Enjoy more benefits, including preventive, vision and hearing care

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Milton Hershey School Post 65 -

School

Dear Plan Participant:

Thank you for considering enrollment in Freedom Blue PPO, which is a Medicare Advantage

Preferred-Provider Organization (PPO) backed by the experience and financial strength of Highmark Blue Shield.

Freedom Blue PPO gives you broad coverage for virtually every health care service you may need and the freedom to choose your own doctors and hospitals anywhere in the United States.

Freedom Blue PPO gives you access to a national network of participating providers

That’s because Blue Plans across the country share their Medicare Advantage PPO networks. You may see any Blue Cross and/or Blue Shield Medicare Advantage PPO contracted doctor or hospital in the United States and receive covered services at the higher, network level of reimbursement.

Freedom Blue PPO members also may choose to see providers outside of our shared Medicare Advantage network. However, if a member chooses to go to a non-participating provider when a

participating Blue Cross and/or Blue Shield Medicare Advantage PPO contracted provider is available in that location, covered services will be reimbursed at the lower out-of-network level.

If a Freedom Blue PPO group member lives or travels in a location where there are no participating Blue Cross and/or Blue Shield Medicare Advantage PPO providers, the member can go to any

Medicare-eligible provider and receive covered services at the higher, network level of reimbursement. Members should confirm that the provider is Medicare-eligible before receiving services. Highmark will not pay for any service received from a provider who has opted out of the Medicare program.

Emergency and urgently needed care is always reimbursed at the higher, network level, regardless of where the care is received.

Enjoy more benefits, including preventive, vision and hearing care

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Z_G199883_S84

Reference Code

13FB9883

120 Fifth Avenue, Pittsburgh, PA 15222

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As a Freedom Blue PPO member, you’re covered for doctor visits, hospital stays, outpatient services, emergency care, even annual routine vision and hearing exams, eyeglasses and hearing aids. You’ll also enjoy valuable preventive care benefits, including an annual routine physical exam, immunizations and important screenings.

Keep yourself and your budget in shape

Take advantage of full access at one of the participating senior-friendly fitness centers located throughout the United States through the award-winning SilverSneakers^®Fitness Program. Use the center’s equipment on your own or join a SilverSneakers class designed especially for people with Medicare. There’s no cost for any services you use.

Save money on prescription drugs

Enjoy enhanced Part D Medicare Prescription Drug Coverage with Freedom Blue PPO. All generic and brand name drugs allowed by Medicare are covered.

Personal, knowledgeable Member Service

Friendly, dedicated Member Service representatives offer you outstanding support. If you have any questions about your benefits, providers, Medicare, or how Freedom Blue PPO works, call toll-free any day of the week between 8:00 a.m. and 8:00 p.m. Eastern.

Have questions now – call toll-free

If you have any questions now about Freedom Blue PPO, please call 1-866-456-7739, TTY users call 711, between 8:00 a.m. and 8:00 p.m. Eastern, seven days a week.

Great benefits, network-level coverage throughout the country, a fitness center membership and the peace of mind knowing your coverage is backed by Highmark Blue Shield, a name people know and trust for over 70 years … there are many reasons to have Freedom Blue PPO. We look forward to serving you.

Sincerely,

Jill Hollingshead

Sales Manager, Highmark Senior Markets

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Section 1 Plan Highlights and Frequently Asked Questions

Section 2 Enrollment Information

Section 3 Summary of Benefits

Section 4 Health and Wellness

Section 5 Network Provider Information

- This section contains participating network doctors near your home and network hospitals within 150 miles of your home. If you would like a complete list of participating network providers, contact Freedom Blue PPO at

1-866-456-7739, TTY users call 711, between 8:00 a.m. and 8:00 p.m. Eastern, seven days a week.

Section 6 Prescription Drug Benefits

Section 1

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Freedom Blue PPO

^SM

gives you exactly

what you want from

your health care

coverage – freedom

of choice

Freedom Blue PPO, a Medicare Advantage Preferred-Provider Organization from Highmark Blue Shield, offers comprehensive benefits and the freedom to use the doctors, hospitals and other professional providers of your choice, both inside and outside the network – with no referrals needed.

• When you receive eligible care from doctors, hospitals and other professional providers in the network, your care is covered at the higher, network level of benefits and you pay lower, in-network costs.

• When you receive eligible care from doctors, hospitals and other professional providers in an area without a network, your care is covered at the higher, network level of

benefits and you pay lower, in-network costs.

• When you receive eligible care from doctors, hospitals and other professional providers outside of the network, your care is covered at the lower, out-of-network level of benefits and you pay slightly higher, out-of-network costs.

Enjoy the higher, network-level of

benefits at lower, in-network costs

throughout the United States – great

for snowbirds and people on the

move!

Freedom Blue PPO offers you unique opportuni- ties to get the health care you need wherever you live or travel throughout the U.S. – and you pay only your network level of cost sharing.

• Freedom Blue PPO features one of the largest Medicare Advantage PPO networks in the country. It includes thousands of family doctors, general practitioners, internists, all types of specialists and most hospitals.

Freedom Blue PPO participating providers are carefully screened before joining the network and regularly reviewed in an ongoing effort to ensure that they meet strict criteria for quality service.

• If you travel, Freedom Blue PPO allows you to receive care from any participating Blue Cross and/or Blue Shield Medicare Advantage PPO doctor, professional provider or hospital available in 31 states and Puerto Rico – including Florida, California, the Carolinas, Ohio, New York and more.

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It’s easy to find a participating Blue Cross and/or Blue Shield Medicare Advantage PPO provider. Just call Member Service at the number printed on the Freedom Blue PPO ID card you will receive after you enroll, visit the Highmark website, or go to “Find a Doctor, Hospital or other Medical Provider” at www.highmarkbcbs.com.

• If you live in or travel to locations where a participating network is not available, you may visit any Medicare-eligible provider. Again, when you do, eligible services will be covered at the higher, network level of benefits. Please refer to the “Freedom Blue PPO Network Provider Information” section for more information.

Important Notes:

1. If you decide to go to a non-participating provider, but a participating Blue Cross and/or Blue Shield Medicare Advantage PPO provider is available in the location where you received eligible services, those services will be covered at the lower, out-of-network level of benefits.

2. Highmark cannot pay a provider who has opted out of the Medicare program. Check with your provider before you receive care to confirm that they have not opted out of Medicare.

3. Emergency and urgently needed care is always covered at the higher network level of benefits, regardless of where the

care is received.

Freedom from claim forms

and referrals

Freedom Blue PPO was designed to eliminate the hassle that many people associate with health insurance. There are no claim forms to file when you show your Freedom Blue PPO ID card at any of our Freedom Blue PPO network provider locations or participating Blue Cross and/or Blue Shield Medicare Advantage PPO

providers throughout the U.S. They will process all the paperwork for you. When you see a provider who is not in the network, always ask the provider or facility to file a claim for you to Freedom Blue PPO.

No referrals are needed for you to get the care you need. Certain services, however, like inpatient admissions or outpatient surgery, do require pre-certification.

Enjoy personal,

reliable Member Service

If you ever have a question about Medicare or Freedom Blue PPO plan benefits, or about how to get care or how to locate a provider – in short, any concern related to your health care coverage – help is just a toll-free call away. You can reach a friendly, knowledgeable, dedicated Member Service representative any day of the week, between 8:00 a.m. and 8:00 p.m. Eastern, by calling the number printed on your Freedom Blue PPO identification card.

Our Member Service representatives specialize in understanding Medicare and the needs of people with Medicare. They are carefully trained to answer your questions and those of your providers…a valuable resource to you, if needed, when you receive care.

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Trust the plan that’s backed by

Highmark Blue Shield

Freedom Blue PPO is backed by more than 70 years of financial strength and experience with Highmark Blue Shield – a name millions of people know and trust.

Highmark Blue Shieldhas been dedicated to offering quality, affordable health care coverage to people with Medicare since the Medicare program began in 1965.

Answers to frequently

asked questions

Q

. Is Freedom Blue PPO a Medicare supplement?

A.

No. Freedom Blue PPO is a Medicare Advantage PPO that makes supplemental insurance unnecessary. Freedom Blue PPO gives

you all the benefits of Medicare and more. As a PPO, Freedom Blue PPO lets you get care from the doctors and hospitals of your choice – either in or out of the network. And no referrals are needed.

Q

. Is everything covered by Freedom Blue PPO?

A.

All Medicare benefits are covered, such as periodic physical exams, immunizations and screenings. Limitations, copayments and coinsurance apply. Please refer to the benefits chart and other information in this brochure for the specific benefits your group provides.

Q

. Can I be sure I’ll receive quality care with Freedom Blue PPO?

A.

Highmark participating health care providers are carefully screened before joining the

Highmark Medicare Advantage PPO Provider Network. They must meet our strict selection criteria and submit to an evaluation by a medical review committee. Then they are reviewed on an ongoing basis.

Q

. Am I still covered by original Medicare Part A and Part B as a Freedom Blue PPO member?

A.

Once you are a member of Freedom Blue PPO, you still have Medicare, but now you are getting your Medicare as a Freedom Blue PPO member. You no longer have to pay original Medicare deductibles and coinsurance charges because Freedom Blue PPO will cover all services and supplies offered by original Medicare, plus some additional services and supplies not covered by original Medicare. Members must continue to pay their Medicare Part B premium. In addition, Freedom Blue PPO does require you to pay a copayment and coinsurance for certain network services and for out-of-network care you receive.

Q

. What if I sign up for Freedom Blue PPO and later want to drop it?

A.

If you disenroll from Freedom Blue PPO outside of the open enrollment period and go to original Medicare insurance, you may have

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the option (if available in your county of

residence) to switch to a Medicare Supplement plan. Be sure to talk to your group benefits office before you disenroll from Freedom Blue PPO and follow the disenrollment guidelines of your former employer or trust fund regarding open enrollment or special election periods.

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Section 2

199883_S84_PG9

Enrolling In

Freedom Blue PPO

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It’s easy to enroll

Follow all enrollment instructions from your employer or trust fund. If you have questions or need help applying for Freedom Blue PPO…

Please call 1-866-456-7739, TTY users call 1-800-988-0668, between 8:00 a.m. and 8:00 p.m., seven days a week for answers to your questions about Freedom Blue PPO benefits, how the plan works, or how to enroll.

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It’s easy to enroll! Please follow the enrollment instructions provided by your former employer. Please Read Carefully

Highmark Blue Shield is a Medicare Advantage Plan so you will need to keep your Medicare Parts A and B. You can only have one Medicare Advantage Plan at a time. If you enroll in another Medicare Advantage [or Prescription Drug Plan] it will automatically disenroll you from Highmark Blue Shield. It is your responsibility to inform Highmark and/or your former employer of any prescription drug

coverage that you have or may get in the future. You can only join one Medicare Prescription Drug Plan. To receive additional information about this plan, please contact Highmark at 1-866-456-7739, TTY 800-988-0668, between 8:00 a.m. and 8:00 p.m., seven days a week. You can also contact Medicare for information on other Medicare Health Plan options that might be available by calling 1-800-Medicare. TTY users should call 1-877-486-2048, 24 hours a day/7days a week. Counseling services may be available in your state to provide advice concerning Medicare supplement insurance or other Medicare Advantage or Prescription Drug plan options as well as medical assistance through the state Medicaid program and the Medicare Savings Program.

Highmark Blue Shield members can reside anywhere in the United States. If you move outside of the U.S., you need to notify the plan and disenroll. You may contact your former employer to discuss other possible coverage. Once you are a member of Highmark Blue Shield, you have the right to appeal plan decisions about payment or services if you disagree. You should read the Evidence of Coverage

document from Highmark Blue Shield when you get it to know which rules you must follow to get coverage with this Medicare Advantage plan. People with Medicare aren't usually covered under Medicare while out of the country except for limited coverage near the U.S. border.

You understand that beginning on the date Highmark Blue Shield coverage begins, you must get all of your health care from Highmark Blue Shield except for emergency or urgently needed services or out-of-area dialysis services. Services authorized by Highmark Blue Shield and other services contained in the Highmark Blue Shield Evidence of Coverage document (also known as a member contract or subscriber agreement) will be covered. Without authorization, NEITHER MEDICARE NOR Highmark Blue Shield WILL PAY FOR THE SERVICES.

You understand that if you are getting assistance from a sales agent, broker, or other individual

employed by or contracted with Highmark Blue Shield he/she may be paid based on your enrollment in Highmark Blue Shield.

You acknowledge that the Medicare health plan will release your information to Medicare and other plans as is necessary for treatment, payment and health care operations. You also acknowledge that Highmark Blue Shield will release your information, including any prescription drug data to Medicare, who may release it for research and other purposes which follow all applicable Federal statutes and regulations.

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Freedom Blue PPO

Covers Most Health Care

Services You Need

Section 3

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Freedom Blue PPO offers comprehensive coverage in and out of the network,

including:

• Hospital care – both inpatient and outpatient

• Emergency and urgent care – always covered at the higher network level

• Annual routine physical exam and other doctors’ visits, including specialist visits

• X-ray, diagnostic tests, lab work, annual mammogram and PAP test, flu and pneumonia shots (authorization may be required for some services)

• Hearing care

• Routine vision

• Mental health and substance abuse treatment

• Screenings, such as bone mass, colorectal and prostate cancer, plus diabetes monitoring

• Home health care

Please be sure to read the enclosed Summary of Benefits for a more detailed description of your covered benefits.

Coverage for important preventive care

Freedom Blue PPO offers preventive benefits to help you stay healthy. You are encouraged to use your wellness benefits that include, for example, immunizations, screenings and annual physical exams.

Emergency and urgently needed care is covered at the highest level – anywhere

in the world

In any medical emergency, at home or while traveling – when you believe that serious jeopardy to your health or impairment or dysfunction of your body may result if you don’t get immediate attention – go to the nearest emergency facility and get treatment. Or call 911 or the local emergency telephone numbers for help. You are responsible for paying a copayment for each emergency room visit, unless you are admitted to the hospital for the same condition within three days and your inpatient admission is authorized.

Urgently needed care is also covered in full after you pay any applicable copayment. Urgently needed care includes services which are provided while you are temporarily outside the Freedom Blue PPO service area or, in extraordinary cases, while you are in the plan’s service area when the Freedom Blue PPO network is unavailable or inaccessible due to an unusual event.

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In-Network Out-of-Network

Plan Deductible $0

Plan Coinsurance No Plan level coinsurance _20%

(Member Cost Sharing) applied

In Network Out-of-Pocket Max $0

Total In and Out of Network

$3,400 Out-of-Pocket

Outpatient Services

$10 PCP, $15 Specialist cost

Doctor Office Visit _sharing 20% coinsurance

Preventive

Covered in Full Covered in Full

Testing/Screenings

Diagnostic Testing including

Lab, X-Rays and Advanced $0 cost sharing 20% coinsurance

Imaging

Outpatient Surgery $0 cost sharing 20% coinsurance

Emergent and Urgent Services

Ambulance $0 cost sharing 20% coinsurance

Emergency Room $50 cost sharing $50 cost sharing

Inpatient Hospital Stay $0 per stay 20% coinsurance

Skilled Nursing Facility

$0 per day 20% coinsurance

(days 1-100 per benefit period) Supplies and Additional Services

Durable Medical Equipment 0% coinsurance 50% coinsurance

Standard eyeglass lenses and frames or contact lenses are

Routine Vision covered in full. A $100 benefit $100 benefit maximum for (covered every two calendar maximum applies to specialty frames or specialty

years) non-standard frames and a $100 contact lenses.

benefit maximum for specialty contact lenses.

Hearing Aids

(covered every three calendar $500 coverage

years)

Milton Hershey School Post 65 - School Reference Code 13FB9883

Benefits continued on next page.

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Freedom Blue PPO Your 2013 Benefits at a Glance

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Medicare Part D Drugs (Up to 34 Day Supply)

• $8 Generic Initial Coverage • $20 Pref. Brand (Up to $2970 in total drug costs) • $50 Non-Pref. Brand

• $50 Specialty

• $8 Generic

• $20 Pref. Brand

Coverage Gap • $50 Non-Pref. Brand

• $50 Specialty

During this stage, the plan will pay most of the cost for your drugs.

•-Either - coinsurance of 5% of the cost of the drug

Catastrophic Coverage •-Or- $2.65 copayment for a generic drug or a drug that is treated like a generic. Or a $6.60 copayment for all other drugs. Our plan pays the rest of the cost.

Please see Summary of Benefits for detailed Information

* See below

Questions? Call 1-866-456-7739 (TTY Users, call 711) 7 days a week between 8 a.m. - 8 p.m. Eastern Reference Code 13FB9883 Please have this number ready when you call.

Please see Summary of Benefits for detailed information.

*Plan drugs may be covered in special circumstances, for instance, illness while traveling outside of the plan's service area where there is no network pharmacy.

Milton Hershey School Post 65 - School

Your 2013 Benefits at a Glance

In-Network Out-of-Network

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SECTION ONE:

INTRODUCTION TO SUMMARY OF BENEFITS

Freedom Blue PPO

January 1, 2013 through December 31, 2013

Thank you for your interest in Freedom Blue PPO. Our plan is offered by Highmark Inc.,a Medicare Advantage Preferred-Provider Organization (PPO). This Summary of Benefits tells you some features of our plan. It doesn’t list every service that we cover or list every limitation or every exclusion. To get a complete list of our benefits, please call Freedom Blue PPO and ask for the “Evidence of Coverage.”

YOU HAVE CHOICES IN YOUR HEALTH CARE

As a Medicare beneficiary, you can choose from different Medicare options. One option is the Original (fee-for-service) Medicare Plan. Another option is a Medicare health plan, like Freedom Blue PPO. You may have other options, too. 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. Please call Freedom Blue PPO at the telephone number listed at the end of this introduction, or 1-800-MEDICARE (1-800-633-4227) for more information. TTY/TDD users should call 1-877-486-2048. You can call this number 24 hours a day, seven days a week.

HOW CAN I COMPARE MY OPTIONS?

You can compare Freedom Blue PPO and the Original Medicare Plan using this Summary of Benefits. The charts in this booklet list some important health benefits. For each benefit, you can see what our plan covers and what the Original Medicare Plan covers.

Our members receive all of the benefits that the Original Medicare Plan offers. We also offer more benefits, which may change from year to year.

WHERE IS FREEDOM BLUE PPO AVAILABLE?

The service area for this plan varies. Please contact Freedom Blue PPO for more information.

WHO IS ELIGIBLE TO JOIN FREEDOM BLUE PPO?

You can join Freedom Blue PPO if you are entitled to Medicare Part A and enrolled in Medicare Part B. However, individuals with End Stage Renal Disease are not eligible to enroll in Freedom Blue PPO. Some exceptions do exist; please contact Highmark for more information.

CAN I CHOOSE MY DOCTORS?

Freedom Blue PPO has formed a network of doctors, specialists, and hospitals. You can use any doctor who is part of our network. You may also go to doctors outside of our network. The health providers within our network can change at any time. Also, the doctors and hospitals available to you may vary, depending on where you reside. You can ask for a current Provider Directory or for an up-to-date list visit us at www.highmark.com.

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Our Customer Service number is listed at the end of this introduction.

WHAT HAPPENS IF I GO TO A DOCTOR WHO’S NOT IN OUR NETWORK?

You can go to doctors, specialists, or hospitals in or out of network. You may have to pay more for the services you receive outside the network, and you may have to follow special rules prior to getting services in and/or out of network.

For more information, please call the Customer Service number at the end of this introduction.

DOES MY PLAN COVER MEDICARE PART B OR PART D DRUGS?

Freedom Blue PPO does cover Medicare Part B Prescription Drugs. Freedom Blue PPO also covers Medicare Part D Prescription Drugs.

WHERE CAN I GET MY PRESCRIPTIONS IF I JOIN THIS PLAN?

Freedom Blue PPO has formed a network of pharmacies. You must use a network pharmacy to receive plan benefits. We may not pay for your prescriptions if you use an out-of-network pharmacy, except in certain cases. The pharmacies in our network can change at any time. You can ask for a current pharmacy directory, or visit us at www.highmark.com. Our Customer Service number is listed at the end of this introduction.

WHAT IS A PRESCRIPTION DRUG FORMULARY?

Freedom Blue PPO uses a formulary. A formulary is a list of drugs covered by your plan to meet patient needs. We may periodically add, remove, or make changes to coverage limitations on certain drugs or change how much you pay for a drug. If we make any formulary change that limits our members’ ability to fill their prescriptions, we will notify the affected enrollees before the change is made. We will send a formulary to you and you can see our complete formulary on our Web site at http://highmark.medicare-approvedformularies.com/.

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

HOW CAN I GET EXTRA HELP WITH PRESCRIPTION DRUG PLAN COSTS?

You may be able to get extra help for your prescription drug premiums and costs. To see if you qualify for getting extra help, call:

• 1-800-MEDICARE (1-800-633-4227). TTY/TDD users should call 1-877-486-2048, 24 hours a day, seven days a week;

• The Social Security Administration at 1-800-772-1213 between 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 THE PLAN?

All Medicare Advantage plans agree to stay in the Medicare program for a full year at a time. Each year, the plans decide whether to continue for another year. Even if a Medicare Advantage plan leaves the program, you will not lose Medicare coverage. If a plan decides not to continue, it must send you a letter at least 90 days before your coverage will end. The letter will explain your options

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for Medicare coverage in your area.

As a member of Freedom Blue PPO, you have the right to request an organization determination, which includes the right to file an appeal if we deny coverage for an item or service, and the right to file a grievance. You have the right to request an organization determination if you want us to provide or pay for an item or service that you believe should be covered. If we deny coverage for your requested item or service, you have the right to appeal and ask us to review our decision. You may ask us for an expedited (fast) coverage determination or appeal if you believe that waiting for a decision could seriously put your life or health at risk, or affect your ability to regain maximum function. If your doctor makes or supports the expedited request, we must expedite our decision. Finally, you have the right to file a grievance with us if you have any type of problem with us or one of our network providers that does not involve coverage for an item or service. If your problem involves quality of care, you also have the right to file a grievance with the Quality Improvement Organization (QIO) for your state.

As a member of Freedom Blue PPO, you have the right to request a coverage determination, which includes the right to request an exception, the right to file an appeal if we deny coverage for 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 believe should be covered. An exception is a type of coverage determination. You may ask us for an exception if you believe you need a drug that is not on our list of covered drugs or believe you should get a non-preferred drug at a lower out-of-pocket cost. You can also ask for an exception to cost utilization rules, such as a limit on the quantity of a drug. If you think you need an exception, you should contact us before you try to fill your prescription at a pharmacy. Your doctor must provide a statement to support your exception request. If we deny coverage for your prescription drug(s), you have the right to appeal and ask us to review our decision. Finally, you have the right to file a grievance if you have any type of problem with us or one of our network pharmacies that does not involve coverage for a prescription drug. If your problem involves quality of care, you also have the right to file a grievance with the Quality Improvement Organization (QIO) for your state.

WHAT IS A MEDICATION THERAPY MANAGEMENT (MTM) PROGRAM?

A Medication Therapy Management (MTM) Program is a free service we may offer. You may be invited to participate in a program designed for your specific health and pharmacy needs. You may decide not to participate, but it is recommended that you take full advantage of this covered service if you are selected. Contact Freedom Blue PPO for more details.

WHAT TYPE OF DRUGS MAY BE COVERED UNDER MEDICARE PART B?

Some outpatient prescription drugs may be covered under Medicare Part B. These may include, but are not limited to, the following types of drugs. Contact Freedom Blue PPO for more details.

• Some Antigens: If they are prepared by a doctor and administered by a properly instructed person (who could be the patient) under doctor supervision.

• Osteoporosis Drugs: Injectable drugs for osteoporosis for certain women with Medicare.

• Erythropoietin (Epoetin alpha or Epogen®): By injection if you have end stage renal disease (permanent kidney failure requiring either dialysis or transplantation) and need this drug to treat anemia.

• Hemophilia Clotting Factors: Self-administered clotting factors if you have hemophilia.

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• Injectable Drugs: Most injectable drugs administered incident to a physician’s service.

• Immunosuppressive Drugs: Immunosuppressive drug therapy for transplant patients if the transplant was paid for by Medicare, or paid by a private insurance that paid as a primary payer to your Medicare Part A coverage, in a Medicare-certified facility.

• Some Oral Cancer Drugs: If the same drug is available in injectable form.

• Oral Anti-Nausea Drugs: If you are part of an anti-cancer chemotherapeutic regimen.

• Inhalation and infusion drugs provided through DME.

WHERE CAN I FIND INFORMATION ON PLAN RATINGS?

The Medicare program rates how well plans perform in different categories (for example, detecting and preventing illness, ratings from patients and customer service). If you have access to the Web, you may use the Web tools on www.medicare.gov and select “Health and Drug Plans” or “Compare Drug and Health Plans” to compare the plan ratings of Medicare plans in your area. You can also call us directly at 1-800-550-8722to obtain a copy of the plan ratings for this plan. TTY users call 711. Please call Highmark Inc.for more information about this plan.

Visit us at www.highmarkblueshield.comor, call us:

Customer Service Hours: Sunday, Monday, Tuesday, Wednesday, Thursday, Friday, Saturday 8:00 a.m. - 8:00 p.m. Eastern.

Current members should call 1-800-550-8722 for questions related to the Medicare

Advantage Program or Medicare Part D Prescription Drug program.(TTY/TDD(888)-422-1226) Prospective members should call 1-866-456-7739 for questions related to the Medicare Advantage or Medicare Part D Prescription Drug Program. (TTY/TDD (800)-227-8210) For more information about Medicare, call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You can call 24 hours a day, seven days a week. Or, visit www.medicare.gov on the Web.

This document may be available in other formats such as Braille, large print or other alternate formats. This document may be available in a non-English language. For additional

information, call customer service at the phone number listed above.

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SummaryofBenefitsEmployerGroupPlan MiltonHersheySchoolPost65-School 199883 GeneralProvisionsFreedomBluePPOIn-NetworkFreedomBluePPOOut-of-Network BenefitPeriod-CalendarYear PlanDeductible $0 PlanCoinsurance(MemberCostSharing) None20% InNetworkOut-of-PocketMaximum$0 TotalInandOut-of-Network Out-of-PocketMaximum$3,400 BenefitCategoryOriginalMedicareFreedomBluePPOEmployerGroupPlan IMPORTANTINFORMATION PremiumandOtherImportantInformationIn2012themonthlyPartBPremiumwasYoumaypayapremiumeachmonthtoyour $99.90andmaychangefor2013andtheretiree/employergroup/trustfund.Youalso annualPartBdeductibleamountwas$140continuetopaytheMedicarePartBpremium andmaychangefor2013.eachmonth. Ifadoctororsupplierdoesnotaccept assignment,theircostsareoftenhigher, whichmeansyoupaymore. Continuedonnextpage Forquestionsaboutthisplan'sbenefitsorcosts,pleasecontactFreedomBluePPO.Currentmemberscall1-800-550-8722 (TTYuserscall711)andprospectivememberscall1-866-456-7739,(TTYuserscall711),sevendaysaweek,between8a.m.and8p.m.Eastern.

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IMPORTANTINFORMATION PremiumandOtherImportantInformationContinuedfrompreviouspage Mostpeoplewillpaythestandardmonthly PartBpremium.However,somepeoplewill payahigherpremiumbecauseoftheiryearly income(over$85,000forsingles,$170,000for marriedcouples). FormoreinformationaboutPartBpremiums basedonincome,callMedicareat 1-800-MEDICARE(1-800-633-4227).TTYusers shouldcall1-877-486-2048.Youmayalsocall SocialSecurityat1-800-772-1213.TTYusers shouldcall1-800-325-0778. DoctorandHospitalChoiceYoumaygotoanydoctor,specialistorIn-Network (Formoreinformation,seeEmergencyCarehospitalthatacceptsMedicare.Noreferralrequiredfornetworkdoctors, andUrgentlyNeededCare.)specialists,andhospitals. InandOut-of-Network Youcangotodoctors,specialistsand hospitalsinoroutofthenetworkthataccept Medicare.Itwillcostyoumoretoget out-of-networkbenefits. Out-of-ServiceArea PlancoversyouwhenyoutravelintheU.S.or itsterritories.

BenefitCategoryOriginalMedicareFreedomBluePPOEmployerGroupPlan Forquestionsaboutthisplan'sbenefitsorcosts,pleasecontactFreedomBluePPO.Currentmemberscall1-800-550-8722 (TTYuserscall711)andprospectivememberscall1-866-456-7739,(TTYuserscall711),sevendaysaweek,between8a.m.and8p.m.Eastern.

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INPATIENTCARE InpatientHospitalCareIn2012theamountsforeachbenefitperiodAuthorizationrulesmayapply. (includesSubstanceAbuseandRehabilitationwere: Services)Days1-60:$1,156deductibleIn-Network Days61-90:$289perdayYoupaycostsharingof$0foreach Days91-150:$578perlifetimereservedayMedicare-coveredstayatanetworkhospital. Theseamountsmaychangefor2013.Thereisnolimittothenumberofdays coveredbytheplaneachbenefitperiod. Call1-800-MEDICARE(1-800-633-4227)for informationaboutlifetimereservedays.Exceptinanemergency,yourdoctormusttell Lifetimereservedayscanonlybeusedonce.theplanthatyouaregoingtobeadmittedto A“benefitperiod”startsthedayyougointoathehospital. hospitalorskillednursingfacility.Itends whenyougofor60daysinarowwithoutOut-of-Network hospitalorskillednursingcare.IfyougointoYoupay20%coinsuranceforeach thehospitalafteronebenefitperiodhasMedicare-coveredstayatanout-of-network ended,anewbenefitperiodbegins.hospital. Youmustpaytheinpatienthospital deductibleforeachbenefitperiod.Thereis nolimittothenumberofbenefitperiodsyou canhave.

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InpatientMentalHealthCareSamedeductibleandcopayasinpatientAuthorizationrulesmayapply. hospitalcare(see"InpatientHospitalCare" above).190daylifetimelimitinaPsychiatricIn-Network Hospital.Youpaycostsharingof$0foreach Medicare-coveredstayatanetworkhospital. Yougetupto190daysinaPsychiatric Hospitalinalifetime. Exceptinanemergency,yourdoctormusttell theplanthatyouaregoingtobeadmittedto thehospital.

Out-of-Network You

pay20%coinsuranceforeach Medicare-coveredstayatanout-of-network hospital.

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SkilledNursingFacility(SNF)In2012theamountsforeachbenefitperiodAuthorizationrulesmayapply. (inaMedicare-certifiedskillednursingfacility)afteratleasta3-daycoveredhospitalstay were:In-Network Days1-20:$0perdayYoupaycostsharingof$0peradmissionfor Days21-100:$144.50perdayMedicare-coveredservicesataskillednursing facility. Theseamountsmaychangefor2013. Plancoversupto100dayseachbenefit 100daysforeachbenefitperiod.A“benefitperiod. period”startsthedayyougointoahospital orSNF.Itendswhenyougofor60daysinaNopriorhospitalstayisrequired. rowwithouthospitalorskillednursingcare.If yougointothehospitalafteronebenefitOut-of-Network periodhasended,anewbenefitperiodYoupay20%coinsurancefor begins.Medicare-coveredservices,days1-100,atan out-of-networkskillednursingfacility. Youmustpaytheinpatienthospital deductibleforeachbenefitperiod.Thereis nolimittothenumberofbenefitperiodsyou canhave. HomeHealthCare$0copay.Authorizationrulesmayapply. (includesmedicallynecessaryintermittent skillednursingcare,homehealthaideIn-Network services,andrehabilitationservices,etc.)Youpaycostsharingof$0for Medicare-coveredhomehealthservices.

pay20%coinsurancefor Medicare-coveredout-of-networkhome healthvisits.

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HospiceYoupaypartofthecostforoutpatientdrugsYoumustgetcarefromaMedicare-certified andinpatientrespitecare.Youmustgetcarehospice.Yourplanwillpayforaconsultative fromaMedicare-certifiedhospice.visitbeforeyouselectahospice. OUTPATIENTCARE DoctorOfficeVisits20%coinsurance In-Network You

paycostsharingof$10foreach OfficeVisitcopaysarenotappliedtoMedicare-coveredprimarycaredoctorvisit. In-Networkoutofpocketmaximumbutare appliedtotheTotalInandOutofNetworkYoupayacostsharingof$15foreach OutofPocketMaximum.Medicare-coveredspecialistvisit. Out-of-Network Youpay20%coinsuranceforeach Medicare-coveredout-of-networkprimary caredoctorofficevisit. Youpay20%coinsuranceforeach Medicare-coveredout-of-networkspecialist visit.

199883_S84_PG26

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ChiropracticServicesSupplementalroutinecarenotcovered. In-Network You

paycostsharingof$15foreach OfficeVisitcopaysarenotappliedto20%coinsuranceformanualmanipulationofMedicare-coveredvisit. In-Networkoutofpocketmaximumbutarethespinetocorrectsubluxation(a appliedtotheTotalInandOutofNetworkdisplacementormisalignmentofajointorMedicare-coveredchiropracticvisitsarefor OutofPocketMaximum.bodypart)ifyougetitfromachiropractorormanualmanipulationofthespinetocorrect otherqualifiedproviders.subluxation(adisplacementormisalignment ofajointorbodypart)ifyougetitfroma chiropractororotherqualifiedproviders. Out-of-Network Youpay20%coinsurancefor Medicare-coveredout-of-networkchiropractic benefits. PodiatryServicesSupplementalroutinecarenotcovered.

In-Network You

paycostsharingof$15foreach OfficeVisitcopaysarenotappliedto20%coinsuranceformedicallynecessaryfootMedicare-coveredvisit. In-Networkoutofpocketmaximumbutarecare,includingcareformedicalconditions appliedtotheTotalInandOutofNetworkaffectingthelowerlimbs.Medicare-coveredpodiatrybenefitsarefor OutofPocketMaximum.medically-necessaryfootcare.

pay20%coinsurancefor Medicare-coveredout-of-networkpodiatry benefits.

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OutpatientMentalHealthCare35%coinsuranceformostoutpatientmentalAuthorizationrulesmayapply. healthservices. OfficeVisitcopaysarenotappliedtoIn-Network In-NetworkoutofpocketmaximumbutareSpecifiedcopaymentforoutpatientpartialYoupaycostsharingof$15foreach appliedtotheTotalInandOutofNetworkhospitalizationprogramservicesfurnishedbyMedicare-coveredindividualorgrouptherapy OutofPocketMaximum.ahospitalorcommunitymentalhealthcentervisits. (CMHC).CopaycannotexceedthePartA inpatienthospitaldeductible.Youpaycostsharingof$0foreach Medicare-coveredpartialhospitalization “Partialhospitalizationprogram”isaprogramservices. structuredprogramofactiveoutpatient psychiatrictreatmentthatismoreintenseOut-of-Network thanthecarereceivedinyourdoctor’sorYoupay20%coinsurancefor therapist’sofficeandisanalternativetoMedicare-coveredout-of-networkmental inpatienthospitalization.healthbenefits. Youpay20%coinsurancefor Medicare-coveredout-of-networkmental healthbenefitswithapsychiatrist. Youpay20%coinsurancefor Medicare-coveredpartialhospitalization programservices. OutpatientSubstanceAbuseCare20%coinsuranceAuthorizationrulesmayapply.

In-Network You

paycostsharingof$15foreach Medicare-coveredindividualorgroupvisits.

pay20%coinsurancefor Medicare-coveredout-of-networkoutpatient substanceabuseservices.

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(29)

OutpatientServices/Surgery20%coinsuranceforthedoctor'sservices.Authorizationrulesmayapply. Specifiedcopaymentforoutpatienthospital facilityservices.CopaycannotexceedthePartIn-Network Ainpatienthospitaldeductible20%Youpaycostsharingof$0foreach coinsuranceforambulatorysurgicalcenterMedicare-coveredambulatorysurgicalcenter facilityservices.and/oroutpatienthospitalfacilityvisitper provider/perday.

pay20%coinsurancefor Medicare-coveredservicesatan out-of-networkambulatorysurgicalcenter. Youpay20%coinsurancefor Medicare-coveredservicesatan out-of-networkoutpatienthospitalfacility. AmbulanceServices20%coinsuranceIn-Network (medicallynecessaryambulanceservices)Youpaycostsharingof$0for Medicare-coveredambulancebenefits.

Out-of-Network Emergency

-Youpaycostsharingof$0for Medicare-coveredambulancebenefits. Non-Emergency-Youpaycostsharingof 20%forMedicare-coveredambulance benefits.

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EmergencyCare20%coinsuranceforthedoctor’sservices.Youpay$50costsharingforeach (YoumaygotoanyemergencyroomifyouMedicare-coveredemergencyroomvisit. reasonablybelieveyouneedemergencySpecifiedcopaymentforoutpatienthospital care.)facilityemergencyservices.Worldwidecoverageforemergencyand EmergencyservicescopaycannotexceedParturgentlyneededcare. Ainpatienthospitaldeductibleforeach serviceprovidedbythehospital.Ifyouareadmittedtothehospitalwithin Youdon’thavetopaytheemergencyroom3-day(s)forthesamecondition,yourcopayis copayifyouareadmittedtothehospitalaswaivedfortheemergencyroomvisit. aninpatientforthesameconditionwithin3 daysoftheemergencyroomvisit. NotcoveredoutsidetheU.S.exceptunder limitedcircumstances. UrgentlyNeededCare20%coinsurance,orasetcopay.Youpaycostsharingof$40for (ThisisNOTemergencycare,andinmostNOTcoveredoutsidetheU.S.exceptunderMedicare-coveredurgentlyneededcarevisits. cases,isoutoftheservicearea.)limitedcircumstances.

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OutpatientRehabilitationServices20%coinsuranceAuthorizationrulesmayapply. (OccupationalTherapy,PhysicalTherapy, SpeechandLanguageTherapy) In-Network You

paya$15costsharingfor OfficeVisitcopaysarenotappliedtoMedicare-coveredoccupationaltherapyvisits. In-Networkoutofpocketmaximumbutare appliedtotheTotalInandOutofNetworkYoupaya$15costsharingfor OutofPocketMaximum.Medicare-coveredphysicaltherapyand/or speechandlanguagepathologyvisits.

pay20%coinsurancefor Medicare-coveredoccupationaltherapyvisits. Youpay20%coinsurancefor Medicare-coveredphysicaltherapyand/or speechandlanguagepathologyvisits. OUTPATIENTMEDICALSERVICESANDSUPPLIES DurableMedicalEquipment20%coinsuranceAuthorizationrulesmayapply. (includeswheelchairs,oxygen,etc.) PaymentfordeluxeorspecialfeaturesforOxygenandoxygen-relatedequipment durablemedicalequipmentmaybemadecoveredinfull. onlywhensuchfeaturesareprescribedbythe attendingphysicianandwhenmedicalIn-Network necessityisestablished.Youpay0%coinsurancefor Medicare-covereddurablemedical equipment. Out-of-Network You

pay50%coinsurancefor Medicare-covereddurablemedical equipment.

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ProstheticDevices20%coinsuranceAuthorizationrulesmayapply. (includesbraces,artificiallimbsandeyes,etc.) PaymentfordeluxeorspecialfeaturesforIn-Network durablemedicalequipmentmaybemadeYoupay0%coinsurancefor onlywhensuchfeaturesareprescribedbytheMedicare-coveredprostheticdevices. attendingphysicianandwhenmedical necessityisestablished. Out-of-Network You

pay50%coinsurancefor Medicare-coveredprostheticdevices. DiabetesProgramsandSupplies20%coinsurancefordiabetesAuthorizationrulesmayapply. (includescoverageforglucosemonitors,testself-managementtraining strips,lancets,screeningtests,In-Network self-managementtraining,retinal20%coinsurancefordiabetessuppliesDiabetesself-monitoingtrainingcoveredin exam/glaucomatest,andfootfull. exam/therapeuticsoftshoes)20%coinsurancefordiabetictherapeutic shoesorinsertsNutritiontherapyfordiabetescoveredinfull. Youpay0%coinsurancefor Medicare-covereddiabetessuppliesand therapeuticshoesorinserts. Ifthedoctorprovidesyouadditionalservices, separatedoctorofficevisitcostsharingmay apply. Out-of-Network You

pay50%coinsurancefor Medicare-covereddiabetesself-monitoring training,nutritiontherapy,andsupplies.

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DiagnosticTests,X-Rays,LabServices,and20%coinsurancefordiagnostictestsandAuthorizationrulesmayapply. RadiologyServicesx-rays In-Network $0copayforMedicare-coveredlabservicesYoupay$0forthefollowing Medicare-coveredservices: LabServices:Medicarecoversmedically necessarydiagnosticlabservicesthatare•Labservices orderedbyyourtreatingdoctorwhenthey•Diagnosticproceduresandtests areprovidedbyaClinicalLaboratory•X-rays ImprovementAmendments(CLIA)certified•Diagnosticradiologyservices(notincluding laboratorythatparticipatesinMedicare.X-rays) Diagnosticlabservicesaredonetohelpyour•Therapeuticradiologyservices doctordiagnoseorruleoutasuspected illnessorcondition.MedicaredoesnotcoverIfthedoctorprovidesyouadditionalservices, mostroutinescreeningtests,likecheckingseparatedoctorofficevisitcostsharingmay yourcholesterol.apply. 20%coinsurancefordigitalrectalexamandOut-of-Network otherrelatedservices.Youpay20%coinsurancefor Medicare-covereddiagnosticprocedures, Coveredonceayearforallmenwithtestsandlabservices. Medicareoverage50. Youpay20%coinsurancefor Medicare-coveredtherapeuticanddiagnostic radiologyservices. Youpay20%coinsuranceforeach Medicare-coveredoutpatientx-ray.

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CardiacandPulmonaryRehabilitation20%coinsuranceforCardiacRehabilitationAuthorizationrulesmayapply. Services services 20%

coinsuranceforPulmonaryRehabilitationIn-Network

services 20%

coinsuranceforIntensiveCardiacYoupay$0forMedicare-coveredcardiacand Rehabilitationservices.Thisappliestopulmonaryrehabservices. programservicesprovidedinadoctor’soffice. SpecifiedcostsharingforprogramservicesOut-of-Network providedbyhospitaloutpatientdepartments. Youpay20%coinsurancefor Medicare-coveredcardiacandpulmonary rehabservices. PREVENTIVESERVICES PreventiveServicesandNocoinsurance,copaymentordeductibleforThereisnocostsharingforallpreventive Wellness/EducationProgramsthefollowing:servicescoveredunderOriginalMedicare. •AbdominalAorticAneurysmScreeningSeparateofficevisitcostsharingmaybe •BoneMassMeasurement.Coveredonceappliedforotherservices. every24months(moreoftenifmedically necessary)ifyoumeetcertainmedical•AbdominalAorticAneurysmscreening conditions.•BoneMassMeasurement •CardiovascularScreening•CardiovascularScreening •CervicalandVaginalCancerScreening.•CervicalandVaginalCancerScreening(Pap Coveredonceevery2years.CoveredonceaTestandPelvicExam) yearforwomenwithMedicareathighrisk.•ColorectalCancerScreening •ColorectalCancerScreening•DiabetesScreening •DiabetesScreening•InfluenzaVaccine •InfluenzaVaccine•HepatitisBVaccine •HepatitisBVaccineforpeoplewithMedicare whoareatriskContinuedonnextpage Continuedonnextpage

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PreventiveServicesandContinuedfrompreviouspageContinuedfrompreviouspage Wellness/EducationPrograms Nocoinsurance,copaymentordeductiblefor•HIVScreening thefollowing:•BreastCancerScreening(Mammogram) •HIVScreening.$0copayfortheHIV•MedicalNutritionTherapyServices screening,butyougenerallypay20%ofthe•PersonalizedPreventionPlanServices Medicareapprovedamountforthedoctor’s(AnnualWellnessVisits) visit.HIVscreeningiscoveredforpeoplewith MedicarewhoarepregnantandpeopleatContinuedonnextpage increasedriskfortheinfection,including anyonewhoasksforthetest.Medicarecovers thistestonceevery12monthsoruptothree timesduringapregnancy. •BreastCancerScreening(Mammogram). Medicarecoversscreeningmammograms onceevery12monthsforallwomenwith Medicareage40andolder.Medicarecovers onebaselinemammogramforwomen betweenages35-39. •MedicalNutritionTherapyServices.Nutrition therapyisforpeoplewhohavediabetesor kidneydisease(butaren’tondialysisor haven’thadakidneytransplant)when referredbyadoctor.Theseservicescanbe givenbyaregistereddietitianandmay includeanutritionalassessmentand counselingtohelpyoumanageyourdiabetes orkidneydisease. •PersonalizedPreventionPlanServices (AnnualWellnessVisits) Continuedonnextpage

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PreventiveServicesandContinuedfrompreviouspageContinuedfrompreviouspage Wellness/EducationPrograms Nocoinsurance,copaymentordeductiblefor•PneumococcalVaccine thefollowing:•ProstateCancerScreening(ProstateSpecific •PneumococcalVaccine.YoumayonlyneedAntigen(PSA)testonly) thePneumoniavaccineonceinyourlifetime.•SmokingCessation(Counselingtostop Callyourdoctorformoreinformation.smoking) •ProstateCancerScreening–Prostate•WelcometoMedicarePhysicalExam(Initial SpecificAntigen(PSA)testonly.CoveredoncePreventivePhysicalExam) ayearforallmenwithMedicareoverage50.HIVscreeningiscoveredforpeoplewith •SmokingCessation(counselingtostopMedicarewhoarepregnantandpeopleat smoking).Coverediforderedbyyourdoctor.increasedriskfortheinfection,including Includestwocounselingattemptswithinaanyonewhoasksforthetest.Medicarecovers 12-monthperiod.Eachcounselingattemptthistestonceevery12monthsoruptothree includesuptofourface-to-facevisits.timesduringapregnancy.Pleasecontactplan •WelcometoMedicarePhysicalExam(initialfordetails. preventivephysicalexam)Whenyoujoin MedicarePartB,thenyouareeligibleasIn-Network follows.Duringthefirst12monthsofyourTheplancoversthefollowingsupplemental newPartBcoverage,youcangeteitheraeducation/wellnessprograms: WelcometoMedicarePhysicalExamoran•HealthClubMembership/FitnessClasses AnnualWellnessVisit.Afteryourfirst12 months,youcangetoneAnnualWellnessOut-of-Network Visitevery12months.Youpay50%ofthecostforhealth/wellness services.

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KidneyDiseaseandConditions20%coinsuranceforrenaldialysisIn-Network 20%coinsuranceforkidneydiseaseeducationThereisnocostsharingforMedicare-covered servicesrenaldialysis. Thereisnocostsharingforkidneydisease educationservices.

pay20%coinsurancefor Medicare-coveredrenaldialysis. OutpatientPrescriptionDrugsMostdrugsarenotcoveredunderOriginalDrugscoveredunderMedicarePartB Medicare.YoucanaddprescriptiondrugSeeSection1formoreInformationon coveragetoOriginalMedicarebyjoiningaMedicarePartBDrugs MedicarePrescriptionDrugPlan,oryoucanYoupay10%;$300quarterlyout-of-pocket getallyourMedicarecoverage,includingmaximumofthecostforPartB-covered prescriptiondrugcoverage,byjoiningachemotherapydrugsandotherPart MedicareAdvantagePlanoraMedicareCostB-covereddrugs. Planthatoffersprescriptiondrugcoverage. Youpay20%ofthecostforPartBdrugs out-of-network. PartBDrugsarenotavailableatretail pharmacies. DrugscoveredunderMedicarePartD Pleaserefertotheprescriptiondrugsection ofthisbookformoredetails. DentalServicesPreventivedentalservices(suchascleaning)Preventivedentalservices(suchascleaning) notcovered.notcovered. Authorizationrulesmayapplyfor Medicare-coveredaccidentaldentalservices.

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HearingServicesSupplementalroutinehearingexamsandIn-Network hearingaidsnotcovered.Costsharingof$15foreach RoutineexamandhearingaidcostsharingisMedicare-covereddiagnostichearingexam. notappliedtothedeductibleoroutofpocket20%coinsurancefordiagnostichearing maximums.exams.Costsharingof$15foreachroutinehearing testupto1testeveryyear. Youarecoveredupto$500forhearingaids every3calendaryears.

pay20%coinsuranceforout-of-network routineandMedicare-coveredhearingexam services.

199883_S84_PG38

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Medicare-coveredVisionServices20%coinsurancefordiagnosisandtreatmentYoupay: ofdiseasesandconditionsoftheeye. In-Network Cost

sharingof$15foreach Routineeyeexamsandglassesnotcovered.Medicare-coveredeyeexamtodiagnoseand treatdiseasesandconditionsoftheeye. Medicarepaysforonepairofeyeglassesor contactlensesaftercataractsurgery.Costsharingof$0foranannualGlaucoma Annualglaucomascreeningscoveredforscreening. peopleatrisk. Youareallowed: Medicare-coveredeyewear(1pairof eyeglassesorcontactlensesaftercataract surgery). Contacts,limitedto1pairofcontactsper operatedeye,withalifetimelimit2. Lenses,limitedto1pairofcontactsper operatedeye,withalifetimelimit2. Frames,limitedto1frameperoperatedeye, withalifetimelimit2.

pay20%coinsurancefor Medicare-coveredout-of-networkeyeexams. Youhavea$200benefitmaximumfor Medicare-coveredout-of-networkeyewear.

199883_S84_PG39

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RoutineVisionServicesRoutineeyeexamsandglassesnotcovered.Youpay: In-Network RoutineexamandeyewearcostsharingisCostsharingof$15foranannualcalendar notappliedtothedeductibleoroutofpocketyearroutineeyeexam. maximums. RoutineVisionEyeWear Limitedtoonepairofeyeglassframeswith eyeglasslensesorcontactlenseseverytwo calendaryears.DavisVisionFashion Collectioneyeglassframes,standardeyeglass lensesandstandardcontactlensesare coveredinfull. A$100benefitmaximumisavailabletowards thepurchaseofnon-DavisVisionCollection framesatparticipatingnetworkprovider locations. A$100benefitmaximumisavailabletowards thepurchaseofspecialtycontactlensesat participatingnetworkproviderlocations. Membersmustpaythedifferencebetween thebenefitmaximumandtheprovider's charge. Out-of-Network $100

benefitmaximumforspecialtyframesor specialtycontactlenses. Over-the-CounterItemsNotcovered.Theplandoesnotcoverover-the-counter items.

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Transportation(Routine)Notcovered. In-Network You

pay$40costsharingpertrip. Costsharingisnotappliedtothedeductible oroutofpocketmaximums.

pay50%ofthecostfortransportation services. AcupunctureNotcovered.Thisplandoesnotcoveracupuncture.

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H3916_12_0701 Accepted

199883_S84_PG42

Enjoy more benefits, including preventive, vision and hearing care

Freedom Blue PPO gives you access to a national network of participating providers

Enjoy more benefits, including preventive, vision and hearing care

Reference Code

13FB9883

Keep yourself and your budget in shape

Save money on prescription drugs

Personal, knowledgeable Member Service

Have questions now – call toll-free

Section 1 Plan Highlights and Frequently Asked Questions

Section 2 Enrollment Information

Section 3 Summary of Benefits

Section 4 Health and Wellness

Section 5 Network Provider Information

Section 6 Prescription Drug Benefits

Table of Contents

Enjoy the Flexibility of a

PPO, Plus the

Dependability of

Highmark

Blue Shield

Section 1

Freedom Blue PPO

gives you exactly

what you want from

your health care

coverage – freedom

of choice

Enjoy the higher, network-level of

benefits at lower, in-network costs

throughout the United States – great

for snowbirds and people on the

move!

Freedom from claim forms

and referrals

Enjoy personal,

reliable Member Service

Trust the plan that’s backed by

Highmark Blue Shield

Answers to frequently

asked questions

Q

A.

Q

A.

Q

A.

Q

A.

Q

A.

Section 2

Enrolling In

Freedom Blue PPO

It’s easy to enroll

Freedom Blue PPO

Covers Most Health Care

Services You Need

Section 3

Freedom Blue PPO offers comprehensive coverage in and out of the network,

including:

Coverage for important preventive care

Emergency and urgently needed care is covered at the highest level – anywhere

in the world

SECTION ONE:

INTRODUCTION TO SUMMARY OF BENEFITS

Freedom Blue PPO

January 1, 2013 through December 31, 2013

YOU HAVE CHOICES IN YOUR HEALTH CARE

HOW CAN I COMPARE MY OPTIONS?

WHERE IS FREEDOM BLUE PPO AVAILABLE?

WHO IS ELIGIBLE TO JOIN FREEDOM BLUE PPO?

CAN I CHOOSE MY DOCTORS?

WHAT HAPPENS IF I GO TO A DOCTOR WHO’S NOT IN OUR NETWORK?

DOES MY PLAN COVER MEDICARE PART B OR PART D DRUGS?

WHERE CAN I GET MY PRESCRIPTIONS IF I JOIN THIS PLAN?

WHAT IS A PRESCRIPTION DRUG FORMULARY?

HOW CAN I GET EXTRA HELP WITH PRESCRIPTION DRUG PLAN COSTS?

WHAT ARE MY PROTECTIONS IN THE PLAN?

WHAT IS A MEDICATION THERAPY MANAGEMENT (MTM) PROGRAM?