your medicare coverage becomes more complete group...

Empire BlueCross

Empire MediBlue Freedom (PPO) with Senior Rx Plus Your Medicare coverage becomes more complete

Group Plan

This guide is intended to be a brief outline of coverage and is not intended to be a legal contract. The entire provisions of benefits and exclusions are contained in the Benefit Chart and Evidence of Coverage (EOC). In the event of a conflict between the Benefit Chart/EOC and this guide, the terms of the Benefit Chart and EOC will prevail.

Si usted necesita asistencia en español para poder entender este documento, podrá requerirla sin costo alguno llamándonos gratis al numero telefónico que se muestra en este material.

M0013_08_014 07/2007

The materials contained in this booklet are available at no cost to you in alternate formats and languages. Please call First Impressions at the number listed in this book.

Empire BlueCross with Senior Rx Plus

Medicare Advantage & Part D with additional prescription drug coverage.

2013

for your interest in our Medicare Advantage plans! You deserve a health care plan you can count on. One that meets your needs and lifestyle. One that’s focused on helping you stay healthy so you can do the things you’ve been wanting to do over the years. That’s why we designed Empire MediBlue Freedom (PPO) coupled with Senior Rx Plus. The Senior Rx Plus plan works with the Empire MediBlue Freedom (PPO), a Local Preferred Provider Organization (LPPO), to provide you with medical and prescription benefits including:

Many services with preset fees – no surprises when it’s time to pay Freedom to choose any provider you want inside or outside your plan’s network when you use

providers that accept Medicare Less paperwork One ID card (the one we send you) for all your covered medical and drug benefits Many preventive care services and gym membership at no extra cost Coverage for drugs in the Part D coverage gap

And, your services will come from a company that you may already know – one that generations have relied on with confidence for many years – Empire BlueCross.

Look over this booklet for benefit details that may make Empire MediBlue Freedom (PPO) with Senior Rx Plus your plan of choice. Please read the provider section. Find out how your plan works and how network and non-network provider costs differ.

Have plan benefit questions? Call the First Impressions Welcome Center at 1-866-205-6551, TTY/TDD 711, Monday through Friday from 8 a.m. to 9 p.m. ET, except holidays. . Have Medicare health or Part D drug benefit questions? Call Medicare at 1-800-MEDICARE (1-800-633-4227), TTY/TDD: 1-877-486-2048, 24 hours a day, 7 days a week.

*Empire BlueCross is a health plan with a Medicare contract. The benefit information provided is a brief summary, not a complete description, of benefits. For more information, contact the plan. Limitations, copayments, and restrictions may apply. Benefits may change upon renewal..

Thank you...

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 . Someone who speaks English/Language can help you. This is a free service. Spanish: Tenemos servicios de intérprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos. Para hablar con un intérprete, por favor llame al . Alguien que hable español le podrá 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。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。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 . Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog. Ito ay libreng serbisyo. French: Nous proposons des services gratuits d'interprétation pour répondre à toutes vos questions relatives à notre régime de santé ou d'assurance-médicaments. Pour accéder au service d'interprétation, il vous suffit de nous appeler au . Un interlocuteur parlant Français pourra vous aider. Ce service est gratuit. Vietnamese: Chúng tôi có dịch vụ thông dịch miễn phí để trả lời các câu hỏi về chương sức khỏe và chương trình thuốc men. Nếu quí vị cần thông dịch viên xin gọi sẽ có nhân viên nói tiếng Việt giúp đỡ quí vị. Đây là dịch vụ miễn phí . German: Unser kostenloser Dolmetscherservice beantwortet Ihren Fragen zu unserem Gesundheits- und Arzneimittelplan. Unsere Dolmetscher erreichen Sie unter . 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 번으로

문의해 주십시오. 한국어를 하는 담당자가 도와 드릴 것입니다. 이 서비스는 무료로

운영됩니다.

1-866-205-6551

1-866-205-6551

1-866-205-6551

1-866-205-6551

1-866-205-6551

1-866-205-6551

1-866-205-6551

1-866-205-6551

1-866-205-6551

Y0071_13_15045_U CMS Accepted 07/29/2012

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 . Вам окажет помощь сотрудник, который говорит по-pусски. Данная услуга бесплатная. Arabic: على للحصول. لدينا األدوية جدول أو بالصحة تتعلق أسئلة أي عن لإلجابة المجانية الفوري المترجم خدمات نقدم إننا

العربية يتحدث ما شخص سيقوم. على بنا االتصال سوى عليك ليس فوري، مترجم ھذه. بمساعدتك مجانية خدمة .

Italian: È disponibile un servizio di interpretariato gratuito per rispondere a eventuali domande sul nostro piano sanitario e farmaceutico. Per un interprete, contattare il numero

. Un nostro incaricato che parla Italianovi fornirà l'assistenza necessaria. È un servizio gratuito. Portugués: Dispomos de serviços de interpretação gratuitos para responder a qualquer questão que tenha acerca do nosso plano de saúde ou de medicação. Para obter um intérprete, contacte-nos através do número . Irá encontrar alguém que fale o idioma Português para o ajudar. Este serviço é gratuito. French Creole: Nou genyen sèvis entèprèt gratis pou reponn tout kesyon ou ta genyen konsènan plan medikal oswa dwòg nou an. Pou jwenn yon entèprèt, jis rele nou nan

. Yon moun ki pale Kreyòl kapab ede w. Sa a se yon sèvis ki gratis. Polish: Umożliwiamy bezpłatne skorzystanie z usług tłumacza ustnego, który pomoże w uzyskaniu odpowiedzi na temat planu zdrowotnego lub dawkowania leków. Aby skorzystać z pomocy tłumacza znającego język polski, należy zadzwonić pod numer . Ta usługa jest bezpłatna.

Hindi: हमारे वा य या दवा की योजना के बारे म आपके िकसी भी प्र न के जवाब देने के िलए हमारे पास मु त दभुािषया सेवाएँ उपल ध ह. एक दभुािषया प्रा त करने के िलए, बस हम

पर फोन कर. कोई यिक्त जो िह दी बोलता है आपकी मदद कर सकता है. यह एक मु त सेवा है.

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、

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。

1556-502-668-1

1-866-205-6551

1-866-205-6551

1-866-205-6551

1-866-205-6551

1-866-205-6551.

1-866-205-6551.

1-866-205-6551.

What’s inside

Section 1 Why Empire MediBlue Freedom (PPO) with Senior Rx Plus may just be right for you ...............................................................................................................4

Section 2 Choosing providers, using your benef tsi ...................................................................................6

Free to choose your providers ............................................................................................................. 6

Information to share with your non-network provider ........................................................................ 7

Empire BlueCross annual health exam and preventive care ............................................................... 11

Contact your support team ................................................................................................................ 11

One ID card ...................................................................................................................................... 11

Programs to help manage your care ................................................................................................... 12

Valued extras for added support ........................................................................................................ 13

Online resources and discounts ......................................................................................................... 14

Medical emergency care/urgent care covered ..................................................................................... 15

Benefits Chart .................................................................................................................................... 16

Prescription coverage comes with your PPO plan .............................................................................. 47

Prescription Drugs Benefit Summaries .............................................................................................. 51

Section 3 Other things you need to know ................................................................................................ 53

Utilization management disclosure statement .................................................................................. 53

Your rights as an Empire MediBlue Freedom (PPO) plan member .................................................... 54

Geographic service areas covered by this plan .................................................................................... 55

Summary of Privacy Practices ............................................................................................................ 56

Empire MediBlue Freedom (PPO) medical exclusions and limitations .............................................. 57

Empire MediBlue Freedom (PPO) prescription drug exclusions and limitations ............................. 60

Contact Information ......................................................................................................................... 61

How to find an Empire MediBlue Freedom (PPO) provider .............................................................. 61

Plan Ratings ...................................................................................................................................... 63

With an Empire MediBlue Freedom (PPO) with Senior Rx Plus, you get: All the benefits that Original Medicare

offers, plus other benefits.

Prescribed drugs covered. Our plan includes coverage for your prescribed drugs and convenient ways to order them.

Peace of mind. You have protection from unexpected medical costs, and many benefits have set copays.

Freedom and choice. You are free to see any provider you want, inside or outside your plan’s network, when you use providers that accept Medicare.

Preventive care access. Coverage that helps improve the quality of your life with a plan that can help reduce member cost share.1

Less paperwork. Take it easy – we’ll do your paperwork.

Emergency care anywhere. We will cover your emergency medical care inside or outside the U.S.*

Dental coverage. Dental benefits may be provided as part of your plan.*

Health management programs. Our disease management programs give you customized tools and the support you need.2

Gym membership. You can join any SilverSneakers® gym to help you stay fit.

24/7 NurseLine. Call the toll-free nurse help line any time day or night to get answers to your health concerns.

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Why Empire MediBlue Freedom (PPO) with Senior Rx Plus may just be right for you

Section 1

*For more benefit information, see the Benefits Chart. 1 Preventive care includes annual wellness visit, breast cancer screening, cervical and vaginal cancer screening, prostate

cancer screening exams, immunizations, colorectal screenings and bone mass measurements. This is not all-inclusive. Please see the Benefit Chart section for more details.

2 See details later in this booklet.

What our PPO plan means to you

Full coverage as soon as your plan starts

Set fees — no surprises when you pay

Customer service focused on you and your needs

Access to the benef ts that Originali Medicare offers, plus additional benef ts such as prescription drugi coverage

A plan that travels with you and saves you money

Empire MediBlue Freedom (PPO) with Senior Rx Plus gives you access to important resources that can help you when you need to make health care decisions. You even have access to discounts. We offer an integrated approach that helps pay for your medical and prescription drug bills and also gives you the customized tools and support you need to get the most from your coverage.

What you get from Custom Care Connection Preventive care services that can help you

stay healthier or help treat problems early. Condition management that can help

you deal with chronic conditions such as diabetes, or some heart ailments.

Care management if you have multiple conditions or acute health issues.

A dedicated 24-hour nurse help line you can call any time day or night.

What your plan covers

Well and sick visits with health care providers

Inpatient hospital stays Outpatient hospital care Emergency room or urgent care Ambulance services to the nearest

appropriate facility* Durable medical equipment Diagnostic testing, including X-rays and

lab services Short-term and maintenance prescription

medicines

When you sign up

Signing up for our PPO plan is easy. You won’t need to have a physical. And, any pre-existing medical condition you may have won’t limit your coverage.

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Care tailored to your needs

*For more benefit information, see the Benefits Chart.

Free to choose your providers

As our PPO plan member, you can go to any provider of your choice in or out of your plan’s network when you use providers that accept Medicare. That is, as long as the care you get is covered and medically needed. Of course, you have the best of both worlds when the one you choose is in your plan’s network. You have the provider you want. You’ll pay less for medical costs.

Why choose a network provider?

Network providers contract with us to accept our plan payment plus the member’s cost share as payment in full. With network providers, you get the highest level of benefits from your plan.

How to find a network provider

To find a network provider that accepts Medicare: Call the First Impressions phone number.

Find resources listed on the Contact Information page of this guide.

Call 1-800-810-BLUE.

Visit the “Doctor & Hospital Finder” at www.empireblue.com.

Using providers in an area without network providers available to see (designated as a “non-network county”)

There may be times when you have to get care from out-of-network providers. Except for emergencies, out-of-network providers can charge you more. If you seek care from providers located in

a non-network county, you can go to out-of-network providers that accept Medicare to get in-network benefits. Upon enrollment with our plan, you’ll receive a Provider Directory that includes a list of network counties, or you can call First Impressions to assist you.

If a provider chooses not to give you care, feel free to find another provider that accepts Medicare.

If you get care from a provider that does not accept Medicare, you will have to pay the full bill. Your plan can’t pay a provider that does not accept, or has opted out of, Medicare.

If you can’t find a provider that accepts Medicare, call the First Impressions Welcome Center at the toll-free number listed on the Contact Information page of this guide. They will respond: – With at least one provider of the type

you want and within a reasonable travel distance.

– Within 72 hours (for standard provider requests).

– On the same day for urgent care (medical care to be given within 12 hours to prevent the onset of an emergency).

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Choosing providers, using your benef ts i

Section 2

Choosing providers, using your benef ts iFree to choose your providers

chooseprovider.asp.No referrals needed for specialists

Our flexible PPO plans let you see any specialists inside or outside the plan network. You don’t need your primary care doctor’s referral to see a specialist. Use your plan’s Provider Directory or visit our website to find out more about network specialists. For some types of care, your provider will need to get an OK from us ahead of time (prior authorization). Please refer to your Benefit Chart for the types of care that need our OK ahead of time.

What to know about your provider

Find out if: Your provider is in your plan’s network.

You may call First Impressions or refer to the Provider Directory you will receive after you enroll.

Your out-of-network provider accepts Medicare and will bill your plan for covered care. Out-of-network providers are not required to render services to members, although they are encouraged to do so. Please check with the provider to make sure he/she takes part in Medicare and will bill the plan for covered services.

If the provider agrees to see you as a patient, you are only required to pay your copay for the covered services. Out-of-network providers must see any patient in an emergency situation.

IYou, or someone acting on your behalf, can access the list of Medicare-contracted providers at www.medicare.gov.

Information to share with your non-network provider

The next page has important information that can help you if you live or visit areas without a provider network. Please be sure to tear out this section and share it with your out-of-network doctor at your next visit.

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Count on us to work for you

We are an independent licensee of the Blue Cross and Blue Shield Association. That means our Blue plan members in the U.S. and Puerto Rico have access to a network shared by Blue licensees and their contracted providers across the country. Through this network, all the Blue plans are able to link with all the Blue providers to process and pay claims using the same electronic system. So, you can get health care from any Blue-contracted provider that accepts Medicare while traveling or living in any Blue plan’s service area.

$

This Blue member is enrolled in an Empire MediBlue Freedom (PPO) with Senior Rx Plus plan. Under this plan, you do not need to be a contracting provider to see and treat this member. Members seeking services from providers located in an area without an Empire MediBlue Freedom (PPO) with Senior Rx Plus provider network receive the same benef ts as members seeking servicesi from network providers. Claims will be paid at the in-network benef t level. If thei member is a current patient, please continue to care for him/her.

Changes in the law effective in 2009 enable health plans to enroll and cover some retiree group members inan Empire MediBlue Freedom (PPO) with Senior Rx Plus plan, even in areas where a provider network is not available.

Members who seek services from providers located in areas without a provider network receive the same benef ts as members seeking services ini areas where network providers are available. The benef ts will be paid at thei in-network benef t level, resulting ini lower copays and deductibles. They may receive care from any Medicare eligible provider, including all providers that accept Medicare.

Out-of-network providers are not re-quired to render services to members, al-though they are encouraged to do so. Please submit claims to your local Blue Cross and/or Blue Shield Plan. You will continue to receive payment based on the Medicare Allowed Amount. You will be paid the full amount in a single pay-ment — there is no need to f le a claim fori supplemental coverage. Members’ claims will be adjudicated according to the benef ts that their health care plan pro-ivides. Claims will be paid according to Centers for Medicare & Medicaid Ser-vices (CMS) guidelines. At a minimum, eligible claims will be reimbursed at the Medicare Allowed Amount minus any ap-plicable member cost-sharing amount. The Medicare Allowed Amount is the fee schedule reimbursement that Medicare would pay to a provider who accepts as-signment of benef ts for services ren-idered to a member. For more information about this member’s benef ts, you may call i1-800-676-BLUE or send an electronic eligibility request transaction. Please contact your local Blue Cross and/or Blue Shield Plan for questions regarding claims submission or payment.

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For your non-network provider Tear out and share

Empire BlueCross annual health exam and preventive care

Contact your support team

One ID card

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Empire BlueCross Annual Health Exam and preventive care at no cost

Help make sure you stay healthy through preventive care. Did you know that your yearly wellness exam, f u andl pneumonia shots, even stop smoking counseling, are available at no cost to you? That is, so long as you go to network providers who accept Medicare. It’s important that you get your preventive screenings and wellness exams right away! See the Benef t Chart to f nd out what types ofii preventive care won’t cost you a penny.

Contact your support team

Want to know more about what your PPO plan covers? Call the First Impressions Welcome Center at the toll-free number listed on the Contact Information page of this booklet – their dedicated representatives are here just for you. They’re fully trained and ready to help you with any coverage and benefit questions you may have.

One ID card

Your Empire MediBlue Freedom (PPO) with Senior Rx Plus ID card is all you need to get all your covered medical and drug benefits.

Programs to help manage your care

If you have a chronic condition

Chronic conditions can impact your life. But they should not keep you down. You can use our disease management program to get preventive care services, or turn to our resources for support. You and your doctor can work with a team of nurses to help you follow your plan of care and reach your wellness goals. With their help, you’ll learn to keep your symptoms under control and manage your health.

If you have multiple conditions

If you’re coping with multiple health issues, we have nurse care managers who will focus on integrating your case management. Our care managers provide:

Lifestyle coaching. Tips to manage the drugs you take. Coordination of care when you need to

see more than one provider. Access to medical management programs

that can enhance your care.

Help for better health outcomes

“I wish I had known” is a regret we don’t want you to have. Through MyHealth Advantage, we can:

Review your health status daily. Alert you and your doctor right away if

we detect risk issues from the drugs you’re taking.

Keep track of your routine tests and checkups.

Send MyHealth Note mailings to remind you to make your next appointment or take other preventive care actions.

Give you tips that may help cut the costs of your prescribed drugs and other health care supplies

If you have questions about the information you get, just call our health coaches toll-free.

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Valued extras for added support*

* The products and services described on this page are not part of our contract with Medicare. They are not subject to the Medicare appeals process. Any disputes about these products or services may be subject to the Empire BlueCross grievance process.

The SilverSneakers® Fitness Program makes it easy to stay f t i

It’s easy and affordable for you to stay fit, have fun and make friends using your complimentary SilverSneakers membership. You’ll have access to nearly 10,000 participating locations across the country, where on-site staff members will help you meet your wellness goals. Locations offer amenities such as exercise equipment and SilverSneakers fitness classes designed specifically for people with Medicare and taught by certified instructors.

Find your closest participating location at www.silversneakers.com.1 Before you go to the SilverSneakers location, call 1-888-423-4632 (TTY: 711) to request your unique SilverSneakers ID number and have your SilverSneakers ID card mailed to you. Take your ID number with you to tour the location, sign up and get started today! (You don’t need to wait until your card arrives in the mail.)

SilverSneakers Online

The SilverSneakers member website, www.silversneakers.com/member, provides a comprehensive, easy-to-use wellness resource. Be part of a thriving and secure member community where you can create exercise and nutrition plans, track your fitness progress, and find health articles, recipes and more.

SilverSneakers® Steps

SilverSneakers Steps is a personalized fitness program that fits the lifestyle of members who don’t have convenient access to a SilverSneakers location. After registering as a Steps member on www.silversneakers.com/member, you’ll receive a Steps kit with tools to help you get fit wherever you are, whenever you like.

RNs can help you by phone at any time, any day

What if you get sick or injured when your doctor’s office is closed? Any time day or night, you can call the 24/7 nurse help line toll free. Registered nurses (RNs) will help assess your symptoms and talk with you about your options for care. Your calls are kept private. Program the nurse line number into all your phones. That way, you’re just one touch away from the help you need. You also have access to hundreds of taped health topics in English and Spanish. Just call the nurse line and follow the prompts to get into the Audiotape Library.

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Please consult with your doctor before you start a physical activity program.

The SilverSneakers Fitness Program is provided by Healthways, Inc., an independent company. SilverSneakers® is a registered mark of Healthways, Inc.

To find SilverSneakers locations near you, visit www.silversneakers.com or call SilverSneakers at 1-888-423-4632. TTY users call 711, Monday through Friday, 8 a.m. to 8 p.m. ET. 1 Vendors and offers are subject to change without prior notice. Empire BlueCross does not endorse and is not responsible for the products, services or information provided by SilverSneakers. Arrangements and discounts were negotiated between SilverSneakers and Empire BlueCross for the benefit of our members.

Online resources and discounts

Tools and resources on our website help you take control of your health.

You can browse our website 24 hours a day to find health information and tools that can help you: Take control of your health. Stay fit. Avoid getting sick.

You’ll find e-newsletters that focus on health items you might want to know about. You can even use a library with thousands of articles dealing with self-care, medicines, conditions, tests and treatments. All you’ll need to do is sign up online once you’re a member.

SpecialOffersSM keeps more money in your pocket

Our online SpecialOffers program helps you achieve your wellness goals and cut costs. As a member, you can access discounts on various health products and services.1 Check these out on our website:

Diet/nutrition and fitness – Jenny Craig®, WeightWatchers®, Lindora®, Living Lean®

Vitamins and personal care – Puritan’s Pride, drugstore.comTM

Vision and hearing - TruVisionTM, Premier LASIK, HearPO, Beltone

Healthy habits - Living FreeTM, Living SmartTM

Easy access to preventive care guidelines

Use our website to find what health screenings you need and when. Just type in “preventive care guidelines” using the Google feature embedded within our website, and you’ll be able to download and print what you need. These guidelines are consistent with those endorsed by the American Academy of Family Physicians.

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Web tools you can use 24/72

Empire BlueCross website

Online pharmacy with drug interaction checker

Online preventive care guidelines

E-newsletters on health topics

1 Vendors and offers are subject to change without prior notice. Empire BlueCross does not endorse and is not responsible for the products, services or information provided by the Special Offers vendors. Arrangements and discounts were negotiated between each vendor and Empire BlueCross for the benefit of our members.

2 These website tools are offered to PPO plan members as extra services. They are not part of the contract and can change or stop.

Medical emergency care/urgent care covered

If you think your health is in serious danger, call 911 or go to the nearest emergency room (ER) right away. We will cover your medical emergency care no matter where you are.* If you think your symptoms may need attention, but not in an ER, call the 24/7 NurseLine for guidance. At any time day or night, you can call the nurse line listed on the back of your ID card.

You may use the following examples as a checklist before you decide to go to an ER. We will cover your care at an ER or urgent care center/clinic if your condition meets the general criteria for emergency or urgent care. We urge you not to use the ER for routine care. It’s best for you to go to your own doctor for routine care. Your doctor knows you and your medical history, and keeps your medical records.

Emergency care versus urgent care: What’s the difference?

Emergency care: Medical care you must have if you believe that your health is in serious danger.

Instances when you need emergency care:

Convulsions/seizures Breathing problems Being unconscious Poisoning Broken bones Shock Chest pain

Urgent care: Medical care for a less severe illness or injury that does not put your health in serious danger.

Instances when you need urgent care:

Pain in the stomach area Bad sunburns or other minor burns Earache Persistent nausea/vomiting Bad flu or sore throat Bad sprain

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*For more benefit information, see the Benefits Chart.

Your 2013 Medical Benefit ChartLocal PPO Plan 0

Y0071_13_15089_I 08/16/2012 2013 STD LPPO Plan 0

Covered services What you must pay for thesecovered services

Important information In-Network Out-of-Network

Doctor and Hospital Choice

You may go to doctors, specialists and hospitals in or out of thenetwork. You do not need a referral. However some benefits may require authorization.

Higher costs may apply for out-of-network services.

Annual Deductible

The deductible applies to covered services as noted within each category below, prior to the copay or coinsurance, if any, being applied.

$0

Combined in-network and out-of-network

Inpatient Services

Inpatient hospital care

Covered services include:

Semi-private room (or a private room if medically necessary)Meals including special dietsRegular nursing servicesCosts of special care units (such as intensive or coronary care units)Drugs and medicationsLab testsX-rays and other radiology servicesNecessary surgical and medical suppliesUse of appliances, such as wheelchairsOperating and recovery room costsPhysical therapy, occupational therapy and speech language therapy

Prior authorization is required for

elective, rehabilitation,

substance abuse, and Medicare-

covered transplantadmissions.

For Medicare-covered hospital

stays:

$0 copay per admission

Providers are encouraged to call

the plan for a predetermination of

coverage for elective, rehabilitation,

substance abuse and Medicare-covered

transplant admissions.


stays:

10% coinsurance per admission

The inpatient hospital out-of-

pocket maximum is $500 per year combined with inpatient mental

health care.

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Inpatient hospital care (con’t)

Inpatient substance abuse services

Inpatient dialysis (if you are admitted as an inpatient to a hospital for special care)

Under certain conditions, the following types of transplants are covered: corneal, kidney, kidney-pancreatic, heart, liver, lung, heart/lung, bone marrow, stem cell and intestinal/multivisceral. If you need a transplant, we will arrange to have your case reviewed by a Medicare-approved transplant center that will decide whether you are a candidate for a transplant. Transplant providers may be local or outside of the service area. If local transplant providers are willing to accept the Original Medicare rate, then you can choose to obtain your transplant services locally or at a distant location offered by the plan. If the plan provides transplant services at a distant location (outside of the service area) and you chose to obtain transplants at this distant location, we will arrange or pay for appropriate lodging and transportation costs for you and a companion. The reimbursement for transportation costs are while you and your companion are traveling to and from the medical providers for services related to the transplant care. The plan defines the distant location as a location that is outside of the member’s service area AND a minimum of 75 miles from the member’s home. Transportation and lodging costs will be reimbursed fortravel mileage and lodging consistent with current IRS travel mileage and lodging guidelines. Accommodations for lodging will be reimbursed at the lesser of: 1) billed charges, or 2) $50 per day per covered person up to a maximum of $100 per day per covered person consistent with IRS guidelines.

Blood – including storage and administration. Coverage of whole blood and packed red cells begins only with the first pint of blood that you need. All other components of blood are covered beginning with the first pint used.

Physician servicesExcept in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital. If possible, plan should be notified of emergency admissions within one business day of admission.

No limit to the number of days

covered by the plan each benefit period.

$0 copay for Medicare-covered physician services received while an inpatient during a Medicare-covered

hospital stay.



10% coinsurance for Medicare-covered physician services received while an inpatient during a Medicare-covered

hospital stay.

If you get authorized inpatient care at an

out-of-network hospital after your

emergency condition is stabilized, your cost is the cost-

sharing you would pay at a network

hospital.

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Inpatient hospital care (con’t)

If you get authorized inpatient care at an out-of-network hospital after your emergency condition is stabilized, your cost is the cost-sharing you would pay at a network hospital.

Note: To be an inpatient, your provider must write an order to admit you to the hospital. Even if you stay in the hospital overnight, you might still be considered an “outpatient.” If you are not sure if you are an inpatient, you should ask the hospital staff.

You can also find more information in a Medicare fact sheet called “Are You a Hospital Inpatient or Outpatient? If You Have Medicare – Ask!” This fact sheet is available on the Web athttp://www.medicare.gov/Publications/Pubs/pdf/11435.pdf or by calling 1-800-MEDICARE (1-800-633-4227). TTY users call 1-877-486-2048. You can call these numbers for free, 24 hours a day, 7 days a week.

Inpatient mental health care

Covered services include mental health care services that require a hospital stay in a psychiatric hospital or the psychiatric unit of a general hospital.

Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital. If possible, plan should be notified of emergency admissions within one business day of admission.


stays:


mental nervous and mental nervous rehabilitation admissions.



stays:


the plan for a predetermination of coverage for elective inpatient admissions.

10% coinsuranceper admission

The inpatient mental health care

out-of-pocket maximum is $500per year combined

with inpatienthospital care.

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Inpatient mental health care (con’t) No limit to the number of days


$0 copay for Medicare-covered physician services received while an inpatient during a Medicare-covered

hospital stay.



10% coinsurancefor Medicare-

covered physician services received while an inpatient during a Medicare-

covered hospital stay.

Skilled nursing facility (SNF) care

Inpatient skilled nursing facility (SNF) coverage is limited to 100 days each benefit period. A “benefit period” begins on the first day you go to a Medicare-covered inpatient hospital or a SNF.The benefit period ends when you have not been an inpatient at any hospital or SNF for 60 days in a row.

Covered services include but are not limited to:

Semi-private room (or a private room if medically necessary)Meals, including special dietsSkilled nursing servicesPhysical therapy, occupational therapy and speech language therapyDrugs administered to you as part of your plan of care (this includes substances that are naturally present in the body, such as blood clotting factors)Blood – including storage and administration. Coverage of whole blood and packed red cells begins only with the first pint of blood that you need. All other components of blood are covered beginning with the first pint used.Medical and surgical supplies ordinarily provided by SNFs

Prior authorization is required for SNF

services.

For Medicare-covered SNF stays:


.


the plan for a predetermination of coverage for SNF.

For Medicare-covered SNF stays:

10% coinsuranceper admission

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Skilled nursing facility (SNF) care (con’t)

Laboratory tests ordinarily provided by SNFsX-rays and other radiology services ordinarily provided by SNFsUse of appliances such as wheelchairs ordinarily provided by SNFsPhysician/Practitioner services

Generally, you will receive your SNF care from plan facilities. However, under certain conditions listed below, you may be able to pay in-network cost-sharing for a facility that isn’t a plan provider, if the facility accepts our plan’s amounts for payment.

A nursing home or continuing care retirement community where you were living right before you went to the hospital (as long as it provides skilled nursing facility care)A SNF where your spouse is living at the time you leave the hospital

Inpatient services covered when the hospital or SNF days are not covered or are no longer coveredIf you have exhausted your inpatient benefits or if the inpatient stay is not reasonable and necessary, we will not cover your inpatient stay. However, in some cases, we will cover certain services you receive while you are in the hospital or the skilled nursing facility (SNF) stay.

Covered services include, but are not limited to:

Physician servicesDiagnostic tests (like lab tests)X-ray, radium and isotope therapy including technician materials and servicesSurgical dressingsSplints, casts and other devices used to reduce fractures and dislocations

After your SNF day limits are used up, this plan will still pay for covered

physician services and other medical services outlined in this benefit chart at

the deductible and/or cost share amounts indicated.

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Inpatient services covered when the hospital or SNF days are not covered or are no longer covered (con’t)

Prosthetic and orthotic devices (other than dental) that replace all or part of an internal body organ (including contiguous tissue), or all or part of the function of a permanently inoperative or malfunctioning internal body organ, including replacement or repairs of such devicesLeg, arm, back and neck braces; trusses and artificial legs, arms and eyes including adjustments, repairs and replacements required because of breakage, wear, loss, or a change in the patient's physical conditionPhysical therapy, occupational therapy and speech language therapy

Home health agency care Prior to receiving home health services, a doctor must certify that you need home health services and will order home health services to be provided by a home health agency. You must be homebound, which means leaving home is a major effort.


Part-time or intermittent skilled nursing and home health aide services (To be covered under the home health care benefit, your skilled nursing and home health aide services combined must total fewer than eight hours per day and 35 hours per week.)Physical therapy, occupational therapy and speech language therapyMedical and social services Medical equipment and supplies

Prior authorization may be required for

select services.

$0 copay for Medicare-covered home health visits

DME copay or coinsurance, if any,

may apply.

Prior authorization is requested for select services.

10% coinsurancefor Medicare-covered home health visits

DME copay or coinsurance, if any,

may apply.

Hospice care

You may receive care from any Medicare-certified hospice program. Your hospice doctor can be a network provider or an out-of-network provider.

You must receive care from a

Medicare-certified hospice.

You must receive care from a

Medicare-certified hospice.

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Hospice care (con’t)For hospice services and for services that are covered by Medicare Part A or B and are related to your terminal condition: Original Medicare (rather than this plan) will pay for your hospice services and any Part A and Part B services related to your terminal condition. While you are in the hospice program, your hospice provider will bill Medicare for the services that Original Medicare pays for.

Service covered by Original Medicare include:

Drugs for symptom control and pain relief Short-term respite care Home care

Our plan covers hospice consultation services (one time only) for a terminally ill person who hasn’t elected the hospice benefit.

For services that are covered by Medicare Part A or B and are not related to your terminal condition: If you need non-emergency, non-urgently needed services that are covered under Medicare Part A or B and that are not related to your terminal condition, your cost for these services depends on whether you use a provider in our plan’s network:

If you obtain the covered services from a network provider, you only pay the plan cost-sharing amount for in-network servicesIf you obtain the covered services from an out-of-network provider, you pay the cost sharing under Fee-for-Service Medicare (Original Medicare)For services that are covered by this plan but are not covered by Medicare Part A or B: This plan will continue to cover plan-covered services that are not covered under Part A or B whether or not they are related to your terminal condition. You pay your plan cost sharing amount for these services.

Note: If you need non-hospice care (care that is not related to your terminal condition), you should contact us to arrange the services. Getting your non-hospice care through our network providers will lower your share of the costs for the services.

When you enroll in a Medicare-

certified hospice program, your

hospice services and your Part A

and Part B services related to

your terminal condition are paid

for by Original Medicare, not this

plan.

$0 copay for the one time only

hospice consultation

When you enroll in a Medicare-

certified hospice program, your

hospice services and your Part A

and Part B services related to

your terminal condition are paid

for by Original Medicare, not this

plan.

10% coinsurance for the one time

only hospice consultation

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Outpatient services

Physician services, including doctor’s office visits


Office visits, including medical and surgical services in a physician’s officeConsultation, diagnosis and treatment by a specialistRetail Health ClinicsBasic diagnostic hearing and balance exams, if your doctor orders it to see if you need medical treatment, when furnished by a physician, audiologist, or other qualified provider Telehealth office visits including consultation, diagnosis and treatment by a specialistSecond opinion by another network provider prior to surgeryPhysician services rendered in the homeOutpatient hospital servicesNon–routine dental care (covered services are limited to surgery of the jaw or related structures, setting fractures of the jaw or facial bones, extraction of teeth to prepare the jaw for radiation treatments of neoplastic cancer disease, or services that would be covered when provided by a physician)Allergy testing and allergy injections

$0 copay per visit to a networkprimary care

physician (PCP) for Medicare-covered

services

$0 copay per visit to a network specialist for

Medicare-covered services

$0 copay per visit to a network retail health clinic for


$0 copay for Medicare-covered

allergy testing

$0 copay for Medicare-covered allergy injections

10% coinsuranceper visit to an out-

of-network primary care physician

(PCP) for Medicare-covered

services.

10% coinsurance per visit to an out-

of-networkspecialist for


10% coinsurance per visit to an out-of-network retail health clinic for


10% coinsurance for Medicare-

covered allergy testing


covered allergy injections

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Chiropractic services


Manual manipulation of the spine to correct subluxation


chiropractic services.

$0 copay for each Medicare-covered

visit

Prior authorization may be requested for chiropractic

services.

10% coinsurance for each Medicare-

covered visit

Podiatry services


Diagnosis and the medical or surgical treatment, in an office setting, of injuries and disease of the feet (such as hammer toe or heel spurs) Medicare-covered routine foot care for member with certain medical conditions affecting the lower limbs.A foot exam is covered every six months for people with diabetic peripheral neuropathy and loss of protective sensations.


visit


covered visit

Outpatient mental health care, including partialhospitalization services


Mental health services provided by a state-licensed psychiatrist or doctor, clinical psychologist, clinical social worker, clinical nurse specialist, nurse practitioner, physician assistant, or other Medicare-qualified mental health care professional as allowed under applicable state laws.

“Partial hospitalization” is a structured program of active psychiatric treatment provided in a hospital outpatient setting, that is more intense than the care received in your doctor’s or therapist’s office and is an alternative to inpatient hospitalization.

Prior authorization may be required for outpatient mental

health visits after the12th visit. Prior

authorization may be required for partial

hospitalization services related to

mental health.


professional individual therapy

visit

Prior authorization is requested for

outpatient mental health visits after the

12th visit. Prior authorization may berequested for partial

hospitalization services related to

mental health.


covered professionalindividual therapy

visit

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Outpatient mental health care, including partial hospitalization services (con’t)

$0 copay for each Medicare-covered professional group

therapy visit

$0 copay for each Medicare-covered professional partial hospitalization visit

$0 copay for each Medicare-covered outpatient hospital facility individual

therapy visit

$0 copay for each Medicare-covered outpatient hospital

facility group therapy visit


partial hospitalization facility visit.


covered professional group therapy visit


covered professional partial

hospitalization visit


covered outpatient hospital facility

individual therapy visit



group therapy visit

10% coinsurance for each Medicare-covered partial hospitalization

facility visit

Outpatient substance abuse services, including partial hospitalization services

“Partial hospitalization” is a structured program of active psychiatric treatment provided in a hospital outpatient setting, that is more intense than the care received in your doctor’s or therapist’s office and is an alternative to inpatient hospitalization.

Prior authorization may be required for outpatient substance abuse visits after the

12th visit. Prior authorization may be required for partial

hospitalization services related to substance abuse.


outpatient substance abuse visits after the

12th visit. Prior authorization may be requested for partial

hospitalization services related to substance abuse.

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Outpatient substance abuse services, including partial hospitalization services (con’t)


professional individual therapy

visit

$0 copay for each Medicare-covered professional group

therapy visit

$0 copay for each Medicare-covered professional partial hospitalization visit

$0 copay for each Medicare-covered outpatient hospital facility individual

therapy visit


facility group therapy visit


partial hospitalization

facility visit


covered professional individual therapy

visit


covered professional group therapy visit


covered professional partial

hospitalization visit



individual therapy visit



group therapy visit

10% coinsurance for each Medicare-covered partial hospitalization

facility visit

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Outpatient surgery including services provided at hospital outpatient facilities and ambulatory surgical centers

Facilities where surgical procedures are performed and the patient is released the same day.

Note: If you are having surgery in a hospital, you should check with your provider about whether you will be an inpatient or outpatient. Unless the provider writes an order to admit you as an inpatient to the hospital, you are an outpatient and pay the cost-sharing amounts for outpatient surgery. Even if you stay in the hospital overnight, you might still be considered an “outpatient.”

You can also find more information in a Medicare fact sheet called “Are You a Hospital Inpatient or Outpatient? If You Have Medicare – Ask!” This fact sheet is available on the Web at http://www.medicare.gov/Publications/Pubs/pdf/11435.pdf or by calling 1-800-MEDICARE (1-800-633-4227). TTY users call 1-877-486-2048. You can call these numbers for free, 24 hours a day, 7 days a week.

Prior authorization is required for select

outpatient surgeries to include, but not

limited to: uvulopalatopharyngo

plasty (UP3), bariatric, orthopedic,

blepharoplasty.


facility or ambulatory surgical

center visit for surgery


outpatient observation room

visit

Prior authorization is requested for select outpatient surgeries to include, but not

limited to: uvulopalatopharyngo

plasty (UP3), bariatric, orthopedic,

blepharoplasty.


covered outpatient hospital facility or

ambulatory surgical center visit for

surgery


covered outpatient observation room

visit

Outpatient hospital services, non-surgical

Covered services include medically necessary services you get in the outpatient department of a hospital for diagnosis or treatment of an illness or injury.

Note: Unless the provider has written an order to admit you as an inpatient to the hospital, you are an outpatient and pay the cost-sharing amounts for outpatient hospital services. Even if you stay in the hospital overnight, you might still be considered an “outpatient.” If you are not sure if you are an outpatient, you should ask the hospital staff.

$0 copay for a visit to a network primary care

physician in an outpatient hospital setting/clinic for

Medicare-covered non-surgical

services

10% coinsurance for a visit to an out-of-network primary care physician in an outpatient hospital setting/clinic for


services

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Outpatient hospital services, non-surgical (con’t)

You can also find more information in a Medicare fact sheet called “Are You a Hospital Inpatient or Outpatient? If You Have Medicare – Ask!” This fact sheet is available on the Web at http://www.medicare.gov/Publications/Pubs/pdf/11435.pdf or by calling 1-800-MEDICARE (1-800-633-4227). TTY users call 1-877-486-2048. You can call these numbers for free, 24 hours a day, 7 days a week.

$0 copay for a visit to a network

specialist in an outpatient hospital setting/clinic for


services


outpatient observation room

visit

10% coinsurance for a visit to an out-

of-network specialist in an

outpatient hospital setting/clinic for


services

10% coinsurance for each Medicare-covered outpatient observation room

visit

Ambulance services

Covered ambulance services include fixed wing, rotary wing and ground ambulance services to the nearest appropriate facility that can provide care only if the services are furnished to a member whose medical condition is such that other means of transportation are contraindicated (could endanger the person’s health) or if authorized by the plan. Non-emergency transportation by ambulance is appropriate if it is documented that the member’s condition is such that other means of transportation are contraindicated (could endanger the person’s health) and that transportation by ambulance is medically required. Ambulance service is not covered for physician office visits.

Prior authorization for nonemergent air and water transportation is required for

network providers and requested for out-of-network providers.

$50 copay for Medicare-coveredambulance services

Cost share, if any, is applied per one-way trip for Medicare-covered ambulance

services.

Emergency careEmergency care refers to services that are:

Furnished by a provider qualified to furnish emergency services, andNeeded to evaluate or stabilize an emergency medical condition

$50 copay for each Medicare-covered emergency room visit

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Emergency care (con’t)

Emergency outpatient copay is waived if the member is admitted to the hospital within 72 hours for the same condition.

A medical emergency is when you, or any other prudent layperson with an average knowledge of health and medicine, believe that you have medical symptoms that require immediatemedical attention to prevent loss of life, loss of a limb, or loss of function of a limb. The medical symptoms may be an illness, injury, severe pain, or a medical condition that is quickly getting worse.

This coverage is worldwide and is limited to what is allowed under the Medicare fee schedule for the services performed/received in the United States.

If you get authorized inpatient care at an out-of-network hospital after your emergency condition is stabilized, your cost is the cost-sharing you would pay at a network hospital.

Urgently needed care

Urgently needed care is available on a world-wide basis.

The Urgently needed care copay is waived if the member is admitted to the hospital within 72 hours for the same condition.

If you are outside of the service area for your plan, your plan covers urgently needed care, including urgently required renal dialysis. Urgently needed care is care provided to treat a non-emergency, unforeseen medical illness, injury, or condition that requires immediate medical care. Urgently needed care may be furnished by in-network providers or by out-of-network providers when network providers are temporarily unavailable or inaccessible. Generally, however, if you are in the plan’s service area and your health is not in serious danger, you should obtain care from a network provider.

$0 copay for each Medicare-covered urgently needed care visit

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Outpatient rehabilitation services

Covered services include: physical therapy, occupational therapy, and speech language therapy.

Outpatient rehabilitation services are provided in various outpatient settings, such as hospital outpatient departments,independent therapist offices, and Comprehensive Outpatient Rehabilitation Facilities (CORFs).


physical therapy, occupational

therapy and speech language therapy

visits.

$0 copay for Medicare-covered physical therapy,

occupational therapy and speech language therapy

visits


physical therapy, occupational

therapy and speech language therapy

visits.


covered physical therapy,

occupational therapy and speech language therapy

visits

Cardiac rehabilitation services

Comprehensive programs of cardiac rehabilitation services that include exercise, education, and counseling are covered for members who meet certain conditions with a doctor’s order. The plan covers intensive cardiac rehabilitation programs that are typically more rigorous or more intense than cardiac rehabilitation programs.


cardiac rehabilitation therapy visits


covered cardiac rehabilitation therapy visits

Pulmonary rehabilitation services

Comprehensive programs of pulmonary rehabilitation are covered for members who have moderate to very severe chronic obstructive pulmonary disease (COPD) and a referral for pulmonary rehabilitation from the doctor treating their chronic respiratory disease.


pulmonary rehabilitation therapy visits


covered pulmonary rehabilitation therapy visits

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Durable medical equipment (DME) and related supplies

(For a definition of “durable medical equipment,” see the “Definition of important words chapter,” later in this booklet.)

Covered items include, but are not limited to: wheelchairs, crutches, hospital bed, IV infusion pump, oxygen equipment, nebulizer and walker. Copay or coinsurance only applies when you are not currently receiving inpatient care. If you are receiving inpatient care your DME will be included in the copay or coinsurance for those services.

We cover all medically necessary durable medical equipment covered by Original Medicare. If our supplier in your area does not carry a particular brand or manufacturer, you may ask them if they can special order it for you.


power operated vehicles, power wheelchairs andaccessories, non-

standard wheelchairs and

non-standard beds.

10% coinsuranceon all Medicare-covered DME

Prior authorization is requested for power operated vehicles, power wheelchairs and accessories, non-

standard wheelchairs and

non-standard beds.

10% coinsurance on all Medicare-covered DME

Prosthetic devices and related supplies

Devices (other than dental) that replace all or a body part or function. These include, but not limited to, colostomy bags and supplies directly related to colostomy care, pacemakers, braces, prosthetic shoes, artificial limbs and breast prostheses (including a surgical brassiere after a mastectomy). Includes certain supplies related to prosthetic devices and repair and/or replacement of prosthetic devices. Also includes some coverage following cataract removal or cataract surgery, see “Vision care” later in this section for more detail.

Prior authorizationis required for prosthetics and

orthotics.

10% coinsuranceon all Medicare-

covered prosthetics and orthotics

Prior authorization is requested for prosthetics and

orthotics.

10% coinsurance on all Medicare-

covered prosthetics and orthotics

Diabetes self-management training, diabetic services and supplies

For all people who have diabetes (insulin and non-insulin users).


Supplies to monitor your blood glucose: Blood glucose monitor, blood glucose test strips, urine test strips, lancet devices and lancets and glucose control solutions for checking the accuracy of test strips and monitors

For Medicare-covered:

10% coinsurancefor a 30-day supply on each Medicare-

covered purchase of glucose test strips, urine test strips,

lancet devices and lancets and glucose

For Medicare-covered:

10% coinsurance for a 30-day supply on each Medicare-

covered purchase of glucose test strips, urine test strips,

lancet devices and lancets and glucose

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Diabetes self-management training, diabetic services and supplies (con’t)

One pair per year of therapeutic custom-molded shoes (including inserts provided with such shoes) and two additional pairs of inserts, or one pair of depth shoes and three pairs of inserts (not including the non-customized removable inserts provided with such shoes) for people with diabetes who have severe diabetic foot disease, including fitting of shoes or insert.Diabetes self-management training is covered under certain conditions.

control solutions for checking the

accuracy of test strips and monitors

10% coinsurance for blood glucose

monitor


covered therapeutic shoes

$0 copay for Medicare-coveredself-management

training

control solutions for checking the

accuracy of test strips and monitors

10% coinsurance for blood glucose

monitor


covered therapeutic shoes

10% coinsurance for Medicare-covered self-management

training

Outpatient diagnostic tests and therapeutic services and supplies


X-rays

Complex diagnostic tests and X-rays

Radiation (radium and isotope) therapy including technician materials and supplies

Testing to confirm chronic obstructive pulmonary disease (COPD)

Surgical supplies, such as dressings

Splints, casts and other devices used to reduce fractures and dislocations

Laboratory tests

Prior authorization may be required for high tech imaging, as well as limited

diagnostic and therapeutic

radiology services including, but not

limited to radiation therapy, PET, CT, SPECT, MRI scans

and echocardiograms, sleep studies and

related sleep study equipment and

supplies.


high tech imaging,as well as limited

diagnostic and therapeutic

radiology services including but not

limited to, radiation therapy, PET, CT, SPECT, MRI scans

and echocardiograms, sleep studies and

related sleep study equipment and

supplies.

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Outpatient diagnostic tests and therapeutic services and supplies (con’t)

Blood – including storage and administration. Coverage of whole blood and packed red cells begins only with the first pint of blood that you need. All other components of blood are covered beginning with the first pint used.

Other outpatient diagnostic testsCertain diagnostic tests and X-rays are considered complex and include heart catheterizations, sleep studies and related sleep study equipment and supplies, computed tomography (CT), magnetic resonance procedures (MRIs and MRAs) and nuclear medicine studies, which includes PET scans.

$0 copay for each Medicare-covered X-ray visit and/or simple diagnostic

test


complex diagnostic test and/or

radiology visit

$0 copay for each Medicare-covered radiation therapy

treatment

$0 copay for Medicare-covered testing to confirm

chronic obstructive pulmonary disease


covered supplies

$0 copay for each Medicare-covered clinical/diagnostic

lab test

$0 copay per Medicare-covered

pint of blood

10% coinsurance for each Medicare-covered X-ray visit

and/or simple diagnostic test


covered complex diagnostic test

and/or radiology visit

10% coinsurance for each Medicare-covered radiation therapy treatment


covered testing to confirm chronic

obstructive pulmonary disease


covered supplies

$0 copay for each Medicare-covered clinical/diagnostic

lab test

$0 copay per Medicare-covered

pint of blood

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Vision care


Outpatient physician services for the diagnosis and treatment of diseases and injuries of the eye, including treatment for age-related macular degeneration.

For people who are at high risk of glaucoma, such as people with a family history of glaucoma, people with diabetes and African-Americans who are age 50 and older: glaucoma screening once per year

An eye exam to check for diabetic retinopathy once every12 months

One pair of eyeglasses or contact lenses after each cataract surgery that includes insertion of an intraocular lens. (If you have two separate cataract operations, you cannot reserve the benefit after the first surgery and purchase two eyeglasses after the second surgery.) Corrective lenses/frames (and replacements) needed after a cataract removal without a lens implant.

$0 copay for visits to a network primary care physician for

Medicare-covered exams to diagnose

and treat diseases of the eye

$0 copay for visits to a network specialist for

Medicare-covered exams to diagnose and treat diseases

of the eye


glaucoma screening

$0 copay for glasses/contacts

following Medicare-coveredcataract surgery

10% coinsurance for visits to an out-of-network primary care physician for Medicare-covered exams to diagnose and treat diseases

of the eye

10% coinsurance for visits to an out-

of-network specialist for

Medicare-covered exams to diagnose and treat diseases

of the eye


covered glaucoma screening

10% coinsurance for glasses/contacts

following Medicare-covered cataract surgery

Preventive services and screening tests

You will see this apple next to preventive services throughout this chart. For all preventive services that are covered at no cost under Original Medicare, we also cover the service at no cost to you in network.However, if you are treated or monitored for an existing medical condition or an additional non-preventive service, during the visit when you receive the preventive service, a copay or coinsurance may apply for that care received. In addition, if an office visit is billed for the existing medical condition or an additional non-preventive service received, the applicable network primary care physician or network specialist copay or coinsurance will apply.

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Abdominal aortic aneurysm screening

A one-time screening ultrasound for people at risk. The plan only covers this screening if you get a referral for it as a result of your “Welcome to Medicare” physical exam.

$0 copay forMedicare-covered

screening


covered screening

Bone mass measurements

For qualified individuals (generally, this means people at risk of losing bone mass or at risk of osteoporosis), the followingservices are covered every 24 months or more frequently if medically necessary: procedures to identify bone mass, detect bone loss, or determine bone quality, including a physician's interpretation of the results.


bone mass measurement


covered bone mass measurement

Colorectal cancer screening and colorectal services

For people 50 and older, the following are covered:

Flexible sigmoidoscopy (or screening barium enema as an alternative) every 48 monthsFecal occult blood test, every 12 months

For people at high risk of colorectal cancer, we cover:

Screening colonoscopy (or screening barium enema as an alternative) every 24 months

For people not at high risk of colorectal cancer we cover:

Screening colonoscopy every 10 years, but not within 48 months of a screening sigmoidoscopy

Colorectal services

Includes the biopsy and removal of any growth during the procedure, in the event the procedure goes beyond a screening exam


screenings and services


covered screenings and services

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HIV Screening

For people who ask for an HIV screening test or who are at increased risk for HIV infection, we cover:

One screening For women who are pregnant, we cover:

exam every 12 months

Up to three screening exams during a pregnancy


screening


covered screening

Screening for sexually transmitted infections (STIs) and counseling to prevent STIs

We cover sexually transmitted infection (STI) screenings for chlamydia, gonorrhea, syphilis, and Hepatitis B. These screenings are covered for pregnant women and for certain people who are at increased risk for an STI when the tests are ordered by a primary care provider. We cover these tests once every 12 months or at certain times during pregnancy.

We also cover up to 2 individual 20 to 30 minute, face-to-face high-intensity behavioral counseling sessions each year for sexually active adults at increased risk for STIs. We will only cover these counseling sessions as a preventive service if they are provided by a primary care provider and take place in a primary care setting, such as a doctor’s office.


services


covered services

Medicare Part B Immunizations


Pneumonia vaccineFlu shots, including H1N1, once a year in the fall or winter Hepatitis B vaccine if you are at high or intermediate risk of getting Hepatitis B


immunizations


immunizations

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Medicare Part B Immunizations (con’t)

Other vaccines if you are at risk and they meet Medicare Part B coverage rules

If Part D prescription drug coverage is included with your medical plan, we also cover some vaccines under our outpatient prescription drug benefit.

Breast cancer screening (mammograms)


One baseline mammogram between the ages of 35 and 39One screening mammogram every 12 months for women age 40 and olderClinical breast exams once every 24 months

$0 copay for Medicare-covered screening exams


covered screening exams

Cervical and vaginal cancer screening


For all women, Pap tests and pelvic exams are covered once every 24 months.If you are at high risk of cervical cancer or have had an abnormal Pap test and are of childbearing age, one Pap test every 12 months.




Prostate cancer screening exams

For men age 50 and older, the following are covered once every 12 months:

Digital rectal examProstate Specific Antigen (PSA) test




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Cardiovascular disease risk reduction visit (therapy for cardiovascular disease)

We cover 1 visit per year with your primary care doctor to help lower your risk for cardiovascular disease. During this visit, your doctor may discuss aspirin use (if appropriate), check your blood pressure, and give you tips to make sure you’re eating well.


visits

10% coinsurance for Medicare-covered visits

Cardiovascular disease testing

Blood tests for the detection of cardiovascular disease (or abnormalities associated with an elevated risk of cardiovascular disease) once every 5 years (60 months).


tests

10% coinsurance for Medicare-covered tests

“Welcome to Medicare ” preventive visit

The plan covers a one-time “Welcome to Medicare” preventive visit. The visit includes a review of your health, measurements of height, weight, body mass index, blood pressure as well as education and counseling about the preventive services you need (including certain screenings and shots), and referrals for other care if needed.

Important: We cover the “Welcome to Medicare” preventive visit only within the first 12 months you have Medicare Part B.When you make your appointment, let your doctor’s office know you would like to schedule your “Welcome to Medicare” preventive visit.


exam

10% coinsurance for Medicare-covered exam

Annual Wellness Visit

If you’ve had Part B for longer than 12 months, you can get an annual wellness visit to develop or update a personalized prevention plan based on your current health and risk factors. This is covered once every 12 months.


visits

10% coinsurance for Medicare-covered visits

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Annual Wellness Visit (con’t)

Note: Your first annual wellness visit can’t take place within 12 months of your “Welcome to Medicare” exam. However, you don’t need to have had a “Welcome to Medicare” exam to be covered for annual wellness visits after you’ve had Part B for 12 months.

Depression screening

We cover one screening for depression per year. The screening must be done in a primary care setting that can provide follow-uptreatment and referrals.


screening


covered screening

Diabetes screening

We cover this screening (includes fasting glucose tests) if you have any of the following risk factors: high blood pressure (hypertension), history of abnormal cholesterol and triglyceride levels (dyslipidemia), obesity, or a history of high blood sugar (glucose). Tests may also be covered if you meet other requirements, like being overweight and having a family history of diabetes.

Based on the results of these tests, you may be eligible for up to two diabetes screenings every 12 months.

$0 copay for Medicare-covered diabetes screening including fasting plasma glucose

tests


covered diabetes screening including

fasting plasma glucose tests

Obesity screening and therapy to promote sustained weight loss

If you have a body mass index of 30 or more, we cover intensive counseling to help you lose weight. This counseling is covered if you get it in a primary care setting, where it can be coordinated with your comprehensive prevention plan. Talk to your primary care doctor or practitioner to find out more.


services


covered services

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Screening and counseling to reduce alcohol misuse

We cover one alcohol misuse screening for adults with Medicare (including pregnant women) who misuse alcohol, but aren’t alcohol dependent.

If you screen positive for alcohol misuse, you can get up to 4 brief face-to-face counseling sessions per year (if you’re competent and alert during counseling) provided by a qualified primary care doctor or practitioner in a primary care setting.


services


covered services

Medical nutrition therapy

This benefit is for people with diabetes, renal (kidney) disease (but not on dialysis), or after a transplant when referred by your doctor.

We cover three hours of one-on-one counseling services during your first year that you receive medical nutrition therapy services under Medicare (this includes our plan, any other Medicare Advantage plan, or Original Medicare), and two hours each year after that. If your condition, treatment, or diagnosis changes, you may be able to receive more hours of treatment with a physician’s referral. A physician must prescribe these services and renew their referral yearly if your treatment is needed into another plan year.


visit


covered visit

Smoking and tobacco use cessation (counseling to quit smoking)

If you use tobacco, but do not have signs or symptoms of tobacco-related disease: We cover two counseling quit attempts within a 12 month period. Each counseling attempt includes up to four face-to-face visits.


visit.


covered visit

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Smoking and tobacco use cessation (counseling to quit smoking) (con’t)

If you use tobacco and have been diagnosed with a tobacco-related disease or are taking medicine that may be affected by tobacco: We cover cessation counseling services. We cover two counseling quit attempts within a 12 month period. Each counseling attempt includes up to four face-to-face visits. These visits must be ordered by your doctor and provided by a qualified doctor or other Medicare-recognized practitioner.

Other Services

Services to treat outpatient kidney disease and conditions


Kidney disease education services to teach kidney care and help members make informed decisions about their care. For members with stage IV chronic kidney disease when referred by their doctor, we cover up to six sessions of kidney disease education services per lifetime.Outpatient dialysis treatments (including dialysis treatments when temporarily out of the service area)Home dialysis or certain home support services (such as, when necessary, visits by trained dialysis workers to check on your home dialysis, to help in emergencies and check your dialysis equipment and water supply)Self-dialysis training (includes training for you and others for the person helping you with your home dialysis treatments)Home dialysis equipment and supplies

Certain drugs for dialysis are covered under your Medicare Part B drug benefit. For information about coverage for Part B Drugs, please go to the section below, “Medicare Part B prescription drugs.”

No prior authorization is

required, however notice is requested

for all members initiating dialysis

treatment.

$0 copay for each Medicare-covered kidney education

session


outpatient or physician office

dialysis

$0 copay for Medicare-covered home dialysis or

home support services

No prior authorization is

required, however notice is requested

for all members initiating dialysis

treatment.


covered kidney education session


outpatient or physician office

dialysis

10% coinsurance for Medicare-covered home

dialysis or home support services

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Services to treat outpatient kidney disease and conditions(con’t)


self-dialysis training


dialysis equipment and supplies

10% coinsurance for Medicare-covered self-

dialysis training


dialysis equipment and supplies

Medicare Part B prescription drugs, covered under your medical plan (Part B drugs)

These drugs are covered under Part B of Original Medicare. Members of our plan receive coverage for these drugs through our plan.

Covered drugs include:

“Drugs” includes substances that are naturally present in the body, such as blood clotting factors. Drugs that usually are not self-administered by the patient and are injected while receiving physician, hospital outpatient, or ambulatory surgical center servicesDrugs you take using durable medical equipment (such as nebulizers) that was authorized by your Medicare Advantage planClotting factors you give yourself by injection if you have hemophiliaImmunosuppressive drugs, if you were enrolled in Medicare Part A at the time of the organ transplantInjectable osteoporosis drugs, if you are homebound, have a bone fracture that a doctor certifies was related to post-menopausal osteoporosis and cannot self-administer the drugAntigensCertain oral anti-cancer drugs and anti-nausea drugs

Prior authorization may be required for certain injectable/ infusible drugs.

20% coinsurance for Medicare-covered Part B

drugs


covered Part B drug administration

20% coinsurancefor Medicare-covered Part B chemotherapy

drugs

20% coinsurancefor Medicare-covered Part B

chemotherapy drug administration


certain injectable/ infusible drugs.


drugs


covered Part B drug administration


chemotherapy drugs


chemotherapy drug administration

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Medicare Part B prescription drugs, covered under your medical plan (Part B drugs) (con’t)

Certain drugs for home dialysis, including heparin, the antidote for heparin when medically necessary, topical anesthetics and erythropoisis-stimulating agents (such as Erythropoietin (Epogen ), Procrit or Epoetin Alfa and Darboetin Alfa (Aranesp )Intravenous Immune Globulin for the home treatment of primary immune deficiency diseases

If Part D prescription drug coverage is included with your medical plan, please refer to your Evidence of Coverage for information on your Part D prescription drug benefits.

Additional Benefits

Hearing services

Routine hearing examsRoutine hearing exams are limited to a $50 maximum benefit peryear combined in-network and out-of-network. Routine hearing exam is limited to one per year combined in-network and out-of-network.

$0 copay for routine hearing exams

After plan paid benefits for routine hearing exams you are responsible for the remaining cost.

$0 copay for routine hearing exams

After plan paid benefits for routine hearing exams you are responsible for the remaining cost.

Routine vision care

Routine vision examsRoutine vision exams are limited to a $50 maximum benefit per year combined in-network and out-of-network. Routine vision exam is limited to one per year combined in-network and out-of-network.

$0 copay for routine

vision exams

After plan paid benefits for routine vision exams, you are responsible for the remaining cost.

$0 copay for routine

vision exams

After plan paid benefits for routine vision exams, you are responsible for the remaining cost.

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Routine foot care

Up to four covered visits per year. Routine foot care includes the cutting or removal of corns and calluses, the trimming, cutting, clipping or debriding of nails and other hygienic and preventive maintenance care.

$0 copay for each visit to a network

primary care physician for

routine foot care

$0 copay for each visit to a network

specialist for routine foot care

After plan paid benefits for routine foot exams you are responsible for the

remaining cost.

10% coinsurance for each visit to an

out-of-networkprimary care physician for

routine foot care

10% coinsurance for each visit to an

out-of-network specialist for

routine foot care

After plan paid benefits for routine foot exams you are responsible for the

remaining cost.

Health and wellness education programs

SilverSneakers®

You can enroll in this fitness program provided by SilverSneakers, an independent company.

As a member, you can participate in the SilverSneakers® Fitness Program or SilverSneakers® Steps at no additional cost. The SilverSneakers Fitness Program, designed exclusively for Medicare-eligible individuals, offers physical activity, health education and social events. With the SilverSneakers premier fitness center network, you’ll have a complimentary membership with access to a variety of participating fitness centers throughout the country. Many sites offer amenities such as:

Fitness equipment, treadmills and free weightsThe signature SilverSneakers Fitness Program classes, designed specifically for older adults and taught by certified instructors

$0 copay for the SilverSneakers fitness benefit

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Health and wellness education programs (con’t)

Additional signature classes, such as YogaStretch, SilverSplash®, CardioFit and WeightCircuit, available at select locationsA designated staff member to help you along the way.

After you enroll in this Medicare Advantage plan, you will receive a brochure that shows the participating fitness centers in your area and describes how to enroll in SilverSneakers.

The SilverSneakers® Fitness Program is not a gym membership,but a specialized program designed specifically for seniors. Gymmemberships or other fitness programs that do not meet theSilverSneakers® Fitness Program criteria are excluded.

Contact Customer Service for more information on this program, or visit www.SilverSneakers.com.

Foreign travel emergency and urgently needed care

Emergency or urgently needed care services while traveling outside the United States during a temporary absence of less than six months. Outpatient copay is waived if member is admitted to hospital within 72 hours for the same condition.

Emergency outpatient careUrgently needed careInpatient care (60 days per lifetime)

This coverage is worldwide and is limited to what is allowed under the Medicare fee schedule for the services performed/received in the United States.

$50 copay for emergency care

$0 copay for urgently needed care

$0 copay per admission for emergency inpatient care

Medicare-approved clinical research studies

A clinical research study is a way that doctors and scientists test new types of medical care, like how well a new cancer drug works. They test new medical care procedures or drugs by asking for volunteers to help with the study.

After Original Medicare has paid its share of the Medicare-approved study, this plan

will pay the difference between what Medicare has paid and this plan’s cost-

sharing for like services.

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Medicare-approved clinical research studies (con’t)

If you participate in a Medicare-approved study, Original Medicare pays the doctors and other providers for the covered services you receive as part of the study.

Although not required, we ask that you notify us if you participate in a Medicare-approved research study.

Any remaining plan cost-sharing you are responsible for will accrue toward this

plan’s out-of-pocket maximum.

Annual out-of-pocket maximum

All copays, coinsurance and deductibles listed in this benefit chart are accrued toward the medical plan out-of-pocket maximum with the exception of foreign travel emergency and urgently needed care copay or coinsurance amounts. Part D Prescription drug deductibles and copays do not apply to the medical plan out-of-pocket maximum.

$3,400

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Prescription coverage comes with your PPO plan

Our prescription drug plans include coverage for your prescribed drugs and provide convenient ways to order them. That’s where the value of an Empire MediBlue Freedom (PPO) with Senior Rx Plus comes in … see the value for yourself.

What Empire MediBlue Freedom (PPO) with Senior Rx Plus means to you:

Benefits that begin right away with no waiting periods.

Benefits under two drug plans that work like one plan.

Coverage for both short-term and long-term prescription needs.

Coverage of drugs to treat most medical conditions.

Convenience – getting your prescriptions is simple

Visit one of your plan’s network pharmacies.

Both drug plans use the same pharmacy network.

Show your ID card. No need for more than one card or

separate claims filings – we do the work for you.

Pay the required amount, based on your plan.

You’re done!

Dedicated network support.

No matter where you are, we will be there for you to help you get the care you need – when you need it. If you have any questions, that’s no problem for First Impressions’ reps. They can help you with any coverage and benefit concerns you may have. As an Empire MediBlue Freedom (PPO) with Senior Rx Plus plan member, you are never left to figure things out on your own – we are here for you!

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Using network pharmacies

You must use network pharmacies to get your covered prescription drugs, except under non-routine circumstances. Also, quantity limitations and restrictions may apply.

Your coverage gives you access to retail network pharmacies across the U.S. Our pharmacy network includes most national chains and local pharmacies. You can feel confident that your Empire BlueCross member ID card will be accepted and honored without question when you use any Empire MediBlue Freedom (PPO) with Senior Rx Plus plan pharmacy. Because you have access to a large network of pharmacies, finding a pharmacy that works with us shouldn’t be a problem. If you need help finding a participating pharmacy nearby, you can call the First Impressions Welcome Center (see the “Contact Information” page at the end of this brochure or visit us online).

Convenient ordering options

Your prescription drug plan gives you coverage for your short-term and long-term pharmacy needs. It also provides you with convenient ways to get your prescription filled and refilled – ultimately saving you money and time.

Retail plan pharmacies for short-term prescriptions. When you need your medicine right away, you can use your plan’s network retail pharmacies or drugstores to fill an order for up to 30 days. Some network retail pharmacies can also fill up to a 90-day retail supply.

Mail-order pharmacy services for long-term or maintenance medications. For prescriptions that you take on an ongoing basis, we offer the convenience of ordering through a network mail-order pharmacy. You will get the most from your prescription drug benefits when you use mail-order. For ease and convenience, you can order your prescription and refills through the mail or by phone..

48

Using out-of-network pharmacies

There are times when you cannot get to a network pharmacy, and you must get your covered prescriptions filled at an out-of-network* pharmacy. You can fill your prescribed drug orders at any pharmacy or drugstore if: You get sick, lose, or run out of your

prescribed drugs while traveling within the U.S. or its territories.

Your prescription is for a medical emergency or urgent care.

You are unable to get a covered drug you need right away within our service area because there isn’t a network pharmacy within a 25-mile driving distance that provides 24-hour service.

You have to fill a prescription for a covered drug that is not regularly stocked (such as a rare or specialty drug) at a participating network pharmacy.

* For more benefit information, see your Benefit Chart

Why you should use a network pharmacy

Always use a network pharmacy unless there isn’t one near you. Your plan has a pharmacy network with retail pharmacies across the country. Your plan’s network pharmacies will use your ID card to automatically send your prescription drug information to us.

49

Generic versus brand-name drugs: What’s the difference? Not much really. One costs less, the other costs more. Generic drugs have the same active ingredients as their brand-name counterparts. They go through the same type of testing by the U.S. Food and Drug Administration before they can be sold to the public. They are a great option to lower your health care costs. In fact, your plan benefits may include coverage for “select generics” at no cost.

Select Generics are a specific list of drugs that have been on the market long enough to have a proven track record for effectiveness and value. Check the Drug Benefit Chart to see if your plan covers Select Generics.

Sometimes your health care provider will prescribe a certain brand-name drug to treat a certain condition. Because brand-name drugs cost more, your share of the costs may be higher. The packet of information you may get after you enroll will have more details about your prescription drug coverage.

When you need Extra Help1

If you qualify for Medicare’s Extra Help and are enrolled in a Part D plan, Medicare can help by paying up to 100% of your prescribed drug costs. This may include: Paying your drug plan’s monthly

premium, yearly deductible, coinsurance and copays for prescription drugs that are on your plan’s list of covered drugs.

No coverage gap.

No late enrollment penalty, if you miss the seven-month eligibility period (three months before you turn 65, the month when you turn 65, and three months after you turn 65).

You will qualify for Extra Help if you have one of these:

Both Medicare and Medicaid Help from Medicaid paying your

Medicare Part B Both Medicare and Supplemental

Security Income (SSI)

To see if you qualify for Extra Help, call: The Social Security Office at

1-800-772-1213, from 7 a.m. to 7 p.m., Monday through Friday. TTY users can call 1-800-325-0778.

Your state’s Medicaid office. 1-800-MEDICARE (1-800-633-4227).

TTY users can call 1-877-486-2048, 24 hours a day/seven days a week.

1 For more benefit information, see your Benefit Chart

Some covered drugs have quantity limit, step therapy or prior authorization requirements. The formulary booklet you will receive in your member welcome packet will let you know which drugs have these requirements.

50

Your 2013 LPPO Prescription Drug Benefit Chart Premier 10/20/40 (with Senior Rx Plus)

Your Retiree Benefits include two drug plans. The chart below shows your cost after you receive basic benefits provided by your Group Part D drug plan and additional benefits

provided under your Senior Rx Plus plan.

A health plan with a Medicare contract.

Y0071_13_14723_I 05/29/2012 2013 STD Premier 10/20/40 P3TARO (10R) NY 09/10/2012

Formulary Premier 3 Tier – Open Mandatory Generic NoDeductible $0Covered Services What you payInitial Coverage Below is your payment responsibility from the time you meet your deductible, if you have one, until the cost paid by you and the Coverage Gap Discount Program for your prescriptions reaches your True Out of Pocket costs of $4,750. Retail Pharmacy per 30-day supply

(Specialty limited to a 30 day supply) � Generics, including Specialty Drugs � Select Generics

$10 copay $0 copay for Select Generics

� Preferred Brands, including Specialty Drugs and Vaccines

$20 copay

� Non-Preferred Brands and Non-Formulary Drugs $40 copay

Typically retail pharmacies dispense a 30-day supply of medication. Some of our retail pharmacies can dispense up to a 90-day supply of medication. If you purchase more than a 30-day supply at these retail pharmacies located in New York, you only pay the mail order copay shown below.Mail Order Pharmacy per 90-day supply

(Specialty limited to a 30 day supply; 30 day Retail copay applies)

� Generics, including Specialty Drugs � Select Generics

$20 copay $0 copay for Select Generics

� Preferred Brands, including Specialty Drugs and Vaccines

$40 copay

� Non-Preferred Brands and Non-Formulary Drugs $80 copay

Generally you must fill prescriptions at a network pharmacy to receive benefits under this Plan. In certain circumstances you may be reimbursed for drug costs when you must get a covered prescription filled at an out-of-network pharmacy. You will have to pay the cost of the drug and submit a claim to us. You will be responsible for all amounts over our negotiated cost, plus any deductible, copayment or coinsurance listed in this benefit chart. Please see “When can you use a pharmacy that is not in your plan’s network?” section of your Evidence of Coverage for complete information.Vaccine Coverage The up front costs for vaccines will vary based upon where the vaccine is purchased and administered. Some vaccines, such as Flu Vaccines, are paid under your Medicare Part B coverage. Vaccines that are covered by Medicare Part B are not covered by your Part D plan. Please see your Evidence of Coverage booklet for a complete explanation of your vaccine coverage.

51

Covered Services What you pay

Y0071_13_14723_I 05/29/2012

Catastrophic CoverageYour payment responsibility changes after the cost you have paid for prescription drugs and the amount of the Coverage Gap Discount reaches your True Out of Pocket cost of $4,750.

� Generic Drugs

� Select Generics

5% coinsurance, with a minimum copay of $2.65 and a

maximum copay of $10.00 (Specialty limited to a 30 day supply)

$0 copay for Select Generics � Brand-Name Drugs 5% coinsurance,

with a minimum copay of $6.60 and a maximum copay of $20.00

(Specialty limited to a 30 day supply) Extra Covered Drug GroupThese are drugs that are covered by your employer plan that are often excluded from Part D Prescription Drug Plans. These drugs do not count towards your True Out of Pocket expenses. They do not qualify for lower Catastrophic copays. BarbituratesCosmeticsCough and Cold DESI Over the Counter Vitamins and Minerals Erectile Dysfunction

See Formulary for complete list of drugs covered

� Generics You pay your retail or mail order generic copay � Brands You pay your retail or mail order brand copay

Contraceptive Devices Copay or coinsurance per Covered Device � Prescription - Retail Pharmacy $20 copay � Prescription - Mail Order Pharmacy $20 copay

Enteral Formula � Prescription - Retail Pharmacy $40 copay up to a 30 day supply � Prescription - Mail Order Pharmacy $80 copay up to a 90 day supply

Fertility Drugs � Prescription - Retail Pharmacy $40 copay up to a 30 day supply � Prescription - Mail Order Pharmacy $80 copay up to a 90 day supply

� Coverage Gap Discount Program: If you are not receiving help to pay your share of drug cost through the Low Income Subsidy or PACE programs, you qualify for a discount on the cost you pay for most covered brand drugs through the Medicare Coverage Gap Discount Program. For prescriptions filled in 2013, once the cost paid by you and this plan reaches $2,970 the cost share you pay will reflect the benefits provided by your plan and the Coverage Gap Discount program. The Coverage Gap Discount program applies until the cost paid by you and the Discount Program reaches $4,750. Drug Manufacturers have agreed to provide a discount on brand drugs which Medicare considers Part D qualified drugs. Please note: Your employer sponsored plan may cover some brand drugs beyond those covered by Medicare. The discount will not apply to drugs listed as “Extra Covered Drugs” in your benefits.

� Senior Rx Plus Plan: Your supplemental drug plan is a non-Medicare drug plan that will supplement benefits paid by your Group Part D plan and the Coverage Gap Discount Program up to the copay or coinsurance shown in this benefit chart.

52

How you qualify for Empire MediBlue Freedom (PPO)

You must meet these guidelines to qualify for this plan: You are now entitled to Medicare Part A

and/or enrolled in Part B. You are a permanent resident in the plan’s

service area. You keep paying your Medicare Part B

premiums, unless they are paid for by Medicaid or through another third party.

You qualify for coverage under your (or your spouse’s) current or former employer’s or union’s group health plan.

Note: If you have end-stage renal disease, you may not be eligible to enroll. Please call the First Impressions Welcome Center at the number listed on the Contact Information page of this booklet, for more information.

Utilization management disclosure statement

From time to time, we may have to review some types of care that your doctors want you to have. It’s a way we make sure those services meet Medicare's and Empire BlueCross's benefit criteria and guidelines. Your covered benefits are described in detail in your Evidence of Coverage. We may even help coordinate your care so you get the care you need and the most from your benefits. These activities are part of utilization management (UM): Preadmission certification Concurrent review Case management

Preadmission certification (our OK ahead of time)

Pre-admission certification is the process of getting our OK or approval ahead of time before you get some types of care. Instances when you would need our OK ahead of time include nonemergency hospital admissions, outpatient tests, outpatient surgery, visits to specialists, home health visits or nursing home admissions..

When you ask for an OK from us

Your treating provider has to make the request through our precertification department by phone, fax or mail.

A precertification department nurse will review the diagnosis and procedures. He or she will make sure both are medically appropriate, under the terms of your benefit coverage. If the nurse can certify the service after the first review, we will approve the request. If not, the nurse will turn it over to one of our doctors to review and decide. Our doctor reviewer may consult with your doctor as part of the process. We make our decisions based on: Medicare coverage criteria and

guidelines. National clinical guidelines, such as

Milliman and Roberts. Internally developed clinical criteria.

Doctors may use the above guidelines to make their precertification decisions.

53

Other things you need to know Section 3

Concurrent review

Our UM staff will monitor your hospital care during an inpatient stay. A UM nurse will do this to help make sure that you get medically necessary care as defined in your Evidence of Coverage. During the concurrent review process, the nurse may review your charts and have face-to-face talks with you (if appropriate), your family members (if available) and the hospital staff. This process also helps make it easier to do your discharge plan. The nurse can help arrange your post-hospital care such as nursing home placement, home health care and durable medical equipment.

Case management

Case management is the collaboration between you, your doctors and all others involved in your care. A care manager may write or call to help you exercise the benefit options that are best for your health needs. Care managers help the treating doctor coordinate your benefits and care if you have complex or serious medical conditions.

Your rights as an Empire MediBlue Freedom (PPO) plan member

Your information is private

We will keep your medical records and other such information from doctors, facilities and/or other service providers private. We will not disclose this information in any way that breaks the law.

Disenrolling from coverage

You may disenroll from your Empire MediBlue Freedom (PPO) plan plan based on the terms made by either your former employer, union or the administrator of your plan coverage. Once we get a written notice that you want to disenroll, we will transfer the administration of your Medicare benefits back to Medicare by the first of the next month after we get the written notice.

You will have access to medical benefits until your effective date with Medicare resumes. Medicare will not penalize you in any way. You will also get a written notice of your disenrollment date. If you choose to disenroll, you must continue to receive all medical services from your Empire MediBlue Freedom (PPO) plan until your disenrollment takes effect.

54

Geographic service areas covered by this plan

55

If you are not happy, you have options

When you’re not happy with your health care service, we’re not happy. We hope that never happens. But if ever you have a concern or cannot agree with a claim decision or a denial, feel free to pursue your options. We will do our best to give you all the information you need. We will listen to your concerns. That’s why we have appeals and grievance procedures. We review a grievance, such as a quality of care complaint, within 30 days after we get the complaint. We address appeals issues, such as payment for services, within 60 days after we get the appeal. If the appeal is for a denied service, we must decide no later than 30 days after we get the appeal. If your health is at risk, we must respond to the appeal within 72 hours. In some instances, you have the right to file an expedited grievance (rush grievance). In such a case, we must respond within 24 hours after we get the grievance.

And, we’re happy to do so!

If you can’t keep your current health plan

By law, Empire BlueCross can decide to end its agreement with the Centers for Medicare & Medicaid Services (CMS). Likewise, CMS has the right to end its contract with Empire BlueCross. If either party chooses to end their contract, your enrollment in the Empire BlueCross plan may end. Empire BlueCross can also choose to reduce its service areas. For example, Empire BlueCross may no longer offer plan coverage in the state in which you live. If any of these instances applies, we will let you know 60 days in advance to give you time to choose other coverage for your health care needs.

Geographic service areas covered by this plan

Our CMS-defined geographic service area includes all 50 states, Puerto Rico and Washington, D.C.

You will f nd information oni

these topics related to the

Senior Rx Plus plan in the

Senior Rx Plus Certif cate. i

You’ll receive the Certif cate ini

your new member materials.

56 565530 30134WPMENMUB SOPP for IND and EGR MA-PD Presales Bklt 06 12

Note: If you decide to enroll, you will receive our Notice of Privacy Practices in accordance with the Health Insurance Portability and Accountability Act (HIPAA) and other relevant state law requirements. The following is only a summary of important facts about our privacy and security program.

We have policies and practices in place that help ensure your protected health information (PHI) and personal information (PI) is kept secure according to standards required by state and federal law. We keep your oral, written and electronic PHI and PI safe through physical, electronic and procedural safeguards. We keep offices that hold PHI and PI secure. Our computers are password-protected. We lock storage areas and filing cabinets. We require our employees to protect PHI and PI through written policies and procedures. Access to PHI and PI is limited only to employees who need the data to do their job. All employees must wear ID badges. This helps keep people out of areas where sensitive data is kept.

Where required by law, our affiliates and nonaffiliates must protect the privacy of data we share in the normal course of business. They cannot give PHI or PI to others without your written OK, except as the law allows.

Under federal law, you have certain rights related to your information. You have the right to access and get a copy of your medical records held at the plan. We are allowed to charge you a fee to copy records. You

have the right to ask to see or get a copy of certain PHI, or ask that we correct your PHI in records held at the plan, if it is missing or wrong. If someone else (such as your doctor) gave us the PHI, we will let you know so you can ask him or her to correct it. We take your rights seriously and remind you of those rights through our Notice of Privacy Practices which we send upon enrollment and make available to you on our website.

If you are enrolled with us through an employer-sponsored group health plan, we may share PHI with

your group health plan. We and/or your group health plan may share PHI with the plan sponsor. By law, plan sponsors that receive PHI must have controls in place to keep PHI from being used for reasons that are not proper.

We will get an OK from you in writing before we use or share your PHI for any other purpose not stated in our Notice of Privacy Practices. You may take back this OK at any time, in writing. We will then stop using

your PHI for that purpose. But, if we have already used or shared your PHI based on your OK, we cannot undo any actions we took before you told us to stop.

Finally, to help prevent and detect Medicare fraud, waste and abuse, we record the Internet Protocol address where you submit your online application from. This applies if YOU enroll, or if an agent or a broker submits the application for you.

Summary of Privacy Practices

Y0071_13_14820_I 06/22/2012 30134WPMENMUB

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Empire MediBlue Freedom (PPO) medical exclusions and limitations

The plan does not cover exclusions or limitations described in the Benefit Chart and anywhere else in this booklet. The plan also does not cover these items:

1. Services considered not reasonable and necessary, according to the standards of Original Medicare, unless these services are listed by our plan as covered services.

2. Experimental medical and surgical procedures, equipment and medications, unless covered by Original Medicare or under a Medicare-approved clinical research study or by our plan. Experimental procedures and items are those items and procedures determined by your plan and Original Medicare to not be generally accepted by the medical community. However, certain services may be covered under a Medicare-approved clinical research study.

3. Surgical treatment for morbid obesity, except when it is considered medically necessary and covered under Original Medicare.

4. Private room in a hospital, except when itis considered medically necessary.

5. Private duty nurses.

6. Personal items in your room at a hospital or a skilled nursing facility, such as a telephone or a television.

7. Full-time nursing care in your home.

8. Custodial care is care provided in a nursing home, hospice, or other facility setting when you do not require skilled

medical care or skilled nursing care. Custodial care is personal care that does not require the continuing attention of trained medical or paramedical personnel, such as care that helps you with activities of daily living, such as bathing or dressing.

9. Homemaker services which provide basic household help, including light housekeeping or light meal preparation.

10. Fees charged by your immediate relativesor members of your household.

11. Meals delivered to your home.

12. Elective or voluntary enhancement procedures or services (including weight loss, hair growth, sexual performance, athletic performance, cosmetic purposes, anti-aging and mental performance), except when medically necessary.

13. Cosmetic surgery or procedures unless needed because of an accidental injury or to improve a malformed part of the body. All stages of reconstruction are covered for a breast after a mastectomy, as well as for the unaffected breast to produce a symmetrical appearance.

14. Routine dental care, such as cleanings, fillings or dentures unless stated in the Benefit Chart. However, non-routine dental care received at a hospital may be covered.

15. Unless specified otherwise in the Benefit Chart, chiropractic care, other than manual manipulation of the spine consistent with Medicare coverage guidelines.

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16. Unless stated in the Benefit Chart, routine foot care, except for the limited coverage provided according to Medicare guidelines.

17. Unless stated in the Benefit Chart, orthopedic shoes, unless the shoes are part of a leg brace and are included in the cost of the brace or the shoes are for a person with diabetic foot disease.

18. Supportive devices for the feet, except for orthopedic or therapeutic shoes for people with diabetic foot disease.

19. Unless stated in the Benefit Chart, hearing aids and routine hearing exams.

20. Unless stated in the Benefit Chart, eyeglasses, routine eye exams, radial keratotomy, LASIK surgery, vision therapy and other low-vision aids. However, eyeglasses are covered for people after cataract surgery.

21. Unless stated in the Benefit Chart, prescription drugs for treatment of sexual dysfunction, including erectile dysfunction, impotence, and anorgasmy or hyporgasmy.

22. Reversal of sterilization procedures, sex change operations, and non-prescription contraceptive supplies.

23. Unless stated in the Benefit Chart, acupuncture.

24. Naturopath services (uses natural or alternative treatments).

25. Services provided to veterans in Veterans Affairs (VA) facilities. However, when emergency services are received at a VA hospital and the VA cost sharing is more than the cost sharing under our plan, we will reimburse veterans for the difference. Members are still responsible for our cost- sharing amounts.

26. Benefits to the extent that they are available as benefits through any governmental unit (except Medicaid), unless required by law or regulation. The payment of benefits will be coordinated with such governmental units to the extent required under existing state or federal laws.

27. Services for illness or injury that occur as a result of any act of war, declaredor undeclared, if care is received in a governmental facility.

28. Services for court-ordered testing or care unless medically necessary and authorized by the plan.

29. Services for which you have no legal obligation to pay in the absence of this or like coverage.

30. Services received from a dental or medical department maintained by or on behalf of an employer, mutual benefit association, labor union, trust or similar person or group.

31. Charges in excess of the maximum allowable amount, unless stated in your Evidence of Coverage.

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32. Charges for completion of claim forms or charges for medical records or reports unless required by law.

33. Charges for missed or canceled appointments.

34. Charges for services incurred prior to your effective date.

35. Charges for services incurred after the termination date of this coverage, except as stated in your Evidence of Coverage.

36. Services or supplies primarily for educational, vocational or training purposes, except as stated in your Benefit Chart.

37. For self-help training and other forms of non-medical self-care, except as stated in your Benefit Chart.

38. Services that are not covered by Medicare unless stated in the Benefit Chart.

39. Any services listed above that aren’t covered will remain not covered even if received at an emergency facility. For example, non-authorized, routine conditions that do not appear to a reasonable person to be based on a medical emergency are not covered if received at an emergency facility.

Empire MediBlue Freedom (PPO) with Senior Rx Plus prescription drug exclusions and limitations

The following items and services are not covered unless the plan covers them under the “Extra Covered Drug” benefit. (Please see the “Extra Covered Drug Groups” section of the Benefit Chart in this booklet to find out which of the drugs listed are covered under your employer or union sponsored plan.)

1. Nonprescription drugs (or over-the-counter drugs)

2. Drugs when used to promote fertility

3. Drugs when used for the symptomatic relief of cough or colds

4. Drugs when used for treatment of anorexia, weight loss or weight gain

5. Drugs when used for cosmetic purposes or to promote hair growth

6. Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations

7. Outpatient drugs for which the manufacturer seeks to require that associated tests or monitoring services be purchased exclusively from the manufacturer as a condition of sale

8. Drugs, such as Viagra, Cialis, Levitra and Caverject, when used for the treatment of sexual or erectile dysfunction

9. Barbiturates, unless prescribed to treat epilepsy, cancer or chronic mental disorders

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Contact Information

Questions or concerns? Keep these phone numbers as a handy reference.

Empire BlueCross First Impressions Welcome Line

1-866-205-6551 TTY: 711 Monday - Friday 8 a.m. to 9 p.m. ET, except holidays

Call the First Impressions phone number for any initial questions you may have prior to your coverage start date.

Medicare

1-800-MEDICARE (1-800-633-4227) TTY/TDD 1-877-486-2048 24 hours a day, seven days a week www.medicare.gov

How to f nd i an Empire MediBlue Freedom (PPO) with Senior Rx Plus provider 1. Call The First Impressions Welcome Line number listed above.

2. Call 1-800-810-BLUE to find an Empire MediBlue Freedom (PPO) with Senior Rx Plus provider.

3. Visit the “Doctor & Hospital Finder” at www.empireblue.com to find a Blue Medicare Advantage PPO provider.

2013_RFMH_LPPO_MAPD_Non-Passive_Age-In

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Employer or Union name Group number

Please write in the name of the plan in which you want to be enrolled.

Requested effective date of coverage(__ __/__ __/__ __ __ __)(M M / D D / Y Y Y Y )Generally the effective date of enrollment will be the first of the month following the enrollment receipt date, unless a future date is requested.

Last name First name Middle initial Mr. Mrs. Ms.

Birthdate (__ __/__ __/__ __ __ __) (M M / D D / Y Y Y Y )

Sex M F

Home phone number ( )Alternate phone number ( )

Permanent residence street address (P.O. Box is not allowed)

City State ZIP code

Mailing address (only if different from your permanent residence address)

City State ZIP code

Email address

Please provide your Medicare insurance information

Please take out your red, white and blue Medicare card to complete this section.

• Please fill in these blanks so they match your Medicare card.

- OR -

• Attach a copy of your Medicare card or your letter from the Social Security Administration or the Railroad Retirement Board.

You must have Medicare Part A and Part B to join a Medicare Advantage plan.

page 1 of 4

S A M P L E O N LY

Name: ___________________________________Medicare Claim Number Sex: M F__ __ __ – __ __ – __ __ __ __ __Is Entitled To________ Effective Date_________HOSPITAL (Part A) ________________________

MEDICAL (Part B) _________________________

583430 30718MUMENMUB

NY

Empire MediBlue Freedom (PPO) with Senior Rx Plus Employer Group Health Plan Enrollment Election Form Please contact Empire BlueCross if you need information in another format, such as large print.

To enroll in Empire MediBlue Freedom (PPO) with Senior Rx Plus, please provide the following information:

Y0071_13_14981_I_029 08/07/2012

Please read and answer these important questions

1. Are you the retiree? Yes No

If “yes,” retirement date (month/date/year) _________________If “no,” name of retiree ________________________________

2. Are you covering a spouse or dependents under this employer or union plan? Yes No

If “yes,” name of spouse ____________________________________________________________________Name of dependents _____________________________________________________________________

3. Do you or your spouse work? Yes No

4. Do you have end-stage renal disease (ESRD)? Yes No

If you have had a successful kidney transplant and/or you don’t need regular dialysis anymore, please attach a note or records from your doctor showing you have had a successful kidney transplant or you don’t need dialysis; otherwise, we may need to contact you to obtain additional information.

5. Do you have other medical insurance? Yes No If “yes,” what is the name of the health plan (e.g., Aetna, Humana, Cigna)? ______________________What are the effective dates of coverage? __________________________________

6. Some individuals may have other drug coverage, including other private insurance, Workers’ Compensation, VA benefits or from state pharmaceutical assistance programs.

If “yes,” please list your other coverage and your identification (ID) number(s) for this coverage.Name of other coverage ID number for coverage_________________________________________ ________________________________________

7. Are you a resident in a long-term care facility, such as a nursing home? Yes No

If “yes,” please provide the following information:Name of institution _______________________________________________________________________Address (number and street) and phone number of institution _______________________________________________________________________________________________________________________________

This document may be available in an alternate format, such as large print. Please call the First Impressions number listed in this document for additional information.

page 2 of 4

Will you have other prescription drug coverage in addition to Empire MediBlue Freedom (PPO) with Senior Rx Plus? Yes No

Signature Today’s Date

If you are the authorized representative, you must sign above and provide the following information:

Name ___________________________________________________________________________________

Address _________________________________________________________________________________

City __________________________________________ State ___________ ZIP code ________________

Phone number ( ____ ) ____ – _________

Relationship to enrollee ______________________________________________

page 3 of 4

Please read and sign below

By completing this enrollment application, I agree to the following: Empire MediBlue Freedom (PPO) with Senior Rx Plus is a Medicare Advantage plan and has a contract with the federal government. I will need to keep my Medicare Parts A and B. I can only be in one Medicare Advantage plan at a time, and I understand that my enrollment in this plan will automatically end my enrollment in another Medicare health plan. It is my responsibility to inform Empire MediBlue Freedom (PPO) with Senior Rx Plus of any prescription drug coverage that I have or may get in the future. If my plan does not include prescription drug coverage, I understand that if I don’t have other Medicare prescription drug coverage, or creditable prescription drug coverage (as good as Medicare’s), I may have to pay a late enrollment penalty if I enroll in Medicare prescription drug coverage in the future. Enrollment in this plan is generally for the entire year. Once I enroll, I may leave this plan or make changes only at certain times of the year if an enrollment period is available (example: Annual Election Period from October 15 - December 7) or under certain special circumstances. Empire MediBlue Freedom (PPO) with Senior Rx Plus serves a specific service area. If I move out of the area that Empire MediBlue Freedom (PPO) with Senior Rx Plus serves, I need to notify the plan so I can disenroll and find a new plan in my new area. Once I am a member of Empire MediBlue Freedom (PPO) with Senior Rx Plus, I have the right to appeal plan decisions about payment or services if I disagree. I will read the Evidence of Coverage document from Empire MediBlue Freedom (PPO) with Senior Rx Plus when I get it to know which rules I must follow in order to get coverage with this Medicare Advantage plan. I understand that Medicare beneficiaries aren’t usually covered under Medicare while out of the country, except for limited coverage near the U.S. border. I understand that generally the effective date of enrollment will be the first of the month following the enrollment receipt date, unless a future date is requested. Beginning on the date Empire MediBlue Freedom (PPO) with Senior Rx Plus coverage begins, I must get all of my health care from Empire MediBlue Freedom (PPO) with Senior Rx Plus, with the exception of emergency or urgently needed services or out-of-area dialysis services. Services authorized by Empire MediBlue Freedom (PPO) with Senior Rx Plus and other services contained in my Empire MediBlue Freedom (PPO) with Senior Rx Plus Evidence of Coverage document (also known as a member contract or subscriber agreement) will be covered. Without authorization, NEITHER MEDICARE NOR Empire MediBlue Freedom (PPO) with Senior Rx Plus WILL PAY FOR THE SERVICES. Release of information: By joining this Medicare health plan, I acknowledge that Empire MediBlue Freedom (PPO) with Senior Rx Plus will release my information to Medicare and other plans as is necessary for treatment, payment and health care operations. I also acknowledge that Empire MediBlue Freedom (PPO) with Senior Rx Plus will release my information, including my prescription drug event data, to Medicare, who may release it for research and other purposes which follow all applicable federal statutes and regulations. The information on this enrollment form is correct to the best of my knowledge. I understand that if I intentionally provide false information on this form, I will be disenrolled from the plan. I understand that my signature (or the signature of the person authorized to act on my behalf under the laws of the state where I live) on this application means that I have read and understand the contents of this application. If signed by an authorized individual (as described above), this signature certifies that: 1) this person is authorized under state law to complete this enrollment and 2) documentation of this authority is available upon request from Medicare.

of 4

Office use only

Please return this application to:

Name of staff member/agent/broker (if assisted in enrollment) _____________________________________

Plan ID # _____________________________________________

Effective date of coverage _______________________________

ICEP/IEP ______ AEP ______ SEP (type) _____ Not eligible ______

30718MUMENMUB_029

Empire BlueCross

P.O. Box 110 Fond du Lac, WI 54936

Please refer to the Empire BlueCross Evidence of Coverage for a complete listing of all plan benefits, conditions, limitations, and exclusions of coverage.

Our plan has free language interpreter services available to answer questions from non-English speaking members.

Please call the First Impressions number listed in this document to request interpreter services.

Empire BlueCross is a health plan with a Medicare contract.

Services provided by Empire HealthChoice Assurance, Inc. licensee of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.

13PPOCVEGR_F

Empire BlueCross is a Health plan with a Medicare contract.Services provided by Empire HealthChoice Assurance, Inc. licensee of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. The SilverSneakers Fitness Program provided by Healthways, Inc., an independent company. SilverSneakers® is a registered mark of Healthways, Inc.

P.O. Box 110 Fond du Lac, WI 54936

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