Blue Cross Blue Shield Healthcare Plan of Georgia - …...Tagalog: Mayroon kaming libreng serbisyo...

• How our members rate our plan's services and care;

• How well our doctors detect illnesses and keep members healthy;

• How well our plan helps our members use recommended and safe prescription medications

Image description. 3 Stars End of image description.

3 Stars

Image description. 5 stars End of image description.




Image description. 1 star End of image description.

The number of stars shows how well our plan performs.

excellent above average average below average poor

Blue Cross Blue Shield Healthcare Plan of Georgia - H5422

CY 2013 Medicare Plan Ratings

The Medicare Program rates all health and prescription drug plans each year, based on a plan's quality andperformance. Medicare Plan Ratings help you know how good a job our plan is doing. You can use this Plan Ratingto compare our plan's performance to other plans. Examples of the areas covered by this rating include:

For 2013, Blue Cross Blue Shield Healthcare Plan of Georgia received the following overall Plan Rating fromMedicare.

Learn more about our plan and how we are different from other plans at www.medicare.gov.

You may also contact us Sunday, Monday, Tuesday, Wednesday, Thursday, Friday, Saturday, 8:00 a.m. - 8:00p.m. Eastern at 800-797-1769 (toll-free) or 711 (TTY/TDD).

Current members please call 866-438-9968 (toll-free) or 711 (TTY/TDD).

Y0071_13_16142_U CMS Accepted 33551GASENHPG

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 1-866-438-9968. 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 1-866-438-9968. 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 1-866-438-9968。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1-866-438-9968。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 1-866-438-9968. 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 1-866-438-9968. 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 1-866-438-9968 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 1-866-438-9968. 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 제공하 고 있습니다. 통역 서비스를 이용하려면 전화 1-866-438-9968 번으로 문의해 주십시오. 한국어를 하 는 담당자가 도와 드릴 것입니다. 이 서비스는 무료로 운영됩니다.

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 1-866-438-9968. Вам окажет помощь сотрудник, который говорит по-pусски. Данная услуга бесплатная.

Arabic:إننا نقدم خدمات المترجم الفوري المجانية لإلجابة عن أي أسئلة تتعلق بالصحة أو جدول األدوية لدينا .

سيقوم شخص1-668-834-8699.للحصول على مترجم فوري، ليس عليك سوى االتصال بنا على. ما يتحدث العربية بمساعدتك. هذه خدمة مجانية

Hindi: हमार ेसवासथय या दवा की योजना क ेबार ेमे ंआपक ेिकसी भी पशन क ेजवाब देन ेक ेिलए हमार ेपास मुफत दुभािषया सेवाए ँउपलबध हैं. एक दुभाियषा परापत करन ेक ेिलए, बस हमे ं1-866-438-9968 पर फोन करें. कोई वयिकत जो िहनदी बोलता ह ैआपकी मदद कर सकता है. यह एक मुफत 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 1-866-438-9968. 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 1-866-438-9968. 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 1-866-438-9968. 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 1-866-438-9968. 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、1-866-438-9968 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。

Y0071_14_18283_U_012 CMS Accepted 30879MUSMLMUB_012

Summary of Benefitsfor BlueValue Basic (HMO) and BlueValue Secure(HMO)

Available in DeKalb, Forsyth, Fulton, and Harris Counties, GA

Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. is an HMO plan with a Medicare contract.Enrollment in Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. depends on contract renewal. BlueCross and Blue Shield of Georgia, Inc. and Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. areindependent licensees of the Blue Cross and Blue Shield Association. The Blue Cross and Blue Shieldnames and symbols are registered marks of the Blue Cross and Blue Shield Association.

Y0071_14_17591_U_030 CMS Accepted 10/01/2013 38881MUSENMUB_030H5422_006_002_GA_HMO

Section I:

Introduction to Summary of BenefitsThank you for your interest in BlueValue Basic (HMO) and BlueValue Secure (HMO). Our plans are offered byBLUE CROSS BLUE SHIELD HEALTHCARE PLAN OF GEORGIA which is also called Blue Cross Blue ShieldHealthcare Plan of Georgia, a Medicare Advantage Health Maintenance Organization (HMO) that contracts with theFederal government. This Summary of Benefits tells you some features of our plan. It doesn't list every service that wecover or list every limitation or exclusion. To get a complete list of our benefits, please call BlueValue Basic (HMO)and BlueValue Secure (HMO) and ask for the "Evidence of Coverage."

You have choices in your health careAs a Medicare beneficiary, you can choose from differentMedicare options. One option is the Original(Fee-for-Service) Medicare Plan. Another option is aMedicare health plan, like BlueValue Basic (HMO) andBlueValue Secure (HMO). You may have other optionstoo. You make the choice. No matter what you decide,you are still in the Medicare Program.

You may join or leave a plan only at certain times. Pleasecall BlueValue Basic (HMO) and BlueValue Secure(HMO) at the telephone number listed at the end of thisintroduction or 1-800-MEDICARE (1-800-633-4227)for more information. TTY/TDD users should call1-877-486-2048. You can call this number 24 hours aday, 7 days a week.

How can I compare my options?You can compare BlueValue Basic (HMO) andBlueValue Secure (HMO) and the Original MedicarePlan using this Summary of Benefits. The charts in thisbooklet list some important health benefits. For eachbenefit, you can see what our plan covers and what theOriginal Medicare Plan covers.

Our members receive all of the benefits that the OriginalMedicare Plan offers. We also offer more benefits, whichmay change from year to year.

Where are BlueValue Basic (HMO) andBlueValue Secure (HMO) available?The service area for these plans includes:

DeKalb, Forsyth, Fulton, Harris Counties, GA.

You must live in one of these areas to join the plan.

There is more than one plan listed in this Summary ofBenefits.

Who is eligible to join BlueValue Basic(HMO) and BlueValue Secure (HMO)?You can join BlueValue Basic (HMO) and BlueValueSecure (HMO) if you are entitled to Medicare Part Aand enrolled in Medicare Part B and live in the servicearea. However, individuals with End-Stage Renal Diseasegenerally are not eligible to enroll in BlueValue Basic(HMO) and BlueValue Secure (HMO) unless they aremembers of our organization and have been since theirdialysis began.

Can I Choose My Doctors?BlueValue Basic (HMO) and BlueValue Secure (HMO)have formed a network of doctors, specialists, andhospitals. You can only use doctors who are part of ournetwork. The health providers in our network can changeat any time.

You can ask for a current provider directory. For anupdated list, visit us athttp://www.bcbsga.com/medicare. Our customer servicenumber is listed at the end of this introduction.

What happens if I go to a doctor who'snot in your network?If you choose to go to a doctor outside of our network,you must pay for these services yourself. Neither the plannor the Original Medicare Plan will pay for these servicesexcept in limited situations (for example, emergency care).

Page 2 – BlueValue Basic (HMO) and BlueValue Secure (HMO)

Where can I get my prescriptions if Ijoin these plans?BlueValue Basic (HMO) and BlueValue Secure (HMO)have formed a network of pharmacies. You must use anetwork pharmacy to receive plan benefits. We may notpay for your prescriptions if you use an out-of-networkpharmacy, except in certain cases. The pharmacies in ournetwork can change at any time. You can ask for apharmacy directory or visit us athttp://www.bcbsga.com/medicare. Our customer servicenumber is listed at the end of this introduction.

BlueValue Basic (HMO) and BlueValue Secure (HMO)have a list of preferred pharmacies. At these pharmacies,you may get your drugs at a lower co-pay or co-insurance.You may go to a non-preferred pharmacy, but you mayhave to pay more for your prescription drugs.

What if my doctor prescribes less thana month's supply?In consultation with your doctor or pharmacist, you mayreceive less than a month's supply of certain drugs. Also,if you live in a long-term care facility, you will receiveless than a month's supply of certain brand and genericdrugs. Dispensing fewer drugs at a time can help reducecost and waste in the Medicare Part D program, whenthis is medically appropriate.

The amount you pay in these circumstances will dependon whether you are responsible for paying coinsurance(a percentage of the cost of the drug) or a copay (a flatdollar amount for the drug). If you are responsible forcoinsurance for the drug, you will continue to pay theapplicable percentage of the drug cost. If you areresponsible for a copay for the drug, a "daily cost-sharingrate" will be applied. If your doctor decides to continuethe drug after a trial period, you should not pay more fora month's supply than you otherwise would have paid.Contact your plan if you have questions aboutcost-sharing when less than a one-month supply isdispensed.

Does my plan cover Medicare Part Bor Part D drugs?BlueValue Basic (HMO) and BlueValue Secure (HMO)do cover both Medicare Part B prescription drugs andMedicare Part D prescription drugs.

What is a prescription drug formulary?BlueValue Basic (HMO) and BlueValue Secure (HMO)use a formulary. A formulary is a list of drugs covered byyour plan to meet patient needs. We may periodicallyadd, remove, or make changes to coverage limitations oncertain drugs or change how much you pay for a drug.If we make any formulary change that limits ourmembers' ability to fill their prescriptions, we will notifythe affected members before the change is made. We willsend a formulary to you and you can see our completeformulary on our Web site athttp://www.bcbsga.com/medicare.

If you are currently taking a drug that is not on ourformulary or subject to additional requirements or limits,you may be able to get a temporary supply of the drug.You can contact us to request an exception or switch toan alternative drug listed on our formulary with yourphysician's help. Call us to see if you can get a temporarysupply of the drug or for more details about our drugtransition policy.

How can I get extra help with myprescription drug plan costs or getextra help with other Medicare costs?You may be able to get extra help to pay for yourprescription drug premiums and costs as well as get helpwith other Medicare costs. To see if you qualify forgetting extra help, call:

* 1-800-MEDICARE (1-800-633-4227). TTY/TDDusers should call 1-877-486-2048, 24 hours a day/7 daysa week; and see http://www.medicare.gov 'Programsfor People with Limited Income and Resources' in thepublication Medicare & You.

* The Social Security Administration at 1-800-772-1213between 7 a.m. and 7 p.m., Monday through Friday.TTY/TDD users should call 1-800-325-0778; or

* Your State Medicaid Office.


What are my protections in theseplans?All Medicare Advantage Plans agree to stay in theprogram for a full calendar year at a time. Plan benefitsand cost-sharing may change from calendar year tocalendar year. Each year, plans can decide whether tocontinue to participate with Medicare Advantage. A planmay continue in their entire service area (geographic areawhere the plan accepts members) or choose to continueonly in certain areas. Also, Medicare may decide to enda contract with a plan. Even if your Medicare AdvantagePlan leaves the program, you will not lose Medicarecoverage. If a plan decides not to continue for anadditional calendar year, it must send you a letter at least90 days before your coverage will end. The letter willexplain your options for Medicare coverage in your area.

As a member of BlueValue Basic (HMO) and BlueValueSecure (HMO), you have the right to request anorganization determination, which includes the right tofile an appeal if we deny coverage for an item or service,and the right to file a grievance. You have the right torequest an organization determination if you want us toprovide or pay for an item or service that you believeshould be covered. If we deny coverage for your requesteditem or service, you have the right to appeal and ask usto review our decision. You may ask us for an expedited(fast) coverage determination or appeal if you believe thatwaiting for a decision could seriously put your life orhealth at risk, or affect your ability to regain maximumfunction. If your doctor makes or supports the expeditedrequest, we must expedite our decision. Finally, you havethe right to file a grievance with us if you have any typeof problem with us or one of our network providers thatdoes not involve coverage for an item or service. If yourproblem involves quality of care, you also have the rightto file a grievance with the Quality ImprovementOrganization (QIO) for your state. Please refer to theEvidence of Coverage (EOC) for the QIO contactinformation.

As a member of BlueValue Basic (HMO) and BlueValueSecure (HMO), you have the right to request a coveragedetermination, which includes the right to request anexception, the right to file an appeal if we deny coveragefor a prescription drug, and the right to file a grievance.You have the right to request a coverage determination

if you want us to cover a Part D drug that you believeshould be covered. An exception is a type of coveragedetermination. You may ask us for an exception if youbelieve you need a drug that is not on our list of covereddrugs or believe you should get a non-preferred drug ata lower out-of-pocket cost. You can also ask for anexception to cost utilization rules, such as a limit on thequantity of a drug. If you think you need an exception,you should contact us before you try to fill yourprescription at a pharmacy. Your doctor must provide astatement to support your exception request. If we denycoverage for your prescription drug(s), you have the rightto appeal and ask us to review our decision. Finally, youhave the right to file a grievance if you have any type ofproblem with us or one of our network pharmacies thatdoes not involve coverage for a prescription drug. If yourproblem involves quality of care, you also have the rightto file a grievance with the Quality ImprovementOrganization (QIO) for your state. Please refer to theEvidence of Coverage (EOC) for the QIO contactinformation.

What is a Medication TherapyManagement (MTM) Program?A Medication Therapy Management (MTM) Programis a free service we offer. You may be invited to participatein a program designed for your specific health andpharmacy needs. You may decide not to participate butit is recommended that you take full advantage of thiscovered service if you are selected. Contact BlueValueBasic (HMO) and BlueValue Secure (HMO) for moredetails.

What types of drugs may be coveredunder Medicare Part B?Some outpatient prescription drugs may be covered underMedicare Part B. These may include, but are not limitedto, the following types of drugs. Contact BlueValue Basic(HMO) and BlueValue Secure (HMO) for more details.

Some Antigens: If they are prepared by a doctor andadministered by a properly instructed person (whocould be the patient) under doctor supervision.Osteoporosis Drugs: Injectable osteoporosis drugs forsome women.


Erythropoietin: By injection if you have end-stagerenal disease (permanent kidney failure requiringeither dialysis or transplantation) and need this drugto treat anemia.Hemophilia Clotting Factors: Self-administeredclotting factors if you have hemophilia.Injectable Drugs: Most injectable drugs administeredincident to a physician's service.Immunosuppressive Drugs: Immunosuppressive drugtherapy for transplant patients if the transplant tookplace in a Medicare-certified facility and was paid forby Medicare or by a private insurance company thatwas the primary payer for Medicare Part A coverage.Some Oral Cancer Drugs: If the same drug is availablein injectable form.Oral Anti-Nausea Drugs: If you are part of ananti-cancer chemotherapeutic regimen.

Inhalation and Infusion Drugs administered throughDurable Medical Equipment.

Where can I find information on planratings?The Medicare program rates how well plans perform indifferent categories (for example, detecting and preventingillness, ratings from patients and customer service). Ifyou have access to the web, you can find the Plan Ratingsinformation by using the “Find health & drug plans”web tool on http://www.medicare.gov to compare theplan ratings for Medicare plans in your area. You canalso call us directly to obtain a copy of the Plan Ratingsfor these plans. Our customer service number is listedbelow.

Please call Blue Cross Blue Shield Healthcare Plan of Georgia for more information aboutBlueValue Basic (HMO) and BlueValue Secure (HMO) Visit us at http://www.bcbsga.com/medicare or, call us:

Customer Service Hours for October 1 – February 14: Sunday, Monday, Tuesday,Wednesday, Thursday, Friday, Saturday, 8:00 a.m. - 8:00 p.m. Eastern Customer Service Hours for February 15 – September 30: Monday, Tuesday,Wednesday, Thursday, Friday, 8:00 a.m. - 8:00 p.m. Eastern Current members should call toll-free 1-866-438-9968 for questions related to theMedicare Advantage and Medicare Part D Prescription Drug Program. (TTY/TDD 711) Prospective members should call toll-free 1-800-797-1769 for questions related tothe Medicare Advantage and Medicare Part D Prescription Drug Program. (TTY/TDD711) Current members should call locally 1-866-438-9968 for questions related to theMedicare Advantage and Medicare Part D Prescription Drug Program. (TTY/TDD 711) Prospective members should call locally 1-800-797-1769 for questions related tothe Medicare Advantage and Medicare Part D Prescription Drug Program. (TTY/TDD711)


For more information about Medicare, please call Medicare at 1-800-MEDICARE(1-800-633-4227). TTY users should call 1-877-486-2048. You can call 24 hours aday, 7 days a week. Or, visit http://www.medicare.gov on the web.

This document may be available in other formats such as Braille, large print or otheralternate formats.

This document may be available in a non-English language. For additional information,call customer service at the phone number listed above.

Este documento podría estar disponible en otros formatos como Braille, textos conletras grandes u otros formatos. Este documento podría estar disponible en idiomas distintos del inglés. Comuníquesecon el número de nuestro Servicio de Atención al Cliente, indicado anteriormente,para obtener más información


BlueValue Secure(HMO)

BlueValue Basic(HMO)

Original MedicareBenefit

IMPORTANT INFORMATION

General$49 monthly plan premiumin addition to your monthlyMedicare Part B premium.

General$21 monthly plan premiumin addition to your monthlyMedicare Part B premium.

In 2013 the monthly Part BPremium was $104.90 andmay change for 2014 and theannual Part B deductible

1 Premium andOther ImportantInformation

amount was $147 and maychange for 2014.

Most people will pay thestandard monthly Part B

Most people will pay thestandard monthly Part B

premium in addition to theirpremium in addition to theirIf a doctor or supplier doesnot accept assignment, their MA plan premium. However,

some people will pay higherMA plan premium. However,some people will pay highercosts are often higher, which

means you pay more. Part B and Part D premiumsbecause of their yearly income

Part B and Part D premiumsbecause of their yearly incomeMost people will pay the

standard monthly Part B (over $85,000 for singles,$170,000 for married

(over $85,000 for singles,$170,000 for marriedpremium. However, some

couples). For morecouples). For morepeople will pay a higherinformation about Part B andinformation about Part B andpremium because of theirPart D premiums based onPart D premiums based onyearly income (over $85,000income, call Medicare atincome, call Medicare atfor singles, $170,000 for1-800-MEDICARE1-800-MEDICAREmarried couples). For more(1-800-633-4227). TTY(1-800-633-4227). TTYinformation about Part Busers should callusers should callpremiums based on income,1-877-486-2048. You may1-877-486-2048. You maycall Medicare atalso call Social Security atalso call Social Security at1-800-MEDICARE1-800-772-1213. TTY usersshould call 1-800-325-0778.

1-800-772-1213. TTY usersshould call 1-800-325-0778.

(1-800-633-4227). TTYusers should call1-877-486-2048. You may In-Network

$5,100 out-of-pocket limitfor Medicare-covered services.

In-Network$5,500 out-of-pocket limitfor Medicare-covered services.

also call Social Security at1-800-772-1213. TTY usersshould call 1-800-325-0778.

If you have any questions about this plan's benefits or costs, please contactBlue Cross Blue Shield Healthcare Plan of Georgia for details

Section II:

Summary of Benefits





In-NetworkYou must go to networkdoctors, specialists, andhospitals.

In-NetworkYou must go to networkdoctors, specialists, andhospitals.

You may go to any doctor,specialist or hospital thataccepts Medicare.

2 Doctor andHospital Choice(For moreinformation, seeEmergency Care- #15 andUrgently NeededCare - #16.)

No referral required fornetwork doctors, specialists,and hospitals.

No referral required fornetwork doctors, specialists,and hospitals.

SUMMARY OF BENEFITS

Inpatient Care

In-NetworkNo limit to the number ofdays covered by the plan eachhospital stay.

In-NetworkNo limit to the number ofdays covered by the plan eachhospital stay.

In 2013 the amounts for eachbenefit period were:

3 InpatientHospital Care(includesSubstance AbuseandRehabilitationServices)

Days 1 - 60: $1,184deductible

For Medicare-covered hospitalstays:


Days 61 - 90: $296 perdayDays 91 - 150: $592 perlifetime reserve day

Days 1 - 6: $275 copayper day


These amounts may changefor 2014.

Days 7 - 90: $0 copay perday

Days 7 - 90: $0 copay perday

$0 copay for additionalnon-Medicare-coveredhospital days

$0 copay for additionalnon-Medicare-coveredhospital days

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

Except in an emergency, yourdoctor must tell the plan that

Except in an emergency, yourdoctor must tell the plan that

information about lifetimereserve days.

you are going to be admittedto the hospital.


Lifetime reserve days can onlybe used once.

A "benefit period" starts theday you go into a hospital orskilled nursing facility. It endswhen you go for 60 days in arow without hospital orskilled nursing care. If you gointo the hospital after onebenefit period has ended, anew benefit period begins.





You must pay the inpatienthospital deductible for eachbenefit period. There is nolimit to the number of benefitperiods you can have.

In-NetworkYou get up to 190 days ofinpatient psychiatric hospital

In-NetworkYou get up to 190 days ofinpatient psychiatric hospital

In 2013 the amounts for eachbenefit period were:

4 Inpatient MentalHealth Care

Days 1 - 60: $1,184deductible care in a lifetime. Inpatient

psychiatric hospital servicescare in a lifetime. Inpatientpsychiatric hospital servicesDays 61 - 90: $296 per

day count toward the 190-daylifetime limitation only if

count toward the 190-daylifetime limitation only ifDays 91 - 150: $592 per

lifetime reserve day certain conditions are met.This limitation does not apply

certain conditions are met.This limitation does not apply


to inpatient psychiatricservices furnished in a generalhospital.

to inpatient psychiatricservices furnished in a generalhospital.



You get up to 190 days ofinpatient psychiatric hospitalcare in a lifetime. Inpatient Days 1 - 6: $245 copay

per dayDays 1 - 6: $239 copayper daypsychiatric hospital services

count toward the 190-day Days 7 - 90: $0 copay perday

Days 7 - 90: $0 copay perdaylifetime limitation only if

certain conditions are met.Plan covers 60 lifetime reservedays. $0 copay per lifetimereserve day.

Plan covers 60 lifetime reservedays. $0 copay per lifetimereserve day.

This limitation does not applyto inpatient psychiatricservices furnished in a generalhospital. Except in an emergency, your

doctor must tell the plan thatExcept in an emergency, yourdoctor must tell the plan that



GeneralAuthorization rules mayapply.


In 2013 the amounts for eachbenefit period after at least a3-day Medicare-coveredhospital stay were:

5 Skilled NursingFacility (SNF)(in aMedicare-certifiedskilled nursingfacility)

In-NetworkPlan covers up to 100 dayseach benefit period

In-NetworkPlan covers up to 100 dayseach benefit period

Days 1 - 20: $0 per dayDays 21 - 100: $148 perday No prior hospital stay is

required.No prior hospital stay isrequired.






For SNF stays:For SNF stays:



Days 21 - 100: $125copay per day

Days 21 - 100: $110copay per day

100 days for each benefitperiod.

A "benefit period" starts theday you go into a hospital orSNF. It ends when you go for60 days in a row withouthospital or skilled nursingcare. If you go into thehospital after one benefitperiod has ended, a newbenefit period begins. Youmust pay the inpatienthospital deductible for eachbenefit period. There is nolimit to the number of benefitperiods you can have.



$0 copay.6 Home HealthCare(includesmedicallynecessaryintermittentskilled nursingcare, home healthaide services, andrehabilitationservices, etc.)

In-Network$0 copay for eachMedicare-covered homehealth visit

In-Network$0 copay for eachMedicare-covered homehealth visit

GeneralYou must get care from aMedicare-certified hospice.

GeneralYou must get care from aMedicare-certified hospice.

You pay part of the cost foroutpatient drugs and inpatientrespite care.

7 Hospice

You must consult with yourplan before you select hospice.

You must consult with yourplan before you select hospice.

You must get care from aMedicare-certified hospice.

5 Skilled NursingFacility (SNF)(in aMedicare-certifiedskilled nursingfacility)(continued)





OUTPATIENT CARE

In-Network$10 copay for eachMedicare-covered primarycare doctor visit.

In-Network$20 copay for eachMedicare-covered primarycare doctor visit.

20% coinsurance8 Doctor OfficeVisits

$35 copay for eachMedicare-covered specialistvisit.

$50 copay for eachMedicare-covered specialistvisit.



Supplemental routine care notcovered

20% coinsurance for manualmanipulation of the spine to

9 ChiropracticServices

In-Network$20 copay for eachMedicare-covered chiropracticvisit

In-Network$20 copay for eachMedicare-covered chiropracticvisit

correct subluxation (adisplacement or misalignmentof a joint or body part).

Medicare-covered chiropracticvisits are for manual

Medicare-covered chiropracticvisits are for manual

manipulation of the spine tomanipulation of the spine tocorrect subluxation (acorrect subluxation (adisplacement or misalignmentof a joint or body part).

displacement or misalignmentof a joint or body part).

In-Network$35 copay for eachMedicare-covered podiatryvisit

In-Network$50 copay for eachMedicare-covered podiatryvisit

Supplemental routine care notcovered.

20% coinsurance formedically necessary foot care,

10 Podiatry Services

including care for medical Medicare-covered podiatryvisits are for medicallynecessary foot care.

Medicare-covered podiatryvisits are for medicallynecessary foot care.

conditions affecting the lowerlimbs.



20% coinsurance for mostoutpatient mental healthservices

11 OutpatientMental HealthCare

In-Network$40 copay for eachMedicare-covered individualtherapy visit

In-Network$40 copay for eachMedicare-covered individualtherapy visit

Specified copayment foroutpatient partialhospitalization programservices furnished by ahospital or community mental





$40 copay for eachMedicare-covered grouptherapy visit

$40 copay for eachMedicare-covered grouptherapy visit

health center (CMHC).Copay cannot exceed the PartA inpatient hospitaldeductible. $40 copay for each

Medicare-covered individual$40 copay for eachMedicare-covered individual"Partial hospitalization

program" is a structured therapy visit with apsychiatrist

therapy visit with apsychiatristprogram of active outpatient

psychiatric treatment that is $40 copay for eachMedicare-covered group

$40 copay for eachMedicare-covered groupmore intense than the care

received in your doctor's or therapy visit with apsychiatrist

therapy visit with apsychiatristtherapist's office and is an

alternative to inpatienthospitalization. $40 copay for

Medicare-covered partial$40 copay forMedicare-covered partial

hospitalization programservices

hospitalization programservices



20% coinsurance12 OutpatientSubstance AbuseCare

In-Network$40 copay forMedicare-covered individual

In-Network$40 copay forMedicare-covered individual

substance abuse outpatienttreatment visits


$40 copay forMedicare-covered group

$40 copay forMedicare-covered group





20% coinsurance for thedoctor's services

Specified copayment foroutpatient hospital facility

13 OutpatientServices

In-Network0% to 20% of the cost foreach Medicare-covered

In-Network0% to 20% of the cost foreach Medicare-covered

services Copay cannot exceedthe Part A inpatient hospitaldeductible. ambulatory surgical center

visitambulatory surgical centervisit20% coinsurance for

ambulatory surgical centerfacility services

$0 to $35 copay [or 0% to20% of the cost] for each

11 OutpatientMental HealthCare(continued)





Medicare-covered outpatienthospital facility visit

$0 to $50 copay [or 0% to20% of the cost] for eachMedicare-covered outpatienthospital facility visit



20% coinsurance14 AmbulanceServices(medicallynecessaryambulanceservices)

In-Network$200 copay forMedicare-covered ambulancebenefits.

In-Network$250 copay forMedicare-covered ambulancebenefits.

General$65 copay forMedicare-covered emergencyroom visits

General$65 copay forMedicare-covered emergencyroom visits

20% coinsurance for thedoctor's services

Specified copayment foroutpatient hospital facilityemergency services.

15 Emergency Care(You may go toany emergencyroom if youreasonably believeyou needemergency care.)

Worldwide coverage.Worldwide coverage.

Emergency services copaycannot exceed Part Ainpatient hospital deductiblefor each service provided bythe hospital.

You don't have to pay theemergency room copay if youare admitted to the hospitalas an inpatient for the samecondition within 3 days of theemergency room visit.

Not covered outside the U.S.except under limitedcircumstances.

General$40 copay forMedicare-coveredurgently-needed-care visits

General$40 copay forMedicare-coveredurgently-needed-care visits

20% coinsurance, or a setcopay

If you are admitted to thehospital within 3 days for the

16 Urgently NeededCare(This is NOTemergency care,and in most cases,is out of theservice area.)

same condition, you pay $0for the urgently-needed-carevisit.

13 OutpatientServices(continued)





NOT covered outside theU.S. except under limitedcircumstances.



20% coinsurance

Medically necessary physicaltherapy, occupational therapy,

17 OutpatientRehabilitationServices(OccupationalTherapy, PhysicalTherapy, Speechand LanguageTherapy)

Medically necessary physicaltherapy, occupational therapy,and speech and languagepathology services are covered.

In-Network$35 copay forMedicare-coveredOccupational Therapy visits

Medically necessary physicaltherapy, occupational therapy,and speech and languagepathology services are covered.

In-Network$50 copay forMedicare-coveredOccupational Therapy visits

and speech and languagepathology services are covered.

$35 copay forMedicare-covered Physical

$50 copay forMedicare-covered Physical

Therapy and/or Speech andLanguage Pathology visits

Therapy and/or Speech andLanguage Pathology visits

Outpatient Medical Services and Supplies



20% coinsurance18 Durable MedicalEquipment(includeswheelchairs,oxygen, etc.) In-Network

20% of the cost forMedicare-covered durablemedical equipment

In-Network20% of the cost forMedicare-covered durablemedical equipment



20% coinsurance

20% coinsurance forMedicare-covered medical

19 ProstheticDevices(includes braces,artificial limbsand eyes, etc.) In-Network

20% of the cost forMedicare-covered prostheticdevices

In-Network20% of the cost forMedicare-covered prostheticdevices

supplies related to prosthetics,splints, and other devices.

20% of the cost forMedicare-covered medical

20% of the cost forMedicare-covered medical





supplies related to prosthetics,splints, and other devices

supplies related to prosthetics,splints, and other devices



20% coinsurance for diabetesself-management training

20% coinsurance for diabetessupplies

20 DiabetesPrograms andSupplies

In-Network$0 copay forMedicare-covered Diabetesself-management training

In-Network$0 copay forMedicare-covered Diabetesself-management training

20% coinsurance for diabetictherapeutic shoes or inserts

$0 copay forMedicare-covered Diabetesmonitoring supplies

$0 copay forMedicare-covered Diabetesmonitoring supplies

$0 copay forMedicare-coveredTherapeutic shoes or inserts

$0 copay forMedicare-coveredTherapeutic shoes or inserts

Diabetic Supplies and Servicesare limited to specific

Diabetic Supplies and Servicesare limited to specific

manufacturers, products and/manufacturers, products and/or brands. Contact the planfor a list of covered supplies.

or brands. Contact the planfor a list of covered supplies.



20% coinsurance fordiagnostic tests and x-rays

$0 copay forMedicare-covered lab services

21 Diagnostic Tests,X-Rays, LabServices, andRadiologyServices In-Network

$20 copay forMedicare-covered lab services

In-Network$25 copay forMedicare-covered lab services

Lab Services: Medicare coversmedically necessary diagnostic

$0 to $185 copay forMedicare-covered diagnosticprocedures and tests

$0 to $250 copay forMedicare-covered diagnosticprocedures and tests

lab services that are orderedby your treating doctor whenthey are provided by aClinical Laboratory $85 copay for

Medicare-covered X-rays$85 copay forMedicare-covered X-raysImprovement Amendments

(CLIA) certified laboratory$85 to $185 copay forMedicare-covered diagnostic

$85 to $250 copay forMedicare-covered diagnostic

that participates in Medicare.Diagnostic lab services are

radiology services (notincluding X-rays)

radiology services (notincluding X-rays)

done to help your doctordiagnose or rule out asuspected illness or condition.





20% of the cost forMedicare-covered therapeuticradiology services

20% of the cost forMedicare-covered therapeuticradiology services

Medicare does not cover mostsupplemental routinescreening tests, like checkingyour cholesterol. If the doctor provides you

services in addition toIf the doctor provides youservices in addition to

Outpatient DiagnosticOutpatient DiagnosticProcedures, Tests and LabProcedures, Tests and LabServices, separate cost sharingof $10 to $35 may apply

Services, separate cost sharingof $20 to $50 may apply

If the doctor provides youservices in addition to

If the doctor provides youservices in addition to

Outpatient Diagnostic andOutpatient Diagnostic andTherapeutic RadiologyTherapeutic RadiologyServices, separate cost sharingof $10 to $35 may apply

Services, separate cost sharingof $20 to $50 may apply

In-Network$35 copay forMedicare-covered CardiacRehabilitation Services

In-Network$50 copay forMedicare-covered CardiacRehabilitation Services

20% coinsurance for CardiacRehabilitation services

20% coinsurance forPulmonary Rehabilitationservices

22 Cardiac andPulmonaryRehabilitationServices

$35 copay forMedicare-covered Intensive

$50 copay forMedicare-covered Intensive20% coinsurance for

Intensive CardiacRehabilitation services

Cardiac RehabilitationServices

$35 copay forMedicare-covered PulmonaryRehabilitation Services

Cardiac RehabilitationServices

$50 copay forMedicare-covered PulmonaryRehabilitation Services

PREVENTIVE SERVICES

General$0 copay for all preventiveservices covered under

General$0 copay for all preventiveservices covered under

No coinsurance, copaymentor deductible for thefollowing:

23 PreventiveServices

Original Medicare at zero costsharing.

Original Medicare at zero costsharing.

Abdominal AorticAneurysm Screening

Any additional preventiveservices approved by Medicare

Any additional preventiveservices approved by Medicare

21 Diagnostic Tests,X-Rays, LabServices, andRadiologyServices(continued)





mid-year will be covered bythe plan or by OriginalMedicare.

mid-year will be covered bythe plan or by OriginalMedicare.

Bone Mass Measurement.Covered once every 24months (more often ifmedically necessary) if youmeet certain medicalconditions.Cardiovascular ScreeningCervical and VaginalCancer Screening.Covered once every 2years. Covered once a yearfor women with Medicareat high risk.Colorectal CancerScreeningDiabetes ScreeningInfluenza VaccineHepatitis B Vaccine forpeople with Medicare whoare at riskHIV Screening. $0 copayfor the HIV screening, butyou generally pay 20% ofthe Medicare-approvedamount for the doctor'svisit. HIV screening iscovered for people withMedicare who arepregnant and people atincreased risk for theinfection, includinganyone who asks for thetest. Medicare covers thistest once every 12 monthsor up to three times duringa pregnancy.

23 PreventiveServices(continued)





Breast Cancer Screening(Mammogram). Medicarecovers screeningmammograms once every12 months for all womenwith Medicare age 40 andolder. Medicare covers onebaseline mammogram forwomen between ages35-39.Medical NutritionTherapy ServicesNutrition therapy is forpeople who have diabetesor kidney disease (butaren't on dialysis orhaven't had a kidneytransplant) when referredby a doctor. These servicescan be given by aregistered dietitian andmay include a nutritionalassessment and counselingto help you manage yourdiabetes or kidney diseasePersonalized PreventionPlan Services (AnnualWellness Visits)Pneumococcal Vaccine.You may only need thePneumonia vaccine oncein your lifetime. Call yourdoctor for moreinformation.Prostate Cancer ScreeningProstate Specific Antigen(PSA) test only. Coveredonce a year for all menwith Medicare over age 50.






Smoking and Tobacco UseCessation (counseling tostop smoking and tobaccouse). Covered if orderedby your doctor. Includestwo counseling attemptswithin a 12-month period.Each counseling attemptincludes up to fourface-to-face visits.Screening and behavioralcounseling interventionsin primary care to reducealcohol misuseScreening for depressionin adultsScreening for sexuallytransmitted infections(STI) and high-intensitybehavioral counseling toprevent STIsIntensive behavioralcounseling forCardiovascular Disease(bi-annual)Intensive behavioraltherapy for obesityWelcome to MedicarePreventive Visits (initialpreventive physical exam)When you join MedicarePart B, then you areeligible as follows. Duringthe first 12 months of yournew Part B coverage, youcan get either a Welcometo Medicare PreventiveVisits or an AnnualWellness Visit. After yourfirst 12 months, you canget one Annual WellnessVisit every 12 months.






In-Network20% of the cost forMedicare-covered renaldialysis

In-Network20% of the cost forMedicare-covered renaldialysis

20% coinsurance for renaldialysis

20% coinsurance for kidneydisease education services

24 Kidney Diseaseand Conditions

$0 copay forMedicare-covered kidneydisease education services

$0 copay forMedicare-covered kidneydisease education services

PRESCRIPTION DRUG BENEFITS

Drugs Covered UnderMedicare Part BGeneral20% of the cost for MedicarePart B chemotherapy drugsand other Part B drugs.

Drugs Covered UnderMedicare Part BGeneral20% of the cost for MedicarePart B chemotherapy drugsand other Part B drugs.

Most drugs are not coveredunder Original Medicare. Youcan add prescription drugcoverage to Original Medicareby joining a MedicarePrescription Drug Plan, oryou can get all your Medicare

25 OutpatientPrescriptionDrugs

Drugs Covered UnderMedicare Part DGeneralThis plan uses a formulary.The plan will send you the

Drugs Covered UnderMedicare Part DGeneralThis plan uses a formulary.The plan will send you the

coverage, includingprescription drug coverage, byjoining a Medicare AdvantagePlan or a Medicare Cost Planthat offers prescription drugcoverage.

formulary. You can also seethe formulary at http://

formulary. You can also seethe formulary at http://

www.bcbsga.com/medicareon the web.

www.bcbsga.com/medicareon the web.

Different out-of-pocket costsmay apply for people who

Different out-of-pocket costsmay apply for people who

have limited incomes,have limited incomes,live in long term carefacilities, or

live in long term carefacilities, orhave access to Indian/Tribal/Urban (IndianHealth Service) providers.

have access to Indian/Tribal/Urban (IndianHealth Service) providers.

The plan offers nationalin-network prescription

The plan offers nationalin-network prescription

coverage (i.e., this would coverage (i.e., this wouldinclude 50 states and the include 50 states and theDistrict of Columbia). This District of Columbia). Thismeans that you will pay the means that you will pay thesame cost-sharing amount for same cost-sharing amount for





your prescription drugs if youget them at an in-network

your prescription drugs if youget them at an in-network

pharmacy outside of the plan'spharmacy outside of the plan'sservice area (for instance whenyou travel).

service area (for instance whenyou travel).

Total yearly drug costs are thetotal drug costs paid by bothyou and a Part D plan.

Total yearly drug costs are thetotal drug costs paid by bothyou and a Part D plan.

The plan may require you tofirst try one drug to treat your

The plan may require you tofirst try one drug to treat your

condition before it will covercondition before it will coveranother drug for thatcondition.

another drug for thatcondition.

Some drugs have quantitylimits.

Some drugs have quantitylimits.

Your provider must get priorauthorization from BlueValue

Your provider must get priorauthorization from BlueValue

Secure (HMO) for certaindrugs.

Basic (HMO) for certaindrugs.

You must go to certainpharmacies for a very limited

You must go to certainpharmacies for a very limited

number of drugs, due tonumber of drugs, due tospecial handling, providerspecial handling, providercoordination, or patientcoordination, or patienteducation requirements thateducation requirements thatcannot be met by mostcannot be met by mostpharmacies in your network.pharmacies in your network.These drugs are listed on theThese drugs are listed on theplan's website, formulary,plan's website, formulary,printed materials, as well asprinted materials, as well ason the Medicare Prescriptionon the Medicare PrescriptionDrug Plan Finder onMedicare.gov.

Drug Plan Finder onMedicare.gov.

If the actual cost of a drug isless than the normal

If the actual cost of a drug isless than the normal

cost-sharing amount for thatcost-sharing amount for thatdrug, you will pay the actualdrug, you will pay the actualcost, not the highercost-sharing amount.

cost, not the highercost-sharing amount.

25 OutpatientPrescriptionDrugs(continued)





If you request a formularyexception for a drug and

If you request a formularyexception for a drug and

BlueValue Secure (HMO)BlueValue Basic (HMO)approves the exception, youapproves the exception, youwill pay Tier 4: Non-Preferredwill pay Tier 4: Non-PreferredBrand cost sharing for thatdrug.

Brand cost sharing for thatdrug.

In-Network$60 deductible on all drugsexcept Tier 1: Preferred

In-Network$145 deductible on all drugsexcept Tier 1: Preferred

Generic, Tier 2:Generic, Tier 5: InjectableNon-Preferred Generic, TierDrugs, Tier 6: Specialty Tier

drugs. 5: Injectable Drugs, Tier 6:Specialty Tier drugs.

Initial CoverageAfter you pay your yearlydeductible, you pay the

Initial CoverageAfter you pay your yearlydeductible, you pay the

following until total yearlydrug costs reach $2,850:

following until total yearlydrug costs reach $2,850:

Retail PharmacyContact your plan if you havequestions about cost-sharing

Retail PharmacyContact your plan if you havequestions about cost-sharing

or billing when less than aor billing when less than aone-month supply isdispensed.

one-month supply isdispensed.

You can get drugs from apreferred and non-preferred

You can get drugs from apreferred and non-preferred

pharmacy the followingway(s):

pharmacy the followingway(s):

Tier 1: PreferredGeneric


$3 copay for a one-month(30-day) supply of drugsin this tier from apreferred pharmacy

$5 copay for a one-month(30-day) supply of drugsin this tier from apreferred pharmacy$10 copay for atwo-month (60-day)supply of drugs in this tierfrom a preferred pharmacy

$6 copay for a two-month(60-day) supply of drugsin this tier from apreferred pharmacy






$9 copay for athree-month (90-day)supply of drugs in this tierfrom a preferred pharmacy

$15 copay for athree-month (90-day)supply of drugs in this tierfrom a preferred pharmacy$10 copay for aone-month (30-day)supply of drugs in this tierfrom a non-preferredpharmacy

$8 copay for a one-month(30-day) supply of drugsin this tier from anon-preferred pharmacy$16 copay for atwo-month (60-day)supply of drugs in this tierfrom a non-preferredpharmacy

$20 copay for atwo-month (60-day)supply of drugs in this tierfrom a non-preferredpharmacy $24 copay for a

three-month (90-day)supply of drugs in this tierfrom a non-preferredpharmacy

$30 copay for athree-month (90-day)supply of drugs in this tierfrom a non-preferredpharmacy

Tier 2: Non-PreferredGeneric


$10 copay for aone-month (30-day)supply of drugs in this tierfrom a preferred pharmacy

$16 copay for aone-month (30-day)supply of drugs in this tierfrom a preferred pharmacy$32 copay for atwo-month (60-day)supply of drugs in this tierfrom a preferred pharmacy

$20 copay for atwo-month (60-day)supply of drugs in this tierfrom a preferred pharmacy$30 copay for athree-month (90-day)supply of drugs in this tierfrom a preferred pharmacy


$15 copay for aone-month (30-day)supply of drugs in this tierfrom a non-preferredpharmacy






$30 copay for atwo-month (60-day)supply of drugs in this tierfrom a non-preferredpharmacy

$42 copay for atwo-month (60-day)supply of drugs in this tierfrom a non-preferredpharmacy$63 copay for athree-month (90-day)supply of drugs in this tierfrom a non-preferredpharmacy


Tier 3: Preferred BrandTier 3: Preferred Brand$40 copay for aone-month (30-day)supply of drugs in this tierfrom a preferred pharmacy




$45 copay for aone-month (30-day)supply of drugs in this tierfrom a non-preferredpharmacy$90 copay for atwo-month (60-day)supply of drugs in this tierfrom a non-preferredpharmacy








Tier 4: Non-PreferredBrand


$90 copay for aone-month (30-day)supply of drugs in this tierfrom a preferred pharmacy




$95 copay for aone-month (30-day)supply of drugs in this tierfrom a non-preferredpharmacy$190 copay for atwo-month (60-day)supply of drugs in this tierfrom a non-preferredpharmacy



Tier 5: Injectable DrugsTier 5: Injectable Drugs33% coinsurance for aone-month (30-day)supply of drugs in this tierfrom a preferred pharmacy

33% coinsurance for aone-month (30-day)supply of drugs in this tierfrom a preferred pharmacy33% coinsurance for atwo-month (60-day)supply of drugs in this tierfrom a preferred pharmacy

33% coinsurance for atwo-month (60-day)supply of drugs in this tierfrom a preferred pharmacy33% coinsurance for athree-month (90-day)supply of drugs in this tierfrom a preferred pharmacy

33% coinsurance for athree-month (90-day)supply of drugs in this tierfrom a preferred pharmacy






33% coinsurance for aone-month (30-day)supply of drugs in this tierfrom a non-preferredpharmacy

33% coinsurance for aone-month (30-day)supply of drugs in this tierfrom a non-preferredpharmacy33% coinsurance for atwo-month (60-day)supply of drugs in this tierfrom a non-preferredpharmacy

33% coinsurance for atwo-month (60-day)supply of drugs in this tierfrom a non-preferredpharmacy33% coinsurance for athree-month (90-day)supply of drugs in this tierfrom a non-preferredpharmacy

33% coinsurance for athree-month (90-day)supply of drugs in this tierfrom a non-preferredpharmacy

Tier 6: Specialty TierTier 6: Specialty Tier33% coinsurance for aone-month (30-day)supply of drugs in this tierfrom a preferred pharmacy

33% coinsurance for aone-month (30-day)supply of drugs in this tierfrom a preferred pharmacy33% coinsurance for aone-month (30-day)supply of drugs in this tierfrom a non-preferredpharmacy

33% coinsurance for aone-month (30-day)supply of drugs in this tierfrom a non-preferredpharmacy

Long-Term Care PharmacyLong term care pharmaciesmust dispense brand name

Long-Term Care PharmacyLong term care pharmaciesmust dispense brand name

drugs in amounts less than adrugs in amounts less than a14 days supply at a time.14 days supply at a time.They may also dispense lessThey may also dispense lessthan a month's supply ofthan a month's supply ofgeneric drugs at a time.generic drugs at a time.Contact your plan if you haveContact your plan if you havequestions about cost-sharingquestions about cost-sharingor billing when less than aor billing when less than aone-month supply isdispensed.


You can get drugs thefollowing way(s):









$8 copay for a one-month(34-day) supply of drugsin this tier

$10 copay for aone-month (34-day)supply of drugs in this tier





Tier 3: Preferred BrandTier 3: Preferred Brand$45 copay for aone-month (34-day)supply of drugs in this tier






Tier 5: Injectable DrugsTier 5: Injectable Drugs33% coinsurance for aone-month (34-day)supply of drugs in this tier

33% coinsurance for aone-month (34-day)supply of drugs in this tier

Tier 6: Specialty TierTier 6: Specialty Tier33% coinsurance for aone-month (34-day)supply of drugs in this tier


Mail OrderContact your plan if you havequestions about cost-sharing

Mail OrderContact your plan if you havequestions about cost-sharing

or billing when less than aor billing when less than aone-month supply isdispensed.












$5 copay for a one-month(30-day) supply of drugsin this tier$10 copay for atwo-month (60-day)supply of drugs in this tier

$6 copay for a two-month(60-day) supply of drugsin this tier$6 copay for athree-month (90-day)supply of drugs in this tier

$10 copay for athree-month (90-day)supply of drugs in this tier




$16 copay for aone-month (30-day)supply of drugs in this tier$32 copay for atwo-month (60-day)supply of drugs in this tier

$20 copay for atwo-month (60-day)supply of drugs in this tier$20 copay for athree-month (90-day)supply of drugs in this tier



$40 copay for aone-month (30-day)supply of drugs in this tier$120 copay for atwo-month (60-day)supply of drugs in this tier












$270 copay for atwo-month (60-day)supply of drugs in this tier




33% coinsurance for aone-month (30-day)supply of drugs in this tier33% coinsurance for atwo-month (60-day)supply of drugs in this tier

33% coinsurance for atwo-month (60-day)supply of drugs in this tier33% coinsurance for athree-month (90-day)supply of drugs in this tier

33% coinsurance for athree-month (90-day)supply of drugs in this tier



Coverage GapAfter your total yearly drugcosts reach $2,850, you

Coverage GapAfter your total yearly drugcosts reach $2,850, you

receive limited coverage byreceive limited coverage bythe plan on certain drugs. Youthe plan on certain drugs. Youwill also receive a discount onwill also receive a discount onbrand name drugs andbrand name drugs andgenerally pay no more thangenerally pay no more than47.5% for the plan's costs for47.5% for the plan's costs forbrand drugs and 72% of thebrand drugs and 72% of theplan's costs for generic drugsplan's costs for generic drugsuntil your yearlyuntil your yearlyout-of-pocket drug costs reach$4,550.

out-of-pocket drug costs reach$4,550.

Catastrophic CoverageAfter your yearlyout-of-pocket drug costs reach

Catastrophic CoverageAfter your yearlyout-of-pocket drug costs reach

$4,550, you pay the greaterof:

$4,550, you pay the greaterof:






5% coinsurance, or5% coinsurance, or$2.55 copay for generic(including brand drugstreated as generic) and a$6.35 copay for all otherdrugs.

$2.55 copay for generic(including brand drugstreated as generic) and a$6.35 copay for all otherdrugs.

Out-of-NetworkPlan drugs may be covered inspecial circumstances, for

Out-of-NetworkPlan drugs may be covered inspecial circumstances, for

instance, illness whileinstance, illness whiletraveling outside of the plan'straveling outside of the plan'sservice area where there is noservice area where there is nonetwork pharmacy. You maynetwork pharmacy. You mayhave to pay more than yourhave to pay more than yournormal cost-sharing amountnormal cost-sharing amountif you get your drugs at anif you get your drugs at anout-of-network pharmacy. Inout-of-network pharmacy. Inaddition, you will likely haveaddition, you will likely haveto pay the pharmacy's fullto pay the pharmacy's fullcharge for the drug andcharge for the drug andsubmit documentation tosubmit documentation toreceive reimbursement fromBlueValue Secure (HMO).

receive reimbursement fromBlueValue Basic (HMO).

You can get out-of-networkdrugs the following way:

You can get out-of-networkdrugs the following way:

Out-of-Network InitialCoverageAfter you pay your yearlydeductible, you will be

Out-of-Network InitialCoverageAfter you pay your yearlydeductible, you will be

reimbursed up to the plan'sreimbursed up to the plan'scost of the drug minus thecost of the drug minus thefollowing for drugs purchasedfollowing for drugs purchasedout-of-network until yourout-of-network until yourtotal yearly drug costs reach$2,850:

total yearly drug costs reach$2,850:
























You will not be reimbursedfor the difference between the


Out-of-Network Pharmacy Out-of-Network Pharmacycharge and the plan's charge and the plan'sIn-Network allowableamount.

In-Network allowableamount.

Out-of-Network CoverageGapYou will be reimbursed up to28% of the plan allowable

Out-of-Network CoverageGapYou will be reimbursed up to28% of the plan allowable

cost for generic drugscost for generic drugspurchased out-of-networkpurchased out-of-networkuntil total yearlyuntil total yearlyout-of-pocket drug costs reachout-of-pocket drug costs reach$4,550. Please note that the$4,550. Please note that the






plan allowable cost may beless than the out-of-network

plan allowable cost may beless than the out-of-network

pharmacy price paid for yourdrug(s).


You will be reimbursed up to52.5% of the plan allowable

You will be reimbursed up to52.5% of the plan allowable

cost for brand name drugs cost for brand name drugspurchased out-of-network purchased out-of-networkuntil your total yearly until your total yearlyout-of-pocket drug costs reach out-of-pocket drug costs reach$4,550. Please note that the $4,550. Please note that theplan allowable cost may be plan allowable cost may beless than the out-of-network less than the out-of-networkpharmacy price paid for yourdrug(s).


Out-of-NetworkCatastrophic CoverageAfter your yearlyout-of-pocket drug costs reach

Out-of-NetworkCatastrophic CoverageAfter your yearlyout-of-pocket drug costs reach

$4,550, you will be$4,550, you will bereimbursed for drugsreimbursed for drugspurchased out-of-network uppurchased out-of-network upto the plan's cost of the drugto the plan's cost of the drugminus your cost share, whichis the greater of:

minus your cost share, whichis the greater of:

5% coinsurance, or5% coinsurance, or$2.55 copay for generic(including brand drugstreated as generic) and a$6.35 copay for all otherdrugs.

$2.55 copay for generic(including brand drugstreated as generic) and a$6.35 copay for all otherdrugs.



Out-of-Network PharmacyOut-of-Network Pharmacycharge and the plan'scharge and the plan'sIn-Network allowableamount.

In-Network allowableamount.






Outpatient Medical Services and Supplies

In-NetworkThis plan covers somepreventive dental benefits for

In-NetworkThis plan covers somepreventive dental benefits for

Preventive dental services(such as cleaning) notcovered.

26 Dental Services

an extra cost (see "OptionalSupplemental Benefits.")

an extra cost (see "OptionalSupplemental Benefits.")

$0 copay forMedicare-covered dentalbenefits

$0 copay forMedicare-covered dentalbenefits

In-NetworkIn general, supplementalroutine hearing exams andhearing aids not covered.

In-NetworkIn general, supplementalroutine hearing exams andhearing aids not covered.

Supplemental routine hearingexams and hearing aids notcovered.

20% coinsurance fordiagnostic hearing exams.

27 Hearing Services

$35 copay forMedicare-covered diagnostichearing exams

$50 copay forMedicare-covered diagnostichearing exams

In-NetworkThis plan covers some visionbenefits for an extra cost (see

In-NetworkThis plan covers some visionbenefits for an extra cost (see

20% coinsurance fordiagnosis and treatment ofdiseases and conditions of the

28 Vision Services

"Optional SupplementalBenefits").

"Optional SupplementalBenefits").

eye, including an annualglaucoma screening for peopleat risk $0 to $35 copay for

Medicare-covered exams to$0 to $50 copay forMedicare-covered exams toSupplemental routine eye

exams and eyeglasses (lensesand frames) not covered.

diagnose and treat diseasesand conditions of the eye,

diagnose and treat diseasesand conditions of the eye,

including an annual glaucomascreening for people at risk

including an annual glaucomascreening for people at risk

Medicare pays for one pair ofeyeglasses or contact lensesafter cataract surgery. $0 copay for one pair of

Medicare-covered eyeglasses$0 copay for one pair ofMedicare-covered eyeglasses

(lenses and frames) or contactlenses after cataract surgery.

(lenses and frames) or contactlenses after cataract surgery.

In-NetworkThe plan covers the followingsupplemental education/wellness programs:

In-NetworkThe plan covers the followingsupplemental education/wellness programs:

Not covered.Wellness/Educationand OtherSupplementalBenefits & Services





Health Club Membership/Fitness Classes

Health Club Membership/Fitness ClassesNursing Hotline Nursing Hotline

GeneralThe plan does not coverOver-the-Counter items.

GeneralThe plan does not coverOver-the-Counter items.

Not covered.Over-the-CounterItems

In-NetworkThis plan does not coversupplemental routinetransportation.

In-NetworkThis plan does not coversupplemental routinetransportation.

Not covered.Transportation(Routine)

In-NetworkThis plan does not coverAcupuncture and otheralternative therapies.

In-NetworkThis plan does not coverAcupuncture and otheralternative therapies.

Not covered.Acupuncture andOther AlternativeTherapies

OPTIONAL SUPPLEMENTAL PACKAGE #1

GeneralPackage: 1 - PreventiveDental Package:

GeneralPackage: 1 - PreventiveDental Package:

Premium and OtherImportantInformation

$11 monthly premium, inaddition to your $49 monthly


plan premium and theplan premium and themonthly Medicare Part Bmonthly Medicare Part Bpremium, for the followingoptional benefits:

premium, for the followingoptional benefits:

Preventive DentalPreventive Dental

In-Network$0 copay for up to 2supplemental oral exam(s)every year


Dental Services

$0 copay for up to 2supplemental cleaning(s)every year


$0 copay for up to 1supplemental dental x-ray(s)every year






$500 plan coverage limit forsupplemental preventivedental benefits every year

$500 plan coverage limit forsupplemental preventivedental benefits every year


GeneralPackage: 2 - Dental andVision Package:

GeneralPackage: 2 - Dental andVision Package:






Preventive DentalPreventive DentalComprehensive Dental Comprehensive Dental

Eye ExamsEye ExamsEyewear Eyewear

GeneralPlan offers additionalsupplemental comprehensivedental benefits.


Dental Services







$1,000 plan coverage limit forsupplemental dental benefitsevery year


Dental Services(continued)





In-Network$0 copay for up to 1 pair(s)of contact lenses every year


Vision Services

$0 copay for up to 1 pair(s)of eyeglasses (lenses andframes) every year


$0 copay for up to 1supplemental routine eyeexam(s) every year


$69 plan coverage limit forsupplemental routine eyeexams every year


$130 plan coverage limit foreyeglasses (lenses and frames)every year.


$80 plan coverage limit forcontact lenses every year.



GeneralPackage: 3 - Enhanced Dentaland Vision Package:

GeneralPackage: 3 - Enhanced Dentaland Vision Package:






Preventive DentalPreventive DentalComprehensive Dental Comprehensive Dental

Eye ExamsEye ExamsEyewear Eyewear



Dental Services















Vision Services











Dental Services(continued)


Blue Cross Blue Shield Healthcare Plan of Georgia - …...Tagalog: Mayroon kaming libreng serbisyo...

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