1. No category

2015
2014
Medicare Advantage
Enrollment Kit
BlueMedicare HMO
A Medicare Advantage HMO Plan
Broward County
www.BlueMedicareFL.com
Y0011_32436 0814 C: 08/2014
Table of contents
Welcome1
Benefits at a glance (includes Understanding drug payment stages)
2
Helping your Medicare dollars work for you
5
Our Provider Networks
6
Frequently asked questions
7
SUMMARY OF BENEFITS
Summary of Benefits
Multi-language Insert
MORE PLAN INFORMATION
Dental, Hearing and Vision Summary of Benefits
Silver Sneakers® Fitness Program
Chain Pharmacies PLAN ENROLLMENT
Understanding enrollment periods
Steps to an easy enrollment: Ready to enroll? Authorization to use and access Protected Health Information Form
Enrollment Checklist Scope of Sales Appointment Confirmation Form
What to Expect After You Enroll
TOCBROW (HMO BROW)
Welcome
Thank you for considering a Medicare Advantage plan through Florida Blue.
Florida Blue promotes and supports your quality of life by offering total healthcare
solutions – when, where and how you need them.
•Coverage for your medical care and prescription drugs
•Many providers to coordinate your care, even specialists when you need one
•Local experts to help you face-to-face when you need support or are ready to
make a change
We are here to provide onging support and solutions as your healthcare needs evolve.
The pursuit of wellness is a journey that everyone takes, and no matter where yours
leads, Florida Blue will be with you every step of the way.
To fully understand which plan best fits your needs be sure to...
•Review the details of each plan.
•Review the “More Plan Information” section in this booklet.
•Check that your drugs are covered and find out what your drug costs would be for an average year under each plan.
•Check that your providers are participating in our network and find out what your cost would be for an average year
under each plan.
•Compare the plans and decide which offers you the best, most affordable coverage.
Please contact us at 1-855-601-9465 for additional information. (TTY users call 1-800-955-8770). We are open from
8 a.m. - 8 p.m., 7 days a week. From February 15th to September 30th, we are open Monday - Friday 8 a.m. - 8 p.m.
Florida Blue is a PPO and RPPO Plan with a Medicare contract.Florida Blue HMO is an HMO Plan with a Medicare contract.
Enrollment in Florida Blue or Florida Blue HMO depends on contract renewal.
1
Y0011_32008 0714R1 CMS Accepted
Benefits at a Glance
BlueMedicare HMO MyTime (HMO) and BlueMedicare HMO LifeTime (HMO)
for Broward County
MyTime
LifeTime
Monthly Plan Premium
Monthly Plan Premium
$01
$01
Amount Member
Pays In-Network
Amount Member
Pays Out-of-Network
Amount Member
Pays In-Network
Amount Member
Pays Out-of-Network
Primary Care Physician
$0 Copay
Not Covered
$0 Copay
Not Covered
Specialist
$20 Copay
Not Covered
$35 Copay
Not Covered
$0 Copay
Not Covered
$0 Copay
Not Covered
Doctor Office Visits
Preventive Services
In-Network Wellness
services as defined
by Medicare
Emergency Services
Urgent Care Centers
$10 Copay
$50 Copay
Emergency Room Facility
Services (per visit)
(copayment waived
if admitted)
$50 Copay
$65 Copay
Ambulance Services
(ground, air and water travel)
$200 Copay
$250 Copay
Inpatient Services
Inpatient Hospital
Facility Services
$150 Per Day,
Days 1-6,
$0 per Day,
After Day 6
Skilled Nursing Facility
$0 Per Day,
Days 1-20
$150 Per Day,
Days 21-100
Not Covered
$285 Per Day,
Days 1-6,
$0 per Day,
After Day 6
Not Covered
Not Covered
$0 Per Day,
Days 1-20
$150 Per Day,
Days 21-100
Not Covered
2
MyTime
LifeTime
Amount Member
Pays In-Network
Amount Member
Pays Out-of-Network
Amount Member
Pays In-Network
Amount Member
Pays Out-of-Network
Home Health Care
$0 Copay
Not Covered
$0 Copay
Not Covered
Independent Clinical Lab
(Blood Work)
$0 Copay
Not Covered
$0 Copay
Not Covered
Independent Diagnostic
Testing Facility Services*
$10 Copay
Not Covered
$50 Copay
Not Covered
Ambulatory Surgical
Center Facility (ASC)
$195 Copay
Not Covered
$250 Copay
Not Covered
Amount Member
Pays Preferred
Pharmacy
Amount Member Pays
Non-Preferred
Pharmacy
Outpatient Services
Part D Prescription Drugs
Deductible
(applies to all drug Tiers)
Amount Member Amount Member Pays
Pays Preferred
Non-Preferred
Pharmacy
Pharmacy
$0
$0
Preferred Generics
$0 Copay
$5 Copay
$2 Copay
$7 Copay
Preferred Brands
$35 Copay
$40 Copay
$40 Copay
$45 Copay
Specialty Drugs
33% Coinsurance
33% Coinsurance
Gap Coverage
Tiers 1, 2 and 5 Generic
Coverage through the Gap
Tiers 1, 2 and 5 Generic
Coverage through the Gap
Out-of-Pocket Maximum
Amount Member Pays In-Network
Amount Member Pays In-Network
Out-of-Pocket Maximum
(does not include Part D costs)
$3,650
$4,400
Additional Benefits
Dental
See “More Plan Information” section for details
Hearing
See “More Plan Information” section for details
Vision
See “More Plan Information” section for details
SilverSneakers® 2
Fitness Program
See “More Plan Information” section for details
3
Benefits at a Glance
Understanding drug payment stages.
INITIAL COVERAGE
STAGE
COVERAGE GAP
STAGE
CATASTROPHIC
COVERAGE STAGE
$0 to $2,960
$2,961 to $4,700
Through end of year
During this stage you pay a flat fee
(copay) or a percentage of a drug’s
total cost (coinsurance) for each
prescription you fill.
During this stage you pay 45% of
negotiated drug costs for brand name
drugs. For generic drugs you pay a flat fee
(copay) for each prescription you fill.
In this stage you pay only a small
copay or coinsurance amount for
each filled prescription.
The plan pays the rest until your
total drug costs (paid by you and
the plan) reach $2,960.
Once your out-of pocket costs
reach $4,700, you move to
catastrophic coverage.
The plan and Medicare pay
the rest until the end of the
calendar year.
Please contact us at 1-855-601-9465 for additional information. (TTY users call 1-800-955-8770). We are open
from 8 a.m. - 8 p.m., 7 days a week. From February 15th to September 30th, we are open Monday - Friday 8 a.m. - 8 p.m.
Florida Blue HMO is an HMO Plan with a Medicare contract. Enrollment in Florida Blue HMO depends on contract renewal.
*Except for Advanced Imaging Services.
You must continue to pay your Medicare Part B premium.
The SilverSneakers Fitness Program is provided by Healthways, Inc., an independent company. SilverSneakers is a
registered mark of Healthways, Inc.
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, formulary, pharmacy network, premium and/or
copayments/co-insurance may change on January 1 of each year.
1
2
4
Y0011_32449 0714R1 CMS Accepted
Helping your Medicare dollars work for you
USE PREFERRRED PHARMACIES
You can lower your out-of-pocket costs by purchasing your prescriptions at one of our preferred pharmacies listed below.
•CVS
•Navarro
•Publix
•Target
•Walgreens
CHOOSE GENERIC OR LOWER TIER DRUGS
B y choosing generic drugs you can reduce the amount you pay at the pharmacy. New generic drugs are available every day.
Check with your doctor to see if any of your drugs may be available as a generic.
Many drugs in Tier 1 and Tier 2 (most generic drugs) may work just as well for your condition as drugs in Tier 3 and Tier 4.
Check with your doctor to see if a lower-tier drug could work for you.
Please contact us at 1-855-601-9465 for additional information. (TTY users call 1-800-955-8770). We are open from
8 a.m. - 8 p.m., 7 days a week. From February 15th to September 30th, we are open Monday - Friday 8 a.m. - 8 p.m.
Florida Blue is an Rx (PDP) plan with a Medicare contract. Florida Blue HMO is an HMO plan with a Medicare contract.
Enrollment in Florida Blue or Florida Blue HMO depends on contract renewal.
5
Y0011_32029 0714R1 CMS Accepted
Our Provider Networks
MEDICARE PROVIDER ACCESS
Medicare Part A (hospital) and Part B (doctor) coverage is the same throughout the United
States so it doesn’t matter where you live. Medicare Part C coverage (which includes Parts A
and B combined) is offered by private companies through Medicare Advantage plans, which
have service areas. These are usually counties, states or regions where a plan offers coverage.
Generally, you must live in a plan’s service area in order to join it. However, all Medicare Advantage plans must offer nationwide coverage for emergency and urgent care.
FLORIDA BLUE HMO’S STRONG NETWORKS OFFER MORE CHOICES
Providing access to doctors you trust is something we value at Florida Blue HMO. We have robust
networks that allow more of our members to see the doctor of their choice.
It is important that you understand how the providers you choose to use for medical care will
affect how much you have to pay for medical services. Under our BlueMedicare Advantage HMO
plan, most services must be rendered by in-network providers in order to be covered. This is true
even when the care you receive is medically necessary (except in the case of emergency services,
urgent care services and kidney dialysis services you receive while temporarily outside the plan’s
service area).
PRIMARY CARE PHYSICIANS (PCP)
The first and most important decision you must make when applying for this Medicare Advantage
HMO plan is the selection of a PCP. PCPs are typically general, family or internal medicine doctors. This decision is important since all covered services, particularly those of most Specialists,
must be coordinated through the PCP you select. If a PCP is not indicated on your application,
Florida Blue HMO will assign one for you.
FINDING A PARTICIPATING PROVIDER
To get the most up-to-date information about BlueMedicare network providers in your area, you can
visit
www.BlueMedicareFL.com or call our Customer Service Department. See contact information
below.
Please contact us at 1-855-601-9465 for additional information. (TTY users call 1-800-955-8770). We
are open from
8 a.m. - 8 p.m., 7 days a week. From February 15th to September 30th, we are open Monday - Friday 8 a.m. - 8 p.m.
Florida Blue HMO is an HMO Plan with a Medicare contract. Enrollment in Florida Blue HMO depends on contract renewal.
6
Y0011_31988 0714R2 CMS Accepted
?
Frequently asked questions
Q: Does Original Medicare cover all of my health care needs?
A: Very few things are covered 100% by Original Medicare. Your out-of-pocket costs for things like deductibles, coinsurance
and copays can add up. While no plan provides 100% coverage for everything, Medicare Advantage plans help you pay less
out-of-pocket costs and may provide the coverage and protection you want.
Q: If I enroll in a Medicare Advantage plan, will I lose my Original Medicare coverage?
A: N
o. With a Medicare Advantage plan, you’re still in the Medicare Program. However, your Medicare Advantage plan will pay
your hospital and doctor (Parts A and B) expenses instead of Original Medicare. In other words, your Medicare Advantage
plan will REPLACE your Original Medicare coverage. You’ll still pay your Medicare Part B premium, if you have one.
Q: What is included in a Medicare Advantage plan?
A: While each Medicare Advantage plan differs from another, one of the best features of a
Medicare Advantage plan is that it combines doctor and hospital coverage that may include prescription drug coverage all
in one convenient plan.
Q: Am I covered if I leave the country?
A: You never need prior authorization for emergency and urgently needed services. No matter where you are in the world,
you’ll be covered for these services. (Please see your plan for additional benefit information.) Prescription drugs obtained
out of the country are not covered under your Medicare Advantage plan.
Q: Am I covered when I am traveling out of state?
A: With Medicare Advantage PPO plans you always have the option of seeing an out-of-network provider, usually at a higher
cost. Our Medicare Advantage PPO plans also offer a Visitor/Traveler benefit allowing members to enjoy greater access to
in-network benefits when traveling outside the state of Florida.
With Medicare Advantage HMO plans you can only see out-of-network providers for emergency, urgent care or kidney
dialysis services outside the plan service area.
Q: What happens if I join a Medicare Advantage plan and then I move? Can I take my plan with me?
A: That depends on where you’re moving. If you’re moving within the service area of your current plan, you can keep the plan.
If you’re moving outside of your plan’s service area, you’ll need to look at your options. You may choose a new Medicare
Advantage plan that serves the area where you are moving. Or you may return to Original Medicare Part A and Part B (with
an optional stand-alone prescription drug plan and/or Medicare supplement policy). If you move or are planning to move,
contact Member Services to find out if your new home is in your plan’s service area and to discuss your options.
Q: I ’m looking at a Medicare Advantage plan, but I don’t know if my doctors belong to its network. How do I
find out?
A: To find out if your doctors are included in a plan’s network, call the plan’s Customer Service number or check the plan’s
website.
7
Y0011_32011 0714R1 C: 07/2014
Q: What if I have trouble paying for prescriptions?
A: If you find you need help and your yearly income and resources are below certain limits, you can apply for Extra Help
from Medicare. This program is also called the “low-income subsidy,” or LIS. To see if you qualify for Extra Help, you
can call 1-800-MEDICARE (1-800-633-4227), TTY 1-877-486-2048, 24 hours a day, 7 days a week; or the Social Security
Office at 1-800-772-1213, TTY 1-800-325-0778, 7 a.m. – 7 p.m., Monday – Friday, or your State Medicaid Office.
Q: Can a network doctor charge me more than the copay amount?
A: No. At Florida Blue we continue to find new ways to provide our members with affordable and quality health
plans. Part of this comes from us negotiating with doctors to set standard copays. Your network doctor can’t ask
you to pay more than the plan’s cost-sharing amount. If you have any questions, please contact a Customer Service
representative.
Q: What is the difference between Medicare Advantage and Medicare supplement —
sometimes referred to as Medigap — plans?
A: M
edicare Advantage plans are health plans that replace Original Medicare Parts A and B benefits by including those
benefits within their plans. Medicare supplement (Medigap) plans provide financial assistance with out-of-pocket expenses
and generally supplement the 20% cost gap of what Original Medicare pays (80%).
Q: What is a Late Enrollment Penalty (LEP) and how does it work if I have a $0 premium plan?
A: S ome members are required to pay an LEP because they did not join a Medicare prescription drug plan when they first
became eligible or because they had a continuous period of 63 days or more without “creditable” prescription drug
coverage. (“Creditable” means the drug coverage is at least as good as Medicare Part D’s standard drug coverage.) For these
members, the Centers for Medicare & Medicaid Services (CMS) advise the plan to bill the designated LEP amount in
addition to the member’s monthly plan premium. For members enrolled in a $0 monthly premium plan, they are still
responsible for paying the LEP, if applicable.
Q: What is a Formulary and where can I view a copy?
A: A formulary is the list of medications covered by a plan, based on Medicare’s guidelines. The formulary is also referred to
as the medication list, drug list or medication guide. Our formulary is online at BlueMedicareFL.com or you can visit
myprime.com.
Q: What is Step Therapy and how does it affect me getting my prescription filled?
A: S tep therapy requires that you try an equally effective drug or drugs on the formulary before the plan will cover the
prescribed drug. For example, if Drug A and Drug B treat the same medical condition, the plan may require you to try Drug
A first. If Drug A does not work for you, the plan may then cover Drug B.
Q: What is the Transition Process? How does it work?
A: If you are within the first 90 days of enrollment in a Florida Blue plan, or a current enrollee and the formulary changes from
one contract year to the next, Florida Blue will automatically provide a temporary transition fill of a non-formulary drug you
are currently taking. This provides time for you to work with your doctor to change to a drug listed on the formulary or request
a formulary exception (including Part D drugs that are on the formulary but require prior authorization or step therapy).
This 90-day timeframe applies to retail, home infusion, long-term care (LTC) and mail-order pharmacies.
In the outpatient retail setting the transition supply is a one-time, 30-day supply of medication, unless the
prescription is written for less than 30 days. For a new enrollee in an LTC facility, the transition supply may be for up
to 31 days (unless the prescription is written for less than 31 days) with multiple fills as necessary during the entire
length of the 90-day transition period.
8
Frequently asked questions
It is important that you understand that this is a temporary transition supply of the drug. Before this supply ends, you
should speak to your doctor about prescribing an alternative that is on the formulary or about requesting an exception to
continue coverage of this drug.
Q: What is the Formulary Exception Process? How does it work?
A: Asking for coverage of a drug that is not on the covered drug list is sometimes called asking for a “formulary exception.”
If a plan agrees to make an exception and cover a drug that is not on the drug list, you will be required to pay the cost-sharing amount that applies to drugs in the highest copay tier for brand or generic drugs.
Q: What is a Scope of Appointment (SOA) form and why am I being asked to complete the form?
A: C MS requires beneficiaries (or their authorized representative) to complete an SOA form, prior to any face-to-face meeting,
that documents the scope of Medicare Advantage and/or Part D products they wish to discuss during the meeting. Agents
are required to only discuss the products that have been selected on the SOA form. The SOA form is intended to protect the
Medicare beneficiary. Completing this form does not constitute enrollment in the plan.
Q: What is a Star Rating? Why is it important?
A: Medicare evaluates plans based on a 5-Star rating system. A Star Rating is a quality rating assigned by CMS to
every Medicare Advantage and Part D plan based on multiple categories that are summarized into an overall plan
rating. The Star Rating along with cost and coverage information is designed to help you compare plans and find a
plan that’s best for you. Star Ratings are calculated each year and may change from one year to the next. For more
information on Star Ratings, you can:
• Visit Medicare.gov/find-a-plan. Enter the appropriate information for a general or personalized search. Once you see the
list of plans, you can view the Star Ratings by selecting the plan name. Or, you can select up to 3 plans to compare.
• Call 1-800-MEDICARE (1-800-633-4227), 24 hours a day/7 days a week. TTY users should call 1-877-486-2048.
Please contact us at 1-855-601-9465 for additional information. (TTY users call 1-800-955-8770). We are open from
8 a.m. - 8 p.m., 7 days a week. From February 15th to September 30th, we are open Monday - Friday 8 a.m. - 8 p.m.
The benefit information provided is a brief summary, not a complete description of benefits. Benefits may change on
January 1 of each year.
Florida Blue is a PPO, RPPO and Rx (PDP) Plan with a Medicare contract. Florida Blue HMO is an HMO Plan with a Medicare
contract. Enrollment in Florida Blue or Florida Blue HMO depends on contract renewal.
9
2015
Summary of
benefits
NOTES
2015
Summary of
benefits
BlueMedicareSM HMO
A Medicare Advantage HMO Plan
Broward
Y0011_32457 0814 CMS Accepted
BlueMedicare HMO MyTime (HMO) and BlueMedicare HMO LifeTime
(HMO)
Summary of Benefits
January 1, 2015 - December 31, 2015
This booklet gives you a summary of what we cover and what you pay. It doesn't list every service that
we cover or list every limitation or exclusion.
Section 1 - Introduction to Summary of Benefits
You have choices about how to get your Medicare benefits
One choice is to get your Medicare benefits through Original Medicare (fee-for-service Medicare).
Original Medicare is run directly by the Federal government.
Another choice is to get your Medicare benefits by joining a Medicare health plan (such as BlueMedicare
HMO PrimeTime or BlueMedicare HMO LifeTime).
Tips for comparing your Medicare choices
This Summary of Benefits booklet gives you a summary of what BlueMedicare HMO MyTime and
BlueMedicare HMO LifeTime cover and what you pay.
If you want to compare our plan with other Medicare health plans, ask the other plans for their Summary
of Benefits booklets. Or, use the Medicare Plan Finder on http://www.medicare.gov.
If you want to know more about the coverage and costs of Original Medicare, look in your current
"Medicare & You" handbook. View it online at http://www.medicare.gov or get a copy by calling
1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call
1-877-486-2048.
Sections in this booklet
Things to Know About BlueMedicare HMO MyTime and BlueMedicare HMO LifeTime
Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services
Covered Medical and Hospital Benefits
Prescription Drug Benefits
This document is available in other formats such as Braille and large print.
This document may be available in a non-English language. For additional information, call us at
1-800-926-6565.
Este documento puede estar disponible en otros idiomas que además del inglés. Para información adicional,
llámenos al 1-800-926-6565.
Things to Know About BlueMedicare HMO MyTime and BlueMedicare HMO LifeTime
Hours of Operation
From October 1 to February 14, you can call us 7 days a week from 8:00 a.m. to 8:00 p.m. Local time.
From February 15 to September 30, you can call us Monday through Friday from 8:00 a.m. to 8:00 p.m.
Local time.
1
BlueMedicare HMO MyTime and BlueMedicare HMO LifeTime Phone Numbers and
Website
If you are a member of this plan, call toll-free 1-800-926-6565.
If you are not a member of this plan, call toll-free 1-855-601-9465.
Our website: BlueMedicareFL.com
Who can join?
To join BlueMedicare HMO PrimeTime or BlueMedicare HMO LifeTime, you must be entitled to Medicare
Part A, be enrolled in Medicare Part B, and live in our service area.
Our service area for BlueMedicare HMO MyTime includes the following county in Florida: Broward.
Our service area for BlueMedicare HMO LifeTime includes the following counties in Florida: Alachua,
Bay , Brevard, Broward, Charlotte, Citrus, Clay, Collier, Duval, Escambia, Hernando, Hillsborough, Lake,
Lee, Manatee, Marion, Martin, Nassau, Okaloosa, Orange, Osceola, Pasco, Polk, Santa Rosa, Sarasota,
Seminole, St. Johns, St. Lucie, and Sumter.
Which doctors, hospitals, and pharmacies can I use?
BlueMedicare HMO MyTime and BlueMedicare HMO LifeTime have a network of doctors, hospitals,
pharmacies, and other providers. If you use the providers that are not in our network, the plan may not pay
for these services.
You must generally use network pharmacies to fill your prescriptions for covered Part D drugs.
Some of our network pharmacies have preferred cost-sharing. You may pay less if you use these pharmacies.
You can see our plan's provider directory at our website (http://www.BlueMedicareFL.com).
You can see our plan's pharmacy directory at our website (http://www.myprime.com).
Or, call us and we will send you a copy of the provider and pharmacy directories.
What do we cover?
Like all Medicare health plans, we cover everything that Original Medicare covers - and more.
Our plan members get all of the benefits covered by Original Medicare. For some of these benefits,
you may pay more in our plan than you would in Original Medicare. For others, you may pay less.
Our plan members also get more than what is covered by Original Medicare. Some of the extra
benefits are outlined in this booklet.
We cover Part D drugs. In addition, we cover Part B drugs such as chemotherapy and some drugs
administered by your provider.
You can see the complete plan formulary (list of Part D prescription drugs) and any restrictions on our
website, MyPrime.com.
Or, call us and we will send you a copy of the formulary.
How will I determine my drug costs?
Our plan groups each medication into one of five "tiers." You will need to use your formulary to locate
what tier your drug is on to determine how much it will cost you. The amount you pay depends on the
2
drug's tier and what stage of the benefit you have reached. Later in this document we discuss the benefit
stages that occur: Initial Coverage, Coverage Gap, and Catastrophic Coverage.
3
If you have any questions about this plan’s benefits or costs, please contact Florida Blue HMO for details.
Section 2 - Summary of Benefits
BlueMedicare HMO MyTime
BlueMedicare HMO LifeTime
MONTHLY PREMIUM, DEDUCTIBLE, AND LIMITS ON HOW MUCH YOU PAY FOR COVERED
SERVICES
How much is
the monthly
premium?
$0 per month. In addition, you must keep
paying your Medicare Part B premium.
$0 per month. In addition, you must keep
paying your Medicare Part B premium.
How much is
the
deductible?
This plan does not have a deductible.
This plan does not have a deductible.
Is there any
limit on how
much I will
pay for my
covered
services?
Yes. Like all Medicare health plans, our plan
protects you by having yearly limits on your
out-of-pocket costs for medical and hospital
care.
Yes. Like all Medicare health plans, our plan
protects you by having yearly limits on your
out-of-pocket costs for medical and hospital
care.
Your yearly limit(s) in this plan:
Your yearly limit(s) in this plan:
$3,650 for services you receive from
in-network providers.
If you reach the limit on out-of-pocket costs,
you keep getting covered hospital and medical
services and we will pay the full cost for the
rest of the year.
$4,400 for services you receive from
in-network providers.
If you reach the limit on out-of-pocket costs,
you keep getting covered hospital and medical
services and we will pay the full cost for the
rest of the year.
Please note that you will still need to pay your
monthly premiums and cost-sharing for your
Part D prescription drugs.
Please note that you will still need to pay your
monthly premiums and cost-sharing for your
Part D prescription drugs.
Our plan has a coverage limit every year for
certain in-network benefits. Contact us for the
services that apply.
Our plan has a coverage limit every year for
certain in-network benefits. Contact us for the
services that apply.
Is there a limit
on how much
the plan will
pay?
Florida Blue HMO is an HMO plan with a Medicare contract. Enrollment in Florida Blue HMO depends on
contract renewal.
COVERED MEDICAL AND HOSPITAL BENEFITS
NOTE:
SERVICES WITH A 1 MAY REQUIRE PRIOR AUTHORIZATION.
SERVICES WITH A 2 MAY REQUIRE A REFERRAL FROM YOUR DOCTOR.
4
BlueMedicare HMO MyTime
BlueMedicare HMO LifeTime
OUTPATIENT CARE AND SERVICES
Acupuncture
and Other
Alternative
Therapies
Not covered
Not covered
Ambulance 1
$200 copay
$250 copay
Except for emergency care, prior authorization
is required for ambulance services.
Except for emergency care, prior authorization
is required for ambulance services.
Chiropractic
Care
Manipulation of the spine to correct a
subluxation (when 1 or more of the bones of
your spine move out of position): $0 - $20
copay, depending on the service
Manipulation of the spine to correct a
subluxation (when 1 or more of the bones of
your spine move out of position): $0 - $20
copay, depending on the service
Dental
Services
Limited dental services (this does not include
services in connection with care, treatment,
filling, removal, or replacement of teeth): $20
copay
Limited dental services (this does not include
services in connection with care, treatment,
filling, removal, or replacement of teeth): $35
copay
Preventive dental services:
Preventive dental services:
Cleaning (for up to 1 every year): You pay
nothing
Dental x-ray(s) (for up to 1): You pay
nothing
Oral exam (for up to 2 every year): You
pay nothing
Please see the Dental Benefit Schedule for
more detailed information.
Cleaning (for up to 1 every year): You pay
nothing
Dental x-ray(s) (for up to 1): You pay
nothing
Oral exam (for up to 2 every year): You
pay nothing
Please see the Dental Benefit Schedule for
more detailed information.
Diabetes monitoring supplies: You pay
nothing
Diabetes monitoring supplies: You pay
nothing
Diabetes self-management training: You pay
nothing
Diabetes self-management training: You pay
nothing
Therapeutic shoes or inserts: You pay nothing
Therapeutic shoes or inserts: You pay nothing
Diagnostic radiology services (such as MRIs,
CT scans): $50 - $250 copay, depending on
the service
Diagnostic radiology services (such as MRIs,
CT scans): $150 - $295 copay, depending on
the service
Diabetes
Supplies and
Services
Diagnostic
Tests, Lab and
Radiology
5
BlueMedicare HMO MyTime
Services, and
X-Rays1,2
Doctor's Office
Visits2
Durable
Medical
Equipment
(wheelchairs,
oxygen, etc.)1
Emergency
Care
BlueMedicare HMO LifeTime
Diagnostic tests and procedures: $0 - $20
copay, depending on the service
Diagnostic tests and procedures: $0 - $50
copay, depending on the service
Lab services: You pay nothing
Lab services: You pay nothing
Outpatient x-rays: $0 - $250 copay, depending
on the service
Outpatient x-rays: $0 - $295 copay, depending
on the service
Therapeutic radiology services (such as
radiation treatment for cancer): $20 copay or
20% of the cost, depending on the service
Therapeutic radiology services (such as
radiation treatment for cancer): $35 copay or
20% of the cost, depending on the service
Prior authorization may be required for certain
services.
Prior authorization may be required for certain
services.
Primary care physician visit: You pay nothing
Primary care physician visit: You pay nothing
Specialist visit: $20 copay
Specialist visit: $35 copay
0 - 20% of the cost, depending on the
equipment
0 - 20% of the cost, depending on the
equipment
Prior authorization will be required for certain
services.
Prior authorization will be required for certain
services.
20% coinsurance for plan-approved
motorized wheelchairs and electric
scooters
0% coinsurance for all other plan-approved
Durable Medical Equipment
20% coinsurance for plan-approved
motorized wheelchairs and electric
scooters
0% coinsurance for all other
plan-approved durable medical equipment
$50 copay
$65 copay
If you are immediately admitted to the
hospital, you do not have to pay your share
of the cost for emergency care. See the
"Inpatient Hospital Care" section of this
booklet for other costs.
If you are immediately admitted to the
hospital, you do not have to pay your share
of the cost for emergency care. See the
"Inpatient Hospital Care" section of this
booklet for other costs.
Before leaving the United States, you are
encouraged to call Florida Blue to understand
what emergency benefits are covered outside
of the US. You should call the BlueCard
Worldwide Service Center at
1-800-810-BLUE (follow prompts for
international provider), or collect at
1-804-673-1177.
Before leaving the United States, you are
encouraged to call Florida Blue to understand
what emergency benefits are covered outside
of the US. You should call the BlueCard
Worldwide Service Center at
1-800-810-BLUE (follow prompts for
international provider), or collect at
1-804-673-1177.
6
BlueMedicare HMO MyTime
Foot Care
(podiatry
services)
Hearing
Services2
Home Health
Care1
Mental Health
Care1
BlueMedicare HMO LifeTime
Foot exams and treatment if you have
diabetes-related nerve damage and/or meet
certain conditions: $20 copay
Foot exams and treatment if you have
diabetes-related nerve damage and/or meet
certain conditions: $35 copay
Routine foot care (for up to 6 visit(s) every
year): $20 copay
Routine foot care (for up to 6 visit(s) every
year): $35 copay
Exam to diagnose and treat hearing and
balance issues: $20 copay
Exam to diagnose and treat hearing and
balance issues: $35 copay
Routine hearing exam (for up to 1 every year):
You pay nothing
Routine hearing exam (for up to 1 every year):
You pay nothing
Hearing aid fitting/evaluation (for up to 1
every year): You pay nothing
Hearing aid fitting/evaluation (for up to 1
every year): You pay nothing
Hearing aid: You pay nothing
Hearing aid: You pay nothing
Our plan pays up to $1,000 every three years
for hearing aids.
Our plan pays up to $1,000 every three years
for hearing aids.
Please see the Hearing Benefit Schedule for
more detailed information.
Please see the Hearing Benefit Schedule for
more detailed information.
You pay nothing.
You pay nothing.
Home Health Agency can submit request
directly to receive authorization.
Home Health Agency can submit request
directly to receive authorization.
Inpatient visit:
Inpatient visit:
Our plan covers up to 190 days in a lifetime
for inpatient mental health care in a
psychiatric hospital. The inpatient hospital
care limit does not apply to inpatient mental
services provided in a general hospital.
Our plan covers up to 190 days in a lifetime
for inpatient mental health care in a
psychiatric hospital. The inpatient hospital
care limit does not apply to inpatient mental
services provided in a general hospital.
Our plan covers 90 days for an inpatient
hospital stay.
Our plan covers 90 days for an inpatient
hospital stay.
Our plan also covers 60 "lifetime reserve
days." These are "extra" days that we cover.
If your hospital stay is longer than 90 days,
you can use these extra days. But once you
have used up these extra 60 days, your
inpatient hospital coverage will be limited to
90 days.
Our plan also covers 60 "lifetime reserve
days." These are "extra" days that we cover.
If your hospital stay is longer than 90 days,
you can use these extra days. But once you
have used up these extra 60 days, your
inpatient hospital coverage will be limited to
90 days.
7
BlueMedicare HMO MyTime
BlueMedicare HMO LifeTime
$150 copay per day for days 1 through 6
You pay nothing per day for days 7
through 90
Outpatient group therapy visit: $25 copay
$295 copay per day for days 1 through 5
You pay nothing per day for days 6
through 90
Outpatient group therapy visit: $40 copay
Outpatient individual therapy visit: $25 copay
Outpatient individual therapy visit: $40 copay
All mental health services are coordinated
through an external vendor. Call
1-866-287-9569 (TTY: 1-800-955-8770) or
contact Member Services for more
information.
All mental health services are coordinated
through an associated vendor. Call
1-866-287-9569 (TTY: 1-800-955-8770) or
contact Member Services for more
information.
Cardiac (heart) rehab services (for a maximum
of 2 one-hour sessions per day for up to 36
sessions up to 36 weeks): $20 - $50 copay,
depending on the service
Cardiac (heart) rehab services (for a maximum
of 2 one-hour sessions per day for up to 36
sessions up to 36 weeks): $35 - $100 copay,
depending on the service
Occupational therapy visit: $20 copay
Occupational therapy visit: $35 copay
Physical therapy and speech and language
therapy visit: $20 copay
Physical therapy and speech and language
therapy visit: $35 copay
Prior authorization will be required for certain
therapy services.
Prior authorization will be required for certain
services.
Outpatient
Substance
Abuse1
Group therapy visit: $25 copay
Group therapy visit: $40 copay
Individual therapy visit: $25 copay
Individual therapy visit: $40 copay
Prior authorization will be required for certain
services. Member an submit request directly
to receive prior authorization.
Prior authorization will be required for certain
services. Member can submit request directly
to receive prior authorization.
Outpatient
Surgery1
Ambulatory surgical center: $195 copay
Ambulatory surgical center: $250 copay
Outpatient hospital: $10 - $250 copay or 20%
of the cost, depending on the service
Outpatient hospital: $35 - $295 copay or 20%
of the cost, depending on the service
Over-theCounter Items
Not Covered
Not Covered
Prosthetic
Devices
(braces,
Prosthetic devices: 20% of the cost
Prosthetic devices: 20% of the cost
Related medical supplies: 20% of the cost
Related medical supplies: 20% of the cost
Mental Health
Care1
(continued)
Outpatient
Rehabilitation1,2
8
BlueMedicare HMO MyTime
BlueMedicare HMO LifeTime
artificial limbs,
etc.)1
Prior authorization will be required for select
items. Orthotics are included in this category.
Prior authorization will be required for select
items. Orthotics are included in this category.
Renal Dialysis1
20% of the cost
20% of the cost
Transportation
Not covered
Not covered
Urgent Care
$5 - $10 copay, depending on the service
$10 - $50 copay, depending on the service.
$5 copay at Convenient Care Centers.
Convenient Care Centers are walk-in
healthcare clinics that specialize in the
treatment of common illnesses and provide
basic health screening service. $10 copay at
an Urgent Care Center.
$10 copay at Convenient Care Centers.
Convenient Care Centers are walk-in
healthcare clinics that specialize in the
treatment of common illnesses and provide
basic health screening service. $50 copay at
an Urgent Care Center.
Exam to diagnose and treat diseases and
conditions of the eye (including yearly
glaucoma screening): $0 - $20 copay,
depending on the service
Exam to diagnose and treat diseases and
conditions of the eye (including yearly
glaucoma screening): $0 - $35 copay,
depending on the service
Routine eye exam (for up to 1 every year):
You pay nothing
Routine eye exam (for up to 1 every year):
You pay nothing
Contact lenses (for up to 1 every two years):
You pay nothing
Contact lenses (for up to 1 every two years):
You pay nothing
Our plan pays up to $100 every two years for
contact lenses.
Our plan pays up to $100 every two years for
contact lenses.
Eyeglasses frames (for up to 1 every two
years): $40 copay
Eyeglasses frames (for up to 1 every two
years): $40 copay
Our plan pays up to $100 every two years for
eyeglass frames.
Our plan pays up to $100 every two years for
eyeglass frames.
Eyeglasses lenses (for up to 1 every two
years): $65 copay
Eyeglasses lenses (for up to 1 every two
years): $65 copay
Eyeglasses or contact lenses after cataract
surgery: You pay nothing
Eyeglasses or contact lenses after cataract
surgery: You pay nothing
In-Network: You pay nothing for diabetic
retinal eye exam.
In-Network: You pay nothing for diabetic
retinal eye exam.
Please see the Vision Benefit Schedule for
more detailed information.
Please see the Vision Benefit Schedule for
more detailed information.
Vision
Services1,2
9
BlueMedicare HMO MyTime
Preventive
Care
Hospice
BlueMedicare HMO LifeTime
You pay nothing
You pay nothing
Our plan covers many preventive services,
including:
Our plan covers many preventive services,
including:
Abdominal aortic aneurysm screening
Alcohol misuse counseling
Bone mass measurement
Breast cancer screening (mammogram)
Cardiovascular disease (behavioral
therapy)
Cardiovascular screenings
Cervical and vaginal cancer screening
Colonoscopy
Colorectal cancer screenings
Depression screening
Diabetes screenings
Fecal occult blood test
Flexible sigmoidoscopy
HIV screening
Medical nutrition therapy services
Obesity screening and counseling
Prostate cancer screenings (PSA)
Sexually transmitted infections screening
and counseling
Tobacco use cessation counseling
(counseling for people with no sign of
tobacco-related disease)
Vaccines, including Flu shots, Hepatitis B
shots, Pneumococcal shots
"Welcome to Medicare" preventive visit
(one-time)
Yearly "Wellness" visit
Any additional preventive services approved
by Medicare during the contract year will be
covered.
Abdominal aortic aneurysm screening
Alcohol misuse counseling
Bone mass measurement
Breast cancer screening (mammogram)
Cardiovascular disease (behavioral
therapy)
Cardiovascular screenings
Cervical and vaginal cancer screening
Colonoscopy
Colorectal cancer screenings
Depression screening
Diabetes screenings
Fecal occult blood test
Flexible sigmoidoscopy
HIV screening
Medical nutrition therapy services
Obesity screening and counseling
Prostate cancer screenings (PSA)
Sexually transmitted infections screening
and counseling
Tobacco use cessation counseling
(counseling for people with no sign of
tobacco-related disease)
Vaccines, including Flu shots, Hepatitis B
shots, Pneumococcal shots
"Welcome to Medicare" preventive visit
(one-time)
Yearly "Wellness" visit
Any additional preventive services approved
by Medicare during the contract year will be
covered.
You pay nothing for hospice care from a
Medicare-certified hospice. You may have to
pay part of the cost for drugs and respite care.
You pay nothing for hospice care from a
Medicare-certified hospice. You may have to
pay part of the cost for drugs and respite care.
10
BlueMedicare HMO MyTime
BlueMedicare HMO LifeTime
Our plan covers an unlimited number of days
for an inpatient hospital stay.
Our plan covers an unlimited number of days
for an inpatient hospital stay.
$150 copay per day for days 1 through 6
You pay nothing per day for days 7
through 90
You pay nothing per day for days 91 and
beyond
Hospital can submit request directly to receive
authorization.
$285 copay per day for days 1 through 6
You pay nothing per day for days 7
through 90
You pay nothing per day for days 91 and
beyond
Hospital can submit request directly to receive
authorization.
Inpatient
Mental Health
Care
For inpatient mental health care, see the
"Mental Health Care" section of this booklet.
For inpatient mental health care, see the
"Mental Health Care" section of this booklet.
Hospital can submit request directly to receive
authorization. All inpatient mental health
services are coordinated through an external
vendor. Call 1-866-287-9569 (TTY:
1-800-955-8770) or contact Member Services
for more information.
Hospital can submit request directly to receive
authorization.All inpatient mental health
services are coordinated through an associated
vendor. Call 1-866-287-9569 (TTY:
1-800-955-8770) or contact Member Services
for more information.
Skilled
Nursing
Facility (SNF)1
Our plan covers up to 100 days in a SNF.
Our plan covers up to 100 days in a SNF.
You pay nothing per day for days 1
through 20
$150 copay per day for days 21 through
100
Facility can submit request directly to receive
authorization.
You pay nothing per day for days 1
through 20
$150 copay per day for days 21 through
100
Facility can submit request directly to receive
authorization.
INPATIENT CARE
Inpatient
Hospital Care1
PRESCRIPTION DRUG BENEFITS
How much do
I pay?
Initial
Coverage
For Part B drugs such as chemotherapy drugs1:
20% of the cost
For Part B drugs such as chemotherapy drugs1:
20% of the cost
Other Part B drugs1: $5 copay or 20% of the
cost depending on the drug
Other Part B drugs1: $5 copay or 20% of the
cost depending on the drug
You pay the following until your total yearly
drug costs reach $2,960. Total yearly drug
costs are the total drug costs paid by both you
and our Part D plan.
You pay the following until your total yearly
drug costs reach $2,960. Total yearly drug
costs are the total drug costs paid by both you
and our Part D plan.
11
BlueMedicare HMO MyTime
Initial
Coverage
(continued)
BlueMedicare HMO LifeTime
You may get your drugs at network retail
pharmacies and mail order pharmacies.
You may get your drugs at network retail
pharmacies and mail order pharmacies.
Preferred Retail Cost-Sharing
One-month Three-month
Tier
supply
supply
Preferred Retail Cost-Sharing
One-month Three-month
Tier
supply
supply
Tier 1
(Preferred
Generic)
$0
$0
Tier 1
(Preferred
Generic)
$2 copay
$6 copay
$5 copay
$15 copay
Tier 2 (NonPreferred
Generic)
$0
$0
Tier 2 (NonPreferred
Generic)
Tier 3
(Preferred
Brand)
$35 copay
$105 copay
Tier 3
(Preferred
Brand)
$40 copay
$120 copay
$90 copay
$270 copay
33% of the
cost
33% of the
cost
Tier 4 (NonPreferred
Brand)
$80 copay
$240 copay
Tier 4 (NonPreferred
Brand)
Tier 5
(Specialty
Tier)
33% of the
cost
33% of the
cost
Tier 5
(Specialty
Tier)
Standard Retail Cost-Sharing
One-month Three-month
Tier
supply
supply
12
Tier 1
(Preferred
Generic)
$7 copay
$21 copay
Tier 2 (NonPreferred
Generic)
$10 copay
$30 copay
Tier 3
(Preferred
Brand)
$45 copay
$135 copay
Tier 4 (NonPreferred
Brand)
$95 copay
$285 copay
Tier 5
(Specialty
Tier)
33% of the
cost
33% of the
cost
Initial
Coverage
(continued)
BlueMedicare HMO MyTime
BlueMedicare HMO LifeTime
Standard Retail Cost-Sharing
One-month Three-month
Tier
supply
supply
Standard Mail Order Cost-Sharing
One-month Three-month
Tier
supply
supply
Tier 1
(Preferred
Generic)
$5 copay
$15 copay
Tier 1
(Preferred
Generic)
$2 copay
$6 copay
$5 copay
$15 copay
Tier 2 (NonPreferred
Generic)
$5 copay
$15 copay
Tier 2 (NonPreferred
Generic)
Tier 3
(Preferred
Brand)
$40 copay
$120 copay
Tier 3
(Preferred
Brand)
$40 copay
$120 copay
$90 copay
$270 copay
33% of the
cost
33% of the
cost
Tier 4 (NonPreferred
Brand)
$85 copay
$255 copay
Tier 4 (NonPreferred
Brand)
Tier 5
(Specialty
Tier)
33% of the
cost
33% of the
cost
Tier 5
(Specialty
Tier)
Standard Mail Order Cost-Sharing
One-month Three-month
Tier
supply
supply
Tier 1
(Preferred
Generic)
$0
$0
Tier 2 (NonPreferred
Generic)
$0
$0
Tier 3
(Preferred
Brand)
$35 copay
$105 copay
Tier 4 (NonPreferred
Brand)
$80 copay
$240 copay
Tier 5
(Specialty
Tier)
33% of the
cost
33% of the
cost
If you reside in a long-term care facility, you
pay the same as at a retail pharmacy.
13
If you reside in a long-term care facility, you
pay the same as at a retail pharmacy.
You may get drugs from an out-of-network
pharmacy at the same cost as an in-network
pharmacy.
BlueMedicare HMO MyTime
BlueMedicare HMO LifeTime
Initial
Coverage
You may get drugs from an out-of-network
pharmacy at the same cost as an in-network
pharmacy.
Coverage Gap
Most Medicare drug plans have a coverage
gap (also called the "donut hole"). This means
that there's a temporary change in what you
will pay for your drugs. The coverage gap
begins after the total yearly drug cost
(including what our plan has paid and what
you have paid) reaches $2,960.
Most Medicare drug plans have a coverage
gap (also called the "donut hole"). This means
that there's a temporary change in what you
will pay for your drugs. The coverage gap
begins after the total yearly drug cost
(including what our plan has paid and what
you have paid) reaches $2,960.
After you enter the coverage gap, you pay
45% of the plan's cost for covered brand name
drugs and 65% of the plan's cost for covered
generic drugs until your costs total $4,700,
which is the end of the coverage gap. Not
everyone will enter the coverage gap.
After you enter the coverage gap, you pay
45% of the plan's cost for covered brand name
drugs and 65% of the plan's cost for covered
generic drugs until your costs total $4,700,
which is the end of the coverage gap. Not
everyone will enter the coverage gap.
Under this plan, you may pay even less for
the brand and generic drugs on the formulary.
Your cost varies by tier. You will need to use
your formulary to locate your drug's tier. See
the chart that follows to find out how much it
will cost you.
Under this plan, you may pay even less for
the brand and generic drugs on the formulary.
Your cost varies by tier. You will need to use
your formulary to locate your drug's tier. See
the chart that follows to find out how much it
will cost you.
Preferred Retail Cost-Sharing
OneDrugs
month
Tier
Covered supply
Preferred Retail Cost-Sharing
OneDrugs
month
Tier
Covered supply
(continued)
Tier 1
(Preferred
Generic)
Tier 2
(NonPreferred
Generic)
Tier 5
(Specialty
Tier)
All
$0
Threemonth
supply
Threemonth
supply
$0
Tier 1
(Preferred
Generic)
All
$2 copay $6 copay
All
$5 copay $15 copay
Some
All
$0
$0
Tier 2
(NonPreferred
Generic)
Some
33% of
the cost
33% of
the cost
Tier 5
(Specialty
Tier)
14
33% of
the cost
33% of
the cost
BlueMedicare HMO MyTime
Coverage Gap
(continued)
Standard Retail Cost-Sharing
OneDrugs
month
Tier
Covered supply
Tier 1
(Preferred
Generic)
Tier 2
(NonPreferred
Generic)
Tier 5
(Specialty
Tier)
All
Some
Standard Retail Cost-Sharing
OneDrugs
month
Tier
Covered supply
Threemonth
supply
$5 copay $15 copay
Tier 1
(Preferred
Generic)
All
$7 copay $21 copay
$5 copay $15 copay
Tier 2
(NonPreferred
Generic)
All
$10 copay $30 copay
33% of
the cost
Tier 5
(Specialty
Tier)
Some
33% of
the cost
33% of
the cost
33% of
the cost
Standard Mail Order Cost-Sharing
ThreeOnemonth
Drugs
month
supply
Tier
Covered supply
Standard Mail Order Cost-Sharing
ThreeOnemonth
Drugs
month
supply
Tier
Covered supply
Tier 1
(Preferred
Generic)
$0
Tier 1
(Preferred
Generic)
All
$2 copay $6 copay
All
$5 copay $15 copay
Some
Tier 2
(NonPreferred
Generic)
Tier 5
(Specialty
Tier)
Catastrophic
Coverage
All
Threemonth
supply
BlueMedicare HMO LifeTime
All
$0
All
$0
$0
Tier 2
(NonPreferred
Generic)
Some
33% of
the cost
33% of
the cost
Tier 5
(Specialty
Tier)
After your yearly out-of-pocket drug costs
(including drugs purchased through your retail
pharmacy and through mail order) reach
$4,700, you pay the greater of:
33% of
the cost
33% of
the cost
After your yearly out-of-pocket drug costs
(including drugs purchased through your retail
pharmacy and through mail order) reach
$4,700, you pay the greater of:
5% of the cost, or
5% of the cost, or
$2.65 copay for generic (including brand
drugs treated as generic) and a $6.60
copayment for all other drugs.
$2.65 copay for generic (including brand
drugs treated as generic) and a $6.60
copayment for all other drugs.
15
NOTES
Multi‐language Interpreter Services English: We have free interpreter services to answer any questions you may have about our health or drug plan. To get an interpreter, just call us at 1‐800‐926‐6565. 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 1‐800‐926‐6565. 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 1‐800‐926‐6565。我们的中文工作人员很乐意帮助您。
这是一项免费服务。 Chinese Cantonese: 您對我們的健康或藥物保險可能存有疑問，為此我們提供免費的翻譯
服務。如需翻譯服務，請致電 1‐800‐926‐6565。我們講中文的人員將樂意為您提供幫助。
這是一項免費服務。 Tagalog: Mayroon kaming libreng serbisyo sa pagsasaling‐wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot. Upang makakuha ng tagasaling‐wika, tawagan lamang kami sa 1‐800‐926‐6565. 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 1‐800‐926‐6565. 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 1‐800‐926‐6565 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 1‐800‐926‐6565. Man wird Ihnen dort auf Deutsch weiterhelfen. Dieser Service ist kostenlos. Korean: 당사는 의료 보험 또는 약품 보험에 관한 질문에 답해 드리고자 무료 통역 서비스를 제공하고 있습니다. 통역 서비스를 이용하려면 전화 1‐800‐926‐6565 번으로 문의해 주십시오. 한국어를 하는 담당자가 도와 드릴 것입니다. 이 서비스는 무료로 운영됩니다. Y0011_31982 0713 CMS Accepted Y0011_31982 0713 EGWP C: 07/2013 Russian: Если у вас возникнут вопросы относительно страхового или медикаментного плана, вы можете воспользоваться нашими бесплатными услугами переводчиков. Чтобы воспользоваться услугами переводчика, позвоните нам по телефону 1‐800‐926‐6565. Вам окажет помощь сотрудник, который говорит по‐pусски. Данная услуга бесплатная. Arabic: ‫ ﻟﻠﺤﺼﻮل ﻋﻠﻰ‬.‫إﻧﻨﺎ ﻧﻘﺪم ﺧﺪﻣﺎت اﻟﻤﺘﺮﺟﻢ اﻟﻔﻮري اﻟﻤﺠﺎﻧﻴﺔ ﻟﻺﺟﺎﺑﺔ ﻋﻦ أي أﺳﺌﻠﺔ ﺗﺘﻌﻠﻖ ﺑﺎﻟﺼﺤﺔ أو ﺟﺪول اﻷدوﻳﺔ ﻟﺪﻳﻨﺎ‬
‫ ﻟﻴﺲ ﻋﻠﻴﻚ ﺳﻮى اﻻﺗﺼﺎل ﺑﻨﺎ ﻋﻠﻰ‬،‫ﻣﺘﺮﺟﻢ ﻓﻮري‬1‐800‐926‐6565‫ ﺳﻴﻘﻮم ﺷﺨﺺ ﻣﺎ ﻳﺘﺤﺪث اﻟﻌﺮﺑﻴﺔ‬. ‫ هﺬﻩ‬.‫ﺑﻤﺴﺎﻋﺪﺗﻚ‬
‫ﺧﺪﻣﺔ ﻣﺠﺎﻧﻴﺔ‬. Hindi: हमारे ःवाःथ्य या दवा की योजना के बारे में आपके िकसी भी ूश्न के जवाब दे ने के
िलए हमारे पास मुफ्त दभ
ु ािषया सेवाएँ उपलब्ध हैं . एक दभ
ु ािषया ूाप्त करने के िलए, बस हमें 1‐
800‐926‐6565 पर फोन करें . कोई व्यिक्त जो िहन्दी बोलता है आपकी मदद कर सकता है . यह
एक मुफ्त सेवा है . 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 1‐800‐926‐
6565. 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 1‐800‐926‐6565. 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 1‐800‐
926‐6565. 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 1‐800‐926‐6565. Ta usługa jest bezpłatna. Japanese: 当社の健康 健康保険と薬品 処方薬プランに関するご質問にお答えするため
に、無料の通訳サービスがありますございます。通訳をご用命になるには、1‐800‐926‐
6565 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。
2015
More plan
information
NOTES
BlueMedicare Group PPO (Employer PPO)
BlueMedicare HMO LifeTime (HMO)
BlueMedicare HMO MyTime (HMO)
BlueMedicare HMO PrimeTime (HMO)
2015 Benefit Schedule for
Dental Care Services
Hearing Services
Vision Services
A Medicare Advantage Dental, Hearing and Vision Benefit
www.BlueMedicareFL.com
Florida Blue is a PPO Plan with a Medicare contract. Florida Blue HMO is an HMO Plan with a Medicare contract. Enrollment in
Florida Blue or Florida Blue HMO depends on contract renewal.
Y0011_32445 0814R2 CMS Accepted
Y0011_32445 0814R2 EGWP C: 08/2014
Welcome
Welcome to your Medicare Advantage dental, hearing and vision benefits. We are proud to include these benefits in
your BlueMedicare HMO or BlueMedicare Group PPO plan. With access to large networks of dentists, hearing centers and
vision outlets and professionals, you’ll enjoy the convenience and choice that you have come to expect from Florida Blue.
This benefit schedule details the features of the dental, hearing and vision services you’ll receive as a
BlueMedicareSM member.
Dental Care Services................................................................................................................................ 2
Hearing Services..................................................................................................................................... 4
Vision Services........................................................................................................................................ 5
This benefit schedule is for the following plans and counties:
BlueMedicare Group PPO
BlueMedicare HMO LifeTime (HMO)
In Alachua, Bay, Brevard, Broward, Charlotte, Citrus, Clay, Collier, Duval, Escambia, Hernando, Hillsborough, Lake, Lee,
Manatee, Marion, Martin, Nassau, Okaloosa, Orange, Osceola, Pasco, Polk, Santa Rosa, Sarasota, Seminole, St. Johns,
St. Lucie and Sumter counties
BlueMedicare HMO PrimeTime and LifeTime (HMO)
In Palm Beach and Pinellas counties
BlueMedicare HMO MyTime (HMO)
In Broward, Hernando, Hillsborough, Orange, Osceola, Pasco , Polk and Seminole counties
Please contact Member Services Service at 1-800-926-6565 for additional information. (TTY users call 1-800-955-8770). We are
open from 8 a.m. - 8 p.m., 7 days a week. From February 15th to September 30th, we are open Monday - Friday 8 a.m. - 8 p.m.
Dental Care Services
Taking care of your health includes caring for your teeth, too. In fact, your dental health can have a direct impact on your
overall health and well-being, and may have an influence on the development of certain conditions such as diabetes
and heart disease. Easy access to preventive dental care is one of the most important things we can provide. That’s why
members never need a referral or pre-authorization to visit an In Network dentist.
As a BlueMedicare member, you have access to a large network of providers, and comprehensive exams and X-rays are
covered each year when you receive services from an In Network dentist.
To find an In Network dentist in your area visit www.BlueMedicareFL.com or call toll-free
1-888-223-4892 or TTY 1-800-955-8770.
The table below outlines the covered services under your BlueMedicare dental plan.
BlueMedicare HMO LifeTime (HMO)*
BlueMedicare HMO PrimeTime and
LifeTime (HMO) *
Benefits for covered services
BlueMedicare HMO MyTime (HMO)*
*See page one for the counties included in
this plan.
BlueMedicare Group PPO
In Network
Out of Network*
In Network
Annual Examination (D0120) –
up to 2 per year**
Comprehensive Examination*
(D0150) – 1 per lifetime, per dentist
$0 Copayment
Not Covered
$0 Copayment
Cleaning (D1110) – 1 per year
$0 Copayment
Not Covered
$0 Copayment
Bitewing X-rays (D0270, D0272,
D0273 or D0274) –
1 set per year**** OR
Full-mouth X-rays (D0210) (D0330) 1 set every 3 years****
$0 Copayment
Not Covered
$0 Copayment
Extraction (D7140) –
up to 2 per year (for an erupted
tooth OR exposed root)
$0 Copayment
Not Covered
$0 Copayment
Denture Adjustment - Complete
or Partial (D5410, D5411, D5421
or D5422) – up to 2 per year
$0 Copayment
Not Covered
$0 Copayment
Out of Network*
Preventive Services
Member pays
50%*** Coinsurance
Payment is based
on the In Network
fee schedule
Additional Services
Member pays
50%*** Coinsurance
Payment is based
on the In Network
fee schedule
2
*Networks are comprised of independent contracted dentists.
**Two exams per year are covered. You can choose to have two annual exams or one annual exam and one
comprehensive exam. However, only one comprehensive exam is covered
per dentist.
***You may be required to pay for Out of Network services up front. Submit your receipt and
you will be reimbursed 50% of the In Network fee for covered services only.
****One set of X-rays per year is covered. You can choose the bitewing or full-mouth set. However, only one set of fullmouth X-rays is covered within a three year period.
Your request for reimbursement can be sent to:
Florida Combined Life
PO Box 1047
Elk Grove Village, IL 60009-1047
7
Florida Combined Life Insurance Company, Inc. is responsible for the administrative functions
of the BlueMedicare dental program. If you have an inquiry, call Monday through Friday, 8:00 am to 8:00 pm ET.
Toll-free: 1-888-223-4892 or TTY 1-800-955-8770.
If you have a grievance or appeal, submit it in
writing to:
Florida Blue/Florida Blue HMO
Attn: Medicare Advantage Member Appeals
PO Box 41609
Jacksonville, FL 32203-1609
3
Hearing Services
If you find that your hearing isn’t as good as it used to be, you can rest assured that
your BlueMedicare plan can offer you assistance. Under your plan, you are entitled
to a comprehensive hearing exam at no charge. You also receive an allowance for
the purchase
of a hearing device. This allowance is automatically included in your plan as long as
you use our partner, HearUSA. To find a HearUSA location (or one of their affiliates)
near you, visit
www.BlueMedicareFL.com or call 1-800-700-3277 or TTY 1-800-955-8770.
The table below outlines the covered services under your
BlueMedicare hearing plan.
Benefits for covered
services
BlueMedicare HMO LifeTime (HMO)*
BlueMedicare HMO PrimeTime and
LifeTime (HMO) *
BlueMedicare HMO MyTime (HMO)*
*See page one for the counties included in
this plan.
BlueMedicare Group PPO
In Network
Out of Network
In Network
Out of Network
$0 Copayment
Not Covered
$0 Copayment
$0 Copayment
$500 per ear
Not Covered
Combined maximum of $500 per ear
for In and Out of Network*
Preventive Services
Annual Hearing Exam &
Routine Hearing Test
Hearing Devices
Device fitting and purchase
allowance (every 3 years)
*If you choose to purchase your hearing device from a provider who is not affiliated with HearUSA, you must pay
for services up front, and submit your receipt. You will be reimbursed up to the amount indicated. Your request for
reimbursement can be sent to:
HearUSA - Claims Department
PO Box 31927
West Palm Beach, FL 33420
HearUSA is responsible for the administrative functions of the BlueMedicare hearing program. If you have an inquiry,
call HearUSA, Monday through Friday, 8:00 am to 8:30 pm ET. Toll-free: 1-800-700-3277 or TTY 1-800-955-8770.
If you have a grievance or appeal, submit it in writing to:
Florida Blue/Florida Blue HMO
Attn: Medicare Advantage Member Appeals
PO Box 41609
Jacksonville, FL 32203-1609
4
Vision Care Services
BlueMedicare understands that you want your vision to be the best it can be. That’s why we have included a vision benefit
in your BlueMedicare plan. We encourage you to have your eyes examined each year. Eye diseases such as glaucoma can
be caught early with a regular checkup. If you have diabetes, an annual eye exam is important for the health of your eyes.
To find eye professionals in your area visit www.BlueMedicareFL.com or call toll-free 1-800-496-1388.
Benefits for
covered services
BlueMedicare HMO LifeTime (HMO)*
BlueMedicare HMO PrimeTime and
LifeTime (HMO) *
BlueMedicare HMO MyTime (HMO)*
*See page one for the counties included in this
plan.
In Network
Out of Network
Preventive Services
$0 member copay
Not Covered
Routine Eye Exam up to 1 per year, including
dilation when necessary
Spectacle Lenses – up to 1 pair covered every 24 months
$20 member copay
Not Covered
Clear Plastic Lenses
(Single Vision, Lined, Bifocal,
Trifocal or Lenticular)
Progressive Lenses
$65 member copay
Not Covered
BlueMedicare Group PPO
In Network
$0 member copay
Up to $25
Member
Reimbursement
Reimbursement
based on type
of lens**
$65 member copay
Up to $30 Member
Reimbursement
1. Other Lenses in addition to the spectacle lens member charge. Lenses are covered in full after both the basic and other lens charges.
No Additional Member
$20 member copay
$20 member copay
Oversize Lenses
Reimbursement
$35 member copay
$35 member copay
Polycarbonate
$0 member copay if
$0 member copay if
medically necessary. (+/medically necessary (+/6.00 diopters or greater)
6.00 diopters or greater)
$105 member copay
$105 member copay
Premium Progressive
(Varilux®, etc.)
$30 member copay
$30 member copay
Intermediate-Vision
$20 member copay
$20
member
copay
Blended Segment
$60 member copay
$60 member copay
High-Index
$75 member copay
$75 member copay
Polarized
$20 member copay
$20 member copay
Photochromic Glass
$70 member copay
$70
member
copay
Plastic Photosensitive
Coatings (Member charges in addition to the spectacle lens member charge.)
$15 member copay
Tinting of plastic lenses
No Additional Member
Not Covered
$15 member copay
$0 member copay
Scratch-Resistant
Reimbursement
$0 member copay
$15 member copay
Ultraviolet
$15 member copay
Anti-Reflective (AR) Standard $40 member copay
$40 member copay
Anti-Reflective (AR) Premium $55 member copay
$55 member copay
Anti-Reflective (AR) Ultra
$69 member copay
$69 member copay
5
$20 member copay
Out of Network*
Benefits for
covered services
BlueMedicare HMO LifeTime (HMO)*
BlueMedicare HMO PrimeTime and
LifeTime (HMO) *
BlueMedicare HMO MyTime (HMO)*
*See page one for the counties included in this
plan.
In Network
Out of Network
BlueMedicare Group PPO
In Network
Scratch Protection Plans (Member charges in addition to the spectacle lens member charge.)
Single Vision lenses
$20 member copay
Not Covered
$20 member copay
Multifocal lenses
$40 member copay
$40 member copay
2. Frames every 24 months
Davis Vision Frame
Collection:
$0 member copay
Fashion level
$15 member copay
Designer level
$40 member copay
Premier level
Non-Davis Vision Collection
Up to a $100 allowance
then 20% discount***
on overage
Not Applicable
Not Covered
$0 member copay
$15 member copay
$40 member copay
Out of Network*
No Additional Member
Reimbursement
Not Applicable
Up to a $100 allowance Up to a $35 member
reimbursement
then 20% discount***
on overage
3. Contact Lenses (in lieu of spectacle lenses and frames) every 24 months
Up to a $100 member Up to a $55 member
Not Covered
Up to a $100 member
Standard and
reimbursement
allowance then
allowance then
Specialty lenses
15% discount*** on
15% discount*** on
overage
overage
Up to a $225 member
$0 member copay
Not Covered
Medically Necessary Lenses $0 member copay
reimbursement
(+/- 6.00 diopters or greater)
Evaluation, Fitting, FollowUp Care: Standard Lens,
Specialty Lens
15% discount
Not Covered
15% discount
Included in the up to
$55 or $225 member
reimbursement
4. Low-Vision Benefits (Your vision provider must obtain prior authorization for any Low-Vision benefits.)
1 comprehensive
1 comprehensive
Not Covered
1 comprehensive
Low-Vision Evaluation
evaluation every 5
evaluation every 5
evaluation every 5
years. Up to $300
years. Up to $300
years. Up to $300
maximum member
maximum member
maximum member
reimbursement.
reimbursement.
reimbursement.
Member pays all
Member pays all
Member pays all
overage.
overage.
overage
4 visits in any 5 year 4 visits in any 5 year
Not Covered
Low-Vision Follow-Up Care 4 visits in any 5 year
period up to $100
period up to $100
period
per visit.
per visit
Up to a $600
Up to a $600
Not Covered
Up to a $600
Low-Vision Aids
annual or $1,200
annual or $1,200
annual or $1,200
(i.e. magnifiers)
lifetime member
lifetime member
lifetime member
reimbursement.
reimbursement.
reimbursement.
Member pays all
Member pays all
Member pays all
overage.
overage.
overage.
6
Benefits for
covered services
5. Additional Discounts
Laser Correction Surgery
(i.e. Lasik)
BlueMedicare HMO LifeTime (HMO)*
BlueMedicare HMO PrimeTime and
LifeTime (HMO) *
BlueMedicare HMO MyTime (HMO)*
*See page one for the counties included in this
plan.
BlueMedicare Group PPO
In Network
Out of Network
In Network
Out of Network*
25% off provider’s
normal rates or a
5% discount on any
“advertised specials”
No Discount
25% off provider’s
normal rates or a
5% discount on any
“advertised specials”
No Discount
* You must pay for services up front and submit your receipt. You will be reimbursed up
to the amount indicated.
**You must pay for services up front and submit your receipt. You will be reimbursed based
on the lens type and any coatings as follows:
Single Vision........................up to $20
Bifocal ..................................up to $30
Trifocal .................................up to $35
Lenticular .............................up to $40
Progressive Standard....up to $30
***Additional discounts not available at Sam’s Club or Wal-Mart.
Your request for reimbursement can be sent to:
Vision Care Processing Unit
P.O. Box 1525
Latham, NY 12110
Davis Vision is responsible for the administrative functions of the BlueMedicare vision program.
Call 1-800-496-1388 for automated help 24/7. Live help is also available seven days a week:
Monday-Friday, 8 a.m.-11 p.m., Saturday, 9 a.m.- 4 p.m., Sunday, 12 p.m.- 4 p.m. ET or TTY
1-800-955-8770.
If you have a grievance or appeal, submit it in writing to:
Florida Blue/Florida Blue HMO
Attn: Medicare Advantage Member Appeals
PO Box 41609
Jacksonville FL 32203-1609
www.BlueMedicareFL.com
Health insurance is offered by Blue Cross and Blue Shield of Florida, D/B/A Florida Blue. HMO coverage is offered by Health Options,
Inc., D/B/A Florida Blue HMO, an HMO subsidiary of Florida Blue. These companies are independent licensees of the Blue Cross and
Blue Shield Association.
M O R E P L A N I N F O R M AT I O N
Silver Sneakers® Fitness Program
It’s easy and affordable for you to get fit, have fun and make friends with Florida Blue—
using your SilverSneakers fitness membership. You have access to more than 11,000
participating locations across the country, where on-site staff will help you meet your
wellness goals. Locations have exercise equipment and SilverSneakers fitness classes
designed specifically for people with Medicare and taught by certified instructors.
SILVERSNEAKERS ONLINE
Go to silversneakers.com to access fitness tools, assess your health and track your
activity. Also get expert advice plus meal planning ideas and healthy recipes. You
can connect with other SilverSneakers members and receive support from the online
community.
SILVERSNEAKERS STEPS – AT HOME OR ON THE GO
Sign up for SilverSneakers® Steps if you can’t get to a fitness location. Select a general
fitness, strength, walking or yoga kit that you can use at home or on the go. Visit silversneakers.com for more information.
OUTSIDE THE GYM
Try SilverSneakers FLEX. FLEX classes and activities are led by certified instructors at parks, recreation centers, churches
and other neighborhood locations. Find classes and activities such as yoga, tai chi, and walking groups, and sign up
at silversneakers.com.
Please contact us at 1-855-601-9465 for additional information. (TTY users call 1-800-955-8770). We are open from
8 a.m. - 8 p.m., 7 days a week. From February 15th to September 30th, we are open Monday - Friday 8 a.m. - 8 p.m.
Florida Blue is a PPO Plan with a Medicare contract. Florida Blue HMO is an HMO Plan with a Medicare contract.
Enrollment in Florida Blue or Florida Blue HMO depends on contract renewal.
Y0011_32071 0714R1 CMS Accepted
M O R E P L A N I N F O R M AT I O N
Chain Pharmacies
The national or regional chain pharmacies below are “network pharmacies” because we have made arrangements
with them to provide prescription drugs to Plan members. Not all national or regional chain pharmacies have a
dedicated toll free phone number. For those pharmacies you will need to call a specific location in your area
(TTY: 1-800-955-8770). If you’d like information on network chain or independent pharmacies in your area,
please visit our web site at www.BlueMedicareFL.com or call our Customer Service number at 1-855-601-9465,
8:00 a.m.– 8:00 p.m., seven days a week. From February 15th to September 30th, we are open Monday - Friday
8 a.m. - 8 p.m. TTY users should call 1-800-955-8770.
AccessHealth
1-800-824-1763
TTY 1-800-955-8770
Albertson’s LLC
1-877-932-7948
TTY 1-800-955-8770
American Pharmacy
Network Solutions
1-866-451-4557
TTY 1-800-955-8770
Costco Pharmacies
1-800-774-2678
TTY 1-800-955-8770
CVS Pharmacy Inc.*
1-800-746-7287
TTY 1-800-955-8770
Epic Pharmacy
Network Inc.
1-800-965-3742
TTY 1-800-955-8770
Family Care Pharmacy
Network (QS1)
Gerimed Ltc
Network Inc.
Managed Pharmacy
Care and Adm Svcs
1-800-456-4374
TTY 1-800-955-8770
1-800-582-5889
TTY 1-800-955-8770
Good Neighbor Pharmacy
Provider Network
(Amerisource)
MaxorXpress
1-800-829-3132
TTY 1-800-955-8770
H. D. Smith Third
Party Network
1-866-232-1222
TTY 1-800-955-8770
Hannaford Bros
Co Inc.
1-800-213-9040
TTY 1-800-955-8770
1-800-687-8629
TTY 1-800-955-8770
Medicine Shoppe
Intl Inc.*
1-800-325-1397
TTY 1-800-955-8770
MHA Long Term
Care Network
1-800-948-7172
TTY 1-800-955-8770
K-Mart Pharmacy*
Navarro Discount
Pharmacies LLC*
(LTC Health Solutions)
1-800-866-0086
TTY 1-800-955-8770
1-888-628-2770
TTY 1-800-955-8770
Leader Drug Stores
Inc.
Progressive Pharmacies
LLC
1-916-922-7979
TTY 1-800-955-8770
1-888-338-3033
TTY 1-800-955-8770
1-800-845-7558
TTY 1-800-955-8770
Y0011_31981 0714R1 CMS Accepted
M O R E P L A N I N F O R M AT I O N
Publix Supermarkets Inc.*
Target Corporation*
United Drugs
1-863-688-1188
TTY 1-800-955-8770
1-877-798-2743
TTY 1-800-955-8770
1-800-800-2988
TTY 1-800-955-8770
Sav Mor Drug Stores
The Kroger Co
Walgreens Drug Store*
1-800-554-8188
TTY 1-800-955-8770
1-800-576-4377
TTY 1-800-955-8770
1-800-925-4733
TTY 1-877-247-7889
Sweetbay*
Third Party Station CP
(Pharmacy First)
1-888-218-3890
TTY 1-800-955-8770
Tampa Family Health
Ctr Inc
1-813-866-0930
TTY 1-800-955-8770
1-800-460-1575
TTY 1-800-955-8770
Trinet (PBA Health)
1-800-333-8097
TTY 1-800-955-8770
Walmart Stores Inc
/Sam’s Club
1-800-925-6278
TTY 1-800-955-8770
Winn Dixie Pharmacy*
1-866-946-6349
TTY 1-800-955-8770
*These pharmacies participate in our Extended Supply Network (ESN) in 2015.
Florida Blue is a PPO, RPPO and Rx (PDP) Plan with a Medicare contract. Florida Blue HMO is an HMO Plan with a Medicare
Contract. Enrollment in Florida Blue or Florida Blue HMO depends on contract renewal.
2015
Plan
enrollment
NOTES
PLAN ENROLLMENT
Understanding enrollment periods
2014
SEPT.
2015
OCT.
NOV.
ENROLL
DEC.
JAN.
FEB.
MCH.
APR.
MAY
JUN.
JLY.
AUG.
You can not enroll in our plan after December 71
OCTOBER 15 – DECEMBER 7
2014
SPECIAL ELECTION PERIOD (YEAR ROUND ENROLLMENT)
ANNUAL ENROLLMENT PERIOD
October 15, 2014 – December 7, 2014
Switch, drop or join a Medicare Advantage plan of your choosing.
Your Medicare Advantage plan selection becomes effective January 1, 2015.
SPECIAL ELECTION PERIOD
(Year-Round Enrollment)
If you answer yes to any of the following questions, you may be eligible for a Special Election
Period. If you think you qualify, talk to your local sales agent.
• Have you recently moved?
• Are you currently receiving “Extra Help” with your prescription drug costs?
• Do you no longer qualify for “Extra Help” with your prescription drug costs?
• Have you recently left a PACE program (Program of All-inclusive Care for the Elderly)?
• Do you live in a long-term care facility?
• Have you recently retired and lost your employer or union coverage?
• Will you be moving into a long-term care facility?
• Have you recently moved out of a long-term care facility?
• Are you currently receiving Medicaid?
• Have you recently stopped receiving Medicaid?
Y0011_32012 0714R1 C: 07/2014
PLAN ENROLLMENT
DISENROLLMENT PERIOD
January 1, 2015– February 14, 2015
For Medicare Advantage plans, you can leave your plan and switch to Original Medicare. lf you switch to Original Medicare,
you have until February 14, 2015, to sign up for a prescription drug plan.
During this period you cannot:
• Switch from Original Medicare to a Medicare Advantage plan.
• Switch from one Medicare Advantage plan to another.
Please contact us at 1-855-601-9465 for additional information. (TTY users call 1-800-955-8770). We are open from
8 a.m. - 8 p.m., 7 days a week. From February 15th to September 30th, we are open Monday - Friday 8 a.m. - 8 p.m.
1
Unless you qualify for a Special Election Period.
Florida Blue is a PPO and RPPO Plan with a Medicare contract. Florida Blue HMO is an HMO Plan with a Medicare contract.
Enrollment in Florida Blue or Florida Blue HMO depends on contract renewal.
PLAN ENROLLMENT
Ready to enroll?
HOW TO ENROLL
1
Have your Medicare ID card available.
2
Complete the enrollment form in its entirety. You may do this one of three ways:
• Complete the paper enrollment form provided to you; OR
• Complete an electronic enrollment form via www.BlueMedicareFL.com; OR
• Call your local agent for assistance in completing your enrollment form.
3
If you and your spouse both wish to enroll in one of our BlueMedicare plans, you will need to complete
separate enrollment forms.
4
Complete all sections of the enrollment form in full. Missing or incomplete information may cause a delay
in the effective date of your coverage. Carefully read and sign all necessary portions of the enrollment form.
5
Complete the Medicare Insurance Information so that we can verify your Medicare eligibility. Fill in the
Part A and Part B effective dates from your Medicare ID card.
6
Please select a payment option even if the plan you select has a $0 premium as a Late Enrollment
Penalty may apply (See “Frequently asked questions” section of this booklet). If you select an Electronic
Funds Transfer (EFT) as your payment option, please don’t forget to write your bank account number and
routing number in the appropriate section of the enrollment form. Also, please include a voided check
that contains this information.
7
Select the appropriate plan. Be sure to select only ONE plan name.
8
Complete the Authorization to Release Protected Health Information form (if applicable).
9
Please provide the information for your Primary Care Physician (PCP) or Physician of Choice, when applicable
(e.g. general, family, internal medicine, etc.). If you are applying for an HMO plan, your enrollment form cannot
be processed unless you select a PCP. If a PCP is not indicated on your enrollment form, Florida Blue HMO will
select one for you.
10
Read and complete applicable information in Section 4. This section highlights enrollment periods.
11
If you have a Durable Power of Attorney, Durable Power of Attorney for Health Care, or you are a legal guardian
or conservator, the legal representative must attest that he/she has this authority under state law and that proof
can be presented if requested by the Centers for Medicare & Medicaid Services (CMS).
12
If you do not have an agent helping you enroll, mail the original copy of the enrollment form and/or
the Authorization to Release Protected Health Information, when applicable, to: Florida Blue P.O. Box
45296, Jacksonville, FL 32232.
Y0011_31986 0714R2 CMS Approved
PLAN ENROLLMENT
WHEN YOU ARE READY TO ENROLL
Contact your local agent to help you choose the best plan and complete the enrollment form; OR call one of our licensed
agents at 1-800-876-2227 (TTY users should call 1-800-955-8770) and the agent can help you enroll over the phone.
If you choose to use your local agent or you contact a licensed agent at the number above to assist with your enrollment,
the person who is discussing plan options with you is a sales agent, broker or other person employed by or contracted with Florida
Blue. The person may be paid based on your enrollment in a plan.
If you currently have health coverage through an employer or union, joining one of our plans could
affect your employer or union health benefits. You could lose your employer or union health
coverage if you join this plan. Read the communications your employer or union sends you. If you
have questions, contact their office. If you can’t find any contact information, your benefits
administrator or the office that answers questions about your coverage can help.
Please contact us at 1-855-601-9465 for additional information. (TTY users call 1-800-955-8770).
We are open from 8 a.m. - 8 p.m., 7 days a week. From February 15th to September 30th, we are open
Monday - Friday 8 a.m. - 8 p.m.
Florida Blue is a PPO, RPPO and Rx (PDP) Plan with a Medicare contract. Florida Blue HMO is an HMO Plan
with a Medicare contract. Enrollment in Florida Blue or Florida Blue HMO depends on contract renewal.
PERF 3/8”
PLAN ENROLLMENT
Authorization to use and access Protected
Health Information
Please complete the entire form and return to:
Florida Blue
Access Authorization Unit
P.O. Box 45296, Jacksonville, FL 32232
PURPOSE
I am the member listed in Section 1.
This authorization is at my request to permit
Blue Cross and Blue Shield of Florida, Inc., and Health Options, Inc. (together, “Florida Blue”) to
respond to customer service inquiries regarding my Protected Health Information regarding health,
dental and long-term care products.
SECTION I
(Please provide the following information regarding the person whose Protected Health
Information is to be released.)
Member Name: ______________________________________________________
Policy or Contract Number: _____________________________________________
Group Number: ______________________Date of Birth: _____________________
SECTION II
I authorize Florida Blue to release, orally and/or in writing, the following Protected Health
Information concerning me:
• Identifying information (e.g., name, address, age, gender);
• Health care coverage information (i.e., general & plan-specific benefit information);
• Past, present and future claims information (except for any period of time during which
a Confidential Communication address1 was in effect); and
• Coordination of Benefit Information.
SECTION III
(Please identify the person(s) to whom the member’s Protected Health Information may be
released and their relationship (i.e., sales agent, employer health benefit representative, parent,
family member, friend, etc.)
My information may be given to the person(s) listed below.
Please Print:
Name: _________________________ Relationship to Member: _______________
Name: _________________________ Relationship to Member: _______________
Name: _________________________ Relationship to Member: _______________
SECTION IV
By law, this authorization must indicate that persons other than Florida Blue receiving member’s
Protected Health Information may not have to obey federal health information privacy laws and
member’s Protected Health Information may be further released by those persons.
I further understand that if I have identified a sales agent or an employer health benefit representative in
Section III to whom my Protected Health Information may be released, Florida Blue will have no
Y0011_30871 0213R2 C:02/2013
PERF 3/8”
PERF 3/8”
PLAN ENROLLMENT
further liability as to the further release of my Protected Health Information by those
designated persons.
This authorization is voluntary and is not a condition of enrollment in a health plan, eligibility
for benefits or payment of claims.
SECTION V
This authorization will expire: ____________/___________/__________
Month Day Year
OR
______________________ The date member’s Florida Blue health coverage ends
It is advised that you place a specific expiration date on this authorization if you are designating a sales agent or employer as an
authorized representative, or any other person for whom you may have designated to assist you with a specific, short-term task.
SECTION VI
Copy of Authorization
Please keep a copy of your signed authorization. A photocopy is as valid as the original.
SECTION VII
Right to Withdraw Authorization
I understand that I may withdraw this authorization at any time by giving written notice to the address listed on page 1 of this
form. I further understand that withdrawal of this authorization will not affect any action taken by Florida Blue in reliance on
this authorization prior to receiving my written notice of withdrawal.
SECTION VIII
Signature
Member Signature: _________________________________________________ Date: ______________
If a legal representative signs this authorization form on behalf of the member, please complete the following information:
Legal Representative’s Name*: ___________________________________________________________
Date Signed: ________________
Relationship to the member: _____________________________________________________________
*Please provide written documentation to support your status as a guardian or other legal
representative.
This information is available for free in other languages. Please call our customer service number at 1-855-601-9465,
8:00 a.m. – 9:00 p.m. ET, seven days a week all year long (TTY: 1-800-955-8771).
A Confidential Communication address is one specified by an adult (age 18 or older) that is different than the address
where the subscriber receives his or her mail.
1
Health insurance is offered by Blue Cross and Blue Shield of Florida, D/B/A Florida Blue. HMO coverage is offered by Health
Options, Inc., D/B/A Florida Blue HMO, an HMO subsidiary of Florida Blue. These companies are independent licensees of
the Blue Cross and Blue Shield Association.
Y0011_30871 0213R2 C:02/2013
PERF 3/8”
PERF 3/8”
PLAN ENROLLMENT
Enrollment checklist
Florida Blue is required by Medicare to contact you within 15 days of receiving your enrollment application.
Within the next 15 days you will receive a letter from Florida Blue to verify that the Medicare Advantage or Part D Prescription
Drug plan was fully explained. This will not affect your ability to enroll in the plan.
Your sales agent will review the following questions with you to verify that the Medicare Advantage or Part D Prescription Drug
plan was fully explained. Check Yes or No as appropriate.
For Medicare Advantage plans:
Yes 
No 
Do you understand that you have applied for a Medicare Advantage plan? This plan is not a
Medicare Supplement “Medigap” plan. This plan replaces Original Medicare.
Yes 
No 
Do you understand that to enroll you must be “entitled” to Part A and enrolled in Part B?
For Part D Prescription Drug plans:
Yes 
No 
Do you understand you have applied for a Part D Prescription Drug plan?
Yes 
No 
Do you understand to enroll you must have Medicare Part A and/or Part B?
For All plans:
Yes 
Yes 
Yes 
Yes 
Yes 
Yes 
Yes 
No 
No 
No 
No 
No 
No 
No 
Drug Name
Did the sales agent fully explain your premium, benefits, copays, and coinsurance amounts?
Did the sales agent show you the Summary of Benefits and give you a copy?
Did the sales agent give you their contact information? (name, phone or business card)
Did the sales agent explain the plan’s drug list (also referred to as a formulary) and drug tiers?
Did the sales agent explain the coverage gap, sometimes referred to as the doughnut hole?
Do you understand that in most cases you must use a pharmacy in our drug plan network?
Did the sales agent confirm that your prescription drugs are covered under the plan’s drug list?
Covered
Yes/No
Tier
Cost/Requirement/Limits
Florida Blue is a PPO, RPPO and Rx (PDP) Plan with a Medicare contract. Florida Blue HMO is an HMO Plan with a Medicare
contract. Enrollment in Florida Blue or Florida Blue HMO depends on contract renewal.
Health insurance is offered by Blue Cross and Blue Shield of Florida, D/B/A Florida Blue. HMO coverage is offered by Health
Options, Inc., D/B/A Florida Blue HMO, an HMO subsidiary of Florida Blue. These companies are independent licensees of
the Blue Cross and Blue Shield Association.
Y0011_31989 0714R1 CMS Accepted
PERF 3/8”
Only for HMO & PPO plans:
Yes 
No 
Do you understand that you must use in-network health care providers to get the in-network
benefits, copays and coinsurances?
Yes 
No 
Do you understand that if you use out-of-network health care providers you will likely pay higher
out-of-pocket costs? (Note: HMO members are not covered out-of-network, except in emergencies,
urgent care and out-of-area dialysis.)
Yes 
No 
Did the sales agent confirm that your doctor(s) is(are) in-network for the plan that you selected?
Providers Name
Par/Non-Par
Provider’s Complete Address
Acknowledgement:
My agent and I have reviewed all my doctor(s), hospital(s) and prescription drug(s) that I have provided
today. We have discussed each provider’s participating status within my plan as well as my cost share and
any requirements or limits regarding my prescription drug(s). I understand that some network providers may
be added or removed from the network at any time. For any additional providers or to get the most up-todate information about my plan’s network providers for my area or my prescription drugs, I will visit www.
BlueMedicareFL.com or call the Member Services Department at 1-800-926-6565, 8:00 a.m. - 8:00 p.m.,
seven days a week. From February 15th to September 30th, we are open Monday - Friday 8 a.m. - 8 p.m
(TTY users should call 1-800-955-8770).
Applicant’s Signature_____________________________________
Agent’s Signature_____________________________________
PERF 3/8”
PLAN ENROLLMENT
Enrollment checklist
Florida Blue is required by Medicare to contact you within 15 days of receiving your enrollment application.
Within the next 15 days you will receive a letter from Florida Blue to verify that the Medicare Advantage or Part D Prescription
Drug plan was fully explained. This will not affect your ability to enroll in the plan.
Your sales agent will review the following questions with you to verify that the Medicare Advantage or Part D Prescription Drug
plan was fully explained. Check Yes or No as appropriate.
For Medicare Advantage plans:
Yes 
No 
Do you understand that you have applied for a Medicare Advantage plan? This plan is not a
Medicare Supplement “Medigap” plan. This plan replaces Original Medicare.
Yes 
No 
Do you understand that to enroll you must be “entitled” to Part A and enrolled in Part B?
For Part D Prescription Drug plans:
Yes 
No 
Do you understand you have applied for a Part D Prescription Drug plan?
Yes 
No 
Do you understand to enroll you must have Medicare Part A and/or Part B?
For All plans:
Yes 
Yes 
Yes 
Yes 
Yes 
Yes 
Yes 
No 
No 
No 
No 
No 
No 
No 
Drug Name
Did the sales agent fully explain your premium, benefits, copays, and coinsurance amounts?
Did the sales agent show you the Summary of Benefits and give you a copy?
Did the sales agent give you their contact information? (name, phone or business card)
Did the sales agent explain the plan’s drug list (also referred to as a formulary) and drug tiers?
Did the sales agent explain the coverage gap, sometimes referred to as the doughnut hole?
Do you understand that in most cases you must use a pharmacy in our drug plan network?
Did the sales agent confirm that your prescription drugs are covered under the plan’s drug list?
Covered
Yes/No
Tier
Cost/Requirement/Limits
Florida Blue is a PPO, RPPO and Rx (PDP) Plan with a Medicare contract. Florida Blue HMO is an HMO Plan with a Medicare
contract. Enrollment in Florida Blue or Florida Blue HMO depends on contract renewal.
Health insurance is offered by Blue Cross and Blue Shield of Florida, D/B/A Florida Blue. HMO coverage is offered by Health
Options, Inc., D/B/A Florida Blue HMO, an HMO subsidiary of Florida Blue. These companies are independent licensees of
the Blue Cross and Blue Shield Association.
Y0011_31989 0714R1 CMS Accepted
PERF 3/8”
Only for HMO & PPO plans:
Yes 
No 
Do you understand that you must use in-network health care providers to get the in-network
benefits, copays and coinsurances?
Yes 
No 
Do you understand that if you use out-of-network health care providers you will likely pay higher
out-of-pocket costs? (Note: HMO members are not covered out-of-network, except in emergencies,
urgent care and out-of-area dialysis.)
Yes 
No 
Did the sales agent confirm that your doctor(s) is(are) in-network for the plan that you selected?
Providers Name
Par/Non-Par
Provider’s Complete Address
Acknowledgement:
My agent and I have reviewed all my doctor(s), hospital(s) and prescription drug(s) that I have provided
today. We have discussed each provider’s participating status within my plan as well as my cost share and
any requirements or limits regarding my prescription drug(s). I understand that some network providers may
be added or removed from the network at any time. For any additional providers or to get the most up-todate information about my plan’s network providers for my area or my prescription drugs, I will visit www.
BlueMedicareFL.com or call the Member Services Department at 1-800-926-6565, 8:00 a.m. - 8:00 p.m.,
seven days a week. From February 15th to September 30th, we are open Monday - Friday 8 a.m. - 8 p.m
(TTY users should call 1-800-955-8770).
Applicant’s Signature_____________________________________
Agent’s Signature_____________________________________
PERF 3/8”
PLAN ENROLLMENT
Scope of Sales Appointment Confirmation Form
The Centers for Medicare & Medicaid Services requires agents to document the scope of a marketing appointment prior to any
face-to-face sales meeting to ensure understanding of what will be discussed between the agent and the Medicare beneficiary
(or their authorized representative). All information provided on this form is confidential and should be completed
by each person with Medicare or his/her authorized representative.
Please initial below beside the type of product(s) you want the agent to discuss.
 Stand-alone Medicare Prescription Drug Plans (Part D)
Medicare Prescription Drug Plan (PDP) — A stand-alone drug plan that adds prescription drug coverage to Original
Medicare, some Medicare Cost Plans, some Medicare Private-Fee-for-Service Plans, and Medicare Medical Savings Account
Plans.
 Medicare Advantage Plans (Part C) and Cost Plans
Medicare Health Maintenance Organization (HMO) — A Medicare Advantage Plan that provides all Original Medicare
Part A and Part B health coverage and sometimes covers Part D prescription drug coverage. In most HMOs, you can only get
your care from doctors or hospitals in the plan’s network (except in emergencies).
Medicare Preferred Provider Organization (PPO) Plan — A Medicare Advantage Plan that provides all Original
Medicare Part A and Part B health coverage and sometimes covers Part D prescription drug coverage. PPOs have network
doctors and hospitals but you can also use
out-of-network providers, usually at a higher cost.
Medicare Private Fee-For-Service (PFFS) Plan — A Medicare Advantage Plan in which you may go to any Medicareapproved doctor, hospital and provider that accepts the plan’s payment, terms and conditions and agrees to treat you – not all
providers will. If you join a PFFS Plan that has a network, you can see any of the network providers who have agreed to always
treat plan members. You will usually pay more to see out-of-network providers.
Medicare Special Needs Plan (SNP) — A Medicare Advantage Plan that has a benefit package designed for people with
special health care needs. Examples of the specific groups served
include people who have both Medicare and Medicaid, people who reside in nursing homes, and people who have certain
chronic medical conditions.
Medicare Medical Savings Account (MSA) Plan — MSA Plans combine a high deductible health plan with a bank
account. The plan deposits money from Medicare into the account. You can use it to pay your medical expenses until your
deductible is met.
Medicare Cost Plan — In a Medicare Cost Plan, you can go to providers both in and out of network. If you get services
outside of the plan’s network, your Medicare-covered services will be paid for under Original Medicare but you will be
responsible for Medicare coinsurance and deductibles.
1 of 3
Y0011_31990 0714R1 CMS Accepted
PERF 3/8”
PERF 3/8”
By signing this form, you agree to a meeting with a sales agent to discuss the types of products you initialed
above. Please note, the person who will discuss the products is either employed or contracted by a Medicare plan. They do not
work directly for the Federal government. This individual may also be paid based on your enrollment in a plan.
Signing this form does NOT obligate you to enroll in a plan, affect your current enrollment,
or enroll you in a Medicare plan.
Beneficiary or Authorized Representative Signature and Signature Date:
Signature:
Signature Date:
If you are the authorized representative, please sign above and print below:
Representative’s Name:_______________________________________________________________________
Your Relationship to the Beneficiary: ______________________________________________________________
To be completed by Agent:
Agent Name:
Agent Phone:
Beneficiary Name:
Beneficiary Phone (Optional):
Beneficiary Address (Optional):
Initial Method of Contact: (Indicate here if beneficiary was a walk-in.)
Agent’s Signature:
Plan(s) the agent represented during this meeting:
Date Appointment Completed:
[Plan Use Only:]
*Scope of Appointment documentation is subject to CMS record retention requirements*
Health insurance is offered by Blue Cross and Blue Shield of Florida, D/B/A Florida Blue. HMO coverage is offered by Health
Options, Inc., D/B/A Florida Blue HMO, an HMO subsidiary of Florida Blue. These companies are independent licensees of
the Blue Cross and Blue Shield Association.
2 of 3
PERF 3/8”
Agent, if the form was signed by the beneficiary at time of appointment, provide written
explanation below why SOA was not documented prior to meeting:
Florida Blue and Florida Blue HMO are Medicare Advantage organizations with a Medicare contract.
Enrollment in Florida Blue or Florida Blue HMO depends on contract renewal.
3 of 3
PLAN ENROLLMENT
What to Expect After You Enroll
Your First 90 days
Once you have joined the Blue Family, our focus is on comprehensive customer support following your enrollment through a variety of additional services! Over the next three months, we’d like the chance to get to know you and your health care needs. Below
are some key items we’ll be doing to be sure that you receive the maximum value of your plan benefits. Florida Blue and you – a
winning partnership in the pursuit of your health.
WHAT HAPPENS?
1
2
3
4
5
6
Copy of completed
paper
enrollment form
Notice to
confirm enrollment
Enrollment
Verification
HOW
Mailed
Mailed
Mailed
Copy of signed paper enrollment form is mailed to you for your records.
Timeline: 7–10 days
Florida Blue or Florida Blue HMO will send you a letter stating that your
enrollment has been approved and that enrollment is now completed.
Timeline: 7–10 days from receipt of eligibility confirmation
from the Centers for Medicare & Medicaid Services (CMS)
Medicare requires that we contact each new member to
make sure the Medicare Advantage plan you selected
was explained to you clearly and thoroughly. We also contact
members who change plan types. This will also allow you to verify
your intent to enroll in the plan and provide instructions on how to
cancel or change your plan if desired. You may receive a call from a
Florida Blue representative if additional information is needed to
process your enrollment.
Timeline: Within 15 days
Mailed
Your Welcome Package includes an Evidence of Coverage, which provides
detailed plan information, a list of the prescriptions that are covered by your
plan, a Provider Directory and other important information about your plan.
Timeline: Within 15 days
Online
By creating a personal account you can view claims history and status, access
claims forms and much more. Go to www.BlueMedicareFl.com to create
your personal account.
Timeline: You can sign up online as soon as you receive your
Welcome Packet.
Mailed
This ID card is what you should use every time you visit your physician,
hospital or pharmacy. Your ID card will be mailed first and is separate
from your Welcome Package.
Timeline: Within 15 days
Welcome Package
Online Account
Identification
Card (ID)
OVERVIEW
Y0011_32013 0714R1 CMS Accepted
PLAN ENROLLMENT
WHAT HAPPENS?
7
HOW
Member Events
Meeting
8
Annual Health
Assessment
Exam
OVERVIEW
Throughout the year you will receive information from Florida Blue
letting you know about seminars, events and health fairs in your area,
including new member meetings. We encourage you to take advantage
of these opportunities to learn more about the coverage, programs and
services that are available to you.
Timeline: Year Round
As part of the orientation process, you are strongly encouraged
to make an appointment with your physician to receive a current
checkup within the first 90 days of coverage. CMS recommends
that you have a follow-up visit with your doctor every six months.
Florida Blue has recently implemented new programs to help
your doctor thoroughly assess your total health care needs. Florida
Blue works with trusted business partners who may contact you to
coordinate a doctor’s office visit or a free checkup in your home.
Timeline: Within 90 days
Please contact us at 1-855-601-9465 for additional information. (TTY users call 1-800-955-8770). We are open from
8 a.m. - 8 p.m., 7 days a week. From February 15th to September 30th, we are open Monday - Friday 8 a.m. - 8 p.m.
Florida Blue is a PPO and RPPO Plan with a Medicare contract. Florida Blue HMO is an HMO plan with a Medicare contract.
Enrollment in Florida Blue or Florida Blue HMO depends on contract renewal.
NOTES
NOTES
2015
Florida Blue HMO is the trade name of Health Options Inc., an HMO subsidiary of Florida Blue,
an Independent Licensee of the Blue Cross and Blue Shield Association.