Blue Medicare HMO � 2013 Plan Benefits

As with any Medicare Advantage plan, members may enroll only during specific times of the year. Details about when you may enroll in Medicare Advantage plans are available at medicare.gov or by calling 1-800-665-8037, 8 a.m. - 8 p.m., seven days a week. (TDD/TYY 1-800-922-3140)

Medicare Part D Plan Selector Tool
Learn about estimated costs and projected savings for your prescription drugs in the new plan year with the Plan Selector Tool.

Standard plan

Medical-only plan

Enhanced plan

Additional monthly premium^1,2

$16.40

Features

Includes basic medical benefits
Standard drug coverage included

Includes our most robust medical benefits

Includes our most robust medical benefits
Enhanced prescription drug coverage included

Provider choice

In-network benefits only
Must use a network provider

In-network benefits only
Must use a network provider

In-network benefits only
Must use a network provider

Primary care physician office visits³

$10 copayment for in-network visits only

$5 copayment for in-network visits only

$5 copayment for in-network visits only

Inpatient hospital stay per day

$195, Up to 6 days

$100, Up to 6 days

$170, Up to 6 days

Medicare prescription drug benefit

Includes our standard drug benefit
No deductible
You pay the following up to $2970 out-of-pocket

Tier 1	Preferred generics	$7
Tier 2	Non-preferred generics	$25
Tier 3	Preferred brand	$40
Tier 4	Non-preferred brand	$80
Tier 5	Specialty	33%

None

Includes our enhanced drug benefit
No deductible
You pay the following up to $2970 out-of-pocket

Tier 1	Preferred generics	$4
Tier 2	Non-preferred generics	$20
Tier 3	Preferred brand	$30
Tier 4	Non-preferred brand	$70
Tier 5	Specialty	33%

During the coverage gap

79% on all generics;
a discount on brand name drugs until your yearly out-of-pocket drug costs reach $4,750

None

$4 on all Preferred generics;
79% on all other generics;
a discount on brand name drugs until your yearly out-of-pocket drug costs reach $4,750

Catastrophic Coverage

You pay 5%
After you reach $4,750 in out-of-pocket costs, the plan pays the majority of the drug costs until the end of the year. You pay the greater of $2.65 for generic, $6.60 for brand name or 5% of the total drug cost.

None

You pay 5%
After you reach $4,750 in out-of-pocket costs, the plan pays the majority of the drug costs until the end of the year. You pay the greater of $2.65 for generic, $6.60 for brand name or 5% of the total drug cost.

For information on how to enroll as well as important information regarding enrollment, refer to our How to Enroll page.

Members may enroll in the plan only during specific times of the year. Contact BCBSNC for more information.

For a Summary of benefits, refer to the Product Brochure.

Compare Blue Medicare HMO and Blue Medicare PPO
View a side-by-side comparison of Blue Medicare HMO and Blue Medicare PPO.

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¹ As a member of the Blue Medicare HMO or Blue Medicare PPO plans, you must continue to pay the Medicare Part B premium in addition to your plan premium. Note that limitations, copayments and restrictions may apply.

² If you decide to switch to premium withhold or move from premium withhold to direct bill, it could take up to three months for the change to take effect, and you will be responsible for premiums during that time.

³ You must receive all routine care from plan providers.

The benefit information provided is a brief summary, but not a complete description of benefits. Additional information about benefits is available to assist you in making a decision about your coverage. This is an advertisement; for more information contact the plan.

For Medicare Advantage and Part D plans, benefits, formulary, pharmacy network, premium and/or co-payments/co-insurance may change on January 1 of each year. For Medicare supplement plans, the changes occur on June 1 of each year. Please contact BCBSNC for details.

BCBSNC is a Medicare Advantage organization with a Medicare contract. BCBSNC is a Medicare-approved Part D sponsor. BCBSNC does not discriminate based on race, ethnicity, national origin, religion, gender, age, mental or physical disability, health status, claims experience, medical history, genetic information, evidence of insurability or geographic location within the service area. All BCBSNC items and services are available to all eligible beneficiaries in the service area. Limitations, copayments, and restrictions may apply. You must be entitled to Medicare Part A and enrolled in Medicare Part B and must reside in CMS-approved service area. You must continue to pay your Medicare Part B premium.

If you would like Medicare Advantage or Part D documents in a different language or format, or your coverage has ended and you need proof of coverage or a Certification of Health Insurance Coverage, you can call us 7 days a week, 8 a.m. to 8 p.m.

Blue Medicare HMO:

1-888-310-4110 (TDD/TYY 1-888-451-9957)

Blue Medicare PPO:

1-877-494-7647 (TDD/TYY 1-888-451-9957)

Blue Medicare Rx (PDP):

1-888-247-4142 (TDD/TYY 1-888-247-4145)

Blue Medicare Supplement:

1-800-672-6584

The SilverSneakers program is provided by Healthways, Inc., a third-party vendor independent of BCBSNC. The program is available only to members covered under Blue Medicare HMO or Blue Medicare PPO plans. BCBSNC is not liable in any way for the services received; results are not guaranteed. Decisions regarding medical care should be made with the advice of a doctor.

The information on this page is current as of 12/10/2012.

Y0079_6085 CMS Approved 12112012