquos supply In consultation with your doctor or pharmacist youmay receive less than a monthrsquos supply of certaindrugs Also if you live in a long-term care facilityyou will receive less than a monthrsquos supply of certainbrand [and generic] drugs Dispensing fewer drugs ata time can help reduce cost and waste in the MedicarePart D program when this is medically appropriate The amount you pay in these circumstances willdepend on whether you are responsible for payingcoinsurance (a percentage of the cost of the drug) ora copay (a flat dollar amount for the drug) If youare responsible for coinsurance for the drug youwill continue to pay the applicable percentage ofthe drug cost If you are responsible for a copay forthe drug a ldquodaily cost-sharing raterdquo will be appliedIf your doctor decides to continue the drug after atrial period you should not pay more for a monthrsquossupply than you otherwise would have paid Contactyour plan if you have questions about cost-sharingwhen less than a one-month supply is dispensed Does my plan cover Medicare Part B or Part D drugs Blue Medicare Rx Standard and Enhanced plans donot cover drugs that are covered under Medicare PartB as prescribed and dispensed Generally we onlycover drugs vaccines biological products and medicalsupplies associated with the delivery of insulin thatare covered under the Medicare Prescription DrugBenefit (Part D) and that are on our formulary

PAG E 22 of 40

Introduction to the

Summary of benefits (continued)

What is a prescription drug formulary Blue Medicare Rx plans use a formularyA formulary is a list of drugs covered by your planto meet patient needs We may periodically addremove or make changes to coverage limitationson certain drugs or change how much you pay for adrug If we make any formulary change that limitsour membersrsquo ability to fill their prescriptions wewill notify the affected members before the changeis made We will send a formulary to you andyou can see our complete formulary on our Website at httpwwwbcbsnccomcontentmedicareformulary-homehtm If you are currently taking a drug that is not on ourformulary or subject to additional requirements orlimits you may be able to get a temporary supply ofthe drug You can contact us to request an exceptionor switch to an alternative drug listed on ourformulary with your physicianrsquos help Call us to seeif you can get a temporary supply of the drug or formore details about our drug transition policy What should I do if I have other insurance in addition to Medicare If you have a Medigap (Medicare Supplement)policy that includes prescription drug coverage youmust contact your Medigap Issuer to let them knowthat you have joined a Medicare Prescription DrugPlan If you decide to keep your current Medigapsupplement policy your Medigap Issuer willremove the prescription drug coverage portion ofyour policy Call your Medigap Issuer for details If you or your spouse has or is able to get employergroup coverage you should talk to your employerto find out how your benefits will be affected if youjoin a Blue Medicare Rx plan Get this informationbefore you decide to enroll in this plan

How can I get extra help with my prescription drug plan costs or get extra help with other Medicare costs You may be able to get extra help to pay for yourprescription drug premiums and costs as well as gethelp with other Medicare costs To see if you qualifyfor getting extra help call +1-800-MEDICARE (1-800-633-4227)

TTYTDD users should call 1-877-486-204824 hours a day7 days a week and seehttpwwwmedicaregov lsquoPrograms for Peoplewith Limited Income and Resourcesrsquo in the publication Medicare amp You

+The Social Security Administration at1-800-772-1213 between 7 am and 7 pmMonday through Friday TTYTDD usersshould call 1-800-325-0778 or

+Your State Medicaid Office What are my protections in this plan All Medicare Prescription Drug Plans agree to stayin the program for a full calendar year at a timePlan benefits and cost-sharing may change fromcalendar year to calendar year Each year plans candecide whether to continue to participate with theMedicare Prescription Drug Program A plan maycontinue in their entire service area (geographicarea where the plan accepts members) or choose tocontinue only in certain areas Also Medicare maydecide to end a contract with a plan Even if yourMedicare Prescription Plan leaves the program youwill not lose Medicare coverage If a plan decidesnot to continue for an additional calendar year itmust send you a letter at least 90 days before yourcoverage will end The letter will explain youroptions for Medicare coverage in your area As a member of a Blue Medicare Rx plan you havethe right to request a coverage determination whichincludes the right to request an exception the right tofile an appeal if we deny coverage for a prescriptiondrug and the right to file a grievance You havethe right to request a coverage determination if youwant us to cover a Part D drug that you believeshould be covered An exception is a type of coveragedetermination You may ask us for an exception ifyou believe you need a drug that is not on our list

PAG E 23 of 40

Call your State Medicaid Office

Hearing and speech impairedMon through Fri 1-800-772-1213

40 of 7 PAGE

2

3

Security Administrationrsquos postage-paid envelope assistance fill it out and return it in the Social If you receive an application for financial

3 for financial assistance$26580 (for a married couple) you may qualify under $13300 (for a single person) or under stocks but not counting your home or car) are If your resources (including your savings and +

3 with youhalf support to other family members living

Paying for Medicare Part D coverage

Footnotes 3 Medicaregov website June 2013

Here are three ways to find out if you qualify to receive

financial assistance

Call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day 7 days a week Hearing and speech impaired(TTYTDD) users call 1-877-486-2048 Or visit Medicarersquos Web sitewwwmedicaregov and click the

rdquoPrescription Drug Planrdquo link

Call the Social Security Administration atbetween 7 am and 7 pm

(TTYTDD users) call 1-800-325-0778

1

Premiums for Medicare Part D plans vary based on the plan that you choose If you have Medicare Part B you must continueto pay your Medicare Part B premium if nototherwise paid for under Medicaid or byanother third party

You may qualify for extra help to pay for plan premiums and prescription drug costs If you have Medicare and have limited incomeand resources you may qualify for specialfinancial assistance to help you pay for yourMedicare Part D plan premiums and prescriptiondrug costs The amount of assistance you qualifyfor will depend on your income and resources

+If your annual income is below $17235 for asingle person (or $23265 if you are marriedand living with your spouse) for 2013 youmay qualify for financial assistance Slightlyhigher income levels may apply if you provide

Prescription drugs coveredby the plans

Here are three ways to enroll in Medicare Part D

Enroll directly with the Medicare Part Dplan you choose via paper or onlineapplication at bcbsnccommedicare

Visit the Centers for Medicare amp Medicaid Services (CMS) Online Enrollment Center at wwwmedicaregov

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

+ Generally you can join or change Medicare Part D plans during the annual enrollment period ndash any time between October 15 and December 7 with an effective date of January 1 of the following year

+ If you are enrolling at a different time of year the effective date of your coverage will depend on your situation and whether or not you qualify for a special election period

+ You may only be enrolled in one Medicare Part D plan at a time

+ If you enroll in a stand-alone Medicare Part D plan while enrolled in a Medicare Advantage plan you will be disenrolled automatically from the Medicare Advantage plan and returned to Original Medicare

PAGE 8 of 40

How to join

Choose a plan Before you select a plan gather anydocumentation you may have on yourprescription drug purchases over thepast year This information will helpyou determine how much you mightsave with a Medicare Part D plan Thenyou can choose a plan that best fits yourneeds and your budget

Enroll in a plan Then you must fill out an enrollment formYou will be enrolled in the Medicare Part D plan you select and Medicare will beinformed that you have enrolled Inaddition to the paper enrollment formBlue Medicare Rx applicants can enrollonline at bcbsnccommedicare

Changing Medicare Part D plans Congress designed Medicare prescriptiondrug coverage to work on an annualenrollment cycle This means that each yearyou will have the option to remain with yourexisting Medicare Part D plan or change plansbetween October 15 and December 7

You may also have another opportunityduring the year to switch plans underlimited circumstances For example if youmove out of your planrsquos service area you willhave an opportunity to choose another planthat serves your new area Please contactBCBSNC if you would like more informationabout other situations in which you mayqualify for coverage or changes in coverageoutside the annual enrollment cycle

Important enrollment information

1

2

3

PAGE 9 of 40

You can join a Medicare Part D plan any time during your initial enrollment period for Medicare Generally a Medicare beneficiaryrsquos initial enrollment is a seven-month period three months prior to becoming Medicare eligible the month you become Medicare eligible and three months following the month you become Medicare eligible

If you were eligible for Medicare on or prior to January 1 2006 and did not enroll in a Medicare Part D plan or Medicare Advantage Prescription Drug Plan by May 15 2006 you may have to pay a penalty for late enrollment This penalty will not apply to Medicare beneficiaries who have equal or better prescription drug benefits through their

employer or another plan As of January 1 2009 these penalties no longer apply to Medicare individuals with Low Income Subsidy (LIS)

The penalty was designed to help hold down the overall costs of the drug program and is similar to the penalty imposed for late enrollment in Medicare Part B The late penalty equals one percent of the national base benchmark premium amount for each month that enrollment is delayed beyond your initial enrollment period For example if you delay enrollment in a Medicare Part D plan for two years you will pay the regular monthly plan premium plus 24 percent of the national base benchmark premium each month

Penalties for late enrollment

Important dates+ October 15 2013

First day you can enroll in a Medicare Part D plan for 2014 or the first day you can elect to switch to a different Medicare Part D plan (unless you qualify for a special election period)

+ December 7 2013 Last day you can enroll in a Medicare Part D plan for 2014 or the last day you can elect to switch to a different Medicare Part D plan (unless you qualify for a special election period)

+ January 1 2014 First day coverage begins (if you join a plan or switch plans by December 7 2013)

PAGE 10 of 40

(PDP)

Important information about our Medicare prescription drug plans

U5073b 813

Y0079_6248 CMS Accepted 08102013 PAGE 11 of 40

Important information

Eligibility for beneficiaries

Eligibility for beneficiaries Everyone who is entitled to Medicare benefitsunder Part A or enrolled in Part B is eligible forthis coverage however you are not enrolledautomatically You must join a plan to receivethe coverage6 This voluntary program is coveragethat you may choose to purchase annually Thisproduct is available to Medicare beneficiariesliving in North Carolina

Additional enrollment criteria You may enroll in only one Part D plan at a timeIf you are enrolled in a Medicare Advantage planyour enrollment in either of the PDP plans fromBlue Cross and Blue Shield of North Carolina (BCBSNC) may automatically disenroll you fromyour Medicare Advantage Plan and re-enroll youin Original Medicare for medical coverage Checkwith your plan for more information

Financial assistance

Financial assistance available People with limited incomes may qualify forExtra Help to pay for their prescription drugcosts If you qualify Medicare could pay for upto seventy-five (75) percent or more of your drugcosts including monthly prescriptiondrug premiums annual deductibles andco-insurance Additionally those who qualifywill not be subject to the coverage gap or a lateenrollment penalty Many people are eligiblefor these savings and donrsquot even know itFor more information about this Extra Helpcontact your local Social Security office or call1-800-MEDICARE (1-800-633-4227) 24 hours perday 7 days per week TTYTDD users shouldcall 1-877-486-2048

This document may be available in alternate formats upon request

Footnote 6 You must join a plan to receive the coverage unless

you are eligible for both Medicare and Medicaid Contact your State Medicaid or medical assistance office if you have questions about your eligibility

Social Security Administration

Phone 1-800-772-1213

TTYTDD 1-800-325-0778

Hours MondayndashFriday7 amndash7 pm

PAGE 12 of 40

Medicare

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

TTYTDD 1-877-486-2048

Hours 24 hours a day7 days a week

Important information

Pharmacy network

Pharmacy network information Our network includes a variety of pharmaciesincluding retail home infusion IndianTribalUrban organizations extended supply and long-term care pharmacies In order to obtain thegreatest savings on your prescription medicationsplease visit one of our preferred network providers(CVS WalMart Kerr and Epic Pharmacies) Formore information about our pharmacy networkand out-of-network policies please see our contactinformation below

Mail order contact information For information on our mail order service or to obtain forms please contact us at

Coverage determination

What is a coverage determination When we make a coverage determination weare making a decision about whether or not toprovide or pay for a Part D drug and what yourshare of the cost is for the drug (also see thedescription of the exceptions process) You mustcontact us if you would like to request a coveragedetermination including an exception Youcannot request an appeal if we have not issueda coverage determination

Mail order contact information

Phone 1-888-247-4142

TTYTDD 1-888-247-4145

Hours 7 days a week8 amndash8 pm

Mail BCBSNC Customer Service PO Box 17509 Winston-Salem NC 27116-7509

Online For a comprehensive list ofall pharmacies please visitbcbsnccommedicare

Examples of when you may ask us for a coverage determination

If you are not getting a prescription drug thatyou believe may be covered by us

If you have received a Part D prescription drugthat you believe may be covered by us while youwere a member but we have refused to pay forthe drug

If you are being told that coverage for a Part Dprescription drug that you have been gettingwill be reduced or stopped and you believe youhave special circumstances that should excludeyou from the reductionnon-coverage

If there is a limit on the quantity (or dose) of thedrug and you disagree with the requirement ordosage limitation

If you bought a drug at a pharmacy that isnot in our network and you want to requestreimbursement for the expense

PAGE 13 of 40

Important information

Coverage determination (continued)

How do I make a request for coverage determination Standard To ask for a standard decision you oryour appointed representative may call ourCustomer Service Department at the numberslisted on the back cover You can also mail a written request to the below address

Fast To ask for a fast decision you your physicianor your appointed representative may call theCustomer Service Department at the numbers listedon the back cover You can also mail a written request to the below address

Standard Generally we must give you our decisionno later than 72 hours after we have received yourrequest but we will make it sooner if your healthcondition requires

Fast If you get a fast review we will give you ourdecision within 24 hours after you or your doctor askfor a fast review mdash sooner if your health requires

PAGE 14 of 40

Contact information

Mail BCBSNC PO Box 17509 Winston-Salem NC 27116-7509

Fax Request 1-888-446-8440

Hours MondayndashFriday8 amndash5 pm

Note You cannot ask for a fast decision on a requestfor coverage of a drug already purchased

For some reviews we may require a supportingstatement from your doctor that explains why the drugyou are asking coverage for is medically necessary

After regular business hours you should consultwith a network pharmacy regarding your need for anemergency or temporary supply of medication untilyou can contact the Plan the next business day Youmay also call our Customer Service Department andleave a message on the Part D After Hours ExceptionRequest voicemail Be sure to ask for a ldquofastrdquoldquoexpeditedrdquo or ldquo24-hourrdquo review

When will I hear back with a decision

Important information

Exceptions process

What is an exception request Exception requests are a kind of coveragedetermination You your authorized representativeor your prescribing physician may request anexception to seek coverage of a drug that

+ Is not on the formulary (list of drugsthe plan covers)

+ Requires prior authorization + Has quantity limitations

Example of an exception request If the Planrsquos formulary does not include a drug thatyou or your prescribing physician feel is necessarythen you or your prescribing physician may requestan exception so that you may obtain coverage ofthis drug If the Plan does not grant the requestedexception then you or your prescribing physicianmay file an appeal

How do I make an exception request You or your prescribing physician may request anexception to the coverage rules for your MedicarePrescription Drug Plan A specific form is notrequired for you to make an exception requestThe request must include your prescribingphysicianrsquos statement that heshe has determinedthat the preferred drug either would not be aseffective or would have adverse effects for you

For your convenience forms are available at bcbsnccomcontentmedicarememberindexhtm

Contact information

Mail BCBSNC Attn PDP Exception RequestsPO Box 17509 Winston-Salem NC 27116-7509

Phone 1-888-247-4142

Physicians call 1-888-298-7552

TTYTDD 1-888-247-4145

Hours 7 days a week8 amndash8 pm

When will I receive a decision on my exception request If your exception request includes a formularyexception or an exception from utilizationmanagement rules such as dosage or quantitylimits we must make our decision no later than 72 hours after we have received your doctorrsquossupporting statement which explains why thedrug you are asking for is medically necessary

If you have asked for a fast or expedited exceptionrequest we must make our decision no later than24 hours after we get your doctorrsquos supporting statement

You will be notified by phone followed by awritten notice of our decision If the decision is not in your favor you have the right to appeal

PAGE 15 of 40

Important informationAppeals process

What is an appeal An appeal is your opportunity to requesta redetermination of an adverse coveragedetermination which includes denied exception requests

Example of an appeal If we deny your request for an exception to covera non-formulary drug then you may file an appealof the denial An appeal can only be filed afteran exception has been requested and denied bythe Plan

How do I file an appeal If you receive a coverage determination denial youor your appointed representative or your doctor orother prescriber may file an appeal A specific formis not required for you to file an appeal An appealmust be filed within 60 calendar days of the date ofa denial notice and must be in writing unless youare filing an expedited or fast appeal You mustsubmit it via mail fax or in person

When will I receive a decision on my appeal

We will perform a standard review of your appealwithin seven calendar days of receipt of your appealor sooner if your health requires We will reviewrequests for an expedited or fast appeal as soon aspossible but no later than 72 hours following ourreceipt of the request An individual who was notinvolved with your original coverage determinationwill make a decision on your appeal

You will receive a written response to your appealThe decision on an expedited appeal will beprovided by phone followed by the written noticeIf our decision is to deny the appeal the notice willadvise you of your right to submit your appeal to the Independent Review Entity (IRE) with instructionson how to do so If we miss our time frames for claims adjudication or review of the appeal wewill automatically forward the appeal to the IREfor a decision There may be additional levels ofappeal available to you We will inform you of youradditional rights in the notice or you may refer toyour Evidence of Coverage for further details

Contact information

Mail BCBSNC Attn Medicare Appeals amp GrievancesPO Box 17509 Winston-Salem NC 27116-7509

Fax 1-888-375-8836 or 1-336-794-8836

In Person

BCBSNC 5660 University PkwyWinston-Salem NC 27105

PAGE 16 of 40

Important information

Grievance process

What is a grievance A grievance is a complaint that you may file ifyou are dissatisfied with the Plan or a contractedprovider for reasons other than a decision ona coverage determination Grievances alsoinclude complaints regarding the timelinessappropriateness access to or setting of a coveredprescription drug

Example of a grievance If you are dissatisfied with the service you receivedfrom a pharmacist or plan representative then youcould file a grievance

How do I file a grievance The grievance must be filed within 60 days after theevent or incident that caused you to be dissatisfiedA specific form is not required for you to file agrievance You or your appointed representativemay file a grievance via the phone by mail faxor in person

When will I receive a decision on my grievance The resolution of a grievance will be made asquickly as your concern requires but no more than30 calendar days after our receipt of the grievanceWe may extend the time frame by up to 14 calendardays if you request the extension or if we justify aneed for additional information and the delay is inyour best interest

If you request a written response to an oralgrievance one will be provided within 30 days afterreceipt of the grievance A written response will beprovided to all written grievances Our decision ona grievance is final and is not subject to an appeal

You have the right to an expedited review ofa grievance concerning our refusal to grant anexpedited coverage determination or expeditedappeal This type of grievance will be responded towithin 24 hours after our receipt of the grievance

Contact information

Phone 1-888-247-4142

Fax 1-888-375-8836 or 1-336-794-8836

Hours 7 days a week8 amndash8 pm

Mail BCBSNC Attn Medicare Appeals amp GrievancesPO Box 17509 Winston-Salem NC 27116-7509

In Person

BCBSNC 5660 University PkwyWinston-Salem NC 27105

PAGE 17 of 40

Important information

Quality improvement

What if I have a concern about the quality of services I received If you have a concern relating to the quality of services that you received under the Medicare Part D planthen in addition to our review you can also request review by the following organizations

The Carolinas Center for Medical Excellence (CCME) Quality Improvement Organization (QIO) in North Carolina CCME formerly known as Medical Review ofNorth Carolina Inc is a nonprofit medical carequality improvement organization CCME has beendesignated by the Centers for Medicare amp MedicaidServices as the Quality Improvement Organization(QIO) for North Carolina The QIO conducts casereviews to ensure that Medicare beneficiaries receive the quality of medical care that they expect andare entitled to CCME serves as an independentimpartial third party to review Medicare beneficiarycomplaints

Quality of care complaints filed with the QIO mustbe made in writing to the address below Assistanceis available via phone or online

The Carolinas Center for Medical Excellence (CCME)

Mail CCME 100 Regency Forest DriveSuite 200 Cary NC 27518-8598

Phone 1-919-380-9860 or 1-800-682-2650

TTYTDD 1-800-735-2962

Hours MondayndashFriday8 amndash5 pm

Web inquiries wwwccmemedicareorg

Seniorsrsquo Health Insurance Information Program (SHIIP) SHIIP is a state consumer division of the North Carolina Department of Insurance SHIIP assistssenior citizens with Medicare Medicare Part D Medicare Advantage Medicare supplementsMedicare fraud and abuse and long-term careinsurance questions Assistance is available viaphone or online

Seniorsrsquo Health Insurance Information Program (SHIIP)

Phone 1-800-443-9354

TYYTDD 1-800-735-2962

Hours MondayndashFriday8 amndash5 pm

Email ncshiipncdoigov

Online wwwncshiipcom

PAGE 18 of 40

Important information

Additional information

Notice of possible contract termination BCBSNC has a contract with the Centers for Medicare amp Medicaid Services (CMS) the government agencythat runs Medicare to provide a Medicare PrescriptionDrug Plan (PDP) This contract renews each year At theend of each year the contract is reviewed and eitherBCBSNC or CMS can decide to end it Members will get 90 days advance written notice in this situationIt is also possible for our contract to end at some othertime If the contract is going to end we will generallytell members 90 days in advance Advance notice maybe as little as 30 days or even fewer days if CMS endsour contract in the middle of the year In this noticewe would provide a written description of alternativesavailable for obtaining qualified prescription drugcoverage in North Carolina We are also required tonotify the general public of a contract termination vialocal newspapers

If BCBSNC decides to stop offering the Medicare PDPor change our service area so that it no longer includesthe area where you live membership in BCBSNCrsquosMedicare PDP will end for everyone in that servicearea and members will have to change to a differentprescription drug plan Members will continue to getprescription drugs through BCBSNCrsquos Medicare PDPuntil the contract ends

PAGE 19 of 40

Important information

For more information

Blue Cross and Blue Shield of North Carolina

Phone 1-800-478-0583

TTYTDD 1-800-922-3140

Hours 7 days a week8 amndash8 pm

Online bcbsnccommedicare

Medicare

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

TTYTDD 1-877-486-2048

Hours 7 days a week24 hours a day

Online wwwmedicaregovClick the ldquoPrescription Drug Planrdquo link

Blue Cross and Blue Shield of North Carolina is a PDP plan with a Medicare contract Enrollment in Blue Cross and Blue Shield of North Carolina depends on contract renewal Benefits formulary pharmacy network premium andor copaymentscoinsurance may change on January 1 2015 Please contact BCBSNC for details

An independent licensee of the Blue Cross and Blue Shield Association

PAGE 20 of 40

(PDP)

2014 Summary of benefits for our Medicare prescription drug plans (Enhanced and Standard)

Contract S5540 Plans 004 and 002 January 1 2014 ndash December 31 2014

U5073c 813

PAGE 21 of 40Y0079_6249 CMS Accepted 09112013

Introduction to the

Summary of benefits for (PDP)

Thank you for your interest in Blue Medicare Rx(PDP) plans Our plans are offered by Blue Crossand Blue Shield of North Carolina a MedicarePrescription Drug Plan that contracts with theFederal government This Summary of Benefits tellsyou some features of our plans It doesnrsquot list everydrug we cover every limitation or exclusionTo get a complete list of our benefits please callBlue Medicare Rx and ask for the ldquoEvidence of Coveragerdquo You have choices in your Medicare prescription drug coverage As a Medicare beneficiary you can choose fromdifferent Medicare prescription drug coverageoptions One option is to get prescription drugcoverage through a Medicare Prescription DrugPlan like Blue Medicare Rx plans Another optionis to get your prescription drug coverage througha Medicare Advantage Plan that offers prescriptiondrug coverage You make the choice How can I compare my options The charts in this booklet list some important drugbenefits You can use this Summary of Benefitsto compare the benefits offered by Blue MedicareRx plans to the benefits offered by other MedicarePrescription Drug Plans or Medicare AdvantagePlans with prescription drug coverage Where are Blue Medicare Rx Plans available The service area for these plans includesNorth Carolina You must live in one of these areas to join one of these plans Who is eligible to join You can join one of these plans if you are entitled toMedicare Part A andor enrolled in Medicare Part Band live in the service area If you are enrolled in an MA coordinated care(HMO or PPO) plan or an MA PFFS plan thatincludes Medicare prescription drugs you maynot enroll in a PDP unless you disenroll from theHMO PPO or MA PFFS plan Enrollees in a private Fee-for-Service plan (PFFS)that does not provide Medicare prescription drugcoverage or an MA Medical Savings Account (MSA)plan may enroll in a PDP Enrollees in an 1876 Costplan may enroll in a PDP

Where can I get my prescriptions Blue Medicare Rx plans have formed a network ofpharmacies You must use a network pharmacyto receive plan benefits We will not pay foryour prescriptions if you use an out-of-networkpharmacy except in certain cases Blue Medicare Rx plans have a list of preferredpharmacies At these pharmacies you may getyour drugs at a lower co-pay or coinsuranceYou may go to a non-preferred pharmacy but youmay have to pay more for your prescription drugs The pharmacies in our network can change at anytime You can ask for a Pharmacy Directory or visit usat wwwmyprimecomMyRxMyPrimeMedicareDpharmacyBCBSNC Our customer service number is listed at the end of this introduction What if my doctor prescribes less than a monthrsquos supply In consultation with your doctor or pharmacist youmay receive less than a monthrsquos supply of certaindrugs Also if you live in a long-term care facilityyou will receive less than a monthrsquos supply of certainbrand [and generic] drugs Dispensing fewer drugs ata time can help reduce cost and waste in the MedicarePart D program when this is medically appropriate The amount you pay in these circumstances willdepend on whether you are responsible for payingcoinsurance (a percentage of the cost of the drug) ora copay (a flat dollar amount for the drug) If youare responsible for coinsurance for the drug youwill continue to pay the applicable percentage ofthe drug cost If you are responsible for a copay forthe drug a ldquodaily cost-sharing raterdquo will be appliedIf your doctor decides to continue the drug after atrial period you should not pay more for a monthrsquossupply than you otherwise would have paid Contactyour plan if you have questions about cost-sharingwhen less than a one-month supply is dispensed Does my plan cover Medicare Part B or Part D drugs Blue Medicare Rx Standard and Enhanced plans donot cover drugs that are covered under Medicare PartB as prescribed and dispensed Generally we onlycover drugs vaccines biological products and medicalsupplies associated with the delivery of insulin thatare covered under the Medicare Prescription DrugBenefit (Part D) and that are on our formulary

PAG E 22 of 40

Introduction to the

Summary of benefits (continued)

What is a prescription drug formulary Blue Medicare Rx plans use a formularyA formulary is a list of drugs covered by your planto meet patient needs We may periodically addremove or make changes to coverage limitationson certain drugs or change how much you pay for adrug If we make any formulary change that limitsour membersrsquo ability to fill their prescriptions wewill notify the affected members before the changeis made We will send a formulary to you andyou can see our complete formulary on our Website at httpwwwbcbsnccomcontentmedicareformulary-homehtm If you are currently taking a drug that is not on ourformulary or subject to additional requirements orlimits you may be able to get a temporary supply ofthe drug You can contact us to request an exceptionor switch to an alternative drug listed on ourformulary with your physicianrsquos help Call us to seeif you can get a temporary supply of the drug or formore details about our drug transition policy What should I do if I have other insurance in addition to Medicare If you have a Medigap (Medicare Supplement)policy that includes prescription drug coverage youmust contact your Medigap Issuer to let them knowthat you have joined a Medicare Prescription DrugPlan If you decide to keep your current Medigapsupplement policy your Medigap Issuer willremove the prescription drug coverage portion ofyour policy Call your Medigap Issuer for details If you or your spouse has or is able to get employergroup coverage you should talk to your employerto find out how your benefits will be affected if youjoin a Blue Medicare Rx plan Get this informationbefore you decide to enroll in this plan

How can I get extra help with my prescription drug plan costs or get extra help with other Medicare costs You may be able to get extra help to pay for yourprescription drug premiums and costs as well as gethelp with other Medicare costs To see if you qualifyfor getting extra help call +1-800-MEDICARE (1-800-633-4227)

TTYTDD users should call 1-877-486-204824 hours a day7 days a week and seehttpwwwmedicaregov lsquoPrograms for Peoplewith Limited Income and Resourcesrsquo in the publication Medicare amp You

+The Social Security Administration at1-800-772-1213 between 7 am and 7 pmMonday through Friday TTYTDD usersshould call 1-800-325-0778 or

+Your State Medicaid Office What are my protections in this plan All Medicare Prescription Drug Plans agree to stayin the program for a full calendar year at a timePlan benefits and cost-sharing may change fromcalendar year to calendar year Each year plans candecide whether to continue to participate with theMedicare Prescription Drug Program A plan maycontinue in their entire service area (geographicarea where the plan accepts members) or choose tocontinue only in certain areas Also Medicare maydecide to end a contract with a plan Even if yourMedicare Prescription Plan leaves the program youwill not lose Medicare coverage If a plan decidesnot to continue for an additional calendar year itmust send you a letter at least 90 days before yourcoverage will end The letter will explain youroptions for Medicare coverage in your area As a member of a Blue Medicare Rx plan you havethe right to request a coverage determination whichincludes the right to request an exception the right tofile an appeal if we deny coverage for a prescriptiondrug and the right to file a grievance You havethe right to request a coverage determination if youwant us to cover a Part D drug that you believeshould be covered An exception is a type of coveragedetermination You may ask us for an exception ifyou believe you need a drug that is not on our list

PAG E 23 of 40

Prescription drugs coveredby the plans

Here are three ways to enroll in Medicare Part D

Enroll directly with the Medicare Part Dplan you choose via paper or onlineapplication at bcbsnccommedicare

Visit the Centers for Medicare amp Medicaid Services (CMS) Online Enrollment Center at wwwmedicaregov

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

+ Generally you can join or change Medicare Part D plans during the annual enrollment period ndash any time between October 15 and December 7 with an effective date of January 1 of the following year

+ If you are enrolling at a different time of year the effective date of your coverage will depend on your situation and whether or not you qualify for a special election period

+ You may only be enrolled in one Medicare Part D plan at a time

+ If you enroll in a stand-alone Medicare Part D plan while enrolled in a Medicare Advantage plan you will be disenrolled automatically from the Medicare Advantage plan and returned to Original Medicare

PAGE 8 of 40

How to join

Choose a plan Before you select a plan gather anydocumentation you may have on yourprescription drug purchases over thepast year This information will helpyou determine how much you mightsave with a Medicare Part D plan Thenyou can choose a plan that best fits yourneeds and your budget

Enroll in a plan Then you must fill out an enrollment formYou will be enrolled in the Medicare Part D plan you select and Medicare will beinformed that you have enrolled Inaddition to the paper enrollment formBlue Medicare Rx applicants can enrollonline at bcbsnccommedicare

Changing Medicare Part D plans Congress designed Medicare prescriptiondrug coverage to work on an annualenrollment cycle This means that each yearyou will have the option to remain with yourexisting Medicare Part D plan or change plansbetween October 15 and December 7

You may also have another opportunityduring the year to switch plans underlimited circumstances For example if youmove out of your planrsquos service area you willhave an opportunity to choose another planthat serves your new area Please contactBCBSNC if you would like more informationabout other situations in which you mayqualify for coverage or changes in coverageoutside the annual enrollment cycle

Important enrollment information

1

2

3

PAGE 9 of 40

You can join a Medicare Part D plan any time during your initial enrollment period for Medicare Generally a Medicare beneficiaryrsquos initial enrollment is a seven-month period three months prior to becoming Medicare eligible the month you become Medicare eligible and three months following the month you become Medicare eligible

If you were eligible for Medicare on or prior to January 1 2006 and did not enroll in a Medicare Part D plan or Medicare Advantage Prescription Drug Plan by May 15 2006 you may have to pay a penalty for late enrollment This penalty will not apply to Medicare beneficiaries who have equal or better prescription drug benefits through their

employer or another plan As of January 1 2009 these penalties no longer apply to Medicare individuals with Low Income Subsidy (LIS)

The penalty was designed to help hold down the overall costs of the drug program and is similar to the penalty imposed for late enrollment in Medicare Part B The late penalty equals one percent of the national base benchmark premium amount for each month that enrollment is delayed beyond your initial enrollment period For example if you delay enrollment in a Medicare Part D plan for two years you will pay the regular monthly plan premium plus 24 percent of the national base benchmark premium each month

Penalties for late enrollment

Important dates+ October 15 2013

First day you can enroll in a Medicare Part D plan for 2014 or the first day you can elect to switch to a different Medicare Part D plan (unless you qualify for a special election period)

+ December 7 2013 Last day you can enroll in a Medicare Part D plan for 2014 or the last day you can elect to switch to a different Medicare Part D plan (unless you qualify for a special election period)

+ January 1 2014 First day coverage begins (if you join a plan or switch plans by December 7 2013)

PAGE 10 of 40

(PDP)

Important information about our Medicare prescription drug plans

U5073b 813

Y0079_6248 CMS Accepted 08102013 PAGE 11 of 40

Important information

Eligibility for beneficiaries

Eligibility for beneficiaries Everyone who is entitled to Medicare benefitsunder Part A or enrolled in Part B is eligible forthis coverage however you are not enrolledautomatically You must join a plan to receivethe coverage6 This voluntary program is coveragethat you may choose to purchase annually Thisproduct is available to Medicare beneficiariesliving in North Carolina

Additional enrollment criteria You may enroll in only one Part D plan at a timeIf you are enrolled in a Medicare Advantage planyour enrollment in either of the PDP plans fromBlue Cross and Blue Shield of North Carolina (BCBSNC) may automatically disenroll you fromyour Medicare Advantage Plan and re-enroll youin Original Medicare for medical coverage Checkwith your plan for more information

Financial assistance

Financial assistance available People with limited incomes may qualify forExtra Help to pay for their prescription drugcosts If you qualify Medicare could pay for upto seventy-five (75) percent or more of your drugcosts including monthly prescriptiondrug premiums annual deductibles andco-insurance Additionally those who qualifywill not be subject to the coverage gap or a lateenrollment penalty Many people are eligiblefor these savings and donrsquot even know itFor more information about this Extra Helpcontact your local Social Security office or call1-800-MEDICARE (1-800-633-4227) 24 hours perday 7 days per week TTYTDD users shouldcall 1-877-486-2048

This document may be available in alternate formats upon request

Footnote 6 You must join a plan to receive the coverage unless

you are eligible for both Medicare and Medicaid Contact your State Medicaid or medical assistance office if you have questions about your eligibility

Social Security Administration

Phone 1-800-772-1213

TTYTDD 1-800-325-0778

Hours MondayndashFriday7 amndash7 pm

PAGE 12 of 40

Medicare

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

TTYTDD 1-877-486-2048

Hours 24 hours a day7 days a week

Important information

Pharmacy network

Pharmacy network information Our network includes a variety of pharmaciesincluding retail home infusion IndianTribalUrban organizations extended supply and long-term care pharmacies In order to obtain thegreatest savings on your prescription medicationsplease visit one of our preferred network providers(CVS WalMart Kerr and Epic Pharmacies) Formore information about our pharmacy networkand out-of-network policies please see our contactinformation below

Mail order contact information For information on our mail order service or to obtain forms please contact us at

Coverage determination

What is a coverage determination When we make a coverage determination weare making a decision about whether or not toprovide or pay for a Part D drug and what yourshare of the cost is for the drug (also see thedescription of the exceptions process) You mustcontact us if you would like to request a coveragedetermination including an exception Youcannot request an appeal if we have not issueda coverage determination

Mail order contact information

Phone 1-888-247-4142

TTYTDD 1-888-247-4145

Hours 7 days a week8 amndash8 pm

Mail BCBSNC Customer Service PO Box 17509 Winston-Salem NC 27116-7509

Online For a comprehensive list ofall pharmacies please visitbcbsnccommedicare

Examples of when you may ask us for a coverage determination

If you are not getting a prescription drug thatyou believe may be covered by us

If you have received a Part D prescription drugthat you believe may be covered by us while youwere a member but we have refused to pay forthe drug

If you are being told that coverage for a Part Dprescription drug that you have been gettingwill be reduced or stopped and you believe youhave special circumstances that should excludeyou from the reductionnon-coverage

If there is a limit on the quantity (or dose) of thedrug and you disagree with the requirement ordosage limitation

If you bought a drug at a pharmacy that isnot in our network and you want to requestreimbursement for the expense

PAGE 13 of 40

Important information

Coverage determination (continued)

How do I make a request for coverage determination Standard To ask for a standard decision you oryour appointed representative may call ourCustomer Service Department at the numberslisted on the back cover You can also mail a written request to the below address

Fast To ask for a fast decision you your physicianor your appointed representative may call theCustomer Service Department at the numbers listedon the back cover You can also mail a written request to the below address

Standard Generally we must give you our decisionno later than 72 hours after we have received yourrequest but we will make it sooner if your healthcondition requires

Fast If you get a fast review we will give you ourdecision within 24 hours after you or your doctor askfor a fast review mdash sooner if your health requires

PAGE 14 of 40

Contact information

Mail BCBSNC PO Box 17509 Winston-Salem NC 27116-7509

Fax Request 1-888-446-8440

Hours MondayndashFriday8 amndash5 pm

Note You cannot ask for a fast decision on a requestfor coverage of a drug already purchased

For some reviews we may require a supportingstatement from your doctor that explains why the drugyou are asking coverage for is medically necessary

After regular business hours you should consultwith a network pharmacy regarding your need for anemergency or temporary supply of medication untilyou can contact the Plan the next business day Youmay also call our Customer Service Department andleave a message on the Part D After Hours ExceptionRequest voicemail Be sure to ask for a ldquofastrdquoldquoexpeditedrdquo or ldquo24-hourrdquo review

When will I hear back with a decision

Important information

Exceptions process

What is an exception request Exception requests are a kind of coveragedetermination You your authorized representativeor your prescribing physician may request anexception to seek coverage of a drug that

+ Is not on the formulary (list of drugsthe plan covers)

+ Requires prior authorization + Has quantity limitations

Example of an exception request If the Planrsquos formulary does not include a drug thatyou or your prescribing physician feel is necessarythen you or your prescribing physician may requestan exception so that you may obtain coverage ofthis drug If the Plan does not grant the requestedexception then you or your prescribing physicianmay file an appeal

How do I make an exception request You or your prescribing physician may request anexception to the coverage rules for your MedicarePrescription Drug Plan A specific form is notrequired for you to make an exception requestThe request must include your prescribingphysicianrsquos statement that heshe has determinedthat the preferred drug either would not be aseffective or would have adverse effects for you

For your convenience forms are available at bcbsnccomcontentmedicarememberindexhtm

Contact information

Mail BCBSNC Attn PDP Exception RequestsPO Box 17509 Winston-Salem NC 27116-7509

Phone 1-888-247-4142

Physicians call 1-888-298-7552

TTYTDD 1-888-247-4145

Hours 7 days a week8 amndash8 pm

When will I receive a decision on my exception request If your exception request includes a formularyexception or an exception from utilizationmanagement rules such as dosage or quantitylimits we must make our decision no later than 72 hours after we have received your doctorrsquossupporting statement which explains why thedrug you are asking for is medically necessary

If you have asked for a fast or expedited exceptionrequest we must make our decision no later than24 hours after we get your doctorrsquos supporting statement

You will be notified by phone followed by awritten notice of our decision If the decision is not in your favor you have the right to appeal

PAGE 15 of 40

Important informationAppeals process

What is an appeal An appeal is your opportunity to requesta redetermination of an adverse coveragedetermination which includes denied exception requests

Example of an appeal If we deny your request for an exception to covera non-formulary drug then you may file an appealof the denial An appeal can only be filed afteran exception has been requested and denied bythe Plan

How do I file an appeal If you receive a coverage determination denial youor your appointed representative or your doctor orother prescriber may file an appeal A specific formis not required for you to file an appeal An appealmust be filed within 60 calendar days of the date ofa denial notice and must be in writing unless youare filing an expedited or fast appeal You mustsubmit it via mail fax or in person

When will I receive a decision on my appeal

We will perform a standard review of your appealwithin seven calendar days of receipt of your appealor sooner if your health requires We will reviewrequests for an expedited or fast appeal as soon aspossible but no later than 72 hours following ourreceipt of the request An individual who was notinvolved with your original coverage determinationwill make a decision on your appeal

You will receive a written response to your appealThe decision on an expedited appeal will beprovided by phone followed by the written noticeIf our decision is to deny the appeal the notice willadvise you of your right to submit your appeal to the Independent Review Entity (IRE) with instructionson how to do so If we miss our time frames for claims adjudication or review of the appeal wewill automatically forward the appeal to the IREfor a decision There may be additional levels ofappeal available to you We will inform you of youradditional rights in the notice or you may refer toyour Evidence of Coverage for further details

Contact information

Mail BCBSNC Attn Medicare Appeals amp GrievancesPO Box 17509 Winston-Salem NC 27116-7509

Fax 1-888-375-8836 or 1-336-794-8836

In Person

BCBSNC 5660 University PkwyWinston-Salem NC 27105

PAGE 16 of 40

Important information

Grievance process

What is a grievance A grievance is a complaint that you may file ifyou are dissatisfied with the Plan or a contractedprovider for reasons other than a decision ona coverage determination Grievances alsoinclude complaints regarding the timelinessappropriateness access to or setting of a coveredprescription drug

Example of a grievance If you are dissatisfied with the service you receivedfrom a pharmacist or plan representative then youcould file a grievance

How do I file a grievance The grievance must be filed within 60 days after theevent or incident that caused you to be dissatisfiedA specific form is not required for you to file agrievance You or your appointed representativemay file a grievance via the phone by mail faxor in person

When will I receive a decision on my grievance The resolution of a grievance will be made asquickly as your concern requires but no more than30 calendar days after our receipt of the grievanceWe may extend the time frame by up to 14 calendardays if you request the extension or if we justify aneed for additional information and the delay is inyour best interest

If you request a written response to an oralgrievance one will be provided within 30 days afterreceipt of the grievance A written response will beprovided to all written grievances Our decision ona grievance is final and is not subject to an appeal

You have the right to an expedited review ofa grievance concerning our refusal to grant anexpedited coverage determination or expeditedappeal This type of grievance will be responded towithin 24 hours after our receipt of the grievance

Contact information

Phone 1-888-247-4142

Fax 1-888-375-8836 or 1-336-794-8836

Hours 7 days a week8 amndash8 pm

Mail BCBSNC Attn Medicare Appeals amp GrievancesPO Box 17509 Winston-Salem NC 27116-7509

In Person

BCBSNC 5660 University PkwyWinston-Salem NC 27105

PAGE 17 of 40

Important information

Quality improvement

What if I have a concern about the quality of services I received If you have a concern relating to the quality of services that you received under the Medicare Part D planthen in addition to our review you can also request review by the following organizations

The Carolinas Center for Medical Excellence (CCME) Quality Improvement Organization (QIO) in North Carolina CCME formerly known as Medical Review ofNorth Carolina Inc is a nonprofit medical carequality improvement organization CCME has beendesignated by the Centers for Medicare amp MedicaidServices as the Quality Improvement Organization(QIO) for North Carolina The QIO conducts casereviews to ensure that Medicare beneficiaries receive the quality of medical care that they expect andare entitled to CCME serves as an independentimpartial third party to review Medicare beneficiarycomplaints

Quality of care complaints filed with the QIO mustbe made in writing to the address below Assistanceis available via phone or online

The Carolinas Center for Medical Excellence (CCME)

Mail CCME 100 Regency Forest DriveSuite 200 Cary NC 27518-8598

Phone 1-919-380-9860 or 1-800-682-2650

TTYTDD 1-800-735-2962

Hours MondayndashFriday8 amndash5 pm

Web inquiries wwwccmemedicareorg

Seniorsrsquo Health Insurance Information Program (SHIIP) SHIIP is a state consumer division of the North Carolina Department of Insurance SHIIP assistssenior citizens with Medicare Medicare Part D Medicare Advantage Medicare supplementsMedicare fraud and abuse and long-term careinsurance questions Assistance is available viaphone or online

Seniorsrsquo Health Insurance Information Program (SHIIP)

Phone 1-800-443-9354

TYYTDD 1-800-735-2962

Hours MondayndashFriday8 amndash5 pm

Email ncshiipncdoigov

Online wwwncshiipcom

PAGE 18 of 40

Important information

Additional information

Notice of possible contract termination BCBSNC has a contract with the Centers for Medicare amp Medicaid Services (CMS) the government agencythat runs Medicare to provide a Medicare PrescriptionDrug Plan (PDP) This contract renews each year At theend of each year the contract is reviewed and eitherBCBSNC or CMS can decide to end it Members will get 90 days advance written notice in this situationIt is also possible for our contract to end at some othertime If the contract is going to end we will generallytell members 90 days in advance Advance notice maybe as little as 30 days or even fewer days if CMS endsour contract in the middle of the year In this noticewe would provide a written description of alternativesavailable for obtaining qualified prescription drugcoverage in North Carolina We are also required tonotify the general public of a contract termination vialocal newspapers

If BCBSNC decides to stop offering the Medicare PDPor change our service area so that it no longer includesthe area where you live membership in BCBSNCrsquosMedicare PDP will end for everyone in that servicearea and members will have to change to a differentprescription drug plan Members will continue to getprescription drugs through BCBSNCrsquos Medicare PDPuntil the contract ends

PAGE 19 of 40

Important information

For more information

Blue Cross and Blue Shield of North Carolina

Phone 1-800-478-0583

TTYTDD 1-800-922-3140

Hours 7 days a week8 amndash8 pm

Online bcbsnccommedicare

Medicare

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

TTYTDD 1-877-486-2048

Hours 7 days a week24 hours a day

Online wwwmedicaregovClick the ldquoPrescription Drug Planrdquo link

Blue Cross and Blue Shield of North Carolina is a PDP plan with a Medicare contract Enrollment in Blue Cross and Blue Shield of North Carolina depends on contract renewal Benefits formulary pharmacy network premium andor copaymentscoinsurance may change on January 1 2015 Please contact BCBSNC for details

An independent licensee of the Blue Cross and Blue Shield Association

PAGE 20 of 40

(PDP)

2014 Summary of benefits for our Medicare prescription drug plans (Enhanced and Standard)

Contract S5540 Plans 004 and 002 January 1 2014 ndash December 31 2014

U5073c 813

PAGE 21 of 40Y0079_6249 CMS Accepted 09112013

Introduction to the

Summary of benefits for (PDP)

Thank you for your interest in Blue Medicare Rx(PDP) plans Our plans are offered by Blue Crossand Blue Shield of North Carolina a MedicarePrescription Drug Plan that contracts with theFederal government This Summary of Benefits tellsyou some features of our plans It doesnrsquot list everydrug we cover every limitation or exclusionTo get a complete list of our benefits please callBlue Medicare Rx and ask for the ldquoEvidence of Coveragerdquo You have choices in your Medicare prescription drug coverage As a Medicare beneficiary you can choose fromdifferent Medicare prescription drug coverageoptions One option is to get prescription drugcoverage through a Medicare Prescription DrugPlan like Blue Medicare Rx plans Another optionis to get your prescription drug coverage througha Medicare Advantage Plan that offers prescriptiondrug coverage You make the choice How can I compare my options The charts in this booklet list some important drugbenefits You can use this Summary of Benefitsto compare the benefits offered by Blue MedicareRx plans to the benefits offered by other MedicarePrescription Drug Plans or Medicare AdvantagePlans with prescription drug coverage Where are Blue Medicare Rx Plans available The service area for these plans includesNorth Carolina You must live in one of these areas to join one of these plans Who is eligible to join You can join one of these plans if you are entitled toMedicare Part A andor enrolled in Medicare Part Band live in the service area If you are enrolled in an MA coordinated care(HMO or PPO) plan or an MA PFFS plan thatincludes Medicare prescription drugs you maynot enroll in a PDP unless you disenroll from theHMO PPO or MA PFFS plan Enrollees in a private Fee-for-Service plan (PFFS)that does not provide Medicare prescription drugcoverage or an MA Medical Savings Account (MSA)plan may enroll in a PDP Enrollees in an 1876 Costplan may enroll in a PDP

Where can I get my prescriptions Blue Medicare Rx plans have formed a network ofpharmacies You must use a network pharmacyto receive plan benefits We will not pay foryour prescriptions if you use an out-of-networkpharmacy except in certain cases Blue Medicare Rx plans have a list of preferredpharmacies At these pharmacies you may getyour drugs at a lower co-pay or coinsuranceYou may go to a non-preferred pharmacy but youmay have to pay more for your prescription drugs The pharmacies in our network can change at anytime You can ask for a Pharmacy Directory or visit usat wwwmyprimecomMyRxMyPrimeMedicareDpharmacyBCBSNC Our customer service number is listed at the end of this introduction What if my doctor prescribes less than a monthrsquos supply In consultation with your doctor or pharmacist youmay receive less than a monthrsquos supply of certaindrugs Also if you live in a long-term care facilityyou will receive less than a monthrsquos supply of certainbrand [and generic] drugs Dispensing fewer drugs ata time can help reduce cost and waste in the MedicarePart D program when this is medically appropriate The amount you pay in these circumstances willdepend on whether you are responsible for payingcoinsurance (a percentage of the cost of the drug) ora copay (a flat dollar amount for the drug) If youare responsible for coinsurance for the drug youwill continue to pay the applicable percentage ofthe drug cost If you are responsible for a copay forthe drug a ldquodaily cost-sharing raterdquo will be appliedIf your doctor decides to continue the drug after atrial period you should not pay more for a monthrsquossupply than you otherwise would have paid Contactyour plan if you have questions about cost-sharingwhen less than a one-month supply is dispensed Does my plan cover Medicare Part B or Part D drugs Blue Medicare Rx Standard and Enhanced plans donot cover drugs that are covered under Medicare PartB as prescribed and dispensed Generally we onlycover drugs vaccines biological products and medicalsupplies associated with the delivery of insulin thatare covered under the Medicare Prescription DrugBenefit (Part D) and that are on our formulary

PAG E 22 of 40

Introduction to the

Summary of benefits (continued)

What is a prescription drug formulary Blue Medicare Rx plans use a formularyA formulary is a list of drugs covered by your planto meet patient needs We may periodically addremove or make changes to coverage limitationson certain drugs or change how much you pay for adrug If we make any formulary change that limitsour membersrsquo ability to fill their prescriptions wewill notify the affected members before the changeis made We will send a formulary to you andyou can see our complete formulary on our Website at httpwwwbcbsnccomcontentmedicareformulary-homehtm If you are currently taking a drug that is not on ourformulary or subject to additional requirements orlimits you may be able to get a temporary supply ofthe drug You can contact us to request an exceptionor switch to an alternative drug listed on ourformulary with your physicianrsquos help Call us to seeif you can get a temporary supply of the drug or formore details about our drug transition policy What should I do if I have other insurance in addition to Medicare If you have a Medigap (Medicare Supplement)policy that includes prescription drug coverage youmust contact your Medigap Issuer to let them knowthat you have joined a Medicare Prescription DrugPlan If you decide to keep your current Medigapsupplement policy your Medigap Issuer willremove the prescription drug coverage portion ofyour policy Call your Medigap Issuer for details If you or your spouse has or is able to get employergroup coverage you should talk to your employerto find out how your benefits will be affected if youjoin a Blue Medicare Rx plan Get this informationbefore you decide to enroll in this plan

How can I get extra help with my prescription drug plan costs or get extra help with other Medicare costs You may be able to get extra help to pay for yourprescription drug premiums and costs as well as gethelp with other Medicare costs To see if you qualifyfor getting extra help call +1-800-MEDICARE (1-800-633-4227)

TTYTDD users should call 1-877-486-204824 hours a day7 days a week and seehttpwwwmedicaregov lsquoPrograms for Peoplewith Limited Income and Resourcesrsquo in the publication Medicare amp You

+The Social Security Administration at1-800-772-1213 between 7 am and 7 pmMonday through Friday TTYTDD usersshould call 1-800-325-0778 or

+Your State Medicaid Office What are my protections in this plan All Medicare Prescription Drug Plans agree to stayin the program for a full calendar year at a timePlan benefits and cost-sharing may change fromcalendar year to calendar year Each year plans candecide whether to continue to participate with theMedicare Prescription Drug Program A plan maycontinue in their entire service area (geographicarea where the plan accepts members) or choose tocontinue only in certain areas Also Medicare maydecide to end a contract with a plan Even if yourMedicare Prescription Plan leaves the program youwill not lose Medicare coverage If a plan decidesnot to continue for an additional calendar year itmust send you a letter at least 90 days before yourcoverage will end The letter will explain youroptions for Medicare coverage in your area As a member of a Blue Medicare Rx plan you havethe right to request a coverage determination whichincludes the right to request an exception the right tofile an appeal if we deny coverage for a prescriptiondrug and the right to file a grievance You havethe right to request a coverage determination if youwant us to cover a Part D drug that you believeshould be covered An exception is a type of coveragedetermination You may ask us for an exception ifyou believe you need a drug that is not on our list

PAG E 23 of 40

PAGE 9 of 40

You can join a Medicare Part D plan any time during your initial enrollment period for Medicare Generally a Medicare beneficiaryrsquos initial enrollment is a seven-month period three months prior to becoming Medicare eligible the month you become Medicare eligible and three months following the month you become Medicare eligible

If you were eligible for Medicare on or prior to January 1 2006 and did not enroll in a Medicare Part D plan or Medicare Advantage Prescription Drug Plan by May 15 2006 you may have to pay a penalty for late enrollment This penalty will not apply to Medicare beneficiaries who have equal or better prescription drug benefits through their

employer or another plan As of January 1 2009 these penalties no longer apply to Medicare individuals with Low Income Subsidy (LIS)

The penalty was designed to help hold down the overall costs of the drug program and is similar to the penalty imposed for late enrollment in Medicare Part B The late penalty equals one percent of the national base benchmark premium amount for each month that enrollment is delayed beyond your initial enrollment period For example if you delay enrollment in a Medicare Part D plan for two years you will pay the regular monthly plan premium plus 24 percent of the national base benchmark premium each month

Penalties for late enrollment

Important dates+ October 15 2013

First day you can enroll in a Medicare Part D plan for 2014 or the first day you can elect to switch to a different Medicare Part D plan (unless you qualify for a special election period)

+ December 7 2013 Last day you can enroll in a Medicare Part D plan for 2014 or the last day you can elect to switch to a different Medicare Part D plan (unless you qualify for a special election period)

+ January 1 2014 First day coverage begins (if you join a plan or switch plans by December 7 2013)

PAGE 10 of 40

(PDP)

Important information about our Medicare prescription drug plans

U5073b 813

Y0079_6248 CMS Accepted 08102013 PAGE 11 of 40

Important information

Eligibility for beneficiaries

Eligibility for beneficiaries Everyone who is entitled to Medicare benefitsunder Part A or enrolled in Part B is eligible forthis coverage however you are not enrolledautomatically You must join a plan to receivethe coverage6 This voluntary program is coveragethat you may choose to purchase annually Thisproduct is available to Medicare beneficiariesliving in North Carolina

Additional enrollment criteria You may enroll in only one Part D plan at a timeIf you are enrolled in a Medicare Advantage planyour enrollment in either of the PDP plans fromBlue Cross and Blue Shield of North Carolina (BCBSNC) may automatically disenroll you fromyour Medicare Advantage Plan and re-enroll youin Original Medicare for medical coverage Checkwith your plan for more information

Financial assistance

Financial assistance available People with limited incomes may qualify forExtra Help to pay for their prescription drugcosts If you qualify Medicare could pay for upto seventy-five (75) percent or more of your drugcosts including monthly prescriptiondrug premiums annual deductibles andco-insurance Additionally those who qualifywill not be subject to the coverage gap or a lateenrollment penalty Many people are eligiblefor these savings and donrsquot even know itFor more information about this Extra Helpcontact your local Social Security office or call1-800-MEDICARE (1-800-633-4227) 24 hours perday 7 days per week TTYTDD users shouldcall 1-877-486-2048

This document may be available in alternate formats upon request

Footnote 6 You must join a plan to receive the coverage unless

you are eligible for both Medicare and Medicaid Contact your State Medicaid or medical assistance office if you have questions about your eligibility

Social Security Administration

Phone 1-800-772-1213

TTYTDD 1-800-325-0778

Hours MondayndashFriday7 amndash7 pm

PAGE 12 of 40

Medicare

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

TTYTDD 1-877-486-2048

Hours 24 hours a day7 days a week

Important information

Pharmacy network

Pharmacy network information Our network includes a variety of pharmaciesincluding retail home infusion IndianTribalUrban organizations extended supply and long-term care pharmacies In order to obtain thegreatest savings on your prescription medicationsplease visit one of our preferred network providers(CVS WalMart Kerr and Epic Pharmacies) Formore information about our pharmacy networkand out-of-network policies please see our contactinformation below

Mail order contact information For information on our mail order service or to obtain forms please contact us at

Coverage determination

What is a coverage determination When we make a coverage determination weare making a decision about whether or not toprovide or pay for a Part D drug and what yourshare of the cost is for the drug (also see thedescription of the exceptions process) You mustcontact us if you would like to request a coveragedetermination including an exception Youcannot request an appeal if we have not issueda coverage determination

Mail order contact information

Phone 1-888-247-4142

TTYTDD 1-888-247-4145

Hours 7 days a week8 amndash8 pm

Mail BCBSNC Customer Service PO Box 17509 Winston-Salem NC 27116-7509

Online For a comprehensive list ofall pharmacies please visitbcbsnccommedicare

Examples of when you may ask us for a coverage determination

If you are not getting a prescription drug thatyou believe may be covered by us

If you have received a Part D prescription drugthat you believe may be covered by us while youwere a member but we have refused to pay forthe drug

If you are being told that coverage for a Part Dprescription drug that you have been gettingwill be reduced or stopped and you believe youhave special circumstances that should excludeyou from the reductionnon-coverage

If there is a limit on the quantity (or dose) of thedrug and you disagree with the requirement ordosage limitation

If you bought a drug at a pharmacy that isnot in our network and you want to requestreimbursement for the expense

PAGE 13 of 40

Important information

Coverage determination (continued)

How do I make a request for coverage determination Standard To ask for a standard decision you oryour appointed representative may call ourCustomer Service Department at the numberslisted on the back cover You can also mail a written request to the below address

Fast To ask for a fast decision you your physicianor your appointed representative may call theCustomer Service Department at the numbers listedon the back cover You can also mail a written request to the below address

Standard Generally we must give you our decisionno later than 72 hours after we have received yourrequest but we will make it sooner if your healthcondition requires

Fast If you get a fast review we will give you ourdecision within 24 hours after you or your doctor askfor a fast review mdash sooner if your health requires

PAGE 14 of 40

Contact information

Mail BCBSNC PO Box 17509 Winston-Salem NC 27116-7509

Fax Request 1-888-446-8440

Hours MondayndashFriday8 amndash5 pm

Note You cannot ask for a fast decision on a requestfor coverage of a drug already purchased

For some reviews we may require a supportingstatement from your doctor that explains why the drugyou are asking coverage for is medically necessary

After regular business hours you should consultwith a network pharmacy regarding your need for anemergency or temporary supply of medication untilyou can contact the Plan the next business day Youmay also call our Customer Service Department andleave a message on the Part D After Hours ExceptionRequest voicemail Be sure to ask for a ldquofastrdquoldquoexpeditedrdquo or ldquo24-hourrdquo review

When will I hear back with a decision

Important information

Exceptions process

What is an exception request Exception requests are a kind of coveragedetermination You your authorized representativeor your prescribing physician may request anexception to seek coverage of a drug that

+ Is not on the formulary (list of drugsthe plan covers)

+ Requires prior authorization + Has quantity limitations

Example of an exception request If the Planrsquos formulary does not include a drug thatyou or your prescribing physician feel is necessarythen you or your prescribing physician may requestan exception so that you may obtain coverage ofthis drug If the Plan does not grant the requestedexception then you or your prescribing physicianmay file an appeal

How do I make an exception request You or your prescribing physician may request anexception to the coverage rules for your MedicarePrescription Drug Plan A specific form is notrequired for you to make an exception requestThe request must include your prescribingphysicianrsquos statement that heshe has determinedthat the preferred drug either would not be aseffective or would have adverse effects for you

For your convenience forms are available at bcbsnccomcontentmedicarememberindexhtm

Contact information

Mail BCBSNC Attn PDP Exception RequestsPO Box 17509 Winston-Salem NC 27116-7509

Phone 1-888-247-4142

Physicians call 1-888-298-7552

TTYTDD 1-888-247-4145

Hours 7 days a week8 amndash8 pm

When will I receive a decision on my exception request If your exception request includes a formularyexception or an exception from utilizationmanagement rules such as dosage or quantitylimits we must make our decision no later than 72 hours after we have received your doctorrsquossupporting statement which explains why thedrug you are asking for is medically necessary

If you have asked for a fast or expedited exceptionrequest we must make our decision no later than24 hours after we get your doctorrsquos supporting statement

You will be notified by phone followed by awritten notice of our decision If the decision is not in your favor you have the right to appeal

PAGE 15 of 40

Important informationAppeals process

What is an appeal An appeal is your opportunity to requesta redetermination of an adverse coveragedetermination which includes denied exception requests

Example of an appeal If we deny your request for an exception to covera non-formulary drug then you may file an appealof the denial An appeal can only be filed afteran exception has been requested and denied bythe Plan

How do I file an appeal If you receive a coverage determination denial youor your appointed representative or your doctor orother prescriber may file an appeal A specific formis not required for you to file an appeal An appealmust be filed within 60 calendar days of the date ofa denial notice and must be in writing unless youare filing an expedited or fast appeal You mustsubmit it via mail fax or in person

When will I receive a decision on my appeal

We will perform a standard review of your appealwithin seven calendar days of receipt of your appealor sooner if your health requires We will reviewrequests for an expedited or fast appeal as soon aspossible but no later than 72 hours following ourreceipt of the request An individual who was notinvolved with your original coverage determinationwill make a decision on your appeal

You will receive a written response to your appealThe decision on an expedited appeal will beprovided by phone followed by the written noticeIf our decision is to deny the appeal the notice willadvise you of your right to submit your appeal to the Independent Review Entity (IRE) with instructionson how to do so If we miss our time frames for claims adjudication or review of the appeal wewill automatically forward the appeal to the IREfor a decision There may be additional levels ofappeal available to you We will inform you of youradditional rights in the notice or you may refer toyour Evidence of Coverage for further details

Contact information

Mail BCBSNC Attn Medicare Appeals amp GrievancesPO Box 17509 Winston-Salem NC 27116-7509

Fax 1-888-375-8836 or 1-336-794-8836

In Person

BCBSNC 5660 University PkwyWinston-Salem NC 27105

PAGE 16 of 40

Important information

Grievance process

What is a grievance A grievance is a complaint that you may file ifyou are dissatisfied with the Plan or a contractedprovider for reasons other than a decision ona coverage determination Grievances alsoinclude complaints regarding the timelinessappropriateness access to or setting of a coveredprescription drug

Example of a grievance If you are dissatisfied with the service you receivedfrom a pharmacist or plan representative then youcould file a grievance

How do I file a grievance The grievance must be filed within 60 days after theevent or incident that caused you to be dissatisfiedA specific form is not required for you to file agrievance You or your appointed representativemay file a grievance via the phone by mail faxor in person

When will I receive a decision on my grievance The resolution of a grievance will be made asquickly as your concern requires but no more than30 calendar days after our receipt of the grievanceWe may extend the time frame by up to 14 calendardays if you request the extension or if we justify aneed for additional information and the delay is inyour best interest

If you request a written response to an oralgrievance one will be provided within 30 days afterreceipt of the grievance A written response will beprovided to all written grievances Our decision ona grievance is final and is not subject to an appeal

You have the right to an expedited review ofa grievance concerning our refusal to grant anexpedited coverage determination or expeditedappeal This type of grievance will be responded towithin 24 hours after our receipt of the grievance

Contact information

Phone 1-888-247-4142

Fax 1-888-375-8836 or 1-336-794-8836

Hours 7 days a week8 amndash8 pm

Mail BCBSNC Attn Medicare Appeals amp GrievancesPO Box 17509 Winston-Salem NC 27116-7509

In Person

BCBSNC 5660 University PkwyWinston-Salem NC 27105

PAGE 17 of 40

Important information

Quality improvement

What if I have a concern about the quality of services I received If you have a concern relating to the quality of services that you received under the Medicare Part D planthen in addition to our review you can also request review by the following organizations

The Carolinas Center for Medical Excellence (CCME) Quality Improvement Organization (QIO) in North Carolina CCME formerly known as Medical Review ofNorth Carolina Inc is a nonprofit medical carequality improvement organization CCME has beendesignated by the Centers for Medicare amp MedicaidServices as the Quality Improvement Organization(QIO) for North Carolina The QIO conducts casereviews to ensure that Medicare beneficiaries receive the quality of medical care that they expect andare entitled to CCME serves as an independentimpartial third party to review Medicare beneficiarycomplaints

Quality of care complaints filed with the QIO mustbe made in writing to the address below Assistanceis available via phone or online

The Carolinas Center for Medical Excellence (CCME)

Mail CCME 100 Regency Forest DriveSuite 200 Cary NC 27518-8598

Phone 1-919-380-9860 or 1-800-682-2650

TTYTDD 1-800-735-2962

Hours MondayndashFriday8 amndash5 pm

Web inquiries wwwccmemedicareorg

Seniorsrsquo Health Insurance Information Program (SHIIP) SHIIP is a state consumer division of the North Carolina Department of Insurance SHIIP assistssenior citizens with Medicare Medicare Part D Medicare Advantage Medicare supplementsMedicare fraud and abuse and long-term careinsurance questions Assistance is available viaphone or online

Seniorsrsquo Health Insurance Information Program (SHIIP)

Phone 1-800-443-9354

TYYTDD 1-800-735-2962

Hours MondayndashFriday8 amndash5 pm

Email ncshiipncdoigov

Online wwwncshiipcom

PAGE 18 of 40

Important information

Additional information

Notice of possible contract termination BCBSNC has a contract with the Centers for Medicare amp Medicaid Services (CMS) the government agencythat runs Medicare to provide a Medicare PrescriptionDrug Plan (PDP) This contract renews each year At theend of each year the contract is reviewed and eitherBCBSNC or CMS can decide to end it Members will get 90 days advance written notice in this situationIt is also possible for our contract to end at some othertime If the contract is going to end we will generallytell members 90 days in advance Advance notice maybe as little as 30 days or even fewer days if CMS endsour contract in the middle of the year In this noticewe would provide a written description of alternativesavailable for obtaining qualified prescription drugcoverage in North Carolina We are also required tonotify the general public of a contract termination vialocal newspapers

If BCBSNC decides to stop offering the Medicare PDPor change our service area so that it no longer includesthe area where you live membership in BCBSNCrsquosMedicare PDP will end for everyone in that servicearea and members will have to change to a differentprescription drug plan Members will continue to getprescription drugs through BCBSNCrsquos Medicare PDPuntil the contract ends

PAGE 19 of 40

Important information

For more information

Blue Cross and Blue Shield of North Carolina

Phone 1-800-478-0583

TTYTDD 1-800-922-3140

Hours 7 days a week8 amndash8 pm

Online bcbsnccommedicare

Medicare

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

TTYTDD 1-877-486-2048

Hours 7 days a week24 hours a day

Online wwwmedicaregovClick the ldquoPrescription Drug Planrdquo link

Blue Cross and Blue Shield of North Carolina is a PDP plan with a Medicare contract Enrollment in Blue Cross and Blue Shield of North Carolina depends on contract renewal Benefits formulary pharmacy network premium andor copaymentscoinsurance may change on January 1 2015 Please contact BCBSNC for details

An independent licensee of the Blue Cross and Blue Shield Association

PAGE 20 of 40

(PDP)

2014 Summary of benefits for our Medicare prescription drug plans (Enhanced and Standard)

Contract S5540 Plans 004 and 002 January 1 2014 ndash December 31 2014

U5073c 813

PAGE 21 of 40Y0079_6249 CMS Accepted 09112013

Introduction to the

Summary of benefits for (PDP)

Thank you for your interest in Blue Medicare Rx(PDP) plans Our plans are offered by Blue Crossand Blue Shield of North Carolina a MedicarePrescription Drug Plan that contracts with theFederal government This Summary of Benefits tellsyou some features of our plans It doesnrsquot list everydrug we cover every limitation or exclusionTo get a complete list of our benefits please callBlue Medicare Rx and ask for the ldquoEvidence of Coveragerdquo You have choices in your Medicare prescription drug coverage As a Medicare beneficiary you can choose fromdifferent Medicare prescription drug coverageoptions One option is to get prescription drugcoverage through a Medicare Prescription DrugPlan like Blue Medicare Rx plans Another optionis to get your prescription drug coverage througha Medicare Advantage Plan that offers prescriptiondrug coverage You make the choice How can I compare my options The charts in this booklet list some important drugbenefits You can use this Summary of Benefitsto compare the benefits offered by Blue MedicareRx plans to the benefits offered by other MedicarePrescription Drug Plans or Medicare AdvantagePlans with prescription drug coverage Where are Blue Medicare Rx Plans available The service area for these plans includesNorth Carolina You must live in one of these areas to join one of these plans Who is eligible to join You can join one of these plans if you are entitled toMedicare Part A andor enrolled in Medicare Part Band live in the service area If you are enrolled in an MA coordinated care(HMO or PPO) plan or an MA PFFS plan thatincludes Medicare prescription drugs you maynot enroll in a PDP unless you disenroll from theHMO PPO or MA PFFS plan Enrollees in a private Fee-for-Service plan (PFFS)that does not provide Medicare prescription drugcoverage or an MA Medical Savings Account (MSA)plan may enroll in a PDP Enrollees in an 1876 Costplan may enroll in a PDP

Where can I get my prescriptions Blue Medicare Rx plans have formed a network ofpharmacies You must use a network pharmacyto receive plan benefits We will not pay foryour prescriptions if you use an out-of-networkpharmacy except in certain cases Blue Medicare Rx plans have a list of preferredpharmacies At these pharmacies you may getyour drugs at a lower co-pay or coinsuranceYou may go to a non-preferred pharmacy but youmay have to pay more for your prescription drugs The pharmacies in our network can change at anytime You can ask for a Pharmacy Directory or visit usat wwwmyprimecomMyRxMyPrimeMedicareDpharmacyBCBSNC Our customer service number is listed at the end of this introduction What if my doctor prescribes less than a monthrsquos supply In consultation with your doctor or pharmacist youmay receive less than a monthrsquos supply of certaindrugs Also if you live in a long-term care facilityyou will receive less than a monthrsquos supply of certainbrand [and generic] drugs Dispensing fewer drugs ata time can help reduce cost and waste in the MedicarePart D program when this is medically appropriate The amount you pay in these circumstances willdepend on whether you are responsible for payingcoinsurance (a percentage of the cost of the drug) ora copay (a flat dollar amount for the drug) If youare responsible for coinsurance for the drug youwill continue to pay the applicable percentage ofthe drug cost If you are responsible for a copay forthe drug a ldquodaily cost-sharing raterdquo will be appliedIf your doctor decides to continue the drug after atrial period you should not pay more for a monthrsquossupply than you otherwise would have paid Contactyour plan if you have questions about cost-sharingwhen less than a one-month supply is dispensed Does my plan cover Medicare Part B or Part D drugs Blue Medicare Rx Standard and Enhanced plans donot cover drugs that are covered under Medicare PartB as prescribed and dispensed Generally we onlycover drugs vaccines biological products and medicalsupplies associated with the delivery of insulin thatare covered under the Medicare Prescription DrugBenefit (Part D) and that are on our formulary

PAG E 22 of 40

Introduction to the

Summary of benefits (continued)

What is a prescription drug formulary Blue Medicare Rx plans use a formularyA formulary is a list of drugs covered by your planto meet patient needs We may periodically addremove or make changes to coverage limitationson certain drugs or change how much you pay for adrug If we make any formulary change that limitsour membersrsquo ability to fill their prescriptions wewill notify the affected members before the changeis made We will send a formulary to you andyou can see our complete formulary on our Website at httpwwwbcbsnccomcontentmedicareformulary-homehtm If you are currently taking a drug that is not on ourformulary or subject to additional requirements orlimits you may be able to get a temporary supply ofthe drug You can contact us to request an exceptionor switch to an alternative drug listed on ourformulary with your physicianrsquos help Call us to seeif you can get a temporary supply of the drug or formore details about our drug transition policy What should I do if I have other insurance in addition to Medicare If you have a Medigap (Medicare Supplement)policy that includes prescription drug coverage youmust contact your Medigap Issuer to let them knowthat you have joined a Medicare Prescription DrugPlan If you decide to keep your current Medigapsupplement policy your Medigap Issuer willremove the prescription drug coverage portion ofyour policy Call your Medigap Issuer for details If you or your spouse has or is able to get employergroup coverage you should talk to your employerto find out how your benefits will be affected if youjoin a Blue Medicare Rx plan Get this informationbefore you decide to enroll in this plan

How can I get extra help with my prescription drug plan costs or get extra help with other Medicare costs You may be able to get extra help to pay for yourprescription drug premiums and costs as well as gethelp with other Medicare costs To see if you qualifyfor getting extra help call +1-800-MEDICARE (1-800-633-4227)

TTYTDD users should call 1-877-486-204824 hours a day7 days a week and seehttpwwwmedicaregov lsquoPrograms for Peoplewith Limited Income and Resourcesrsquo in the publication Medicare amp You

+The Social Security Administration at1-800-772-1213 between 7 am and 7 pmMonday through Friday TTYTDD usersshould call 1-800-325-0778 or

+Your State Medicaid Office What are my protections in this plan All Medicare Prescription Drug Plans agree to stayin the program for a full calendar year at a timePlan benefits and cost-sharing may change fromcalendar year to calendar year Each year plans candecide whether to continue to participate with theMedicare Prescription Drug Program A plan maycontinue in their entire service area (geographicarea where the plan accepts members) or choose tocontinue only in certain areas Also Medicare maydecide to end a contract with a plan Even if yourMedicare Prescription Plan leaves the program youwill not lose Medicare coverage If a plan decidesnot to continue for an additional calendar year itmust send you a letter at least 90 days before yourcoverage will end The letter will explain youroptions for Medicare coverage in your area As a member of a Blue Medicare Rx plan you havethe right to request a coverage determination whichincludes the right to request an exception the right tofile an appeal if we deny coverage for a prescriptiondrug and the right to file a grievance You havethe right to request a coverage determination if youwant us to cover a Part D drug that you believeshould be covered An exception is a type of coveragedetermination You may ask us for an exception ifyou believe you need a drug that is not on our list

PAG E 23 of 40

Important dates+ October 15 2013

First day you can enroll in a Medicare Part D plan for 2014 or the first day you can elect to switch to a different Medicare Part D plan (unless you qualify for a special election period)

+ December 7 2013 Last day you can enroll in a Medicare Part D plan for 2014 or the last day you can elect to switch to a different Medicare Part D plan (unless you qualify for a special election period)

+ January 1 2014 First day coverage begins (if you join a plan or switch plans by December 7 2013)

PAGE 10 of 40

(PDP)

Important information about our Medicare prescription drug plans

U5073b 813

Y0079_6248 CMS Accepted 08102013 PAGE 11 of 40

Important information

Eligibility for beneficiaries

Eligibility for beneficiaries Everyone who is entitled to Medicare benefitsunder Part A or enrolled in Part B is eligible forthis coverage however you are not enrolledautomatically You must join a plan to receivethe coverage6 This voluntary program is coveragethat you may choose to purchase annually Thisproduct is available to Medicare beneficiariesliving in North Carolina

Additional enrollment criteria You may enroll in only one Part D plan at a timeIf you are enrolled in a Medicare Advantage planyour enrollment in either of the PDP plans fromBlue Cross and Blue Shield of North Carolina (BCBSNC) may automatically disenroll you fromyour Medicare Advantage Plan and re-enroll youin Original Medicare for medical coverage Checkwith your plan for more information

Financial assistance

Financial assistance available People with limited incomes may qualify forExtra Help to pay for their prescription drugcosts If you qualify Medicare could pay for upto seventy-five (75) percent or more of your drugcosts including monthly prescriptiondrug premiums annual deductibles andco-insurance Additionally those who qualifywill not be subject to the coverage gap or a lateenrollment penalty Many people are eligiblefor these savings and donrsquot even know itFor more information about this Extra Helpcontact your local Social Security office or call1-800-MEDICARE (1-800-633-4227) 24 hours perday 7 days per week TTYTDD users shouldcall 1-877-486-2048

This document may be available in alternate formats upon request

Footnote 6 You must join a plan to receive the coverage unless

you are eligible for both Medicare and Medicaid Contact your State Medicaid or medical assistance office if you have questions about your eligibility

Social Security Administration

Phone 1-800-772-1213

TTYTDD 1-800-325-0778

Hours MondayndashFriday7 amndash7 pm

PAGE 12 of 40

Medicare

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

TTYTDD 1-877-486-2048

Hours 24 hours a day7 days a week

Important information

Pharmacy network

Pharmacy network information Our network includes a variety of pharmaciesincluding retail home infusion IndianTribalUrban organizations extended supply and long-term care pharmacies In order to obtain thegreatest savings on your prescription medicationsplease visit one of our preferred network providers(CVS WalMart Kerr and Epic Pharmacies) Formore information about our pharmacy networkand out-of-network policies please see our contactinformation below

Mail order contact information For information on our mail order service or to obtain forms please contact us at

Coverage determination

What is a coverage determination When we make a coverage determination weare making a decision about whether or not toprovide or pay for a Part D drug and what yourshare of the cost is for the drug (also see thedescription of the exceptions process) You mustcontact us if you would like to request a coveragedetermination including an exception Youcannot request an appeal if we have not issueda coverage determination

Mail order contact information

Phone 1-888-247-4142

TTYTDD 1-888-247-4145

Hours 7 days a week8 amndash8 pm

Mail BCBSNC Customer Service PO Box 17509 Winston-Salem NC 27116-7509

Online For a comprehensive list ofall pharmacies please visitbcbsnccommedicare

Examples of when you may ask us for a coverage determination

If you are not getting a prescription drug thatyou believe may be covered by us

If you have received a Part D prescription drugthat you believe may be covered by us while youwere a member but we have refused to pay forthe drug

If you are being told that coverage for a Part Dprescription drug that you have been gettingwill be reduced or stopped and you believe youhave special circumstances that should excludeyou from the reductionnon-coverage

If there is a limit on the quantity (or dose) of thedrug and you disagree with the requirement ordosage limitation

If you bought a drug at a pharmacy that isnot in our network and you want to requestreimbursement for the expense

PAGE 13 of 40

Important information

Coverage determination (continued)

How do I make a request for coverage determination Standard To ask for a standard decision you oryour appointed representative may call ourCustomer Service Department at the numberslisted on the back cover You can also mail a written request to the below address

Fast To ask for a fast decision you your physicianor your appointed representative may call theCustomer Service Department at the numbers listedon the back cover You can also mail a written request to the below address

Standard Generally we must give you our decisionno later than 72 hours after we have received yourrequest but we will make it sooner if your healthcondition requires

Fast If you get a fast review we will give you ourdecision within 24 hours after you or your doctor askfor a fast review mdash sooner if your health requires

PAGE 14 of 40

Contact information

Mail BCBSNC PO Box 17509 Winston-Salem NC 27116-7509

Fax Request 1-888-446-8440

Hours MondayndashFriday8 amndash5 pm

Note You cannot ask for a fast decision on a requestfor coverage of a drug already purchased

For some reviews we may require a supportingstatement from your doctor that explains why the drugyou are asking coverage for is medically necessary

After regular business hours you should consultwith a network pharmacy regarding your need for anemergency or temporary supply of medication untilyou can contact the Plan the next business day Youmay also call our Customer Service Department andleave a message on the Part D After Hours ExceptionRequest voicemail Be sure to ask for a ldquofastrdquoldquoexpeditedrdquo or ldquo24-hourrdquo review

When will I hear back with a decision

Important information

Exceptions process

What is an exception request Exception requests are a kind of coveragedetermination You your authorized representativeor your prescribing physician may request anexception to seek coverage of a drug that

+ Is not on the formulary (list of drugsthe plan covers)

+ Requires prior authorization + Has quantity limitations

Example of an exception request If the Planrsquos formulary does not include a drug thatyou or your prescribing physician feel is necessarythen you or your prescribing physician may requestan exception so that you may obtain coverage ofthis drug If the Plan does not grant the requestedexception then you or your prescribing physicianmay file an appeal

How do I make an exception request You or your prescribing physician may request anexception to the coverage rules for your MedicarePrescription Drug Plan A specific form is notrequired for you to make an exception requestThe request must include your prescribingphysicianrsquos statement that heshe has determinedthat the preferred drug either would not be aseffective or would have adverse effects for you

For your convenience forms are available at bcbsnccomcontentmedicarememberindexhtm

Contact information

Mail BCBSNC Attn PDP Exception RequestsPO Box 17509 Winston-Salem NC 27116-7509

Phone 1-888-247-4142

Physicians call 1-888-298-7552

TTYTDD 1-888-247-4145

Hours 7 days a week8 amndash8 pm

When will I receive a decision on my exception request If your exception request includes a formularyexception or an exception from utilizationmanagement rules such as dosage or quantitylimits we must make our decision no later than 72 hours after we have received your doctorrsquossupporting statement which explains why thedrug you are asking for is medically necessary

If you have asked for a fast or expedited exceptionrequest we must make our decision no later than24 hours after we get your doctorrsquos supporting statement

You will be notified by phone followed by awritten notice of our decision If the decision is not in your favor you have the right to appeal

PAGE 15 of 40

Important informationAppeals process

What is an appeal An appeal is your opportunity to requesta redetermination of an adverse coveragedetermination which includes denied exception requests

Example of an appeal If we deny your request for an exception to covera non-formulary drug then you may file an appealof the denial An appeal can only be filed afteran exception has been requested and denied bythe Plan

How do I file an appeal If you receive a coverage determination denial youor your appointed representative or your doctor orother prescriber may file an appeal A specific formis not required for you to file an appeal An appealmust be filed within 60 calendar days of the date ofa denial notice and must be in writing unless youare filing an expedited or fast appeal You mustsubmit it via mail fax or in person

When will I receive a decision on my appeal

We will perform a standard review of your appealwithin seven calendar days of receipt of your appealor sooner if your health requires We will reviewrequests for an expedited or fast appeal as soon aspossible but no later than 72 hours following ourreceipt of the request An individual who was notinvolved with your original coverage determinationwill make a decision on your appeal

You will receive a written response to your appealThe decision on an expedited appeal will beprovided by phone followed by the written noticeIf our decision is to deny the appeal the notice willadvise you of your right to submit your appeal to the Independent Review Entity (IRE) with instructionson how to do so If we miss our time frames for claims adjudication or review of the appeal wewill automatically forward the appeal to the IREfor a decision There may be additional levels ofappeal available to you We will inform you of youradditional rights in the notice or you may refer toyour Evidence of Coverage for further details

Contact information

Mail BCBSNC Attn Medicare Appeals amp GrievancesPO Box 17509 Winston-Salem NC 27116-7509

Fax 1-888-375-8836 or 1-336-794-8836

In Person

BCBSNC 5660 University PkwyWinston-Salem NC 27105

PAGE 16 of 40

Important information

Grievance process

What is a grievance A grievance is a complaint that you may file ifyou are dissatisfied with the Plan or a contractedprovider for reasons other than a decision ona coverage determination Grievances alsoinclude complaints regarding the timelinessappropriateness access to or setting of a coveredprescription drug

Example of a grievance If you are dissatisfied with the service you receivedfrom a pharmacist or plan representative then youcould file a grievance

How do I file a grievance The grievance must be filed within 60 days after theevent or incident that caused you to be dissatisfiedA specific form is not required for you to file agrievance You or your appointed representativemay file a grievance via the phone by mail faxor in person

When will I receive a decision on my grievance The resolution of a grievance will be made asquickly as your concern requires but no more than30 calendar days after our receipt of the grievanceWe may extend the time frame by up to 14 calendardays if you request the extension or if we justify aneed for additional information and the delay is inyour best interest

If you request a written response to an oralgrievance one will be provided within 30 days afterreceipt of the grievance A written response will beprovided to all written grievances Our decision ona grievance is final and is not subject to an appeal

You have the right to an expedited review ofa grievance concerning our refusal to grant anexpedited coverage determination or expeditedappeal This type of grievance will be responded towithin 24 hours after our receipt of the grievance

Contact information

Phone 1-888-247-4142

Fax 1-888-375-8836 or 1-336-794-8836

Hours 7 days a week8 amndash8 pm

Mail BCBSNC Attn Medicare Appeals amp GrievancesPO Box 17509 Winston-Salem NC 27116-7509

In Person

BCBSNC 5660 University PkwyWinston-Salem NC 27105

PAGE 17 of 40

Important information

Quality improvement

What if I have a concern about the quality of services I received If you have a concern relating to the quality of services that you received under the Medicare Part D planthen in addition to our review you can also request review by the following organizations

The Carolinas Center for Medical Excellence (CCME) Quality Improvement Organization (QIO) in North Carolina CCME formerly known as Medical Review ofNorth Carolina Inc is a nonprofit medical carequality improvement organization CCME has beendesignated by the Centers for Medicare amp MedicaidServices as the Quality Improvement Organization(QIO) for North Carolina The QIO conducts casereviews to ensure that Medicare beneficiaries receive the quality of medical care that they expect andare entitled to CCME serves as an independentimpartial third party to review Medicare beneficiarycomplaints

Quality of care complaints filed with the QIO mustbe made in writing to the address below Assistanceis available via phone or online

The Carolinas Center for Medical Excellence (CCME)

Mail CCME 100 Regency Forest DriveSuite 200 Cary NC 27518-8598

Phone 1-919-380-9860 or 1-800-682-2650

TTYTDD 1-800-735-2962

Hours MondayndashFriday8 amndash5 pm

Web inquiries wwwccmemedicareorg

Seniorsrsquo Health Insurance Information Program (SHIIP) SHIIP is a state consumer division of the North Carolina Department of Insurance SHIIP assistssenior citizens with Medicare Medicare Part D Medicare Advantage Medicare supplementsMedicare fraud and abuse and long-term careinsurance questions Assistance is available viaphone or online

Seniorsrsquo Health Insurance Information Program (SHIIP)

Phone 1-800-443-9354

TYYTDD 1-800-735-2962

Hours MondayndashFriday8 amndash5 pm

Email ncshiipncdoigov

Online wwwncshiipcom

PAGE 18 of 40

Important information

Additional information

Notice of possible contract termination BCBSNC has a contract with the Centers for Medicare amp Medicaid Services (CMS) the government agencythat runs Medicare to provide a Medicare PrescriptionDrug Plan (PDP) This contract renews each year At theend of each year the contract is reviewed and eitherBCBSNC or CMS can decide to end it Members will get 90 days advance written notice in this situationIt is also possible for our contract to end at some othertime If the contract is going to end we will generallytell members 90 days in advance Advance notice maybe as little as 30 days or even fewer days if CMS endsour contract in the middle of the year In this noticewe would provide a written description of alternativesavailable for obtaining qualified prescription drugcoverage in North Carolina We are also required tonotify the general public of a contract termination vialocal newspapers

If BCBSNC decides to stop offering the Medicare PDPor change our service area so that it no longer includesthe area where you live membership in BCBSNCrsquosMedicare PDP will end for everyone in that servicearea and members will have to change to a differentprescription drug plan Members will continue to getprescription drugs through BCBSNCrsquos Medicare PDPuntil the contract ends

PAGE 19 of 40

Important information

For more information

Blue Cross and Blue Shield of North Carolina

Phone 1-800-478-0583

TTYTDD 1-800-922-3140

Hours 7 days a week8 amndash8 pm

Online bcbsnccommedicare

Medicare

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

TTYTDD 1-877-486-2048

Hours 7 days a week24 hours a day

Online wwwmedicaregovClick the ldquoPrescription Drug Planrdquo link

Blue Cross and Blue Shield of North Carolina is a PDP plan with a Medicare contract Enrollment in Blue Cross and Blue Shield of North Carolina depends on contract renewal Benefits formulary pharmacy network premium andor copaymentscoinsurance may change on January 1 2015 Please contact BCBSNC for details

An independent licensee of the Blue Cross and Blue Shield Association

PAGE 20 of 40

(PDP)

2014 Summary of benefits for our Medicare prescription drug plans (Enhanced and Standard)

Contract S5540 Plans 004 and 002 January 1 2014 ndash December 31 2014

U5073c 813

PAGE 21 of 40Y0079_6249 CMS Accepted 09112013

Introduction to the

Summary of benefits for (PDP)

Thank you for your interest in Blue Medicare Rx(PDP) plans Our plans are offered by Blue Crossand Blue Shield of North Carolina a MedicarePrescription Drug Plan that contracts with theFederal government This Summary of Benefits tellsyou some features of our plans It doesnrsquot list everydrug we cover every limitation or exclusionTo get a complete list of our benefits please callBlue Medicare Rx and ask for the ldquoEvidence of Coveragerdquo You have choices in your Medicare prescription drug coverage As a Medicare beneficiary you can choose fromdifferent Medicare prescription drug coverageoptions One option is to get prescription drugcoverage through a Medicare Prescription DrugPlan like Blue Medicare Rx plans Another optionis to get your prescription drug coverage througha Medicare Advantage Plan that offers prescriptiondrug coverage You make the choice How can I compare my options The charts in this booklet list some important drugbenefits You can use this Summary of Benefitsto compare the benefits offered by Blue MedicareRx plans to the benefits offered by other MedicarePrescription Drug Plans or Medicare AdvantagePlans with prescription drug coverage Where are Blue Medicare Rx Plans available The service area for these plans includesNorth Carolina You must live in one of these areas to join one of these plans Who is eligible to join You can join one of these plans if you are entitled toMedicare Part A andor enrolled in Medicare Part Band live in the service area If you are enrolled in an MA coordinated care(HMO or PPO) plan or an MA PFFS plan thatincludes Medicare prescription drugs you maynot enroll in a PDP unless you disenroll from theHMO PPO or MA PFFS plan Enrollees in a private Fee-for-Service plan (PFFS)that does not provide Medicare prescription drugcoverage or an MA Medical Savings Account (MSA)plan may enroll in a PDP Enrollees in an 1876 Costplan may enroll in a PDP

Where can I get my prescriptions Blue Medicare Rx plans have formed a network ofpharmacies You must use a network pharmacyto receive plan benefits We will not pay foryour prescriptions if you use an out-of-networkpharmacy except in certain cases Blue Medicare Rx plans have a list of preferredpharmacies At these pharmacies you may getyour drugs at a lower co-pay or coinsuranceYou may go to a non-preferred pharmacy but youmay have to pay more for your prescription drugs The pharmacies in our network can change at anytime You can ask for a Pharmacy Directory or visit usat wwwmyprimecomMyRxMyPrimeMedicareDpharmacyBCBSNC Our customer service number is listed at the end of this introduction What if my doctor prescribes less than a monthrsquos supply In consultation with your doctor or pharmacist youmay receive less than a monthrsquos supply of certaindrugs Also if you live in a long-term care facilityyou will receive less than a monthrsquos supply of certainbrand [and generic] drugs Dispensing fewer drugs ata time can help reduce cost and waste in the MedicarePart D program when this is medically appropriate The amount you pay in these circumstances willdepend on whether you are responsible for payingcoinsurance (a percentage of the cost of the drug) ora copay (a flat dollar amount for the drug) If youare responsible for coinsurance for the drug youwill continue to pay the applicable percentage ofthe drug cost If you are responsible for a copay forthe drug a ldquodaily cost-sharing raterdquo will be appliedIf your doctor decides to continue the drug after atrial period you should not pay more for a monthrsquossupply than you otherwise would have paid Contactyour plan if you have questions about cost-sharingwhen less than a one-month supply is dispensed Does my plan cover Medicare Part B or Part D drugs Blue Medicare Rx Standard and Enhanced plans donot cover drugs that are covered under Medicare PartB as prescribed and dispensed Generally we onlycover drugs vaccines biological products and medicalsupplies associated with the delivery of insulin thatare covered under the Medicare Prescription DrugBenefit (Part D) and that are on our formulary

PAG E 22 of 40

Introduction to the

Summary of benefits (continued)

What is a prescription drug formulary Blue Medicare Rx plans use a formularyA formulary is a list of drugs covered by your planto meet patient needs We may periodically addremove or make changes to coverage limitationson certain drugs or change how much you pay for adrug If we make any formulary change that limitsour membersrsquo ability to fill their prescriptions wewill notify the affected members before the changeis made We will send a formulary to you andyou can see our complete formulary on our Website at httpwwwbcbsnccomcontentmedicareformulary-homehtm If you are currently taking a drug that is not on ourformulary or subject to additional requirements orlimits you may be able to get a temporary supply ofthe drug You can contact us to request an exceptionor switch to an alternative drug listed on ourformulary with your physicianrsquos help Call us to seeif you can get a temporary supply of the drug or formore details about our drug transition policy What should I do if I have other insurance in addition to Medicare If you have a Medigap (Medicare Supplement)policy that includes prescription drug coverage youmust contact your Medigap Issuer to let them knowthat you have joined a Medicare Prescription DrugPlan If you decide to keep your current Medigapsupplement policy your Medigap Issuer willremove the prescription drug coverage portion ofyour policy Call your Medigap Issuer for details If you or your spouse has or is able to get employergroup coverage you should talk to your employerto find out how your benefits will be affected if youjoin a Blue Medicare Rx plan Get this informationbefore you decide to enroll in this plan

How can I get extra help with my prescription drug plan costs or get extra help with other Medicare costs You may be able to get extra help to pay for yourprescription drug premiums and costs as well as gethelp with other Medicare costs To see if you qualifyfor getting extra help call +1-800-MEDICARE (1-800-633-4227)

TTYTDD users should call 1-877-486-204824 hours a day7 days a week and seehttpwwwmedicaregov lsquoPrograms for Peoplewith Limited Income and Resourcesrsquo in the publication Medicare amp You

+The Social Security Administration at1-800-772-1213 between 7 am and 7 pmMonday through Friday TTYTDD usersshould call 1-800-325-0778 or

+Your State Medicaid Office What are my protections in this plan All Medicare Prescription Drug Plans agree to stayin the program for a full calendar year at a timePlan benefits and cost-sharing may change fromcalendar year to calendar year Each year plans candecide whether to continue to participate with theMedicare Prescription Drug Program A plan maycontinue in their entire service area (geographicarea where the plan accepts members) or choose tocontinue only in certain areas Also Medicare maydecide to end a contract with a plan Even if yourMedicare Prescription Plan leaves the program youwill not lose Medicare coverage If a plan decidesnot to continue for an additional calendar year itmust send you a letter at least 90 days before yourcoverage will end The letter will explain youroptions for Medicare coverage in your area As a member of a Blue Medicare Rx plan you havethe right to request a coverage determination whichincludes the right to request an exception the right tofile an appeal if we deny coverage for a prescriptiondrug and the right to file a grievance You havethe right to request a coverage determination if youwant us to cover a Part D drug that you believeshould be covered An exception is a type of coveragedetermination You may ask us for an exception ifyou believe you need a drug that is not on our list

PAG E 23 of 40

(PDP)

Important information about our Medicare prescription drug plans

U5073b 813

Y0079_6248 CMS Accepted 08102013 PAGE 11 of 40

Important information

Eligibility for beneficiaries

Eligibility for beneficiaries Everyone who is entitled to Medicare benefitsunder Part A or enrolled in Part B is eligible forthis coverage however you are not enrolledautomatically You must join a plan to receivethe coverage6 This voluntary program is coveragethat you may choose to purchase annually Thisproduct is available to Medicare beneficiariesliving in North Carolina

Additional enrollment criteria You may enroll in only one Part D plan at a timeIf you are enrolled in a Medicare Advantage planyour enrollment in either of the PDP plans fromBlue Cross and Blue Shield of North Carolina (BCBSNC) may automatically disenroll you fromyour Medicare Advantage Plan and re-enroll youin Original Medicare for medical coverage Checkwith your plan for more information

Financial assistance

Financial assistance available People with limited incomes may qualify forExtra Help to pay for their prescription drugcosts If you qualify Medicare could pay for upto seventy-five (75) percent or more of your drugcosts including monthly prescriptiondrug premiums annual deductibles andco-insurance Additionally those who qualifywill not be subject to the coverage gap or a lateenrollment penalty Many people are eligiblefor these savings and donrsquot even know itFor more information about this Extra Helpcontact your local Social Security office or call1-800-MEDICARE (1-800-633-4227) 24 hours perday 7 days per week TTYTDD users shouldcall 1-877-486-2048

This document may be available in alternate formats upon request

Footnote 6 You must join a plan to receive the coverage unless

you are eligible for both Medicare and Medicaid Contact your State Medicaid or medical assistance office if you have questions about your eligibility

Social Security Administration

Phone 1-800-772-1213

TTYTDD 1-800-325-0778

Hours MondayndashFriday7 amndash7 pm

PAGE 12 of 40

Medicare

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

TTYTDD 1-877-486-2048

Hours 24 hours a day7 days a week

Important information

Pharmacy network

Pharmacy network information Our network includes a variety of pharmaciesincluding retail home infusion IndianTribalUrban organizations extended supply and long-term care pharmacies In order to obtain thegreatest savings on your prescription medicationsplease visit one of our preferred network providers(CVS WalMart Kerr and Epic Pharmacies) Formore information about our pharmacy networkand out-of-network policies please see our contactinformation below

Mail order contact information For information on our mail order service or to obtain forms please contact us at

Coverage determination

What is a coverage determination When we make a coverage determination weare making a decision about whether or not toprovide or pay for a Part D drug and what yourshare of the cost is for the drug (also see thedescription of the exceptions process) You mustcontact us if you would like to request a coveragedetermination including an exception Youcannot request an appeal if we have not issueda coverage determination

Mail order contact information

Phone 1-888-247-4142

TTYTDD 1-888-247-4145

Hours 7 days a week8 amndash8 pm

Mail BCBSNC Customer Service PO Box 17509 Winston-Salem NC 27116-7509

Online For a comprehensive list ofall pharmacies please visitbcbsnccommedicare

Examples of when you may ask us for a coverage determination

If you are not getting a prescription drug thatyou believe may be covered by us

If you have received a Part D prescription drugthat you believe may be covered by us while youwere a member but we have refused to pay forthe drug

If you are being told that coverage for a Part Dprescription drug that you have been gettingwill be reduced or stopped and you believe youhave special circumstances that should excludeyou from the reductionnon-coverage

If there is a limit on the quantity (or dose) of thedrug and you disagree with the requirement ordosage limitation

If you bought a drug at a pharmacy that isnot in our network and you want to requestreimbursement for the expense

PAGE 13 of 40

Important information

Coverage determination (continued)

How do I make a request for coverage determination Standard To ask for a standard decision you oryour appointed representative may call ourCustomer Service Department at the numberslisted on the back cover You can also mail a written request to the below address

Fast To ask for a fast decision you your physicianor your appointed representative may call theCustomer Service Department at the numbers listedon the back cover You can also mail a written request to the below address

Standard Generally we must give you our decisionno later than 72 hours after we have received yourrequest but we will make it sooner if your healthcondition requires

Fast If you get a fast review we will give you ourdecision within 24 hours after you or your doctor askfor a fast review mdash sooner if your health requires

PAGE 14 of 40

Contact information

Mail BCBSNC PO Box 17509 Winston-Salem NC 27116-7509

Fax Request 1-888-446-8440

Hours MondayndashFriday8 amndash5 pm

Note You cannot ask for a fast decision on a requestfor coverage of a drug already purchased

For some reviews we may require a supportingstatement from your doctor that explains why the drugyou are asking coverage for is medically necessary

After regular business hours you should consultwith a network pharmacy regarding your need for anemergency or temporary supply of medication untilyou can contact the Plan the next business day Youmay also call our Customer Service Department andleave a message on the Part D After Hours ExceptionRequest voicemail Be sure to ask for a ldquofastrdquoldquoexpeditedrdquo or ldquo24-hourrdquo review

When will I hear back with a decision

Important information

Exceptions process

What is an exception request Exception requests are a kind of coveragedetermination You your authorized representativeor your prescribing physician may request anexception to seek coverage of a drug that

+ Is not on the formulary (list of drugsthe plan covers)

+ Requires prior authorization + Has quantity limitations

Example of an exception request If the Planrsquos formulary does not include a drug thatyou or your prescribing physician feel is necessarythen you or your prescribing physician may requestan exception so that you may obtain coverage ofthis drug If the Plan does not grant the requestedexception then you or your prescribing physicianmay file an appeal

How do I make an exception request You or your prescribing physician may request anexception to the coverage rules for your MedicarePrescription Drug Plan A specific form is notrequired for you to make an exception requestThe request must include your prescribingphysicianrsquos statement that heshe has determinedthat the preferred drug either would not be aseffective or would have adverse effects for you

For your convenience forms are available at bcbsnccomcontentmedicarememberindexhtm

Contact information

Mail BCBSNC Attn PDP Exception RequestsPO Box 17509 Winston-Salem NC 27116-7509

Phone 1-888-247-4142

Physicians call 1-888-298-7552

TTYTDD 1-888-247-4145

Hours 7 days a week8 amndash8 pm

When will I receive a decision on my exception request If your exception request includes a formularyexception or an exception from utilizationmanagement rules such as dosage or quantitylimits we must make our decision no later than 72 hours after we have received your doctorrsquossupporting statement which explains why thedrug you are asking for is medically necessary

If you have asked for a fast or expedited exceptionrequest we must make our decision no later than24 hours after we get your doctorrsquos supporting statement

You will be notified by phone followed by awritten notice of our decision If the decision is not in your favor you have the right to appeal

PAGE 15 of 40

Important informationAppeals process

What is an appeal An appeal is your opportunity to requesta redetermination of an adverse coveragedetermination which includes denied exception requests

Example of an appeal If we deny your request for an exception to covera non-formulary drug then you may file an appealof the denial An appeal can only be filed afteran exception has been requested and denied bythe Plan

How do I file an appeal If you receive a coverage determination denial youor your appointed representative or your doctor orother prescriber may file an appeal A specific formis not required for you to file an appeal An appealmust be filed within 60 calendar days of the date ofa denial notice and must be in writing unless youare filing an expedited or fast appeal You mustsubmit it via mail fax or in person

When will I receive a decision on my appeal

We will perform a standard review of your appealwithin seven calendar days of receipt of your appealor sooner if your health requires We will reviewrequests for an expedited or fast appeal as soon aspossible but no later than 72 hours following ourreceipt of the request An individual who was notinvolved with your original coverage determinationwill make a decision on your appeal

You will receive a written response to your appealThe decision on an expedited appeal will beprovided by phone followed by the written noticeIf our decision is to deny the appeal the notice willadvise you of your right to submit your appeal to the Independent Review Entity (IRE) with instructionson how to do so If we miss our time frames for claims adjudication or review of the appeal wewill automatically forward the appeal to the IREfor a decision There may be additional levels ofappeal available to you We will inform you of youradditional rights in the notice or you may refer toyour Evidence of Coverage for further details

Contact information

Mail BCBSNC Attn Medicare Appeals amp GrievancesPO Box 17509 Winston-Salem NC 27116-7509

Fax 1-888-375-8836 or 1-336-794-8836

In Person

BCBSNC 5660 University PkwyWinston-Salem NC 27105

PAGE 16 of 40

Important information

Grievance process

What is a grievance A grievance is a complaint that you may file ifyou are dissatisfied with the Plan or a contractedprovider for reasons other than a decision ona coverage determination Grievances alsoinclude complaints regarding the timelinessappropriateness access to or setting of a coveredprescription drug

Example of a grievance If you are dissatisfied with the service you receivedfrom a pharmacist or plan representative then youcould file a grievance

How do I file a grievance The grievance must be filed within 60 days after theevent or incident that caused you to be dissatisfiedA specific form is not required for you to file agrievance You or your appointed representativemay file a grievance via the phone by mail faxor in person

When will I receive a decision on my grievance The resolution of a grievance will be made asquickly as your concern requires but no more than30 calendar days after our receipt of the grievanceWe may extend the time frame by up to 14 calendardays if you request the extension or if we justify aneed for additional information and the delay is inyour best interest

If you request a written response to an oralgrievance one will be provided within 30 days afterreceipt of the grievance A written response will beprovided to all written grievances Our decision ona grievance is final and is not subject to an appeal

You have the right to an expedited review ofa grievance concerning our refusal to grant anexpedited coverage determination or expeditedappeal This type of grievance will be responded towithin 24 hours after our receipt of the grievance

Contact information

Phone 1-888-247-4142

Fax 1-888-375-8836 or 1-336-794-8836

Hours 7 days a week8 amndash8 pm

Mail BCBSNC Attn Medicare Appeals amp GrievancesPO Box 17509 Winston-Salem NC 27116-7509

In Person

BCBSNC 5660 University PkwyWinston-Salem NC 27105

PAGE 17 of 40

Important information

Quality improvement

What if I have a concern about the quality of services I received If you have a concern relating to the quality of services that you received under the Medicare Part D planthen in addition to our review you can also request review by the following organizations

The Carolinas Center for Medical Excellence (CCME) Quality Improvement Organization (QIO) in North Carolina CCME formerly known as Medical Review ofNorth Carolina Inc is a nonprofit medical carequality improvement organization CCME has beendesignated by the Centers for Medicare amp MedicaidServices as the Quality Improvement Organization(QIO) for North Carolina The QIO conducts casereviews to ensure that Medicare beneficiaries receive the quality of medical care that they expect andare entitled to CCME serves as an independentimpartial third party to review Medicare beneficiarycomplaints

Quality of care complaints filed with the QIO mustbe made in writing to the address below Assistanceis available via phone or online

The Carolinas Center for Medical Excellence (CCME)

Mail CCME 100 Regency Forest DriveSuite 200 Cary NC 27518-8598

Phone 1-919-380-9860 or 1-800-682-2650

TTYTDD 1-800-735-2962

Hours MondayndashFriday8 amndash5 pm

Web inquiries wwwccmemedicareorg

Seniorsrsquo Health Insurance Information Program (SHIIP) SHIIP is a state consumer division of the North Carolina Department of Insurance SHIIP assistssenior citizens with Medicare Medicare Part D Medicare Advantage Medicare supplementsMedicare fraud and abuse and long-term careinsurance questions Assistance is available viaphone or online

Seniorsrsquo Health Insurance Information Program (SHIIP)

Phone 1-800-443-9354

TYYTDD 1-800-735-2962

Hours MondayndashFriday8 amndash5 pm

Email ncshiipncdoigov

Online wwwncshiipcom

PAGE 18 of 40

Important information

Additional information

Notice of possible contract termination BCBSNC has a contract with the Centers for Medicare amp Medicaid Services (CMS) the government agencythat runs Medicare to provide a Medicare PrescriptionDrug Plan (PDP) This contract renews each year At theend of each year the contract is reviewed and eitherBCBSNC or CMS can decide to end it Members will get 90 days advance written notice in this situationIt is also possible for our contract to end at some othertime If the contract is going to end we will generallytell members 90 days in advance Advance notice maybe as little as 30 days or even fewer days if CMS endsour contract in the middle of the year In this noticewe would provide a written description of alternativesavailable for obtaining qualified prescription drugcoverage in North Carolina We are also required tonotify the general public of a contract termination vialocal newspapers

If BCBSNC decides to stop offering the Medicare PDPor change our service area so that it no longer includesthe area where you live membership in BCBSNCrsquosMedicare PDP will end for everyone in that servicearea and members will have to change to a differentprescription drug plan Members will continue to getprescription drugs through BCBSNCrsquos Medicare PDPuntil the contract ends

PAGE 19 of 40

Important information

For more information

Blue Cross and Blue Shield of North Carolina

Phone 1-800-478-0583

TTYTDD 1-800-922-3140

Hours 7 days a week8 amndash8 pm

Online bcbsnccommedicare

Medicare

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

TTYTDD 1-877-486-2048

Hours 7 days a week24 hours a day

Online wwwmedicaregovClick the ldquoPrescription Drug Planrdquo link

Blue Cross and Blue Shield of North Carolina is a PDP plan with a Medicare contract Enrollment in Blue Cross and Blue Shield of North Carolina depends on contract renewal Benefits formulary pharmacy network premium andor copaymentscoinsurance may change on January 1 2015 Please contact BCBSNC for details

An independent licensee of the Blue Cross and Blue Shield Association

PAGE 20 of 40

(PDP)

2014 Summary of benefits for our Medicare prescription drug plans (Enhanced and Standard)

Contract S5540 Plans 004 and 002 January 1 2014 ndash December 31 2014

U5073c 813

PAGE 21 of 40Y0079_6249 CMS Accepted 09112013

Introduction to the

Summary of benefits for (PDP)

Thank you for your interest in Blue Medicare Rx(PDP) plans Our plans are offered by Blue Crossand Blue Shield of North Carolina a MedicarePrescription Drug Plan that contracts with theFederal government This Summary of Benefits tellsyou some features of our plans It doesnrsquot list everydrug we cover every limitation or exclusionTo get a complete list of our benefits please callBlue Medicare Rx and ask for the ldquoEvidence of Coveragerdquo You have choices in your Medicare prescription drug coverage As a Medicare beneficiary you can choose fromdifferent Medicare prescription drug coverageoptions One option is to get prescription drugcoverage through a Medicare Prescription DrugPlan like Blue Medicare Rx plans Another optionis to get your prescription drug coverage througha Medicare Advantage Plan that offers prescriptiondrug coverage You make the choice How can I compare my options The charts in this booklet list some important drugbenefits You can use this Summary of Benefitsto compare the benefits offered by Blue MedicareRx plans to the benefits offered by other MedicarePrescription Drug Plans or Medicare AdvantagePlans with prescription drug coverage Where are Blue Medicare Rx Plans available The service area for these plans includesNorth Carolina You must live in one of these areas to join one of these plans Who is eligible to join You can join one of these plans if you are entitled toMedicare Part A andor enrolled in Medicare Part Band live in the service area If you are enrolled in an MA coordinated care(HMO or PPO) plan or an MA PFFS plan thatincludes Medicare prescription drugs you maynot enroll in a PDP unless you disenroll from theHMO PPO or MA PFFS plan Enrollees in a private Fee-for-Service plan (PFFS)that does not provide Medicare prescription drugcoverage or an MA Medical Savings Account (MSA)plan may enroll in a PDP Enrollees in an 1876 Costplan may enroll in a PDP

Where can I get my prescriptions Blue Medicare Rx plans have formed a network ofpharmacies You must use a network pharmacyto receive plan benefits We will not pay foryour prescriptions if you use an out-of-networkpharmacy except in certain cases Blue Medicare Rx plans have a list of preferredpharmacies At these pharmacies you may getyour drugs at a lower co-pay or coinsuranceYou may go to a non-preferred pharmacy but youmay have to pay more for your prescription drugs The pharmacies in our network can change at anytime You can ask for a Pharmacy Directory or visit usat wwwmyprimecomMyRxMyPrimeMedicareDpharmacyBCBSNC Our customer service number is listed at the end of this introduction What if my doctor prescribes less than a monthrsquos supply In consultation with your doctor or pharmacist youmay receive less than a monthrsquos supply of certaindrugs Also if you live in a long-term care facilityyou will receive less than a monthrsquos supply of certainbrand [and generic] drugs Dispensing fewer drugs ata time can help reduce cost and waste in the MedicarePart D program when this is medically appropriate The amount you pay in these circumstances willdepend on whether you are responsible for payingcoinsurance (a percentage of the cost of the drug) ora copay (a flat dollar amount for the drug) If youare responsible for coinsurance for the drug youwill continue to pay the applicable percentage ofthe drug cost If you are responsible for a copay forthe drug a ldquodaily cost-sharing raterdquo will be appliedIf your doctor decides to continue the drug after atrial period you should not pay more for a monthrsquossupply than you otherwise would have paid Contactyour plan if you have questions about cost-sharingwhen less than a one-month supply is dispensed Does my plan cover Medicare Part B or Part D drugs Blue Medicare Rx Standard and Enhanced plans donot cover drugs that are covered under Medicare PartB as prescribed and dispensed Generally we onlycover drugs vaccines biological products and medicalsupplies associated with the delivery of insulin thatare covered under the Medicare Prescription DrugBenefit (Part D) and that are on our formulary

PAG E 22 of 40

Introduction to the

Summary of benefits (continued)

What is a prescription drug formulary Blue Medicare Rx plans use a formularyA formulary is a list of drugs covered by your planto meet patient needs We may periodically addremove or make changes to coverage limitationson certain drugs or change how much you pay for adrug If we make any formulary change that limitsour membersrsquo ability to fill their prescriptions wewill notify the affected members before the changeis made We will send a formulary to you andyou can see our complete formulary on our Website at httpwwwbcbsnccomcontentmedicareformulary-homehtm If you are currently taking a drug that is not on ourformulary or subject to additional requirements orlimits you may be able to get a temporary supply ofthe drug You can contact us to request an exceptionor switch to an alternative drug listed on ourformulary with your physicianrsquos help Call us to seeif you can get a temporary supply of the drug or formore details about our drug transition policy What should I do if I have other insurance in addition to Medicare If you have a Medigap (Medicare Supplement)policy that includes prescription drug coverage youmust contact your Medigap Issuer to let them knowthat you have joined a Medicare Prescription DrugPlan If you decide to keep your current Medigapsupplement policy your Medigap Issuer willremove the prescription drug coverage portion ofyour policy Call your Medigap Issuer for details If you or your spouse has or is able to get employergroup coverage you should talk to your employerto find out how your benefits will be affected if youjoin a Blue Medicare Rx plan Get this informationbefore you decide to enroll in this plan

How can I get extra help with my prescription drug plan costs or get extra help with other Medicare costs You may be able to get extra help to pay for yourprescription drug premiums and costs as well as gethelp with other Medicare costs To see if you qualifyfor getting extra help call +1-800-MEDICARE (1-800-633-4227)

TTYTDD users should call 1-877-486-204824 hours a day7 days a week and seehttpwwwmedicaregov lsquoPrograms for Peoplewith Limited Income and Resourcesrsquo in the publication Medicare amp You

+The Social Security Administration at1-800-772-1213 between 7 am and 7 pmMonday through Friday TTYTDD usersshould call 1-800-325-0778 or

+Your State Medicaid Office What are my protections in this plan All Medicare Prescription Drug Plans agree to stayin the program for a full calendar year at a timePlan benefits and cost-sharing may change fromcalendar year to calendar year Each year plans candecide whether to continue to participate with theMedicare Prescription Drug Program A plan maycontinue in their entire service area (geographicarea where the plan accepts members) or choose tocontinue only in certain areas Also Medicare maydecide to end a contract with a plan Even if yourMedicare Prescription Plan leaves the program youwill not lose Medicare coverage If a plan decidesnot to continue for an additional calendar year itmust send you a letter at least 90 days before yourcoverage will end The letter will explain youroptions for Medicare coverage in your area As a member of a Blue Medicare Rx plan you havethe right to request a coverage determination whichincludes the right to request an exception the right tofile an appeal if we deny coverage for a prescriptiondrug and the right to file a grievance You havethe right to request a coverage determination if youwant us to cover a Part D drug that you believeshould be covered An exception is a type of coveragedetermination You may ask us for an exception ifyou believe you need a drug that is not on our list

PAG E 23 of 40

Important information

Eligibility for beneficiaries

Eligibility for beneficiaries Everyone who is entitled to Medicare benefitsunder Part A or enrolled in Part B is eligible forthis coverage however you are not enrolledautomatically You must join a plan to receivethe coverage6 This voluntary program is coveragethat you may choose to purchase annually Thisproduct is available to Medicare beneficiariesliving in North Carolina

Additional enrollment criteria You may enroll in only one Part D plan at a timeIf you are enrolled in a Medicare Advantage planyour enrollment in either of the PDP plans fromBlue Cross and Blue Shield of North Carolina (BCBSNC) may automatically disenroll you fromyour Medicare Advantage Plan and re-enroll youin Original Medicare for medical coverage Checkwith your plan for more information

Financial assistance

Financial assistance available People with limited incomes may qualify forExtra Help to pay for their prescription drugcosts If you qualify Medicare could pay for upto seventy-five (75) percent or more of your drugcosts including monthly prescriptiondrug premiums annual deductibles andco-insurance Additionally those who qualifywill not be subject to the coverage gap or a lateenrollment penalty Many people are eligiblefor these savings and donrsquot even know itFor more information about this Extra Helpcontact your local Social Security office or call1-800-MEDICARE (1-800-633-4227) 24 hours perday 7 days per week TTYTDD users shouldcall 1-877-486-2048

This document may be available in alternate formats upon request

Footnote 6 You must join a plan to receive the coverage unless

you are eligible for both Medicare and Medicaid Contact your State Medicaid or medical assistance office if you have questions about your eligibility

Social Security Administration

Phone 1-800-772-1213

TTYTDD 1-800-325-0778

Hours MondayndashFriday7 amndash7 pm

PAGE 12 of 40

Medicare

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

TTYTDD 1-877-486-2048

Hours 24 hours a day7 days a week

Important information

Pharmacy network

Pharmacy network information Our network includes a variety of pharmaciesincluding retail home infusion IndianTribalUrban organizations extended supply and long-term care pharmacies In order to obtain thegreatest savings on your prescription medicationsplease visit one of our preferred network providers(CVS WalMart Kerr and Epic Pharmacies) Formore information about our pharmacy networkand out-of-network policies please see our contactinformation below

Mail order contact information For information on our mail order service or to obtain forms please contact us at

Coverage determination

What is a coverage determination When we make a coverage determination weare making a decision about whether or not toprovide or pay for a Part D drug and what yourshare of the cost is for the drug (also see thedescription of the exceptions process) You mustcontact us if you would like to request a coveragedetermination including an exception Youcannot request an appeal if we have not issueda coverage determination

Mail order contact information

Phone 1-888-247-4142

TTYTDD 1-888-247-4145

Hours 7 days a week8 amndash8 pm

Mail BCBSNC Customer Service PO Box 17509 Winston-Salem NC 27116-7509

Online For a comprehensive list ofall pharmacies please visitbcbsnccommedicare

Examples of when you may ask us for a coverage determination

If you are not getting a prescription drug thatyou believe may be covered by us

If you have received a Part D prescription drugthat you believe may be covered by us while youwere a member but we have refused to pay forthe drug

If you are being told that coverage for a Part Dprescription drug that you have been gettingwill be reduced or stopped and you believe youhave special circumstances that should excludeyou from the reductionnon-coverage

If there is a limit on the quantity (or dose) of thedrug and you disagree with the requirement ordosage limitation

If you bought a drug at a pharmacy that isnot in our network and you want to requestreimbursement for the expense

PAGE 13 of 40

Important information

Coverage determination (continued)

How do I make a request for coverage determination Standard To ask for a standard decision you oryour appointed representative may call ourCustomer Service Department at the numberslisted on the back cover You can also mail a written request to the below address

Fast To ask for a fast decision you your physicianor your appointed representative may call theCustomer Service Department at the numbers listedon the back cover You can also mail a written request to the below address

Standard Generally we must give you our decisionno later than 72 hours after we have received yourrequest but we will make it sooner if your healthcondition requires

Fast If you get a fast review we will give you ourdecision within 24 hours after you or your doctor askfor a fast review mdash sooner if your health requires

PAGE 14 of 40

Contact information

Mail BCBSNC PO Box 17509 Winston-Salem NC 27116-7509

Fax Request 1-888-446-8440

Hours MondayndashFriday8 amndash5 pm

Note You cannot ask for a fast decision on a requestfor coverage of a drug already purchased

For some reviews we may require a supportingstatement from your doctor that explains why the drugyou are asking coverage for is medically necessary

After regular business hours you should consultwith a network pharmacy regarding your need for anemergency or temporary supply of medication untilyou can contact the Plan the next business day Youmay also call our Customer Service Department andleave a message on the Part D After Hours ExceptionRequest voicemail Be sure to ask for a ldquofastrdquoldquoexpeditedrdquo or ldquo24-hourrdquo review

When will I hear back with a decision

Important information

Exceptions process

What is an exception request Exception requests are a kind of coveragedetermination You your authorized representativeor your prescribing physician may request anexception to seek coverage of a drug that

+ Is not on the formulary (list of drugsthe plan covers)

+ Requires prior authorization + Has quantity limitations

Example of an exception request If the Planrsquos formulary does not include a drug thatyou or your prescribing physician feel is necessarythen you or your prescribing physician may requestan exception so that you may obtain coverage ofthis drug If the Plan does not grant the requestedexception then you or your prescribing physicianmay file an appeal

How do I make an exception request You or your prescribing physician may request anexception to the coverage rules for your MedicarePrescription Drug Plan A specific form is notrequired for you to make an exception requestThe request must include your prescribingphysicianrsquos statement that heshe has determinedthat the preferred drug either would not be aseffective or would have adverse effects for you

For your convenience forms are available at bcbsnccomcontentmedicarememberindexhtm

Contact information

Mail BCBSNC Attn PDP Exception RequestsPO Box 17509 Winston-Salem NC 27116-7509

Phone 1-888-247-4142

Physicians call 1-888-298-7552

TTYTDD 1-888-247-4145

Hours 7 days a week8 amndash8 pm

When will I receive a decision on my exception request If your exception request includes a formularyexception or an exception from utilizationmanagement rules such as dosage or quantitylimits we must make our decision no later than 72 hours after we have received your doctorrsquossupporting statement which explains why thedrug you are asking for is medically necessary

If you have asked for a fast or expedited exceptionrequest we must make our decision no later than24 hours after we get your doctorrsquos supporting statement

You will be notified by phone followed by awritten notice of our decision If the decision is not in your favor you have the right to appeal

PAGE 15 of 40

Important informationAppeals process

What is an appeal An appeal is your opportunity to requesta redetermination of an adverse coveragedetermination which includes denied exception requests

Example of an appeal If we deny your request for an exception to covera non-formulary drug then you may file an appealof the denial An appeal can only be filed afteran exception has been requested and denied bythe Plan

How do I file an appeal If you receive a coverage determination denial youor your appointed representative or your doctor orother prescriber may file an appeal A specific formis not required for you to file an appeal An appealmust be filed within 60 calendar days of the date ofa denial notice and must be in writing unless youare filing an expedited or fast appeal You mustsubmit it via mail fax or in person

When will I receive a decision on my appeal

We will perform a standard review of your appealwithin seven calendar days of receipt of your appealor sooner if your health requires We will reviewrequests for an expedited or fast appeal as soon aspossible but no later than 72 hours following ourreceipt of the request An individual who was notinvolved with your original coverage determinationwill make a decision on your appeal

You will receive a written response to your appealThe decision on an expedited appeal will beprovided by phone followed by the written noticeIf our decision is to deny the appeal the notice willadvise you of your right to submit your appeal to the Independent Review Entity (IRE) with instructionson how to do so If we miss our time frames for claims adjudication or review of the appeal wewill automatically forward the appeal to the IREfor a decision There may be additional levels ofappeal available to you We will inform you of youradditional rights in the notice or you may refer toyour Evidence of Coverage for further details

Contact information

Mail BCBSNC Attn Medicare Appeals amp GrievancesPO Box 17509 Winston-Salem NC 27116-7509

Fax 1-888-375-8836 or 1-336-794-8836

In Person

BCBSNC 5660 University PkwyWinston-Salem NC 27105

PAGE 16 of 40

Important information

Grievance process

What is a grievance A grievance is a complaint that you may file ifyou are dissatisfied with the Plan or a contractedprovider for reasons other than a decision ona coverage determination Grievances alsoinclude complaints regarding the timelinessappropriateness access to or setting of a coveredprescription drug

Example of a grievance If you are dissatisfied with the service you receivedfrom a pharmacist or plan representative then youcould file a grievance

How do I file a grievance The grievance must be filed within 60 days after theevent or incident that caused you to be dissatisfiedA specific form is not required for you to file agrievance You or your appointed representativemay file a grievance via the phone by mail faxor in person

When will I receive a decision on my grievance The resolution of a grievance will be made asquickly as your concern requires but no more than30 calendar days after our receipt of the grievanceWe may extend the time frame by up to 14 calendardays if you request the extension or if we justify aneed for additional information and the delay is inyour best interest

If you request a written response to an oralgrievance one will be provided within 30 days afterreceipt of the grievance A written response will beprovided to all written grievances Our decision ona grievance is final and is not subject to an appeal

You have the right to an expedited review ofa grievance concerning our refusal to grant anexpedited coverage determination or expeditedappeal This type of grievance will be responded towithin 24 hours after our receipt of the grievance

Contact information

Phone 1-888-247-4142

Fax 1-888-375-8836 or 1-336-794-8836

Hours 7 days a week8 amndash8 pm

Mail BCBSNC Attn Medicare Appeals amp GrievancesPO Box 17509 Winston-Salem NC 27116-7509

In Person

BCBSNC 5660 University PkwyWinston-Salem NC 27105

PAGE 17 of 40

Important information

Quality improvement

What if I have a concern about the quality of services I received If you have a concern relating to the quality of services that you received under the Medicare Part D planthen in addition to our review you can also request review by the following organizations

The Carolinas Center for Medical Excellence (CCME) Quality Improvement Organization (QIO) in North Carolina CCME formerly known as Medical Review ofNorth Carolina Inc is a nonprofit medical carequality improvement organization CCME has beendesignated by the Centers for Medicare amp MedicaidServices as the Quality Improvement Organization(QIO) for North Carolina The QIO conducts casereviews to ensure that Medicare beneficiaries receive the quality of medical care that they expect andare entitled to CCME serves as an independentimpartial third party to review Medicare beneficiarycomplaints

Quality of care complaints filed with the QIO mustbe made in writing to the address below Assistanceis available via phone or online

The Carolinas Center for Medical Excellence (CCME)

Mail CCME 100 Regency Forest DriveSuite 200 Cary NC 27518-8598

Phone 1-919-380-9860 or 1-800-682-2650

TTYTDD 1-800-735-2962

Hours MondayndashFriday8 amndash5 pm

Web inquiries wwwccmemedicareorg

Seniorsrsquo Health Insurance Information Program (SHIIP) SHIIP is a state consumer division of the North Carolina Department of Insurance SHIIP assistssenior citizens with Medicare Medicare Part D Medicare Advantage Medicare supplementsMedicare fraud and abuse and long-term careinsurance questions Assistance is available viaphone or online

Seniorsrsquo Health Insurance Information Program (SHIIP)

Phone 1-800-443-9354

TYYTDD 1-800-735-2962

Hours MondayndashFriday8 amndash5 pm

Email ncshiipncdoigov

Online wwwncshiipcom

PAGE 18 of 40

Important information

Additional information

Notice of possible contract termination BCBSNC has a contract with the Centers for Medicare amp Medicaid Services (CMS) the government agencythat runs Medicare to provide a Medicare PrescriptionDrug Plan (PDP) This contract renews each year At theend of each year the contract is reviewed and eitherBCBSNC or CMS can decide to end it Members will get 90 days advance written notice in this situationIt is also possible for our contract to end at some othertime If the contract is going to end we will generallytell members 90 days in advance Advance notice maybe as little as 30 days or even fewer days if CMS endsour contract in the middle of the year In this noticewe would provide a written description of alternativesavailable for obtaining qualified prescription drugcoverage in North Carolina We are also required tonotify the general public of a contract termination vialocal newspapers

If BCBSNC decides to stop offering the Medicare PDPor change our service area so that it no longer includesthe area where you live membership in BCBSNCrsquosMedicare PDP will end for everyone in that servicearea and members will have to change to a differentprescription drug plan Members will continue to getprescription drugs through BCBSNCrsquos Medicare PDPuntil the contract ends

PAGE 19 of 40

Important information

For more information

Blue Cross and Blue Shield of North Carolina

Phone 1-800-478-0583

TTYTDD 1-800-922-3140

Hours 7 days a week8 amndash8 pm

Online bcbsnccommedicare

Medicare

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

TTYTDD 1-877-486-2048

Hours 7 days a week24 hours a day

Online wwwmedicaregovClick the ldquoPrescription Drug Planrdquo link

Blue Cross and Blue Shield of North Carolina is a PDP plan with a Medicare contract Enrollment in Blue Cross and Blue Shield of North Carolina depends on contract renewal Benefits formulary pharmacy network premium andor copaymentscoinsurance may change on January 1 2015 Please contact BCBSNC for details

An independent licensee of the Blue Cross and Blue Shield Association

PAGE 20 of 40

(PDP)

2014 Summary of benefits for our Medicare prescription drug plans (Enhanced and Standard)

Contract S5540 Plans 004 and 002 January 1 2014 ndash December 31 2014

U5073c 813

PAGE 21 of 40Y0079_6249 CMS Accepted 09112013

Introduction to the

Summary of benefits for (PDP)

Thank you for your interest in Blue Medicare Rx(PDP) plans Our plans are offered by Blue Crossand Blue Shield of North Carolina a MedicarePrescription Drug Plan that contracts with theFederal government This Summary of Benefits tellsyou some features of our plans It doesnrsquot list everydrug we cover every limitation or exclusionTo get a complete list of our benefits please callBlue Medicare Rx and ask for the ldquoEvidence of Coveragerdquo You have choices in your Medicare prescription drug coverage As a Medicare beneficiary you can choose fromdifferent Medicare prescription drug coverageoptions One option is to get prescription drugcoverage through a Medicare Prescription DrugPlan like Blue Medicare Rx plans Another optionis to get your prescription drug coverage througha Medicare Advantage Plan that offers prescriptiondrug coverage You make the choice How can I compare my options The charts in this booklet list some important drugbenefits You can use this Summary of Benefitsto compare the benefits offered by Blue MedicareRx plans to the benefits offered by other MedicarePrescription Drug Plans or Medicare AdvantagePlans with prescription drug coverage Where are Blue Medicare Rx Plans available The service area for these plans includesNorth Carolina You must live in one of these areas to join one of these plans Who is eligible to join You can join one of these plans if you are entitled toMedicare Part A andor enrolled in Medicare Part Band live in the service area If you are enrolled in an MA coordinated care(HMO or PPO) plan or an MA PFFS plan thatincludes Medicare prescription drugs you maynot enroll in a PDP unless you disenroll from theHMO PPO or MA PFFS plan Enrollees in a private Fee-for-Service plan (PFFS)that does not provide Medicare prescription drugcoverage or an MA Medical Savings Account (MSA)plan may enroll in a PDP Enrollees in an 1876 Costplan may enroll in a PDP

Where can I get my prescriptions Blue Medicare Rx plans have formed a network ofpharmacies You must use a network pharmacyto receive plan benefits We will not pay foryour prescriptions if you use an out-of-networkpharmacy except in certain cases Blue Medicare Rx plans have a list of preferredpharmacies At these pharmacies you may getyour drugs at a lower co-pay or coinsuranceYou may go to a non-preferred pharmacy but youmay have to pay more for your prescription drugs The pharmacies in our network can change at anytime You can ask for a Pharmacy Directory or visit usat wwwmyprimecomMyRxMyPrimeMedicareDpharmacyBCBSNC Our customer service number is listed at the end of this introduction What if my doctor prescribes less than a monthrsquos supply In consultation with your doctor or pharmacist youmay receive less than a monthrsquos supply of certaindrugs Also if you live in a long-term care facilityyou will receive less than a monthrsquos supply of certainbrand [and generic] drugs Dispensing fewer drugs ata time can help reduce cost and waste in the MedicarePart D program when this is medically appropriate The amount you pay in these circumstances willdepend on whether you are responsible for payingcoinsurance (a percentage of the cost of the drug) ora copay (a flat dollar amount for the drug) If youare responsible for coinsurance for the drug youwill continue to pay the applicable percentage ofthe drug cost If you are responsible for a copay forthe drug a ldquodaily cost-sharing raterdquo will be appliedIf your doctor decides to continue the drug after atrial period you should not pay more for a monthrsquossupply than you otherwise would have paid Contactyour plan if you have questions about cost-sharingwhen less than a one-month supply is dispensed Does my plan cover Medicare Part B or Part D drugs Blue Medicare Rx Standard and Enhanced plans donot cover drugs that are covered under Medicare PartB as prescribed and dispensed Generally we onlycover drugs vaccines biological products and medicalsupplies associated with the delivery of insulin thatare covered under the Medicare Prescription DrugBenefit (Part D) and that are on our formulary

PAG E 22 of 40

Introduction to the

Summary of benefits (continued)

What is a prescription drug formulary Blue Medicare Rx plans use a formularyA formulary is a list of drugs covered by your planto meet patient needs We may periodically addremove or make changes to coverage limitationson certain drugs or change how much you pay for adrug If we make any formulary change that limitsour membersrsquo ability to fill their prescriptions wewill notify the affected members before the changeis made We will send a formulary to you andyou can see our complete formulary on our Website at httpwwwbcbsnccomcontentmedicareformulary-homehtm If you are currently taking a drug that is not on ourformulary or subject to additional requirements orlimits you may be able to get a temporary supply ofthe drug You can contact us to request an exceptionor switch to an alternative drug listed on ourformulary with your physicianrsquos help Call us to seeif you can get a temporary supply of the drug or formore details about our drug transition policy What should I do if I have other insurance in addition to Medicare If you have a Medigap (Medicare Supplement)policy that includes prescription drug coverage youmust contact your Medigap Issuer to let them knowthat you have joined a Medicare Prescription DrugPlan If you decide to keep your current Medigapsupplement policy your Medigap Issuer willremove the prescription drug coverage portion ofyour policy Call your Medigap Issuer for details If you or your spouse has or is able to get employergroup coverage you should talk to your employerto find out how your benefits will be affected if youjoin a Blue Medicare Rx plan Get this informationbefore you decide to enroll in this plan

How can I get extra help with my prescription drug plan costs or get extra help with other Medicare costs You may be able to get extra help to pay for yourprescription drug premiums and costs as well as gethelp with other Medicare costs To see if you qualifyfor getting extra help call +1-800-MEDICARE (1-800-633-4227)

TTYTDD users should call 1-877-486-204824 hours a day7 days a week and seehttpwwwmedicaregov lsquoPrograms for Peoplewith Limited Income and Resourcesrsquo in the publication Medicare amp You

+The Social Security Administration at1-800-772-1213 between 7 am and 7 pmMonday through Friday TTYTDD usersshould call 1-800-325-0778 or

+Your State Medicaid Office What are my protections in this plan All Medicare Prescription Drug Plans agree to stayin the program for a full calendar year at a timePlan benefits and cost-sharing may change fromcalendar year to calendar year Each year plans candecide whether to continue to participate with theMedicare Prescription Drug Program A plan maycontinue in their entire service area (geographicarea where the plan accepts members) or choose tocontinue only in certain areas Also Medicare maydecide to end a contract with a plan Even if yourMedicare Prescription Plan leaves the program youwill not lose Medicare coverage If a plan decidesnot to continue for an additional calendar year itmust send you a letter at least 90 days before yourcoverage will end The letter will explain youroptions for Medicare coverage in your area As a member of a Blue Medicare Rx plan you havethe right to request a coverage determination whichincludes the right to request an exception the right tofile an appeal if we deny coverage for a prescriptiondrug and the right to file a grievance You havethe right to request a coverage determination if youwant us to cover a Part D drug that you believeshould be covered An exception is a type of coveragedetermination You may ask us for an exception ifyou believe you need a drug that is not on our list

PAG E 23 of 40

Important information

Pharmacy network

Pharmacy network information Our network includes a variety of pharmaciesincluding retail home infusion IndianTribalUrban organizations extended supply and long-term care pharmacies In order to obtain thegreatest savings on your prescription medicationsplease visit one of our preferred network providers(CVS WalMart Kerr and Epic Pharmacies) Formore information about our pharmacy networkand out-of-network policies please see our contactinformation below

Mail order contact information For information on our mail order service or to obtain forms please contact us at

Coverage determination

What is a coverage determination When we make a coverage determination weare making a decision about whether or not toprovide or pay for a Part D drug and what yourshare of the cost is for the drug (also see thedescription of the exceptions process) You mustcontact us if you would like to request a coveragedetermination including an exception Youcannot request an appeal if we have not issueda coverage determination

Mail order contact information

Phone 1-888-247-4142

TTYTDD 1-888-247-4145

Hours 7 days a week8 amndash8 pm

Mail BCBSNC Customer Service PO Box 17509 Winston-Salem NC 27116-7509

Online For a comprehensive list ofall pharmacies please visitbcbsnccommedicare

Examples of when you may ask us for a coverage determination

If you are not getting a prescription drug thatyou believe may be covered by us

If you have received a Part D prescription drugthat you believe may be covered by us while youwere a member but we have refused to pay forthe drug

If you are being told that coverage for a Part Dprescription drug that you have been gettingwill be reduced or stopped and you believe youhave special circumstances that should excludeyou from the reductionnon-coverage

If there is a limit on the quantity (or dose) of thedrug and you disagree with the requirement ordosage limitation

If you bought a drug at a pharmacy that isnot in our network and you want to requestreimbursement for the expense

PAGE 13 of 40

Important information

Coverage determination (continued)

How do I make a request for coverage determination Standard To ask for a standard decision you oryour appointed representative may call ourCustomer Service Department at the numberslisted on the back cover You can also mail a written request to the below address

Fast To ask for a fast decision you your physicianor your appointed representative may call theCustomer Service Department at the numbers listedon the back cover You can also mail a written request to the below address

Standard Generally we must give you our decisionno later than 72 hours after we have received yourrequest but we will make it sooner if your healthcondition requires

Fast If you get a fast review we will give you ourdecision within 24 hours after you or your doctor askfor a fast review mdash sooner if your health requires

PAGE 14 of 40

Contact information

Mail BCBSNC PO Box 17509 Winston-Salem NC 27116-7509

Fax Request 1-888-446-8440

Hours MondayndashFriday8 amndash5 pm

Note You cannot ask for a fast decision on a requestfor coverage of a drug already purchased

For some reviews we may require a supportingstatement from your doctor that explains why the drugyou are asking coverage for is medically necessary

After regular business hours you should consultwith a network pharmacy regarding your need for anemergency or temporary supply of medication untilyou can contact the Plan the next business day Youmay also call our Customer Service Department andleave a message on the Part D After Hours ExceptionRequest voicemail Be sure to ask for a ldquofastrdquoldquoexpeditedrdquo or ldquo24-hourrdquo review

When will I hear back with a decision

Important information

Exceptions process

What is an exception request Exception requests are a kind of coveragedetermination You your authorized representativeor your prescribing physician may request anexception to seek coverage of a drug that

+ Is not on the formulary (list of drugsthe plan covers)

+ Requires prior authorization + Has quantity limitations

Example of an exception request If the Planrsquos formulary does not include a drug thatyou or your prescribing physician feel is necessarythen you or your prescribing physician may requestan exception so that you may obtain coverage ofthis drug If the Plan does not grant the requestedexception then you or your prescribing physicianmay file an appeal

How do I make an exception request You or your prescribing physician may request anexception to the coverage rules for your MedicarePrescription Drug Plan A specific form is notrequired for you to make an exception requestThe request must include your prescribingphysicianrsquos statement that heshe has determinedthat the preferred drug either would not be aseffective or would have adverse effects for you

For your convenience forms are available at bcbsnccomcontentmedicarememberindexhtm

Contact information

Mail BCBSNC Attn PDP Exception RequestsPO Box 17509 Winston-Salem NC 27116-7509

Phone 1-888-247-4142

Physicians call 1-888-298-7552

TTYTDD 1-888-247-4145

Hours 7 days a week8 amndash8 pm

When will I receive a decision on my exception request If your exception request includes a formularyexception or an exception from utilizationmanagement rules such as dosage or quantitylimits we must make our decision no later than 72 hours after we have received your doctorrsquossupporting statement which explains why thedrug you are asking for is medically necessary

If you have asked for a fast or expedited exceptionrequest we must make our decision no later than24 hours after we get your doctorrsquos supporting statement

You will be notified by phone followed by awritten notice of our decision If the decision is not in your favor you have the right to appeal

PAGE 15 of 40

Important informationAppeals process

What is an appeal An appeal is your opportunity to requesta redetermination of an adverse coveragedetermination which includes denied exception requests

Example of an appeal If we deny your request for an exception to covera non-formulary drug then you may file an appealof the denial An appeal can only be filed afteran exception has been requested and denied bythe Plan

How do I file an appeal If you receive a coverage determination denial youor your appointed representative or your doctor orother prescriber may file an appeal A specific formis not required for you to file an appeal An appealmust be filed within 60 calendar days of the date ofa denial notice and must be in writing unless youare filing an expedited or fast appeal You mustsubmit it via mail fax or in person

When will I receive a decision on my appeal

We will perform a standard review of your appealwithin seven calendar days of receipt of your appealor sooner if your health requires We will reviewrequests for an expedited or fast appeal as soon aspossible but no later than 72 hours following ourreceipt of the request An individual who was notinvolved with your original coverage determinationwill make a decision on your appeal

You will receive a written response to your appealThe decision on an expedited appeal will beprovided by phone followed by the written noticeIf our decision is to deny the appeal the notice willadvise you of your right to submit your appeal to the Independent Review Entity (IRE) with instructionson how to do so If we miss our time frames for claims adjudication or review of the appeal wewill automatically forward the appeal to the IREfor a decision There may be additional levels ofappeal available to you We will inform you of youradditional rights in the notice or you may refer toyour Evidence of Coverage for further details

Contact information

Mail BCBSNC Attn Medicare Appeals amp GrievancesPO Box 17509 Winston-Salem NC 27116-7509

Fax 1-888-375-8836 or 1-336-794-8836

In Person

BCBSNC 5660 University PkwyWinston-Salem NC 27105

PAGE 16 of 40

Important information

Grievance process

What is a grievance A grievance is a complaint that you may file ifyou are dissatisfied with the Plan or a contractedprovider for reasons other than a decision ona coverage determination Grievances alsoinclude complaints regarding the timelinessappropriateness access to or setting of a coveredprescription drug

Example of a grievance If you are dissatisfied with the service you receivedfrom a pharmacist or plan representative then youcould file a grievance

How do I file a grievance The grievance must be filed within 60 days after theevent or incident that caused you to be dissatisfiedA specific form is not required for you to file agrievance You or your appointed representativemay file a grievance via the phone by mail faxor in person

When will I receive a decision on my grievance The resolution of a grievance will be made asquickly as your concern requires but no more than30 calendar days after our receipt of the grievanceWe may extend the time frame by up to 14 calendardays if you request the extension or if we justify aneed for additional information and the delay is inyour best interest

If you request a written response to an oralgrievance one will be provided within 30 days afterreceipt of the grievance A written response will beprovided to all written grievances Our decision ona grievance is final and is not subject to an appeal

You have the right to an expedited review ofa grievance concerning our refusal to grant anexpedited coverage determination or expeditedappeal This type of grievance will be responded towithin 24 hours after our receipt of the grievance

Contact information

Phone 1-888-247-4142

Fax 1-888-375-8836 or 1-336-794-8836

Hours 7 days a week8 amndash8 pm

Mail BCBSNC Attn Medicare Appeals amp GrievancesPO Box 17509 Winston-Salem NC 27116-7509

In Person

BCBSNC 5660 University PkwyWinston-Salem NC 27105

PAGE 17 of 40

Important information

Quality improvement

What if I have a concern about the quality of services I received If you have a concern relating to the quality of services that you received under the Medicare Part D planthen in addition to our review you can also request review by the following organizations

The Carolinas Center for Medical Excellence (CCME) Quality Improvement Organization (QIO) in North Carolina CCME formerly known as Medical Review ofNorth Carolina Inc is a nonprofit medical carequality improvement organization CCME has beendesignated by the Centers for Medicare amp MedicaidServices as the Quality Improvement Organization(QIO) for North Carolina The QIO conducts casereviews to ensure that Medicare beneficiaries receive the quality of medical care that they expect andare entitled to CCME serves as an independentimpartial third party to review Medicare beneficiarycomplaints

Quality of care complaints filed with the QIO mustbe made in writing to the address below Assistanceis available via phone or online

The Carolinas Center for Medical Excellence (CCME)

Mail CCME 100 Regency Forest DriveSuite 200 Cary NC 27518-8598

Phone 1-919-380-9860 or 1-800-682-2650

TTYTDD 1-800-735-2962

Hours MondayndashFriday8 amndash5 pm

Web inquiries wwwccmemedicareorg

Seniorsrsquo Health Insurance Information Program (SHIIP) SHIIP is a state consumer division of the North Carolina Department of Insurance SHIIP assistssenior citizens with Medicare Medicare Part D Medicare Advantage Medicare supplementsMedicare fraud and abuse and long-term careinsurance questions Assistance is available viaphone or online

Seniorsrsquo Health Insurance Information Program (SHIIP)

Phone 1-800-443-9354

TYYTDD 1-800-735-2962

Hours MondayndashFriday8 amndash5 pm

Email ncshiipncdoigov

Online wwwncshiipcom

PAGE 18 of 40

Important information

Additional information

Notice of possible contract termination BCBSNC has a contract with the Centers for Medicare amp Medicaid Services (CMS) the government agencythat runs Medicare to provide a Medicare PrescriptionDrug Plan (PDP) This contract renews each year At theend of each year the contract is reviewed and eitherBCBSNC or CMS can decide to end it Members will get 90 days advance written notice in this situationIt is also possible for our contract to end at some othertime If the contract is going to end we will generallytell members 90 days in advance Advance notice maybe as little as 30 days or even fewer days if CMS endsour contract in the middle of the year In this noticewe would provide a written description of alternativesavailable for obtaining qualified prescription drugcoverage in North Carolina We are also required tonotify the general public of a contract termination vialocal newspapers

If BCBSNC decides to stop offering the Medicare PDPor change our service area so that it no longer includesthe area where you live membership in BCBSNCrsquosMedicare PDP will end for everyone in that servicearea and members will have to change to a differentprescription drug plan Members will continue to getprescription drugs through BCBSNCrsquos Medicare PDPuntil the contract ends

PAGE 19 of 40

Important information

For more information

Blue Cross and Blue Shield of North Carolina

Phone 1-800-478-0583

TTYTDD 1-800-922-3140

Hours 7 days a week8 amndash8 pm

Online bcbsnccommedicare

Medicare

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

TTYTDD 1-877-486-2048

Hours 7 days a week24 hours a day

Online wwwmedicaregovClick the ldquoPrescription Drug Planrdquo link

Blue Cross and Blue Shield of North Carolina is a PDP plan with a Medicare contract Enrollment in Blue Cross and Blue Shield of North Carolina depends on contract renewal Benefits formulary pharmacy network premium andor copaymentscoinsurance may change on January 1 2015 Please contact BCBSNC for details

An independent licensee of the Blue Cross and Blue Shield Association

PAGE 20 of 40

(PDP)

2014 Summary of benefits for our Medicare prescription drug plans (Enhanced and Standard)

Contract S5540 Plans 004 and 002 January 1 2014 ndash December 31 2014

U5073c 813

PAGE 21 of 40Y0079_6249 CMS Accepted 09112013

Introduction to the

Summary of benefits for (PDP)

Thank you for your interest in Blue Medicare Rx(PDP) plans Our plans are offered by Blue Crossand Blue Shield of North Carolina a MedicarePrescription Drug Plan that contracts with theFederal government This Summary of Benefits tellsyou some features of our plans It doesnrsquot list everydrug we cover every limitation or exclusionTo get a complete list of our benefits please callBlue Medicare Rx and ask for the ldquoEvidence of Coveragerdquo You have choices in your Medicare prescription drug coverage As a Medicare beneficiary you can choose fromdifferent Medicare prescription drug coverageoptions One option is to get prescription drugcoverage through a Medicare Prescription DrugPlan like Blue Medicare Rx plans Another optionis to get your prescription drug coverage througha Medicare Advantage Plan that offers prescriptiondrug coverage You make the choice How can I compare my options The charts in this booklet list some important drugbenefits You can use this Summary of Benefitsto compare the benefits offered by Blue MedicareRx plans to the benefits offered by other MedicarePrescription Drug Plans or Medicare AdvantagePlans with prescription drug coverage Where are Blue Medicare Rx Plans available The service area for these plans includesNorth Carolina You must live in one of these areas to join one of these plans Who is eligible to join You can join one of these plans if you are entitled toMedicare Part A andor enrolled in Medicare Part Band live in the service area If you are enrolled in an MA coordinated care(HMO or PPO) plan or an MA PFFS plan thatincludes Medicare prescription drugs you maynot enroll in a PDP unless you disenroll from theHMO PPO or MA PFFS plan Enrollees in a private Fee-for-Service plan (PFFS)that does not provide Medicare prescription drugcoverage or an MA Medical Savings Account (MSA)plan may enroll in a PDP Enrollees in an 1876 Costplan may enroll in a PDP

Where can I get my prescriptions Blue Medicare Rx plans have formed a network ofpharmacies You must use a network pharmacyto receive plan benefits We will not pay foryour prescriptions if you use an out-of-networkpharmacy except in certain cases Blue Medicare Rx plans have a list of preferredpharmacies At these pharmacies you may getyour drugs at a lower co-pay or coinsuranceYou may go to a non-preferred pharmacy but youmay have to pay more for your prescription drugs The pharmacies in our network can change at anytime You can ask for a Pharmacy Directory or visit usat wwwmyprimecomMyRxMyPrimeMedicareDpharmacyBCBSNC Our customer service number is listed at the end of this introduction What if my doctor prescribes less than a monthrsquos supply In consultation with your doctor or pharmacist youmay receive less than a monthrsquos supply of certaindrugs Also if you live in a long-term care facilityyou will receive less than a monthrsquos supply of certainbrand [and generic] drugs Dispensing fewer drugs ata time can help reduce cost and waste in the MedicarePart D program when this is medically appropriate The amount you pay in these circumstances willdepend on whether you are responsible for payingcoinsurance (a percentage of the cost of the drug) ora copay (a flat dollar amount for the drug) If youare responsible for coinsurance for the drug youwill continue to pay the applicable percentage ofthe drug cost If you are responsible for a copay forthe drug a ldquodaily cost-sharing raterdquo will be appliedIf your doctor decides to continue the drug after atrial period you should not pay more for a monthrsquossupply than you otherwise would have paid Contactyour plan if you have questions about cost-sharingwhen less than a one-month supply is dispensed Does my plan cover Medicare Part B or Part D drugs Blue Medicare Rx Standard and Enhanced plans donot cover drugs that are covered under Medicare PartB as prescribed and dispensed Generally we onlycover drugs vaccines biological products and medicalsupplies associated with the delivery of insulin thatare covered under the Medicare Prescription DrugBenefit (Part D) and that are on our formulary

PAG E 22 of 40

Introduction to the

Summary of benefits (continued)

What is a prescription drug formulary Blue Medicare Rx plans use a formularyA formulary is a list of drugs covered by your planto meet patient needs We may periodically addremove or make changes to coverage limitationson certain drugs or change how much you pay for adrug If we make any formulary change that limitsour membersrsquo ability to fill their prescriptions wewill notify the affected members before the changeis made We will send a formulary to you andyou can see our complete formulary on our Website at httpwwwbcbsnccomcontentmedicareformulary-homehtm If you are currently taking a drug that is not on ourformulary or subject to additional requirements orlimits you may be able to get a temporary supply ofthe drug You can contact us to request an exceptionor switch to an alternative drug listed on ourformulary with your physicianrsquos help Call us to seeif you can get a temporary supply of the drug or formore details about our drug transition policy What should I do if I have other insurance in addition to Medicare If you have a Medigap (Medicare Supplement)policy that includes prescription drug coverage youmust contact your Medigap Issuer to let them knowthat you have joined a Medicare Prescription DrugPlan If you decide to keep your current Medigapsupplement policy your Medigap Issuer willremove the prescription drug coverage portion ofyour policy Call your Medigap Issuer for details If you or your spouse has or is able to get employergroup coverage you should talk to your employerto find out how your benefits will be affected if youjoin a Blue Medicare Rx plan Get this informationbefore you decide to enroll in this plan

How can I get extra help with my prescription drug plan costs or get extra help with other Medicare costs You may be able to get extra help to pay for yourprescription drug premiums and costs as well as gethelp with other Medicare costs To see if you qualifyfor getting extra help call +1-800-MEDICARE (1-800-633-4227)

TTYTDD users should call 1-877-486-204824 hours a day7 days a week and seehttpwwwmedicaregov lsquoPrograms for Peoplewith Limited Income and Resourcesrsquo in the publication Medicare amp You

+The Social Security Administration at1-800-772-1213 between 7 am and 7 pmMonday through Friday TTYTDD usersshould call 1-800-325-0778 or

+Your State Medicaid Office What are my protections in this plan All Medicare Prescription Drug Plans agree to stayin the program for a full calendar year at a timePlan benefits and cost-sharing may change fromcalendar year to calendar year Each year plans candecide whether to continue to participate with theMedicare Prescription Drug Program A plan maycontinue in their entire service area (geographicarea where the plan accepts members) or choose tocontinue only in certain areas Also Medicare maydecide to end a contract with a plan Even if yourMedicare Prescription Plan leaves the program youwill not lose Medicare coverage If a plan decidesnot to continue for an additional calendar year itmust send you a letter at least 90 days before yourcoverage will end The letter will explain youroptions for Medicare coverage in your area As a member of a Blue Medicare Rx plan you havethe right to request a coverage determination whichincludes the right to request an exception the right tofile an appeal if we deny coverage for a prescriptiondrug and the right to file a grievance You havethe right to request a coverage determination if youwant us to cover a Part D drug that you believeshould be covered An exception is a type of coveragedetermination You may ask us for an exception ifyou believe you need a drug that is not on our list

PAG E 23 of 40

Important information

Coverage determination (continued)

How do I make a request for coverage determination Standard To ask for a standard decision you oryour appointed representative may call ourCustomer Service Department at the numberslisted on the back cover You can also mail a written request to the below address

Fast To ask for a fast decision you your physicianor your appointed representative may call theCustomer Service Department at the numbers listedon the back cover You can also mail a written request to the below address

Standard Generally we must give you our decisionno later than 72 hours after we have received yourrequest but we will make it sooner if your healthcondition requires

Fast If you get a fast review we will give you ourdecision within 24 hours after you or your doctor askfor a fast review mdash sooner if your health requires

PAGE 14 of 40

Contact information

Mail BCBSNC PO Box 17509 Winston-Salem NC 27116-7509

Fax Request 1-888-446-8440

Hours MondayndashFriday8 amndash5 pm

Note You cannot ask for a fast decision on a requestfor coverage of a drug already purchased

For some reviews we may require a supportingstatement from your doctor that explains why the drugyou are asking coverage for is medically necessary

After regular business hours you should consultwith a network pharmacy regarding your need for anemergency or temporary supply of medication untilyou can contact the Plan the next business day Youmay also call our Customer Service Department andleave a message on the Part D After Hours ExceptionRequest voicemail Be sure to ask for a ldquofastrdquoldquoexpeditedrdquo or ldquo24-hourrdquo review

When will I hear back with a decision

Important information

Exceptions process

What is an exception request Exception requests are a kind of coveragedetermination You your authorized representativeor your prescribing physician may request anexception to seek coverage of a drug that

+ Is not on the formulary (list of drugsthe plan covers)

+ Requires prior authorization + Has quantity limitations

Example of an exception request If the Planrsquos formulary does not include a drug thatyou or your prescribing physician feel is necessarythen you or your prescribing physician may requestan exception so that you may obtain coverage ofthis drug If the Plan does not grant the requestedexception then you or your prescribing physicianmay file an appeal

How do I make an exception request You or your prescribing physician may request anexception to the coverage rules for your MedicarePrescription Drug Plan A specific form is notrequired for you to make an exception requestThe request must include your prescribingphysicianrsquos statement that heshe has determinedthat the preferred drug either would not be aseffective or would have adverse effects for you

For your convenience forms are available at bcbsnccomcontentmedicarememberindexhtm

Contact information

Mail BCBSNC Attn PDP Exception RequestsPO Box 17509 Winston-Salem NC 27116-7509

Phone 1-888-247-4142

Physicians call 1-888-298-7552

TTYTDD 1-888-247-4145

Hours 7 days a week8 amndash8 pm

When will I receive a decision on my exception request If your exception request includes a formularyexception or an exception from utilizationmanagement rules such as dosage or quantitylimits we must make our decision no later than 72 hours after we have received your doctorrsquossupporting statement which explains why thedrug you are asking for is medically necessary

If you have asked for a fast or expedited exceptionrequest we must make our decision no later than24 hours after we get your doctorrsquos supporting statement

You will be notified by phone followed by awritten notice of our decision If the decision is not in your favor you have the right to appeal

PAGE 15 of 40

Important informationAppeals process

What is an appeal An appeal is your opportunity to requesta redetermination of an adverse coveragedetermination which includes denied exception requests

Example of an appeal If we deny your request for an exception to covera non-formulary drug then you may file an appealof the denial An appeal can only be filed afteran exception has been requested and denied bythe Plan

How do I file an appeal If you receive a coverage determination denial youor your appointed representative or your doctor orother prescriber may file an appeal A specific formis not required for you to file an appeal An appealmust be filed within 60 calendar days of the date ofa denial notice and must be in writing unless youare filing an expedited or fast appeal You mustsubmit it via mail fax or in person

When will I receive a decision on my appeal

We will perform a standard review of your appealwithin seven calendar days of receipt of your appealor sooner if your health requires We will reviewrequests for an expedited or fast appeal as soon aspossible but no later than 72 hours following ourreceipt of the request An individual who was notinvolved with your original coverage determinationwill make a decision on your appeal

You will receive a written response to your appealThe decision on an expedited appeal will beprovided by phone followed by the written noticeIf our decision is to deny the appeal the notice willadvise you of your right to submit your appeal to the Independent Review Entity (IRE) with instructionson how to do so If we miss our time frames for claims adjudication or review of the appeal wewill automatically forward the appeal to the IREfor a decision There may be additional levels ofappeal available to you We will inform you of youradditional rights in the notice or you may refer toyour Evidence of Coverage for further details

Contact information

Mail BCBSNC Attn Medicare Appeals amp GrievancesPO Box 17509 Winston-Salem NC 27116-7509

Fax 1-888-375-8836 or 1-336-794-8836

In Person

BCBSNC 5660 University PkwyWinston-Salem NC 27105

PAGE 16 of 40

Important information

Grievance process

What is a grievance A grievance is a complaint that you may file ifyou are dissatisfied with the Plan or a contractedprovider for reasons other than a decision ona coverage determination Grievances alsoinclude complaints regarding the timelinessappropriateness access to or setting of a coveredprescription drug

Example of a grievance If you are dissatisfied with the service you receivedfrom a pharmacist or plan representative then youcould file a grievance

How do I file a grievance The grievance must be filed within 60 days after theevent or incident that caused you to be dissatisfiedA specific form is not required for you to file agrievance You or your appointed representativemay file a grievance via the phone by mail faxor in person

When will I receive a decision on my grievance The resolution of a grievance will be made asquickly as your concern requires but no more than30 calendar days after our receipt of the grievanceWe may extend the time frame by up to 14 calendardays if you request the extension or if we justify aneed for additional information and the delay is inyour best interest

If you request a written response to an oralgrievance one will be provided within 30 days afterreceipt of the grievance A written response will beprovided to all written grievances Our decision ona grievance is final and is not subject to an appeal

You have the right to an expedited review ofa grievance concerning our refusal to grant anexpedited coverage determination or expeditedappeal This type of grievance will be responded towithin 24 hours after our receipt of the grievance

Contact information

Phone 1-888-247-4142

Fax 1-888-375-8836 or 1-336-794-8836

Hours 7 days a week8 amndash8 pm

Mail BCBSNC Attn Medicare Appeals amp GrievancesPO Box 17509 Winston-Salem NC 27116-7509

In Person

BCBSNC 5660 University PkwyWinston-Salem NC 27105

PAGE 17 of 40

Important information

Quality improvement

What if I have a concern about the quality of services I received If you have a concern relating to the quality of services that you received under the Medicare Part D planthen in addition to our review you can also request review by the following organizations

The Carolinas Center for Medical Excellence (CCME) Quality Improvement Organization (QIO) in North Carolina CCME formerly known as Medical Review ofNorth Carolina Inc is a nonprofit medical carequality improvement organization CCME has beendesignated by the Centers for Medicare amp MedicaidServices as the Quality Improvement Organization(QIO) for North Carolina The QIO conducts casereviews to ensure that Medicare beneficiaries receive the quality of medical care that they expect andare entitled to CCME serves as an independentimpartial third party to review Medicare beneficiarycomplaints

Quality of care complaints filed with the QIO mustbe made in writing to the address below Assistanceis available via phone or online

The Carolinas Center for Medical Excellence (CCME)

Mail CCME 100 Regency Forest DriveSuite 200 Cary NC 27518-8598

Phone 1-919-380-9860 or 1-800-682-2650

TTYTDD 1-800-735-2962

Hours MondayndashFriday8 amndash5 pm

Web inquiries wwwccmemedicareorg

Seniorsrsquo Health Insurance Information Program (SHIIP) SHIIP is a state consumer division of the North Carolina Department of Insurance SHIIP assistssenior citizens with Medicare Medicare Part D Medicare Advantage Medicare supplementsMedicare fraud and abuse and long-term careinsurance questions Assistance is available viaphone or online

Seniorsrsquo Health Insurance Information Program (SHIIP)

Phone 1-800-443-9354

TYYTDD 1-800-735-2962

Hours MondayndashFriday8 amndash5 pm

Email ncshiipncdoigov

Online wwwncshiipcom

PAGE 18 of 40

Important information

Additional information

Notice of possible contract termination BCBSNC has a contract with the Centers for Medicare amp Medicaid Services (CMS) the government agencythat runs Medicare to provide a Medicare PrescriptionDrug Plan (PDP) This contract renews each year At theend of each year the contract is reviewed and eitherBCBSNC or CMS can decide to end it Members will get 90 days advance written notice in this situationIt is also possible for our contract to end at some othertime If the contract is going to end we will generallytell members 90 days in advance Advance notice maybe as little as 30 days or even fewer days if CMS endsour contract in the middle of the year In this noticewe would provide a written description of alternativesavailable for obtaining qualified prescription drugcoverage in North Carolina We are also required tonotify the general public of a contract termination vialocal newspapers

If BCBSNC decides to stop offering the Medicare PDPor change our service area so that it no longer includesthe area where you live membership in BCBSNCrsquosMedicare PDP will end for everyone in that servicearea and members will have to change to a differentprescription drug plan Members will continue to getprescription drugs through BCBSNCrsquos Medicare PDPuntil the contract ends

PAGE 19 of 40

Important information

For more information

Blue Cross and Blue Shield of North Carolina

Phone 1-800-478-0583

TTYTDD 1-800-922-3140

Hours 7 days a week8 amndash8 pm

Online bcbsnccommedicare

Medicare

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

TTYTDD 1-877-486-2048

Hours 7 days a week24 hours a day

Online wwwmedicaregovClick the ldquoPrescription Drug Planrdquo link

Blue Cross and Blue Shield of North Carolina is a PDP plan with a Medicare contract Enrollment in Blue Cross and Blue Shield of North Carolina depends on contract renewal Benefits formulary pharmacy network premium andor copaymentscoinsurance may change on January 1 2015 Please contact BCBSNC for details

An independent licensee of the Blue Cross and Blue Shield Association

PAGE 20 of 40

(PDP)

2014 Summary of benefits for our Medicare prescription drug plans (Enhanced and Standard)

Contract S5540 Plans 004 and 002 January 1 2014 ndash December 31 2014

U5073c 813

PAGE 21 of 40Y0079_6249 CMS Accepted 09112013

Introduction to the

Summary of benefits for (PDP)

Thank you for your interest in Blue Medicare Rx(PDP) plans Our plans are offered by Blue Crossand Blue Shield of North Carolina a MedicarePrescription Drug Plan that contracts with theFederal government This Summary of Benefits tellsyou some features of our plans It doesnrsquot list everydrug we cover every limitation or exclusionTo get a complete list of our benefits please callBlue Medicare Rx and ask for the ldquoEvidence of Coveragerdquo You have choices in your Medicare prescription drug coverage As a Medicare beneficiary you can choose fromdifferent Medicare prescription drug coverageoptions One option is to get prescription drugcoverage through a Medicare Prescription DrugPlan like Blue Medicare Rx plans Another optionis to get your prescription drug coverage througha Medicare Advantage Plan that offers prescriptiondrug coverage You make the choice How can I compare my options The charts in this booklet list some important drugbenefits You can use this Summary of Benefitsto compare the benefits offered by Blue MedicareRx plans to the benefits offered by other MedicarePrescription Drug Plans or Medicare AdvantagePlans with prescription drug coverage Where are Blue Medicare Rx Plans available The service area for these plans includesNorth Carolina You must live in one of these areas to join one of these plans Who is eligible to join You can join one of these plans if you are entitled toMedicare Part A andor enrolled in Medicare Part Band live in the service area If you are enrolled in an MA coordinated care(HMO or PPO) plan or an MA PFFS plan thatincludes Medicare prescription drugs you maynot enroll in a PDP unless you disenroll from theHMO PPO or MA PFFS plan Enrollees in a private Fee-for-Service plan (PFFS)that does not provide Medicare prescription drugcoverage or an MA Medical Savings Account (MSA)plan may enroll in a PDP Enrollees in an 1876 Costplan may enroll in a PDP

Where can I get my prescriptions Blue Medicare Rx plans have formed a network ofpharmacies You must use a network pharmacyto receive plan benefits We will not pay foryour prescriptions if you use an out-of-networkpharmacy except in certain cases Blue Medicare Rx plans have a list of preferredpharmacies At these pharmacies you may getyour drugs at a lower co-pay or coinsuranceYou may go to a non-preferred pharmacy but youmay have to pay more for your prescription drugs The pharmacies in our network can change at anytime You can ask for a Pharmacy Directory or visit usat wwwmyprimecomMyRxMyPrimeMedicareDpharmacyBCBSNC Our customer service number is listed at the end of this introduction What if my doctor prescribes less than a monthrsquos supply In consultation with your doctor or pharmacist youmay receive less than a monthrsquos supply of certaindrugs Also if you live in a long-term care facilityyou will receive less than a monthrsquos supply of certainbrand [and generic] drugs Dispensing fewer drugs ata time can help reduce cost and waste in the MedicarePart D program when this is medically appropriate The amount you pay in these circumstances willdepend on whether you are responsible for payingcoinsurance (a percentage of the cost of the drug) ora copay (a flat dollar amount for the drug) If youare responsible for coinsurance for the drug youwill continue to pay the applicable percentage ofthe drug cost If you are responsible for a copay forthe drug a ldquodaily cost-sharing raterdquo will be appliedIf your doctor decides to continue the drug after atrial period you should not pay more for a monthrsquossupply than you otherwise would have paid Contactyour plan if you have questions about cost-sharingwhen less than a one-month supply is dispensed Does my plan cover Medicare Part B or Part D drugs Blue Medicare Rx Standard and Enhanced plans donot cover drugs that are covered under Medicare PartB as prescribed and dispensed Generally we onlycover drugs vaccines biological products and medicalsupplies associated with the delivery of insulin thatare covered under the Medicare Prescription DrugBenefit (Part D) and that are on our formulary

PAG E 22 of 40

Introduction to the

Summary of benefits (continued)

What is a prescription drug formulary Blue Medicare Rx plans use a formularyA formulary is a list of drugs covered by your planto meet patient needs We may periodically addremove or make changes to coverage limitationson certain drugs or change how much you pay for adrug If we make any formulary change that limitsour membersrsquo ability to fill their prescriptions wewill notify the affected members before the changeis made We will send a formulary to you andyou can see our complete formulary on our Website at httpwwwbcbsnccomcontentmedicareformulary-homehtm If you are currently taking a drug that is not on ourformulary or subject to additional requirements orlimits you may be able to get a temporary supply ofthe drug You can contact us to request an exceptionor switch to an alternative drug listed on ourformulary with your physicianrsquos help Call us to seeif you can get a temporary supply of the drug or formore details about our drug transition policy What should I do if I have other insurance in addition to Medicare If you have a Medigap (Medicare Supplement)policy that includes prescription drug coverage youmust contact your Medigap Issuer to let them knowthat you have joined a Medicare Prescription DrugPlan If you decide to keep your current Medigapsupplement policy your Medigap Issuer willremove the prescription drug coverage portion ofyour policy Call your Medigap Issuer for details If you or your spouse has or is able to get employergroup coverage you should talk to your employerto find out how your benefits will be affected if youjoin a Blue Medicare Rx plan Get this informationbefore you decide to enroll in this plan

How can I get extra help with my prescription drug plan costs or get extra help with other Medicare costs You may be able to get extra help to pay for yourprescription drug premiums and costs as well as gethelp with other Medicare costs To see if you qualifyfor getting extra help call +1-800-MEDICARE (1-800-633-4227)

TTYTDD users should call 1-877-486-204824 hours a day7 days a week and seehttpwwwmedicaregov lsquoPrograms for Peoplewith Limited Income and Resourcesrsquo in the publication Medicare amp You

+The Social Security Administration at1-800-772-1213 between 7 am and 7 pmMonday through Friday TTYTDD usersshould call 1-800-325-0778 or

+Your State Medicaid Office What are my protections in this plan All Medicare Prescription Drug Plans agree to stayin the program for a full calendar year at a timePlan benefits and cost-sharing may change fromcalendar year to calendar year Each year plans candecide whether to continue to participate with theMedicare Prescription Drug Program A plan maycontinue in their entire service area (geographicarea where the plan accepts members) or choose tocontinue only in certain areas Also Medicare maydecide to end a contract with a plan Even if yourMedicare Prescription Plan leaves the program youwill not lose Medicare coverage If a plan decidesnot to continue for an additional calendar year itmust send you a letter at least 90 days before yourcoverage will end The letter will explain youroptions for Medicare coverage in your area As a member of a Blue Medicare Rx plan you havethe right to request a coverage determination whichincludes the right to request an exception the right tofile an appeal if we deny coverage for a prescriptiondrug and the right to file a grievance You havethe right to request a coverage determination if youwant us to cover a Part D drug that you believeshould be covered An exception is a type of coveragedetermination You may ask us for an exception ifyou believe you need a drug that is not on our list

PAG E 23 of 40

Important information

Exceptions process

What is an exception request Exception requests are a kind of coveragedetermination You your authorized representativeor your prescribing physician may request anexception to seek coverage of a drug that

+ Is not on the formulary (list of drugsthe plan covers)

+ Requires prior authorization + Has quantity limitations

Example of an exception request If the Planrsquos formulary does not include a drug thatyou or your prescribing physician feel is necessarythen you or your prescribing physician may requestan exception so that you may obtain coverage ofthis drug If the Plan does not grant the requestedexception then you or your prescribing physicianmay file an appeal

How do I make an exception request You or your prescribing physician may request anexception to the coverage rules for your MedicarePrescription Drug Plan A specific form is notrequired for you to make an exception requestThe request must include your prescribingphysicianrsquos statement that heshe has determinedthat the preferred drug either would not be aseffective or would have adverse effects for you

For your convenience forms are available at bcbsnccomcontentmedicarememberindexhtm

Contact information

Mail BCBSNC Attn PDP Exception RequestsPO Box 17509 Winston-Salem NC 27116-7509

Phone 1-888-247-4142

Physicians call 1-888-298-7552

TTYTDD 1-888-247-4145

Hours 7 days a week8 amndash8 pm

When will I receive a decision on my exception request If your exception request includes a formularyexception or an exception from utilizationmanagement rules such as dosage or quantitylimits we must make our decision no later than 72 hours after we have received your doctorrsquossupporting statement which explains why thedrug you are asking for is medically necessary

If you have asked for a fast or expedited exceptionrequest we must make our decision no later than24 hours after we get your doctorrsquos supporting statement

You will be notified by phone followed by awritten notice of our decision If the decision is not in your favor you have the right to appeal

PAGE 15 of 40

Important informationAppeals process

What is an appeal An appeal is your opportunity to requesta redetermination of an adverse coveragedetermination which includes denied exception requests

Example of an appeal If we deny your request for an exception to covera non-formulary drug then you may file an appealof the denial An appeal can only be filed afteran exception has been requested and denied bythe Plan

How do I file an appeal If you receive a coverage determination denial youor your appointed representative or your doctor orother prescriber may file an appeal A specific formis not required for you to file an appeal An appealmust be filed within 60 calendar days of the date ofa denial notice and must be in writing unless youare filing an expedited or fast appeal You mustsubmit it via mail fax or in person

When will I receive a decision on my appeal

We will perform a standard review of your appealwithin seven calendar days of receipt of your appealor sooner if your health requires We will reviewrequests for an expedited or fast appeal as soon aspossible but no later than 72 hours following ourreceipt of the request An individual who was notinvolved with your original coverage determinationwill make a decision on your appeal

You will receive a written response to your appealThe decision on an expedited appeal will beprovided by phone followed by the written noticeIf our decision is to deny the appeal the notice willadvise you of your right to submit your appeal to the Independent Review Entity (IRE) with instructionson how to do so If we miss our time frames for claims adjudication or review of the appeal wewill automatically forward the appeal to the IREfor a decision There may be additional levels ofappeal available to you We will inform you of youradditional rights in the notice or you may refer toyour Evidence of Coverage for further details

Contact information

Mail BCBSNC Attn Medicare Appeals amp GrievancesPO Box 17509 Winston-Salem NC 27116-7509

Fax 1-888-375-8836 or 1-336-794-8836

In Person

BCBSNC 5660 University PkwyWinston-Salem NC 27105

PAGE 16 of 40

Important information

Grievance process

What is a grievance A grievance is a complaint that you may file ifyou are dissatisfied with the Plan or a contractedprovider for reasons other than a decision ona coverage determination Grievances alsoinclude complaints regarding the timelinessappropriateness access to or setting of a coveredprescription drug

Example of a grievance If you are dissatisfied with the service you receivedfrom a pharmacist or plan representative then youcould file a grievance

How do I file a grievance The grievance must be filed within 60 days after theevent or incident that caused you to be dissatisfiedA specific form is not required for you to file agrievance You or your appointed representativemay file a grievance via the phone by mail faxor in person

When will I receive a decision on my grievance The resolution of a grievance will be made asquickly as your concern requires but no more than30 calendar days after our receipt of the grievanceWe may extend the time frame by up to 14 calendardays if you request the extension or if we justify aneed for additional information and the delay is inyour best interest

If you request a written response to an oralgrievance one will be provided within 30 days afterreceipt of the grievance A written response will beprovided to all written grievances Our decision ona grievance is final and is not subject to an appeal

You have the right to an expedited review ofa grievance concerning our refusal to grant anexpedited coverage determination or expeditedappeal This type of grievance will be responded towithin 24 hours after our receipt of the grievance

Contact information

Phone 1-888-247-4142

Fax 1-888-375-8836 or 1-336-794-8836

Hours 7 days a week8 amndash8 pm

Mail BCBSNC Attn Medicare Appeals amp GrievancesPO Box 17509 Winston-Salem NC 27116-7509

In Person

BCBSNC 5660 University PkwyWinston-Salem NC 27105

PAGE 17 of 40

Important information

Quality improvement

What if I have a concern about the quality of services I received If you have a concern relating to the quality of services that you received under the Medicare Part D planthen in addition to our review you can also request review by the following organizations

The Carolinas Center for Medical Excellence (CCME) Quality Improvement Organization (QIO) in North Carolina CCME formerly known as Medical Review ofNorth Carolina Inc is a nonprofit medical carequality improvement organization CCME has beendesignated by the Centers for Medicare amp MedicaidServices as the Quality Improvement Organization(QIO) for North Carolina The QIO conducts casereviews to ensure that Medicare beneficiaries receive the quality of medical care that they expect andare entitled to CCME serves as an independentimpartial third party to review Medicare beneficiarycomplaints

Quality of care complaints filed with the QIO mustbe made in writing to the address below Assistanceis available via phone or online

The Carolinas Center for Medical Excellence (CCME)

Mail CCME 100 Regency Forest DriveSuite 200 Cary NC 27518-8598

Phone 1-919-380-9860 or 1-800-682-2650

TTYTDD 1-800-735-2962

Hours MondayndashFriday8 amndash5 pm

Web inquiries wwwccmemedicareorg

Seniorsrsquo Health Insurance Information Program (SHIIP) SHIIP is a state consumer division of the North Carolina Department of Insurance SHIIP assistssenior citizens with Medicare Medicare Part D Medicare Advantage Medicare supplementsMedicare fraud and abuse and long-term careinsurance questions Assistance is available viaphone or online

Seniorsrsquo Health Insurance Information Program (SHIIP)

Phone 1-800-443-9354

TYYTDD 1-800-735-2962

Hours MondayndashFriday8 amndash5 pm

Email ncshiipncdoigov

Online wwwncshiipcom

PAGE 18 of 40

Important information

Additional information

Notice of possible contract termination BCBSNC has a contract with the Centers for Medicare amp Medicaid Services (CMS) the government agencythat runs Medicare to provide a Medicare PrescriptionDrug Plan (PDP) This contract renews each year At theend of each year the contract is reviewed and eitherBCBSNC or CMS can decide to end it Members will get 90 days advance written notice in this situationIt is also possible for our contract to end at some othertime If the contract is going to end we will generallytell members 90 days in advance Advance notice maybe as little as 30 days or even fewer days if CMS endsour contract in the middle of the year In this noticewe would provide a written description of alternativesavailable for obtaining qualified prescription drugcoverage in North Carolina We are also required tonotify the general public of a contract termination vialocal newspapers

If BCBSNC decides to stop offering the Medicare PDPor change our service area so that it no longer includesthe area where you live membership in BCBSNCrsquosMedicare PDP will end for everyone in that servicearea and members will have to change to a differentprescription drug plan Members will continue to getprescription drugs through BCBSNCrsquos Medicare PDPuntil the contract ends

PAGE 19 of 40

Important information

For more information

Blue Cross and Blue Shield of North Carolina

Phone 1-800-478-0583

TTYTDD 1-800-922-3140

Hours 7 days a week8 amndash8 pm

Online bcbsnccommedicare

Medicare

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

TTYTDD 1-877-486-2048

Hours 7 days a week24 hours a day

Online wwwmedicaregovClick the ldquoPrescription Drug Planrdquo link

Blue Cross and Blue Shield of North Carolina is a PDP plan with a Medicare contract Enrollment in Blue Cross and Blue Shield of North Carolina depends on contract renewal Benefits formulary pharmacy network premium andor copaymentscoinsurance may change on January 1 2015 Please contact BCBSNC for details

An independent licensee of the Blue Cross and Blue Shield Association

PAGE 20 of 40

(PDP)

2014 Summary of benefits for our Medicare prescription drug plans (Enhanced and Standard)

Contract S5540 Plans 004 and 002 January 1 2014 ndash December 31 2014

U5073c 813

PAGE 21 of 40Y0079_6249 CMS Accepted 09112013

Introduction to the

Summary of benefits for (PDP)

Thank you for your interest in Blue Medicare Rx(PDP) plans Our plans are offered by Blue Crossand Blue Shield of North Carolina a MedicarePrescription Drug Plan that contracts with theFederal government This Summary of Benefits tellsyou some features of our plans It doesnrsquot list everydrug we cover every limitation or exclusionTo get a complete list of our benefits please callBlue Medicare Rx and ask for the ldquoEvidence of Coveragerdquo You have choices in your Medicare prescription drug coverage As a Medicare beneficiary you can choose fromdifferent Medicare prescription drug coverageoptions One option is to get prescription drugcoverage through a Medicare Prescription DrugPlan like Blue Medicare Rx plans Another optionis to get your prescription drug coverage througha Medicare Advantage Plan that offers prescriptiondrug coverage You make the choice How can I compare my options The charts in this booklet list some important drugbenefits You can use this Summary of Benefitsto compare the benefits offered by Blue MedicareRx plans to the benefits offered by other MedicarePrescription Drug Plans or Medicare AdvantagePlans with prescription drug coverage Where are Blue Medicare Rx Plans available The service area for these plans includesNorth Carolina You must live in one of these areas to join one of these plans Who is eligible to join You can join one of these plans if you are entitled toMedicare Part A andor enrolled in Medicare Part Band live in the service area If you are enrolled in an MA coordinated care(HMO or PPO) plan or an MA PFFS plan thatincludes Medicare prescription drugs you maynot enroll in a PDP unless you disenroll from theHMO PPO or MA PFFS plan Enrollees in a private Fee-for-Service plan (PFFS)that does not provide Medicare prescription drugcoverage or an MA Medical Savings Account (MSA)plan may enroll in a PDP Enrollees in an 1876 Costplan may enroll in a PDP

Where can I get my prescriptions Blue Medicare Rx plans have formed a network ofpharmacies You must use a network pharmacyto receive plan benefits We will not pay foryour prescriptions if you use an out-of-networkpharmacy except in certain cases Blue Medicare Rx plans have a list of preferredpharmacies At these pharmacies you may getyour drugs at a lower co-pay or coinsuranceYou may go to a non-preferred pharmacy but youmay have to pay more for your prescription drugs The pharmacies in our network can change at anytime You can ask for a Pharmacy Directory or visit usat wwwmyprimecomMyRxMyPrimeMedicareDpharmacyBCBSNC Our customer service number is listed at the end of this introduction What if my doctor prescribes less than a monthrsquos supply In consultation with your doctor or pharmacist youmay receive less than a monthrsquos supply of certaindrugs Also if you live in a long-term care facilityyou will receive less than a monthrsquos supply of certainbrand [and generic] drugs Dispensing fewer drugs ata time can help reduce cost and waste in the MedicarePart D program when this is medically appropriate The amount you pay in these circumstances willdepend on whether you are responsible for payingcoinsurance (a percentage of the cost of the drug) ora copay (a flat dollar amount for the drug) If youare responsible for coinsurance for the drug youwill continue to pay the applicable percentage ofthe drug cost If you are responsible for a copay forthe drug a ldquodaily cost-sharing raterdquo will be appliedIf your doctor decides to continue the drug after atrial period you should not pay more for a monthrsquossupply than you otherwise would have paid Contactyour plan if you have questions about cost-sharingwhen less than a one-month supply is dispensed Does my plan cover Medicare Part B or Part D drugs Blue Medicare Rx Standard and Enhanced plans donot cover drugs that are covered under Medicare PartB as prescribed and dispensed Generally we onlycover drugs vaccines biological products and medicalsupplies associated with the delivery of insulin thatare covered under the Medicare Prescription DrugBenefit (Part D) and that are on our formulary

PAG E 22 of 40

Introduction to the

Summary of benefits (continued)

What is a prescription drug formulary Blue Medicare Rx plans use a formularyA formulary is a list of drugs covered by your planto meet patient needs We may periodically addremove or make changes to coverage limitationson certain drugs or change how much you pay for adrug If we make any formulary change that limitsour membersrsquo ability to fill their prescriptions wewill notify the affected members before the changeis made We will send a formulary to you andyou can see our complete formulary on our Website at httpwwwbcbsnccomcontentmedicareformulary-homehtm If you are currently taking a drug that is not on ourformulary or subject to additional requirements orlimits you may be able to get a temporary supply ofthe drug You can contact us to request an exceptionor switch to an alternative drug listed on ourformulary with your physicianrsquos help Call us to seeif you can get a temporary supply of the drug or formore details about our drug transition policy What should I do if I have other insurance in addition to Medicare If you have a Medigap (Medicare Supplement)policy that includes prescription drug coverage youmust contact your Medigap Issuer to let them knowthat you have joined a Medicare Prescription DrugPlan If you decide to keep your current Medigapsupplement policy your Medigap Issuer willremove the prescription drug coverage portion ofyour policy Call your Medigap Issuer for details If you or your spouse has or is able to get employergroup coverage you should talk to your employerto find out how your benefits will be affected if youjoin a Blue Medicare Rx plan Get this informationbefore you decide to enroll in this plan

How can I get extra help with my prescription drug plan costs or get extra help with other Medicare costs You may be able to get extra help to pay for yourprescription drug premiums and costs as well as gethelp with other Medicare costs To see if you qualifyfor getting extra help call +1-800-MEDICARE (1-800-633-4227)

TTYTDD users should call 1-877-486-204824 hours a day7 days a week and seehttpwwwmedicaregov lsquoPrograms for Peoplewith Limited Income and Resourcesrsquo in the publication Medicare amp You

+The Social Security Administration at1-800-772-1213 between 7 am and 7 pmMonday through Friday TTYTDD usersshould call 1-800-325-0778 or

+Your State Medicaid Office What are my protections in this plan All Medicare Prescription Drug Plans agree to stayin the program for a full calendar year at a timePlan benefits and cost-sharing may change fromcalendar year to calendar year Each year plans candecide whether to continue to participate with theMedicare Prescription Drug Program A plan maycontinue in their entire service area (geographicarea where the plan accepts members) or choose tocontinue only in certain areas Also Medicare maydecide to end a contract with a plan Even if yourMedicare Prescription Plan leaves the program youwill not lose Medicare coverage If a plan decidesnot to continue for an additional calendar year itmust send you a letter at least 90 days before yourcoverage will end The letter will explain youroptions for Medicare coverage in your area As a member of a Blue Medicare Rx plan you havethe right to request a coverage determination whichincludes the right to request an exception the right tofile an appeal if we deny coverage for a prescriptiondrug and the right to file a grievance You havethe right to request a coverage determination if youwant us to cover a Part D drug that you believeshould be covered An exception is a type of coveragedetermination You may ask us for an exception ifyou believe you need a drug that is not on our list

PAG E 23 of 40

Important informationAppeals process

What is an appeal An appeal is your opportunity to requesta redetermination of an adverse coveragedetermination which includes denied exception requests

Example of an appeal If we deny your request for an exception to covera non-formulary drug then you may file an appealof the denial An appeal can only be filed afteran exception has been requested and denied bythe Plan

How do I file an appeal If you receive a coverage determination denial youor your appointed representative or your doctor orother prescriber may file an appeal A specific formis not required for you to file an appeal An appealmust be filed within 60 calendar days of the date ofa denial notice and must be in writing unless youare filing an expedited or fast appeal You mustsubmit it via mail fax or in person

When will I receive a decision on my appeal

We will perform a standard review of your appealwithin seven calendar days of receipt of your appealor sooner if your health requires We will reviewrequests for an expedited or fast appeal as soon aspossible but no later than 72 hours following ourreceipt of the request An individual who was notinvolved with your original coverage determinationwill make a decision on your appeal

You will receive a written response to your appealThe decision on an expedited appeal will beprovided by phone followed by the written noticeIf our decision is to deny the appeal the notice willadvise you of your right to submit your appeal to the Independent Review Entity (IRE) with instructionson how to do so If we miss our time frames for claims adjudication or review of the appeal wewill automatically forward the appeal to the IREfor a decision There may be additional levels ofappeal available to you We will inform you of youradditional rights in the notice or you may refer toyour Evidence of Coverage for further details

Contact information

Mail BCBSNC Attn Medicare Appeals amp GrievancesPO Box 17509 Winston-Salem NC 27116-7509

Fax 1-888-375-8836 or 1-336-794-8836

In Person

BCBSNC 5660 University PkwyWinston-Salem NC 27105

PAGE 16 of 40

Important information

Grievance process

What is a grievance A grievance is a complaint that you may file ifyou are dissatisfied with the Plan or a contractedprovider for reasons other than a decision ona coverage determination Grievances alsoinclude complaints regarding the timelinessappropriateness access to or setting of a coveredprescription drug

Example of a grievance If you are dissatisfied with the service you receivedfrom a pharmacist or plan representative then youcould file a grievance

How do I file a grievance The grievance must be filed within 60 days after theevent or incident that caused you to be dissatisfiedA specific form is not required for you to file agrievance You or your appointed representativemay file a grievance via the phone by mail faxor in person

When will I receive a decision on my grievance The resolution of a grievance will be made asquickly as your concern requires but no more than30 calendar days after our receipt of the grievanceWe may extend the time frame by up to 14 calendardays if you request the extension or if we justify aneed for additional information and the delay is inyour best interest

If you request a written response to an oralgrievance one will be provided within 30 days afterreceipt of the grievance A written response will beprovided to all written grievances Our decision ona grievance is final and is not subject to an appeal

You have the right to an expedited review ofa grievance concerning our refusal to grant anexpedited coverage determination or expeditedappeal This type of grievance will be responded towithin 24 hours after our receipt of the grievance

Contact information

Phone 1-888-247-4142

Fax 1-888-375-8836 or 1-336-794-8836

Hours 7 days a week8 amndash8 pm

Mail BCBSNC Attn Medicare Appeals amp GrievancesPO Box 17509 Winston-Salem NC 27116-7509

In Person

BCBSNC 5660 University PkwyWinston-Salem NC 27105

PAGE 17 of 40

Important information

Quality improvement

What if I have a concern about the quality of services I received If you have a concern relating to the quality of services that you received under the Medicare Part D planthen in addition to our review you can also request review by the following organizations

The Carolinas Center for Medical Excellence (CCME) Quality Improvement Organization (QIO) in North Carolina CCME formerly known as Medical Review ofNorth Carolina Inc is a nonprofit medical carequality improvement organization CCME has beendesignated by the Centers for Medicare amp MedicaidServices as the Quality Improvement Organization(QIO) for North Carolina The QIO conducts casereviews to ensure that Medicare beneficiaries receive the quality of medical care that they expect andare entitled to CCME serves as an independentimpartial third party to review Medicare beneficiarycomplaints

Quality of care complaints filed with the QIO mustbe made in writing to the address below Assistanceis available via phone or online

The Carolinas Center for Medical Excellence (CCME)

Mail CCME 100 Regency Forest DriveSuite 200 Cary NC 27518-8598

Phone 1-919-380-9860 or 1-800-682-2650

TTYTDD 1-800-735-2962

Hours MondayndashFriday8 amndash5 pm

Web inquiries wwwccmemedicareorg

Seniorsrsquo Health Insurance Information Program (SHIIP) SHIIP is a state consumer division of the North Carolina Department of Insurance SHIIP assistssenior citizens with Medicare Medicare Part D Medicare Advantage Medicare supplementsMedicare fraud and abuse and long-term careinsurance questions Assistance is available viaphone or online

Seniorsrsquo Health Insurance Information Program (SHIIP)

Phone 1-800-443-9354

TYYTDD 1-800-735-2962

Hours MondayndashFriday8 amndash5 pm

Email ncshiipncdoigov

Online wwwncshiipcom

PAGE 18 of 40

Important information

Additional information

Notice of possible contract termination BCBSNC has a contract with the Centers for Medicare amp Medicaid Services (CMS) the government agencythat runs Medicare to provide a Medicare PrescriptionDrug Plan (PDP) This contract renews each year At theend of each year the contract is reviewed and eitherBCBSNC or CMS can decide to end it Members will get 90 days advance written notice in this situationIt is also possible for our contract to end at some othertime If the contract is going to end we will generallytell members 90 days in advance Advance notice maybe as little as 30 days or even fewer days if CMS endsour contract in the middle of the year In this noticewe would provide a written description of alternativesavailable for obtaining qualified prescription drugcoverage in North Carolina We are also required tonotify the general public of a contract termination vialocal newspapers

If BCBSNC decides to stop offering the Medicare PDPor change our service area so that it no longer includesthe area where you live membership in BCBSNCrsquosMedicare PDP will end for everyone in that servicearea and members will have to change to a differentprescription drug plan Members will continue to getprescription drugs through BCBSNCrsquos Medicare PDPuntil the contract ends

PAGE 19 of 40

Important information

For more information

Blue Cross and Blue Shield of North Carolina

Phone 1-800-478-0583

TTYTDD 1-800-922-3140

Hours 7 days a week8 amndash8 pm

Online bcbsnccommedicare

Medicare

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

TTYTDD 1-877-486-2048

Hours 7 days a week24 hours a day

Online wwwmedicaregovClick the ldquoPrescription Drug Planrdquo link

Blue Cross and Blue Shield of North Carolina is a PDP plan with a Medicare contract Enrollment in Blue Cross and Blue Shield of North Carolina depends on contract renewal Benefits formulary pharmacy network premium andor copaymentscoinsurance may change on January 1 2015 Please contact BCBSNC for details

An independent licensee of the Blue Cross and Blue Shield Association

PAGE 20 of 40

(PDP)

2014 Summary of benefits for our Medicare prescription drug plans (Enhanced and Standard)

Contract S5540 Plans 004 and 002 January 1 2014 ndash December 31 2014

U5073c 813

PAGE 21 of 40Y0079_6249 CMS Accepted 09112013

Introduction to the

Summary of benefits for (PDP)

Thank you for your interest in Blue Medicare Rx(PDP) plans Our plans are offered by Blue Crossand Blue Shield of North Carolina a MedicarePrescription Drug Plan that contracts with theFederal government This Summary of Benefits tellsyou some features of our plans It doesnrsquot list everydrug we cover every limitation or exclusionTo get a complete list of our benefits please callBlue Medicare Rx and ask for the ldquoEvidence of Coveragerdquo You have choices in your Medicare prescription drug coverage As a Medicare beneficiary you can choose fromdifferent Medicare prescription drug coverageoptions One option is to get prescription drugcoverage through a Medicare Prescription DrugPlan like Blue Medicare Rx plans Another optionis to get your prescription drug coverage througha Medicare Advantage Plan that offers prescriptiondrug coverage You make the choice How can I compare my options The charts in this booklet list some important drugbenefits You can use this Summary of Benefitsto compare the benefits offered by Blue MedicareRx plans to the benefits offered by other MedicarePrescription Drug Plans or Medicare AdvantagePlans with prescription drug coverage Where are Blue Medicare Rx Plans available The service area for these plans includesNorth Carolina You must live in one of these areas to join one of these plans Who is eligible to join You can join one of these plans if you are entitled toMedicare Part A andor enrolled in Medicare Part Band live in the service area If you are enrolled in an MA coordinated care(HMO or PPO) plan or an MA PFFS plan thatincludes Medicare prescription drugs you maynot enroll in a PDP unless you disenroll from theHMO PPO or MA PFFS plan Enrollees in a private Fee-for-Service plan (PFFS)that does not provide Medicare prescription drugcoverage or an MA Medical Savings Account (MSA)plan may enroll in a PDP Enrollees in an 1876 Costplan may enroll in a PDP

Where can I get my prescriptions Blue Medicare Rx plans have formed a network ofpharmacies You must use a network pharmacyto receive plan benefits We will not pay foryour prescriptions if you use an out-of-networkpharmacy except in certain cases Blue Medicare Rx plans have a list of preferredpharmacies At these pharmacies you may getyour drugs at a lower co-pay or coinsuranceYou may go to a non-preferred pharmacy but youmay have to pay more for your prescription drugs The pharmacies in our network can change at anytime You can ask for a Pharmacy Directory or visit usat wwwmyprimecomMyRxMyPrimeMedicareDpharmacyBCBSNC Our customer service number is listed at the end of this introduction What if my doctor prescribes less than a monthrsquos supply In consultation with your doctor or pharmacist youmay receive less than a monthrsquos supply of certaindrugs Also if you live in a long-term care facilityyou will receive less than a monthrsquos supply of certainbrand [and generic] drugs Dispensing fewer drugs ata time can help reduce cost and waste in the MedicarePart D program when this is medically appropriate The amount you pay in these circumstances willdepend on whether you are responsible for payingcoinsurance (a percentage of the cost of the drug) ora copay (a flat dollar amount for the drug) If youare responsible for coinsurance for the drug youwill continue to pay the applicable percentage ofthe drug cost If you are responsible for a copay forthe drug a ldquodaily cost-sharing raterdquo will be appliedIf your doctor decides to continue the drug after atrial period you should not pay more for a monthrsquossupply than you otherwise would have paid Contactyour plan if you have questions about cost-sharingwhen less than a one-month supply is dispensed Does my plan cover Medicare Part B or Part D drugs Blue Medicare Rx Standard and Enhanced plans donot cover drugs that are covered under Medicare PartB as prescribed and dispensed Generally we onlycover drugs vaccines biological products and medicalsupplies associated with the delivery of insulin thatare covered under the Medicare Prescription DrugBenefit (Part D) and that are on our formulary

PAG E 22 of 40

Introduction to the

Summary of benefits (continued)

What is a prescription drug formulary Blue Medicare Rx plans use a formularyA formulary is a list of drugs covered by your planto meet patient needs We may periodically addremove or make changes to coverage limitationson certain drugs or change how much you pay for adrug If we make any formulary change that limitsour membersrsquo ability to fill their prescriptions wewill notify the affected members before the changeis made We will send a formulary to you andyou can see our complete formulary on our Website at httpwwwbcbsnccomcontentmedicareformulary-homehtm If you are currently taking a drug that is not on ourformulary or subject to additional requirements orlimits you may be able to get a temporary supply ofthe drug You can contact us to request an exceptionor switch to an alternative drug listed on ourformulary with your physicianrsquos help Call us to seeif you can get a temporary supply of the drug or formore details about our drug transition policy What should I do if I have other insurance in addition to Medicare If you have a Medigap (Medicare Supplement)policy that includes prescription drug coverage youmust contact your Medigap Issuer to let them knowthat you have joined a Medicare Prescription DrugPlan If you decide to keep your current Medigapsupplement policy your Medigap Issuer willremove the prescription drug coverage portion ofyour policy Call your Medigap Issuer for details If you or your spouse has or is able to get employergroup coverage you should talk to your employerto find out how your benefits will be affected if youjoin a Blue Medicare Rx plan Get this informationbefore you decide to enroll in this plan

How can I get extra help with my prescription drug plan costs or get extra help with other Medicare costs You may be able to get extra help to pay for yourprescription drug premiums and costs as well as gethelp with other Medicare costs To see if you qualifyfor getting extra help call +1-800-MEDICARE (1-800-633-4227)

TTYTDD users should call 1-877-486-204824 hours a day7 days a week and seehttpwwwmedicaregov lsquoPrograms for Peoplewith Limited Income and Resourcesrsquo in the publication Medicare amp You

+The Social Security Administration at1-800-772-1213 between 7 am and 7 pmMonday through Friday TTYTDD usersshould call 1-800-325-0778 or

+Your State Medicaid Office What are my protections in this plan All Medicare Prescription Drug Plans agree to stayin the program for a full calendar year at a timePlan benefits and cost-sharing may change fromcalendar year to calendar year Each year plans candecide whether to continue to participate with theMedicare Prescription Drug Program A plan maycontinue in their entire service area (geographicarea where the plan accepts members) or choose tocontinue only in certain areas Also Medicare maydecide to end a contract with a plan Even if yourMedicare Prescription Plan leaves the program youwill not lose Medicare coverage If a plan decidesnot to continue for an additional calendar year itmust send you a letter at least 90 days before yourcoverage will end The letter will explain youroptions for Medicare coverage in your area As a member of a Blue Medicare Rx plan you havethe right to request a coverage determination whichincludes the right to request an exception the right tofile an appeal if we deny coverage for a prescriptiondrug and the right to file a grievance You havethe right to request a coverage determination if youwant us to cover a Part D drug that you believeshould be covered An exception is a type of coveragedetermination You may ask us for an exception ifyou believe you need a drug that is not on our list

PAG E 23 of 40

Important information

Grievance process

What is a grievance A grievance is a complaint that you may file ifyou are dissatisfied with the Plan or a contractedprovider for reasons other than a decision ona coverage determination Grievances alsoinclude complaints regarding the timelinessappropriateness access to or setting of a coveredprescription drug

Example of a grievance If you are dissatisfied with the service you receivedfrom a pharmacist or plan representative then youcould file a grievance

How do I file a grievance The grievance must be filed within 60 days after theevent or incident that caused you to be dissatisfiedA specific form is not required for you to file agrievance You or your appointed representativemay file a grievance via the phone by mail faxor in person

When will I receive a decision on my grievance The resolution of a grievance will be made asquickly as your concern requires but no more than30 calendar days after our receipt of the grievanceWe may extend the time frame by up to 14 calendardays if you request the extension or if we justify aneed for additional information and the delay is inyour best interest

If you request a written response to an oralgrievance one will be provided within 30 days afterreceipt of the grievance A written response will beprovided to all written grievances Our decision ona grievance is final and is not subject to an appeal

You have the right to an expedited review ofa grievance concerning our refusal to grant anexpedited coverage determination or expeditedappeal This type of grievance will be responded towithin 24 hours after our receipt of the grievance

Contact information

Phone 1-888-247-4142

Fax 1-888-375-8836 or 1-336-794-8836

Hours 7 days a week8 amndash8 pm

Mail BCBSNC Attn Medicare Appeals amp GrievancesPO Box 17509 Winston-Salem NC 27116-7509

In Person

BCBSNC 5660 University PkwyWinston-Salem NC 27105

PAGE 17 of 40

Important information

Quality improvement

What if I have a concern about the quality of services I received If you have a concern relating to the quality of services that you received under the Medicare Part D planthen in addition to our review you can also request review by the following organizations

The Carolinas Center for Medical Excellence (CCME) Quality Improvement Organization (QIO) in North Carolina CCME formerly known as Medical Review ofNorth Carolina Inc is a nonprofit medical carequality improvement organization CCME has beendesignated by the Centers for Medicare amp MedicaidServices as the Quality Improvement Organization(QIO) for North Carolina The QIO conducts casereviews to ensure that Medicare beneficiaries receive the quality of medical care that they expect andare entitled to CCME serves as an independentimpartial third party to review Medicare beneficiarycomplaints

Quality of care complaints filed with the QIO mustbe made in writing to the address below Assistanceis available via phone or online

The Carolinas Center for Medical Excellence (CCME)

Mail CCME 100 Regency Forest DriveSuite 200 Cary NC 27518-8598

Phone 1-919-380-9860 or 1-800-682-2650

TTYTDD 1-800-735-2962

Hours MondayndashFriday8 amndash5 pm

Web inquiries wwwccmemedicareorg

Seniorsrsquo Health Insurance Information Program (SHIIP) SHIIP is a state consumer division of the North Carolina Department of Insurance SHIIP assistssenior citizens with Medicare Medicare Part D Medicare Advantage Medicare supplementsMedicare fraud and abuse and long-term careinsurance questions Assistance is available viaphone or online

Seniorsrsquo Health Insurance Information Program (SHIIP)

Phone 1-800-443-9354

TYYTDD 1-800-735-2962

Hours MondayndashFriday8 amndash5 pm

Email ncshiipncdoigov

Online wwwncshiipcom

PAGE 18 of 40

Important information

Additional information

Notice of possible contract termination BCBSNC has a contract with the Centers for Medicare amp Medicaid Services (CMS) the government agencythat runs Medicare to provide a Medicare PrescriptionDrug Plan (PDP) This contract renews each year At theend of each year the contract is reviewed and eitherBCBSNC or CMS can decide to end it Members will get 90 days advance written notice in this situationIt is also possible for our contract to end at some othertime If the contract is going to end we will generallytell members 90 days in advance Advance notice maybe as little as 30 days or even fewer days if CMS endsour contract in the middle of the year In this noticewe would provide a written description of alternativesavailable for obtaining qualified prescription drugcoverage in North Carolina We are also required tonotify the general public of a contract termination vialocal newspapers

If BCBSNC decides to stop offering the Medicare PDPor change our service area so that it no longer includesthe area where you live membership in BCBSNCrsquosMedicare PDP will end for everyone in that servicearea and members will have to change to a differentprescription drug plan Members will continue to getprescription drugs through BCBSNCrsquos Medicare PDPuntil the contract ends

PAGE 19 of 40

Important information

For more information

Blue Cross and Blue Shield of North Carolina

Phone 1-800-478-0583

TTYTDD 1-800-922-3140

Hours 7 days a week8 amndash8 pm

Online bcbsnccommedicare

Medicare

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

TTYTDD 1-877-486-2048

Hours 7 days a week24 hours a day

Online wwwmedicaregovClick the ldquoPrescription Drug Planrdquo link

Blue Cross and Blue Shield of North Carolina is a PDP plan with a Medicare contract Enrollment in Blue Cross and Blue Shield of North Carolina depends on contract renewal Benefits formulary pharmacy network premium andor copaymentscoinsurance may change on January 1 2015 Please contact BCBSNC for details

An independent licensee of the Blue Cross and Blue Shield Association

PAGE 20 of 40

(PDP)

2014 Summary of benefits for our Medicare prescription drug plans (Enhanced and Standard)

Contract S5540 Plans 004 and 002 January 1 2014 ndash December 31 2014

U5073c 813

PAGE 21 of 40Y0079_6249 CMS Accepted 09112013

Introduction to the

Summary of benefits for (PDP)

Thank you for your interest in Blue Medicare Rx(PDP) plans Our plans are offered by Blue Crossand Blue Shield of North Carolina a MedicarePrescription Drug Plan that contracts with theFederal government This Summary of Benefits tellsyou some features of our plans It doesnrsquot list everydrug we cover every limitation or exclusionTo get a complete list of our benefits please callBlue Medicare Rx and ask for the ldquoEvidence of Coveragerdquo You have choices in your Medicare prescription drug coverage As a Medicare beneficiary you can choose fromdifferent Medicare prescription drug coverageoptions One option is to get prescription drugcoverage through a Medicare Prescription DrugPlan like Blue Medicare Rx plans Another optionis to get your prescription drug coverage througha Medicare Advantage Plan that offers prescriptiondrug coverage You make the choice How can I compare my options The charts in this booklet list some important drugbenefits You can use this Summary of Benefitsto compare the benefits offered by Blue MedicareRx plans to the benefits offered by other MedicarePrescription Drug Plans or Medicare AdvantagePlans with prescription drug coverage Where are Blue Medicare Rx Plans available The service area for these plans includesNorth Carolina You must live in one of these areas to join one of these plans Who is eligible to join You can join one of these plans if you are entitled toMedicare Part A andor enrolled in Medicare Part Band live in the service area If you are enrolled in an MA coordinated care(HMO or PPO) plan or an MA PFFS plan thatincludes Medicare prescription drugs you maynot enroll in a PDP unless you disenroll from theHMO PPO or MA PFFS plan Enrollees in a private Fee-for-Service plan (PFFS)that does not provide Medicare prescription drugcoverage or an MA Medical Savings Account (MSA)plan may enroll in a PDP Enrollees in an 1876 Costplan may enroll in a PDP

Where can I get my prescriptions Blue Medicare Rx plans have formed a network ofpharmacies You must use a network pharmacyto receive plan benefits We will not pay foryour prescriptions if you use an out-of-networkpharmacy except in certain cases Blue Medicare Rx plans have a list of preferredpharmacies At these pharmacies you may getyour drugs at a lower co-pay or coinsuranceYou may go to a non-preferred pharmacy but youmay have to pay more for your prescription drugs The pharmacies in our network can change at anytime You can ask for a Pharmacy Directory or visit usat wwwmyprimecomMyRxMyPrimeMedicareDpharmacyBCBSNC Our customer service number is listed at the end of this introduction What if my doctor prescribes less than a monthrsquos supply In consultation with your doctor or pharmacist youmay receive less than a monthrsquos supply of certaindrugs Also if you live in a long-term care facilityyou will receive less than a monthrsquos supply of certainbrand [and generic] drugs Dispensing fewer drugs ata time can help reduce cost and waste in the MedicarePart D program when this is medically appropriate The amount you pay in these circumstances willdepend on whether you are responsible for payingcoinsurance (a percentage of the cost of the drug) ora copay (a flat dollar amount for the drug) If youare responsible for coinsurance for the drug youwill continue to pay the applicable percentage ofthe drug cost If you are responsible for a copay forthe drug a ldquodaily cost-sharing raterdquo will be appliedIf your doctor decides to continue the drug after atrial period you should not pay more for a monthrsquossupply than you otherwise would have paid Contactyour plan if you have questions about cost-sharingwhen less than a one-month supply is dispensed Does my plan cover Medicare Part B or Part D drugs Blue Medicare Rx Standard and Enhanced plans donot cover drugs that are covered under Medicare PartB as prescribed and dispensed Generally we onlycover drugs vaccines biological products and medicalsupplies associated with the delivery of insulin thatare covered under the Medicare Prescription DrugBenefit (Part D) and that are on our formulary

PAG E 22 of 40

Introduction to the

Summary of benefits (continued)

What is a prescription drug formulary Blue Medicare Rx plans use a formularyA formulary is a list of drugs covered by your planto meet patient needs We may periodically addremove or make changes to coverage limitationson certain drugs or change how much you pay for adrug If we make any formulary change that limitsour membersrsquo ability to fill their prescriptions wewill notify the affected members before the changeis made We will send a formulary to you andyou can see our complete formulary on our Website at httpwwwbcbsnccomcontentmedicareformulary-homehtm If you are currently taking a drug that is not on ourformulary or subject to additional requirements orlimits you may be able to get a temporary supply ofthe drug You can contact us to request an exceptionor switch to an alternative drug listed on ourformulary with your physicianrsquos help Call us to seeif you can get a temporary supply of the drug or formore details about our drug transition policy What should I do if I have other insurance in addition to Medicare If you have a Medigap (Medicare Supplement)policy that includes prescription drug coverage youmust contact your Medigap Issuer to let them knowthat you have joined a Medicare Prescription DrugPlan If you decide to keep your current Medigapsupplement policy your Medigap Issuer willremove the prescription drug coverage portion ofyour policy Call your Medigap Issuer for details If you or your spouse has or is able to get employergroup coverage you should talk to your employerto find out how your benefits will be affected if youjoin a Blue Medicare Rx plan Get this informationbefore you decide to enroll in this plan

How can I get extra help with my prescription drug plan costs or get extra help with other Medicare costs You may be able to get extra help to pay for yourprescription drug premiums and costs as well as gethelp with other Medicare costs To see if you qualifyfor getting extra help call +1-800-MEDICARE (1-800-633-4227)

TTYTDD users should call 1-877-486-204824 hours a day7 days a week and seehttpwwwmedicaregov lsquoPrograms for Peoplewith Limited Income and Resourcesrsquo in the publication Medicare amp You

+The Social Security Administration at1-800-772-1213 between 7 am and 7 pmMonday through Friday TTYTDD usersshould call 1-800-325-0778 or

+Your State Medicaid Office What are my protections in this plan All Medicare Prescription Drug Plans agree to stayin the program for a full calendar year at a timePlan benefits and cost-sharing may change fromcalendar year to calendar year Each year plans candecide whether to continue to participate with theMedicare Prescription Drug Program A plan maycontinue in their entire service area (geographicarea where the plan accepts members) or choose tocontinue only in certain areas Also Medicare maydecide to end a contract with a plan Even if yourMedicare Prescription Plan leaves the program youwill not lose Medicare coverage If a plan decidesnot to continue for an additional calendar year itmust send you a letter at least 90 days before yourcoverage will end The letter will explain youroptions for Medicare coverage in your area As a member of a Blue Medicare Rx plan you havethe right to request a coverage determination whichincludes the right to request an exception the right tofile an appeal if we deny coverage for a prescriptiondrug and the right to file a grievance You havethe right to request a coverage determination if youwant us to cover a Part D drug that you believeshould be covered An exception is a type of coveragedetermination You may ask us for an exception ifyou believe you need a drug that is not on our list

PAG E 23 of 40

Important information

Quality improvement

What if I have a concern about the quality of services I received If you have a concern relating to the quality of services that you received under the Medicare Part D planthen in addition to our review you can also request review by the following organizations

The Carolinas Center for Medical Excellence (CCME) Quality Improvement Organization (QIO) in North Carolina CCME formerly known as Medical Review ofNorth Carolina Inc is a nonprofit medical carequality improvement organization CCME has beendesignated by the Centers for Medicare amp MedicaidServices as the Quality Improvement Organization(QIO) for North Carolina The QIO conducts casereviews to ensure that Medicare beneficiaries receive the quality of medical care that they expect andare entitled to CCME serves as an independentimpartial third party to review Medicare beneficiarycomplaints

Quality of care complaints filed with the QIO mustbe made in writing to the address below Assistanceis available via phone or online

The Carolinas Center for Medical Excellence (CCME)

Mail CCME 100 Regency Forest DriveSuite 200 Cary NC 27518-8598

Phone 1-919-380-9860 or 1-800-682-2650

TTYTDD 1-800-735-2962

Hours MondayndashFriday8 amndash5 pm

Web inquiries wwwccmemedicareorg

Seniorsrsquo Health Insurance Information Program (SHIIP) SHIIP is a state consumer division of the North Carolina Department of Insurance SHIIP assistssenior citizens with Medicare Medicare Part D Medicare Advantage Medicare supplementsMedicare fraud and abuse and long-term careinsurance questions Assistance is available viaphone or online

Seniorsrsquo Health Insurance Information Program (SHIIP)

Phone 1-800-443-9354

TYYTDD 1-800-735-2962

Hours MondayndashFriday8 amndash5 pm

Email ncshiipncdoigov

Online wwwncshiipcom

PAGE 18 of 40

Important information

Additional information

Notice of possible contract termination BCBSNC has a contract with the Centers for Medicare amp Medicaid Services (CMS) the government agencythat runs Medicare to provide a Medicare PrescriptionDrug Plan (PDP) This contract renews each year At theend of each year the contract is reviewed and eitherBCBSNC or CMS can decide to end it Members will get 90 days advance written notice in this situationIt is also possible for our contract to end at some othertime If the contract is going to end we will generallytell members 90 days in advance Advance notice maybe as little as 30 days or even fewer days if CMS endsour contract in the middle of the year In this noticewe would provide a written description of alternativesavailable for obtaining qualified prescription drugcoverage in North Carolina We are also required tonotify the general public of a contract termination vialocal newspapers

If BCBSNC decides to stop offering the Medicare PDPor change our service area so that it no longer includesthe area where you live membership in BCBSNCrsquosMedicare PDP will end for everyone in that servicearea and members will have to change to a differentprescription drug plan Members will continue to getprescription drugs through BCBSNCrsquos Medicare PDPuntil the contract ends

PAGE 19 of 40

Important information

For more information

Blue Cross and Blue Shield of North Carolina

Phone 1-800-478-0583

TTYTDD 1-800-922-3140

Hours 7 days a week8 amndash8 pm

Online bcbsnccommedicare

Medicare

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

TTYTDD 1-877-486-2048

Hours 7 days a week24 hours a day

Online wwwmedicaregovClick the ldquoPrescription Drug Planrdquo link

Blue Cross and Blue Shield of North Carolina is a PDP plan with a Medicare contract Enrollment in Blue Cross and Blue Shield of North Carolina depends on contract renewal Benefits formulary pharmacy network premium andor copaymentscoinsurance may change on January 1 2015 Please contact BCBSNC for details

An independent licensee of the Blue Cross and Blue Shield Association

PAGE 20 of 40

(PDP)

2014 Summary of benefits for our Medicare prescription drug plans (Enhanced and Standard)

Contract S5540 Plans 004 and 002 January 1 2014 ndash December 31 2014

U5073c 813

PAGE 21 of 40Y0079_6249 CMS Accepted 09112013

Introduction to the

Summary of benefits for (PDP)

Thank you for your interest in Blue Medicare Rx(PDP) plans Our plans are offered by Blue Crossand Blue Shield of North Carolina a MedicarePrescription Drug Plan that contracts with theFederal government This Summary of Benefits tellsyou some features of our plans It doesnrsquot list everydrug we cover every limitation or exclusionTo get a complete list of our benefits please callBlue Medicare Rx and ask for the ldquoEvidence of Coveragerdquo You have choices in your Medicare prescription drug coverage As a Medicare beneficiary you can choose fromdifferent Medicare prescription drug coverageoptions One option is to get prescription drugcoverage through a Medicare Prescription DrugPlan like Blue Medicare Rx plans Another optionis to get your prescription drug coverage througha Medicare Advantage Plan that offers prescriptiondrug coverage You make the choice How can I compare my options The charts in this booklet list some important drugbenefits You can use this Summary of Benefitsto compare the benefits offered by Blue MedicareRx plans to the benefits offered by other MedicarePrescription Drug Plans or Medicare AdvantagePlans with prescription drug coverage Where are Blue Medicare Rx Plans available The service area for these plans includesNorth Carolina You must live in one of these areas to join one of these plans Who is eligible to join You can join one of these plans if you are entitled toMedicare Part A andor enrolled in Medicare Part Band live in the service area If you are enrolled in an MA coordinated care(HMO or PPO) plan or an MA PFFS plan thatincludes Medicare prescription drugs you maynot enroll in a PDP unless you disenroll from theHMO PPO or MA PFFS plan Enrollees in a private Fee-for-Service plan (PFFS)that does not provide Medicare prescription drugcoverage or an MA Medical Savings Account (MSA)plan may enroll in a PDP Enrollees in an 1876 Costplan may enroll in a PDP

Where can I get my prescriptions Blue Medicare Rx plans have formed a network ofpharmacies You must use a network pharmacyto receive plan benefits We will not pay foryour prescriptions if you use an out-of-networkpharmacy except in certain cases Blue Medicare Rx plans have a list of preferredpharmacies At these pharmacies you may getyour drugs at a lower co-pay or coinsuranceYou may go to a non-preferred pharmacy but youmay have to pay more for your prescription drugs The pharmacies in our network can change at anytime You can ask for a Pharmacy Directory or visit usat wwwmyprimecomMyRxMyPrimeMedicareDpharmacyBCBSNC Our customer service number is listed at the end of this introduction What if my doctor prescribes less than a monthrsquos supply In consultation with your doctor or pharmacist youmay receive less than a monthrsquos supply of certaindrugs Also if you live in a long-term care facilityyou will receive less than a monthrsquos supply of certainbrand [and generic] drugs Dispensing fewer drugs ata time can help reduce cost and waste in the MedicarePart D program when this is medically appropriate The amount you pay in these circumstances willdepend on whether you are responsible for payingcoinsurance (a percentage of the cost of the drug) ora copay (a flat dollar amount for the drug) If youare responsible for coinsurance for the drug youwill continue to pay the applicable percentage ofthe drug cost If you are responsible for a copay forthe drug a ldquodaily cost-sharing raterdquo will be appliedIf your doctor decides to continue the drug after atrial period you should not pay more for a monthrsquossupply than you otherwise would have paid Contactyour plan if you have questions about cost-sharingwhen less than a one-month supply is dispensed Does my plan cover Medicare Part B or Part D drugs Blue Medicare Rx Standard and Enhanced plans donot cover drugs that are covered under Medicare PartB as prescribed and dispensed Generally we onlycover drugs vaccines biological products and medicalsupplies associated with the delivery of insulin thatare covered under the Medicare Prescription DrugBenefit (Part D) and that are on our formulary

PAG E 22 of 40

Introduction to the

Summary of benefits (continued)

What is a prescription drug formulary Blue Medicare Rx plans use a formularyA formulary is a list of drugs covered by your planto meet patient needs We may periodically addremove or make changes to coverage limitationson certain drugs or change how much you pay for adrug If we make any formulary change that limitsour membersrsquo ability to fill their prescriptions wewill notify the affected members before the changeis made We will send a formulary to you andyou can see our complete formulary on our Website at httpwwwbcbsnccomcontentmedicareformulary-homehtm If you are currently taking a drug that is not on ourformulary or subject to additional requirements orlimits you may be able to get a temporary supply ofthe drug You can contact us to request an exceptionor switch to an alternative drug listed on ourformulary with your physicianrsquos help Call us to seeif you can get a temporary supply of the drug or formore details about our drug transition policy What should I do if I have other insurance in addition to Medicare If you have a Medigap (Medicare Supplement)policy that includes prescription drug coverage youmust contact your Medigap Issuer to let them knowthat you have joined a Medicare Prescription DrugPlan If you decide to keep your current Medigapsupplement policy your Medigap Issuer willremove the prescription drug coverage portion ofyour policy Call your Medigap Issuer for details If you or your spouse has or is able to get employergroup coverage you should talk to your employerto find out how your benefits will be affected if youjoin a Blue Medicare Rx plan Get this informationbefore you decide to enroll in this plan

How can I get extra help with my prescription drug plan costs or get extra help with other Medicare costs You may be able to get extra help to pay for yourprescription drug premiums and costs as well as gethelp with other Medicare costs To see if you qualifyfor getting extra help call +1-800-MEDICARE (1-800-633-4227)

TTYTDD users should call 1-877-486-204824 hours a day7 days a week and seehttpwwwmedicaregov lsquoPrograms for Peoplewith Limited Income and Resourcesrsquo in the publication Medicare amp You

+The Social Security Administration at1-800-772-1213 between 7 am and 7 pmMonday through Friday TTYTDD usersshould call 1-800-325-0778 or

+Your State Medicaid Office What are my protections in this plan All Medicare Prescription Drug Plans agree to stayin the program for a full calendar year at a timePlan benefits and cost-sharing may change fromcalendar year to calendar year Each year plans candecide whether to continue to participate with theMedicare Prescription Drug Program A plan maycontinue in their entire service area (geographicarea where the plan accepts members) or choose tocontinue only in certain areas Also Medicare maydecide to end a contract with a plan Even if yourMedicare Prescription Plan leaves the program youwill not lose Medicare coverage If a plan decidesnot to continue for an additional calendar year itmust send you a letter at least 90 days before yourcoverage will end The letter will explain youroptions for Medicare coverage in your area As a member of a Blue Medicare Rx plan you havethe right to request a coverage determination whichincludes the right to request an exception the right tofile an appeal if we deny coverage for a prescriptiondrug and the right to file a grievance You havethe right to request a coverage determination if youwant us to cover a Part D drug that you believeshould be covered An exception is a type of coveragedetermination You may ask us for an exception ifyou believe you need a drug that is not on our list

PAG E 23 of 40

Important information

Additional information

Notice of possible contract termination BCBSNC has a contract with the Centers for Medicare amp Medicaid Services (CMS) the government agencythat runs Medicare to provide a Medicare PrescriptionDrug Plan (PDP) This contract renews each year At theend of each year the contract is reviewed and eitherBCBSNC or CMS can decide to end it Members will get 90 days advance written notice in this situationIt is also possible for our contract to end at some othertime If the contract is going to end we will generallytell members 90 days in advance Advance notice maybe as little as 30 days or even fewer days if CMS endsour contract in the middle of the year In this noticewe would provide a written description of alternativesavailable for obtaining qualified prescription drugcoverage in North Carolina We are also required tonotify the general public of a contract termination vialocal newspapers

If BCBSNC decides to stop offering the Medicare PDPor change our service area so that it no longer includesthe area where you live membership in BCBSNCrsquosMedicare PDP will end for everyone in that servicearea and members will have to change to a differentprescription drug plan Members will continue to getprescription drugs through BCBSNCrsquos Medicare PDPuntil the contract ends

PAGE 19 of 40

Important information

For more information

Blue Cross and Blue Shield of North Carolina

Phone 1-800-478-0583

TTYTDD 1-800-922-3140

Hours 7 days a week8 amndash8 pm

Online bcbsnccommedicare

Medicare

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

TTYTDD 1-877-486-2048

Hours 7 days a week24 hours a day

Online wwwmedicaregovClick the ldquoPrescription Drug Planrdquo link

Blue Cross and Blue Shield of North Carolina is a PDP plan with a Medicare contract Enrollment in Blue Cross and Blue Shield of North Carolina depends on contract renewal Benefits formulary pharmacy network premium andor copaymentscoinsurance may change on January 1 2015 Please contact BCBSNC for details

An independent licensee of the Blue Cross and Blue Shield Association

PAGE 20 of 40

(PDP)

2014 Summary of benefits for our Medicare prescription drug plans (Enhanced and Standard)

Contract S5540 Plans 004 and 002 January 1 2014 ndash December 31 2014

U5073c 813

PAGE 21 of 40Y0079_6249 CMS Accepted 09112013

Introduction to the

Summary of benefits for (PDP)

Thank you for your interest in Blue Medicare Rx(PDP) plans Our plans are offered by Blue Crossand Blue Shield of North Carolina a MedicarePrescription Drug Plan that contracts with theFederal government This Summary of Benefits tellsyou some features of our plans It doesnrsquot list everydrug we cover every limitation or exclusionTo get a complete list of our benefits please callBlue Medicare Rx and ask for the ldquoEvidence of Coveragerdquo You have choices in your Medicare prescription drug coverage As a Medicare beneficiary you can choose fromdifferent Medicare prescription drug coverageoptions One option is to get prescription drugcoverage through a Medicare Prescription DrugPlan like Blue Medicare Rx plans Another optionis to get your prescription drug coverage througha Medicare Advantage Plan that offers prescriptiondrug coverage You make the choice How can I compare my options The charts in this booklet list some important drugbenefits You can use this Summary of Benefitsto compare the benefits offered by Blue MedicareRx plans to the benefits offered by other MedicarePrescription Drug Plans or Medicare AdvantagePlans with prescription drug coverage Where are Blue Medicare Rx Plans available The service area for these plans includesNorth Carolina You must live in one of these areas to join one of these plans Who is eligible to join You can join one of these plans if you are entitled toMedicare Part A andor enrolled in Medicare Part Band live in the service area If you are enrolled in an MA coordinated care(HMO or PPO) plan or an MA PFFS plan thatincludes Medicare prescription drugs you maynot enroll in a PDP unless you disenroll from theHMO PPO or MA PFFS plan Enrollees in a private Fee-for-Service plan (PFFS)that does not provide Medicare prescription drugcoverage or an MA Medical Savings Account (MSA)plan may enroll in a PDP Enrollees in an 1876 Costplan may enroll in a PDP

Where can I get my prescriptions Blue Medicare Rx plans have formed a network ofpharmacies You must use a network pharmacyto receive plan benefits We will not pay foryour prescriptions if you use an out-of-networkpharmacy except in certain cases Blue Medicare Rx plans have a list of preferredpharmacies At these pharmacies you may getyour drugs at a lower co-pay or coinsuranceYou may go to a non-preferred pharmacy but youmay have to pay more for your prescription drugs The pharmacies in our network can change at anytime You can ask for a Pharmacy Directory or visit usat wwwmyprimecomMyRxMyPrimeMedicareDpharmacyBCBSNC Our customer service number is listed at the end of this introduction What if my doctor prescribes less than a monthrsquos supply In consultation with your doctor or pharmacist youmay receive less than a monthrsquos supply of certaindrugs Also if you live in a long-term care facilityyou will receive less than a monthrsquos supply of certainbrand [and generic] drugs Dispensing fewer drugs ata time can help reduce cost and waste in the MedicarePart D program when this is medically appropriate The amount you pay in these circumstances willdepend on whether you are responsible for payingcoinsurance (a percentage of the cost of the drug) ora copay (a flat dollar amount for the drug) If youare responsible for coinsurance for the drug youwill continue to pay the applicable percentage ofthe drug cost If you are responsible for a copay forthe drug a ldquodaily cost-sharing raterdquo will be appliedIf your doctor decides to continue the drug after atrial period you should not pay more for a monthrsquossupply than you otherwise would have paid Contactyour plan if you have questions about cost-sharingwhen less than a one-month supply is dispensed Does my plan cover Medicare Part B or Part D drugs Blue Medicare Rx Standard and Enhanced plans donot cover drugs that are covered under Medicare PartB as prescribed and dispensed Generally we onlycover drugs vaccines biological products and medicalsupplies associated with the delivery of insulin thatare covered under the Medicare Prescription DrugBenefit (Part D) and that are on our formulary

PAG E 22 of 40

Introduction to the

Summary of benefits (continued)

What is a prescription drug formulary Blue Medicare Rx plans use a formularyA formulary is a list of drugs covered by your planto meet patient needs We may periodically addremove or make changes to coverage limitationson certain drugs or change how much you pay for adrug If we make any formulary change that limitsour membersrsquo ability to fill their prescriptions wewill notify the affected members before the changeis made We will send a formulary to you andyou can see our complete formulary on our Website at httpwwwbcbsnccomcontentmedicareformulary-homehtm If you are currently taking a drug that is not on ourformulary or subject to additional requirements orlimits you may be able to get a temporary supply ofthe drug You can contact us to request an exceptionor switch to an alternative drug listed on ourformulary with your physicianrsquos help Call us to seeif you can get a temporary supply of the drug or formore details about our drug transition policy What should I do if I have other insurance in addition to Medicare If you have a Medigap (Medicare Supplement)policy that includes prescription drug coverage youmust contact your Medigap Issuer to let them knowthat you have joined a Medicare Prescription DrugPlan If you decide to keep your current Medigapsupplement policy your Medigap Issuer willremove the prescription drug coverage portion ofyour policy Call your Medigap Issuer for details If you or your spouse has or is able to get employergroup coverage you should talk to your employerto find out how your benefits will be affected if youjoin a Blue Medicare Rx plan Get this informationbefore you decide to enroll in this plan

How can I get extra help with my prescription drug plan costs or get extra help with other Medicare costs You may be able to get extra help to pay for yourprescription drug premiums and costs as well as gethelp with other Medicare costs To see if you qualifyfor getting extra help call +1-800-MEDICARE (1-800-633-4227)

TTYTDD users should call 1-877-486-204824 hours a day7 days a week and seehttpwwwmedicaregov lsquoPrograms for Peoplewith Limited Income and Resourcesrsquo in the publication Medicare amp You

+The Social Security Administration at1-800-772-1213 between 7 am and 7 pmMonday through Friday TTYTDD usersshould call 1-800-325-0778 or

+Your State Medicaid Office What are my protections in this plan All Medicare Prescription Drug Plans agree to stayin the program for a full calendar year at a timePlan benefits and cost-sharing may change fromcalendar year to calendar year Each year plans candecide whether to continue to participate with theMedicare Prescription Drug Program A plan maycontinue in their entire service area (geographicarea where the plan accepts members) or choose tocontinue only in certain areas Also Medicare maydecide to end a contract with a plan Even if yourMedicare Prescription Plan leaves the program youwill not lose Medicare coverage If a plan decidesnot to continue for an additional calendar year itmust send you a letter at least 90 days before yourcoverage will end The letter will explain youroptions for Medicare coverage in your area As a member of a Blue Medicare Rx plan you havethe right to request a coverage determination whichincludes the right to request an exception the right tofile an appeal if we deny coverage for a prescriptiondrug and the right to file a grievance You havethe right to request a coverage determination if youwant us to cover a Part D drug that you believeshould be covered An exception is a type of coveragedetermination You may ask us for an exception ifyou believe you need a drug that is not on our list

PAG E 23 of 40

Important information

For more information

Blue Cross and Blue Shield of North Carolina

Phone 1-800-478-0583

TTYTDD 1-800-922-3140

Hours 7 days a week8 amndash8 pm

Online bcbsnccommedicare

Medicare

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

TTYTDD 1-877-486-2048

Hours 7 days a week24 hours a day

Online wwwmedicaregovClick the ldquoPrescription Drug Planrdquo link

Blue Cross and Blue Shield of North Carolina is a PDP plan with a Medicare contract Enrollment in Blue Cross and Blue Shield of North Carolina depends on contract renewal Benefits formulary pharmacy network premium andor copaymentscoinsurance may change on January 1 2015 Please contact BCBSNC for details

An independent licensee of the Blue Cross and Blue Shield Association

PAGE 20 of 40

(PDP)

2014 Summary of benefits for our Medicare prescription drug plans (Enhanced and Standard)

Contract S5540 Plans 004 and 002 January 1 2014 ndash December 31 2014

U5073c 813

PAGE 21 of 40Y0079_6249 CMS Accepted 09112013

Introduction to the

Summary of benefits for (PDP)

Thank you for your interest in Blue Medicare Rx(PDP) plans Our plans are offered by Blue Crossand Blue Shield of North Carolina a MedicarePrescription Drug Plan that contracts with theFederal government This Summary of Benefits tellsyou some features of our plans It doesnrsquot list everydrug we cover every limitation or exclusionTo get a complete list of our benefits please callBlue Medicare Rx and ask for the ldquoEvidence of Coveragerdquo You have choices in your Medicare prescription drug coverage As a Medicare beneficiary you can choose fromdifferent Medicare prescription drug coverageoptions One option is to get prescription drugcoverage through a Medicare Prescription DrugPlan like Blue Medicare Rx plans Another optionis to get your prescription drug coverage througha Medicare Advantage Plan that offers prescriptiondrug coverage You make the choice How can I compare my options The charts in this booklet list some important drugbenefits You can use this Summary of Benefitsto compare the benefits offered by Blue MedicareRx plans to the benefits offered by other MedicarePrescription Drug Plans or Medicare AdvantagePlans with prescription drug coverage Where are Blue Medicare Rx Plans available The service area for these plans includesNorth Carolina You must live in one of these areas to join one of these plans Who is eligible to join You can join one of these plans if you are entitled toMedicare Part A andor enrolled in Medicare Part Band live in the service area If you are enrolled in an MA coordinated care(HMO or PPO) plan or an MA PFFS plan thatincludes Medicare prescription drugs you maynot enroll in a PDP unless you disenroll from theHMO PPO or MA PFFS plan Enrollees in a private Fee-for-Service plan (PFFS)that does not provide Medicare prescription drugcoverage or an MA Medical Savings Account (MSA)plan may enroll in a PDP Enrollees in an 1876 Costplan may enroll in a PDP

Where can I get my prescriptions Blue Medicare Rx plans have formed a network ofpharmacies You must use a network pharmacyto receive plan benefits We will not pay foryour prescriptions if you use an out-of-networkpharmacy except in certain cases Blue Medicare Rx plans have a list of preferredpharmacies At these pharmacies you may getyour drugs at a lower co-pay or coinsuranceYou may go to a non-preferred pharmacy but youmay have to pay more for your prescription drugs The pharmacies in our network can change at anytime You can ask for a Pharmacy Directory or visit usat wwwmyprimecomMyRxMyPrimeMedicareDpharmacyBCBSNC Our customer service number is listed at the end of this introduction What if my doctor prescribes less than a monthrsquos supply In consultation with your doctor or pharmacist youmay receive less than a monthrsquos supply of certaindrugs Also if you live in a long-term care facilityyou will receive less than a monthrsquos supply of certainbrand [and generic] drugs Dispensing fewer drugs ata time can help reduce cost and waste in the MedicarePart D program when this is medically appropriate The amount you pay in these circumstances willdepend on whether you are responsible for payingcoinsurance (a percentage of the cost of the drug) ora copay (a flat dollar amount for the drug) If youare responsible for coinsurance for the drug youwill continue to pay the applicable percentage ofthe drug cost If you are responsible for a copay forthe drug a ldquodaily cost-sharing raterdquo will be appliedIf your doctor decides to continue the drug after atrial period you should not pay more for a monthrsquossupply than you otherwise would have paid Contactyour plan if you have questions about cost-sharingwhen less than a one-month supply is dispensed Does my plan cover Medicare Part B or Part D drugs Blue Medicare Rx Standard and Enhanced plans donot cover drugs that are covered under Medicare PartB as prescribed and dispensed Generally we onlycover drugs vaccines biological products and medicalsupplies associated with the delivery of insulin thatare covered under the Medicare Prescription DrugBenefit (Part D) and that are on our formulary

PAG E 22 of 40

Introduction to the

Summary of benefits (continued)

What is a prescription drug formulary Blue Medicare Rx plans use a formularyA formulary is a list of drugs covered by your planto meet patient needs We may periodically addremove or make changes to coverage limitationson certain drugs or change how much you pay for adrug If we make any formulary change that limitsour membersrsquo ability to fill their prescriptions wewill notify the affected members before the changeis made We will send a formulary to you andyou can see our complete formulary on our Website at httpwwwbcbsnccomcontentmedicareformulary-homehtm If you are currently taking a drug that is not on ourformulary or subject to additional requirements orlimits you may be able to get a temporary supply ofthe drug You can contact us to request an exceptionor switch to an alternative drug listed on ourformulary with your physicianrsquos help Call us to seeif you can get a temporary supply of the drug or formore details about our drug transition policy What should I do if I have other insurance in addition to Medicare If you have a Medigap (Medicare Supplement)policy that includes prescription drug coverage youmust contact your Medigap Issuer to let them knowthat you have joined a Medicare Prescription DrugPlan If you decide to keep your current Medigapsupplement policy your Medigap Issuer willremove the prescription drug coverage portion ofyour policy Call your Medigap Issuer for details If you or your spouse has or is able to get employergroup coverage you should talk to your employerto find out how your benefits will be affected if youjoin a Blue Medicare Rx plan Get this informationbefore you decide to enroll in this plan

How can I get extra help with my prescription drug plan costs or get extra help with other Medicare costs You may be able to get extra help to pay for yourprescription drug premiums and costs as well as gethelp with other Medicare costs To see if you qualifyfor getting extra help call +1-800-MEDICARE (1-800-633-4227)

TTYTDD users should call 1-877-486-204824 hours a day7 days a week and seehttpwwwmedicaregov lsquoPrograms for Peoplewith Limited Income and Resourcesrsquo in the publication Medicare amp You

+The Social Security Administration at1-800-772-1213 between 7 am and 7 pmMonday through Friday TTYTDD usersshould call 1-800-325-0778 or

+Your State Medicaid Office What are my protections in this plan All Medicare Prescription Drug Plans agree to stayin the program for a full calendar year at a timePlan benefits and cost-sharing may change fromcalendar year to calendar year Each year plans candecide whether to continue to participate with theMedicare Prescription Drug Program A plan maycontinue in their entire service area (geographicarea where the plan accepts members) or choose tocontinue only in certain areas Also Medicare maydecide to end a contract with a plan Even if yourMedicare Prescription Plan leaves the program youwill not lose Medicare coverage If a plan decidesnot to continue for an additional calendar year itmust send you a letter at least 90 days before yourcoverage will end The letter will explain youroptions for Medicare coverage in your area As a member of a Blue Medicare Rx plan you havethe right to request a coverage determination whichincludes the right to request an exception the right tofile an appeal if we deny coverage for a prescriptiondrug and the right to file a grievance You havethe right to request a coverage determination if youwant us to cover a Part D drug that you believeshould be covered An exception is a type of coveragedetermination You may ask us for an exception ifyou believe you need a drug that is not on our list

PAG E 23 of 40

(PDP)

2014 Summary of benefits for our Medicare prescription drug plans (Enhanced and Standard)

Contract S5540 Plans 004 and 002 January 1 2014 ndash December 31 2014

U5073c 813

PAGE 21 of 40Y0079_6249 CMS Accepted 09112013

Introduction to the

Summary of benefits for (PDP)

Thank you for your interest in Blue Medicare Rx(PDP) plans Our plans are offered by Blue Crossand Blue Shield of North Carolina a MedicarePrescription Drug Plan that contracts with theFederal government This Summary of Benefits tellsyou some features of our plans It doesnrsquot list everydrug we cover every limitation or exclusionTo get a complete list of our benefits please callBlue Medicare Rx and ask for the ldquoEvidence of Coveragerdquo You have choices in your Medicare prescription drug coverage As a Medicare beneficiary you can choose fromdifferent Medicare prescription drug coverageoptions One option is to get prescription drugcoverage through a Medicare Prescription DrugPlan like Blue Medicare Rx plans Another optionis to get your prescription drug coverage througha Medicare Advantage Plan that offers prescriptiondrug coverage You make the choice How can I compare my options The charts in this booklet list some important drugbenefits You can use this Summary of Benefitsto compare the benefits offered by Blue MedicareRx plans to the benefits offered by other MedicarePrescription Drug Plans or Medicare AdvantagePlans with prescription drug coverage Where are Blue Medicare Rx Plans available The service area for these plans includesNorth Carolina You must live in one of these areas to join one of these plans Who is eligible to join You can join one of these plans if you are entitled toMedicare Part A andor enrolled in Medicare Part Band live in the service area If you are enrolled in an MA coordinated care(HMO or PPO) plan or an MA PFFS plan thatincludes Medicare prescription drugs you maynot enroll in a PDP unless you disenroll from theHMO PPO or MA PFFS plan Enrollees in a private Fee-for-Service plan (PFFS)that does not provide Medicare prescription drugcoverage or an MA Medical Savings Account (MSA)plan may enroll in a PDP Enrollees in an 1876 Costplan may enroll in a PDP

Where can I get my prescriptions Blue Medicare Rx plans have formed a network ofpharmacies You must use a network pharmacyto receive plan benefits We will not pay foryour prescriptions if you use an out-of-networkpharmacy except in certain cases Blue Medicare Rx plans have a list of preferredpharmacies At these pharmacies you may getyour drugs at a lower co-pay or coinsuranceYou may go to a non-preferred pharmacy but youmay have to pay more for your prescription drugs The pharmacies in our network can change at anytime You can ask for a Pharmacy Directory or visit usat wwwmyprimecomMyRxMyPrimeMedicareDpharmacyBCBSNC Our customer service number is listed at the end of this introduction What if my doctor prescribes less than a monthrsquos supply In consultation with your doctor or pharmacist youmay receive less than a monthrsquos supply of certaindrugs Also if you live in a long-term care facilityyou will receive less than a monthrsquos supply of certainbrand [and generic] drugs Dispensing fewer drugs ata time can help reduce cost and waste in the MedicarePart D program when this is medically appropriate The amount you pay in these circumstances willdepend on whether you are responsible for payingcoinsurance (a percentage of the cost of the drug) ora copay (a flat dollar amount for the drug) If youare responsible for coinsurance for the drug youwill continue to pay the applicable percentage ofthe drug cost If you are responsible for a copay forthe drug a ldquodaily cost-sharing raterdquo will be appliedIf your doctor decides to continue the drug after atrial period you should not pay more for a monthrsquossupply than you otherwise would have paid Contactyour plan if you have questions about cost-sharingwhen less than a one-month supply is dispensed Does my plan cover Medicare Part B or Part D drugs Blue Medicare Rx Standard and Enhanced plans donot cover drugs that are covered under Medicare PartB as prescribed and dispensed Generally we onlycover drugs vaccines biological products and medicalsupplies associated with the delivery of insulin thatare covered under the Medicare Prescription DrugBenefit (Part D) and that are on our formulary

PAG E 22 of 40

Introduction to the

Summary of benefits (continued)

What is a prescription drug formulary Blue Medicare Rx plans use a formularyA formulary is a list of drugs covered by your planto meet patient needs We may periodically addremove or make changes to coverage limitationson certain drugs or change how much you pay for adrug If we make any formulary change that limitsour membersrsquo ability to fill their prescriptions wewill notify the affected members before the changeis made We will send a formulary to you andyou can see our complete formulary on our Website at httpwwwbcbsnccomcontentmedicareformulary-homehtm If you are currently taking a drug that is not on ourformulary or subject to additional requirements orlimits you may be able to get a temporary supply ofthe drug You can contact us to request an exceptionor switch to an alternative drug listed on ourformulary with your physicianrsquos help Call us to seeif you can get a temporary supply of the drug or formore details about our drug transition policy What should I do if I have other insurance in addition to Medicare If you have a Medigap (Medicare Supplement)policy that includes prescription drug coverage youmust contact your Medigap Issuer to let them knowthat you have joined a Medicare Prescription DrugPlan If you decide to keep your current Medigapsupplement policy your Medigap Issuer willremove the prescription drug coverage portion ofyour policy Call your Medigap Issuer for details If you or your spouse has or is able to get employergroup coverage you should talk to your employerto find out how your benefits will be affected if youjoin a Blue Medicare Rx plan Get this informationbefore you decide to enroll in this plan

How can I get extra help with my prescription drug plan costs or get extra help with other Medicare costs You may be able to get extra help to pay for yourprescription drug premiums and costs as well as gethelp with other Medicare costs To see if you qualifyfor getting extra help call +1-800-MEDICARE (1-800-633-4227)

TTYTDD users should call 1-877-486-204824 hours a day7 days a week and seehttpwwwmedicaregov lsquoPrograms for Peoplewith Limited Income and Resourcesrsquo in the publication Medicare amp You

+The Social Security Administration at1-800-772-1213 between 7 am and 7 pmMonday through Friday TTYTDD usersshould call 1-800-325-0778 or

+Your State Medicaid Office What are my protections in this plan All Medicare Prescription Drug Plans agree to stayin the program for a full calendar year at a timePlan benefits and cost-sharing may change fromcalendar year to calendar year Each year plans candecide whether to continue to participate with theMedicare Prescription Drug Program A plan maycontinue in their entire service area (geographicarea where the plan accepts members) or choose tocontinue only in certain areas Also Medicare maydecide to end a contract with a plan Even if yourMedicare Prescription Plan leaves the program youwill not lose Medicare coverage If a plan decidesnot to continue for an additional calendar year itmust send you a letter at least 90 days before yourcoverage will end The letter will explain youroptions for Medicare coverage in your area As a member of a Blue Medicare Rx plan you havethe right to request a coverage determination whichincludes the right to request an exception the right tofile an appeal if we deny coverage for a prescriptiondrug and the right to file a grievance You havethe right to request a coverage determination if youwant us to cover a Part D drug that you believeshould be covered An exception is a type of coveragedetermination You may ask us for an exception ifyou believe you need a drug that is not on our list

PAG E 23 of 40

Introduction to the

Summary of benefits for (PDP)

Thank you for your interest in Blue Medicare Rx(PDP) plans Our plans are offered by Blue Crossand Blue Shield of North Carolina a MedicarePrescription Drug Plan that contracts with theFederal government This Summary of Benefits tellsyou some features of our plans It doesnrsquot list everydrug we cover every limitation or exclusionTo get a complete list of our benefits please callBlue Medicare Rx and ask for the ldquoEvidence of Coveragerdquo You have choices in your Medicare prescription drug coverage As a Medicare beneficiary you can choose fromdifferent Medicare prescription drug coverageoptions One option is to get prescription drugcoverage through a Medicare Prescription DrugPlan like Blue Medicare Rx plans Another optionis to get your prescription drug coverage througha Medicare Advantage Plan that offers prescriptiondrug coverage You make the choice How can I compare my options The charts in this booklet list some important drugbenefits You can use this Summary of Benefitsto compare the benefits offered by Blue MedicareRx plans to the benefits offered by other MedicarePrescription Drug Plans or Medicare AdvantagePlans with prescription drug coverage Where are Blue Medicare Rx Plans available The service area for these plans includesNorth Carolina You must live in one of these areas to join one of these plans Who is eligible to join You can join one of these plans if you are entitled toMedicare Part A andor enrolled in Medicare Part Band live in the service area If you are enrolled in an MA coordinated care(HMO or PPO) plan or an MA PFFS plan thatincludes Medicare prescription drugs you maynot enroll in a PDP unless you disenroll from theHMO PPO or MA PFFS plan Enrollees in a private Fee-for-Service plan (PFFS)that does not provide Medicare prescription drugcoverage or an MA Medical Savings Account (MSA)plan may enroll in a PDP Enrollees in an 1876 Costplan may enroll in a PDP

Where can I get my prescriptions Blue Medicare Rx plans have formed a network ofpharmacies You must use a network pharmacyto receive plan benefits We will not pay foryour prescriptions if you use an out-of-networkpharmacy except in certain cases Blue Medicare Rx plans have a list of preferredpharmacies At these pharmacies you may getyour drugs at a lower co-pay or coinsuranceYou may go to a non-preferred pharmacy but youmay have to pay more for your prescription drugs The pharmacies in our network can change at anytime You can ask for a Pharmacy Directory or visit usat wwwmyprimecomMyRxMyPrimeMedicareDpharmacyBCBSNC Our customer service number is listed at the end of this introduction What if my doctor prescribes less than a monthrsquos supply In consultation with your doctor or pharmacist youmay receive less than a monthrsquos supply of certaindrugs Also if you live in a long-term care facilityyou will receive less than a monthrsquos supply of certainbrand [and generic] drugs Dispensing fewer drugs ata time can help reduce cost and waste in the MedicarePart D program when this is medically appropriate The amount you pay in these circumstances willdepend on whether you are responsible for payingcoinsurance (a percentage of the cost of the drug) ora copay (a flat dollar amount for the drug) If youare responsible for coinsurance for the drug youwill continue to pay the applicable percentage ofthe drug cost If you are responsible for a copay forthe drug a ldquodaily cost-sharing raterdquo will be appliedIf your doctor decides to continue the drug after atrial period you should not pay more for a monthrsquossupply than you otherwise would have paid Contactyour plan if you have questions about cost-sharingwhen less than a one-month supply is dispensed Does my plan cover Medicare Part B or Part D drugs Blue Medicare Rx Standard and Enhanced plans donot cover drugs that are covered under Medicare PartB as prescribed and dispensed Generally we onlycover drugs vaccines biological products and medicalsupplies associated with the delivery of insulin thatare covered under the Medicare Prescription DrugBenefit (Part D) and that are on our formulary

PAG E 22 of 40

Introduction to the

Summary of benefits (continued)

What is a prescription drug formulary Blue Medicare Rx plans use a formularyA formulary is a list of drugs covered by your planto meet patient needs We may periodically addremove or make changes to coverage limitationson certain drugs or change how much you pay for adrug If we make any formulary change that limitsour membersrsquo ability to fill their prescriptions wewill notify the affected members before the changeis made We will send a formulary to you andyou can see our complete formulary on our Website at httpwwwbcbsnccomcontentmedicareformulary-homehtm If you are currently taking a drug that is not on ourformulary or subject to additional requirements orlimits you may be able to get a temporary supply ofthe drug You can contact us to request an exceptionor switch to an alternative drug listed on ourformulary with your physicianrsquos help Call us to seeif you can get a temporary supply of the drug or formore details about our drug transition policy What should I do if I have other insurance in addition to Medicare If you have a Medigap (Medicare Supplement)policy that includes prescription drug coverage youmust contact your Medigap Issuer to let them knowthat you have joined a Medicare Prescription DrugPlan If you decide to keep your current Medigapsupplement policy your Medigap Issuer willremove the prescription drug coverage portion ofyour policy Call your Medigap Issuer for details If you or your spouse has or is able to get employergroup coverage you should talk to your employerto find out how your benefits will be affected if youjoin a Blue Medicare Rx plan Get this informationbefore you decide to enroll in this plan

How can I get extra help with my prescription drug plan costs or get extra help with other Medicare costs You may be able to get extra help to pay for yourprescription drug premiums and costs as well as gethelp with other Medicare costs To see if you qualifyfor getting extra help call +1-800-MEDICARE (1-800-633-4227)

TTYTDD users should call 1-877-486-204824 hours a day7 days a week and seehttpwwwmedicaregov lsquoPrograms for Peoplewith Limited Income and Resourcesrsquo in the publication Medicare amp You

+The Social Security Administration at1-800-772-1213 between 7 am and 7 pmMonday through Friday TTYTDD usersshould call 1-800-325-0778 or

+Your State Medicaid Office What are my protections in this plan All Medicare Prescription Drug Plans agree to stayin the program for a full calendar year at a timePlan benefits and cost-sharing may change fromcalendar year to calendar year Each year plans candecide whether to continue to participate with theMedicare Prescription Drug Program A plan maycontinue in their entire service area (geographicarea where the plan accepts members) or choose tocontinue only in certain areas Also Medicare maydecide to end a contract with a plan Even if yourMedicare Prescription Plan leaves the program youwill not lose Medicare coverage If a plan decidesnot to continue for an additional calendar year itmust send you a letter at least 90 days before yourcoverage will end The letter will explain youroptions for Medicare coverage in your area As a member of a Blue Medicare Rx plan you havethe right to request a coverage determination whichincludes the right to request an exception the right tofile an appeal if we deny coverage for a prescriptiondrug and the right to file a grievance You havethe right to request a coverage determination if youwant us to cover a Part D drug that you believeshould be covered An exception is a type of coveragedetermination You may ask us for an exception ifyou believe you need a drug that is not on our list

PAG E 23 of 40

Introduction to the

Summary of benefits (continued)

What is a prescription drug formulary Blue Medicare Rx plans use a formularyA formulary is a list of drugs covered by your planto meet patient needs We may periodically addremove or make changes to coverage limitationson certain drugs or change how much you pay for adrug If we make any formulary change that limitsour membersrsquo ability to fill their prescriptions wewill notify the affected members before the changeis made We will send a formulary to you andyou can see our complete formulary on our Website at httpwwwbcbsnccomcontentmedicareformulary-homehtm If you are currently taking a drug that is not on ourformulary or subject to additional requirements orlimits you may be able to get a temporary supply ofthe drug You can contact us to request an exceptionor switch to an alternative drug listed on ourformulary with your physicianrsquos help Call us to seeif you can get a temporary supply of the drug or formore details about our drug transition policy What should I do if I have other insurance in addition to Medicare If you have a Medigap (Medicare Supplement)policy that includes prescription drug coverage youmust contact your Medigap Issuer to let them knowthat you have joined a Medicare Prescription DrugPlan If you decide to keep your current Medigapsupplement policy your Medigap Issuer willremove the prescription drug coverage portion ofyour policy Call your Medigap Issuer for details If you or your spouse has or is able to get employergroup coverage you should talk to your employerto find out how your benefits will be affected if youjoin a Blue Medicare Rx plan Get this informationbefore you decide to enroll in this plan

How can I get extra help with my prescription drug plan costs or get extra help with other Medicare costs You may be able to get extra help to pay for yourprescription drug premiums and costs as well as gethelp with other Medicare costs To see if you qualifyfor getting extra help call +1-800-MEDICARE (1-800-633-4227)

TTYTDD users should call 1-877-486-204824 hours a day7 days a week and seehttpwwwmedicaregov lsquoPrograms for Peoplewith Limited Income and Resourcesrsquo in the publication Medicare amp You

+The Social Security Administration at1-800-772-1213 between 7 am and 7 pmMonday through Friday TTYTDD usersshould call 1-800-325-0778 or

+Your State Medicaid Office What are my protections in this plan All Medicare Prescription Drug Plans agree to stayin the program for a full calendar year at a timePlan benefits and cost-sharing may change fromcalendar year to calendar year Each year plans candecide whether to continue to participate with theMedicare Prescription Drug Program A plan maycontinue in their entire service area (geographicarea where the plan accepts members) or choose tocontinue only in certain areas Also Medicare maydecide to end a contract with a plan Even if yourMedicare Prescription Plan leaves the program youwill not lose Medicare coverage If a plan decidesnot to continue for an additional calendar year itmust send you a letter at least 90 days before yourcoverage will end The letter will explain youroptions for Medicare coverage in your area As a member of a Blue Medicare Rx plan you havethe right to request a coverage determination whichincludes the right to request an exception the right tofile an appeal if we deny coverage for a prescriptiondrug and the right to file a grievance You havethe right to request a coverage determination if youwant us to cover a Part D drug that you believeshould be covered An exception is a type of coveragedetermination You may ask us for an exception ifyou believe you need a drug that is not on our list

PAG E 23 of 40

Introduction to the

Summary of benefits (continued)

of covered drugs or believe you should get a non-preferred drug at a lower out-of-pocket cost Youcan also ask for an exception to cost utilization rulessuch as a limit on the quantity of a drug If you thinkyou need an exception you should contact us beforeyou try to fill your prescription at a pharmacy Yourdoctor must provide a statement to support yourexception request If we deny coverage for yourprescription drug(s) you have the right to appealand ask us to review our decision Finally you havethe right to file a grievance if you have any type ofproblem with us or one of our network pharmaciesthat does not involve coverage for a prescriptiondrug If your problem involves quality of care youalso have the right to file a grievance with the QualityImprovement Organization (QIO) for your statePlease refer to the Evidence of Coverage (EOC) for theQIO contact information

What is a Medication Therapy Management (MTM) program A Medication Therapy Management (MTM) Programis a free service we offer You may be invited toparticipate in a program designed for your specifichealth and pharmacy needs You may decide not toparticipate but it is recommended that you take fulladvantage of this covered service if you are selectedContact Blue Medicare Rx for more details

Where can I find information on plan ratings The Medicare program rates how well plans performin different categories (for example detecting andpreventing illness ratings from patients and customerservice) If you have access to the web you can findthe Plan Ratings information by using the Find healthamp drug plans web tool on medicaregov to comparethe plan ratings for Medicare plans in your area Youcan also call us directly to obtain a copy of the planratings for this plan Our customer service number islisted below

Please call Blue Cross and Blue Shield of North Carolina for more information about our Blue Medicare Rx plans

Visit us at httpwwwbcbsnccommedicare or call us

Customer Service hours for October 1 - February 14 Sunday Monday Tuesday Wednesday Thursday Friday Saturday800 amndash800 pm Eastern

Customer Service hours for February 15 - September 30 Sunday Monday Tuesday Wednesday Thursday Friday Saturday800 amndash800 pm Eastern

Current members should call toll-free (888)247-4142 (TTYTDD (888)247-4145)

Prospective members should call toll-free (800)478-0583 (TTYTDD (800)922-3140)

Current members should call locally (888)247-4142 (TTYTDD (888)247-4145)

Prospective members should call locally (800)478-0583 (TTYTDD (800)922-3140)

For more information about Medicare please call Medicare at 1-800-MEDICARE (1-800-633-4227)TTY users should call 1-877-486-2048 You can call 24 hours a day 7 days a weekOr visit httpwwwmedicaregov on the Web

This document may be available in other formats such as Braille large print or other alternate formats This document may be available in a non-English language For additional information call customer service at the phone number listed above If you have any questions about this planrsquos benefits or costs please contact Blue Cross and Blue Shield of North Carolina for details

PAG E 24 of 40

Section 2

Summary of benefits for (PDP) Contract S5540 Plan 004 and Plan 002

Benefit Outpatient Prescription Drugs Original Medicare Most drugs are not covered under Original Medicare You can

Add prescription drug coverage to Original You can get all your Medicare coverage includingMedicare by joining a Medicare Prescription prescription drug coverage by joining a MedicareORDrug Plan Advantage Plan or a Medicare Cost Plan that offers

prescription drug coverage

Original Medicare

Blue Medicare Rx Enhanced (PDP) (Plan 004)

Blue Medicare Rx Standard (PDP) (Plan 002)

Drugs covered under Medicare Part DGeneral This plan uses a formulary The plan will send you the formulary You can also see theformulary at httpwwwbcbsnccomcontentmedicareformulary-homehtm on the web

Different out-of-pocket costs may apply for people who+ have limited incomes + live in long term care facilities or+ have access to IndianTribalUrban (Indian Health Service) providers

$7860 Monthly premium $4100 Monthly premium

Most people will pay their Part D premium However some people will pay a higher premiumbecause of their yearly income (over $85000 for singles $170000 for married couples) For moreinformation about Part D premiums based on income call Medicare at 1-800-MEDICARE (1-800-633-4227) TTY users should call 1-877-486-2048 You may also call Social Security at 1-800-772-1213 TTY users should call 1-800-325-0778 The plan offers national in-network prescription coverage (ie this would include 50 states andthe District of Columbia) This means that you will pay the same cost-sharing amount for yourprescription drugs if you get them at an in-network pharmacy outside of the planrsquos service area(for instance when you travel) Total yearly drug costs are the total drug costs paid by both you and a Part D plan

The plan may require you to first try one drug to treat your condition before it will cover anotherdrug for that condition Some drugs have quantity limits

Your provider must get prior authorizationfrom Blue Medicare Rx Enhanced (PDP) for certain drugs

Your provider must get prior authorizationfrom Blue Medicare Rx Standard (PDP) for certain drugs

You must go to certain pharmacies for a very limited number of drugs due to specialhandling provider coordination or patient education requirements that cannot be met bymost pharmacies in your network These drugs are listed on the planrsquos website formularyprinted materials as well as on the Medicare Prescription Drug Plan Finder on Medicaregov If the actual cost of a drug is less than the normal cost-sharing amount for that drug you will paythe actual cost not the higher cost-sharing amount

PAG E 25 of 40

Section 2 - Summary of benefits for ndash Benefit Outpatient Prescription Drugs Contract S5540 Plan 004 and Plan 002

Original Medicare

Blue Medicare Rx Enhanced (PDP) (Plan 004)

Blue Medicare Rx Standard (PDP) (Plan 002)

If you request a formulary exception for adrug and Blue Medicare Rx Enhanced (PDP)approves the exception you will pay Tier 4 Non-Preferred Brand cost sharing for that drug

If you request a formulary exception for adrug and Blue Medicare Rx Standard (PDP)approves the exception you will pay Tier 4 Non-Preferred Brand cost sharing for that drug

In-network $0 deductible In-network $145 annual deductible

Initial Coverage You pay the following until totalyearly drug costs reach $2850

Initial Coverage After you pay your yearlydeductible you pay the following until totalyearly drug costs reach $2850

Retail pharmacy Contact your plan if you have questions aboutcost-sharing or billing when less than a one-month supply is dispensed You can get drugsfrom a preferred and non-preferred pharmacy thefollowing way(s) Tier 1 - Preferred Generic + $3 copay for a one-month (30-day) supply of

drugs in this tier from a preferred pharmacy + $6 copay for a two-month (60-day) supply of

drugs in this tier from a preferred pharmacy + $9 copay for a three-month (90-day)supply of

drugs in this tier from a preferred pharmacy + $8 copay for a one-month (30-day) supply of

drugs in this tier from a non-preferred pharmacy + $16 copay for a two-month (60-day) supply of

drugs in this tier from a non-preferred pharmacy + $24 copay for a three-month (90-day) supply of

drugs in this tier from a non-preferred pharmacy

Retail pharmacy Contact your plan if you have questions aboutcost-sharing or billing when less than a one-month supply is dispensed You can get drugsfrom a preferred and non-preferred pharmacy thefollowing way(s) Tier 1 - Preferred Generic + $4 copay for a one-month (30-day) supply of

drugs in this tier from a preferred pharmacy + $8 copay for a two-month (60-day)supply of

drugs in this tier from a preferred pharmacy + $12 copay for a three-month (90-day) supply of

drugs in this tier from a preferred pharmacy + $10 copay for a one-month (30-day) supply of

drugs in this tier from a non-preferred pharmacy + $20 copay for a two-month (60-day) supply of

drugs in this tier from a non-preferred pharmacy + $30 copay for a three-month (90-day) supply of

drugs in this tier from a non-preferred pharmacy

Not all drugs on this tier are available at this extended day supply Please contactthe plan for more information

Tier 2 - Non-Preferred Generic + $6 copay for a one-month (30-day) supply of

drugs in this tier from a preferred pharmacy + $12 copay for a two-month (60-day)supply of

drugs in this tier from a preferred pharmacy + $18 copay for a three-month (90-day) supply of

drugs in this tier from a preferred pharmacy + $20 copay for a one-month (30-day) supply of

drugs in this tier from a non-preferred pharmacy + $40 copay for a two-month (60-day) supply of

drugs in this tier from a non-preferred pharmacy + $60 copay for a three-month (90-day) supply of

drugs in this tier from a non-preferred pharmacy

Tier 2 - Non-Preferred Generic + $10 copay for a one-month (30-day) supply of

drugs in this tier from a preferred pharmacy + $20 copay for a two-month (60-day)supply of

drugs in this tier from a preferred pharmacy + $30 copay for a three-month (90-day) supply of

drugs in this tier from a preferred pharmacy + $33 copay for a one-month (30-day) supply of

drugs in this tier from a non-preferred pharmacy + $66 copay for a two-month (60-day) supply of

drugs in this tier from a non-preferred pharmacy + $99 copay for a three-month (90-day) supply of

drugs in this tier from a non-preferred pharmacy

Not all drugs on this tier are available at this extended day supply Please contactthe plan for more information

PAG E 26 of 40

Original Medicare

Blue Medicare Rx Enhanced (PDP) (Plan 004)

Blue Medicare Rx Standard (PDP) (Plan 002)

Tier 3 - Preferred Brand + $30 copay for a one-month (30-day) supply of

drugs in this tier from a preferred pharmacy+ $60 copay for a two-month (60-day) supply of

drugs in this tier from a preferred pharmacy+ $90 copay for a three-month (90-day) supply of

drugs in this tier from a preferred pharmacy+ $45 copay for a one-month (30-day) supply of

drugs in this tier from a non-preferred pharmacy+ $90 copay for a two-month (60-day) supply of

drugs in this tier from a non-preferred pharmacy+ $135 copay for a three-month (90-day) supply of

drugs in this tier from a non-preferred pharmacy

Tier 3 - Preferred Brand + $40 copay for a one-month (30-day) supply of

drugs in this tier from a preferred pharmacy+ $80 copay for a two-month (60-day) supply of

drugs in this tier from a preferred pharmacy+ $120 copay for a three-month (90-day) supply of

drugs in this tier from a preferred pharmacy+ $45 copay for a one-month (30-day) supply of

drugs in this tier from a non-preferred pharmacy+ $90 copay for a two-month (60-day) supply of

drugs in this tier from a non-preferred pharmacy+ $135 copay for a three-month (90-day) supply of

drugs in this tier from a non-preferred pharmacy Not all drugs on this tier are available at this extended day supply Please contact

the plan for more information Tier 4 - Non-Preferred Brand + $70 copay for a one-month (30-day) supply of

drugs in this tier from a preferred pharmacy+ $140 copay for a two-month (60-day) supply of

drugs in this tier from a preferred pharmacy+ $210 copay for a three-month (90-day) supply of

drugs in this tier from a preferred pharmacy+ $95 copay for a one-month (30-day) supply of

drugs in this tier from a non-preferred pharmacy+ $190 copay for a two-month (60-day) supply of

drugs in this tier from a non-preferred pharmacy+ $285 copay for a three-month (90-day) supply of

drugs in this tier from a non-preferred pharmacy

Tier 4 - Non-Preferred Brand + $85 copay for a one-month (30-day) supply of

drugs in this tier from a preferred pharmacy+ $170 copay for a two-month (60-day) supply of

drugs in this tier from a preferred pharmacy+ $255 copay for a three-month (90-day) supply of

drugs in this tier from a preferred pharmacy+ $95 copay for a one-month (30-day) supply of

drugs in this tier from a non-preferred pharmacy+ $190 copay for a two-month (60-day) supply of

drugs in this tier from a non-preferred pharmacy+ $285 copay for a three-month (90-day) supply of

drugs in this tier from a non-preferred pharmacy Not all drugs on this tier are available at this extended day supply Please contact

the plan for more information Tier 5 - Specialty Tier + 33 coinsurance for a one-month (30-day)

supply of drugs in this tier from a preferredpharmacy

+ 33 coinsurance for a two-month (60-day)supply of drugs in this tier from a preferredpharmacy

+ 33 coinsurance for a three-month (90- day)supply of drugs in this tier from a preferredpharmacy

+ 33 coinsurance for a one-month (30-day)supply of drugs in this tier from a non-preferredpharmacy

+ 33 coinsurance for a two-month (60-day)supply of drugs in this tier from a non-preferredpharmacy

+ 33 coinsurance for a three-month (90-day)supply of drugs in this tier from a non-preferredpharmacy

Tier 5 - Specialty Tier + 29 coinsurance for a one-month (30-day)

supply of drugs in this tier from a preferredpharmacy

+ 29 coinsurance for a two-month (60-day)supply of drugs in this tier from a preferredpharmacy

+ 29 coinsurance for a three-month (90-day)supply of drugs in this tier from a preferredpharmacy

+ 29 coinsurance for a one-month (30-day)supply of drugs in this tier from a non-preferredpharmacy

+ 29 coinsurance for a two-month (60-day)supply of drugs in this tier from a non-preferredpharmacy

+ 29 coinsurance for a three-month (90-day)supply of drugs in this tier from a non-preferredpharmacy

Not all drugs on this tier are available at this extended day supply Please contactthe plan for more information

PAG E 27 of 40

Section 2 - Summary of benefits for ndash Benefit Outpatient Prescription Drugs Contract S5540 Plan 004 and Plan 002

Original Medicare

Blue Medicare Rx Enhanced (PDP) (Plan 004)

Blue Medicare Rx Standard (PDP) (Plan 002)

Long Term Care Pharmacy Long term care pharmacies must dispense brand name drugs in amounts less than a 14 days supply at a time They may also dispenseless than a monthrsquos supply of generic drugs at a time Contact your plan if you have questionsabout cost-sharing or billing when less than aone-month supply is dispensed You can get drugs the following way(s)Tier 1 - Preferred Generic + $8 copay for a one-month (31-day)

supply of drugs in this tierTier 2 - Non-Preferred Generic + $20 copay for a one-month (31-day)

supply of drugs in this tierTier 3 - Preferred Brand + $45 copay for a one-month (31-day)

supply of drugs in this tierTier 4 - Non-Preferred Brand + $95 copay for a one-month (31-day)

supply of drugs in this tierTier 5 - Specialty Tier + 33 coinsurance for a one-month (31-day)

supply of drugs in this tier

Long Term Care Pharmacy Long term care pharmacies must dispense brand name drugs in amounts less than a 14 days supply at a time They may also dispenseless than a monthrsquos supply of generic drugs at a time Contact your plan if you have questionsabout cost-sharing or billing when less than aone-month supply is dispensed You can get drugs the following way(s)Tier 1 - Preferred Generic + $10 copay for a one-month (31-day)

supply of drugs in this tierTier 2 - Non-Preferred Generic + $33 copay for a one-month (31-day)

supply of drugs in this tierTier 3 - Preferred Brand + $45 copay for a one-month (31-day)

supply of drugs in this tierTier 4 - Non-Preferred Brand + $95 copay for a one-month (31-day)

supply of drugs in this tierTier 5 - Specialty Tier + 29 coinsurance for a one-month (31-day)

supply of drugs in this tier Mail order Contact your plan if you have questions aboutcost-sharing or billing when less than a one-month supply is dispensed You can get drugs from a preferred and non-preferred mail order pharmacy the following way(s)Tier 1 - Preferred Generic + $3 copay for a one-month (30-day)

supply of drugs in this tier from apreferred mail order pharmacy

+ $0 copay for a two-month (60-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $0 copay for a three-month (90-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $8 copay for a one-month (30-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $16 copay for a two-month (60-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $24 copay for a three-month (90-day)supply of drugs in this tier from anon-preferred mail order pharmacy

Mail order Contact your plan if you have questions aboutcost-sharing or billing when less than a one-month supply is dispensed You can get drugs from a preferred and non-preferred mail order pharmacy the following way(s)Tier 1 - Preferred Generic + $4 copay for a one-month (30-day)

supply of drugs in this tier from apreferred mail order pharmacy

+ $0 copay for a two-month (60-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $0 copay for a three-month (90-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $10 copay for a one-month (30-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $20 copay for a two-month (60-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $30 copay for a three-month (90-day)supply of drugs in this tier from anon-preferred mail order pharmacy

Not all drugs on this tier are available at this extended day supplyPlease contact the plan for more information

PAG E 28 of 40

Original Medicare

Blue Medicare Rx Enhanced (PDP) (Plan 004)

Blue Medicare Rx Standard (PDP) (Plan 002)

Mail order (continued) Tier 2 - Non-Preferred Generic

+ $6 copay for a one-month (30-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $12 copay for a two-month (60-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $15 copay for a three-month (90-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $20 copay for a one-month (30-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $40 copay for a two-month (60-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $60 copay for a three-month (90-day)supply of drugs in this tier from anon-preferred mail order pharmacy

Mail order (continued) Tier 2 - Non-Preferred Generic

+ $10 copay for a one-month (30-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $20 copay for a two-month (60-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $25 copay for a three-month (90-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $33 copay for a one-month (30-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $66 copay for a two-month (60-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $99 copay for a three-month (90-day)supply of drugs in this tier from anon-preferred mail order pharmacy

Not all drugs on this tier are available at this extended day supply Please contactthe plan for more information

Tier 3 - Preferred Brand + $30 copay for a one-month (30-day)

supply of drugs in this tier from apreferred mail order pharmacy

+ $60 copay for a two-month (60-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $75 copay for a three-month (90-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $45 copay for a one-month (30-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $90 copay for a two-month (60-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $135 copay for a three-month (90-day)supply of drugs in this tier from anon-preferred mail order pharmacy

Tier 3 - Preferred Brand + $40 copay for a one-month (30-day)

supply of drugs in this tier from apreferred mail order pharmacy

+ $80 copay for a two-month (60-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $100 copay for a three-month (90-day) supply of drugs in this tier from apreferred mail order pharmacy

+ $45 copay for a one-month (30-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $90 copay for a two-month (60-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $135 copay for a three-month (90-day)supply of drugs in this tier from anon-preferred mail order pharmacy

Not all drugs on this tier are available at this extended day supply Please contactthe plan for more information

PAG E 29 of 40

Section 2 - Summary of benefits for ndash Benefit Outpatient Prescription Drugs Contract S5540 Plan 004 and Plan 002

Original Medicare

Blue Medicare Rx Enhanced (PDP) (Plan 004)

Blue Medicare Rx Standard (PDP) (Plan 002)

Mail order (continued) Tier 4 - Non-Preferred Brand

+ $70 copay for a one-month (30-day) supply of drugs in this tier from apreferred mail order pharmacy

+ $140 copay for a two-month (60-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $175 copay for a three-month (90-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $95 copay for a one-month (30-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $190 copay for a two-month (60-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $285 copay for a three-month (90-day)supply of drugs in this tier from anon-preferred mail order pharmacy

Mail order (continued) Tier 4 - Non-Preferred Brand + $85 copay for a one-month (30-day)

supply of drugs in this tier from apreferred mail order pharmacy

+ $170 copay for a two-month (60-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $21250 copay for a three-month (90-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $95 copay for a one-month (30-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $190 copay for a two-month (60-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $285 copay for a three-month (90-day)supply of drugs in this tier from anon-preferred mail order pharmacy

Not all drugs on this tier are available at this extended day supply Please contactthe plan for more information

Tier 5 - Specialty Tier

+ 33 coinsurance for a one-month (30-day) supply of drugs in this tier from apreferred mail order pharmacy

+ 33 coinsurance for a two-month (60-day) supply of drugs in this tier from apreferred mail order pharmacy

+ 33 coinsurance for a three-month (90-day) supply of drugs in this tier from apreferred mail order pharmacy

+ 33 coinsurance for a one-month (30-day) supply of drugs in this tier froma non-preferred mail order pharmacy

+ 33 coinsurance for a two-month (60-day) supply of drugs in this tier from anon-preferred mail order pharmacy

+ 33 coinsurance for a three-month (90-day) supply of drugs in this tier froma non-preferred mail order pharmacy

Tier 5 - Specialty Tier

+ 29 coinsurance for a one-month (30-day)supply of drugs in this tier from apreferred mail order pharmacy

+ 29 coinsurance for a two-month (60-day) supply of drugs in this tier from apreferred mail order pharmacy

+ 29 coinsurance for a three-month (90-day)supply of drugs in this tier from a preferredmail order pharmacy

+ 29 coinsurance for a one-month (30-day)supply of drugs in this tier froma non-preferred mail order pharmacy

+ 29 coinsurance for a two-month (60-day) supply of drugs in this tier from anon-preferred mail order pharmacy

+ 29 coinsurance for a three-month (90-day)supply of drugs in this tier froma non-preferred mail order pharmacy

Not all drugs on this tier are available at this extended day supply Please contactthe plan for more information

PAG E 30 of 40

Original Medicare

Blue Medicare Rx Enhanced (PDP) (Plan 004)

Blue Medicare Rx Standard (PDP) (Plan 002)

Coverage gap After your total yearly drug costs reach $2850 you receive limited coverage by the plan on certaindrugs You will also receive a discount on brand name drugs and generally pay no more than 475for the planrsquos costs for brand drugs and 72 of the planrsquos costs for generic drugs until your yearly out-of-pocket drug costs reach $4550 Additional Coverage gap The plan covers some formulary generics (10-64 of formularygeneric drugs) through the coverage gap The plan offers additional coverage in the gap for thefollowing tiers You pay the following Retail Pharmacy Contact your plan if you have questions about cost-sharing orbilling when less than a one-month supply is dispensed

Tier 1 Preferred Generic + $3 copay for a one-month (30-day) supply of all drugs

covered within this tier from a preferred pharmacy + $6 copay for a two-month (60-day) supply of all drugs

covered within this tier from a preferred pharmacy + $9 copay for a three-month (90-day) supply of all drugs

covered within this tier from a preferred pharmacy + $8 copay for a one-month (30-day) supply of all drugs

covered within this tier at a non-preferred pharmacy + $16 copay for a two-month (60-day) supply of all drugs

covered within this tier from a non-preferred pharmacy + $24 copay for a three-month (90-day) supply of all drugs

covered within this tier from a non-preferred pharmacy

Not all drugs on this tier are available at this extended daysupply Please contact the plan for more information

Long Term Care Pharmacy Long term care pharmacies must dispense brand name drugsin amounts less than a 14 days supply at a time They may alsodispense less than a monthrsquos supply of generic drugs at a timeContact your plan if you have questions about cost-sharing orbilling when less than a one-month supply is dispensed Tier 1 Preferred Generic + $8 copay for a one-month (31-day) supply of all drugs

covered in this tier

PAG E 31 of 40

Section 2 - Summary of benefits for ndash Benefit Outpatient Prescription Drugs Contract S5540 Plan 004 and Plan 002

Original Medicare

Blue Medicare Rx Enhanced (PDP) (Plan 004)

Blue Medicare Rx Standard (PDP) (Plan 002)

Mail Order Contact your plan if you have questions about cost-sharing orbilling when less than a one-month supply is dispensed Tier 1 Preferred Generic + $3 copay for a one-month (30-day) supply of all drugs

covered within this tier from a preferred mail order pharmacy + $0 copay for a two-month (60-day) supply of all drugs

covered within this tier from a preferred mail order pharmacy + $0 copay for a three-month (90-day) supply of all drugs

covered within this tier from a preferred mail order pharmacy + $8 copay for a one-month (30-day) supply of all drugs

covered within this tier from a non-preferred mail orderpharmacy

+ $16 copay for a two-month (60-day) supply of all drugscovered within this tier from a non-preferred mail orderpharmacy

+ $24 copay for a three-month (90-day) supply of all drugscovered within this tier from a non-preferred mail orderpharmacy

Not all drugs on this tier are available at this extended daysupply Please contact the plan for more information

PAG E 32 of 40

Original Medicare

Blue Medicare Rx Enhanced (PDP) (Plan 004)

Blue Medicare Rx Standard (PDP) (Plan 002)

Catastrophic coverage After your yearly out-of-pocket drug costs reach $4550 you pay the greater of + 5 coinsurance or + $255 copay for generic (including brand drugs treated as generic) and a $635

copay for all other drugs

Out-of-network Plan drugs may be covered in special circumstances for instance illness while traveling outside ofthe planrsquos service area where there is no network pharmacy You may have to pay more than yournormal cost-sharing amount if you get your drugs at an out-of-network pharmacy In addition youwill likely have to pay the pharmacyrsquos full charge for the drug and submit documentation to receivereimbursement from Blue Medicare Rx (PDP)

You can get out-of-network drugs the following way

Out-of-network initial coverage

You will be reimbursed up to the planrsquos costof the drug minus the following for drugspurchased out-of-network until total yearlydrug costs reach $2850 Tier 1 - Preferred Generic

+ $8 copay for a one-month (30-day)supply of drugs in this tier Tier 2 - Non-Preferred Generic

+ $20 copay for a one-month (30-day)supply of drugs in this tier

Tier 3 - Preferred Brand

+ $45 copay for a one-month (30-day)supply of drugs in this tier

Tier 4 - Non-Preferred Brand

+ $95 copay for a one-month (30-day)supply of drugs in this tier

Tier 5 - Specialty Tier

+ 33 coinsurance for a one-month (30-day)supply of drugs in this tier

Out-of-network initial coverage

After you pay your yearly deductible you willbe reimbursed up to the planrsquos cost of the drugminus the following for drugs purchasedout-of-network until total yearly drug costsreach $2850 Tier 1 - Preferred Generic

+ $10 copay for a one-month (30-day)supply of drugs in this tier

Tier 2 - Non-Preferred Generic

+ $33 copay for a one-month (30-day)supply of drugs in this tier

Tier 3 - Preferred Brand

+ $45 copay for a one-month (30-day)supply of drugs in this tier

Tier 4 - Non-Preferred Brand

+ $95 copay for a one-month (30-day)supply of drugs in this tier

Tier 5 - Specialty Tier

+ 29 coinsurance for a one-month (30-day)supply of drugs in this tier

You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge andthe planrsquos In-Network allowable amount

Out-of-Network Coverage Gap You will be reimbursed up to 28 of the plan allowable cost for generic drugs purchasedout-of-network until total yearly out-of-pocket drug costs reach $4550 Please note that theplan allowable cost may be less than the out-of-network pharmacy price paid for your drug(s)

PAG E 33 of 40

Section 2 - Summary of benefits for ndash Benefit Outpatient Prescription Drugs Contract S5540 Plan 004 and Plan 002

Original Medicare

Blue Medicare Rx Enhanced (PDP) (Plan 004)

Blue Medicare Rx Standard (PDP) (Plan 002)

Out-of-Network Coverage Gap (continued)

You will be reimbursed up to 525 of the plan allowable cost for brand name drugs purchasedout-of-network until your total yearly out-of-pocket drug costs reach $4550 Please note that theplan allowable cost may be less than the out-of-network pharmacy price paid for your drug(s)

Additional Out-of-Network Coverage Gap

You will be reimbursed for these drugspurchased out-of-network up to the planrsquoscost of the drug minus the following

Tier 1 Preferred Generic

+ $8 copay for a one-month (30-day) supplyof all drugs covered within this tier

Out-of-network Catastrophic Coverage After your yearly out-of-pocket drug costs reach $4550 you will be reimbursed for drugs purchasedout-of-network up to the planrsquos cost of the drug minus your cost share which is the greater of+ 5 coinsurance or+ $255 copay for generic (including brand drugs treated as generic) and+ $635 copay for all other drugs

You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge andthe planrsquos In-Network allowable amount

PAG E 34 of 40

PAGE 35 of 40

(PDP)

Multi-language Interpreter Services

English We have free interpreter services to answer any questions you may have about our health or drug plan To get an interpreter just call us at 1-800-478-0583 Someone who speaks EnglishLanguage can help you This is a free service

Spanish Tenemos servicios de inteacuterprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos Para hablar con un inteacuterprete por favor llame al 1-800-478-0583 Alguien que hable espantildeol le podraacute ayudar Este es un servicio gratuito

Chinese Mandarin 我们提供免们的翻们服们们助们解答们于健康或们物保们的任何疑 们如果们需要此翻们服们们致们 phone number我们的中文工作人们很们意们助们 们是一们免们服们

Chinese Cantonese 您對我們的健康或藥物保險可能存有疑問為此我們提供免費的翻譯服務如需翻譯服務請致電 1-800-478-0583我們講中文的人員將樂意為您提供幫助這是一項免費服務

Tagalog Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot Upang makakuha ng tagasaling-wika tawagan lamang kami sa 1-800-478-0583 Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog Ito ay libreng serbisyo

French Nous proposons des services gratuits dinterpreacutetation pour reacutepondre agrave toutes vos questions relatives agrave notre reacutegime de santeacute ou dassurance-meacutedicaments Pour acceacuteder au service dinterpreacutetation il vous suffit de nous appeler au 1-800-478-0583 Un interlocuteur parlant Franccedilais pourra vous aider Ce service est gratuit

Vietnamese Chuacuteng tocirci coacute dịch vụ thocircng dịch miễn phiacute để trả lời caacutec cacircu hỏi về chương sức khỏe vagrave chương trigravenh thuốc men Nếu quiacute vị cần thocircng dịch viecircn xin gọi 1-800-478-0583 sẽ coacute nhacircn viecircn noacutei tiếng Việt giuacutep đỡ quiacute vị Đacircy lagrave dịch vụ miễn phiacute

German Unser kostenloser Dolmetscherservice beantwortet Ihren Fragen zu unserem Gesundheits- und Arzneimittelplan Unsere Dolmetscher erreichen Sie unter 1-800-478-0583 Man wird Ihnen dort auf Deutsch weiterhelfen Dieser Service ist kostenlos

Korean 당사는 의료 보험 또는 약품 보험에 관한 질문에 답해 드리고자 무료 통역 서비스를 제공하고 있습니다 통역 서비스를 이용하려면 전화 1-800-478-0583 번으로 문의해 주십시오 한국어를 하는 담당자가 도와 드릴 것입니다 이 서비스는 무료로 운영됩니다

Y0079_6200 CMS Approved 07082013 U5073d 813

116

Appendix 4 ndash Multi-Language Insert

Multi-language Interpreter Services

English We have free interpreter services to answer any questions you may have about our health or drug plan To get an interpreter just call us at [1-xxx-xxx-xxxx] Someone who speaks EnglishLanguage can help you This is a free service

Spanish Tenemos servicios de inteacuterprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos Para hablar con un inteacuterprete por favor llame al [1-xxx-xxx-xxxx] Alguien que hable espantildeol le podraacute ayudar Este es un servicio gratuito

Chinese Mandarin 我们提供免费的翻译服务帮助您解答关于健康或药物保险的任何疑

问如果您需要此翻译服务请致电 1-xxx-xxx-xxxx我们的中文工作人员很乐意帮助您

这是一项免费服务

Chinese Cantonese 您對我們的健康或藥物保險可能存有疑問為此我們提供免費的翻譯

服務如需翻譯服務請致電 1-xxx-xxx-xxxx我們講中文的人員將樂意為您提供幫助這

是一項免費服務

Tagalog Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot Upang makakuha ng tagasaling-wika tawagan lamang kami sa [1-xxx-xxx-xxxx] Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog Ito ay libreng serbisyo French Nous proposons des services gratuits dinterpreacutetation pour reacutepondre agrave toutes vos questions relatives agrave notre reacutegime de santeacute ou dassurance-meacutedicaments Pour acceacuteder au service dinterpreacutetation il vous suffit de nous appeler au [1-xxx-xxx-xxxx] Un interlocuteur parlant Franccedilais pourra vous aider Ce service est gratuit Vietnamese Chuacuteng tocirci coacute dịch vụ thocircng dịch miễn phiacute để trả lời caacutec cacircu hỏi về chương sức khỏe vagrave chương trigravenh thuốc men Nếu quiacute vị cần thocircng dịch viecircn xin gọi [1-xxx-xxx-xxxx] sẽ coacute nhacircn viecircn noacutei tiếng Việt giuacutep đỡ quiacute vị Đacircy lagrave dịch vụ miễn phiacute

116

Appendix 4 ndash Multi-Language Insert

Multi-language Interpreter Services

English We have free interpreter services to answer any questions you may have about our health or drug plan To get an interpreter just call us at [1-xxx-xxx-xxxx] Someone who speaks EnglishLanguage can help you This is a free service

Spanish Tenemos servicios de inteacuterprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos Para hablar con un inteacuterprete por favor llame al [1-xxx-xxx-xxxx] Alguien que hable espantildeol le podraacute ayudar Este es un servicio gratuito

Chinese Mandarin 我们提供免费的翻译服务帮助您解答关于健康或药物保险的任何疑

问如果您需要此翻译服务请致电 1-xxx-xxx-xxxx我们的中文工作人员很乐意帮助您

这是一项免费服务

Chinese Cantonese 您對我們的健康或藥物保險可能存有疑問為此我們提供免費的翻譯

服務如需翻譯服務請致電 1-xxx-xxx-xxxx我們講中文的人員將樂意為您提供幫助這

是一項免費服務

Tagalog Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot Upang makakuha ng tagasaling-wika tawagan lamang kami sa [1-xxx-xxx-xxxx] Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog Ito ay libreng serbisyo French Nous proposons des services gratuits dinterpreacutetation pour reacutepondre agrave toutes vos questions relatives agrave notre reacutegime de santeacute ou dassurance-meacutedicaments Pour acceacuteder au service dinterpreacutetation il vous suffit de nous appeler au [1-xxx-xxx-xxxx] Un interlocuteur parlant Franccedilais pourra vous aider Ce service est gratuit Vietnamese Chuacuteng tocirci coacute dịch vụ thocircng dịch miễn phiacute để trả lời caacutec cacircu hỏi về chương sức khỏe vagrave chương trigravenh thuốc men Nếu quiacute vị cần thocircng dịch viecircn xin gọi [1-xxx-xxx-xxxx] sẽ coacute nhacircn viecircn noacutei tiếng Việt giuacutep đỡ quiacute vị Đacircy lagrave dịch vụ miễn phiacute

116

Appendix 4 ndash Multi-Language Insert

Multi-language Interpreter Services

English We have free interpreter services to answer any questions you may have about our health or drug plan To get an interpreter just call us at [1-xxx-xxx-xxxx] Someone who speaks EnglishLanguage can help you This is a free service

Spanish Tenemos servicios de inteacuterprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos Para hablar con un inteacuterprete por favor llame al [1-xxx-xxx-xxxx] Alguien que hable espantildeol le podraacute ayudar Este es un servicio gratuito

Chinese Mandarin 我们提供免费的翻译服务帮助您解答关于健康或药物保险的任何疑

问如果您需要此翻译服务请致电 1-xxx-xxx-xxxx我们的中文工作人员很乐意帮助您

这是一项免费服务

Chinese Cantonese 您對我們的健康或藥物保險可能存有疑問為此我們提供免費的翻譯

服務如需翻譯服務請致電 1-xxx-xxx-xxxx我們講中文的人員將樂意為您提供幫助這

是一項免費服務

Tagalog Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot Upang makakuha ng tagasaling-wika tawagan lamang kami sa [1-xxx-xxx-xxxx] Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog Ito ay libreng serbisyo French Nous proposons des services gratuits dinterpreacutetation pour reacutepondre agrave toutes vos questions relatives agrave notre reacutegime de santeacute ou dassurance-meacutedicaments Pour acceacuteder au service dinterpreacutetation il vous suffit de nous appeler au [1-xxx-xxx-xxxx] Un interlocuteur parlant Franccedilais pourra vous aider Ce service est gratuit Vietnamese Chuacuteng tocirci coacute dịch vụ thocircng dịch miễn phiacute để trả lời caacutec cacircu hỏi về chương sức khỏe vagrave chương trigravenh thuốc men Nếu quiacute vị cần thocircng dịch viecircn xin gọi [1-xxx-xxx-xxxx] sẽ coacute nhacircn viecircn noacutei tiếng Việt giuacutep đỡ quiacute vị Đacircy lagrave dịch vụ miễn phiacute

1-800-478-0583

PAGE 36 of 40

(PDP)

Multi-language Interpreter Services (continued)

Russian Если у вас возникнут вопросы относительно страхового или медикаментного плана вы можете воспользоваться нашими бесплатными услугами переводчиков Чтобы воспользоваться услугами переводчика позвоните нам по телефону 1-800-478-0583 Вам окажет помощь сотрудник который говорит по-pусски Данная услуга бесплатная

Arabicةيودألا لودج وأ ةحصلاب قلعتت ةلئسأ يأ نع ةباجإلل ةيناجملا يروفلا مجرتملا تامدخ مدقن اننإ صخش موقيس 0583-478-800-1 ىلع انب لاصتالا ىوس كيلع سيل يروف مجرتم ىلع لوصحلل انيدلةيناجم ةمدخ هذه كتدعاسمب ةيبرعلا ثدحتي ام

Hindi हमार सवासथय या दवा की योजना क बार म आपक किसी भी परशन क जवाब दन क लिए हमार पास मफत दभाषिया सवाए उपलबध ह एक दभाषिया परापत करन क लिए बस हम 1-800-478-0583 पर फोन कर कोई वयकति जो हिनदी बोलता ह आपकी मदद कर सकता ह यह एक मफत सवा ह

Italian Egrave disponibile un servizio di interpretariato gratuito per rispondere a eventuali domande sul nostro piano sanitario e farmaceutico Per un interprete contattare il numero 1-800-478-0583 Un nostro incaricato che parla Italianovi forniragrave lassistenza necessaria Egrave un servizio gratuito

Portugueacutes Dispomos de serviccedilos de interpretaccedilatildeo gratuitos para responder a qualquer questatildeo que tenha acerca do nosso plano de sauacutede ou de medicaccedilatildeo Para obter um inteacuterprete contacte-nos atraveacutes do nuacutemero 1-800-478-0583 Iraacute encontrar algueacutem que fale o idioma Portuguecircs para o ajudar Este serviccedilo eacute gratuito

French Creole Nou genyen segravevis entegravepregravet gratis pou reponn tout kesyon ou ta genyen konsegravenan plan medikal oswa dwograveg nou an Pou jwenn yon entegravepregravet jis rele nou nan 1-800-478-0583 Yon moun ki pale Kreyogravel kapab ede w Sa a se yon segravevis ki gratis

Polish Umożliwiamy bezpłatne skorzystanie z usług tłumacza ustnego ktoacutery pomoże w uzyskaniu odpowiedzi na temat planu zdrowotnego lub dawkowania lekoacutew Aby skorzystać z pomocy tłumacza znającego język polski należy zadzwonić pod numer 1-800-478-0583 Ta usługa jest bezpłatna

Japanese 当社の健康 健康保険と薬品 処方薬プランに関するご質問にお答えするために無

料の通訳サービスがありますございます通訳をご用命になるには1-800-478-0583 にお電

話ください日本語を話す人 者 が支援いたしますこれは無料のサービスです

Notes

PAG E 37 of 40

Notes

PAG E 38 of 40

Notes

U5073e 813

PAGE 39 of 40

Awarded to BCBSNC by the Ethisphere Institute In 2013 companies in more than 100 countries and 36 industries were reviewed and of those 138 organizations were designated as Worldrsquos Most Ethical

BCBSNC Blue Medicare Rx products are only available to Medicare beneficiaries residing in North Carolina The information described in this brochure is for 2014 and may change on January 1 2015 The benefit information provided is a brief summary not a complete description of benefits For more information contact the plan This brochure may be available in alternate formats upon request Blue Cross and Blue Shield of North Carolina is a PDP plan with a Medicare contract Enrollment in Blue Cross and Blue Shield of North Carolina depends on contract renewal An independent licensee of the Blue Cross and Blue Shield Association reg SM Marks of the Blue Cross and Blue Shield Association SM1 Mark of Blue Cross and Blue Shield of North Carolina

If you are covered by oreligible for Medicare contactyour local Authorized SalesRepresentative to learn aboutour Medicare Part D plans

How can we help Call 1-800-478-0583 7 days aweek 8 am-8 pm For hearing and speech impaired(TTYTDD) usersCall 1-800-922-3140 7 days aweek 8 am-8 pm

Preferred Pharmacy NetworkBlue Medicare Rx (PDP)

Standard Plan Enhanced Plan Many of the popular drugsare covered ndash more than 1000included

Extensive list of covered drugs ndashmore than 1800 included

You pay $145 annual deductible No deductible ndash coverage beginsright away

$4 and $40 copayments for mostdrugs when you use our preferredpharmacy network up to $2850total drug cost

$3 and $30 copayments for mostdrugs when you use our preferredpharmacy network up to $2850total drug cost

You pay 72 on all generic drugsand you receive a discount onbrand-name drugs during the

ldquocoverage gaprdquo until true out-of-pocket costs reach $4550

You pay $3 copayment forpreferred generic drugs you pay72 for most other generic drugsand you receive a discount forbrand-name drugs during the

ldquocoverage gaprdquo until true out-of-pocket costs reach $4550

Generally 5 coinsurance after ldquocoverage gaprdquo ends Preferred Pharmacy Network includes CVS WalMart

Kerr Drugs and Epic Pharmacies

Non-preferred Pharmacy NetworkBlue Medicare Rx (PDP)

Standard Plan Enhanced Plan Many of the popular drugsare covered ndash more than 1000included

Extensive list of covered drugs ndashmore than 1800 included

You pay $145 annual deductible No deductible ndash coverage beginsright away

$10 and $45 copayments for mostdrugs up to $2850 total drug cost

$8 and $45 copayments for mostdrugs up to $2850 total drug cost

You pay 72 on all generic drugsand you receive a discount onbrand-name drugs during the

ldquocoverage gaprdquo until true out-of-pocket costs reach $4550

You pay $8 copayment forpreferred generic drugs you pay72 for most other generic drugsand you receive a discount forbrand-name drugs during the

ldquocoverage gaprdquo until true out-of-pocket costs reach $4550

Generally 5 coinsurance after ldquocoverage gaprdquo ends

PAGE 40 of 40

Y0079_6250 CMS Approved 08062013

Section 2 - Summary of benefits for ndash Benefit Outpatient Prescription Drugs Contract S5540 Plan 004 and Plan 002

Original Medicare

Blue Medicare Rx Enhanced (PDP) (Plan 004)

Blue Medicare Rx Standard (PDP) (Plan 002)

If you request a formulary exception for adrug and Blue Medicare Rx Enhanced (PDP)approves the exception you will pay Tier 4 Non-Preferred Brand cost sharing for that drug

If you request a formulary exception for adrug and Blue Medicare Rx Standard (PDP)approves the exception you will pay Tier 4 Non-Preferred Brand cost sharing for that drug

In-network $0 deductible In-network $145 annual deductible

Initial Coverage You pay the following until totalyearly drug costs reach $2850

Initial Coverage After you pay your yearlydeductible you pay the following until totalyearly drug costs reach $2850

Retail pharmacy Contact your plan if you have questions aboutcost-sharing or billing when less than a one-month supply is dispensed You can get drugsfrom a preferred and non-preferred pharmacy thefollowing way(s) Tier 1 - Preferred Generic + $3 copay for a one-month (30-day) supply of

drugs in this tier from a preferred pharmacy + $6 copay for a two-month (60-day) supply of

drugs in this tier from a preferred pharmacy + $9 copay for a three-month (90-day)supply of

drugs in this tier from a preferred pharmacy + $8 copay for a one-month (30-day) supply of

drugs in this tier from a non-preferred pharmacy + $16 copay for a two-month (60-day) supply of

drugs in this tier from a non-preferred pharmacy + $24 copay for a three-month (90-day) supply of

drugs in this tier from a non-preferred pharmacy

Retail pharmacy Contact your plan if you have questions aboutcost-sharing or billing when less than a one-month supply is dispensed You can get drugsfrom a preferred and non-preferred pharmacy thefollowing way(s) Tier 1 - Preferred Generic + $4 copay for a one-month (30-day) supply of

drugs in this tier from a preferred pharmacy + $8 copay for a two-month (60-day)supply of

drugs in this tier from a preferred pharmacy + $12 copay for a three-month (90-day) supply of

drugs in this tier from a preferred pharmacy + $10 copay for a one-month (30-day) supply of

drugs in this tier from a non-preferred pharmacy + $20 copay for a two-month (60-day) supply of

drugs in this tier from a non-preferred pharmacy + $30 copay for a three-month (90-day) supply of

drugs in this tier from a non-preferred pharmacy

Not all drugs on this tier are available at this extended day supply Please contactthe plan for more information

Tier 2 - Non-Preferred Generic + $6 copay for a one-month (30-day) supply of

drugs in this tier from a preferred pharmacy + $12 copay for a two-month (60-day)supply of

drugs in this tier from a preferred pharmacy + $18 copay for a three-month (90-day) supply of

drugs in this tier from a preferred pharmacy + $20 copay for a one-month (30-day) supply of

drugs in this tier from a non-preferred pharmacy + $40 copay for a two-month (60-day) supply of

drugs in this tier from a non-preferred pharmacy + $60 copay for a three-month (90-day) supply of

drugs in this tier from a non-preferred pharmacy

Tier 2 - Non-Preferred Generic + $10 copay for a one-month (30-day) supply of

drugs in this tier from a preferred pharmacy + $20 copay for a two-month (60-day)supply of

drugs in this tier from a preferred pharmacy + $30 copay for a three-month (90-day) supply of

drugs in this tier from a preferred pharmacy + $33 copay for a one-month (30-day) supply of

drugs in this tier from a non-preferred pharmacy + $66 copay for a two-month (60-day) supply of

drugs in this tier from a non-preferred pharmacy + $99 copay for a three-month (90-day) supply of

drugs in this tier from a non-preferred pharmacy

Not all drugs on this tier are available at this extended day supply Please contactthe plan for more information

PAG E 26 of 40

Original Medicare

Blue Medicare Rx Enhanced (PDP) (Plan 004)

Blue Medicare Rx Standard (PDP) (Plan 002)

Tier 3 - Preferred Brand + $30 copay for a one-month (30-day) supply of

drugs in this tier from a preferred pharmacy+ $60 copay for a two-month (60-day) supply of

drugs in this tier from a preferred pharmacy+ $90 copay for a three-month (90-day) supply of

drugs in this tier from a preferred pharmacy+ $45 copay for a one-month (30-day) supply of

drugs in this tier from a non-preferred pharmacy+ $90 copay for a two-month (60-day) supply of

drugs in this tier from a non-preferred pharmacy+ $135 copay for a three-month (90-day) supply of

drugs in this tier from a non-preferred pharmacy

Tier 3 - Preferred Brand + $40 copay for a one-month (30-day) supply of

drugs in this tier from a preferred pharmacy+ $80 copay for a two-month (60-day) supply of

drugs in this tier from a preferred pharmacy+ $120 copay for a three-month (90-day) supply of

drugs in this tier from a preferred pharmacy+ $45 copay for a one-month (30-day) supply of

drugs in this tier from a non-preferred pharmacy+ $90 copay for a two-month (60-day) supply of

drugs in this tier from a non-preferred pharmacy+ $135 copay for a three-month (90-day) supply of

drugs in this tier from a non-preferred pharmacy Not all drugs on this tier are available at this extended day supply Please contact

the plan for more information Tier 4 - Non-Preferred Brand + $70 copay for a one-month (30-day) supply of

drugs in this tier from a preferred pharmacy+ $140 copay for a two-month (60-day) supply of

drugs in this tier from a preferred pharmacy+ $210 copay for a three-month (90-day) supply of

drugs in this tier from a preferred pharmacy+ $95 copay for a one-month (30-day) supply of

drugs in this tier from a non-preferred pharmacy+ $190 copay for a two-month (60-day) supply of

drugs in this tier from a non-preferred pharmacy+ $285 copay for a three-month (90-day) supply of

drugs in this tier from a non-preferred pharmacy

Tier 4 - Non-Preferred Brand + $85 copay for a one-month (30-day) supply of

drugs in this tier from a preferred pharmacy+ $170 copay for a two-month (60-day) supply of

drugs in this tier from a preferred pharmacy+ $255 copay for a three-month (90-day) supply of

drugs in this tier from a preferred pharmacy+ $95 copay for a one-month (30-day) supply of

drugs in this tier from a non-preferred pharmacy+ $190 copay for a two-month (60-day) supply of

drugs in this tier from a non-preferred pharmacy+ $285 copay for a three-month (90-day) supply of

drugs in this tier from a non-preferred pharmacy Not all drugs on this tier are available at this extended day supply Please contact

the plan for more information Tier 5 - Specialty Tier + 33 coinsurance for a one-month (30-day)

supply of drugs in this tier from a preferredpharmacy

+ 33 coinsurance for a two-month (60-day)supply of drugs in this tier from a preferredpharmacy

+ 33 coinsurance for a three-month (90- day)supply of drugs in this tier from a preferredpharmacy

+ 33 coinsurance for a one-month (30-day)supply of drugs in this tier from a non-preferredpharmacy

+ 33 coinsurance for a two-month (60-day)supply of drugs in this tier from a non-preferredpharmacy

+ 33 coinsurance for a three-month (90-day)supply of drugs in this tier from a non-preferredpharmacy

Tier 5 - Specialty Tier + 29 coinsurance for a one-month (30-day)

supply of drugs in this tier from a preferredpharmacy

+ 29 coinsurance for a two-month (60-day)supply of drugs in this tier from a preferredpharmacy

+ 29 coinsurance for a three-month (90-day)supply of drugs in this tier from a preferredpharmacy

+ 29 coinsurance for a one-month (30-day)supply of drugs in this tier from a non-preferredpharmacy

+ 29 coinsurance for a two-month (60-day)supply of drugs in this tier from a non-preferredpharmacy

+ 29 coinsurance for a three-month (90-day)supply of drugs in this tier from a non-preferredpharmacy

Not all drugs on this tier are available at this extended day supply Please contactthe plan for more information

PAG E 27 of 40

Section 2 - Summary of benefits for ndash Benefit Outpatient Prescription Drugs Contract S5540 Plan 004 and Plan 002

Original Medicare

Blue Medicare Rx Enhanced (PDP) (Plan 004)

Blue Medicare Rx Standard (PDP) (Plan 002)

Long Term Care Pharmacy Long term care pharmacies must dispense brand name drugs in amounts less than a 14 days supply at a time They may also dispenseless than a monthrsquos supply of generic drugs at a time Contact your plan if you have questionsabout cost-sharing or billing when less than aone-month supply is dispensed You can get drugs the following way(s)Tier 1 - Preferred Generic + $8 copay for a one-month (31-day)

supply of drugs in this tierTier 2 - Non-Preferred Generic + $20 copay for a one-month (31-day)

supply of drugs in this tierTier 3 - Preferred Brand + $45 copay for a one-month (31-day)

supply of drugs in this tierTier 4 - Non-Preferred Brand + $95 copay for a one-month (31-day)

supply of drugs in this tierTier 5 - Specialty Tier + 33 coinsurance for a one-month (31-day)

supply of drugs in this tier

Long Term Care Pharmacy Long term care pharmacies must dispense brand name drugs in amounts less than a 14 days supply at a time They may also dispenseless than a monthrsquos supply of generic drugs at a time Contact your plan if you have questionsabout cost-sharing or billing when less than aone-month supply is dispensed You can get drugs the following way(s)Tier 1 - Preferred Generic + $10 copay for a one-month (31-day)

supply of drugs in this tierTier 2 - Non-Preferred Generic + $33 copay for a one-month (31-day)

supply of drugs in this tierTier 3 - Preferred Brand + $45 copay for a one-month (31-day)

supply of drugs in this tierTier 4 - Non-Preferred Brand + $95 copay for a one-month (31-day)

supply of drugs in this tierTier 5 - Specialty Tier + 29 coinsurance for a one-month (31-day)

supply of drugs in this tier Mail order Contact your plan if you have questions aboutcost-sharing or billing when less than a one-month supply is dispensed You can get drugs from a preferred and non-preferred mail order pharmacy the following way(s)Tier 1 - Preferred Generic + $3 copay for a one-month (30-day)

supply of drugs in this tier from apreferred mail order pharmacy

+ $0 copay for a two-month (60-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $0 copay for a three-month (90-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $8 copay for a one-month (30-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $16 copay for a two-month (60-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $24 copay for a three-month (90-day)supply of drugs in this tier from anon-preferred mail order pharmacy

Mail order Contact your plan if you have questions aboutcost-sharing or billing when less than a one-month supply is dispensed You can get drugs from a preferred and non-preferred mail order pharmacy the following way(s)Tier 1 - Preferred Generic + $4 copay for a one-month (30-day)

supply of drugs in this tier from apreferred mail order pharmacy

+ $0 copay for a two-month (60-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $0 copay for a three-month (90-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $10 copay for a one-month (30-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $20 copay for a two-month (60-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $30 copay for a three-month (90-day)supply of drugs in this tier from anon-preferred mail order pharmacy

Not all drugs on this tier are available at this extended day supplyPlease contact the plan for more information

PAG E 28 of 40

Original Medicare

Blue Medicare Rx Enhanced (PDP) (Plan 004)

Blue Medicare Rx Standard (PDP) (Plan 002)

Mail order (continued) Tier 2 - Non-Preferred Generic

+ $6 copay for a one-month (30-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $12 copay for a two-month (60-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $15 copay for a three-month (90-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $20 copay for a one-month (30-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $40 copay for a two-month (60-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $60 copay for a three-month (90-day)supply of drugs in this tier from anon-preferred mail order pharmacy

Mail order (continued) Tier 2 - Non-Preferred Generic

+ $10 copay for a one-month (30-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $20 copay for a two-month (60-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $25 copay for a three-month (90-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $33 copay for a one-month (30-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $66 copay for a two-month (60-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $99 copay for a three-month (90-day)supply of drugs in this tier from anon-preferred mail order pharmacy

Not all drugs on this tier are available at this extended day supply Please contactthe plan for more information

Tier 3 - Preferred Brand + $30 copay for a one-month (30-day)

supply of drugs in this tier from apreferred mail order pharmacy

+ $60 copay for a two-month (60-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $75 copay for a three-month (90-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $45 copay for a one-month (30-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $90 copay for a two-month (60-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $135 copay for a three-month (90-day)supply of drugs in this tier from anon-preferred mail order pharmacy

Tier 3 - Preferred Brand + $40 copay for a one-month (30-day)

supply of drugs in this tier from apreferred mail order pharmacy

+ $80 copay for a two-month (60-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $100 copay for a three-month (90-day) supply of drugs in this tier from apreferred mail order pharmacy

+ $45 copay for a one-month (30-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $90 copay for a two-month (60-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $135 copay for a three-month (90-day)supply of drugs in this tier from anon-preferred mail order pharmacy

Not all drugs on this tier are available at this extended day supply Please contactthe plan for more information

PAG E 29 of 40

Section 2 - Summary of benefits for ndash Benefit Outpatient Prescription Drugs Contract S5540 Plan 004 and Plan 002

Original Medicare

Blue Medicare Rx Enhanced (PDP) (Plan 004)

Blue Medicare Rx Standard (PDP) (Plan 002)

Mail order (continued) Tier 4 - Non-Preferred Brand

+ $70 copay for a one-month (30-day) supply of drugs in this tier from apreferred mail order pharmacy

+ $140 copay for a two-month (60-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $175 copay for a three-month (90-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $95 copay for a one-month (30-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $190 copay for a two-month (60-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $285 copay for a three-month (90-day)supply of drugs in this tier from anon-preferred mail order pharmacy

Mail order (continued) Tier 4 - Non-Preferred Brand + $85 copay for a one-month (30-day)

supply of drugs in this tier from apreferred mail order pharmacy

+ $170 copay for a two-month (60-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $21250 copay for a three-month (90-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $95 copay for a one-month (30-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $190 copay for a two-month (60-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $285 copay for a three-month (90-day)supply of drugs in this tier from anon-preferred mail order pharmacy

Not all drugs on this tier are available at this extended day supply Please contactthe plan for more information

Tier 5 - Specialty Tier

+ 33 coinsurance for a one-month (30-day) supply of drugs in this tier from apreferred mail order pharmacy

+ 33 coinsurance for a two-month (60-day) supply of drugs in this tier from apreferred mail order pharmacy

+ 33 coinsurance for a three-month (90-day) supply of drugs in this tier from apreferred mail order pharmacy

+ 33 coinsurance for a one-month (30-day) supply of drugs in this tier froma non-preferred mail order pharmacy

+ 33 coinsurance for a two-month (60-day) supply of drugs in this tier from anon-preferred mail order pharmacy

+ 33 coinsurance for a three-month (90-day) supply of drugs in this tier froma non-preferred mail order pharmacy

Tier 5 - Specialty Tier

+ 29 coinsurance for a one-month (30-day)supply of drugs in this tier from apreferred mail order pharmacy

+ 29 coinsurance for a two-month (60-day) supply of drugs in this tier from apreferred mail order pharmacy

+ 29 coinsurance for a three-month (90-day)supply of drugs in this tier from a preferredmail order pharmacy

+ 29 coinsurance for a one-month (30-day)supply of drugs in this tier froma non-preferred mail order pharmacy

+ 29 coinsurance for a two-month (60-day) supply of drugs in this tier from anon-preferred mail order pharmacy

+ 29 coinsurance for a three-month (90-day)supply of drugs in this tier froma non-preferred mail order pharmacy

Not all drugs on this tier are available at this extended day supply Please contactthe plan for more information

PAG E 30 of 40

Original Medicare

Blue Medicare Rx Enhanced (PDP) (Plan 004)

Blue Medicare Rx Standard (PDP) (Plan 002)

Coverage gap After your total yearly drug costs reach $2850 you receive limited coverage by the plan on certaindrugs You will also receive a discount on brand name drugs and generally pay no more than 475for the planrsquos costs for brand drugs and 72 of the planrsquos costs for generic drugs until your yearly out-of-pocket drug costs reach $4550 Additional Coverage gap The plan covers some formulary generics (10-64 of formularygeneric drugs) through the coverage gap The plan offers additional coverage in the gap for thefollowing tiers You pay the following Retail Pharmacy Contact your plan if you have questions about cost-sharing orbilling when less than a one-month supply is dispensed

Tier 1 Preferred Generic + $3 copay for a one-month (30-day) supply of all drugs

covered within this tier from a preferred pharmacy + $6 copay for a two-month (60-day) supply of all drugs

covered within this tier from a preferred pharmacy + $9 copay for a three-month (90-day) supply of all drugs

covered within this tier from a preferred pharmacy + $8 copay for a one-month (30-day) supply of all drugs

covered within this tier at a non-preferred pharmacy + $16 copay for a two-month (60-day) supply of all drugs

covered within this tier from a non-preferred pharmacy + $24 copay for a three-month (90-day) supply of all drugs

covered within this tier from a non-preferred pharmacy

Not all drugs on this tier are available at this extended daysupply Please contact the plan for more information

Long Term Care Pharmacy Long term care pharmacies must dispense brand name drugsin amounts less than a 14 days supply at a time They may alsodispense less than a monthrsquos supply of generic drugs at a timeContact your plan if you have questions about cost-sharing orbilling when less than a one-month supply is dispensed Tier 1 Preferred Generic + $8 copay for a one-month (31-day) supply of all drugs

covered in this tier

PAG E 31 of 40

Section 2 - Summary of benefits for ndash Benefit Outpatient Prescription Drugs Contract S5540 Plan 004 and Plan 002

Original Medicare

Blue Medicare Rx Enhanced (PDP) (Plan 004)

Blue Medicare Rx Standard (PDP) (Plan 002)

Mail Order Contact your plan if you have questions about cost-sharing orbilling when less than a one-month supply is dispensed Tier 1 Preferred Generic + $3 copay for a one-month (30-day) supply of all drugs

covered within this tier from a preferred mail order pharmacy + $0 copay for a two-month (60-day) supply of all drugs

covered within this tier from a preferred mail order pharmacy + $0 copay for a three-month (90-day) supply of all drugs

covered within this tier from a preferred mail order pharmacy + $8 copay for a one-month (30-day) supply of all drugs

covered within this tier from a non-preferred mail orderpharmacy

+ $16 copay for a two-month (60-day) supply of all drugscovered within this tier from a non-preferred mail orderpharmacy

+ $24 copay for a three-month (90-day) supply of all drugscovered within this tier from a non-preferred mail orderpharmacy

Not all drugs on this tier are available at this extended daysupply Please contact the plan for more information

PAG E 32 of 40

Original Medicare

Blue Medicare Rx Enhanced (PDP) (Plan 004)

Blue Medicare Rx Standard (PDP) (Plan 002)

Catastrophic coverage After your yearly out-of-pocket drug costs reach $4550 you pay the greater of + 5 coinsurance or + $255 copay for generic (including brand drugs treated as generic) and a $635

copay for all other drugs

Out-of-network Plan drugs may be covered in special circumstances for instance illness while traveling outside ofthe planrsquos service area where there is no network pharmacy You may have to pay more than yournormal cost-sharing amount if you get your drugs at an out-of-network pharmacy In addition youwill likely have to pay the pharmacyrsquos full charge for the drug and submit documentation to receivereimbursement from Blue Medicare Rx (PDP)

You can get out-of-network drugs the following way

Out-of-network initial coverage

You will be reimbursed up to the planrsquos costof the drug minus the following for drugspurchased out-of-network until total yearlydrug costs reach $2850 Tier 1 - Preferred Generic

+ $8 copay for a one-month (30-day)supply of drugs in this tier Tier 2 - Non-Preferred Generic

+ $20 copay for a one-month (30-day)supply of drugs in this tier

Tier 3 - Preferred Brand

+ $45 copay for a one-month (30-day)supply of drugs in this tier

Tier 4 - Non-Preferred Brand

+ $95 copay for a one-month (30-day)supply of drugs in this tier

Tier 5 - Specialty Tier

+ 33 coinsurance for a one-month (30-day)supply of drugs in this tier

Out-of-network initial coverage

After you pay your yearly deductible you willbe reimbursed up to the planrsquos cost of the drugminus the following for drugs purchasedout-of-network until total yearly drug costsreach $2850 Tier 1 - Preferred Generic

+ $10 copay for a one-month (30-day)supply of drugs in this tier

Tier 2 - Non-Preferred Generic

+ $33 copay for a one-month (30-day)supply of drugs in this tier

Tier 3 - Preferred Brand

+ $45 copay for a one-month (30-day)supply of drugs in this tier

Tier 4 - Non-Preferred Brand

+ $95 copay for a one-month (30-day)supply of drugs in this tier

Tier 5 - Specialty Tier

+ 29 coinsurance for a one-month (30-day)supply of drugs in this tier

You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge andthe planrsquos In-Network allowable amount

Out-of-Network Coverage Gap You will be reimbursed up to 28 of the plan allowable cost for generic drugs purchasedout-of-network until total yearly out-of-pocket drug costs reach $4550 Please note that theplan allowable cost may be less than the out-of-network pharmacy price paid for your drug(s)

PAG E 33 of 40

Section 2 - Summary of benefits for ndash Benefit Outpatient Prescription Drugs Contract S5540 Plan 004 and Plan 002

Original Medicare

Blue Medicare Rx Enhanced (PDP) (Plan 004)

Blue Medicare Rx Standard (PDP) (Plan 002)

Out-of-Network Coverage Gap (continued)

You will be reimbursed up to 525 of the plan allowable cost for brand name drugs purchasedout-of-network until your total yearly out-of-pocket drug costs reach $4550 Please note that theplan allowable cost may be less than the out-of-network pharmacy price paid for your drug(s)

Additional Out-of-Network Coverage Gap

You will be reimbursed for these drugspurchased out-of-network up to the planrsquoscost of the drug minus the following

Tier 1 Preferred Generic

+ $8 copay for a one-month (30-day) supplyof all drugs covered within this tier

Out-of-network Catastrophic Coverage After your yearly out-of-pocket drug costs reach $4550 you will be reimbursed for drugs purchasedout-of-network up to the planrsquos cost of the drug minus your cost share which is the greater of+ 5 coinsurance or+ $255 copay for generic (including brand drugs treated as generic) and+ $635 copay for all other drugs

You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge andthe planrsquos In-Network allowable amount

PAG E 34 of 40

PAGE 35 of 40

(PDP)

Multi-language Interpreter Services

English We have free interpreter services to answer any questions you may have about our health or drug plan To get an interpreter just call us at 1-800-478-0583 Someone who speaks EnglishLanguage can help you This is a free service

Spanish Tenemos servicios de inteacuterprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos Para hablar con un inteacuterprete por favor llame al 1-800-478-0583 Alguien que hable espantildeol le podraacute ayudar Este es un servicio gratuito

Chinese Mandarin 我们提供免们的翻们服们们助们解答们于健康或们物保们的任何疑 们如果们需要此翻们服们们致们 phone number我们的中文工作人们很们意们助们 们是一们免们服们

Chinese Cantonese 您對我們的健康或藥物保險可能存有疑問為此我們提供免費的翻譯服務如需翻譯服務請致電 1-800-478-0583我們講中文的人員將樂意為您提供幫助這是一項免費服務

Tagalog Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot Upang makakuha ng tagasaling-wika tawagan lamang kami sa 1-800-478-0583 Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog Ito ay libreng serbisyo

French Nous proposons des services gratuits dinterpreacutetation pour reacutepondre agrave toutes vos questions relatives agrave notre reacutegime de santeacute ou dassurance-meacutedicaments Pour acceacuteder au service dinterpreacutetation il vous suffit de nous appeler au 1-800-478-0583 Un interlocuteur parlant Franccedilais pourra vous aider Ce service est gratuit

Vietnamese Chuacuteng tocirci coacute dịch vụ thocircng dịch miễn phiacute để trả lời caacutec cacircu hỏi về chương sức khỏe vagrave chương trigravenh thuốc men Nếu quiacute vị cần thocircng dịch viecircn xin gọi 1-800-478-0583 sẽ coacute nhacircn viecircn noacutei tiếng Việt giuacutep đỡ quiacute vị Đacircy lagrave dịch vụ miễn phiacute

German Unser kostenloser Dolmetscherservice beantwortet Ihren Fragen zu unserem Gesundheits- und Arzneimittelplan Unsere Dolmetscher erreichen Sie unter 1-800-478-0583 Man wird Ihnen dort auf Deutsch weiterhelfen Dieser Service ist kostenlos

Korean 당사는 의료 보험 또는 약품 보험에 관한 질문에 답해 드리고자 무료 통역 서비스를 제공하고 있습니다 통역 서비스를 이용하려면 전화 1-800-478-0583 번으로 문의해 주십시오 한국어를 하는 담당자가 도와 드릴 것입니다 이 서비스는 무료로 운영됩니다

Y0079_6200 CMS Approved 07082013 U5073d 813

116

Appendix 4 ndash Multi-Language Insert

Multi-language Interpreter Services

English We have free interpreter services to answer any questions you may have about our health or drug plan To get an interpreter just call us at [1-xxx-xxx-xxxx] Someone who speaks EnglishLanguage can help you This is a free service

Spanish Tenemos servicios de inteacuterprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos Para hablar con un inteacuterprete por favor llame al [1-xxx-xxx-xxxx] Alguien que hable espantildeol le podraacute ayudar Este es un servicio gratuito

Chinese Mandarin 我们提供免费的翻译服务帮助您解答关于健康或药物保险的任何疑

问如果您需要此翻译服务请致电 1-xxx-xxx-xxxx我们的中文工作人员很乐意帮助您

这是一项免费服务

Chinese Cantonese 您對我們的健康或藥物保險可能存有疑問為此我們提供免費的翻譯

服務如需翻譯服務請致電 1-xxx-xxx-xxxx我們講中文的人員將樂意為您提供幫助這

是一項免費服務

Tagalog Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot Upang makakuha ng tagasaling-wika tawagan lamang kami sa [1-xxx-xxx-xxxx] Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog Ito ay libreng serbisyo French Nous proposons des services gratuits dinterpreacutetation pour reacutepondre agrave toutes vos questions relatives agrave notre reacutegime de santeacute ou dassurance-meacutedicaments Pour acceacuteder au service dinterpreacutetation il vous suffit de nous appeler au [1-xxx-xxx-xxxx] Un interlocuteur parlant Franccedilais pourra vous aider Ce service est gratuit Vietnamese Chuacuteng tocirci coacute dịch vụ thocircng dịch miễn phiacute để trả lời caacutec cacircu hỏi về chương sức khỏe vagrave chương trigravenh thuốc men Nếu quiacute vị cần thocircng dịch viecircn xin gọi [1-xxx-xxx-xxxx] sẽ coacute nhacircn viecircn noacutei tiếng Việt giuacutep đỡ quiacute vị Đacircy lagrave dịch vụ miễn phiacute

116

Appendix 4 ndash Multi-Language Insert

Multi-language Interpreter Services

English We have free interpreter services to answer any questions you may have about our health or drug plan To get an interpreter just call us at [1-xxx-xxx-xxxx] Someone who speaks EnglishLanguage can help you This is a free service

Spanish Tenemos servicios de inteacuterprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos Para hablar con un inteacuterprete por favor llame al [1-xxx-xxx-xxxx] Alguien que hable espantildeol le podraacute ayudar Este es un servicio gratuito

Chinese Mandarin 我们提供免费的翻译服务帮助您解答关于健康或药物保险的任何疑

问如果您需要此翻译服务请致电 1-xxx-xxx-xxxx我们的中文工作人员很乐意帮助您

这是一项免费服务

Chinese Cantonese 您對我們的健康或藥物保險可能存有疑問為此我們提供免費的翻譯

服務如需翻譯服務請致電 1-xxx-xxx-xxxx我們講中文的人員將樂意為您提供幫助這

是一項免費服務

Tagalog Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot Upang makakuha ng tagasaling-wika tawagan lamang kami sa [1-xxx-xxx-xxxx] Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog Ito ay libreng serbisyo French Nous proposons des services gratuits dinterpreacutetation pour reacutepondre agrave toutes vos questions relatives agrave notre reacutegime de santeacute ou dassurance-meacutedicaments Pour acceacuteder au service dinterpreacutetation il vous suffit de nous appeler au [1-xxx-xxx-xxxx] Un interlocuteur parlant Franccedilais pourra vous aider Ce service est gratuit Vietnamese Chuacuteng tocirci coacute dịch vụ thocircng dịch miễn phiacute để trả lời caacutec cacircu hỏi về chương sức khỏe vagrave chương trigravenh thuốc men Nếu quiacute vị cần thocircng dịch viecircn xin gọi [1-xxx-xxx-xxxx] sẽ coacute nhacircn viecircn noacutei tiếng Việt giuacutep đỡ quiacute vị Đacircy lagrave dịch vụ miễn phiacute

116

Appendix 4 ndash Multi-Language Insert

Multi-language Interpreter Services

English We have free interpreter services to answer any questions you may have about our health or drug plan To get an interpreter just call us at [1-xxx-xxx-xxxx] Someone who speaks EnglishLanguage can help you This is a free service

Spanish Tenemos servicios de inteacuterprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos Para hablar con un inteacuterprete por favor llame al [1-xxx-xxx-xxxx] Alguien que hable espantildeol le podraacute ayudar Este es un servicio gratuito

Chinese Mandarin 我们提供免费的翻译服务帮助您解答关于健康或药物保险的任何疑

问如果您需要此翻译服务请致电 1-xxx-xxx-xxxx我们的中文工作人员很乐意帮助您

这是一项免费服务

Chinese Cantonese 您對我們的健康或藥物保險可能存有疑問為此我們提供免費的翻譯

服務如需翻譯服務請致電 1-xxx-xxx-xxxx我們講中文的人員將樂意為您提供幫助這

是一項免費服務

Tagalog Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot Upang makakuha ng tagasaling-wika tawagan lamang kami sa [1-xxx-xxx-xxxx] Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog Ito ay libreng serbisyo French Nous proposons des services gratuits dinterpreacutetation pour reacutepondre agrave toutes vos questions relatives agrave notre reacutegime de santeacute ou dassurance-meacutedicaments Pour acceacuteder au service dinterpreacutetation il vous suffit de nous appeler au [1-xxx-xxx-xxxx] Un interlocuteur parlant Franccedilais pourra vous aider Ce service est gratuit Vietnamese Chuacuteng tocirci coacute dịch vụ thocircng dịch miễn phiacute để trả lời caacutec cacircu hỏi về chương sức khỏe vagrave chương trigravenh thuốc men Nếu quiacute vị cần thocircng dịch viecircn xin gọi [1-xxx-xxx-xxxx] sẽ coacute nhacircn viecircn noacutei tiếng Việt giuacutep đỡ quiacute vị Đacircy lagrave dịch vụ miễn phiacute

1-800-478-0583

PAGE 36 of 40

(PDP)

Multi-language Interpreter Services (continued)

Russian Если у вас возникнут вопросы относительно страхового или медикаментного плана вы можете воспользоваться нашими бесплатными услугами переводчиков Чтобы воспользоваться услугами переводчика позвоните нам по телефону 1-800-478-0583 Вам окажет помощь сотрудник который говорит по-pусски Данная услуга бесплатная

Arabicةيودألا لودج وأ ةحصلاب قلعتت ةلئسأ يأ نع ةباجإلل ةيناجملا يروفلا مجرتملا تامدخ مدقن اننإ صخش موقيس 0583-478-800-1 ىلع انب لاصتالا ىوس كيلع سيل يروف مجرتم ىلع لوصحلل انيدلةيناجم ةمدخ هذه كتدعاسمب ةيبرعلا ثدحتي ام

Hindi हमार सवासथय या दवा की योजना क बार म आपक किसी भी परशन क जवाब दन क लिए हमार पास मफत दभाषिया सवाए उपलबध ह एक दभाषिया परापत करन क लिए बस हम 1-800-478-0583 पर फोन कर कोई वयकति जो हिनदी बोलता ह आपकी मदद कर सकता ह यह एक मफत सवा ह

Italian Egrave disponibile un servizio di interpretariato gratuito per rispondere a eventuali domande sul nostro piano sanitario e farmaceutico Per un interprete contattare il numero 1-800-478-0583 Un nostro incaricato che parla Italianovi forniragrave lassistenza necessaria Egrave un servizio gratuito

Portugueacutes Dispomos de serviccedilos de interpretaccedilatildeo gratuitos para responder a qualquer questatildeo que tenha acerca do nosso plano de sauacutede ou de medicaccedilatildeo Para obter um inteacuterprete contacte-nos atraveacutes do nuacutemero 1-800-478-0583 Iraacute encontrar algueacutem que fale o idioma Portuguecircs para o ajudar Este serviccedilo eacute gratuito

French Creole Nou genyen segravevis entegravepregravet gratis pou reponn tout kesyon ou ta genyen konsegravenan plan medikal oswa dwograveg nou an Pou jwenn yon entegravepregravet jis rele nou nan 1-800-478-0583 Yon moun ki pale Kreyogravel kapab ede w Sa a se yon segravevis ki gratis

Polish Umożliwiamy bezpłatne skorzystanie z usług tłumacza ustnego ktoacutery pomoże w uzyskaniu odpowiedzi na temat planu zdrowotnego lub dawkowania lekoacutew Aby skorzystać z pomocy tłumacza znającego język polski należy zadzwonić pod numer 1-800-478-0583 Ta usługa jest bezpłatna

Japanese 当社の健康 健康保険と薬品 処方薬プランに関するご質問にお答えするために無

料の通訳サービスがありますございます通訳をご用命になるには1-800-478-0583 にお電

話ください日本語を話す人 者 が支援いたしますこれは無料のサービスです

Notes

PAG E 37 of 40

Notes

PAG E 38 of 40

Notes

U5073e 813

PAGE 39 of 40

Awarded to BCBSNC by the Ethisphere Institute In 2013 companies in more than 100 countries and 36 industries were reviewed and of those 138 organizations were designated as Worldrsquos Most Ethical

BCBSNC Blue Medicare Rx products are only available to Medicare beneficiaries residing in North Carolina The information described in this brochure is for 2014 and may change on January 1 2015 The benefit information provided is a brief summary not a complete description of benefits For more information contact the plan This brochure may be available in alternate formats upon request Blue Cross and Blue Shield of North Carolina is a PDP plan with a Medicare contract Enrollment in Blue Cross and Blue Shield of North Carolina depends on contract renewal An independent licensee of the Blue Cross and Blue Shield Association reg SM Marks of the Blue Cross and Blue Shield Association SM1 Mark of Blue Cross and Blue Shield of North Carolina

If you are covered by oreligible for Medicare contactyour local Authorized SalesRepresentative to learn aboutour Medicare Part D plans

How can we help Call 1-800-478-0583 7 days aweek 8 am-8 pm For hearing and speech impaired(TTYTDD) usersCall 1-800-922-3140 7 days aweek 8 am-8 pm

Preferred Pharmacy NetworkBlue Medicare Rx (PDP)

Standard Plan Enhanced Plan Many of the popular drugsare covered ndash more than 1000included

Extensive list of covered drugs ndashmore than 1800 included

You pay $145 annual deductible No deductible ndash coverage beginsright away

$4 and $40 copayments for mostdrugs when you use our preferredpharmacy network up to $2850total drug cost

$3 and $30 copayments for mostdrugs when you use our preferredpharmacy network up to $2850total drug cost

You pay 72 on all generic drugsand you receive a discount onbrand-name drugs during the

ldquocoverage gaprdquo until true out-of-pocket costs reach $4550

You pay $3 copayment forpreferred generic drugs you pay72 for most other generic drugsand you receive a discount forbrand-name drugs during the

ldquocoverage gaprdquo until true out-of-pocket costs reach $4550

Generally 5 coinsurance after ldquocoverage gaprdquo ends Preferred Pharmacy Network includes CVS WalMart

Kerr Drugs and Epic Pharmacies

Non-preferred Pharmacy NetworkBlue Medicare Rx (PDP)

Standard Plan Enhanced Plan Many of the popular drugsare covered ndash more than 1000included

Extensive list of covered drugs ndashmore than 1800 included

You pay $145 annual deductible No deductible ndash coverage beginsright away

$10 and $45 copayments for mostdrugs up to $2850 total drug cost

$8 and $45 copayments for mostdrugs up to $2850 total drug cost

You pay 72 on all generic drugsand you receive a discount onbrand-name drugs during the

ldquocoverage gaprdquo until true out-of-pocket costs reach $4550

You pay $8 copayment forpreferred generic drugs you pay72 for most other generic drugsand you receive a discount forbrand-name drugs during the

ldquocoverage gaprdquo until true out-of-pocket costs reach $4550

Generally 5 coinsurance after ldquocoverage gaprdquo ends

PAGE 40 of 40

Y0079_6250 CMS Approved 08062013

Original Medicare

Blue Medicare Rx Enhanced (PDP) (Plan 004)

Blue Medicare Rx Standard (PDP) (Plan 002)

Tier 3 - Preferred Brand + $30 copay for a one-month (30-day) supply of

drugs in this tier from a preferred pharmacy+ $60 copay for a two-month (60-day) supply of

drugs in this tier from a preferred pharmacy+ $90 copay for a three-month (90-day) supply of

drugs in this tier from a preferred pharmacy+ $45 copay for a one-month (30-day) supply of

drugs in this tier from a non-preferred pharmacy+ $90 copay for a two-month (60-day) supply of

drugs in this tier from a non-preferred pharmacy+ $135 copay for a three-month (90-day) supply of

drugs in this tier from a non-preferred pharmacy

Tier 3 - Preferred Brand + $40 copay for a one-month (30-day) supply of

drugs in this tier from a preferred pharmacy+ $80 copay for a two-month (60-day) supply of

drugs in this tier from a preferred pharmacy+ $120 copay for a three-month (90-day) supply of

drugs in this tier from a preferred pharmacy+ $45 copay for a one-month (30-day) supply of

drugs in this tier from a non-preferred pharmacy+ $90 copay for a two-month (60-day) supply of

drugs in this tier from a non-preferred pharmacy+ $135 copay for a three-month (90-day) supply of

drugs in this tier from a non-preferred pharmacy Not all drugs on this tier are available at this extended day supply Please contact

the plan for more information Tier 4 - Non-Preferred Brand + $70 copay for a one-month (30-day) supply of

drugs in this tier from a preferred pharmacy+ $140 copay for a two-month (60-day) supply of

drugs in this tier from a preferred pharmacy+ $210 copay for a three-month (90-day) supply of

drugs in this tier from a preferred pharmacy+ $95 copay for a one-month (30-day) supply of

drugs in this tier from a non-preferred pharmacy+ $190 copay for a two-month (60-day) supply of

drugs in this tier from a non-preferred pharmacy+ $285 copay for a three-month (90-day) supply of

drugs in this tier from a non-preferred pharmacy

Tier 4 - Non-Preferred Brand + $85 copay for a one-month (30-day) supply of

drugs in this tier from a preferred pharmacy+ $170 copay for a two-month (60-day) supply of

drugs in this tier from a preferred pharmacy+ $255 copay for a three-month (90-day) supply of

drugs in this tier from a preferred pharmacy+ $95 copay for a one-month (30-day) supply of

drugs in this tier from a non-preferred pharmacy+ $190 copay for a two-month (60-day) supply of

drugs in this tier from a non-preferred pharmacy+ $285 copay for a three-month (90-day) supply of

drugs in this tier from a non-preferred pharmacy Not all drugs on this tier are available at this extended day supply Please contact

the plan for more information Tier 5 - Specialty Tier + 33 coinsurance for a one-month (30-day)

supply of drugs in this tier from a preferredpharmacy

+ 33 coinsurance for a two-month (60-day)supply of drugs in this tier from a preferredpharmacy

+ 33 coinsurance for a three-month (90- day)supply of drugs in this tier from a preferredpharmacy

+ 33 coinsurance for a one-month (30-day)supply of drugs in this tier from a non-preferredpharmacy

+ 33 coinsurance for a two-month (60-day)supply of drugs in this tier from a non-preferredpharmacy

+ 33 coinsurance for a three-month (90-day)supply of drugs in this tier from a non-preferredpharmacy

Tier 5 - Specialty Tier + 29 coinsurance for a one-month (30-day)

supply of drugs in this tier from a preferredpharmacy

+ 29 coinsurance for a two-month (60-day)supply of drugs in this tier from a preferredpharmacy

+ 29 coinsurance for a three-month (90-day)supply of drugs in this tier from a preferredpharmacy

+ 29 coinsurance for a one-month (30-day)supply of drugs in this tier from a non-preferredpharmacy

+ 29 coinsurance for a two-month (60-day)supply of drugs in this tier from a non-preferredpharmacy

+ 29 coinsurance for a three-month (90-day)supply of drugs in this tier from a non-preferredpharmacy

Not all drugs on this tier are available at this extended day supply Please contactthe plan for more information

PAG E 27 of 40

Section 2 - Summary of benefits for ndash Benefit Outpatient Prescription Drugs Contract S5540 Plan 004 and Plan 002

Original Medicare

Blue Medicare Rx Enhanced (PDP) (Plan 004)

Blue Medicare Rx Standard (PDP) (Plan 002)

Long Term Care Pharmacy Long term care pharmacies must dispense brand name drugs in amounts less than a 14 days supply at a time They may also dispenseless than a monthrsquos supply of generic drugs at a time Contact your plan if you have questionsabout cost-sharing or billing when less than aone-month supply is dispensed You can get drugs the following way(s)Tier 1 - Preferred Generic + $8 copay for a one-month (31-day)

supply of drugs in this tierTier 2 - Non-Preferred Generic + $20 copay for a one-month (31-day)

supply of drugs in this tierTier 3 - Preferred Brand + $45 copay for a one-month (31-day)

supply of drugs in this tierTier 4 - Non-Preferred Brand + $95 copay for a one-month (31-day)

supply of drugs in this tierTier 5 - Specialty Tier + 33 coinsurance for a one-month (31-day)

supply of drugs in this tier

Long Term Care Pharmacy Long term care pharmacies must dispense brand name drugs in amounts less than a 14 days supply at a time They may also dispenseless than a monthrsquos supply of generic drugs at a time Contact your plan if you have questionsabout cost-sharing or billing when less than aone-month supply is dispensed You can get drugs the following way(s)Tier 1 - Preferred Generic + $10 copay for a one-month (31-day)

supply of drugs in this tierTier 2 - Non-Preferred Generic + $33 copay for a one-month (31-day)

supply of drugs in this tierTier 3 - Preferred Brand + $45 copay for a one-month (31-day)

supply of drugs in this tierTier 4 - Non-Preferred Brand + $95 copay for a one-month (31-day)

supply of drugs in this tierTier 5 - Specialty Tier + 29 coinsurance for a one-month (31-day)

supply of drugs in this tier Mail order Contact your plan if you have questions aboutcost-sharing or billing when less than a one-month supply is dispensed You can get drugs from a preferred and non-preferred mail order pharmacy the following way(s)Tier 1 - Preferred Generic + $3 copay for a one-month (30-day)

supply of drugs in this tier from apreferred mail order pharmacy

+ $0 copay for a two-month (60-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $0 copay for a three-month (90-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $8 copay for a one-month (30-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $16 copay for a two-month (60-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $24 copay for a three-month (90-day)supply of drugs in this tier from anon-preferred mail order pharmacy

Mail order Contact your plan if you have questions aboutcost-sharing or billing when less than a one-month supply is dispensed You can get drugs from a preferred and non-preferred mail order pharmacy the following way(s)Tier 1 - Preferred Generic + $4 copay for a one-month (30-day)

supply of drugs in this tier from apreferred mail order pharmacy

+ $0 copay for a two-month (60-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $0 copay for a three-month (90-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $10 copay for a one-month (30-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $20 copay for a two-month (60-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $30 copay for a three-month (90-day)supply of drugs in this tier from anon-preferred mail order pharmacy

Not all drugs on this tier are available at this extended day supplyPlease contact the plan for more information

PAG E 28 of 40

Original Medicare

Blue Medicare Rx Enhanced (PDP) (Plan 004)

Blue Medicare Rx Standard (PDP) (Plan 002)

Mail order (continued) Tier 2 - Non-Preferred Generic

+ $6 copay for a one-month (30-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $12 copay for a two-month (60-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $15 copay for a three-month (90-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $20 copay for a one-month (30-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $40 copay for a two-month (60-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $60 copay for a three-month (90-day)supply of drugs in this tier from anon-preferred mail order pharmacy

Mail order (continued) Tier 2 - Non-Preferred Generic

+ $10 copay for a one-month (30-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $20 copay for a two-month (60-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $25 copay for a three-month (90-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $33 copay for a one-month (30-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $66 copay for a two-month (60-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $99 copay for a three-month (90-day)supply of drugs in this tier from anon-preferred mail order pharmacy

Not all drugs on this tier are available at this extended day supply Please contactthe plan for more information

Tier 3 - Preferred Brand + $30 copay for a one-month (30-day)

supply of drugs in this tier from apreferred mail order pharmacy

+ $60 copay for a two-month (60-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $75 copay for a three-month (90-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $45 copay for a one-month (30-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $90 copay for a two-month (60-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $135 copay for a three-month (90-day)supply of drugs in this tier from anon-preferred mail order pharmacy

Tier 3 - Preferred Brand + $40 copay for a one-month (30-day)

supply of drugs in this tier from apreferred mail order pharmacy

+ $80 copay for a two-month (60-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $100 copay for a three-month (90-day) supply of drugs in this tier from apreferred mail order pharmacy

+ $45 copay for a one-month (30-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $90 copay for a two-month (60-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $135 copay for a three-month (90-day)supply of drugs in this tier from anon-preferred mail order pharmacy

Not all drugs on this tier are available at this extended day supply Please contactthe plan for more information

PAG E 29 of 40

Section 2 - Summary of benefits for ndash Benefit Outpatient Prescription Drugs Contract S5540 Plan 004 and Plan 002

Original Medicare

Blue Medicare Rx Enhanced (PDP) (Plan 004)

Blue Medicare Rx Standard (PDP) (Plan 002)

Mail order (continued) Tier 4 - Non-Preferred Brand

+ $70 copay for a one-month (30-day) supply of drugs in this tier from apreferred mail order pharmacy

+ $140 copay for a two-month (60-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $175 copay for a three-month (90-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $95 copay for a one-month (30-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $190 copay for a two-month (60-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $285 copay for a three-month (90-day)supply of drugs in this tier from anon-preferred mail order pharmacy

Mail order (continued) Tier 4 - Non-Preferred Brand + $85 copay for a one-month (30-day)

supply of drugs in this tier from apreferred mail order pharmacy

+ $170 copay for a two-month (60-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $21250 copay for a three-month (90-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $95 copay for a one-month (30-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $190 copay for a two-month (60-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $285 copay for a three-month (90-day)supply of drugs in this tier from anon-preferred mail order pharmacy

Not all drugs on this tier are available at this extended day supply Please contactthe plan for more information

Tier 5 - Specialty Tier

+ 33 coinsurance for a one-month (30-day) supply of drugs in this tier from apreferred mail order pharmacy

+ 33 coinsurance for a two-month (60-day) supply of drugs in this tier from apreferred mail order pharmacy

+ 33 coinsurance for a three-month (90-day) supply of drugs in this tier from apreferred mail order pharmacy

+ 33 coinsurance for a one-month (30-day) supply of drugs in this tier froma non-preferred mail order pharmacy

+ 33 coinsurance for a two-month (60-day) supply of drugs in this tier from anon-preferred mail order pharmacy

+ 33 coinsurance for a three-month (90-day) supply of drugs in this tier froma non-preferred mail order pharmacy

Tier 5 - Specialty Tier

+ 29 coinsurance for a one-month (30-day)supply of drugs in this tier from apreferred mail order pharmacy

+ 29 coinsurance for a two-month (60-day) supply of drugs in this tier from apreferred mail order pharmacy

+ 29 coinsurance for a three-month (90-day)supply of drugs in this tier from a preferredmail order pharmacy

+ 29 coinsurance for a one-month (30-day)supply of drugs in this tier froma non-preferred mail order pharmacy

+ 29 coinsurance for a two-month (60-day) supply of drugs in this tier from anon-preferred mail order pharmacy

+ 29 coinsurance for a three-month (90-day)supply of drugs in this tier froma non-preferred mail order pharmacy

Not all drugs on this tier are available at this extended day supply Please contactthe plan for more information

PAG E 30 of 40

Original Medicare

Blue Medicare Rx Enhanced (PDP) (Plan 004)

Blue Medicare Rx Standard (PDP) (Plan 002)

Coverage gap After your total yearly drug costs reach $2850 you receive limited coverage by the plan on certaindrugs You will also receive a discount on brand name drugs and generally pay no more than 475for the planrsquos costs for brand drugs and 72 of the planrsquos costs for generic drugs until your yearly out-of-pocket drug costs reach $4550 Additional Coverage gap The plan covers some formulary generics (10-64 of formularygeneric drugs) through the coverage gap The plan offers additional coverage in the gap for thefollowing tiers You pay the following Retail Pharmacy Contact your plan if you have questions about cost-sharing orbilling when less than a one-month supply is dispensed

Tier 1 Preferred Generic + $3 copay for a one-month (30-day) supply of all drugs

covered within this tier from a preferred pharmacy + $6 copay for a two-month (60-day) supply of all drugs

covered within this tier from a preferred pharmacy + $9 copay for a three-month (90-day) supply of all drugs

covered within this tier from a preferred pharmacy + $8 copay for a one-month (30-day) supply of all drugs

covered within this tier at a non-preferred pharmacy + $16 copay for a two-month (60-day) supply of all drugs

covered within this tier from a non-preferred pharmacy + $24 copay for a three-month (90-day) supply of all drugs

covered within this tier from a non-preferred pharmacy

Not all drugs on this tier are available at this extended daysupply Please contact the plan for more information

Long Term Care Pharmacy Long term care pharmacies must dispense brand name drugsin amounts less than a 14 days supply at a time They may alsodispense less than a monthrsquos supply of generic drugs at a timeContact your plan if you have questions about cost-sharing orbilling when less than a one-month supply is dispensed Tier 1 Preferred Generic + $8 copay for a one-month (31-day) supply of all drugs

covered in this tier

PAG E 31 of 40

Section 2 - Summary of benefits for ndash Benefit Outpatient Prescription Drugs Contract S5540 Plan 004 and Plan 002

Original Medicare

Blue Medicare Rx Enhanced (PDP) (Plan 004)

Blue Medicare Rx Standard (PDP) (Plan 002)

Mail Order Contact your plan if you have questions about cost-sharing orbilling when less than a one-month supply is dispensed Tier 1 Preferred Generic + $3 copay for a one-month (30-day) supply of all drugs

covered within this tier from a preferred mail order pharmacy + $0 copay for a two-month (60-day) supply of all drugs

covered within this tier from a preferred mail order pharmacy + $0 copay for a three-month (90-day) supply of all drugs

covered within this tier from a preferred mail order pharmacy + $8 copay for a one-month (30-day) supply of all drugs

covered within this tier from a non-preferred mail orderpharmacy

+ $16 copay for a two-month (60-day) supply of all drugscovered within this tier from a non-preferred mail orderpharmacy

+ $24 copay for a three-month (90-day) supply of all drugscovered within this tier from a non-preferred mail orderpharmacy

Not all drugs on this tier are available at this extended daysupply Please contact the plan for more information

PAG E 32 of 40

Original Medicare

Blue Medicare Rx Enhanced (PDP) (Plan 004)

Blue Medicare Rx Standard (PDP) (Plan 002)

Catastrophic coverage After your yearly out-of-pocket drug costs reach $4550 you pay the greater of + 5 coinsurance or + $255 copay for generic (including brand drugs treated as generic) and a $635

copay for all other drugs

Out-of-network Plan drugs may be covered in special circumstances for instance illness while traveling outside ofthe planrsquos service area where there is no network pharmacy You may have to pay more than yournormal cost-sharing amount if you get your drugs at an out-of-network pharmacy In addition youwill likely have to pay the pharmacyrsquos full charge for the drug and submit documentation to receivereimbursement from Blue Medicare Rx (PDP)

You can get out-of-network drugs the following way

Out-of-network initial coverage

You will be reimbursed up to the planrsquos costof the drug minus the following for drugspurchased out-of-network until total yearlydrug costs reach $2850 Tier 1 - Preferred Generic

+ $8 copay for a one-month (30-day)supply of drugs in this tier Tier 2 - Non-Preferred Generic

+ $20 copay for a one-month (30-day)supply of drugs in this tier

Tier 3 - Preferred Brand

+ $45 copay for a one-month (30-day)supply of drugs in this tier

Tier 4 - Non-Preferred Brand

+ $95 copay for a one-month (30-day)supply of drugs in this tier

Tier 5 - Specialty Tier

+ 33 coinsurance for a one-month (30-day)supply of drugs in this tier

Out-of-network initial coverage

After you pay your yearly deductible you willbe reimbursed up to the planrsquos cost of the drugminus the following for drugs purchasedout-of-network until total yearly drug costsreach $2850 Tier 1 - Preferred Generic

+ $10 copay for a one-month (30-day)supply of drugs in this tier

Tier 2 - Non-Preferred Generic

+ $33 copay for a one-month (30-day)supply of drugs in this tier

Tier 3 - Preferred Brand

+ $45 copay for a one-month (30-day)supply of drugs in this tier

Tier 4 - Non-Preferred Brand

+ $95 copay for a one-month (30-day)supply of drugs in this tier

Tier 5 - Specialty Tier

+ 29 coinsurance for a one-month (30-day)supply of drugs in this tier

You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge andthe planrsquos In-Network allowable amount

Out-of-Network Coverage Gap You will be reimbursed up to 28 of the plan allowable cost for generic drugs purchasedout-of-network until total yearly out-of-pocket drug costs reach $4550 Please note that theplan allowable cost may be less than the out-of-network pharmacy price paid for your drug(s)

PAG E 33 of 40

Section 2 - Summary of benefits for ndash Benefit Outpatient Prescription Drugs Contract S5540 Plan 004 and Plan 002

Original Medicare

Blue Medicare Rx Enhanced (PDP) (Plan 004)

Blue Medicare Rx Standard (PDP) (Plan 002)

Out-of-Network Coverage Gap (continued)

You will be reimbursed up to 525 of the plan allowable cost for brand name drugs purchasedout-of-network until your total yearly out-of-pocket drug costs reach $4550 Please note that theplan allowable cost may be less than the out-of-network pharmacy price paid for your drug(s)

Additional Out-of-Network Coverage Gap

You will be reimbursed for these drugspurchased out-of-network up to the planrsquoscost of the drug minus the following

Tier 1 Preferred Generic

+ $8 copay for a one-month (30-day) supplyof all drugs covered within this tier

Out-of-network Catastrophic Coverage After your yearly out-of-pocket drug costs reach $4550 you will be reimbursed for drugs purchasedout-of-network up to the planrsquos cost of the drug minus your cost share which is the greater of+ 5 coinsurance or+ $255 copay for generic (including brand drugs treated as generic) and+ $635 copay for all other drugs

You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge andthe planrsquos In-Network allowable amount

PAG E 34 of 40

PAGE 35 of 40

(PDP)

Multi-language Interpreter Services

English We have free interpreter services to answer any questions you may have about our health or drug plan To get an interpreter just call us at 1-800-478-0583 Someone who speaks EnglishLanguage can help you This is a free service

Spanish Tenemos servicios de inteacuterprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos Para hablar con un inteacuterprete por favor llame al 1-800-478-0583 Alguien que hable espantildeol le podraacute ayudar Este es un servicio gratuito

Chinese Mandarin 我们提供免们的翻们服们们助们解答们于健康或们物保们的任何疑 们如果们需要此翻们服们们致们 phone number我们的中文工作人们很们意们助们 们是一们免们服们

Chinese Cantonese 您對我們的健康或藥物保險可能存有疑問為此我們提供免費的翻譯服務如需翻譯服務請致電 1-800-478-0583我們講中文的人員將樂意為您提供幫助這是一項免費服務

Tagalog Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot Upang makakuha ng tagasaling-wika tawagan lamang kami sa 1-800-478-0583 Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog Ito ay libreng serbisyo

French Nous proposons des services gratuits dinterpreacutetation pour reacutepondre agrave toutes vos questions relatives agrave notre reacutegime de santeacute ou dassurance-meacutedicaments Pour acceacuteder au service dinterpreacutetation il vous suffit de nous appeler au 1-800-478-0583 Un interlocuteur parlant Franccedilais pourra vous aider Ce service est gratuit

Vietnamese Chuacuteng tocirci coacute dịch vụ thocircng dịch miễn phiacute để trả lời caacutec cacircu hỏi về chương sức khỏe vagrave chương trigravenh thuốc men Nếu quiacute vị cần thocircng dịch viecircn xin gọi 1-800-478-0583 sẽ coacute nhacircn viecircn noacutei tiếng Việt giuacutep đỡ quiacute vị Đacircy lagrave dịch vụ miễn phiacute

German Unser kostenloser Dolmetscherservice beantwortet Ihren Fragen zu unserem Gesundheits- und Arzneimittelplan Unsere Dolmetscher erreichen Sie unter 1-800-478-0583 Man wird Ihnen dort auf Deutsch weiterhelfen Dieser Service ist kostenlos

Korean 당사는 의료 보험 또는 약품 보험에 관한 질문에 답해 드리고자 무료 통역 서비스를 제공하고 있습니다 통역 서비스를 이용하려면 전화 1-800-478-0583 번으로 문의해 주십시오 한국어를 하는 담당자가 도와 드릴 것입니다 이 서비스는 무료로 운영됩니다

Y0079_6200 CMS Approved 07082013 U5073d 813

116

Appendix 4 ndash Multi-Language Insert

Multi-language Interpreter Services

English We have free interpreter services to answer any questions you may have about our health or drug plan To get an interpreter just call us at [1-xxx-xxx-xxxx] Someone who speaks EnglishLanguage can help you This is a free service

Spanish Tenemos servicios de inteacuterprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos Para hablar con un inteacuterprete por favor llame al [1-xxx-xxx-xxxx] Alguien que hable espantildeol le podraacute ayudar Este es un servicio gratuito

Chinese Mandarin 我们提供免费的翻译服务帮助您解答关于健康或药物保险的任何疑

问如果您需要此翻译服务请致电 1-xxx-xxx-xxxx我们的中文工作人员很乐意帮助您

这是一项免费服务

Chinese Cantonese 您對我們的健康或藥物保險可能存有疑問為此我們提供免費的翻譯

服務如需翻譯服務請致電 1-xxx-xxx-xxxx我們講中文的人員將樂意為您提供幫助這

是一項免費服務

Tagalog Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot Upang makakuha ng tagasaling-wika tawagan lamang kami sa [1-xxx-xxx-xxxx] Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog Ito ay libreng serbisyo French Nous proposons des services gratuits dinterpreacutetation pour reacutepondre agrave toutes vos questions relatives agrave notre reacutegime de santeacute ou dassurance-meacutedicaments Pour acceacuteder au service dinterpreacutetation il vous suffit de nous appeler au [1-xxx-xxx-xxxx] Un interlocuteur parlant Franccedilais pourra vous aider Ce service est gratuit Vietnamese Chuacuteng tocirci coacute dịch vụ thocircng dịch miễn phiacute để trả lời caacutec cacircu hỏi về chương sức khỏe vagrave chương trigravenh thuốc men Nếu quiacute vị cần thocircng dịch viecircn xin gọi [1-xxx-xxx-xxxx] sẽ coacute nhacircn viecircn noacutei tiếng Việt giuacutep đỡ quiacute vị Đacircy lagrave dịch vụ miễn phiacute

116

Appendix 4 ndash Multi-Language Insert

Multi-language Interpreter Services

English We have free interpreter services to answer any questions you may have about our health or drug plan To get an interpreter just call us at [1-xxx-xxx-xxxx] Someone who speaks EnglishLanguage can help you This is a free service

Spanish Tenemos servicios de inteacuterprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos Para hablar con un inteacuterprete por favor llame al [1-xxx-xxx-xxxx] Alguien que hable espantildeol le podraacute ayudar Este es un servicio gratuito

Chinese Mandarin 我们提供免费的翻译服务帮助您解答关于健康或药物保险的任何疑

问如果您需要此翻译服务请致电 1-xxx-xxx-xxxx我们的中文工作人员很乐意帮助您

这是一项免费服务

Chinese Cantonese 您對我們的健康或藥物保險可能存有疑問為此我們提供免費的翻譯

服務如需翻譯服務請致電 1-xxx-xxx-xxxx我們講中文的人員將樂意為您提供幫助這

是一項免費服務

Tagalog Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot Upang makakuha ng tagasaling-wika tawagan lamang kami sa [1-xxx-xxx-xxxx] Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog Ito ay libreng serbisyo French Nous proposons des services gratuits dinterpreacutetation pour reacutepondre agrave toutes vos questions relatives agrave notre reacutegime de santeacute ou dassurance-meacutedicaments Pour acceacuteder au service dinterpreacutetation il vous suffit de nous appeler au [1-xxx-xxx-xxxx] Un interlocuteur parlant Franccedilais pourra vous aider Ce service est gratuit Vietnamese Chuacuteng tocirci coacute dịch vụ thocircng dịch miễn phiacute để trả lời caacutec cacircu hỏi về chương sức khỏe vagrave chương trigravenh thuốc men Nếu quiacute vị cần thocircng dịch viecircn xin gọi [1-xxx-xxx-xxxx] sẽ coacute nhacircn viecircn noacutei tiếng Việt giuacutep đỡ quiacute vị Đacircy lagrave dịch vụ miễn phiacute

116

Appendix 4 ndash Multi-Language Insert

Multi-language Interpreter Services

English We have free interpreter services to answer any questions you may have about our health or drug plan To get an interpreter just call us at [1-xxx-xxx-xxxx] Someone who speaks EnglishLanguage can help you This is a free service

Spanish Tenemos servicios de inteacuterprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos Para hablar con un inteacuterprete por favor llame al [1-xxx-xxx-xxxx] Alguien que hable espantildeol le podraacute ayudar Este es un servicio gratuito

Chinese Mandarin 我们提供免费的翻译服务帮助您解答关于健康或药物保险的任何疑

问如果您需要此翻译服务请致电 1-xxx-xxx-xxxx我们的中文工作人员很乐意帮助您

这是一项免费服务

Chinese Cantonese 您對我們的健康或藥物保險可能存有疑問為此我們提供免費的翻譯

服務如需翻譯服務請致電 1-xxx-xxx-xxxx我們講中文的人員將樂意為您提供幫助這

是一項免費服務

Tagalog Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot Upang makakuha ng tagasaling-wika tawagan lamang kami sa [1-xxx-xxx-xxxx] Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog Ito ay libreng serbisyo French Nous proposons des services gratuits dinterpreacutetation pour reacutepondre agrave toutes vos questions relatives agrave notre reacutegime de santeacute ou dassurance-meacutedicaments Pour acceacuteder au service dinterpreacutetation il vous suffit de nous appeler au [1-xxx-xxx-xxxx] Un interlocuteur parlant Franccedilais pourra vous aider Ce service est gratuit Vietnamese Chuacuteng tocirci coacute dịch vụ thocircng dịch miễn phiacute để trả lời caacutec cacircu hỏi về chương sức khỏe vagrave chương trigravenh thuốc men Nếu quiacute vị cần thocircng dịch viecircn xin gọi [1-xxx-xxx-xxxx] sẽ coacute nhacircn viecircn noacutei tiếng Việt giuacutep đỡ quiacute vị Đacircy lagrave dịch vụ miễn phiacute

1-800-478-0583

PAGE 36 of 40

(PDP)

Multi-language Interpreter Services (continued)

Russian Если у вас возникнут вопросы относительно страхового или медикаментного плана вы можете воспользоваться нашими бесплатными услугами переводчиков Чтобы воспользоваться услугами переводчика позвоните нам по телефону 1-800-478-0583 Вам окажет помощь сотрудник который говорит по-pусски Данная услуга бесплатная

Arabicةيودألا لودج وأ ةحصلاب قلعتت ةلئسأ يأ نع ةباجإلل ةيناجملا يروفلا مجرتملا تامدخ مدقن اننإ صخش موقيس 0583-478-800-1 ىلع انب لاصتالا ىوس كيلع سيل يروف مجرتم ىلع لوصحلل انيدلةيناجم ةمدخ هذه كتدعاسمب ةيبرعلا ثدحتي ام

Hindi हमार सवासथय या दवा की योजना क बार म आपक किसी भी परशन क जवाब दन क लिए हमार पास मफत दभाषिया सवाए उपलबध ह एक दभाषिया परापत करन क लिए बस हम 1-800-478-0583 पर फोन कर कोई वयकति जो हिनदी बोलता ह आपकी मदद कर सकता ह यह एक मफत सवा ह

Italian Egrave disponibile un servizio di interpretariato gratuito per rispondere a eventuali domande sul nostro piano sanitario e farmaceutico Per un interprete contattare il numero 1-800-478-0583 Un nostro incaricato che parla Italianovi forniragrave lassistenza necessaria Egrave un servizio gratuito

Portugueacutes Dispomos de serviccedilos de interpretaccedilatildeo gratuitos para responder a qualquer questatildeo que tenha acerca do nosso plano de sauacutede ou de medicaccedilatildeo Para obter um inteacuterprete contacte-nos atraveacutes do nuacutemero 1-800-478-0583 Iraacute encontrar algueacutem que fale o idioma Portuguecircs para o ajudar Este serviccedilo eacute gratuito

French Creole Nou genyen segravevis entegravepregravet gratis pou reponn tout kesyon ou ta genyen konsegravenan plan medikal oswa dwograveg nou an Pou jwenn yon entegravepregravet jis rele nou nan 1-800-478-0583 Yon moun ki pale Kreyogravel kapab ede w Sa a se yon segravevis ki gratis

Polish Umożliwiamy bezpłatne skorzystanie z usług tłumacza ustnego ktoacutery pomoże w uzyskaniu odpowiedzi na temat planu zdrowotnego lub dawkowania lekoacutew Aby skorzystać z pomocy tłumacza znającego język polski należy zadzwonić pod numer 1-800-478-0583 Ta usługa jest bezpłatna

Japanese 当社の健康 健康保険と薬品 処方薬プランに関するご質問にお答えするために無

料の通訳サービスがありますございます通訳をご用命になるには1-800-478-0583 にお電

話ください日本語を話す人 者 が支援いたしますこれは無料のサービスです

Notes

PAG E 37 of 40

Notes

PAG E 38 of 40

Notes

U5073e 813

PAGE 39 of 40

Awarded to BCBSNC by the Ethisphere Institute In 2013 companies in more than 100 countries and 36 industries were reviewed and of those 138 organizations were designated as Worldrsquos Most Ethical

BCBSNC Blue Medicare Rx products are only available to Medicare beneficiaries residing in North Carolina The information described in this brochure is for 2014 and may change on January 1 2015 The benefit information provided is a brief summary not a complete description of benefits For more information contact the plan This brochure may be available in alternate formats upon request Blue Cross and Blue Shield of North Carolina is a PDP plan with a Medicare contract Enrollment in Blue Cross and Blue Shield of North Carolina depends on contract renewal An independent licensee of the Blue Cross and Blue Shield Association reg SM Marks of the Blue Cross and Blue Shield Association SM1 Mark of Blue Cross and Blue Shield of North Carolina

If you are covered by oreligible for Medicare contactyour local Authorized SalesRepresentative to learn aboutour Medicare Part D plans

How can we help Call 1-800-478-0583 7 days aweek 8 am-8 pm For hearing and speech impaired(TTYTDD) usersCall 1-800-922-3140 7 days aweek 8 am-8 pm

Preferred Pharmacy NetworkBlue Medicare Rx (PDP)

Standard Plan Enhanced Plan Many of the popular drugsare covered ndash more than 1000included

Extensive list of covered drugs ndashmore than 1800 included

You pay $145 annual deductible No deductible ndash coverage beginsright away

$4 and $40 copayments for mostdrugs when you use our preferredpharmacy network up to $2850total drug cost

$3 and $30 copayments for mostdrugs when you use our preferredpharmacy network up to $2850total drug cost

You pay 72 on all generic drugsand you receive a discount onbrand-name drugs during the

ldquocoverage gaprdquo until true out-of-pocket costs reach $4550

You pay $3 copayment forpreferred generic drugs you pay72 for most other generic drugsand you receive a discount forbrand-name drugs during the

ldquocoverage gaprdquo until true out-of-pocket costs reach $4550

Generally 5 coinsurance after ldquocoverage gaprdquo ends Preferred Pharmacy Network includes CVS WalMart

Kerr Drugs and Epic Pharmacies

Non-preferred Pharmacy NetworkBlue Medicare Rx (PDP)

Standard Plan Enhanced Plan Many of the popular drugsare covered ndash more than 1000included

Extensive list of covered drugs ndashmore than 1800 included

You pay $145 annual deductible No deductible ndash coverage beginsright away

$10 and $45 copayments for mostdrugs up to $2850 total drug cost

$8 and $45 copayments for mostdrugs up to $2850 total drug cost

You pay 72 on all generic drugsand you receive a discount onbrand-name drugs during the

ldquocoverage gaprdquo until true out-of-pocket costs reach $4550

You pay $8 copayment forpreferred generic drugs you pay72 for most other generic drugsand you receive a discount forbrand-name drugs during the

ldquocoverage gaprdquo until true out-of-pocket costs reach $4550

Generally 5 coinsurance after ldquocoverage gaprdquo ends

PAGE 40 of 40

Y0079_6250 CMS Approved 08062013

Section 2 - Summary of benefits for ndash Benefit Outpatient Prescription Drugs Contract S5540 Plan 004 and Plan 002

Original Medicare

Blue Medicare Rx Enhanced (PDP) (Plan 004)

Blue Medicare Rx Standard (PDP) (Plan 002)

Long Term Care Pharmacy Long term care pharmacies must dispense brand name drugs in amounts less than a 14 days supply at a time They may also dispenseless than a monthrsquos supply of generic drugs at a time Contact your plan if you have questionsabout cost-sharing or billing when less than aone-month supply is dispensed You can get drugs the following way(s)Tier 1 - Preferred Generic + $8 copay for a one-month (31-day)

supply of drugs in this tierTier 2 - Non-Preferred Generic + $20 copay for a one-month (31-day)

supply of drugs in this tierTier 3 - Preferred Brand + $45 copay for a one-month (31-day)

supply of drugs in this tierTier 4 - Non-Preferred Brand + $95 copay for a one-month (31-day)

supply of drugs in this tierTier 5 - Specialty Tier + 33 coinsurance for a one-month (31-day)

supply of drugs in this tier

Long Term Care Pharmacy Long term care pharmacies must dispense brand name drugs in amounts less than a 14 days supply at a time They may also dispenseless than a monthrsquos supply of generic drugs at a time Contact your plan if you have questionsabout cost-sharing or billing when less than aone-month supply is dispensed You can get drugs the following way(s)Tier 1 - Preferred Generic + $10 copay for a one-month (31-day)

supply of drugs in this tierTier 2 - Non-Preferred Generic + $33 copay for a one-month (31-day)

supply of drugs in this tierTier 3 - Preferred Brand + $45 copay for a one-month (31-day)

supply of drugs in this tierTier 4 - Non-Preferred Brand + $95 copay for a one-month (31-day)

supply of drugs in this tierTier 5 - Specialty Tier + 29 coinsurance for a one-month (31-day)

supply of drugs in this tier Mail order Contact your plan if you have questions aboutcost-sharing or billing when less than a one-month supply is dispensed You can get drugs from a preferred and non-preferred mail order pharmacy the following way(s)Tier 1 - Preferred Generic + $3 copay for a one-month (30-day)

supply of drugs in this tier from apreferred mail order pharmacy

+ $0 copay for a two-month (60-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $0 copay for a three-month (90-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $8 copay for a one-month (30-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $16 copay for a two-month (60-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $24 copay for a three-month (90-day)supply of drugs in this tier from anon-preferred mail order pharmacy

Mail order Contact your plan if you have questions aboutcost-sharing or billing when less than a one-month supply is dispensed You can get drugs from a preferred and non-preferred mail order pharmacy the following way(s)Tier 1 - Preferred Generic + $4 copay for a one-month (30-day)

supply of drugs in this tier from apreferred mail order pharmacy

+ $0 copay for a two-month (60-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $0 copay for a three-month (90-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $10 copay for a one-month (30-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $20 copay for a two-month (60-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $30 copay for a three-month (90-day)supply of drugs in this tier from anon-preferred mail order pharmacy

Not all drugs on this tier are available at this extended day supplyPlease contact the plan for more information

PAG E 28 of 40

Original Medicare

Blue Medicare Rx Enhanced (PDP) (Plan 004)

Blue Medicare Rx Standard (PDP) (Plan 002)

Mail order (continued) Tier 2 - Non-Preferred Generic

+ $6 copay for a one-month (30-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $12 copay for a two-month (60-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $15 copay for a three-month (90-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $20 copay for a one-month (30-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $40 copay for a two-month (60-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $60 copay for a three-month (90-day)supply of drugs in this tier from anon-preferred mail order pharmacy

Mail order (continued) Tier 2 - Non-Preferred Generic

+ $10 copay for a one-month (30-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $20 copay for a two-month (60-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $25 copay for a three-month (90-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $33 copay for a one-month (30-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $66 copay for a two-month (60-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $99 copay for a three-month (90-day)supply of drugs in this tier from anon-preferred mail order pharmacy

Not all drugs on this tier are available at this extended day supply Please contactthe plan for more information

Tier 3 - Preferred Brand + $30 copay for a one-month (30-day)

supply of drugs in this tier from apreferred mail order pharmacy

+ $60 copay for a two-month (60-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $75 copay for a three-month (90-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $45 copay for a one-month (30-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $90 copay for a two-month (60-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $135 copay for a three-month (90-day)supply of drugs in this tier from anon-preferred mail order pharmacy

Tier 3 - Preferred Brand + $40 copay for a one-month (30-day)

supply of drugs in this tier from apreferred mail order pharmacy

+ $80 copay for a two-month (60-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $100 copay for a three-month (90-day) supply of drugs in this tier from apreferred mail order pharmacy

+ $45 copay for a one-month (30-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $90 copay for a two-month (60-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $135 copay for a three-month (90-day)supply of drugs in this tier from anon-preferred mail order pharmacy

Not all drugs on this tier are available at this extended day supply Please contactthe plan for more information

PAG E 29 of 40

Section 2 - Summary of benefits for ndash Benefit Outpatient Prescription Drugs Contract S5540 Plan 004 and Plan 002

Original Medicare

Blue Medicare Rx Enhanced (PDP) (Plan 004)

Blue Medicare Rx Standard (PDP) (Plan 002)

Mail order (continued) Tier 4 - Non-Preferred Brand

+ $70 copay for a one-month (30-day) supply of drugs in this tier from apreferred mail order pharmacy

+ $140 copay for a two-month (60-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $175 copay for a three-month (90-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $95 copay for a one-month (30-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $190 copay for a two-month (60-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $285 copay for a three-month (90-day)supply of drugs in this tier from anon-preferred mail order pharmacy

Mail order (continued) Tier 4 - Non-Preferred Brand + $85 copay for a one-month (30-day)

supply of drugs in this tier from apreferred mail order pharmacy

+ $170 copay for a two-month (60-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $21250 copay for a three-month (90-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $95 copay for a one-month (30-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $190 copay for a two-month (60-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $285 copay for a three-month (90-day)supply of drugs in this tier from anon-preferred mail order pharmacy

Not all drugs on this tier are available at this extended day supply Please contactthe plan for more information

Tier 5 - Specialty Tier

+ 33 coinsurance for a one-month (30-day) supply of drugs in this tier from apreferred mail order pharmacy

+ 33 coinsurance for a two-month (60-day) supply of drugs in this tier from apreferred mail order pharmacy

+ 33 coinsurance for a three-month (90-day) supply of drugs in this tier from apreferred mail order pharmacy

+ 33 coinsurance for a one-month (30-day) supply of drugs in this tier froma non-preferred mail order pharmacy

+ 33 coinsurance for a two-month (60-day) supply of drugs in this tier from anon-preferred mail order pharmacy

+ 33 coinsurance for a three-month (90-day) supply of drugs in this tier froma non-preferred mail order pharmacy

Tier 5 - Specialty Tier

+ 29 coinsurance for a one-month (30-day)supply of drugs in this tier from apreferred mail order pharmacy

+ 29 coinsurance for a two-month (60-day) supply of drugs in this tier from apreferred mail order pharmacy

+ 29 coinsurance for a three-month (90-day)supply of drugs in this tier from a preferredmail order pharmacy

+ 29 coinsurance for a one-month (30-day)supply of drugs in this tier froma non-preferred mail order pharmacy

+ 29 coinsurance for a two-month (60-day) supply of drugs in this tier from anon-preferred mail order pharmacy

+ 29 coinsurance for a three-month (90-day)supply of drugs in this tier froma non-preferred mail order pharmacy

Not all drugs on this tier are available at this extended day supply Please contactthe plan for more information

PAG E 30 of 40

Original Medicare

Blue Medicare Rx Enhanced (PDP) (Plan 004)

Blue Medicare Rx Standard (PDP) (Plan 002)

Coverage gap After your total yearly drug costs reach $2850 you receive limited coverage by the plan on certaindrugs You will also receive a discount on brand name drugs and generally pay no more than 475for the planrsquos costs for brand drugs and 72 of the planrsquos costs for generic drugs until your yearly out-of-pocket drug costs reach $4550 Additional Coverage gap The plan covers some formulary generics (10-64 of formularygeneric drugs) through the coverage gap The plan offers additional coverage in the gap for thefollowing tiers You pay the following Retail Pharmacy Contact your plan if you have questions about cost-sharing orbilling when less than a one-month supply is dispensed

Tier 1 Preferred Generic + $3 copay for a one-month (30-day) supply of all drugs

covered within this tier from a preferred pharmacy + $6 copay for a two-month (60-day) supply of all drugs

covered within this tier from a preferred pharmacy + $9 copay for a three-month (90-day) supply of all drugs

covered within this tier from a preferred pharmacy + $8 copay for a one-month (30-day) supply of all drugs

covered within this tier at a non-preferred pharmacy + $16 copay for a two-month (60-day) supply of all drugs

covered within this tier from a non-preferred pharmacy + $24 copay for a three-month (90-day) supply of all drugs

covered within this tier from a non-preferred pharmacy

Not all drugs on this tier are available at this extended daysupply Please contact the plan for more information

Long Term Care Pharmacy Long term care pharmacies must dispense brand name drugsin amounts less than a 14 days supply at a time They may alsodispense less than a monthrsquos supply of generic drugs at a timeContact your plan if you have questions about cost-sharing orbilling when less than a one-month supply is dispensed Tier 1 Preferred Generic + $8 copay for a one-month (31-day) supply of all drugs

covered in this tier

PAG E 31 of 40

Section 2 - Summary of benefits for ndash Benefit Outpatient Prescription Drugs Contract S5540 Plan 004 and Plan 002

Original Medicare

Blue Medicare Rx Enhanced (PDP) (Plan 004)

Blue Medicare Rx Standard (PDP) (Plan 002)

Mail Order Contact your plan if you have questions about cost-sharing orbilling when less than a one-month supply is dispensed Tier 1 Preferred Generic + $3 copay for a one-month (30-day) supply of all drugs

covered within this tier from a preferred mail order pharmacy + $0 copay for a two-month (60-day) supply of all drugs

covered within this tier from a preferred mail order pharmacy + $0 copay for a three-month (90-day) supply of all drugs

covered within this tier from a preferred mail order pharmacy + $8 copay for a one-month (30-day) supply of all drugs

covered within this tier from a non-preferred mail orderpharmacy

+ $16 copay for a two-month (60-day) supply of all drugscovered within this tier from a non-preferred mail orderpharmacy

+ $24 copay for a three-month (90-day) supply of all drugscovered within this tier from a non-preferred mail orderpharmacy

Not all drugs on this tier are available at this extended daysupply Please contact the plan for more information

PAG E 32 of 40

Original Medicare

Blue Medicare Rx Enhanced (PDP) (Plan 004)

Blue Medicare Rx Standard (PDP) (Plan 002)

Catastrophic coverage After your yearly out-of-pocket drug costs reach $4550 you pay the greater of + 5 coinsurance or + $255 copay for generic (including brand drugs treated as generic) and a $635

copay for all other drugs

Out-of-network Plan drugs may be covered in special circumstances for instance illness while traveling outside ofthe planrsquos service area where there is no network pharmacy You may have to pay more than yournormal cost-sharing amount if you get your drugs at an out-of-network pharmacy In addition youwill likely have to pay the pharmacyrsquos full charge for the drug and submit documentation to receivereimbursement from Blue Medicare Rx (PDP)

You can get out-of-network drugs the following way

Out-of-network initial coverage

You will be reimbursed up to the planrsquos costof the drug minus the following for drugspurchased out-of-network until total yearlydrug costs reach $2850 Tier 1 - Preferred Generic

+ $8 copay for a one-month (30-day)supply of drugs in this tier Tier 2 - Non-Preferred Generic

+ $20 copay for a one-month (30-day)supply of drugs in this tier

Tier 3 - Preferred Brand

+ $45 copay for a one-month (30-day)supply of drugs in this tier

Tier 4 - Non-Preferred Brand

+ $95 copay for a one-month (30-day)supply of drugs in this tier

Tier 5 - Specialty Tier

+ 33 coinsurance for a one-month (30-day)supply of drugs in this tier

Out-of-network initial coverage

After you pay your yearly deductible you willbe reimbursed up to the planrsquos cost of the drugminus the following for drugs purchasedout-of-network until total yearly drug costsreach $2850 Tier 1 - Preferred Generic

+ $10 copay for a one-month (30-day)supply of drugs in this tier

Tier 2 - Non-Preferred Generic

+ $33 copay for a one-month (30-day)supply of drugs in this tier

Tier 3 - Preferred Brand

+ $45 copay for a one-month (30-day)supply of drugs in this tier

Tier 4 - Non-Preferred Brand

+ $95 copay for a one-month (30-day)supply of drugs in this tier

Tier 5 - Specialty Tier

+ 29 coinsurance for a one-month (30-day)supply of drugs in this tier

You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge andthe planrsquos In-Network allowable amount

Out-of-Network Coverage Gap You will be reimbursed up to 28 of the plan allowable cost for generic drugs purchasedout-of-network until total yearly out-of-pocket drug costs reach $4550 Please note that theplan allowable cost may be less than the out-of-network pharmacy price paid for your drug(s)

PAG E 33 of 40

Section 2 - Summary of benefits for ndash Benefit Outpatient Prescription Drugs Contract S5540 Plan 004 and Plan 002

Original Medicare

Blue Medicare Rx Enhanced (PDP) (Plan 004)

Blue Medicare Rx Standard (PDP) (Plan 002)

Out-of-Network Coverage Gap (continued)

You will be reimbursed up to 525 of the plan allowable cost for brand name drugs purchasedout-of-network until your total yearly out-of-pocket drug costs reach $4550 Please note that theplan allowable cost may be less than the out-of-network pharmacy price paid for your drug(s)

Additional Out-of-Network Coverage Gap

You will be reimbursed for these drugspurchased out-of-network up to the planrsquoscost of the drug minus the following

Tier 1 Preferred Generic

+ $8 copay for a one-month (30-day) supplyof all drugs covered within this tier

Out-of-network Catastrophic Coverage After your yearly out-of-pocket drug costs reach $4550 you will be reimbursed for drugs purchasedout-of-network up to the planrsquos cost of the drug minus your cost share which is the greater of+ 5 coinsurance or+ $255 copay for generic (including brand drugs treated as generic) and+ $635 copay for all other drugs

You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge andthe planrsquos In-Network allowable amount

PAG E 34 of 40

PAGE 35 of 40

(PDP)

Multi-language Interpreter Services

English We have free interpreter services to answer any questions you may have about our health or drug plan To get an interpreter just call us at 1-800-478-0583 Someone who speaks EnglishLanguage can help you This is a free service

Spanish Tenemos servicios de inteacuterprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos Para hablar con un inteacuterprete por favor llame al 1-800-478-0583 Alguien que hable espantildeol le podraacute ayudar Este es un servicio gratuito

Chinese Mandarin 我们提供免们的翻们服们们助们解答们于健康或们物保们的任何疑 们如果们需要此翻们服们们致们 phone number我们的中文工作人们很们意们助们 们是一们免们服们

Chinese Cantonese 您對我們的健康或藥物保險可能存有疑問為此我們提供免費的翻譯服務如需翻譯服務請致電 1-800-478-0583我們講中文的人員將樂意為您提供幫助這是一項免費服務

Tagalog Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot Upang makakuha ng tagasaling-wika tawagan lamang kami sa 1-800-478-0583 Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog Ito ay libreng serbisyo

French Nous proposons des services gratuits dinterpreacutetation pour reacutepondre agrave toutes vos questions relatives agrave notre reacutegime de santeacute ou dassurance-meacutedicaments Pour acceacuteder au service dinterpreacutetation il vous suffit de nous appeler au 1-800-478-0583 Un interlocuteur parlant Franccedilais pourra vous aider Ce service est gratuit

Vietnamese Chuacuteng tocirci coacute dịch vụ thocircng dịch miễn phiacute để trả lời caacutec cacircu hỏi về chương sức khỏe vagrave chương trigravenh thuốc men Nếu quiacute vị cần thocircng dịch viecircn xin gọi 1-800-478-0583 sẽ coacute nhacircn viecircn noacutei tiếng Việt giuacutep đỡ quiacute vị Đacircy lagrave dịch vụ miễn phiacute

German Unser kostenloser Dolmetscherservice beantwortet Ihren Fragen zu unserem Gesundheits- und Arzneimittelplan Unsere Dolmetscher erreichen Sie unter 1-800-478-0583 Man wird Ihnen dort auf Deutsch weiterhelfen Dieser Service ist kostenlos

Korean 당사는 의료 보험 또는 약품 보험에 관한 질문에 답해 드리고자 무료 통역 서비스를 제공하고 있습니다 통역 서비스를 이용하려면 전화 1-800-478-0583 번으로 문의해 주십시오 한국어를 하는 담당자가 도와 드릴 것입니다 이 서비스는 무료로 운영됩니다

Y0079_6200 CMS Approved 07082013 U5073d 813

116

Appendix 4 ndash Multi-Language Insert

Multi-language Interpreter Services

English We have free interpreter services to answer any questions you may have about our health or drug plan To get an interpreter just call us at [1-xxx-xxx-xxxx] Someone who speaks EnglishLanguage can help you This is a free service

Spanish Tenemos servicios de inteacuterprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos Para hablar con un inteacuterprete por favor llame al [1-xxx-xxx-xxxx] Alguien que hable espantildeol le podraacute ayudar Este es un servicio gratuito

Chinese Mandarin 我们提供免费的翻译服务帮助您解答关于健康或药物保险的任何疑

问如果您需要此翻译服务请致电 1-xxx-xxx-xxxx我们的中文工作人员很乐意帮助您

这是一项免费服务

Chinese Cantonese 您對我們的健康或藥物保險可能存有疑問為此我們提供免費的翻譯

服務如需翻譯服務請致電 1-xxx-xxx-xxxx我們講中文的人員將樂意為您提供幫助這

是一項免費服務

Tagalog Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot Upang makakuha ng tagasaling-wika tawagan lamang kami sa [1-xxx-xxx-xxxx] Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog Ito ay libreng serbisyo French Nous proposons des services gratuits dinterpreacutetation pour reacutepondre agrave toutes vos questions relatives agrave notre reacutegime de santeacute ou dassurance-meacutedicaments Pour acceacuteder au service dinterpreacutetation il vous suffit de nous appeler au [1-xxx-xxx-xxxx] Un interlocuteur parlant Franccedilais pourra vous aider Ce service est gratuit Vietnamese Chuacuteng tocirci coacute dịch vụ thocircng dịch miễn phiacute để trả lời caacutec cacircu hỏi về chương sức khỏe vagrave chương trigravenh thuốc men Nếu quiacute vị cần thocircng dịch viecircn xin gọi [1-xxx-xxx-xxxx] sẽ coacute nhacircn viecircn noacutei tiếng Việt giuacutep đỡ quiacute vị Đacircy lagrave dịch vụ miễn phiacute

116

Appendix 4 ndash Multi-Language Insert

Multi-language Interpreter Services

English We have free interpreter services to answer any questions you may have about our health or drug plan To get an interpreter just call us at [1-xxx-xxx-xxxx] Someone who speaks EnglishLanguage can help you This is a free service

Spanish Tenemos servicios de inteacuterprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos Para hablar con un inteacuterprete por favor llame al [1-xxx-xxx-xxxx] Alguien que hable espantildeol le podraacute ayudar Este es un servicio gratuito

Chinese Mandarin 我们提供免费的翻译服务帮助您解答关于健康或药物保险的任何疑

问如果您需要此翻译服务请致电 1-xxx-xxx-xxxx我们的中文工作人员很乐意帮助您

这是一项免费服务

Chinese Cantonese 您對我們的健康或藥物保險可能存有疑問為此我們提供免費的翻譯

服務如需翻譯服務請致電 1-xxx-xxx-xxxx我們講中文的人員將樂意為您提供幫助這

是一項免費服務

Tagalog Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot Upang makakuha ng tagasaling-wika tawagan lamang kami sa [1-xxx-xxx-xxxx] Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog Ito ay libreng serbisyo French Nous proposons des services gratuits dinterpreacutetation pour reacutepondre agrave toutes vos questions relatives agrave notre reacutegime de santeacute ou dassurance-meacutedicaments Pour acceacuteder au service dinterpreacutetation il vous suffit de nous appeler au [1-xxx-xxx-xxxx] Un interlocuteur parlant Franccedilais pourra vous aider Ce service est gratuit Vietnamese Chuacuteng tocirci coacute dịch vụ thocircng dịch miễn phiacute để trả lời caacutec cacircu hỏi về chương sức khỏe vagrave chương trigravenh thuốc men Nếu quiacute vị cần thocircng dịch viecircn xin gọi [1-xxx-xxx-xxxx] sẽ coacute nhacircn viecircn noacutei tiếng Việt giuacutep đỡ quiacute vị Đacircy lagrave dịch vụ miễn phiacute

116

Appendix 4 ndash Multi-Language Insert

Multi-language Interpreter Services

English We have free interpreter services to answer any questions you may have about our health or drug plan To get an interpreter just call us at [1-xxx-xxx-xxxx] Someone who speaks EnglishLanguage can help you This is a free service

Spanish Tenemos servicios de inteacuterprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos Para hablar con un inteacuterprete por favor llame al [1-xxx-xxx-xxxx] Alguien que hable espantildeol le podraacute ayudar Este es un servicio gratuito

Chinese Mandarin 我们提供免费的翻译服务帮助您解答关于健康或药物保险的任何疑

问如果您需要此翻译服务请致电 1-xxx-xxx-xxxx我们的中文工作人员很乐意帮助您

这是一项免费服务

Chinese Cantonese 您對我們的健康或藥物保險可能存有疑問為此我們提供免費的翻譯

服務如需翻譯服務請致電 1-xxx-xxx-xxxx我們講中文的人員將樂意為您提供幫助這

是一項免費服務

Tagalog Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot Upang makakuha ng tagasaling-wika tawagan lamang kami sa [1-xxx-xxx-xxxx] Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog Ito ay libreng serbisyo French Nous proposons des services gratuits dinterpreacutetation pour reacutepondre agrave toutes vos questions relatives agrave notre reacutegime de santeacute ou dassurance-meacutedicaments Pour acceacuteder au service dinterpreacutetation il vous suffit de nous appeler au [1-xxx-xxx-xxxx] Un interlocuteur parlant Franccedilais pourra vous aider Ce service est gratuit Vietnamese Chuacuteng tocirci coacute dịch vụ thocircng dịch miễn phiacute để trả lời caacutec cacircu hỏi về chương sức khỏe vagrave chương trigravenh thuốc men Nếu quiacute vị cần thocircng dịch viecircn xin gọi [1-xxx-xxx-xxxx] sẽ coacute nhacircn viecircn noacutei tiếng Việt giuacutep đỡ quiacute vị Đacircy lagrave dịch vụ miễn phiacute

1-800-478-0583

PAGE 36 of 40

(PDP)

Multi-language Interpreter Services (continued)

Russian Если у вас возникнут вопросы относительно страхового или медикаментного плана вы можете воспользоваться нашими бесплатными услугами переводчиков Чтобы воспользоваться услугами переводчика позвоните нам по телефону 1-800-478-0583 Вам окажет помощь сотрудник который говорит по-pусски Данная услуга бесплатная

Arabicةيودألا لودج وأ ةحصلاب قلعتت ةلئسأ يأ نع ةباجإلل ةيناجملا يروفلا مجرتملا تامدخ مدقن اننإ صخش موقيس 0583-478-800-1 ىلع انب لاصتالا ىوس كيلع سيل يروف مجرتم ىلع لوصحلل انيدلةيناجم ةمدخ هذه كتدعاسمب ةيبرعلا ثدحتي ام

Hindi हमार सवासथय या दवा की योजना क बार म आपक किसी भी परशन क जवाब दन क लिए हमार पास मफत दभाषिया सवाए उपलबध ह एक दभाषिया परापत करन क लिए बस हम 1-800-478-0583 पर फोन कर कोई वयकति जो हिनदी बोलता ह आपकी मदद कर सकता ह यह एक मफत सवा ह

Italian Egrave disponibile un servizio di interpretariato gratuito per rispondere a eventuali domande sul nostro piano sanitario e farmaceutico Per un interprete contattare il numero 1-800-478-0583 Un nostro incaricato che parla Italianovi forniragrave lassistenza necessaria Egrave un servizio gratuito

Portugueacutes Dispomos de serviccedilos de interpretaccedilatildeo gratuitos para responder a qualquer questatildeo que tenha acerca do nosso plano de sauacutede ou de medicaccedilatildeo Para obter um inteacuterprete contacte-nos atraveacutes do nuacutemero 1-800-478-0583 Iraacute encontrar algueacutem que fale o idioma Portuguecircs para o ajudar Este serviccedilo eacute gratuito

French Creole Nou genyen segravevis entegravepregravet gratis pou reponn tout kesyon ou ta genyen konsegravenan plan medikal oswa dwograveg nou an Pou jwenn yon entegravepregravet jis rele nou nan 1-800-478-0583 Yon moun ki pale Kreyogravel kapab ede w Sa a se yon segravevis ki gratis

Polish Umożliwiamy bezpłatne skorzystanie z usług tłumacza ustnego ktoacutery pomoże w uzyskaniu odpowiedzi na temat planu zdrowotnego lub dawkowania lekoacutew Aby skorzystać z pomocy tłumacza znającego język polski należy zadzwonić pod numer 1-800-478-0583 Ta usługa jest bezpłatna

Japanese 当社の健康 健康保険と薬品 処方薬プランに関するご質問にお答えするために無

料の通訳サービスがありますございます通訳をご用命になるには1-800-478-0583 にお電

話ください日本語を話す人 者 が支援いたしますこれは無料のサービスです

Notes

PAG E 37 of 40

Notes

PAG E 38 of 40

Notes

U5073e 813

PAGE 39 of 40

Awarded to BCBSNC by the Ethisphere Institute In 2013 companies in more than 100 countries and 36 industries were reviewed and of those 138 organizations were designated as Worldrsquos Most Ethical

BCBSNC Blue Medicare Rx products are only available to Medicare beneficiaries residing in North Carolina The information described in this brochure is for 2014 and may change on January 1 2015 The benefit information provided is a brief summary not a complete description of benefits For more information contact the plan This brochure may be available in alternate formats upon request Blue Cross and Blue Shield of North Carolina is a PDP plan with a Medicare contract Enrollment in Blue Cross and Blue Shield of North Carolina depends on contract renewal An independent licensee of the Blue Cross and Blue Shield Association reg SM Marks of the Blue Cross and Blue Shield Association SM1 Mark of Blue Cross and Blue Shield of North Carolina

If you are covered by oreligible for Medicare contactyour local Authorized SalesRepresentative to learn aboutour Medicare Part D plans

How can we help Call 1-800-478-0583 7 days aweek 8 am-8 pm For hearing and speech impaired(TTYTDD) usersCall 1-800-922-3140 7 days aweek 8 am-8 pm

Preferred Pharmacy NetworkBlue Medicare Rx (PDP)

Standard Plan Enhanced Plan Many of the popular drugsare covered ndash more than 1000included

Extensive list of covered drugs ndashmore than 1800 included

You pay $145 annual deductible No deductible ndash coverage beginsright away

$4 and $40 copayments for mostdrugs when you use our preferredpharmacy network up to $2850total drug cost

$3 and $30 copayments for mostdrugs when you use our preferredpharmacy network up to $2850total drug cost

You pay 72 on all generic drugsand you receive a discount onbrand-name drugs during the

ldquocoverage gaprdquo until true out-of-pocket costs reach $4550

You pay $3 copayment forpreferred generic drugs you pay72 for most other generic drugsand you receive a discount forbrand-name drugs during the

ldquocoverage gaprdquo until true out-of-pocket costs reach $4550

Generally 5 coinsurance after ldquocoverage gaprdquo ends Preferred Pharmacy Network includes CVS WalMart

Kerr Drugs and Epic Pharmacies

Non-preferred Pharmacy NetworkBlue Medicare Rx (PDP)

Standard Plan Enhanced Plan Many of the popular drugsare covered ndash more than 1000included

Extensive list of covered drugs ndashmore than 1800 included

You pay $145 annual deductible No deductible ndash coverage beginsright away

$10 and $45 copayments for mostdrugs up to $2850 total drug cost

$8 and $45 copayments for mostdrugs up to $2850 total drug cost

You pay 72 on all generic drugsand you receive a discount onbrand-name drugs during the

ldquocoverage gaprdquo until true out-of-pocket costs reach $4550

You pay $8 copayment forpreferred generic drugs you pay72 for most other generic drugsand you receive a discount forbrand-name drugs during the

ldquocoverage gaprdquo until true out-of-pocket costs reach $4550

Generally 5 coinsurance after ldquocoverage gaprdquo ends

PAGE 40 of 40

Y0079_6250 CMS Approved 08062013

Original Medicare

Blue Medicare Rx Enhanced (PDP) (Plan 004)

Blue Medicare Rx Standard (PDP) (Plan 002)

Mail order (continued) Tier 2 - Non-Preferred Generic

+ $6 copay for a one-month (30-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $12 copay for a two-month (60-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $15 copay for a three-month (90-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $20 copay for a one-month (30-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $40 copay for a two-month (60-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $60 copay for a three-month (90-day)supply of drugs in this tier from anon-preferred mail order pharmacy

Mail order (continued) Tier 2 - Non-Preferred Generic

+ $10 copay for a one-month (30-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $20 copay for a two-month (60-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $25 copay for a three-month (90-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $33 copay for a one-month (30-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $66 copay for a two-month (60-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $99 copay for a three-month (90-day)supply of drugs in this tier from anon-preferred mail order pharmacy

Not all drugs on this tier are available at this extended day supply Please contactthe plan for more information

Tier 3 - Preferred Brand + $30 copay for a one-month (30-day)

supply of drugs in this tier from apreferred mail order pharmacy

+ $60 copay for a two-month (60-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $75 copay for a three-month (90-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $45 copay for a one-month (30-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $90 copay for a two-month (60-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $135 copay for a three-month (90-day)supply of drugs in this tier from anon-preferred mail order pharmacy

Tier 3 - Preferred Brand + $40 copay for a one-month (30-day)

supply of drugs in this tier from apreferred mail order pharmacy

+ $80 copay for a two-month (60-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $100 copay for a three-month (90-day) supply of drugs in this tier from apreferred mail order pharmacy

+ $45 copay for a one-month (30-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $90 copay for a two-month (60-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $135 copay for a three-month (90-day)supply of drugs in this tier from anon-preferred mail order pharmacy

Not all drugs on this tier are available at this extended day supply Please contactthe plan for more information

PAG E 29 of 40

Section 2 - Summary of benefits for ndash Benefit Outpatient Prescription Drugs Contract S5540 Plan 004 and Plan 002

Original Medicare

Blue Medicare Rx Enhanced (PDP) (Plan 004)

Blue Medicare Rx Standard (PDP) (Plan 002)

Mail order (continued) Tier 4 - Non-Preferred Brand

+ $70 copay for a one-month (30-day) supply of drugs in this tier from apreferred mail order pharmacy

+ $140 copay for a two-month (60-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $175 copay for a three-month (90-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $95 copay for a one-month (30-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $190 copay for a two-month (60-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $285 copay for a three-month (90-day)supply of drugs in this tier from anon-preferred mail order pharmacy

Mail order (continued) Tier 4 - Non-Preferred Brand + $85 copay for a one-month (30-day)

supply of drugs in this tier from apreferred mail order pharmacy

+ $170 copay for a two-month (60-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $21250 copay for a three-month (90-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $95 copay for a one-month (30-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $190 copay for a two-month (60-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $285 copay for a three-month (90-day)supply of drugs in this tier from anon-preferred mail order pharmacy

Not all drugs on this tier are available at this extended day supply Please contactthe plan for more information

Tier 5 - Specialty Tier

+ 33 coinsurance for a one-month (30-day) supply of drugs in this tier from apreferred mail order pharmacy

+ 33 coinsurance for a two-month (60-day) supply of drugs in this tier from apreferred mail order pharmacy

+ 33 coinsurance for a three-month (90-day) supply of drugs in this tier from apreferred mail order pharmacy

+ 33 coinsurance for a one-month (30-day) supply of drugs in this tier froma non-preferred mail order pharmacy

+ 33 coinsurance for a two-month (60-day) supply of drugs in this tier from anon-preferred mail order pharmacy

+ 33 coinsurance for a three-month (90-day) supply of drugs in this tier froma non-preferred mail order pharmacy

Tier 5 - Specialty Tier

+ 29 coinsurance for a one-month (30-day)supply of drugs in this tier from apreferred mail order pharmacy

+ 29 coinsurance for a two-month (60-day) supply of drugs in this tier from apreferred mail order pharmacy

+ 29 coinsurance for a three-month (90-day)supply of drugs in this tier from a preferredmail order pharmacy

+ 29 coinsurance for a one-month (30-day)supply of drugs in this tier froma non-preferred mail order pharmacy

+ 29 coinsurance for a two-month (60-day) supply of drugs in this tier from anon-preferred mail order pharmacy

+ 29 coinsurance for a three-month (90-day)supply of drugs in this tier froma non-preferred mail order pharmacy

Not all drugs on this tier are available at this extended day supply Please contactthe plan for more information

PAG E 30 of 40

Original Medicare

Blue Medicare Rx Enhanced (PDP) (Plan 004)

Blue Medicare Rx Standard (PDP) (Plan 002)

Coverage gap After your total yearly drug costs reach $2850 you receive limited coverage by the plan on certaindrugs You will also receive a discount on brand name drugs and generally pay no more than 475for the planrsquos costs for brand drugs and 72 of the planrsquos costs for generic drugs until your yearly out-of-pocket drug costs reach $4550 Additional Coverage gap The plan covers some formulary generics (10-64 of formularygeneric drugs) through the coverage gap The plan offers additional coverage in the gap for thefollowing tiers You pay the following Retail Pharmacy Contact your plan if you have questions about cost-sharing orbilling when less than a one-month supply is dispensed

Tier 1 Preferred Generic + $3 copay for a one-month (30-day) supply of all drugs

covered within this tier from a preferred pharmacy + $6 copay for a two-month (60-day) supply of all drugs

covered within this tier from a preferred pharmacy + $9 copay for a three-month (90-day) supply of all drugs

covered within this tier from a preferred pharmacy + $8 copay for a one-month (30-day) supply of all drugs

covered within this tier at a non-preferred pharmacy + $16 copay for a two-month (60-day) supply of all drugs

covered within this tier from a non-preferred pharmacy + $24 copay for a three-month (90-day) supply of all drugs

covered within this tier from a non-preferred pharmacy

Not all drugs on this tier are available at this extended daysupply Please contact the plan for more information

Long Term Care Pharmacy Long term care pharmacies must dispense brand name drugsin amounts less than a 14 days supply at a time They may alsodispense less than a monthrsquos supply of generic drugs at a timeContact your plan if you have questions about cost-sharing orbilling when less than a one-month supply is dispensed Tier 1 Preferred Generic + $8 copay for a one-month (31-day) supply of all drugs

covered in this tier

PAG E 31 of 40

Section 2 - Summary of benefits for ndash Benefit Outpatient Prescription Drugs Contract S5540 Plan 004 and Plan 002

Original Medicare

Blue Medicare Rx Enhanced (PDP) (Plan 004)

Blue Medicare Rx Standard (PDP) (Plan 002)

Mail Order Contact your plan if you have questions about cost-sharing orbilling when less than a one-month supply is dispensed Tier 1 Preferred Generic + $3 copay for a one-month (30-day) supply of all drugs

covered within this tier from a preferred mail order pharmacy + $0 copay for a two-month (60-day) supply of all drugs

covered within this tier from a preferred mail order pharmacy + $0 copay for a three-month (90-day) supply of all drugs

covered within this tier from a preferred mail order pharmacy + $8 copay for a one-month (30-day) supply of all drugs

covered within this tier from a non-preferred mail orderpharmacy

+ $16 copay for a two-month (60-day) supply of all drugscovered within this tier from a non-preferred mail orderpharmacy

+ $24 copay for a three-month (90-day) supply of all drugscovered within this tier from a non-preferred mail orderpharmacy

Not all drugs on this tier are available at this extended daysupply Please contact the plan for more information

PAG E 32 of 40

Original Medicare

Blue Medicare Rx Enhanced (PDP) (Plan 004)

Blue Medicare Rx Standard (PDP) (Plan 002)

Catastrophic coverage After your yearly out-of-pocket drug costs reach $4550 you pay the greater of + 5 coinsurance or + $255 copay for generic (including brand drugs treated as generic) and a $635

copay for all other drugs

Out-of-network Plan drugs may be covered in special circumstances for instance illness while traveling outside ofthe planrsquos service area where there is no network pharmacy You may have to pay more than yournormal cost-sharing amount if you get your drugs at an out-of-network pharmacy In addition youwill likely have to pay the pharmacyrsquos full charge for the drug and submit documentation to receivereimbursement from Blue Medicare Rx (PDP)

You can get out-of-network drugs the following way

Out-of-network initial coverage

You will be reimbursed up to the planrsquos costof the drug minus the following for drugspurchased out-of-network until total yearlydrug costs reach $2850 Tier 1 - Preferred Generic

+ $8 copay for a one-month (30-day)supply of drugs in this tier Tier 2 - Non-Preferred Generic

+ $20 copay for a one-month (30-day)supply of drugs in this tier

Tier 3 - Preferred Brand

+ $45 copay for a one-month (30-day)supply of drugs in this tier

Tier 4 - Non-Preferred Brand

+ $95 copay for a one-month (30-day)supply of drugs in this tier

Tier 5 - Specialty Tier

+ 33 coinsurance for a one-month (30-day)supply of drugs in this tier

Out-of-network initial coverage

After you pay your yearly deductible you willbe reimbursed up to the planrsquos cost of the drugminus the following for drugs purchasedout-of-network until total yearly drug costsreach $2850 Tier 1 - Preferred Generic

+ $10 copay for a one-month (30-day)supply of drugs in this tier

Tier 2 - Non-Preferred Generic

+ $33 copay for a one-month (30-day)supply of drugs in this tier

Tier 3 - Preferred Brand

+ $45 copay for a one-month (30-day)supply of drugs in this tier

Tier 4 - Non-Preferred Brand

+ $95 copay for a one-month (30-day)supply of drugs in this tier

Tier 5 - Specialty Tier

+ 29 coinsurance for a one-month (30-day)supply of drugs in this tier

You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge andthe planrsquos In-Network allowable amount

Out-of-Network Coverage Gap You will be reimbursed up to 28 of the plan allowable cost for generic drugs purchasedout-of-network until total yearly out-of-pocket drug costs reach $4550 Please note that theplan allowable cost may be less than the out-of-network pharmacy price paid for your drug(s)

PAG E 33 of 40

Section 2 - Summary of benefits for ndash Benefit Outpatient Prescription Drugs Contract S5540 Plan 004 and Plan 002

Original Medicare

Blue Medicare Rx Enhanced (PDP) (Plan 004)

Blue Medicare Rx Standard (PDP) (Plan 002)

Out-of-Network Coverage Gap (continued)

You will be reimbursed up to 525 of the plan allowable cost for brand name drugs purchasedout-of-network until your total yearly out-of-pocket drug costs reach $4550 Please note that theplan allowable cost may be less than the out-of-network pharmacy price paid for your drug(s)

Additional Out-of-Network Coverage Gap

You will be reimbursed for these drugspurchased out-of-network up to the planrsquoscost of the drug minus the following

Tier 1 Preferred Generic

+ $8 copay for a one-month (30-day) supplyof all drugs covered within this tier

Out-of-network Catastrophic Coverage After your yearly out-of-pocket drug costs reach $4550 you will be reimbursed for drugs purchasedout-of-network up to the planrsquos cost of the drug minus your cost share which is the greater of+ 5 coinsurance or+ $255 copay for generic (including brand drugs treated as generic) and+ $635 copay for all other drugs

You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge andthe planrsquos In-Network allowable amount

PAG E 34 of 40

PAGE 35 of 40

(PDP)

Multi-language Interpreter Services

English We have free interpreter services to answer any questions you may have about our health or drug plan To get an interpreter just call us at 1-800-478-0583 Someone who speaks EnglishLanguage can help you This is a free service

Spanish Tenemos servicios de inteacuterprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos Para hablar con un inteacuterprete por favor llame al 1-800-478-0583 Alguien que hable espantildeol le podraacute ayudar Este es un servicio gratuito

Chinese Mandarin 我们提供免们的翻们服们们助们解答们于健康或们物保们的任何疑 们如果们需要此翻们服们们致们 phone number我们的中文工作人们很们意们助们 们是一们免们服们

Chinese Cantonese 您對我們的健康或藥物保險可能存有疑問為此我們提供免費的翻譯服務如需翻譯服務請致電 1-800-478-0583我們講中文的人員將樂意為您提供幫助這是一項免費服務

Tagalog Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot Upang makakuha ng tagasaling-wika tawagan lamang kami sa 1-800-478-0583 Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog Ito ay libreng serbisyo

French Nous proposons des services gratuits dinterpreacutetation pour reacutepondre agrave toutes vos questions relatives agrave notre reacutegime de santeacute ou dassurance-meacutedicaments Pour acceacuteder au service dinterpreacutetation il vous suffit de nous appeler au 1-800-478-0583 Un interlocuteur parlant Franccedilais pourra vous aider Ce service est gratuit

Vietnamese Chuacuteng tocirci coacute dịch vụ thocircng dịch miễn phiacute để trả lời caacutec cacircu hỏi về chương sức khỏe vagrave chương trigravenh thuốc men Nếu quiacute vị cần thocircng dịch viecircn xin gọi 1-800-478-0583 sẽ coacute nhacircn viecircn noacutei tiếng Việt giuacutep đỡ quiacute vị Đacircy lagrave dịch vụ miễn phiacute

German Unser kostenloser Dolmetscherservice beantwortet Ihren Fragen zu unserem Gesundheits- und Arzneimittelplan Unsere Dolmetscher erreichen Sie unter 1-800-478-0583 Man wird Ihnen dort auf Deutsch weiterhelfen Dieser Service ist kostenlos

Korean 당사는 의료 보험 또는 약품 보험에 관한 질문에 답해 드리고자 무료 통역 서비스를 제공하고 있습니다 통역 서비스를 이용하려면 전화 1-800-478-0583 번으로 문의해 주십시오 한국어를 하는 담당자가 도와 드릴 것입니다 이 서비스는 무료로 운영됩니다

Y0079_6200 CMS Approved 07082013 U5073d 813

116

Appendix 4 ndash Multi-Language Insert

Multi-language Interpreter Services

English We have free interpreter services to answer any questions you may have about our health or drug plan To get an interpreter just call us at [1-xxx-xxx-xxxx] Someone who speaks EnglishLanguage can help you This is a free service

Spanish Tenemos servicios de inteacuterprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos Para hablar con un inteacuterprete por favor llame al [1-xxx-xxx-xxxx] Alguien que hable espantildeol le podraacute ayudar Este es un servicio gratuito

Chinese Mandarin 我们提供免费的翻译服务帮助您解答关于健康或药物保险的任何疑

问如果您需要此翻译服务请致电 1-xxx-xxx-xxxx我们的中文工作人员很乐意帮助您

这是一项免费服务

Chinese Cantonese 您對我們的健康或藥物保險可能存有疑問為此我們提供免費的翻譯

服務如需翻譯服務請致電 1-xxx-xxx-xxxx我們講中文的人員將樂意為您提供幫助這

是一項免費服務

Tagalog Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot Upang makakuha ng tagasaling-wika tawagan lamang kami sa [1-xxx-xxx-xxxx] Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog Ito ay libreng serbisyo French Nous proposons des services gratuits dinterpreacutetation pour reacutepondre agrave toutes vos questions relatives agrave notre reacutegime de santeacute ou dassurance-meacutedicaments Pour acceacuteder au service dinterpreacutetation il vous suffit de nous appeler au [1-xxx-xxx-xxxx] Un interlocuteur parlant Franccedilais pourra vous aider Ce service est gratuit Vietnamese Chuacuteng tocirci coacute dịch vụ thocircng dịch miễn phiacute để trả lời caacutec cacircu hỏi về chương sức khỏe vagrave chương trigravenh thuốc men Nếu quiacute vị cần thocircng dịch viecircn xin gọi [1-xxx-xxx-xxxx] sẽ coacute nhacircn viecircn noacutei tiếng Việt giuacutep đỡ quiacute vị Đacircy lagrave dịch vụ miễn phiacute

116

Appendix 4 ndash Multi-Language Insert

Multi-language Interpreter Services

English We have free interpreter services to answer any questions you may have about our health or drug plan To get an interpreter just call us at [1-xxx-xxx-xxxx] Someone who speaks EnglishLanguage can help you This is a free service

Spanish Tenemos servicios de inteacuterprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos Para hablar con un inteacuterprete por favor llame al [1-xxx-xxx-xxxx] Alguien que hable espantildeol le podraacute ayudar Este es un servicio gratuito

Chinese Mandarin 我们提供免费的翻译服务帮助您解答关于健康或药物保险的任何疑

问如果您需要此翻译服务请致电 1-xxx-xxx-xxxx我们的中文工作人员很乐意帮助您

这是一项免费服务

Chinese Cantonese 您對我們的健康或藥物保險可能存有疑問為此我們提供免費的翻譯

服務如需翻譯服務請致電 1-xxx-xxx-xxxx我們講中文的人員將樂意為您提供幫助這

是一項免費服務

Tagalog Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot Upang makakuha ng tagasaling-wika tawagan lamang kami sa [1-xxx-xxx-xxxx] Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog Ito ay libreng serbisyo French Nous proposons des services gratuits dinterpreacutetation pour reacutepondre agrave toutes vos questions relatives agrave notre reacutegime de santeacute ou dassurance-meacutedicaments Pour acceacuteder au service dinterpreacutetation il vous suffit de nous appeler au [1-xxx-xxx-xxxx] Un interlocuteur parlant Franccedilais pourra vous aider Ce service est gratuit Vietnamese Chuacuteng tocirci coacute dịch vụ thocircng dịch miễn phiacute để trả lời caacutec cacircu hỏi về chương sức khỏe vagrave chương trigravenh thuốc men Nếu quiacute vị cần thocircng dịch viecircn xin gọi [1-xxx-xxx-xxxx] sẽ coacute nhacircn viecircn noacutei tiếng Việt giuacutep đỡ quiacute vị Đacircy lagrave dịch vụ miễn phiacute

116

Appendix 4 ndash Multi-Language Insert

Multi-language Interpreter Services

English We have free interpreter services to answer any questions you may have about our health or drug plan To get an interpreter just call us at [1-xxx-xxx-xxxx] Someone who speaks EnglishLanguage can help you This is a free service

Spanish Tenemos servicios de inteacuterprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos Para hablar con un inteacuterprete por favor llame al [1-xxx-xxx-xxxx] Alguien que hable espantildeol le podraacute ayudar Este es un servicio gratuito

Chinese Mandarin 我们提供免费的翻译服务帮助您解答关于健康或药物保险的任何疑

问如果您需要此翻译服务请致电 1-xxx-xxx-xxxx我们的中文工作人员很乐意帮助您

这是一项免费服务

Chinese Cantonese 您對我們的健康或藥物保險可能存有疑問為此我們提供免費的翻譯

服務如需翻譯服務請致電 1-xxx-xxx-xxxx我們講中文的人員將樂意為您提供幫助這

是一項免費服務

Tagalog Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot Upang makakuha ng tagasaling-wika tawagan lamang kami sa [1-xxx-xxx-xxxx] Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog Ito ay libreng serbisyo French Nous proposons des services gratuits dinterpreacutetation pour reacutepondre agrave toutes vos questions relatives agrave notre reacutegime de santeacute ou dassurance-meacutedicaments Pour acceacuteder au service dinterpreacutetation il vous suffit de nous appeler au [1-xxx-xxx-xxxx] Un interlocuteur parlant Franccedilais pourra vous aider Ce service est gratuit Vietnamese Chuacuteng tocirci coacute dịch vụ thocircng dịch miễn phiacute để trả lời caacutec cacircu hỏi về chương sức khỏe vagrave chương trigravenh thuốc men Nếu quiacute vị cần thocircng dịch viecircn xin gọi [1-xxx-xxx-xxxx] sẽ coacute nhacircn viecircn noacutei tiếng Việt giuacutep đỡ quiacute vị Đacircy lagrave dịch vụ miễn phiacute

1-800-478-0583

PAGE 36 of 40

(PDP)

Multi-language Interpreter Services (continued)

Russian Если у вас возникнут вопросы относительно страхового или медикаментного плана вы можете воспользоваться нашими бесплатными услугами переводчиков Чтобы воспользоваться услугами переводчика позвоните нам по телефону 1-800-478-0583 Вам окажет помощь сотрудник который говорит по-pусски Данная услуга бесплатная

Arabicةيودألا لودج وأ ةحصلاب قلعتت ةلئسأ يأ نع ةباجإلل ةيناجملا يروفلا مجرتملا تامدخ مدقن اننإ صخش موقيس 0583-478-800-1 ىلع انب لاصتالا ىوس كيلع سيل يروف مجرتم ىلع لوصحلل انيدلةيناجم ةمدخ هذه كتدعاسمب ةيبرعلا ثدحتي ام

Hindi हमार सवासथय या दवा की योजना क बार म आपक किसी भी परशन क जवाब दन क लिए हमार पास मफत दभाषिया सवाए उपलबध ह एक दभाषिया परापत करन क लिए बस हम 1-800-478-0583 पर फोन कर कोई वयकति जो हिनदी बोलता ह आपकी मदद कर सकता ह यह एक मफत सवा ह

Italian Egrave disponibile un servizio di interpretariato gratuito per rispondere a eventuali domande sul nostro piano sanitario e farmaceutico Per un interprete contattare il numero 1-800-478-0583 Un nostro incaricato che parla Italianovi forniragrave lassistenza necessaria Egrave un servizio gratuito

Portugueacutes Dispomos de serviccedilos de interpretaccedilatildeo gratuitos para responder a qualquer questatildeo que tenha acerca do nosso plano de sauacutede ou de medicaccedilatildeo Para obter um inteacuterprete contacte-nos atraveacutes do nuacutemero 1-800-478-0583 Iraacute encontrar algueacutem que fale o idioma Portuguecircs para o ajudar Este serviccedilo eacute gratuito

French Creole Nou genyen segravevis entegravepregravet gratis pou reponn tout kesyon ou ta genyen konsegravenan plan medikal oswa dwograveg nou an Pou jwenn yon entegravepregravet jis rele nou nan 1-800-478-0583 Yon moun ki pale Kreyogravel kapab ede w Sa a se yon segravevis ki gratis

Polish Umożliwiamy bezpłatne skorzystanie z usług tłumacza ustnego ktoacutery pomoże w uzyskaniu odpowiedzi na temat planu zdrowotnego lub dawkowania lekoacutew Aby skorzystać z pomocy tłumacza znającego język polski należy zadzwonić pod numer 1-800-478-0583 Ta usługa jest bezpłatna

Japanese 当社の健康 健康保険と薬品 処方薬プランに関するご質問にお答えするために無

料の通訳サービスがありますございます通訳をご用命になるには1-800-478-0583 にお電

話ください日本語を話す人 者 が支援いたしますこれは無料のサービスです

Notes

PAG E 37 of 40

Notes

PAG E 38 of 40

Notes

U5073e 813

PAGE 39 of 40

Awarded to BCBSNC by the Ethisphere Institute In 2013 companies in more than 100 countries and 36 industries were reviewed and of those 138 organizations were designated as Worldrsquos Most Ethical

BCBSNC Blue Medicare Rx products are only available to Medicare beneficiaries residing in North Carolina The information described in this brochure is for 2014 and may change on January 1 2015 The benefit information provided is a brief summary not a complete description of benefits For more information contact the plan This brochure may be available in alternate formats upon request Blue Cross and Blue Shield of North Carolina is a PDP plan with a Medicare contract Enrollment in Blue Cross and Blue Shield of North Carolina depends on contract renewal An independent licensee of the Blue Cross and Blue Shield Association reg SM Marks of the Blue Cross and Blue Shield Association SM1 Mark of Blue Cross and Blue Shield of North Carolina

If you are covered by oreligible for Medicare contactyour local Authorized SalesRepresentative to learn aboutour Medicare Part D plans

How can we help Call 1-800-478-0583 7 days aweek 8 am-8 pm For hearing and speech impaired(TTYTDD) usersCall 1-800-922-3140 7 days aweek 8 am-8 pm

Preferred Pharmacy NetworkBlue Medicare Rx (PDP)

Standard Plan Enhanced Plan Many of the popular drugsare covered ndash more than 1000included

Extensive list of covered drugs ndashmore than 1800 included

You pay $145 annual deductible No deductible ndash coverage beginsright away

$4 and $40 copayments for mostdrugs when you use our preferredpharmacy network up to $2850total drug cost

$3 and $30 copayments for mostdrugs when you use our preferredpharmacy network up to $2850total drug cost

You pay 72 on all generic drugsand you receive a discount onbrand-name drugs during the

ldquocoverage gaprdquo until true out-of-pocket costs reach $4550

You pay $3 copayment forpreferred generic drugs you pay72 for most other generic drugsand you receive a discount forbrand-name drugs during the

ldquocoverage gaprdquo until true out-of-pocket costs reach $4550

Generally 5 coinsurance after ldquocoverage gaprdquo ends Preferred Pharmacy Network includes CVS WalMart

Kerr Drugs and Epic Pharmacies

Non-preferred Pharmacy NetworkBlue Medicare Rx (PDP)

Standard Plan Enhanced Plan Many of the popular drugsare covered ndash more than 1000included

Extensive list of covered drugs ndashmore than 1800 included

You pay $145 annual deductible No deductible ndash coverage beginsright away

$10 and $45 copayments for mostdrugs up to $2850 total drug cost

$8 and $45 copayments for mostdrugs up to $2850 total drug cost

You pay 72 on all generic drugsand you receive a discount onbrand-name drugs during the

ldquocoverage gaprdquo until true out-of-pocket costs reach $4550

You pay $8 copayment forpreferred generic drugs you pay72 for most other generic drugsand you receive a discount forbrand-name drugs during the

ldquocoverage gaprdquo until true out-of-pocket costs reach $4550

Generally 5 coinsurance after ldquocoverage gaprdquo ends

PAGE 40 of 40

Y0079_6250 CMS Approved 08062013

Section 2 - Summary of benefits for ndash Benefit Outpatient Prescription Drugs Contract S5540 Plan 004 and Plan 002

Original Medicare

Blue Medicare Rx Enhanced (PDP) (Plan 004)

Blue Medicare Rx Standard (PDP) (Plan 002)

Mail order (continued) Tier 4 - Non-Preferred Brand

+ $70 copay for a one-month (30-day) supply of drugs in this tier from apreferred mail order pharmacy

+ $140 copay for a two-month (60-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $175 copay for a three-month (90-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $95 copay for a one-month (30-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $190 copay for a two-month (60-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $285 copay for a three-month (90-day)supply of drugs in this tier from anon-preferred mail order pharmacy

Mail order (continued) Tier 4 - Non-Preferred Brand + $85 copay for a one-month (30-day)

supply of drugs in this tier from apreferred mail order pharmacy

+ $170 copay for a two-month (60-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $21250 copay for a three-month (90-day)supply of drugs in this tier from apreferred mail order pharmacy

+ $95 copay for a one-month (30-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $190 copay for a two-month (60-day)supply of drugs in this tier from anon-preferred mail order pharmacy

+ $285 copay for a three-month (90-day)supply of drugs in this tier from anon-preferred mail order pharmacy

Not all drugs on this tier are available at this extended day supply Please contactthe plan for more information

Tier 5 - Specialty Tier

+ 33 coinsurance for a one-month (30-day) supply of drugs in this tier from apreferred mail order pharmacy

+ 33 coinsurance for a two-month (60-day) supply of drugs in this tier from apreferred mail order pharmacy

+ 33 coinsurance for a three-month (90-day) supply of drugs in this tier from apreferred mail order pharmacy

+ 33 coinsurance for a one-month (30-day) supply of drugs in this tier froma non-preferred mail order pharmacy

+ 33 coinsurance for a two-month (60-day) supply of drugs in this tier from anon-preferred mail order pharmacy

+ 33 coinsurance for a three-month (90-day) supply of drugs in this tier froma non-preferred mail order pharmacy

Tier 5 - Specialty Tier

+ 29 coinsurance for a one-month (30-day)supply of drugs in this tier from apreferred mail order pharmacy

+ 29 coinsurance for a two-month (60-day) supply of drugs in this tier from apreferred mail order pharmacy

+ 29 coinsurance for a three-month (90-day)supply of drugs in this tier from a preferredmail order pharmacy

+ 29 coinsurance for a one-month (30-day)supply of drugs in this tier froma non-preferred mail order pharmacy

+ 29 coinsurance for a two-month (60-day) supply of drugs in this tier from anon-preferred mail order pharmacy

+ 29 coinsurance for a three-month (90-day)supply of drugs in this tier froma non-preferred mail order pharmacy

Not all drugs on this tier are available at this extended day supply Please contactthe plan for more information

PAG E 30 of 40

Original Medicare

Blue Medicare Rx Enhanced (PDP) (Plan 004)

Blue Medicare Rx Standard (PDP) (Plan 002)

Coverage gap After your total yearly drug costs reach $2850 you receive limited coverage by the plan on certaindrugs You will also receive a discount on brand name drugs and generally pay no more than 475for the planrsquos costs for brand drugs and 72 of the planrsquos costs for generic drugs until your yearly out-of-pocket drug costs reach $4550 Additional Coverage gap The plan covers some formulary generics (10-64 of formularygeneric drugs) through the coverage gap The plan offers additional coverage in the gap for thefollowing tiers You pay the following Retail Pharmacy Contact your plan if you have questions about cost-sharing orbilling when less than a one-month supply is dispensed

Tier 1 Preferred Generic + $3 copay for a one-month (30-day) supply of all drugs

covered within this tier from a preferred pharmacy + $6 copay for a two-month (60-day) supply of all drugs

covered within this tier from a preferred pharmacy + $9 copay for a three-month (90-day) supply of all drugs

covered within this tier from a preferred pharmacy + $8 copay for a one-month (30-day) supply of all drugs

covered within this tier at a non-preferred pharmacy + $16 copay for a two-month (60-day) supply of all drugs

covered within this tier from a non-preferred pharmacy + $24 copay for a three-month (90-day) supply of all drugs

covered within this tier from a non-preferred pharmacy

Not all drugs on this tier are available at this extended daysupply Please contact the plan for more information

Long Term Care Pharmacy Long term care pharmacies must dispense brand name drugsin amounts less than a 14 days supply at a time They may alsodispense less than a monthrsquos supply of generic drugs at a timeContact your plan if you have questions about cost-sharing orbilling when less than a one-month supply is dispensed Tier 1 Preferred Generic + $8 copay for a one-month (31-day) supply of all drugs

covered in this tier

PAG E 31 of 40

Section 2 - Summary of benefits for ndash Benefit Outpatient Prescription Drugs Contract S5540 Plan 004 and Plan 002

Original Medicare

Blue Medicare Rx Enhanced (PDP) (Plan 004)

Blue Medicare Rx Standard (PDP) (Plan 002)

Mail Order Contact your plan if you have questions about cost-sharing orbilling when less than a one-month supply is dispensed Tier 1 Preferred Generic + $3 copay for a one-month (30-day) supply of all drugs

covered within this tier from a preferred mail order pharmacy + $0 copay for a two-month (60-day) supply of all drugs

covered within this tier from a preferred mail order pharmacy + $0 copay for a three-month (90-day) supply of all drugs

covered within this tier from a preferred mail order pharmacy + $8 copay for a one-month (30-day) supply of all drugs

covered within this tier from a non-preferred mail orderpharmacy

+ $16 copay for a two-month (60-day) supply of all drugscovered within this tier from a non-preferred mail orderpharmacy

+ $24 copay for a three-month (90-day) supply of all drugscovered within this tier from a non-preferred mail orderpharmacy

Not all drugs on this tier are available at this extended daysupply Please contact the plan for more information

PAG E 32 of 40

Original Medicare

Blue Medicare Rx Enhanced (PDP) (Plan 004)

Blue Medicare Rx Standard (PDP) (Plan 002)

Catastrophic coverage After your yearly out-of-pocket drug costs reach $4550 you pay the greater of + 5 coinsurance or + $255 copay for generic (including brand drugs treated as generic) and a $635

copay for all other drugs

Out-of-network Plan drugs may be covered in special circumstances for instance illness while traveling outside ofthe planrsquos service area where there is no network pharmacy You may have to pay more than yournormal cost-sharing amount if you get your drugs at an out-of-network pharmacy In addition youwill likely have to pay the pharmacyrsquos full charge for the drug and submit documentation to receivereimbursement from Blue Medicare Rx (PDP)

You can get out-of-network drugs the following way

Out-of-network initial coverage

You will be reimbursed up to the planrsquos costof the drug minus the following for drugspurchased out-of-network until total yearlydrug costs reach $2850 Tier 1 - Preferred Generic

+ $8 copay for a one-month (30-day)supply of drugs in this tier Tier 2 - Non-Preferred Generic

+ $20 copay for a one-month (30-day)supply of drugs in this tier

Tier 3 - Preferred Brand

+ $45 copay for a one-month (30-day)supply of drugs in this tier

Tier 4 - Non-Preferred Brand

+ $95 copay for a one-month (30-day)supply of drugs in this tier

Tier 5 - Specialty Tier

+ 33 coinsurance for a one-month (30-day)supply of drugs in this tier

Out-of-network initial coverage

After you pay your yearly deductible you willbe reimbursed up to the planrsquos cost of the drugminus the following for drugs purchasedout-of-network until total yearly drug costsreach $2850 Tier 1 - Preferred Generic

+ $10 copay for a one-month (30-day)supply of drugs in this tier

Tier 2 - Non-Preferred Generic

+ $33 copay for a one-month (30-day)supply of drugs in this tier

Tier 3 - Preferred Brand

+ $45 copay for a one-month (30-day)supply of drugs in this tier

Tier 4 - Non-Preferred Brand

+ $95 copay for a one-month (30-day)supply of drugs in this tier

Tier 5 - Specialty Tier

+ 29 coinsurance for a one-month (30-day)supply of drugs in this tier

You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge andthe planrsquos In-Network allowable amount

Out-of-Network Coverage Gap You will be reimbursed up to 28 of the plan allowable cost for generic drugs purchasedout-of-network until total yearly out-of-pocket drug costs reach $4550 Please note that theplan allowable cost may be less than the out-of-network pharmacy price paid for your drug(s)

PAG E 33 of 40

Section 2 - Summary of benefits for ndash Benefit Outpatient Prescription Drugs Contract S5540 Plan 004 and Plan 002

Original Medicare

Blue Medicare Rx Enhanced (PDP) (Plan 004)

Blue Medicare Rx Standard (PDP) (Plan 002)

Out-of-Network Coverage Gap (continued)

You will be reimbursed up to 525 of the plan allowable cost for brand name drugs purchasedout-of-network until your total yearly out-of-pocket drug costs reach $4550 Please note that theplan allowable cost may be less than the out-of-network pharmacy price paid for your drug(s)

Additional Out-of-Network Coverage Gap

You will be reimbursed for these drugspurchased out-of-network up to the planrsquoscost of the drug minus the following

Tier 1 Preferred Generic

+ $8 copay for a one-month (30-day) supplyof all drugs covered within this tier

Out-of-network Catastrophic Coverage After your yearly out-of-pocket drug costs reach $4550 you will be reimbursed for drugs purchasedout-of-network up to the planrsquos cost of the drug minus your cost share which is the greater of+ 5 coinsurance or+ $255 copay for generic (including brand drugs treated as generic) and+ $635 copay for all other drugs

You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge andthe planrsquos In-Network allowable amount

PAG E 34 of 40

PAGE 35 of 40

(PDP)

Multi-language Interpreter Services

English We have free interpreter services to answer any questions you may have about our health or drug plan To get an interpreter just call us at 1-800-478-0583 Someone who speaks EnglishLanguage can help you This is a free service

Spanish Tenemos servicios de inteacuterprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos Para hablar con un inteacuterprete por favor llame al 1-800-478-0583 Alguien que hable espantildeol le podraacute ayudar Este es un servicio gratuito

Chinese Mandarin 我们提供免们的翻们服们们助们解答们于健康或们物保们的任何疑 们如果们需要此翻们服们们致们 phone number我们的中文工作人们很们意们助们 们是一们免们服们

Chinese Cantonese 您對我們的健康或藥物保險可能存有疑問為此我們提供免費的翻譯服務如需翻譯服務請致電 1-800-478-0583我們講中文的人員將樂意為您提供幫助這是一項免費服務

Tagalog Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot Upang makakuha ng tagasaling-wika tawagan lamang kami sa 1-800-478-0583 Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog Ito ay libreng serbisyo

French Nous proposons des services gratuits dinterpreacutetation pour reacutepondre agrave toutes vos questions relatives agrave notre reacutegime de santeacute ou dassurance-meacutedicaments Pour acceacuteder au service dinterpreacutetation il vous suffit de nous appeler au 1-800-478-0583 Un interlocuteur parlant Franccedilais pourra vous aider Ce service est gratuit

Vietnamese Chuacuteng tocirci coacute dịch vụ thocircng dịch miễn phiacute để trả lời caacutec cacircu hỏi về chương sức khỏe vagrave chương trigravenh thuốc men Nếu quiacute vị cần thocircng dịch viecircn xin gọi 1-800-478-0583 sẽ coacute nhacircn viecircn noacutei tiếng Việt giuacutep đỡ quiacute vị Đacircy lagrave dịch vụ miễn phiacute

German Unser kostenloser Dolmetscherservice beantwortet Ihren Fragen zu unserem Gesundheits- und Arzneimittelplan Unsere Dolmetscher erreichen Sie unter 1-800-478-0583 Man wird Ihnen dort auf Deutsch weiterhelfen Dieser Service ist kostenlos

Korean 당사는 의료 보험 또는 약품 보험에 관한 질문에 답해 드리고자 무료 통역 서비스를 제공하고 있습니다 통역 서비스를 이용하려면 전화 1-800-478-0583 번으로 문의해 주십시오 한국어를 하는 담당자가 도와 드릴 것입니다 이 서비스는 무료로 운영됩니다

Y0079_6200 CMS Approved 07082013 U5073d 813

116

Appendix 4 ndash Multi-Language Insert

Multi-language Interpreter Services

English We have free interpreter services to answer any questions you may have about our health or drug plan To get an interpreter just call us at [1-xxx-xxx-xxxx] Someone who speaks EnglishLanguage can help you This is a free service

Spanish Tenemos servicios de inteacuterprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos Para hablar con un inteacuterprete por favor llame al [1-xxx-xxx-xxxx] Alguien que hable espantildeol le podraacute ayudar Este es un servicio gratuito

Chinese Mandarin 我们提供免费的翻译服务帮助您解答关于健康或药物保险的任何疑

问如果您需要此翻译服务请致电 1-xxx-xxx-xxxx我们的中文工作人员很乐意帮助您

这是一项免费服务

Chinese Cantonese 您對我們的健康或藥物保險可能存有疑問為此我們提供免費的翻譯

服務如需翻譯服務請致電 1-xxx-xxx-xxxx我們講中文的人員將樂意為您提供幫助這

是一項免費服務

Tagalog Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot Upang makakuha ng tagasaling-wika tawagan lamang kami sa [1-xxx-xxx-xxxx] Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog Ito ay libreng serbisyo French Nous proposons des services gratuits dinterpreacutetation pour reacutepondre agrave toutes vos questions relatives agrave notre reacutegime de santeacute ou dassurance-meacutedicaments Pour acceacuteder au service dinterpreacutetation il vous suffit de nous appeler au [1-xxx-xxx-xxxx] Un interlocuteur parlant Franccedilais pourra vous aider Ce service est gratuit Vietnamese Chuacuteng tocirci coacute dịch vụ thocircng dịch miễn phiacute để trả lời caacutec cacircu hỏi về chương sức khỏe vagrave chương trigravenh thuốc men Nếu quiacute vị cần thocircng dịch viecircn xin gọi [1-xxx-xxx-xxxx] sẽ coacute nhacircn viecircn noacutei tiếng Việt giuacutep đỡ quiacute vị Đacircy lagrave dịch vụ miễn phiacute

116

Appendix 4 ndash Multi-Language Insert

Multi-language Interpreter Services

English We have free interpreter services to answer any questions you may have about our health or drug plan To get an interpreter just call us at [1-xxx-xxx-xxxx] Someone who speaks EnglishLanguage can help you This is a free service

Spanish Tenemos servicios de inteacuterprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos Para hablar con un inteacuterprete por favor llame al [1-xxx-xxx-xxxx] Alguien que hable espantildeol le podraacute ayudar Este es un servicio gratuito

Chinese Mandarin 我们提供免费的翻译服务帮助您解答关于健康或药物保险的任何疑

问如果您需要此翻译服务请致电 1-xxx-xxx-xxxx我们的中文工作人员很乐意帮助您

这是一项免费服务

Chinese Cantonese 您對我們的健康或藥物保險可能存有疑問為此我們提供免費的翻譯

服務如需翻譯服務請致電 1-xxx-xxx-xxxx我們講中文的人員將樂意為您提供幫助這

是一項免費服務

Tagalog Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot Upang makakuha ng tagasaling-wika tawagan lamang kami sa [1-xxx-xxx-xxxx] Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog Ito ay libreng serbisyo French Nous proposons des services gratuits dinterpreacutetation pour reacutepondre agrave toutes vos questions relatives agrave notre reacutegime de santeacute ou dassurance-meacutedicaments Pour acceacuteder au service dinterpreacutetation il vous suffit de nous appeler au [1-xxx-xxx-xxxx] Un interlocuteur parlant Franccedilais pourra vous aider Ce service est gratuit Vietnamese Chuacuteng tocirci coacute dịch vụ thocircng dịch miễn phiacute để trả lời caacutec cacircu hỏi về chương sức khỏe vagrave chương trigravenh thuốc men Nếu quiacute vị cần thocircng dịch viecircn xin gọi [1-xxx-xxx-xxxx] sẽ coacute nhacircn viecircn noacutei tiếng Việt giuacutep đỡ quiacute vị Đacircy lagrave dịch vụ miễn phiacute

116

Appendix 4 ndash Multi-Language Insert

Multi-language Interpreter Services

English We have free interpreter services to answer any questions you may have about our health or drug plan To get an interpreter just call us at [1-xxx-xxx-xxxx] Someone who speaks EnglishLanguage can help you This is a free service

Spanish Tenemos servicios de inteacuterprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos Para hablar con un inteacuterprete por favor llame al [1-xxx-xxx-xxxx] Alguien que hable espantildeol le podraacute ayudar Este es un servicio gratuito

Chinese Mandarin 我们提供免费的翻译服务帮助您解答关于健康或药物保险的任何疑

问如果您需要此翻译服务请致电 1-xxx-xxx-xxxx我们的中文工作人员很乐意帮助您

这是一项免费服务

Chinese Cantonese 您對我們的健康或藥物保險可能存有疑問為此我們提供免費的翻譯

服務如需翻譯服務請致電 1-xxx-xxx-xxxx我們講中文的人員將樂意為您提供幫助這

是一項免費服務

Tagalog Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot Upang makakuha ng tagasaling-wika tawagan lamang kami sa [1-xxx-xxx-xxxx] Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog Ito ay libreng serbisyo French Nous proposons des services gratuits dinterpreacutetation pour reacutepondre agrave toutes vos questions relatives agrave notre reacutegime de santeacute ou dassurance-meacutedicaments Pour acceacuteder au service dinterpreacutetation il vous suffit de nous appeler au [1-xxx-xxx-xxxx] Un interlocuteur parlant Franccedilais pourra vous aider Ce service est gratuit Vietnamese Chuacuteng tocirci coacute dịch vụ thocircng dịch miễn phiacute để trả lời caacutec cacircu hỏi về chương sức khỏe vagrave chương trigravenh thuốc men Nếu quiacute vị cần thocircng dịch viecircn xin gọi [1-xxx-xxx-xxxx] sẽ coacute nhacircn viecircn noacutei tiếng Việt giuacutep đỡ quiacute vị Đacircy lagrave dịch vụ miễn phiacute

1-800-478-0583

PAGE 36 of 40

(PDP)

Multi-language Interpreter Services (continued)

Russian Если у вас возникнут вопросы относительно страхового или медикаментного плана вы можете воспользоваться нашими бесплатными услугами переводчиков Чтобы воспользоваться услугами переводчика позвоните нам по телефону 1-800-478-0583 Вам окажет помощь сотрудник который говорит по-pусски Данная услуга бесплатная

Arabicةيودألا لودج وأ ةحصلاب قلعتت ةلئسأ يأ نع ةباجإلل ةيناجملا يروفلا مجرتملا تامدخ مدقن اننإ صخش موقيس 0583-478-800-1 ىلع انب لاصتالا ىوس كيلع سيل يروف مجرتم ىلع لوصحلل انيدلةيناجم ةمدخ هذه كتدعاسمب ةيبرعلا ثدحتي ام

Hindi हमार सवासथय या दवा की योजना क बार म आपक किसी भी परशन क जवाब दन क लिए हमार पास मफत दभाषिया सवाए उपलबध ह एक दभाषिया परापत करन क लिए बस हम 1-800-478-0583 पर फोन कर कोई वयकति जो हिनदी बोलता ह आपकी मदद कर सकता ह यह एक मफत सवा ह

Italian Egrave disponibile un servizio di interpretariato gratuito per rispondere a eventuali domande sul nostro piano sanitario e farmaceutico Per un interprete contattare il numero 1-800-478-0583 Un nostro incaricato che parla Italianovi forniragrave lassistenza necessaria Egrave un servizio gratuito

Portugueacutes Dispomos de serviccedilos de interpretaccedilatildeo gratuitos para responder a qualquer questatildeo que tenha acerca do nosso plano de sauacutede ou de medicaccedilatildeo Para obter um inteacuterprete contacte-nos atraveacutes do nuacutemero 1-800-478-0583 Iraacute encontrar algueacutem que fale o idioma Portuguecircs para o ajudar Este serviccedilo eacute gratuito

French Creole Nou genyen segravevis entegravepregravet gratis pou reponn tout kesyon ou ta genyen konsegravenan plan medikal oswa dwograveg nou an Pou jwenn yon entegravepregravet jis rele nou nan 1-800-478-0583 Yon moun ki pale Kreyogravel kapab ede w Sa a se yon segravevis ki gratis

Polish Umożliwiamy bezpłatne skorzystanie z usług tłumacza ustnego ktoacutery pomoże w uzyskaniu odpowiedzi na temat planu zdrowotnego lub dawkowania lekoacutew Aby skorzystać z pomocy tłumacza znającego język polski należy zadzwonić pod numer 1-800-478-0583 Ta usługa jest bezpłatna

Japanese 当社の健康 健康保険と薬品 処方薬プランに関するご質問にお答えするために無

料の通訳サービスがありますございます通訳をご用命になるには1-800-478-0583 にお電

話ください日本語を話す人 者 が支援いたしますこれは無料のサービスです

Notes

PAG E 37 of 40

Notes

PAG E 38 of 40

Notes

U5073e 813

PAGE 39 of 40

Awarded to BCBSNC by the Ethisphere Institute In 2013 companies in more than 100 countries and 36 industries were reviewed and of those 138 organizations were designated as Worldrsquos Most Ethical

BCBSNC Blue Medicare Rx products are only available to Medicare beneficiaries residing in North Carolina The information described in this brochure is for 2014 and may change on January 1 2015 The benefit information provided is a brief summary not a complete description of benefits For more information contact the plan This brochure may be available in alternate formats upon request Blue Cross and Blue Shield of North Carolina is a PDP plan with a Medicare contract Enrollment in Blue Cross and Blue Shield of North Carolina depends on contract renewal An independent licensee of the Blue Cross and Blue Shield Association reg SM Marks of the Blue Cross and Blue Shield Association SM1 Mark of Blue Cross and Blue Shield of North Carolina

If you are covered by oreligible for Medicare contactyour local Authorized SalesRepresentative to learn aboutour Medicare Part D plans

How can we help Call 1-800-478-0583 7 days aweek 8 am-8 pm For hearing and speech impaired(TTYTDD) usersCall 1-800-922-3140 7 days aweek 8 am-8 pm

Preferred Pharmacy NetworkBlue Medicare Rx (PDP)

Standard Plan Enhanced Plan Many of the popular drugsare covered ndash more than 1000included

Extensive list of covered drugs ndashmore than 1800 included

You pay $145 annual deductible No deductible ndash coverage beginsright away

$4 and $40 copayments for mostdrugs when you use our preferredpharmacy network up to $2850total drug cost

$3 and $30 copayments for mostdrugs when you use our preferredpharmacy network up to $2850total drug cost

You pay 72 on all generic drugsand you receive a discount onbrand-name drugs during the

ldquocoverage gaprdquo until true out-of-pocket costs reach $4550

You pay $3 copayment forpreferred generic drugs you pay72 for most other generic drugsand you receive a discount forbrand-name drugs during the

ldquocoverage gaprdquo until true out-of-pocket costs reach $4550

Generally 5 coinsurance after ldquocoverage gaprdquo ends Preferred Pharmacy Network includes CVS WalMart

Kerr Drugs and Epic Pharmacies

Non-preferred Pharmacy NetworkBlue Medicare Rx (PDP)

Standard Plan Enhanced Plan Many of the popular drugsare covered ndash more than 1000included

Extensive list of covered drugs ndashmore than 1800 included

You pay $145 annual deductible No deductible ndash coverage beginsright away

$10 and $45 copayments for mostdrugs up to $2850 total drug cost

$8 and $45 copayments for mostdrugs up to $2850 total drug cost

You pay 72 on all generic drugsand you receive a discount onbrand-name drugs during the

ldquocoverage gaprdquo until true out-of-pocket costs reach $4550

You pay $8 copayment forpreferred generic drugs you pay72 for most other generic drugsand you receive a discount forbrand-name drugs during the

ldquocoverage gaprdquo until true out-of-pocket costs reach $4550

Generally 5 coinsurance after ldquocoverage gaprdquo ends

PAGE 40 of 40

Y0079_6250 CMS Approved 08062013

Original Medicare

Blue Medicare Rx Enhanced (PDP) (Plan 004)

Blue Medicare Rx Standard (PDP) (Plan 002)

Coverage gap After your total yearly drug costs reach $2850 you receive limited coverage by the plan on certaindrugs You will also receive a discount on brand name drugs and generally pay no more than 475for the planrsquos costs for brand drugs and 72 of the planrsquos costs for generic drugs until your yearly out-of-pocket drug costs reach $4550 Additional Coverage gap The plan covers some formulary generics (10-64 of formularygeneric drugs) through the coverage gap The plan offers additional coverage in the gap for thefollowing tiers You pay the following Retail Pharmacy Contact your plan if you have questions about cost-sharing orbilling when less than a one-month supply is dispensed

Tier 1 Preferred Generic + $3 copay for a one-month (30-day) supply of all drugs

covered within this tier from a preferred pharmacy + $6 copay for a two-month (60-day) supply of all drugs

covered within this tier from a preferred pharmacy + $9 copay for a three-month (90-day) supply of all drugs

covered within this tier from a preferred pharmacy + $8 copay for a one-month (30-day) supply of all drugs

covered within this tier at a non-preferred pharmacy + $16 copay for a two-month (60-day) supply of all drugs

covered within this tier from a non-preferred pharmacy + $24 copay for a three-month (90-day) supply of all drugs

covered within this tier from a non-preferred pharmacy

Not all drugs on this tier are available at this extended daysupply Please contact the plan for more information

Long Term Care Pharmacy Long term care pharmacies must dispense brand name drugsin amounts less than a 14 days supply at a time They may alsodispense less than a monthrsquos supply of generic drugs at a timeContact your plan if you have questions about cost-sharing orbilling when less than a one-month supply is dispensed Tier 1 Preferred Generic + $8 copay for a one-month (31-day) supply of all drugs

covered in this tier

PAG E 31 of 40

Section 2 - Summary of benefits for ndash Benefit Outpatient Prescription Drugs Contract S5540 Plan 004 and Plan 002

Original Medicare

Blue Medicare Rx Enhanced (PDP) (Plan 004)

Blue Medicare Rx Standard (PDP) (Plan 002)

Mail Order Contact your plan if you have questions about cost-sharing orbilling when less than a one-month supply is dispensed Tier 1 Preferred Generic + $3 copay for a one-month (30-day) supply of all drugs

covered within this tier from a preferred mail order pharmacy + $0 copay for a two-month (60-day) supply of all drugs

covered within this tier from a preferred mail order pharmacy + $0 copay for a three-month (90-day) supply of all drugs

covered within this tier from a preferred mail order pharmacy + $8 copay for a one-month (30-day) supply of all drugs

covered within this tier from a non-preferred mail orderpharmacy

+ $16 copay for a two-month (60-day) supply of all drugscovered within this tier from a non-preferred mail orderpharmacy

+ $24 copay for a three-month (90-day) supply of all drugscovered within this tier from a non-preferred mail orderpharmacy

Not all drugs on this tier are available at this extended daysupply Please contact the plan for more information

PAG E 32 of 40

Original Medicare

Blue Medicare Rx Enhanced (PDP) (Plan 004)

Blue Medicare Rx Standard (PDP) (Plan 002)

Catastrophic coverage After your yearly out-of-pocket drug costs reach $4550 you pay the greater of + 5 coinsurance or + $255 copay for generic (including brand drugs treated as generic) and a $635

copay for all other drugs

Out-of-network Plan drugs may be covered in special circumstances for instance illness while traveling outside ofthe planrsquos service area where there is no network pharmacy You may have to pay more than yournormal cost-sharing amount if you get your drugs at an out-of-network pharmacy In addition youwill likely have to pay the pharmacyrsquos full charge for the drug and submit documentation to receivereimbursement from Blue Medicare Rx (PDP)

You can get out-of-network drugs the following way

Out-of-network initial coverage

You will be reimbursed up to the planrsquos costof the drug minus the following for drugspurchased out-of-network until total yearlydrug costs reach $2850 Tier 1 - Preferred Generic

+ $8 copay for a one-month (30-day)supply of drugs in this tier Tier 2 - Non-Preferred Generic

+ $20 copay for a one-month (30-day)supply of drugs in this tier

Tier 3 - Preferred Brand

+ $45 copay for a one-month (30-day)supply of drugs in this tier

Tier 4 - Non-Preferred Brand

+ $95 copay for a one-month (30-day)supply of drugs in this tier

Tier 5 - Specialty Tier

+ 33 coinsurance for a one-month (30-day)supply of drugs in this tier

Out-of-network initial coverage

After you pay your yearly deductible you willbe reimbursed up to the planrsquos cost of the drugminus the following for drugs purchasedout-of-network until total yearly drug costsreach $2850 Tier 1 - Preferred Generic

+ $10 copay for a one-month (30-day)supply of drugs in this tier

Tier 2 - Non-Preferred Generic

+ $33 copay for a one-month (30-day)supply of drugs in this tier

Tier 3 - Preferred Brand

+ $45 copay for a one-month (30-day)supply of drugs in this tier

Tier 4 - Non-Preferred Brand

+ $95 copay for a one-month (30-day)supply of drugs in this tier

Tier 5 - Specialty Tier

+ 29 coinsurance for a one-month (30-day)supply of drugs in this tier

You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge andthe planrsquos In-Network allowable amount

Out-of-Network Coverage Gap You will be reimbursed up to 28 of the plan allowable cost for generic drugs purchasedout-of-network until total yearly out-of-pocket drug costs reach $4550 Please note that theplan allowable cost may be less than the out-of-network pharmacy price paid for your drug(s)

PAG E 33 of 40

Section 2 - Summary of benefits for ndash Benefit Outpatient Prescription Drugs Contract S5540 Plan 004 and Plan 002

Original Medicare

Blue Medicare Rx Enhanced (PDP) (Plan 004)

Blue Medicare Rx Standard (PDP) (Plan 002)

Out-of-Network Coverage Gap (continued)

You will be reimbursed up to 525 of the plan allowable cost for brand name drugs purchasedout-of-network until your total yearly out-of-pocket drug costs reach $4550 Please note that theplan allowable cost may be less than the out-of-network pharmacy price paid for your drug(s)

Additional Out-of-Network Coverage Gap

You will be reimbursed for these drugspurchased out-of-network up to the planrsquoscost of the drug minus the following

Tier 1 Preferred Generic

+ $8 copay for a one-month (30-day) supplyof all drugs covered within this tier

Out-of-network Catastrophic Coverage After your yearly out-of-pocket drug costs reach $4550 you will be reimbursed for drugs purchasedout-of-network up to the planrsquos cost of the drug minus your cost share which is the greater of+ 5 coinsurance or+ $255 copay for generic (including brand drugs treated as generic) and+ $635 copay for all other drugs

You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge andthe planrsquos In-Network allowable amount

PAG E 34 of 40

PAGE 35 of 40

(PDP)

Multi-language Interpreter Services

English We have free interpreter services to answer any questions you may have about our health or drug plan To get an interpreter just call us at 1-800-478-0583 Someone who speaks EnglishLanguage can help you This is a free service

Spanish Tenemos servicios de inteacuterprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos Para hablar con un inteacuterprete por favor llame al 1-800-478-0583 Alguien que hable espantildeol le podraacute ayudar Este es un servicio gratuito

Chinese Mandarin 我们提供免们的翻们服们们助们解答们于健康或们物保们的任何疑 们如果们需要此翻们服们们致们 phone number我们的中文工作人们很们意们助们 们是一们免们服们

Chinese Cantonese 您對我們的健康或藥物保險可能存有疑問為此我們提供免費的翻譯服務如需翻譯服務請致電 1-800-478-0583我們講中文的人員將樂意為您提供幫助這是一項免費服務

Tagalog Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot Upang makakuha ng tagasaling-wika tawagan lamang kami sa 1-800-478-0583 Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog Ito ay libreng serbisyo

French Nous proposons des services gratuits dinterpreacutetation pour reacutepondre agrave toutes vos questions relatives agrave notre reacutegime de santeacute ou dassurance-meacutedicaments Pour acceacuteder au service dinterpreacutetation il vous suffit de nous appeler au 1-800-478-0583 Un interlocuteur parlant Franccedilais pourra vous aider Ce service est gratuit

Vietnamese Chuacuteng tocirci coacute dịch vụ thocircng dịch miễn phiacute để trả lời caacutec cacircu hỏi về chương sức khỏe vagrave chương trigravenh thuốc men Nếu quiacute vị cần thocircng dịch viecircn xin gọi 1-800-478-0583 sẽ coacute nhacircn viecircn noacutei tiếng Việt giuacutep đỡ quiacute vị Đacircy lagrave dịch vụ miễn phiacute

German Unser kostenloser Dolmetscherservice beantwortet Ihren Fragen zu unserem Gesundheits- und Arzneimittelplan Unsere Dolmetscher erreichen Sie unter 1-800-478-0583 Man wird Ihnen dort auf Deutsch weiterhelfen Dieser Service ist kostenlos

Korean 당사는 의료 보험 또는 약품 보험에 관한 질문에 답해 드리고자 무료 통역 서비스를 제공하고 있습니다 통역 서비스를 이용하려면 전화 1-800-478-0583 번으로 문의해 주십시오 한국어를 하는 담당자가 도와 드릴 것입니다 이 서비스는 무료로 운영됩니다

Y0079_6200 CMS Approved 07082013 U5073d 813

116

Appendix 4 ndash Multi-Language Insert

Multi-language Interpreter Services

English We have free interpreter services to answer any questions you may have about our health or drug plan To get an interpreter just call us at [1-xxx-xxx-xxxx] Someone who speaks EnglishLanguage can help you This is a free service

Spanish Tenemos servicios de inteacuterprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos Para hablar con un inteacuterprete por favor llame al [1-xxx-xxx-xxxx] Alguien que hable espantildeol le podraacute ayudar Este es un servicio gratuito

Chinese Mandarin 我们提供免费的翻译服务帮助您解答关于健康或药物保险的任何疑

问如果您需要此翻译服务请致电 1-xxx-xxx-xxxx我们的中文工作人员很乐意帮助您

这是一项免费服务

Chinese Cantonese 您對我們的健康或藥物保險可能存有疑問為此我們提供免費的翻譯

服務如需翻譯服務請致電 1-xxx-xxx-xxxx我們講中文的人員將樂意為您提供幫助這

是一項免費服務

Tagalog Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot Upang makakuha ng tagasaling-wika tawagan lamang kami sa [1-xxx-xxx-xxxx] Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog Ito ay libreng serbisyo French Nous proposons des services gratuits dinterpreacutetation pour reacutepondre agrave toutes vos questions relatives agrave notre reacutegime de santeacute ou dassurance-meacutedicaments Pour acceacuteder au service dinterpreacutetation il vous suffit de nous appeler au [1-xxx-xxx-xxxx] Un interlocuteur parlant Franccedilais pourra vous aider Ce service est gratuit Vietnamese Chuacuteng tocirci coacute dịch vụ thocircng dịch miễn phiacute để trả lời caacutec cacircu hỏi về chương sức khỏe vagrave chương trigravenh thuốc men Nếu quiacute vị cần thocircng dịch viecircn xin gọi [1-xxx-xxx-xxxx] sẽ coacute nhacircn viecircn noacutei tiếng Việt giuacutep đỡ quiacute vị Đacircy lagrave dịch vụ miễn phiacute

116

Appendix 4 ndash Multi-Language Insert

Multi-language Interpreter Services

English We have free interpreter services to answer any questions you may have about our health or drug plan To get an interpreter just call us at [1-xxx-xxx-xxxx] Someone who speaks EnglishLanguage can help you This is a free service

Spanish Tenemos servicios de inteacuterprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos Para hablar con un inteacuterprete por favor llame al [1-xxx-xxx-xxxx] Alguien que hable espantildeol le podraacute ayudar Este es un servicio gratuito

Chinese Mandarin 我们提供免费的翻译服务帮助您解答关于健康或药物保险的任何疑

问如果您需要此翻译服务请致电 1-xxx-xxx-xxxx我们的中文工作人员很乐意帮助您

这是一项免费服务

Chinese Cantonese 您對我們的健康或藥物保險可能存有疑問為此我們提供免費的翻譯

服務如需翻譯服務請致電 1-xxx-xxx-xxxx我們講中文的人員將樂意為您提供幫助這

是一項免費服務

Tagalog Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot Upang makakuha ng tagasaling-wika tawagan lamang kami sa [1-xxx-xxx-xxxx] Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog Ito ay libreng serbisyo French Nous proposons des services gratuits dinterpreacutetation pour reacutepondre agrave toutes vos questions relatives agrave notre reacutegime de santeacute ou dassurance-meacutedicaments Pour acceacuteder au service dinterpreacutetation il vous suffit de nous appeler au [1-xxx-xxx-xxxx] Un interlocuteur parlant Franccedilais pourra vous aider Ce service est gratuit Vietnamese Chuacuteng tocirci coacute dịch vụ thocircng dịch miễn phiacute để trả lời caacutec cacircu hỏi về chương sức khỏe vagrave chương trigravenh thuốc men Nếu quiacute vị cần thocircng dịch viecircn xin gọi [1-xxx-xxx-xxxx] sẽ coacute nhacircn viecircn noacutei tiếng Việt giuacutep đỡ quiacute vị Đacircy lagrave dịch vụ miễn phiacute

116

Appendix 4 ndash Multi-Language Insert

Multi-language Interpreter Services

English We have free interpreter services to answer any questions you may have about our health or drug plan To get an interpreter just call us at [1-xxx-xxx-xxxx] Someone who speaks EnglishLanguage can help you This is a free service

Spanish Tenemos servicios de inteacuterprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos Para hablar con un inteacuterprete por favor llame al [1-xxx-xxx-xxxx] Alguien que hable espantildeol le podraacute ayudar Este es un servicio gratuito

Chinese Mandarin 我们提供免费的翻译服务帮助您解答关于健康或药物保险的任何疑

问如果您需要此翻译服务请致电 1-xxx-xxx-xxxx我们的中文工作人员很乐意帮助您

这是一项免费服务

Chinese Cantonese 您對我們的健康或藥物保險可能存有疑問為此我們提供免費的翻譯

服務如需翻譯服務請致電 1-xxx-xxx-xxxx我們講中文的人員將樂意為您提供幫助這

是一項免費服務

Tagalog Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot Upang makakuha ng tagasaling-wika tawagan lamang kami sa [1-xxx-xxx-xxxx] Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog Ito ay libreng serbisyo French Nous proposons des services gratuits dinterpreacutetation pour reacutepondre agrave toutes vos questions relatives agrave notre reacutegime de santeacute ou dassurance-meacutedicaments Pour acceacuteder au service dinterpreacutetation il vous suffit de nous appeler au [1-xxx-xxx-xxxx] Un interlocuteur parlant Franccedilais pourra vous aider Ce service est gratuit Vietnamese Chuacuteng tocirci coacute dịch vụ thocircng dịch miễn phiacute để trả lời caacutec cacircu hỏi về chương sức khỏe vagrave chương trigravenh thuốc men Nếu quiacute vị cần thocircng dịch viecircn xin gọi [1-xxx-xxx-xxxx] sẽ coacute nhacircn viecircn noacutei tiếng Việt giuacutep đỡ quiacute vị Đacircy lagrave dịch vụ miễn phiacute

1-800-478-0583

PAGE 36 of 40

(PDP)

Multi-language Interpreter Services (continued)

Russian Если у вас возникнут вопросы относительно страхового или медикаментного плана вы можете воспользоваться нашими бесплатными услугами переводчиков Чтобы воспользоваться услугами переводчика позвоните нам по телефону 1-800-478-0583 Вам окажет помощь сотрудник который говорит по-pусски Данная услуга бесплатная

Arabicةيودألا لودج وأ ةحصلاب قلعتت ةلئسأ يأ نع ةباجإلل ةيناجملا يروفلا مجرتملا تامدخ مدقن اننإ صخش موقيس 0583-478-800-1 ىلع انب لاصتالا ىوس كيلع سيل يروف مجرتم ىلع لوصحلل انيدلةيناجم ةمدخ هذه كتدعاسمب ةيبرعلا ثدحتي ام

Hindi हमार सवासथय या दवा की योजना क बार म आपक किसी भी परशन क जवाब दन क लिए हमार पास मफत दभाषिया सवाए उपलबध ह एक दभाषिया परापत करन क लिए बस हम 1-800-478-0583 पर फोन कर कोई वयकति जो हिनदी बोलता ह आपकी मदद कर सकता ह यह एक मफत सवा ह

Italian Egrave disponibile un servizio di interpretariato gratuito per rispondere a eventuali domande sul nostro piano sanitario e farmaceutico Per un interprete contattare il numero 1-800-478-0583 Un nostro incaricato che parla Italianovi forniragrave lassistenza necessaria Egrave un servizio gratuito

Portugueacutes Dispomos de serviccedilos de interpretaccedilatildeo gratuitos para responder a qualquer questatildeo que tenha acerca do nosso plano de sauacutede ou de medicaccedilatildeo Para obter um inteacuterprete contacte-nos atraveacutes do nuacutemero 1-800-478-0583 Iraacute encontrar algueacutem que fale o idioma Portuguecircs para o ajudar Este serviccedilo eacute gratuito

French Creole Nou genyen segravevis entegravepregravet gratis pou reponn tout kesyon ou ta genyen konsegravenan plan medikal oswa dwograveg nou an Pou jwenn yon entegravepregravet jis rele nou nan 1-800-478-0583 Yon moun ki pale Kreyogravel kapab ede w Sa a se yon segravevis ki gratis

Polish Umożliwiamy bezpłatne skorzystanie z usług tłumacza ustnego ktoacutery pomoże w uzyskaniu odpowiedzi na temat planu zdrowotnego lub dawkowania lekoacutew Aby skorzystać z pomocy tłumacza znającego język polski należy zadzwonić pod numer 1-800-478-0583 Ta usługa jest bezpłatna

Japanese 当社の健康 健康保険と薬品 処方薬プランに関するご質問にお答えするために無

料の通訳サービスがありますございます通訳をご用命になるには1-800-478-0583 にお電

話ください日本語を話す人 者 が支援いたしますこれは無料のサービスです

Notes

PAG E 37 of 40

Notes

PAG E 38 of 40

Notes

U5073e 813

PAGE 39 of 40

Awarded to BCBSNC by the Ethisphere Institute In 2013 companies in more than 100 countries and 36 industries were reviewed and of those 138 organizations were designated as Worldrsquos Most Ethical

BCBSNC Blue Medicare Rx products are only available to Medicare beneficiaries residing in North Carolina The information described in this brochure is for 2014 and may change on January 1 2015 The benefit information provided is a brief summary not a complete description of benefits For more information contact the plan This brochure may be available in alternate formats upon request Blue Cross and Blue Shield of North Carolina is a PDP plan with a Medicare contract Enrollment in Blue Cross and Blue Shield of North Carolina depends on contract renewal An independent licensee of the Blue Cross and Blue Shield Association reg SM Marks of the Blue Cross and Blue Shield Association SM1 Mark of Blue Cross and Blue Shield of North Carolina

If you are covered by oreligible for Medicare contactyour local Authorized SalesRepresentative to learn aboutour Medicare Part D plans

How can we help Call 1-800-478-0583 7 days aweek 8 am-8 pm For hearing and speech impaired(TTYTDD) usersCall 1-800-922-3140 7 days aweek 8 am-8 pm

Preferred Pharmacy NetworkBlue Medicare Rx (PDP)

Standard Plan Enhanced Plan Many of the popular drugsare covered ndash more than 1000included

Extensive list of covered drugs ndashmore than 1800 included

You pay $145 annual deductible No deductible ndash coverage beginsright away

$4 and $40 copayments for mostdrugs when you use our preferredpharmacy network up to $2850total drug cost

$3 and $30 copayments for mostdrugs when you use our preferredpharmacy network up to $2850total drug cost

You pay 72 on all generic drugsand you receive a discount onbrand-name drugs during the

ldquocoverage gaprdquo until true out-of-pocket costs reach $4550

You pay $3 copayment forpreferred generic drugs you pay72 for most other generic drugsand you receive a discount forbrand-name drugs during the

ldquocoverage gaprdquo until true out-of-pocket costs reach $4550

Generally 5 coinsurance after ldquocoverage gaprdquo ends Preferred Pharmacy Network includes CVS WalMart

Kerr Drugs and Epic Pharmacies

Non-preferred Pharmacy NetworkBlue Medicare Rx (PDP)

Standard Plan Enhanced Plan Many of the popular drugsare covered ndash more than 1000included

Extensive list of covered drugs ndashmore than 1800 included

You pay $145 annual deductible No deductible ndash coverage beginsright away

$10 and $45 copayments for mostdrugs up to $2850 total drug cost

$8 and $45 copayments for mostdrugs up to $2850 total drug cost

You pay 72 on all generic drugsand you receive a discount onbrand-name drugs during the

ldquocoverage gaprdquo until true out-of-pocket costs reach $4550

You pay $8 copayment forpreferred generic drugs you pay72 for most other generic drugsand you receive a discount forbrand-name drugs during the

ldquocoverage gaprdquo until true out-of-pocket costs reach $4550

Generally 5 coinsurance after ldquocoverage gaprdquo ends

PAGE 40 of 40

Y0079_6250 CMS Approved 08062013

Section 2 - Summary of benefits for ndash Benefit Outpatient Prescription Drugs Contract S5540 Plan 004 and Plan 002

Original Medicare

Blue Medicare Rx Enhanced (PDP) (Plan 004)

Blue Medicare Rx Standard (PDP) (Plan 002)

Mail Order Contact your plan if you have questions about cost-sharing orbilling when less than a one-month supply is dispensed Tier 1 Preferred Generic + $3 copay for a one-month (30-day) supply of all drugs

covered within this tier from a preferred mail order pharmacy + $0 copay for a two-month (60-day) supply of all drugs

covered within this tier from a preferred mail order pharmacy + $0 copay for a three-month (90-day) supply of all drugs

covered within this tier from a preferred mail order pharmacy + $8 copay for a one-month (30-day) supply of all drugs

covered within this tier from a non-preferred mail orderpharmacy

+ $16 copay for a two-month (60-day) supply of all drugscovered within this tier from a non-preferred mail orderpharmacy

+ $24 copay for a three-month (90-day) supply of all drugscovered within this tier from a non-preferred mail orderpharmacy

Not all drugs on this tier are available at this extended daysupply Please contact the plan for more information

PAG E 32 of 40

Original Medicare

Blue Medicare Rx Enhanced (PDP) (Plan 004)

Blue Medicare Rx Standard (PDP) (Plan 002)

Catastrophic coverage After your yearly out-of-pocket drug costs reach $4550 you pay the greater of + 5 coinsurance or + $255 copay for generic (including brand drugs treated as generic) and a $635

copay for all other drugs

Out-of-network Plan drugs may be covered in special circumstances for instance illness while traveling outside ofthe planrsquos service area where there is no network pharmacy You may have to pay more than yournormal cost-sharing amount if you get your drugs at an out-of-network pharmacy In addition youwill likely have to pay the pharmacyrsquos full charge for the drug and submit documentation to receivereimbursement from Blue Medicare Rx (PDP)

You can get out-of-network drugs the following way

Out-of-network initial coverage

You will be reimbursed up to the planrsquos costof the drug minus the following for drugspurchased out-of-network until total yearlydrug costs reach $2850 Tier 1 - Preferred Generic

+ $8 copay for a one-month (30-day)supply of drugs in this tier Tier 2 - Non-Preferred Generic

+ $20 copay for a one-month (30-day)supply of drugs in this tier

Tier 3 - Preferred Brand

+ $45 copay for a one-month (30-day)supply of drugs in this tier

Tier 4 - Non-Preferred Brand

+ $95 copay for a one-month (30-day)supply of drugs in this tier

Tier 5 - Specialty Tier

+ 33 coinsurance for a one-month (30-day)supply of drugs in this tier

Out-of-network initial coverage

After you pay your yearly deductible you willbe reimbursed up to the planrsquos cost of the drugminus the following for drugs purchasedout-of-network until total yearly drug costsreach $2850 Tier 1 - Preferred Generic

+ $10 copay for a one-month (30-day)supply of drugs in this tier

Tier 2 - Non-Preferred Generic

+ $33 copay for a one-month (30-day)supply of drugs in this tier

Tier 3 - Preferred Brand

+ $45 copay for a one-month (30-day)supply of drugs in this tier

Tier 4 - Non-Preferred Brand

+ $95 copay for a one-month (30-day)supply of drugs in this tier

Tier 5 - Specialty Tier

+ 29 coinsurance for a one-month (30-day)supply of drugs in this tier

You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge andthe planrsquos In-Network allowable amount

Out-of-Network Coverage Gap You will be reimbursed up to 28 of the plan allowable cost for generic drugs purchasedout-of-network until total yearly out-of-pocket drug costs reach $4550 Please note that theplan allowable cost may be less than the out-of-network pharmacy price paid for your drug(s)

PAG E 33 of 40

Section 2 - Summary of benefits for ndash Benefit Outpatient Prescription Drugs Contract S5540 Plan 004 and Plan 002

Original Medicare

Blue Medicare Rx Enhanced (PDP) (Plan 004)

Blue Medicare Rx Standard (PDP) (Plan 002)

Out-of-Network Coverage Gap (continued)

You will be reimbursed up to 525 of the plan allowable cost for brand name drugs purchasedout-of-network until your total yearly out-of-pocket drug costs reach $4550 Please note that theplan allowable cost may be less than the out-of-network pharmacy price paid for your drug(s)

Additional Out-of-Network Coverage Gap

You will be reimbursed for these drugspurchased out-of-network up to the planrsquoscost of the drug minus the following

Tier 1 Preferred Generic

+ $8 copay for a one-month (30-day) supplyof all drugs covered within this tier

Out-of-network Catastrophic Coverage After your yearly out-of-pocket drug costs reach $4550 you will be reimbursed for drugs purchasedout-of-network up to the planrsquos cost of the drug minus your cost share which is the greater of+ 5 coinsurance or+ $255 copay for generic (including brand drugs treated as generic) and+ $635 copay for all other drugs

You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge andthe planrsquos In-Network allowable amount

PAG E 34 of 40

PAGE 35 of 40

(PDP)

Multi-language Interpreter Services

English We have free interpreter services to answer any questions you may have about our health or drug plan To get an interpreter just call us at 1-800-478-0583 Someone who speaks EnglishLanguage can help you This is a free service

Spanish Tenemos servicios de inteacuterprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos Para hablar con un inteacuterprete por favor llame al 1-800-478-0583 Alguien que hable espantildeol le podraacute ayudar Este es un servicio gratuito

Chinese Mandarin 我们提供免们的翻们服们们助们解答们于健康或们物保们的任何疑 们如果们需要此翻们服们们致们 phone number我们的中文工作人们很们意们助们 们是一们免们服们

Chinese Cantonese 您對我們的健康或藥物保險可能存有疑問為此我們提供免費的翻譯服務如需翻譯服務請致電 1-800-478-0583我們講中文的人員將樂意為您提供幫助這是一項免費服務

Tagalog Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot Upang makakuha ng tagasaling-wika tawagan lamang kami sa 1-800-478-0583 Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog Ito ay libreng serbisyo

French Nous proposons des services gratuits dinterpreacutetation pour reacutepondre agrave toutes vos questions relatives agrave notre reacutegime de santeacute ou dassurance-meacutedicaments Pour acceacuteder au service dinterpreacutetation il vous suffit de nous appeler au 1-800-478-0583 Un interlocuteur parlant Franccedilais pourra vous aider Ce service est gratuit

Vietnamese Chuacuteng tocirci coacute dịch vụ thocircng dịch miễn phiacute để trả lời caacutec cacircu hỏi về chương sức khỏe vagrave chương trigravenh thuốc men Nếu quiacute vị cần thocircng dịch viecircn xin gọi 1-800-478-0583 sẽ coacute nhacircn viecircn noacutei tiếng Việt giuacutep đỡ quiacute vị Đacircy lagrave dịch vụ miễn phiacute

German Unser kostenloser Dolmetscherservice beantwortet Ihren Fragen zu unserem Gesundheits- und Arzneimittelplan Unsere Dolmetscher erreichen Sie unter 1-800-478-0583 Man wird Ihnen dort auf Deutsch weiterhelfen Dieser Service ist kostenlos

Korean 당사는 의료 보험 또는 약품 보험에 관한 질문에 답해 드리고자 무료 통역 서비스를 제공하고 있습니다 통역 서비스를 이용하려면 전화 1-800-478-0583 번으로 문의해 주십시오 한국어를 하는 담당자가 도와 드릴 것입니다 이 서비스는 무료로 운영됩니다

Y0079_6200 CMS Approved 07082013 U5073d 813

116

Appendix 4 ndash Multi-Language Insert

Multi-language Interpreter Services

English We have free interpreter services to answer any questions you may have about our health or drug plan To get an interpreter just call us at [1-xxx-xxx-xxxx] Someone who speaks EnglishLanguage can help you This is a free service

Spanish Tenemos servicios de inteacuterprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos Para hablar con un inteacuterprete por favor llame al [1-xxx-xxx-xxxx] Alguien que hable espantildeol le podraacute ayudar Este es un servicio gratuito

Chinese Mandarin 我们提供免费的翻译服务帮助您解答关于健康或药物保险的任何疑

问如果您需要此翻译服务请致电 1-xxx-xxx-xxxx我们的中文工作人员很乐意帮助您

这是一项免费服务

Chinese Cantonese 您對我們的健康或藥物保險可能存有疑問為此我們提供免費的翻譯

服務如需翻譯服務請致電 1-xxx-xxx-xxxx我們講中文的人員將樂意為您提供幫助這

是一項免費服務

Tagalog Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot Upang makakuha ng tagasaling-wika tawagan lamang kami sa [1-xxx-xxx-xxxx] Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog Ito ay libreng serbisyo French Nous proposons des services gratuits dinterpreacutetation pour reacutepondre agrave toutes vos questions relatives agrave notre reacutegime de santeacute ou dassurance-meacutedicaments Pour acceacuteder au service dinterpreacutetation il vous suffit de nous appeler au [1-xxx-xxx-xxxx] Un interlocuteur parlant Franccedilais pourra vous aider Ce service est gratuit Vietnamese Chuacuteng tocirci coacute dịch vụ thocircng dịch miễn phiacute để trả lời caacutec cacircu hỏi về chương sức khỏe vagrave chương trigravenh thuốc men Nếu quiacute vị cần thocircng dịch viecircn xin gọi [1-xxx-xxx-xxxx] sẽ coacute nhacircn viecircn noacutei tiếng Việt giuacutep đỡ quiacute vị Đacircy lagrave dịch vụ miễn phiacute

116

Appendix 4 ndash Multi-Language Insert

Multi-language Interpreter Services

English We have free interpreter services to answer any questions you may have about our health or drug plan To get an interpreter just call us at [1-xxx-xxx-xxxx] Someone who speaks EnglishLanguage can help you This is a free service

Spanish Tenemos servicios de inteacuterprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos Para hablar con un inteacuterprete por favor llame al [1-xxx-xxx-xxxx] Alguien que hable espantildeol le podraacute ayudar Este es un servicio gratuito

Chinese Mandarin 我们提供免费的翻译服务帮助您解答关于健康或药物保险的任何疑

问如果您需要此翻译服务请致电 1-xxx-xxx-xxxx我们的中文工作人员很乐意帮助您

这是一项免费服务

Chinese Cantonese 您對我們的健康或藥物保險可能存有疑問為此我們提供免費的翻譯

服務如需翻譯服務請致電 1-xxx-xxx-xxxx我們講中文的人員將樂意為您提供幫助這

是一項免費服務

Tagalog Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot Upang makakuha ng tagasaling-wika tawagan lamang kami sa [1-xxx-xxx-xxxx] Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog Ito ay libreng serbisyo French Nous proposons des services gratuits dinterpreacutetation pour reacutepondre agrave toutes vos questions relatives agrave notre reacutegime de santeacute ou dassurance-meacutedicaments Pour acceacuteder au service dinterpreacutetation il vous suffit de nous appeler au [1-xxx-xxx-xxxx] Un interlocuteur parlant Franccedilais pourra vous aider Ce service est gratuit Vietnamese Chuacuteng tocirci coacute dịch vụ thocircng dịch miễn phiacute để trả lời caacutec cacircu hỏi về chương sức khỏe vagrave chương trigravenh thuốc men Nếu quiacute vị cần thocircng dịch viecircn xin gọi [1-xxx-xxx-xxxx] sẽ coacute nhacircn viecircn noacutei tiếng Việt giuacutep đỡ quiacute vị Đacircy lagrave dịch vụ miễn phiacute

116

Appendix 4 ndash Multi-Language Insert

Multi-language Interpreter Services

English We have free interpreter services to answer any questions you may have about our health or drug plan To get an interpreter just call us at [1-xxx-xxx-xxxx] Someone who speaks EnglishLanguage can help you This is a free service

Spanish Tenemos servicios de inteacuterprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos Para hablar con un inteacuterprete por favor llame al [1-xxx-xxx-xxxx] Alguien que hable espantildeol le podraacute ayudar Este es un servicio gratuito

Chinese Mandarin 我们提供免费的翻译服务帮助您解答关于健康或药物保险的任何疑

问如果您需要此翻译服务请致电 1-xxx-xxx-xxxx我们的中文工作人员很乐意帮助您

这是一项免费服务

Chinese Cantonese 您對我們的健康或藥物保險可能存有疑問為此我們提供免費的翻譯

服務如需翻譯服務請致電 1-xxx-xxx-xxxx我們講中文的人員將樂意為您提供幫助這

是一項免費服務

Tagalog Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot Upang makakuha ng tagasaling-wika tawagan lamang kami sa [1-xxx-xxx-xxxx] Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog Ito ay libreng serbisyo French Nous proposons des services gratuits dinterpreacutetation pour reacutepondre agrave toutes vos questions relatives agrave notre reacutegime de santeacute ou dassurance-meacutedicaments Pour acceacuteder au service dinterpreacutetation il vous suffit de nous appeler au [1-xxx-xxx-xxxx] Un interlocuteur parlant Franccedilais pourra vous aider Ce service est gratuit Vietnamese Chuacuteng tocirci coacute dịch vụ thocircng dịch miễn phiacute để trả lời caacutec cacircu hỏi về chương sức khỏe vagrave chương trigravenh thuốc men Nếu quiacute vị cần thocircng dịch viecircn xin gọi [1-xxx-xxx-xxxx] sẽ coacute nhacircn viecircn noacutei tiếng Việt giuacutep đỡ quiacute vị Đacircy lagrave dịch vụ miễn phiacute

1-800-478-0583

PAGE 36 of 40

(PDP)

Multi-language Interpreter Services (continued)

Russian Если у вас возникнут вопросы относительно страхового или медикаментного плана вы можете воспользоваться нашими бесплатными услугами переводчиков Чтобы воспользоваться услугами переводчика позвоните нам по телефону 1-800-478-0583 Вам окажет помощь сотрудник который говорит по-pусски Данная услуга бесплатная

Arabicةيودألا لودج وأ ةحصلاب قلعتت ةلئسأ يأ نع ةباجإلل ةيناجملا يروفلا مجرتملا تامدخ مدقن اننإ صخش موقيس 0583-478-800-1 ىلع انب لاصتالا ىوس كيلع سيل يروف مجرتم ىلع لوصحلل انيدلةيناجم ةمدخ هذه كتدعاسمب ةيبرعلا ثدحتي ام

Hindi हमार सवासथय या दवा की योजना क बार म आपक किसी भी परशन क जवाब दन क लिए हमार पास मफत दभाषिया सवाए उपलबध ह एक दभाषिया परापत करन क लिए बस हम 1-800-478-0583 पर फोन कर कोई वयकति जो हिनदी बोलता ह आपकी मदद कर सकता ह यह एक मफत सवा ह

Italian Egrave disponibile un servizio di interpretariato gratuito per rispondere a eventuali domande sul nostro piano sanitario e farmaceutico Per un interprete contattare il numero 1-800-478-0583 Un nostro incaricato che parla Italianovi forniragrave lassistenza necessaria Egrave un servizio gratuito

Portugueacutes Dispomos de serviccedilos de interpretaccedilatildeo gratuitos para responder a qualquer questatildeo que tenha acerca do nosso plano de sauacutede ou de medicaccedilatildeo Para obter um inteacuterprete contacte-nos atraveacutes do nuacutemero 1-800-478-0583 Iraacute encontrar algueacutem que fale o idioma Portuguecircs para o ajudar Este serviccedilo eacute gratuito

French Creole Nou genyen segravevis entegravepregravet gratis pou reponn tout kesyon ou ta genyen konsegravenan plan medikal oswa dwograveg nou an Pou jwenn yon entegravepregravet jis rele nou nan 1-800-478-0583 Yon moun ki pale Kreyogravel kapab ede w Sa a se yon segravevis ki gratis

Polish Umożliwiamy bezpłatne skorzystanie z usług tłumacza ustnego ktoacutery pomoże w uzyskaniu odpowiedzi na temat planu zdrowotnego lub dawkowania lekoacutew Aby skorzystać z pomocy tłumacza znającego język polski należy zadzwonić pod numer 1-800-478-0583 Ta usługa jest bezpłatna

Japanese 当社の健康 健康保険と薬品 処方薬プランに関するご質問にお答えするために無

料の通訳サービスがありますございます通訳をご用命になるには1-800-478-0583 にお電

話ください日本語を話す人 者 が支援いたしますこれは無料のサービスです

Notes

PAG E 37 of 40

Notes

PAG E 38 of 40

Notes

U5073e 813

PAGE 39 of 40

Awarded to BCBSNC by the Ethisphere Institute In 2013 companies in more than 100 countries and 36 industries were reviewed and of those 138 organizations were designated as Worldrsquos Most Ethical

BCBSNC Blue Medicare Rx products are only available to Medicare beneficiaries residing in North Carolina The information described in this brochure is for 2014 and may change on January 1 2015 The benefit information provided is a brief summary not a complete description of benefits For more information contact the plan This brochure may be available in alternate formats upon request Blue Cross and Blue Shield of North Carolina is a PDP plan with a Medicare contract Enrollment in Blue Cross and Blue Shield of North Carolina depends on contract renewal An independent licensee of the Blue Cross and Blue Shield Association reg SM Marks of the Blue Cross and Blue Shield Association SM1 Mark of Blue Cross and Blue Shield of North Carolina

If you are covered by oreligible for Medicare contactyour local Authorized SalesRepresentative to learn aboutour Medicare Part D plans

How can we help Call 1-800-478-0583 7 days aweek 8 am-8 pm For hearing and speech impaired(TTYTDD) usersCall 1-800-922-3140 7 days aweek 8 am-8 pm

Preferred Pharmacy NetworkBlue Medicare Rx (PDP)

Standard Plan Enhanced Plan Many of the popular drugsare covered ndash more than 1000included

Extensive list of covered drugs ndashmore than 1800 included

You pay $145 annual deductible No deductible ndash coverage beginsright away

$4 and $40 copayments for mostdrugs when you use our preferredpharmacy network up to $2850total drug cost

$3 and $30 copayments for mostdrugs when you use our preferredpharmacy network up to $2850total drug cost

You pay 72 on all generic drugsand you receive a discount onbrand-name drugs during the

ldquocoverage gaprdquo until true out-of-pocket costs reach $4550

You pay $3 copayment forpreferred generic drugs you pay72 for most other generic drugsand you receive a discount forbrand-name drugs during the

ldquocoverage gaprdquo until true out-of-pocket costs reach $4550

Generally 5 coinsurance after ldquocoverage gaprdquo ends Preferred Pharmacy Network includes CVS WalMart

Kerr Drugs and Epic Pharmacies

Non-preferred Pharmacy NetworkBlue Medicare Rx (PDP)

Standard Plan Enhanced Plan Many of the popular drugsare covered ndash more than 1000included

Extensive list of covered drugs ndashmore than 1800 included

You pay $145 annual deductible No deductible ndash coverage beginsright away

$10 and $45 copayments for mostdrugs up to $2850 total drug cost

$8 and $45 copayments for mostdrugs up to $2850 total drug cost

You pay 72 on all generic drugsand you receive a discount onbrand-name drugs during the

ldquocoverage gaprdquo until true out-of-pocket costs reach $4550

You pay $8 copayment forpreferred generic drugs you pay72 for most other generic drugsand you receive a discount forbrand-name drugs during the

ldquocoverage gaprdquo until true out-of-pocket costs reach $4550

Generally 5 coinsurance after ldquocoverage gaprdquo ends

PAGE 40 of 40

Y0079_6250 CMS Approved 08062013

Original Medicare

Blue Medicare Rx Enhanced (PDP) (Plan 004)

Blue Medicare Rx Standard (PDP) (Plan 002)

Catastrophic coverage After your yearly out-of-pocket drug costs reach $4550 you pay the greater of + 5 coinsurance or + $255 copay for generic (including brand drugs treated as generic) and a $635

copay for all other drugs

Out-of-network Plan drugs may be covered in special circumstances for instance illness while traveling outside ofthe planrsquos service area where there is no network pharmacy You may have to pay more than yournormal cost-sharing amount if you get your drugs at an out-of-network pharmacy In addition youwill likely have to pay the pharmacyrsquos full charge for the drug and submit documentation to receivereimbursement from Blue Medicare Rx (PDP)

You can get out-of-network drugs the following way

Out-of-network initial coverage

You will be reimbursed up to the planrsquos costof the drug minus the following for drugspurchased out-of-network until total yearlydrug costs reach $2850 Tier 1 - Preferred Generic

+ $8 copay for a one-month (30-day)supply of drugs in this tier Tier 2 - Non-Preferred Generic

+ $20 copay for a one-month (30-day)supply of drugs in this tier

Tier 3 - Preferred Brand

+ $45 copay for a one-month (30-day)supply of drugs in this tier

Tier 4 - Non-Preferred Brand

+ $95 copay for a one-month (30-day)supply of drugs in this tier

Tier 5 - Specialty Tier

+ 33 coinsurance for a one-month (30-day)supply of drugs in this tier

Out-of-network initial coverage

After you pay your yearly deductible you willbe reimbursed up to the planrsquos cost of the drugminus the following for drugs purchasedout-of-network until total yearly drug costsreach $2850 Tier 1 - Preferred Generic

+ $10 copay for a one-month (30-day)supply of drugs in this tier

Tier 2 - Non-Preferred Generic

+ $33 copay for a one-month (30-day)supply of drugs in this tier

Tier 3 - Preferred Brand

+ $45 copay for a one-month (30-day)supply of drugs in this tier

Tier 4 - Non-Preferred Brand

+ $95 copay for a one-month (30-day)supply of drugs in this tier

Tier 5 - Specialty Tier

+ 29 coinsurance for a one-month (30-day)supply of drugs in this tier

You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge andthe planrsquos In-Network allowable amount

Out-of-Network Coverage Gap You will be reimbursed up to 28 of the plan allowable cost for generic drugs purchasedout-of-network until total yearly out-of-pocket drug costs reach $4550 Please note that theplan allowable cost may be less than the out-of-network pharmacy price paid for your drug(s)

PAG E 33 of 40

Section 2 - Summary of benefits for ndash Benefit Outpatient Prescription Drugs Contract S5540 Plan 004 and Plan 002

Original Medicare

Blue Medicare Rx Enhanced (PDP) (Plan 004)

Blue Medicare Rx Standard (PDP) (Plan 002)

Out-of-Network Coverage Gap (continued)

You will be reimbursed up to 525 of the plan allowable cost for brand name drugs purchasedout-of-network until your total yearly out-of-pocket drug costs reach $4550 Please note that theplan allowable cost may be less than the out-of-network pharmacy price paid for your drug(s)

Additional Out-of-Network Coverage Gap

You will be reimbursed for these drugspurchased out-of-network up to the planrsquoscost of the drug minus the following

Tier 1 Preferred Generic

+ $8 copay for a one-month (30-day) supplyof all drugs covered within this tier

Out-of-network Catastrophic Coverage After your yearly out-of-pocket drug costs reach $4550 you will be reimbursed for drugs purchasedout-of-network up to the planrsquos cost of the drug minus your cost share which is the greater of+ 5 coinsurance or+ $255 copay for generic (including brand drugs treated as generic) and+ $635 copay for all other drugs

You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge andthe planrsquos In-Network allowable amount

PAG E 34 of 40

PAGE 35 of 40

(PDP)

Multi-language Interpreter Services

English We have free interpreter services to answer any questions you may have about our health or drug plan To get an interpreter just call us at 1-800-478-0583 Someone who speaks EnglishLanguage can help you This is a free service

Spanish Tenemos servicios de inteacuterprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos Para hablar con un inteacuterprete por favor llame al 1-800-478-0583 Alguien que hable espantildeol le podraacute ayudar Este es un servicio gratuito

Chinese Mandarin 我们提供免们的翻们服们们助们解答们于健康或们物保们的任何疑 们如果们需要此翻们服们们致们 phone number我们的中文工作人们很们意们助们 们是一们免们服们

Chinese Cantonese 您對我們的健康或藥物保險可能存有疑問為此我們提供免費的翻譯服務如需翻譯服務請致電 1-800-478-0583我們講中文的人員將樂意為您提供幫助這是一項免費服務

Tagalog Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot Upang makakuha ng tagasaling-wika tawagan lamang kami sa 1-800-478-0583 Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog Ito ay libreng serbisyo

French Nous proposons des services gratuits dinterpreacutetation pour reacutepondre agrave toutes vos questions relatives agrave notre reacutegime de santeacute ou dassurance-meacutedicaments Pour acceacuteder au service dinterpreacutetation il vous suffit de nous appeler au 1-800-478-0583 Un interlocuteur parlant Franccedilais pourra vous aider Ce service est gratuit

Vietnamese Chuacuteng tocirci coacute dịch vụ thocircng dịch miễn phiacute để trả lời caacutec cacircu hỏi về chương sức khỏe vagrave chương trigravenh thuốc men Nếu quiacute vị cần thocircng dịch viecircn xin gọi 1-800-478-0583 sẽ coacute nhacircn viecircn noacutei tiếng Việt giuacutep đỡ quiacute vị Đacircy lagrave dịch vụ miễn phiacute

German Unser kostenloser Dolmetscherservice beantwortet Ihren Fragen zu unserem Gesundheits- und Arzneimittelplan Unsere Dolmetscher erreichen Sie unter 1-800-478-0583 Man wird Ihnen dort auf Deutsch weiterhelfen Dieser Service ist kostenlos

Korean 당사는 의료 보험 또는 약품 보험에 관한 질문에 답해 드리고자 무료 통역 서비스를 제공하고 있습니다 통역 서비스를 이용하려면 전화 1-800-478-0583 번으로 문의해 주십시오 한국어를 하는 담당자가 도와 드릴 것입니다 이 서비스는 무료로 운영됩니다

Y0079_6200 CMS Approved 07082013 U5073d 813

116

Appendix 4 ndash Multi-Language Insert

Multi-language Interpreter Services

English We have free interpreter services to answer any questions you may have about our health or drug plan To get an interpreter just call us at [1-xxx-xxx-xxxx] Someone who speaks EnglishLanguage can help you This is a free service

Spanish Tenemos servicios de inteacuterprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos Para hablar con un inteacuterprete por favor llame al [1-xxx-xxx-xxxx] Alguien que hable espantildeol le podraacute ayudar Este es un servicio gratuito

Chinese Mandarin 我们提供免费的翻译服务帮助您解答关于健康或药物保险的任何疑

问如果您需要此翻译服务请致电 1-xxx-xxx-xxxx我们的中文工作人员很乐意帮助您

这是一项免费服务

Chinese Cantonese 您對我們的健康或藥物保險可能存有疑問為此我們提供免費的翻譯

服務如需翻譯服務請致電 1-xxx-xxx-xxxx我們講中文的人員將樂意為您提供幫助這

是一項免費服務

Tagalog Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot Upang makakuha ng tagasaling-wika tawagan lamang kami sa [1-xxx-xxx-xxxx] Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog Ito ay libreng serbisyo French Nous proposons des services gratuits dinterpreacutetation pour reacutepondre agrave toutes vos questions relatives agrave notre reacutegime de santeacute ou dassurance-meacutedicaments Pour acceacuteder au service dinterpreacutetation il vous suffit de nous appeler au [1-xxx-xxx-xxxx] Un interlocuteur parlant Franccedilais pourra vous aider Ce service est gratuit Vietnamese Chuacuteng tocirci coacute dịch vụ thocircng dịch miễn phiacute để trả lời caacutec cacircu hỏi về chương sức khỏe vagrave chương trigravenh thuốc men Nếu quiacute vị cần thocircng dịch viecircn xin gọi [1-xxx-xxx-xxxx] sẽ coacute nhacircn viecircn noacutei tiếng Việt giuacutep đỡ quiacute vị Đacircy lagrave dịch vụ miễn phiacute

116

Appendix 4 ndash Multi-Language Insert

Multi-language Interpreter Services

English We have free interpreter services to answer any questions you may have about our health or drug plan To get an interpreter just call us at [1-xxx-xxx-xxxx] Someone who speaks EnglishLanguage can help you This is a free service

Spanish Tenemos servicios de inteacuterprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos Para hablar con un inteacuterprete por favor llame al [1-xxx-xxx-xxxx] Alguien que hable espantildeol le podraacute ayudar Este es un servicio gratuito

Chinese Mandarin 我们提供免费的翻译服务帮助您解答关于健康或药物保险的任何疑

问如果您需要此翻译服务请致电 1-xxx-xxx-xxxx我们的中文工作人员很乐意帮助您

这是一项免费服务

Chinese Cantonese 您對我們的健康或藥物保險可能存有疑問為此我們提供免費的翻譯

服務如需翻譯服務請致電 1-xxx-xxx-xxxx我們講中文的人員將樂意為您提供幫助這

是一項免費服務

Tagalog Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot Upang makakuha ng tagasaling-wika tawagan lamang kami sa [1-xxx-xxx-xxxx] Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog Ito ay libreng serbisyo French Nous proposons des services gratuits dinterpreacutetation pour reacutepondre agrave toutes vos questions relatives agrave notre reacutegime de santeacute ou dassurance-meacutedicaments Pour acceacuteder au service dinterpreacutetation il vous suffit de nous appeler au [1-xxx-xxx-xxxx] Un interlocuteur parlant Franccedilais pourra vous aider Ce service est gratuit Vietnamese Chuacuteng tocirci coacute dịch vụ thocircng dịch miễn phiacute để trả lời caacutec cacircu hỏi về chương sức khỏe vagrave chương trigravenh thuốc men Nếu quiacute vị cần thocircng dịch viecircn xin gọi [1-xxx-xxx-xxxx] sẽ coacute nhacircn viecircn noacutei tiếng Việt giuacutep đỡ quiacute vị Đacircy lagrave dịch vụ miễn phiacute

116

Appendix 4 ndash Multi-Language Insert

Multi-language Interpreter Services

English We have free interpreter services to answer any questions you may have about our health or drug plan To get an interpreter just call us at [1-xxx-xxx-xxxx] Someone who speaks EnglishLanguage can help you This is a free service

Spanish Tenemos servicios de inteacuterprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos Para hablar con un inteacuterprete por favor llame al [1-xxx-xxx-xxxx] Alguien que hable espantildeol le podraacute ayudar Este es un servicio gratuito

Chinese Mandarin 我们提供免费的翻译服务帮助您解答关于健康或药物保险的任何疑

问如果您需要此翻译服务请致电 1-xxx-xxx-xxxx我们的中文工作人员很乐意帮助您

这是一项免费服务

Chinese Cantonese 您對我們的健康或藥物保險可能存有疑問為此我們提供免費的翻譯

服務如需翻譯服務請致電 1-xxx-xxx-xxxx我們講中文的人員將樂意為您提供幫助這

是一項免費服務

Tagalog Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot Upang makakuha ng tagasaling-wika tawagan lamang kami sa [1-xxx-xxx-xxxx] Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog Ito ay libreng serbisyo French Nous proposons des services gratuits dinterpreacutetation pour reacutepondre agrave toutes vos questions relatives agrave notre reacutegime de santeacute ou dassurance-meacutedicaments Pour acceacuteder au service dinterpreacutetation il vous suffit de nous appeler au [1-xxx-xxx-xxxx] Un interlocuteur parlant Franccedilais pourra vous aider Ce service est gratuit Vietnamese Chuacuteng tocirci coacute dịch vụ thocircng dịch miễn phiacute để trả lời caacutec cacircu hỏi về chương sức khỏe vagrave chương trigravenh thuốc men Nếu quiacute vị cần thocircng dịch viecircn xin gọi [1-xxx-xxx-xxxx] sẽ coacute nhacircn viecircn noacutei tiếng Việt giuacutep đỡ quiacute vị Đacircy lagrave dịch vụ miễn phiacute

1-800-478-0583

PAGE 36 of 40

(PDP)

Multi-language Interpreter Services (continued)

Russian Если у вас возникнут вопросы относительно страхового или медикаментного плана вы можете воспользоваться нашими бесплатными услугами переводчиков Чтобы воспользоваться услугами переводчика позвоните нам по телефону 1-800-478-0583 Вам окажет помощь сотрудник который говорит по-pусски Данная услуга бесплатная

Arabicةيودألا لودج وأ ةحصلاب قلعتت ةلئسأ يأ نع ةباجإلل ةيناجملا يروفلا مجرتملا تامدخ مدقن اننإ صخش موقيس 0583-478-800-1 ىلع انب لاصتالا ىوس كيلع سيل يروف مجرتم ىلع لوصحلل انيدلةيناجم ةمدخ هذه كتدعاسمب ةيبرعلا ثدحتي ام

Hindi हमार सवासथय या दवा की योजना क बार म आपक किसी भी परशन क जवाब दन क लिए हमार पास मफत दभाषिया सवाए उपलबध ह एक दभाषिया परापत करन क लिए बस हम 1-800-478-0583 पर फोन कर कोई वयकति जो हिनदी बोलता ह आपकी मदद कर सकता ह यह एक मफत सवा ह

Italian Egrave disponibile un servizio di interpretariato gratuito per rispondere a eventuali domande sul nostro piano sanitario e farmaceutico Per un interprete contattare il numero 1-800-478-0583 Un nostro incaricato che parla Italianovi forniragrave lassistenza necessaria Egrave un servizio gratuito

Portugueacutes Dispomos de serviccedilos de interpretaccedilatildeo gratuitos para responder a qualquer questatildeo que tenha acerca do nosso plano de sauacutede ou de medicaccedilatildeo Para obter um inteacuterprete contacte-nos atraveacutes do nuacutemero 1-800-478-0583 Iraacute encontrar algueacutem que fale o idioma Portuguecircs para o ajudar Este serviccedilo eacute gratuito

French Creole Nou genyen segravevis entegravepregravet gratis pou reponn tout kesyon ou ta genyen konsegravenan plan medikal oswa dwograveg nou an Pou jwenn yon entegravepregravet jis rele nou nan 1-800-478-0583 Yon moun ki pale Kreyogravel kapab ede w Sa a se yon segravevis ki gratis

Polish Umożliwiamy bezpłatne skorzystanie z usług tłumacza ustnego ktoacutery pomoże w uzyskaniu odpowiedzi na temat planu zdrowotnego lub dawkowania lekoacutew Aby skorzystać z pomocy tłumacza znającego język polski należy zadzwonić pod numer 1-800-478-0583 Ta usługa jest bezpłatna

Japanese 当社の健康 健康保険と薬品 処方薬プランに関するご質問にお答えするために無

料の通訳サービスがありますございます通訳をご用命になるには1-800-478-0583 にお電

話ください日本語を話す人 者 が支援いたしますこれは無料のサービスです

Notes

PAG E 37 of 40

Notes

PAG E 38 of 40

Notes

U5073e 813

PAGE 39 of 40

Awarded to BCBSNC by the Ethisphere Institute In 2013 companies in more than 100 countries and 36 industries were reviewed and of those 138 organizations were designated as Worldrsquos Most Ethical

BCBSNC Blue Medicare Rx products are only available to Medicare beneficiaries residing in North Carolina The information described in this brochure is for 2014 and may change on January 1 2015 The benefit information provided is a brief summary not a complete description of benefits For more information contact the plan This brochure may be available in alternate formats upon request Blue Cross and Blue Shield of North Carolina is a PDP plan with a Medicare contract Enrollment in Blue Cross and Blue Shield of North Carolina depends on contract renewal An independent licensee of the Blue Cross and Blue Shield Association reg SM Marks of the Blue Cross and Blue Shield Association SM1 Mark of Blue Cross and Blue Shield of North Carolina

If you are covered by oreligible for Medicare contactyour local Authorized SalesRepresentative to learn aboutour Medicare Part D plans

How can we help Call 1-800-478-0583 7 days aweek 8 am-8 pm For hearing and speech impaired(TTYTDD) usersCall 1-800-922-3140 7 days aweek 8 am-8 pm

Preferred Pharmacy NetworkBlue Medicare Rx (PDP)

Standard Plan Enhanced Plan Many of the popular drugsare covered ndash more than 1000included

Extensive list of covered drugs ndashmore than 1800 included

You pay $145 annual deductible No deductible ndash coverage beginsright away

$4 and $40 copayments for mostdrugs when you use our preferredpharmacy network up to $2850total drug cost

$3 and $30 copayments for mostdrugs when you use our preferredpharmacy network up to $2850total drug cost

You pay 72 on all generic drugsand you receive a discount onbrand-name drugs during the

ldquocoverage gaprdquo until true out-of-pocket costs reach $4550

You pay $3 copayment forpreferred generic drugs you pay72 for most other generic drugsand you receive a discount forbrand-name drugs during the

ldquocoverage gaprdquo until true out-of-pocket costs reach $4550

Generally 5 coinsurance after ldquocoverage gaprdquo ends Preferred Pharmacy Network includes CVS WalMart

Kerr Drugs and Epic Pharmacies

Non-preferred Pharmacy NetworkBlue Medicare Rx (PDP)

Standard Plan Enhanced Plan Many of the popular drugsare covered ndash more than 1000included

Extensive list of covered drugs ndashmore than 1800 included

You pay $145 annual deductible No deductible ndash coverage beginsright away

$10 and $45 copayments for mostdrugs up to $2850 total drug cost

$8 and $45 copayments for mostdrugs up to $2850 total drug cost

You pay 72 on all generic drugsand you receive a discount onbrand-name drugs during the

ldquocoverage gaprdquo until true out-of-pocket costs reach $4550

You pay $8 copayment forpreferred generic drugs you pay72 for most other generic drugsand you receive a discount forbrand-name drugs during the

ldquocoverage gaprdquo until true out-of-pocket costs reach $4550

Generally 5 coinsurance after ldquocoverage gaprdquo ends

PAGE 40 of 40

Y0079_6250 CMS Approved 08062013

Section 2 - Summary of benefits for ndash Benefit Outpatient Prescription Drugs Contract S5540 Plan 004 and Plan 002

Original Medicare

Blue Medicare Rx Enhanced (PDP) (Plan 004)

Blue Medicare Rx Standard (PDP) (Plan 002)

Out-of-Network Coverage Gap (continued)

You will be reimbursed up to 525 of the plan allowable cost for brand name drugs purchasedout-of-network until your total yearly out-of-pocket drug costs reach $4550 Please note that theplan allowable cost may be less than the out-of-network pharmacy price paid for your drug(s)

Additional Out-of-Network Coverage Gap

You will be reimbursed for these drugspurchased out-of-network up to the planrsquoscost of the drug minus the following

Tier 1 Preferred Generic

+ $8 copay for a one-month (30-day) supplyof all drugs covered within this tier

Out-of-network Catastrophic Coverage After your yearly out-of-pocket drug costs reach $4550 you will be reimbursed for drugs purchasedout-of-network up to the planrsquos cost of the drug minus your cost share which is the greater of+ 5 coinsurance or+ $255 copay for generic (including brand drugs treated as generic) and+ $635 copay for all other drugs

You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge andthe planrsquos In-Network allowable amount

PAG E 34 of 40

PAGE 35 of 40

(PDP)

Multi-language Interpreter Services

English We have free interpreter services to answer any questions you may have about our health or drug plan To get an interpreter just call us at 1-800-478-0583 Someone who speaks EnglishLanguage can help you This is a free service

Spanish Tenemos servicios de inteacuterprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos Para hablar con un inteacuterprete por favor llame al 1-800-478-0583 Alguien que hable espantildeol le podraacute ayudar Este es un servicio gratuito

Chinese Mandarin 我们提供免们的翻们服们们助们解答们于健康或们物保们的任何疑 们如果们需要此翻们服们们致们 phone number我们的中文工作人们很们意们助们 们是一们免们服们

Chinese Cantonese 您對我們的健康或藥物保險可能存有疑問為此我們提供免費的翻譯服務如需翻譯服務請致電 1-800-478-0583我們講中文的人員將樂意為您提供幫助這是一項免費服務

Tagalog Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot Upang makakuha ng tagasaling-wika tawagan lamang kami sa 1-800-478-0583 Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog Ito ay libreng serbisyo

French Nous proposons des services gratuits dinterpreacutetation pour reacutepondre agrave toutes vos questions relatives agrave notre reacutegime de santeacute ou dassurance-meacutedicaments Pour acceacuteder au service dinterpreacutetation il vous suffit de nous appeler au 1-800-478-0583 Un interlocuteur parlant Franccedilais pourra vous aider Ce service est gratuit

Vietnamese Chuacuteng tocirci coacute dịch vụ thocircng dịch miễn phiacute để trả lời caacutec cacircu hỏi về chương sức khỏe vagrave chương trigravenh thuốc men Nếu quiacute vị cần thocircng dịch viecircn xin gọi 1-800-478-0583 sẽ coacute nhacircn viecircn noacutei tiếng Việt giuacutep đỡ quiacute vị Đacircy lagrave dịch vụ miễn phiacute

German Unser kostenloser Dolmetscherservice beantwortet Ihren Fragen zu unserem Gesundheits- und Arzneimittelplan Unsere Dolmetscher erreichen Sie unter 1-800-478-0583 Man wird Ihnen dort auf Deutsch weiterhelfen Dieser Service ist kostenlos

Korean 당사는 의료 보험 또는 약품 보험에 관한 질문에 답해 드리고자 무료 통역 서비스를 제공하고 있습니다 통역 서비스를 이용하려면 전화 1-800-478-0583 번으로 문의해 주십시오 한국어를 하는 담당자가 도와 드릴 것입니다 이 서비스는 무료로 운영됩니다

Y0079_6200 CMS Approved 07082013 U5073d 813

116

Appendix 4 ndash Multi-Language Insert

Multi-language Interpreter Services

English We have free interpreter services to answer any questions you may have about our health or drug plan To get an interpreter just call us at [1-xxx-xxx-xxxx] Someone who speaks EnglishLanguage can help you This is a free service

Spanish Tenemos servicios de inteacuterprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos Para hablar con un inteacuterprete por favor llame al [1-xxx-xxx-xxxx] Alguien que hable espantildeol le podraacute ayudar Este es un servicio gratuito

Chinese Mandarin 我们提供免费的翻译服务帮助您解答关于健康或药物保险的任何疑

问如果您需要此翻译服务请致电 1-xxx-xxx-xxxx我们的中文工作人员很乐意帮助您

这是一项免费服务

Chinese Cantonese 您對我們的健康或藥物保險可能存有疑問為此我們提供免費的翻譯

服務如需翻譯服務請致電 1-xxx-xxx-xxxx我們講中文的人員將樂意為您提供幫助這

是一項免費服務

Tagalog Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot Upang makakuha ng tagasaling-wika tawagan lamang kami sa [1-xxx-xxx-xxxx] Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog Ito ay libreng serbisyo French Nous proposons des services gratuits dinterpreacutetation pour reacutepondre agrave toutes vos questions relatives agrave notre reacutegime de santeacute ou dassurance-meacutedicaments Pour acceacuteder au service dinterpreacutetation il vous suffit de nous appeler au [1-xxx-xxx-xxxx] Un interlocuteur parlant Franccedilais pourra vous aider Ce service est gratuit Vietnamese Chuacuteng tocirci coacute dịch vụ thocircng dịch miễn phiacute để trả lời caacutec cacircu hỏi về chương sức khỏe vagrave chương trigravenh thuốc men Nếu quiacute vị cần thocircng dịch viecircn xin gọi [1-xxx-xxx-xxxx] sẽ coacute nhacircn viecircn noacutei tiếng Việt giuacutep đỡ quiacute vị Đacircy lagrave dịch vụ miễn phiacute

116

Appendix 4 ndash Multi-Language Insert

Multi-language Interpreter Services

English We have free interpreter services to answer any questions you may have about our health or drug plan To get an interpreter just call us at [1-xxx-xxx-xxxx] Someone who speaks EnglishLanguage can help you This is a free service

Spanish Tenemos servicios de inteacuterprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos Para hablar con un inteacuterprete por favor llame al [1-xxx-xxx-xxxx] Alguien que hable espantildeol le podraacute ayudar Este es un servicio gratuito

Chinese Mandarin 我们提供免费的翻译服务帮助您解答关于健康或药物保险的任何疑

问如果您需要此翻译服务请致电 1-xxx-xxx-xxxx我们的中文工作人员很乐意帮助您

这是一项免费服务

Chinese Cantonese 您對我們的健康或藥物保險可能存有疑問為此我們提供免費的翻譯

服務如需翻譯服務請致電 1-xxx-xxx-xxxx我們講中文的人員將樂意為您提供幫助這

是一項免費服務

Tagalog Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot Upang makakuha ng tagasaling-wika tawagan lamang kami sa [1-xxx-xxx-xxxx] Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog Ito ay libreng serbisyo French Nous proposons des services gratuits dinterpreacutetation pour reacutepondre agrave toutes vos questions relatives agrave notre reacutegime de santeacute ou dassurance-meacutedicaments Pour acceacuteder au service dinterpreacutetation il vous suffit de nous appeler au [1-xxx-xxx-xxxx] Un interlocuteur parlant Franccedilais pourra vous aider Ce service est gratuit Vietnamese Chuacuteng tocirci coacute dịch vụ thocircng dịch miễn phiacute để trả lời caacutec cacircu hỏi về chương sức khỏe vagrave chương trigravenh thuốc men Nếu quiacute vị cần thocircng dịch viecircn xin gọi [1-xxx-xxx-xxxx] sẽ coacute nhacircn viecircn noacutei tiếng Việt giuacutep đỡ quiacute vị Đacircy lagrave dịch vụ miễn phiacute

116

Appendix 4 ndash Multi-Language Insert

Multi-language Interpreter Services

English We have free interpreter services to answer any questions you may have about our health or drug plan To get an interpreter just call us at [1-xxx-xxx-xxxx] Someone who speaks EnglishLanguage can help you This is a free service

Spanish Tenemos servicios de inteacuterprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos Para hablar con un inteacuterprete por favor llame al [1-xxx-xxx-xxxx] Alguien que hable espantildeol le podraacute ayudar Este es un servicio gratuito

Chinese Mandarin 我们提供免费的翻译服务帮助您解答关于健康或药物保险的任何疑

问如果您需要此翻译服务请致电 1-xxx-xxx-xxxx我们的中文工作人员很乐意帮助您

这是一项免费服务

Chinese Cantonese 您對我們的健康或藥物保險可能存有疑問為此我們提供免費的翻譯

服務如需翻譯服務請致電 1-xxx-xxx-xxxx我們講中文的人員將樂意為您提供幫助這

是一項免費服務

Tagalog Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot Upang makakuha ng tagasaling-wika tawagan lamang kami sa [1-xxx-xxx-xxxx] Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog Ito ay libreng serbisyo French Nous proposons des services gratuits dinterpreacutetation pour reacutepondre agrave toutes vos questions relatives agrave notre reacutegime de santeacute ou dassurance-meacutedicaments Pour acceacuteder au service dinterpreacutetation il vous suffit de nous appeler au [1-xxx-xxx-xxxx] Un interlocuteur parlant Franccedilais pourra vous aider Ce service est gratuit Vietnamese Chuacuteng tocirci coacute dịch vụ thocircng dịch miễn phiacute để trả lời caacutec cacircu hỏi về chương sức khỏe vagrave chương trigravenh thuốc men Nếu quiacute vị cần thocircng dịch viecircn xin gọi [1-xxx-xxx-xxxx] sẽ coacute nhacircn viecircn noacutei tiếng Việt giuacutep đỡ quiacute vị Đacircy lagrave dịch vụ miễn phiacute

1-800-478-0583

PAGE 36 of 40

(PDP)

Multi-language Interpreter Services (continued)

Russian Если у вас возникнут вопросы относительно страхового или медикаментного плана вы можете воспользоваться нашими бесплатными услугами переводчиков Чтобы воспользоваться услугами переводчика позвоните нам по телефону 1-800-478-0583 Вам окажет помощь сотрудник который говорит по-pусски Данная услуга бесплатная

Arabicةيودألا لودج وأ ةحصلاب قلعتت ةلئسأ يأ نع ةباجإلل ةيناجملا يروفلا مجرتملا تامدخ مدقن اننإ صخش موقيس 0583-478-800-1 ىلع انب لاصتالا ىوس كيلع سيل يروف مجرتم ىلع لوصحلل انيدلةيناجم ةمدخ هذه كتدعاسمب ةيبرعلا ثدحتي ام

Hindi हमार सवासथय या दवा की योजना क बार म आपक किसी भी परशन क जवाब दन क लिए हमार पास मफत दभाषिया सवाए उपलबध ह एक दभाषिया परापत करन क लिए बस हम 1-800-478-0583 पर फोन कर कोई वयकति जो हिनदी बोलता ह आपकी मदद कर सकता ह यह एक मफत सवा ह

Italian Egrave disponibile un servizio di interpretariato gratuito per rispondere a eventuali domande sul nostro piano sanitario e farmaceutico Per un interprete contattare il numero 1-800-478-0583 Un nostro incaricato che parla Italianovi forniragrave lassistenza necessaria Egrave un servizio gratuito

Portugueacutes Dispomos de serviccedilos de interpretaccedilatildeo gratuitos para responder a qualquer questatildeo que tenha acerca do nosso plano de sauacutede ou de medicaccedilatildeo Para obter um inteacuterprete contacte-nos atraveacutes do nuacutemero 1-800-478-0583 Iraacute encontrar algueacutem que fale o idioma Portuguecircs para o ajudar Este serviccedilo eacute gratuito

French Creole Nou genyen segravevis entegravepregravet gratis pou reponn tout kesyon ou ta genyen konsegravenan plan medikal oswa dwograveg nou an Pou jwenn yon entegravepregravet jis rele nou nan 1-800-478-0583 Yon moun ki pale Kreyogravel kapab ede w Sa a se yon segravevis ki gratis

Polish Umożliwiamy bezpłatne skorzystanie z usług tłumacza ustnego ktoacutery pomoże w uzyskaniu odpowiedzi na temat planu zdrowotnego lub dawkowania lekoacutew Aby skorzystać z pomocy tłumacza znającego język polski należy zadzwonić pod numer 1-800-478-0583 Ta usługa jest bezpłatna

Japanese 当社の健康 健康保険と薬品 処方薬プランに関するご質問にお答えするために無

料の通訳サービスがありますございます通訳をご用命になるには1-800-478-0583 にお電

話ください日本語を話す人 者 が支援いたしますこれは無料のサービスです

Notes

PAG E 37 of 40

Notes

PAG E 38 of 40

Notes

U5073e 813

PAGE 39 of 40

Awarded to BCBSNC by the Ethisphere Institute In 2013 companies in more than 100 countries and 36 industries were reviewed and of those 138 organizations were designated as Worldrsquos Most Ethical

BCBSNC Blue Medicare Rx products are only available to Medicare beneficiaries residing in North Carolina The information described in this brochure is for 2014 and may change on January 1 2015 The benefit information provided is a brief summary not a complete description of benefits For more information contact the plan This brochure may be available in alternate formats upon request Blue Cross and Blue Shield of North Carolina is a PDP plan with a Medicare contract Enrollment in Blue Cross and Blue Shield of North Carolina depends on contract renewal An independent licensee of the Blue Cross and Blue Shield Association reg SM Marks of the Blue Cross and Blue Shield Association SM1 Mark of Blue Cross and Blue Shield of North Carolina

If you are covered by oreligible for Medicare contactyour local Authorized SalesRepresentative to learn aboutour Medicare Part D plans

How can we help Call 1-800-478-0583 7 days aweek 8 am-8 pm For hearing and speech impaired(TTYTDD) usersCall 1-800-922-3140 7 days aweek 8 am-8 pm

Preferred Pharmacy NetworkBlue Medicare Rx (PDP)

Standard Plan Enhanced Plan Many of the popular drugsare covered ndash more than 1000included

Extensive list of covered drugs ndashmore than 1800 included

You pay $145 annual deductible No deductible ndash coverage beginsright away

$4 and $40 copayments for mostdrugs when you use our preferredpharmacy network up to $2850total drug cost

$3 and $30 copayments for mostdrugs when you use our preferredpharmacy network up to $2850total drug cost

You pay 72 on all generic drugsand you receive a discount onbrand-name drugs during the

ldquocoverage gaprdquo until true out-of-pocket costs reach $4550

You pay $3 copayment forpreferred generic drugs you pay72 for most other generic drugsand you receive a discount forbrand-name drugs during the

ldquocoverage gaprdquo until true out-of-pocket costs reach $4550

Generally 5 coinsurance after ldquocoverage gaprdquo ends Preferred Pharmacy Network includes CVS WalMart

Kerr Drugs and Epic Pharmacies

Non-preferred Pharmacy NetworkBlue Medicare Rx (PDP)

Standard Plan Enhanced Plan Many of the popular drugsare covered ndash more than 1000included

Extensive list of covered drugs ndashmore than 1800 included

You pay $145 annual deductible No deductible ndash coverage beginsright away

$10 and $45 copayments for mostdrugs up to $2850 total drug cost

$8 and $45 copayments for mostdrugs up to $2850 total drug cost

You pay 72 on all generic drugsand you receive a discount onbrand-name drugs during the

ldquocoverage gaprdquo until true out-of-pocket costs reach $4550

You pay $8 copayment forpreferred generic drugs you pay72 for most other generic drugsand you receive a discount forbrand-name drugs during the

ldquocoverage gaprdquo until true out-of-pocket costs reach $4550

Generally 5 coinsurance after ldquocoverage gaprdquo ends

PAGE 40 of 40

Y0079_6250 CMS Approved 08062013

PAGE 35 of 40

(PDP)

Multi-language Interpreter Services

English We have free interpreter services to answer any questions you may have about our health or drug plan To get an interpreter just call us at 1-800-478-0583 Someone who speaks EnglishLanguage can help you This is a free service

Spanish Tenemos servicios de inteacuterprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos Para hablar con un inteacuterprete por favor llame al 1-800-478-0583 Alguien que hable espantildeol le podraacute ayudar Este es un servicio gratuito

Chinese Mandarin 我们提供免们的翻们服们们助们解答们于健康或们物保们的任何疑 们如果们需要此翻们服们们致们 phone number我们的中文工作人们很们意们助们 们是一们免们服们

Chinese Cantonese 您對我們的健康或藥物保險可能存有疑問為此我們提供免費的翻譯服務如需翻譯服務請致電 1-800-478-0583我們講中文的人員將樂意為您提供幫助這是一項免費服務

Tagalog Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot Upang makakuha ng tagasaling-wika tawagan lamang kami sa 1-800-478-0583 Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog Ito ay libreng serbisyo

French Nous proposons des services gratuits dinterpreacutetation pour reacutepondre agrave toutes vos questions relatives agrave notre reacutegime de santeacute ou dassurance-meacutedicaments Pour acceacuteder au service dinterpreacutetation il vous suffit de nous appeler au 1-800-478-0583 Un interlocuteur parlant Franccedilais pourra vous aider Ce service est gratuit

Vietnamese Chuacuteng tocirci coacute dịch vụ thocircng dịch miễn phiacute để trả lời caacutec cacircu hỏi về chương sức khỏe vagrave chương trigravenh thuốc men Nếu quiacute vị cần thocircng dịch viecircn xin gọi 1-800-478-0583 sẽ coacute nhacircn viecircn noacutei tiếng Việt giuacutep đỡ quiacute vị Đacircy lagrave dịch vụ miễn phiacute

German Unser kostenloser Dolmetscherservice beantwortet Ihren Fragen zu unserem Gesundheits- und Arzneimittelplan Unsere Dolmetscher erreichen Sie unter 1-800-478-0583 Man wird Ihnen dort auf Deutsch weiterhelfen Dieser Service ist kostenlos

Korean 당사는 의료 보험 또는 약품 보험에 관한 질문에 답해 드리고자 무료 통역 서비스를 제공하고 있습니다 통역 서비스를 이용하려면 전화 1-800-478-0583 번으로 문의해 주십시오 한국어를 하는 담당자가 도와 드릴 것입니다 이 서비스는 무료로 운영됩니다

Y0079_6200 CMS Approved 07082013 U5073d 813

116

Appendix 4 ndash Multi-Language Insert

Multi-language Interpreter Services

English We have free interpreter services to answer any questions you may have about our health or drug plan To get an interpreter just call us at [1-xxx-xxx-xxxx] Someone who speaks EnglishLanguage can help you This is a free service

Spanish Tenemos servicios de inteacuterprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos Para hablar con un inteacuterprete por favor llame al [1-xxx-xxx-xxxx] Alguien que hable espantildeol le podraacute ayudar Este es un servicio gratuito

Chinese Mandarin 我们提供免费的翻译服务帮助您解答关于健康或药物保险的任何疑

问如果您需要此翻译服务请致电 1-xxx-xxx-xxxx我们的中文工作人员很乐意帮助您

这是一项免费服务

Chinese Cantonese 您對我們的健康或藥物保險可能存有疑問為此我們提供免費的翻譯

服務如需翻譯服務請致電 1-xxx-xxx-xxxx我們講中文的人員將樂意為您提供幫助這

是一項免費服務

Tagalog Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot Upang makakuha ng tagasaling-wika tawagan lamang kami sa [1-xxx-xxx-xxxx] Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog Ito ay libreng serbisyo French Nous proposons des services gratuits dinterpreacutetation pour reacutepondre agrave toutes vos questions relatives agrave notre reacutegime de santeacute ou dassurance-meacutedicaments Pour acceacuteder au service dinterpreacutetation il vous suffit de nous appeler au [1-xxx-xxx-xxxx] Un interlocuteur parlant Franccedilais pourra vous aider Ce service est gratuit Vietnamese Chuacuteng tocirci coacute dịch vụ thocircng dịch miễn phiacute để trả lời caacutec cacircu hỏi về chương sức khỏe vagrave chương trigravenh thuốc men Nếu quiacute vị cần thocircng dịch viecircn xin gọi [1-xxx-xxx-xxxx] sẽ coacute nhacircn viecircn noacutei tiếng Việt giuacutep đỡ quiacute vị Đacircy lagrave dịch vụ miễn phiacute

116

Appendix 4 ndash Multi-Language Insert

Multi-language Interpreter Services

English We have free interpreter services to answer any questions you may have about our health or drug plan To get an interpreter just call us at [1-xxx-xxx-xxxx] Someone who speaks EnglishLanguage can help you This is a free service

Spanish Tenemos servicios de inteacuterprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos Para hablar con un inteacuterprete por favor llame al [1-xxx-xxx-xxxx] Alguien que hable espantildeol le podraacute ayudar Este es un servicio gratuito

Chinese Mandarin 我们提供免费的翻译服务帮助您解答关于健康或药物保险的任何疑

问如果您需要此翻译服务请致电 1-xxx-xxx-xxxx我们的中文工作人员很乐意帮助您

这是一项免费服务

Chinese Cantonese 您對我們的健康或藥物保險可能存有疑問為此我們提供免費的翻譯

服務如需翻譯服務請致電 1-xxx-xxx-xxxx我們講中文的人員將樂意為您提供幫助這

是一項免費服務

Tagalog Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot Upang makakuha ng tagasaling-wika tawagan lamang kami sa [1-xxx-xxx-xxxx] Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog Ito ay libreng serbisyo French Nous proposons des services gratuits dinterpreacutetation pour reacutepondre agrave toutes vos questions relatives agrave notre reacutegime de santeacute ou dassurance-meacutedicaments Pour acceacuteder au service dinterpreacutetation il vous suffit de nous appeler au [1-xxx-xxx-xxxx] Un interlocuteur parlant Franccedilais pourra vous aider Ce service est gratuit Vietnamese Chuacuteng tocirci coacute dịch vụ thocircng dịch miễn phiacute để trả lời caacutec cacircu hỏi về chương sức khỏe vagrave chương trigravenh thuốc men Nếu quiacute vị cần thocircng dịch viecircn xin gọi [1-xxx-xxx-xxxx] sẽ coacute nhacircn viecircn noacutei tiếng Việt giuacutep đỡ quiacute vị Đacircy lagrave dịch vụ miễn phiacute

116

Appendix 4 ndash Multi-Language Insert

Multi-language Interpreter Services

English We have free interpreter services to answer any questions you may have about our health or drug plan To get an interpreter just call us at [1-xxx-xxx-xxxx] Someone who speaks EnglishLanguage can help you This is a free service

Spanish Tenemos servicios de inteacuterprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos Para hablar con un inteacuterprete por favor llame al [1-xxx-xxx-xxxx] Alguien que hable espantildeol le podraacute ayudar Este es un servicio gratuito

Chinese Mandarin 我们提供免费的翻译服务帮助您解答关于健康或药物保险的任何疑

问如果您需要此翻译服务请致电 1-xxx-xxx-xxxx我们的中文工作人员很乐意帮助您

这是一项免费服务

Chinese Cantonese 您對我們的健康或藥物保險可能存有疑問為此我們提供免費的翻譯

服務如需翻譯服務請致電 1-xxx-xxx-xxxx我們講中文的人員將樂意為您提供幫助這

是一項免費服務

Tagalog Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot Upang makakuha ng tagasaling-wika tawagan lamang kami sa [1-xxx-xxx-xxxx] Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog Ito ay libreng serbisyo French Nous proposons des services gratuits dinterpreacutetation pour reacutepondre agrave toutes vos questions relatives agrave notre reacutegime de santeacute ou dassurance-meacutedicaments Pour acceacuteder au service dinterpreacutetation il vous suffit de nous appeler au [1-xxx-xxx-xxxx] Un interlocuteur parlant Franccedilais pourra vous aider Ce service est gratuit Vietnamese Chuacuteng tocirci coacute dịch vụ thocircng dịch miễn phiacute để trả lời caacutec cacircu hỏi về chương sức khỏe vagrave chương trigravenh thuốc men Nếu quiacute vị cần thocircng dịch viecircn xin gọi [1-xxx-xxx-xxxx] sẽ coacute nhacircn viecircn noacutei tiếng Việt giuacutep đỡ quiacute vị Đacircy lagrave dịch vụ miễn phiacute

1-800-478-0583

PAGE 36 of 40

(PDP)

Multi-language Interpreter Services (continued)

Russian Если у вас возникнут вопросы относительно страхового или медикаментного плана вы можете воспользоваться нашими бесплатными услугами переводчиков Чтобы воспользоваться услугами переводчика позвоните нам по телефону 1-800-478-0583 Вам окажет помощь сотрудник который говорит по-pусски Данная услуга бесплатная

Arabicةيودألا لودج وأ ةحصلاب قلعتت ةلئسأ يأ نع ةباجإلل ةيناجملا يروفلا مجرتملا تامدخ مدقن اننإ صخش موقيس 0583-478-800-1 ىلع انب لاصتالا ىوس كيلع سيل يروف مجرتم ىلع لوصحلل انيدلةيناجم ةمدخ هذه كتدعاسمب ةيبرعلا ثدحتي ام

Hindi हमार सवासथय या दवा की योजना क बार म आपक किसी भी परशन क जवाब दन क लिए हमार पास मफत दभाषिया सवाए उपलबध ह एक दभाषिया परापत करन क लिए बस हम 1-800-478-0583 पर फोन कर कोई वयकति जो हिनदी बोलता ह आपकी मदद कर सकता ह यह एक मफत सवा ह

Italian Egrave disponibile un servizio di interpretariato gratuito per rispondere a eventuali domande sul nostro piano sanitario e farmaceutico Per un interprete contattare il numero 1-800-478-0583 Un nostro incaricato che parla Italianovi forniragrave lassistenza necessaria Egrave un servizio gratuito

Portugueacutes Dispomos de serviccedilos de interpretaccedilatildeo gratuitos para responder a qualquer questatildeo que tenha acerca do nosso plano de sauacutede ou de medicaccedilatildeo Para obter um inteacuterprete contacte-nos atraveacutes do nuacutemero 1-800-478-0583 Iraacute encontrar algueacutem que fale o idioma Portuguecircs para o ajudar Este serviccedilo eacute gratuito

French Creole Nou genyen segravevis entegravepregravet gratis pou reponn tout kesyon ou ta genyen konsegravenan plan medikal oswa dwograveg nou an Pou jwenn yon entegravepregravet jis rele nou nan 1-800-478-0583 Yon moun ki pale Kreyogravel kapab ede w Sa a se yon segravevis ki gratis

Polish Umożliwiamy bezpłatne skorzystanie z usług tłumacza ustnego ktoacutery pomoże w uzyskaniu odpowiedzi na temat planu zdrowotnego lub dawkowania lekoacutew Aby skorzystać z pomocy tłumacza znającego język polski należy zadzwonić pod numer 1-800-478-0583 Ta usługa jest bezpłatna

Japanese 当社の健康 健康保険と薬品 処方薬プランに関するご質問にお答えするために無

料の通訳サービスがありますございます通訳をご用命になるには1-800-478-0583 にお電

話ください日本語を話す人 者 が支援いたしますこれは無料のサービスです

Notes

PAG E 37 of 40

Notes

PAG E 38 of 40

Notes

U5073e 813

PAGE 39 of 40

Awarded to BCBSNC by the Ethisphere Institute In 2013 companies in more than 100 countries and 36 industries were reviewed and of those 138 organizations were designated as Worldrsquos Most Ethical

BCBSNC Blue Medicare Rx products are only available to Medicare beneficiaries residing in North Carolina The information described in this brochure is for 2014 and may change on January 1 2015 The benefit information provided is a brief summary not a complete description of benefits For more information contact the plan This brochure may be available in alternate formats upon request Blue Cross and Blue Shield of North Carolina is a PDP plan with a Medicare contract Enrollment in Blue Cross and Blue Shield of North Carolina depends on contract renewal An independent licensee of the Blue Cross and Blue Shield Association reg SM Marks of the Blue Cross and Blue Shield Association SM1 Mark of Blue Cross and Blue Shield of North Carolina

If you are covered by oreligible for Medicare contactyour local Authorized SalesRepresentative to learn aboutour Medicare Part D plans

How can we help Call 1-800-478-0583 7 days aweek 8 am-8 pm For hearing and speech impaired(TTYTDD) usersCall 1-800-922-3140 7 days aweek 8 am-8 pm

Preferred Pharmacy NetworkBlue Medicare Rx (PDP)

Standard Plan Enhanced Plan Many of the popular drugsare covered ndash more than 1000included

Extensive list of covered drugs ndashmore than 1800 included

You pay $145 annual deductible No deductible ndash coverage beginsright away

$4 and $40 copayments for mostdrugs when you use our preferredpharmacy network up to $2850total drug cost

$3 and $30 copayments for mostdrugs when you use our preferredpharmacy network up to $2850total drug cost

You pay 72 on all generic drugsand you receive a discount onbrand-name drugs during the

ldquocoverage gaprdquo until true out-of-pocket costs reach $4550

You pay $3 copayment forpreferred generic drugs you pay72 for most other generic drugsand you receive a discount forbrand-name drugs during the

ldquocoverage gaprdquo until true out-of-pocket costs reach $4550

Generally 5 coinsurance after ldquocoverage gaprdquo ends Preferred Pharmacy Network includes CVS WalMart

Kerr Drugs and Epic Pharmacies

Non-preferred Pharmacy NetworkBlue Medicare Rx (PDP)

Standard Plan Enhanced Plan Many of the popular drugsare covered ndash more than 1000included

Extensive list of covered drugs ndashmore than 1800 included

You pay $145 annual deductible No deductible ndash coverage beginsright away

$10 and $45 copayments for mostdrugs up to $2850 total drug cost

$8 and $45 copayments for mostdrugs up to $2850 total drug cost

You pay 72 on all generic drugsand you receive a discount onbrand-name drugs during the

ldquocoverage gaprdquo until true out-of-pocket costs reach $4550

You pay $8 copayment forpreferred generic drugs you pay72 for most other generic drugsand you receive a discount forbrand-name drugs during the

ldquocoverage gaprdquo until true out-of-pocket costs reach $4550

Generally 5 coinsurance after ldquocoverage gaprdquo ends

PAGE 40 of 40

Y0079_6250 CMS Approved 08062013

PAGE 36 of 40

(PDP)

Multi-language Interpreter Services (continued)

Russian Если у вас возникнут вопросы относительно страхового или медикаментного плана вы можете воспользоваться нашими бесплатными услугами переводчиков Чтобы воспользоваться услугами переводчика позвоните нам по телефону 1-800-478-0583 Вам окажет помощь сотрудник который говорит по-pусски Данная услуга бесплатная

Arabicةيودألا لودج وأ ةحصلاب قلعتت ةلئسأ يأ نع ةباجإلل ةيناجملا يروفلا مجرتملا تامدخ مدقن اننإ صخش موقيس 0583-478-800-1 ىلع انب لاصتالا ىوس كيلع سيل يروف مجرتم ىلع لوصحلل انيدلةيناجم ةمدخ هذه كتدعاسمب ةيبرعلا ثدحتي ام

Hindi हमार सवासथय या दवा की योजना क बार म आपक किसी भी परशन क जवाब दन क लिए हमार पास मफत दभाषिया सवाए उपलबध ह एक दभाषिया परापत करन क लिए बस हम 1-800-478-0583 पर फोन कर कोई वयकति जो हिनदी बोलता ह आपकी मदद कर सकता ह यह एक मफत सवा ह

Italian Egrave disponibile un servizio di interpretariato gratuito per rispondere a eventuali domande sul nostro piano sanitario e farmaceutico Per un interprete contattare il numero 1-800-478-0583 Un nostro incaricato che parla Italianovi forniragrave lassistenza necessaria Egrave un servizio gratuito

Portugueacutes Dispomos de serviccedilos de interpretaccedilatildeo gratuitos para responder a qualquer questatildeo que tenha acerca do nosso plano de sauacutede ou de medicaccedilatildeo Para obter um inteacuterprete contacte-nos atraveacutes do nuacutemero 1-800-478-0583 Iraacute encontrar algueacutem que fale o idioma Portuguecircs para o ajudar Este serviccedilo eacute gratuito

French Creole Nou genyen segravevis entegravepregravet gratis pou reponn tout kesyon ou ta genyen konsegravenan plan medikal oswa dwograveg nou an Pou jwenn yon entegravepregravet jis rele nou nan 1-800-478-0583 Yon moun ki pale Kreyogravel kapab ede w Sa a se yon segravevis ki gratis

Polish Umożliwiamy bezpłatne skorzystanie z usług tłumacza ustnego ktoacutery pomoże w uzyskaniu odpowiedzi na temat planu zdrowotnego lub dawkowania lekoacutew Aby skorzystać z pomocy tłumacza znającego język polski należy zadzwonić pod numer 1-800-478-0583 Ta usługa jest bezpłatna

Japanese 当社の健康 健康保険と薬品 処方薬プランに関するご質問にお答えするために無

料の通訳サービスがありますございます通訳をご用命になるには1-800-478-0583 にお電

話ください日本語を話す人 者 が支援いたしますこれは無料のサービスです

Notes

PAG E 37 of 40

Notes

PAG E 38 of 40

Notes

U5073e 813

PAGE 39 of 40

Awarded to BCBSNC by the Ethisphere Institute In 2013 companies in more than 100 countries and 36 industries were reviewed and of those 138 organizations were designated as Worldrsquos Most Ethical

BCBSNC Blue Medicare Rx products are only available to Medicare beneficiaries residing in North Carolina The information described in this brochure is for 2014 and may change on January 1 2015 The benefit information provided is a brief summary not a complete description of benefits For more information contact the plan This brochure may be available in alternate formats upon request Blue Cross and Blue Shield of North Carolina is a PDP plan with a Medicare contract Enrollment in Blue Cross and Blue Shield of North Carolina depends on contract renewal An independent licensee of the Blue Cross and Blue Shield Association reg SM Marks of the Blue Cross and Blue Shield Association SM1 Mark of Blue Cross and Blue Shield of North Carolina

If you are covered by oreligible for Medicare contactyour local Authorized SalesRepresentative to learn aboutour Medicare Part D plans

How can we help Call 1-800-478-0583 7 days aweek 8 am-8 pm For hearing and speech impaired(TTYTDD) usersCall 1-800-922-3140 7 days aweek 8 am-8 pm

Preferred Pharmacy NetworkBlue Medicare Rx (PDP)

Standard Plan Enhanced Plan Many of the popular drugsare covered ndash more than 1000included

Extensive list of covered drugs ndashmore than 1800 included

You pay $145 annual deductible No deductible ndash coverage beginsright away

$4 and $40 copayments for mostdrugs when you use our preferredpharmacy network up to $2850total drug cost

$3 and $30 copayments for mostdrugs when you use our preferredpharmacy network up to $2850total drug cost

You pay 72 on all generic drugsand you receive a discount onbrand-name drugs during the

ldquocoverage gaprdquo until true out-of-pocket costs reach $4550

You pay $3 copayment forpreferred generic drugs you pay72 for most other generic drugsand you receive a discount forbrand-name drugs during the

ldquocoverage gaprdquo until true out-of-pocket costs reach $4550

Generally 5 coinsurance after ldquocoverage gaprdquo ends Preferred Pharmacy Network includes CVS WalMart

Kerr Drugs and Epic Pharmacies

Non-preferred Pharmacy NetworkBlue Medicare Rx (PDP)

Standard Plan Enhanced Plan Many of the popular drugsare covered ndash more than 1000included

Extensive list of covered drugs ndashmore than 1800 included

You pay $145 annual deductible No deductible ndash coverage beginsright away

$10 and $45 copayments for mostdrugs up to $2850 total drug cost

$8 and $45 copayments for mostdrugs up to $2850 total drug cost

You pay 72 on all generic drugsand you receive a discount onbrand-name drugs during the

ldquocoverage gaprdquo until true out-of-pocket costs reach $4550

You pay $8 copayment forpreferred generic drugs you pay72 for most other generic drugsand you receive a discount forbrand-name drugs during the

ldquocoverage gaprdquo until true out-of-pocket costs reach $4550

Generally 5 coinsurance after ldquocoverage gaprdquo ends

PAGE 40 of 40

Y0079_6250 CMS Approved 08062013

Notes

PAG E 37 of 40

Notes

PAG E 38 of 40

Notes

U5073e 813

PAGE 39 of 40

Awarded to BCBSNC by the Ethisphere Institute In 2013 companies in more than 100 countries and 36 industries were reviewed and of those 138 organizations were designated as Worldrsquos Most Ethical

BCBSNC Blue Medicare Rx products are only available to Medicare beneficiaries residing in North Carolina The information described in this brochure is for 2014 and may change on January 1 2015 The benefit information provided is a brief summary not a complete description of benefits For more information contact the plan This brochure may be available in alternate formats upon request Blue Cross and Blue Shield of North Carolina is a PDP plan with a Medicare contract Enrollment in Blue Cross and Blue Shield of North Carolina depends on contract renewal An independent licensee of the Blue Cross and Blue Shield Association reg SM Marks of the Blue Cross and Blue Shield Association SM1 Mark of Blue Cross and Blue Shield of North Carolina

If you are covered by oreligible for Medicare contactyour local Authorized SalesRepresentative to learn aboutour Medicare Part D plans

How can we help Call 1-800-478-0583 7 days aweek 8 am-8 pm For hearing and speech impaired(TTYTDD) usersCall 1-800-922-3140 7 days aweek 8 am-8 pm

Preferred Pharmacy NetworkBlue Medicare Rx (PDP)

Standard Plan Enhanced Plan Many of the popular drugsare covered ndash more than 1000included

Extensive list of covered drugs ndashmore than 1800 included

You pay $145 annual deductible No deductible ndash coverage beginsright away

$4 and $40 copayments for mostdrugs when you use our preferredpharmacy network up to $2850total drug cost

$3 and $30 copayments for mostdrugs when you use our preferredpharmacy network up to $2850total drug cost

You pay 72 on all generic drugsand you receive a discount onbrand-name drugs during the

ldquocoverage gaprdquo until true out-of-pocket costs reach $4550

You pay $3 copayment forpreferred generic drugs you pay72 for most other generic drugsand you receive a discount forbrand-name drugs during the

ldquocoverage gaprdquo until true out-of-pocket costs reach $4550

Generally 5 coinsurance after ldquocoverage gaprdquo ends Preferred Pharmacy Network includes CVS WalMart

Kerr Drugs and Epic Pharmacies

Non-preferred Pharmacy NetworkBlue Medicare Rx (PDP)

Standard Plan Enhanced Plan Many of the popular drugsare covered ndash more than 1000included

Extensive list of covered drugs ndashmore than 1800 included

You pay $145 annual deductible No deductible ndash coverage beginsright away

$10 and $45 copayments for mostdrugs up to $2850 total drug cost

$8 and $45 copayments for mostdrugs up to $2850 total drug cost

You pay 72 on all generic drugsand you receive a discount onbrand-name drugs during the

ldquocoverage gaprdquo until true out-of-pocket costs reach $4550

You pay $8 copayment forpreferred generic drugs you pay72 for most other generic drugsand you receive a discount forbrand-name drugs during the

ldquocoverage gaprdquo until true out-of-pocket costs reach $4550

Generally 5 coinsurance after ldquocoverage gaprdquo ends

PAGE 40 of 40

Y0079_6250 CMS Approved 08062013

Notes

PAG E 38 of 40

Notes

U5073e 813

PAGE 39 of 40

Awarded to BCBSNC by the Ethisphere Institute In 2013 companies in more than 100 countries and 36 industries were reviewed and of those 138 organizations were designated as Worldrsquos Most Ethical

BCBSNC Blue Medicare Rx products are only available to Medicare beneficiaries residing in North Carolina The information described in this brochure is for 2014 and may change on January 1 2015 The benefit information provided is a brief summary not a complete description of benefits For more information contact the plan This brochure may be available in alternate formats upon request Blue Cross and Blue Shield of North Carolina is a PDP plan with a Medicare contract Enrollment in Blue Cross and Blue Shield of North Carolina depends on contract renewal An independent licensee of the Blue Cross and Blue Shield Association reg SM Marks of the Blue Cross and Blue Shield Association SM1 Mark of Blue Cross and Blue Shield of North Carolina

If you are covered by oreligible for Medicare contactyour local Authorized SalesRepresentative to learn aboutour Medicare Part D plans

How can we help Call 1-800-478-0583 7 days aweek 8 am-8 pm For hearing and speech impaired(TTYTDD) usersCall 1-800-922-3140 7 days aweek 8 am-8 pm

Preferred Pharmacy NetworkBlue Medicare Rx (PDP)

Standard Plan Enhanced Plan Many of the popular drugsare covered ndash more than 1000included

Extensive list of covered drugs ndashmore than 1800 included

You pay $145 annual deductible No deductible ndash coverage beginsright away

$4 and $40 copayments for mostdrugs when you use our preferredpharmacy network up to $2850total drug cost

$3 and $30 copayments for mostdrugs when you use our preferredpharmacy network up to $2850total drug cost

You pay 72 on all generic drugsand you receive a discount onbrand-name drugs during the

ldquocoverage gaprdquo until true out-of-pocket costs reach $4550

You pay $3 copayment forpreferred generic drugs you pay72 for most other generic drugsand you receive a discount forbrand-name drugs during the

ldquocoverage gaprdquo until true out-of-pocket costs reach $4550

Generally 5 coinsurance after ldquocoverage gaprdquo ends Preferred Pharmacy Network includes CVS WalMart

Kerr Drugs and Epic Pharmacies

Non-preferred Pharmacy NetworkBlue Medicare Rx (PDP)

Standard Plan Enhanced Plan Many of the popular drugsare covered ndash more than 1000included

Extensive list of covered drugs ndashmore than 1800 included

You pay $145 annual deductible No deductible ndash coverage beginsright away

$10 and $45 copayments for mostdrugs up to $2850 total drug cost

$8 and $45 copayments for mostdrugs up to $2850 total drug cost

You pay 72 on all generic drugsand you receive a discount onbrand-name drugs during the

ldquocoverage gaprdquo until true out-of-pocket costs reach $4550

You pay $8 copayment forpreferred generic drugs you pay72 for most other generic drugsand you receive a discount forbrand-name drugs during the

ldquocoverage gaprdquo until true out-of-pocket costs reach $4550

Generally 5 coinsurance after ldquocoverage gaprdquo ends

PAGE 40 of 40

Y0079_6250 CMS Approved 08062013

Notes

U5073e 813

PAGE 39 of 40

Awarded to BCBSNC by the Ethisphere Institute In 2013 companies in more than 100 countries and 36 industries were reviewed and of those 138 organizations were designated as Worldrsquos Most Ethical

BCBSNC Blue Medicare Rx products are only available to Medicare beneficiaries residing in North Carolina The information described in this brochure is for 2014 and may change on January 1 2015 The benefit information provided is a brief summary not a complete description of benefits For more information contact the plan This brochure may be available in alternate formats upon request Blue Cross and Blue Shield of North Carolina is a PDP plan with a Medicare contract Enrollment in Blue Cross and Blue Shield of North Carolina depends on contract renewal An independent licensee of the Blue Cross and Blue Shield Association reg SM Marks of the Blue Cross and Blue Shield Association SM1 Mark of Blue Cross and Blue Shield of North Carolina

If you are covered by oreligible for Medicare contactyour local Authorized SalesRepresentative to learn aboutour Medicare Part D plans

How can we help Call 1-800-478-0583 7 days aweek 8 am-8 pm For hearing and speech impaired(TTYTDD) usersCall 1-800-922-3140 7 days aweek 8 am-8 pm

Preferred Pharmacy NetworkBlue Medicare Rx (PDP)

Standard Plan Enhanced Plan Many of the popular drugsare covered ndash more than 1000included

Extensive list of covered drugs ndashmore than 1800 included

You pay $145 annual deductible No deductible ndash coverage beginsright away

$4 and $40 copayments for mostdrugs when you use our preferredpharmacy network up to $2850total drug cost

$3 and $30 copayments for mostdrugs when you use our preferredpharmacy network up to $2850total drug cost

You pay 72 on all generic drugsand you receive a discount onbrand-name drugs during the

ldquocoverage gaprdquo until true out-of-pocket costs reach $4550

You pay $3 copayment forpreferred generic drugs you pay72 for most other generic drugsand you receive a discount forbrand-name drugs during the

ldquocoverage gaprdquo until true out-of-pocket costs reach $4550

Generally 5 coinsurance after ldquocoverage gaprdquo ends Preferred Pharmacy Network includes CVS WalMart

Kerr Drugs and Epic Pharmacies

Non-preferred Pharmacy NetworkBlue Medicare Rx (PDP)

Standard Plan Enhanced Plan Many of the popular drugsare covered ndash more than 1000included

Extensive list of covered drugs ndashmore than 1800 included

You pay $145 annual deductible No deductible ndash coverage beginsright away

$10 and $45 copayments for mostdrugs up to $2850 total drug cost

$8 and $45 copayments for mostdrugs up to $2850 total drug cost

You pay 72 on all generic drugsand you receive a discount onbrand-name drugs during the

ldquocoverage gaprdquo until true out-of-pocket costs reach $4550

You pay $8 copayment forpreferred generic drugs you pay72 for most other generic drugsand you receive a discount forbrand-name drugs during the

ldquocoverage gaprdquo until true out-of-pocket costs reach $4550

Generally 5 coinsurance after ldquocoverage gaprdquo ends

PAGE 40 of 40

Y0079_6250 CMS Approved 08062013

Awarded to BCBSNC by the Ethisphere Institute In 2013 companies in more than 100 countries and 36 industries were reviewed and of those 138 organizations were designated as Worldrsquos Most Ethical

BCBSNC Blue Medicare Rx products are only available to Medicare beneficiaries residing in North Carolina The information described in this brochure is for 2014 and may change on January 1 2015 The benefit information provided is a brief summary not a complete description of benefits For more information contact the plan This brochure may be available in alternate formats upon request Blue Cross and Blue Shield of North Carolina is a PDP plan with a Medicare contract Enrollment in Blue Cross and Blue Shield of North Carolina depends on contract renewal An independent licensee of the Blue Cross and Blue Shield Association reg SM Marks of the Blue Cross and Blue Shield Association SM1 Mark of Blue Cross and Blue Shield of North Carolina

If you are covered by oreligible for Medicare contactyour local Authorized SalesRepresentative to learn aboutour Medicare Part D plans

How can we help Call 1-800-478-0583 7 days aweek 8 am-8 pm For hearing and speech impaired(TTYTDD) usersCall 1-800-922-3140 7 days aweek 8 am-8 pm

Preferred Pharmacy NetworkBlue Medicare Rx (PDP)

Standard Plan Enhanced Plan Many of the popular drugsare covered ndash more than 1000included

Extensive list of covered drugs ndashmore than 1800 included

You pay $145 annual deductible No deductible ndash coverage beginsright away

$4 and $40 copayments for mostdrugs when you use our preferredpharmacy network up to $2850total drug cost

$3 and $30 copayments for mostdrugs when you use our preferredpharmacy network up to $2850total drug cost

You pay 72 on all generic drugsand you receive a discount onbrand-name drugs during the

ldquocoverage gaprdquo until true out-of-pocket costs reach $4550

You pay $3 copayment forpreferred generic drugs you pay72 for most other generic drugsand you receive a discount forbrand-name drugs during the

ldquocoverage gaprdquo until true out-of-pocket costs reach $4550

Generally 5 coinsurance after ldquocoverage gaprdquo ends Preferred Pharmacy Network includes CVS WalMart

Kerr Drugs and Epic Pharmacies

Non-preferred Pharmacy NetworkBlue Medicare Rx (PDP)

Standard Plan Enhanced Plan Many of the popular drugsare covered ndash more than 1000included

Extensive list of covered drugs ndashmore than 1800 included

You pay $145 annual deductible No deductible ndash coverage beginsright away

$10 and $45 copayments for mostdrugs up to $2850 total drug cost

$8 and $45 copayments for mostdrugs up to $2850 total drug cost

You pay 72 on all generic drugsand you receive a discount onbrand-name drugs during the

ldquocoverage gaprdquo until true out-of-pocket costs reach $4550

You pay $8 copayment forpreferred generic drugs you pay72 for most other generic drugsand you receive a discount forbrand-name drugs during the

ldquocoverage gaprdquo until true out-of-pocket costs reach $4550

Generally 5 coinsurance after ldquocoverage gaprdquo ends

PAGE 40 of 40

Y0079_6250 CMS Approved 08062013