Medicare Advantage plans
2014 Blue Medicare HMOSM Blue Medicare PPOSM
No additional cost! 1
Y0079_6204 CMS Approved 08132013 U5047a, 8/13
Contents�
The benefits of Original Medicare plus
additional coverage ... 3
Compare our plans ...4
Eligibility requirements ... 5
Service area map ...6
Understanding your Part D benefits ... 7
Additional member benefits...10
Enrollment is easy with these simple steps ... 11�
Understanding how your benefits work ... . 12�
Important information ... 14�
2014 Summary of Benefits... 21�
Contact information ...110�
Multi-language Interpreter Services ... 111�
What You Get
+ $0 monthly premium plans available*
+ No referrals required to see specialists
+ Predictable copayments and costs
+ Health care benefits and Medicare prescription drug coverage in one plan
+ All from a local company you can trust
Original Medicare and Medicare Advantage plans can sometimes be overwhelming, especially when there are so many choices.
That’s why we want to give you information to help you decide which options work best for you.
In this guide, you’ll find: information about Blue Medicare HMO and Blue Medicare PPO Medicare Advantage plans, charts to help you compare plan options, information about Medicare Prescription Drug (Part D) coverage, details about how to enroll in a plan, summaries of benefits for available plans, and more.
Understanding your choices
Footnote:
1 The SilverSneakers program is provided by Healthways, Inc., a third-party vendor independent of BCBSNC. The program is available only to members covered under Blue Medicare HMO, Blue Medicare PPO and Blue Medicare Supplement plans.
BCBSNC is not liable in any way for the
services received; results are not guaranteed.
Decisions regarding medical care should be made with the advice of a doctor. SilverSneakers is a registered trademark of Healthways, Inc.
* Rate is for Blue Medicare HMO Standard and Blue Medicare HMO Medical-Only plans, 2014.
PAGE 2 of 120
The benefits of Original Medicare plus additional coverage
Health benefits and Medicare prescription drug coverage – all in one plan
Blue Medicare HMO and Blue Medicare PPO plans can provide you with more coverage than Original Medicare and help limit your out-of- pocket costs.
And since Medicare prescription drug (Part D) coverage is built right into most plans, there’s no need to buy one plan for enhanced medical benefits and another plan for your Medicare prescription drug benefits.
Choices to meet your needs and budget
Blue Medicare HMO offers you health coverage within an extensive network of doctors and specialists2 that you can see without referrals.
You can also select a plan with $0 monthly premiums* with or without Part D coverage.3 Blue Medicare PPO gives you the freedom to see providers in or out of network.4 You can see specialists without a referral, and all medically necessary benefits are covered in and out of network. All PPO plans include Part D coverage.3
Additional benefits that help limit your out-of-pocket costs
Both Blue Medicare HMO and Blue Medicare PPO plans offer coverage for:
+ Inpatient/outpatient services + Skilled nursing facility care + Home health care
+ Worldwide emergency medical care + Ambulance and urgent care
+ Preventive care + And more
Footnotes:
2 You must use the plan’s providers except in emergency or urgent care situations or for out-of-area renal dialysis. If you obtain routine care from out-of-network providers neither Medicare nor BCBSNC will be responsible for the costs.
3 Formulary applies for all plans that include Medicare prescription drug coverage.
4 With the exception of emergency or urgent care, member liability with Blue Medicare PPO may be greater for services received out-of-network than services received in-network. Many out-of-network services are subject to coinsurance, which are based on the Medicare allowed amount and not on the potentially lower contract amount.
* Rate is for Blue Medicare HMO Standard and Blue Medicare HMO Medical-Only plans, 2014.
PAGE 3 of 120
Compare our plans
Review the chart below to find out which plan is best for you. Please note that limitations, copayments, and restrictions may apply. For a complete outline of coverage, please refer to the Blue Medicare HMO and Blue Medicare PPO Summary of Benefits starting on page 21.
Medical only Standard Enhanced Enhanced Enhanced Freedom Additional
monthly premium5 $0 $0 $18.90 $38 $121.30
Provider choice
+ In-network benefits only; must visit a participating provider
+ No referrals required to see network specialists
+ In- and
out-of-network benefits
+ Choose any in-network provider for less cost; or choose an out-of-network provider for a higher cost
+ In- and
out-of-network benefits
+ Choose any in-network or out-of-network provider and pay virtually the same costs
Primary care/
Specialist office visits
$5/$20 copayment in-network for
visits only
$15/$40 copayment in-network for
visits only
$10/$35 copayment in-network for
visits only
$20/$40 copayment for in-network visits;
20% coinsurance for out-of-network
primary care and specialist visits
$15/$35 copayment for in-network visits;
$35 copayment for out-of-network primary care and
specialist visits Inpatient
hospital
$100 per day up to
7 days
$220 per day up to
7 days
$170 per day up to
7 days
$220 per day up to
7 days
$170 per day up to
7 days Diagnostic tests,
lab work and X-rays
coinsurance 5% 20%
coinsurance 15%
coinsurance
20% coinsurance in-network and out-of-network
15% coinsurance in-network and
out-of-network Medicare
prescription drug
coverage6 None Standard
benefits drug
Enhanced benefits drug
Standard drug
benefits Enhanced drug benefits
Footnotes:�
5 You must continue to pay the Medicare Part B premium in addition to your plan premium.�
6 Formulary applies for all plans that include Medicare prescription drug coverage.�
PAGE 4 of 120
Eligibility requirements for enrolling in a plan
First things first: who is eligible
To be eligible for a Blue Medicare HMO or Blue Medicare PPO plan, you must:
+ Be entitled to Medicare Part A and enrolled in Medicare Part B
+ Live in the plan’s service area (see map and chart of counties) Due to Federal regulations, you may not be eligible to join a Blue Medicare HMO or Blue Medicare PPO plan if you are medically determined to have end-stage renal disease (ESRD) unless you meet exception qualifications.
Please call for more information.
Part D late enrollment penalties
Everyone with Medicare is eligible for Part D coverage, but it’s not mandatory. Part D coverage is a voluntary program that you may choose to purchase annually. However, if you do not enroll when you first become eligible, you may have to pay more for prescription drug coverage if you decide to enroll later.
You may be able to get Extra Help to pay for your prescription drug premiums and costs.
To see if you qualify for extra help, call:
+ 1-800-MEDICARE (1-800-633-4227).
TTY users should call 1-877-486-2048, 24 hours a day/7 days a week;
+ The Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Mon. through Fri.
TTY users should call, 1-800-325-0778; or + Your State Medicaid Office
Enrollment periods
Initial coverage enrollment period begins three months immediately before you become eligible for both Medicare Part A and Part B and ends on the later of either:
+ The last day of the month preceding your eligibility to both Part A and Part B, or + The last day of your Part B initial
enrollment period.
Annual enrollment period
October 15 through December 7 of every year.
Annual disenrollment period
January 1 through February 14 of every year.
Special enrollment period
If you didn’t sign up for Medicare coverage under Part A, Part B or Part D when you were first eligible, you may be eligible to sign up without waiting for an open enrollment period.
Additionally, you may be able to sign up without paying a penalty (higher premium).
Call the BCBSNC Sales Department at 1 ‑800‑665‑8037, 7 days a week, 8 a.m.–8 p.m.
For the hearing and speech impaired (TTY/TDD), call: 1‑800‑922‑3140.
PAGE 5 of 120
Service area map�
2014 HMO and PPO Service Area
Blue Medicare HMO and Blue Medicare PPO plans are available in the following counties:*
Alamance Catawba Granville Madison Pitt Vance
Alexander Chatham Greene Martin Polk Wake
Alleghany Chowan Guilford McDowell Randolph Warren
Anson Cleveland Halifax Mecklenburg Richmond Washington
Ashe Columbus Harnett Mitchell Robeson Watauga
Avery Cumberland Haywood Montgomery Rockingham Wayne
Beaufort Davidson Henderson Nash Rowan Wilkes
Bertie Davie Hertford New Hanover Sampson Wilson
Bladen Duplin Hoke Northampton Scotland Yadkin
Brunswick Durham Hyde Onslow Stanly Yancey
Buncombe Edgecombe Iredell Orange Stokes
Cabarrus Forsyth Johnston Pamlico Surry
Caldwell Franklin Jones Pender Transylvania
Carteret Gaston Lee Perquimans Tyrrell
Caswell Gates Lincoln Person Union
* Bold counties are new for 2014
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Understanding your Part D benefits
Medicare offers prescription drug (Part D) Our plans also offer the convenience of using coverage to help you pay for your prescription the preferred mail-order pharmacy at a reduced drugs. With this coverage, you can fill your cost to you. You pay a $3 copay for a 30 day prescriptions at participating pharmacies supply of preferred generic drugs ordered close to where you live. You may go to any
participating pharmacy, but you will see your greatest savings by going to one of our preferred pharmacies.
BCBSNC’s Preferred Pharmacy Network includes CVS, Walmart, Kerr and Epic Pharmacies. This select network of national and local independent pharmacies has worked with BCBSNC to get you the savings and value that you are looking for by offering lower costs and better value from your prescription plan, without sacrificing convenience.
through mail order, and a $0 copay for a 60-day and 90-day supply of covered preferred
generic drugs.
Medicare prescription drug coverage is
available with most Blue Medicare HMO and Blue Medicare PPO plans. That means you can have your medical benefits and prescription drug coverage with one plan, for one premium.
(You must continue to pay your Medicare Part B premium.)
Please review the preferred and non-preferred benefit charts to understand the Part D benefits that are included with the Blue Medicare HMO and Blue Medicare PPO benefits. The total amount you spend on prescription drugs increases during the calendar year as
you move through some or all of the phases of coverage. Remember, you must always present your plan’s member ID card to fill your prescriptions.
NOTE: For members who qualify for low-income assistance, benefits may vary.
PAGE 7 of 120
Preferred Pharmacy Network benefits�
Our preferred network includes CVS, Walmart, Kerr and Epic Pharmacies
Plan Feature Drug List (Formulary) Tier 1: Preferred Generic
Tier 2:
Non-Preferred Generic
Tier 3: Preferred Brand
Tier 4:
Non-Preferred Brand
Tier 5: Specialty Annual
deductible
Initial
Retail
Preferred mail order
Coverage gap
Retail
Preferred mail order
Catastrophic Catastrophic
coverage
Standard Enhanced Enhanced Enhanced Freedom Includes nearly 100% of the drugs covered by Medicare Part D
$3 $3 $3 $3
$6 $6 $6 $6
$40 $30 $40 $30
$80 $70 $80 $70
33% coinsurance You pay $0
You pay no annual deductible.
You + Plan = $2,850
You pay the copayment per 30-day supply or coinsurance for your drugs, and the plan pays the remainder until total drug costs reach $2,850.
You pay $0 copay for a 60- or 90-day supply of preferred generic drugs at our preferred mail-order pharmacy through the initial phase. You pay $3 at our preferred mail-order pharmacy for a 30-day supply of preferred generic drugs.
You pay 72%
on all generic drugs. You
receive a discount for brand-name
drugs.
You pay 72% for generic drugs all
You pay $3 for Tier 1 Preferred
Generic drugs;
You pay 72% for all other generic drugs. You receive
a discount for brand-name drugs.
You pay $3 for Tier 1 Preferred
Generic drugs;
You pay 72% for all other generic drugs.
You pay 72%
on all generic drugs. You
receive a discount for brand-name
drugs.
You pay 72% for generic drugs all
You pay $3 for Tier 1 Preferred
Generic drugs;
You pay 72% for all other generic drugs. You receive
a discount for brand-name drugs.
You pay $3 for Tier 1 Preferred
Generic drugs;
You pay 72% for all other generic drugs.
You receive a discount for brand-name drugs. You remain in the coverage gap until your yearly out-of-pocket drug costs (not including premiums) equal $4,550.
PAGE 8 of 120
You pay 5%
After you reach $4,550 in out-of-pocket costs, the plan pays the majority of the drug costs until the end of the year. You pay the greater of $2.55 for generic,
$6.35 for brand-name or 5% of the total drug cost.
Non-Preferred Pharmacy Network benefits
Plan Feature
Standard Enhanced Enhanced Enhanced Freedom Drug List
(Formulary) Includes nearly 100% of the drugs covered by Medicare Part D Tier 1: Preferred
Generic $8 $8 $8 $8
Tier 2:
Non-Preferred
Generic $25 $20 $25 $20
Tier 3: Preferred
Brand $45 $45 $45 $45
Tier 4:
Non-Preferred
Brand $95 $95 $95 $95
Tier 5: Specialty 33% coinsurance
Annual
deductible You pay no annual deductible. You pay $0
Initial
Retail You + Plan = $2,850
You pay the copayment per 30-day supply or coinsurance for your drugs, and the plan pays the remainder until total drug costs reach $2,850.
Non-preferred mail order
You pay $8 for a 30-day supply of preferred generic drugs. Pay 3 times the copay for a 90-day supply of preferred generic and brand-name drugs
at our mail-order pharmacy through the initial phase.
Coverage gap
Retail
You pay 72%
on all generic drugs. You
receive a discount for brand-name
drugs.
You pay $8 for Tier 1 Preferred Generic drugs; You pay 72% for all other
generic drugs. You receive a discount for brand-name
drugs.
You pay 72%
on all generic drugs. You
receive a discount for brand-name
drugs.
You pay $8 for Tier 1 Preferred Generic drugs; You pay 72% for all other
generic drugs. You receive a discount for brand-name
drugs.
Non-preferred mail order
You pay 72%
for all generic drugs
You pay $8 for Tier 1 Preferred Generic drugs;
You pay 72% for all other generic drugs.
You pay 72%
for all generic drugs
You pay $8 for Tier 1 Preferred Generic drugs;
You pay 72% for all other generic drugs.
You receive a discount for brand-name drugs. You remain in the coverage gap until your yearly out-of-pocket drug costs (not including premiums) equal $4,550.
Catastrophic Catastrophic
coverage
You pay 5%
After you reach $4,550 in out-of-pocket costs, the plan pays the majority of the drug costs until the end of the year. You pay the greater of $2.55 for generic,
$6.35 for brand-name or 5% of the total drug cost.
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Our Blue Medicare PPO Travel Program enables Blue Medicare PPO members traveling in certain states and Puerto Rico to use the networks of other participating Blue Cross and/or Blue Shield Medicare Advantage PPO plans. Please call for more details.
States/territory with visitor/traveler benefits for PPO members only
Alabama Georgia Massachusetts New Jersey Pennsylvania Washington Arkansas Hawaii Michigan New Mexico South Carolina West Virginia
California Idaho Missouri New York Tennessee Wisconsin
Colorado Indiana Montana Ohio Texas
Connecticut Kentucky Nevada Oklahoma Utah Puerto Rico
Florida Maine New Hampshire Oregon Virginia
PPO Travel Program
PAGE 10 of 120 Footnote:
7 The SilverSneakers program is provided by Healthways, Inc., a third-party vendor independent of BCBSNC. The program is available only to members covered under Blue Medicare HMO, Blue Medicare PPO and Blue Medicare Supplement plans. BCBSNC is not liable in any way for the services received; results are not guaranteed. Decisions regarding medical care should be made with the advice of a doctor. SilverSneakers is a registered trademark of Healthways, Inc.
8 Blue365 offers access to savings on items that Members may purchase directly from independent vendors, which are different from items that are covered under the policies with BCBSNC. Any disputes regarding these products and services may be subject to BCBSNC’s grievance process.
Blue Cross and Blue Shield Association (BCBSA) may receive payments from Blue365 vendors.
Neither BCBSNC nor BCBSA recommends, endorses, warrants or guarantees any specific Blue365 vendor or item. This program may be modified or discontinued at any time without prior notice.
Gym membership offered on website does not replace Silver Sneakers benefit.
SilverSneakers – a fitness program that also offers health education and social events – is included with Blue Medicare HMO and PPO plans at no additional cost.7
Additional member benefits
Save with exclusive member discounts through Blue365.®, 8 This program offers discounts on a variety of products and services that can help you live a more healthy and active lifestyle – all at no additional cost. Save on:
+ Hearing aids + Medical bracelets + Laser eye surgery + Healthy eating + Vision services + And more!
3
4
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Enrollment is easy with these simple steps
Choose a plan
After reviewing the enclosed material, decide in which plan you want to enroll. (You will indicate your plan choice on the enrollment form by checking the appropriate box beside the plan you select.)
Select a primary care provider (PCP)
In order to select a PCP, please visit www.bcbsnc.com/medicare to review the plan’s participating providers. If you need assistance finding a provider, you may contact your agent or speak to an authorized sales representative by calling 1-800-665-8037, 7 days a week, 8 a.m.–8 p.m. For the hearing and speech impaired (TTY/TDD), please call
1-800-922-3140.
Complete the enrollment form
Fill out the enrollment form. You must complete one enrollment form per person. Do not forget to sign and date the form. Do not forget to check the appropriate box beside the plan you want.
After completing your enrollment form, return it in the envelope provided.
1
2
5
Option – enroll online
If you want to enroll online, please visit www.bcbsnc.com/medicare.
Medicare beneficiaries may also enroll in Blue Medicare HMO or Blue Medicare PPO through the Centers for Medicare
& Medicaid Services online Enrollment Center, located at www.medicare.gov. For more information, contact
BCBSNC at 1-800-665-8037. Hearing and speech impaired (TTY/TDD), call 1-800-922-3140, 7 days a week, 8 a.m.–8 p.m., or visit
www.bcbsnc.com/medicare.
Enrollment confirmation
You will receive acknowledgement of your enrollment request via mail.
NOTE: There are some limits set by the federal government on when and how often Medicare beneficiaries may enroll in or change Medicare Advantage and Medicare Prescription Drug Plans. For more information on these enrollment rules, refer to “Enrollment Periods”
on page 5, or call the BCBSNC Sales Department at 1-800-665-8037, 7 days a week, 8 a.m.–8 p.m.
For the hearing and speech impaired (TTY/TDD), call:
1-800-922-3140.
Understanding how your�
benefits work
Visiting the doctor
Blue Medicare HMO
As a member of Blue Medicare HMO, you may only visit doctors within the network of contracted doctors in order to access your benefits. You must choose a primary care provider (PCP) from within that network to coordinate your care. For your PCP, you can select a family practice doctor, general practice doctor, internal medicine doctor, or nurse practitioner or physician assistant, where available.
You must use the plan’s providers except in emergency or urgent care situations or for out-of-area renal dialysis. If you obtain routine care from out-of-network providers neither Medicare nor BCBSNC will be responsible for the costs.
Blue Medicare PPO
As a member of Blue Medicare PPO, you have access to a network of doctors. You must choose a PCP to coordinate your care. For your PCP, you can select a family practice doctor, general practice doctor, internal medicine doctor, or nurse practitioner or physician assistant, where available. You may visit a doctor outside of the network; however, you may be responsible for more of the cost. You may also visit a doctor or specialist at any time without a referral.
Using your Part D benefits
Covered prescription drugs
Enhanced and standard benefits are both based on a formulary (a preferred list of prescription drugs) that was developed using guidelines from the Federal government. The formulary covers many drugs eligible for coverage under Medicare Part D – more than 1,800 drugs. The formulary includes generic, brand-name and specialty drugs.
Both the standard and enhanced benefits cover:
prescription drugs, vaccines (not all vaccines are covered), insulin, and certain medical supplies associated with injection of insulin (syringes, needles, alcohol swabs and gauze).
Prescription drugs that are not covered
Medicare Part D plans do not cover certain drugs, or classes of drugs, which are excluded by law, such as over-the-counter medications, prescription vitamins and erectile dysfunction drugs.
In general, all drugs covered by Medicare prescription drug benefits must be:
+ Available only by prescription + Approved by the FDA
+ Used for a medically accepted indication
PAGE 12 of 120
2
1 2
How to find out if your prescriptions are covered by the formulary
All plans include Prior Approval (PA), Quantity Limit (QL) and Step Therapy (ST) programs for select drugs.
Go to www.bcbsnc.com/medicare. Click on the Find a Drug link and then select the appropriate formulary.
Call 1-800-665-8037, 7 days a week, 8 a.m.–8 p.m. and speak to an authorized sales representative to determine if a specific drug is covered. Hearing and speech impaired (TTY/TDD users) call 1-800-922-3140.
Filling your prescriptions
You can fill your prescriptions at a network of participating pharmacies throughout North Carolina. Most of the major chain pharmacies are part of the network, and you can fill your prescriptions at any of their locations nationwide. You must use participating pharmacies to fill your prescriptions in order to receive coverage, except in the case of an emergency or in certain situations when traveling outside of the service area. Quantity limitations and restrictions may also apply.
Mail order
You can also fill your prescriptions through our Preferred mail order prescription program.
To enroll in the mail order program, you must complete a mail order form. To request this form, please call: 1-888-310-4110 for Blue Medicare HMO or 1-877-494-7647 for Blue Medicare PPO, 7 days a week, 8 a.m.–8 p.m.
Hearing and speech impaired (TTY/TDD), please call 1-888-451-9957.
90-day supply
If your doctor writes you a prescription for a 90-day supply of covered prescription drugs, you can receive the full supply at one time at most network pharmacies or through mail order. Your cost for a 90-day supply will vary depending on your phase of coverage.
Finding a participating pharmacy
Our network includes a variety of pharmacies, including retail, home infusion, Indian/Tribal/
Urban organizations, extended supply and long-term care pharmacies. In order to obtain the greatest savings on your prescription medications, please visit one of our preferred network providers (CVS, Walmart, Kerr, and Epic Pharmacies). To locate a pharmacy near you, you can:
Go to www.bcbsnc.com/medicare. Click on Find a Pharmacy.
Speak with an authorized sales
representative by calling 1-800-665-8037, 7 days a week, 8 a.m.–8 p.m. Hearing and speech impaired (TTY/TDD), please call 1-800-922-3140. Representatives can help find a pharmacy near you.
Compare Medicare plans
+ Find out which Medicare plans are available in your area.
+ Learn about plan benefits and costs.
+ Compare ratings by quality, premium, estimated annual costs and more.
+ Compare BCBSNC Plan ratings, included in the enrollment kit, or visit www.medicare.gov. Plan ratings are available upon request for this plan by calling BCBSNC directly at 1-800-665-8037, 7 days a week, 8 a.m.-8 p.m. For the hearing impaired (TTY/TDD), call 1-800-922-3140.
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eligible for these savings and don’t even know it. For more information about this Extra Help, contact your local Social Security office or call 1-800-MEDICARE (1-800-633-4227), 24 hours per day, 7 days per week. TTY/TTD users should call 1-877-486-2048.
Important information�
Qualifying for
financial assistance
If you have both Medicare and Medicaid, you already qualify for low-income assistance.
If you do not qualify for Medicaid, you may still qualify for some assistance. The amount of assistance will depend on your income and resources and will be applied to the cost of the Medicare prescription drug coverage portion of your Medicare Advantage plan. Once you have enrolled in Blue Medicare HMO or Blue Medicare PPO, Medicare will tell the plan how much assistance you are receiving and you will be sent information on the amount you will pay.
People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If you qualify, Medicare could pay for up to seventy-five (75) percent or more of your drug costs including monthly prescription drug premiums, annual deductibles, and co-insurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are
You may be able to get extra help to pay for your prescription drug premiums and costs. To see if you qualify for extra help, call:
+ 1-800-MEDICARE (1-800-633-4227).
TTY/TDD users should call 1-877-486-2048, 24 hours a day/7 days a week;
+ The Social Security Office at 1-800-772-1213, between 7 a.m. and 7 p.m., Mon. through Fri.
TTY/TDD users should call 1-800-325-0778; or + Your State Medicaid Office
About your benefits
+ BCBSNC provides services according to the coverage guidelines established by Medicare.
+ The medical care, services, supplies and equipment that are described as covered services must be medically necessary.
+ Some services are covered only if your doctor or other network provider gets Prior Approval (PA) from BCBSNC.
Frequently asked questions
What happens to my Medicare coverage when I join a Medicare Advantage plan?
Once you become a member of
Blue Medicare HMO or Blue Medicare PPO, you transfer the administration of your
Medicare benefits to the plan. This means you maintain your status as a Medicare beneficiary, plus you gain the enhanced coverage available through your Medicare Advantage health plan.
You will receive a member ID card that you must present when using your benefits.
PAGE 14 of 120�
Are annual physicals covered?
Yes. Routine health examinations are covered and encouraged for all members.
What happens if I have a medical emergency?
If you have a medical emergency, go to the nearest medical facility or call 911.
Emergency medical services are covered for you in or out of the service area. Please contact your primary care provider (PCP) within 48 hours so your PCP can coordinate your follow-up care. Emergency services require a copayment, but it will be waived if you are admitted to the hospital for the same condition on an inpatient basis within 48 hours. This coverage is available worldwide. Members can get help
locating providers and obtain information regarding submitting a claim for out-of- country emergency services by calling 1-800-810-BLUE or by calling collect at 1-804-673-1177.
If I am a military retiree, can I join a Medicare Advantage plan without losing my military benefits?
Once you join Blue Medicare HMO or
Blue Medicare PPO, you can continue to use your military benefits at military facilities, and you can use your Medicare Advantage plan benefits outside of the military system.
Can I buy a stand-alone Medicare prescription drug package?
Yes, but if you enroll in Medicare Advantage plan and want Medicare prescription drug coverage, you must enroll in a Medicare Advantage Prescription Drug Plan – one
that includes both medical and prescription drug benefits. Enrollment in a stand-alone prescription drug plan automatically disenrolls you from a Medicare Advantage plan. Enrollment in a Medicare Advantage plan automatically disenrolls you from a stand-alone prescription drug plan.
If I choose the Blue Medicare HMO plan that does not include Medicare prescription drug coverage, can I buy this drug coverage separately from another source?
No. If you choose to enroll in a
Medicare Advantage plan that does not include drug coverage, like our Medical-Only plan, federal regulations prohibit you from purchasing a separate Medicare prescription drug plan.
Can I use my Medicare prescription drug coverage to order my drugs from Canada?
No. Only drugs purchased in the United States are eligible for Medicare prescription drug coverage.
Can I continue to use my drug discount card?
There are non-Medicare approved drug discount cards that may continue to exist.
If you enroll in a Medicare Advantage plan that includes Medicare prescription drug coverage, you should contact the issuer of the card to see if you can keep your non-Medicare-approved drug discount card to use in addition to your coverage.
PAGE 15 of 120
Coverage determinations, appeals and
grievances for prescription drug coverage
Requesting a coverage determination Standard: To ask for a standard decision, you or your appointed representative may call the Customer Service Department at 1-888-310-4110 for Blue Medicare HMO or 1-877-494-7647 for Blue Medicare PPO, 7 days a week, 8 a.m.–8 p.m. (Hearing and speech impaired TTY/TDD, call: 1-888-451-9957).
You can also deliver a written request to BCBSNC, 5660 University Parkway,
Winston-Salem, NC 27105, Mon. through Fri from 8 a.m.–5 p.m. You may fax your request to 1-888-446-8535.
Fast: To ask for a fast decision, you, your physician, or your appointed representative may call the Customer Service Department at 1-888-310-4110 for Blue Medicare HMO or 1-877-494-7647 for Blue Medicare PPO, 7 days a week, 8 a.m.–8 p.m. (Hearing and speech impaired TTY/TDD, call: 1-888-451-9957).
You can also deliver a written request to BCBSNC, 5660 University Parkway,
Winston-Salem, NC 27105, Mon. through Fri.
from 8 a.m.–5 p.m. You may fax your request to 1-888-446-8535. After regular business hours, you should consult with a contracting pharmacy regarding your need for an
emergency or temporary supply of medication.
You may also call our Customer Service Department and leave a message on the Part D After Hours Exception Request Voicemail.
Be sure to ask for a “fast,” “expedited,” or
“24-hour” review. NOTE: You cannot ask for a fast decision on a request for coverage of a drug already purchased.
Receiving your coverage determination decision Generally, you will receive a decision no later than 72 hours after your request has been received, but it may be made sooner if your health condition requires. If your request involves a request for an exception (including a formulary exception or an exception from utilization management rules, such as dosage or quantity limits), a decision must be made no later than 72 hours after your doctor’s
“supporting statement” (explaining why the drug you are asking for is medically necessary) has been received.
If you are requesting an exception, you should submit your prescribing doctor’s supporting statement with the request, if possible. You will be notified verbally about the prescription drug you have requested. You will get this notification when a decision has been made under the
timeframe explained above. If your request is not approved, you will receive an explanation in writing and be advised of your right to appeal the decision.
If you get a fast review, you will receive a decision within 24 hours after you or your doctor asks for a fast review – sooner if your health requires. If your request involves a request for an exception, you must receive a decision no later than 24 hours after we get your doctor’s “supporting statement.”
Exceptions to coverage rules
Exceptions are part of the coverage determination process. You, your authorized representative, or your prescribing physician may request an exception to seek coverage of a drug that:
+ Is not on the formulary + Requires prior authorization + Has quantity limitations PAGE 16 of 120
Example of an exception request
If the Plan’s formulary does not include a drug that you or your prescribing physician feel is necessary, then you or your prescribing physician may request an exception so that you may obtain coverage of this drug. If the Plan does not grant the requested exception, then you or your prescribing physician may file an appeal.
Making an exception request
You or your prescribing physician may request an exception to the coverage rules for your Medicare prescription drug plan via:
+ Phone: 1-888-310-4110 for Blue Medicare HMO or 1-877-494-7647 for Blue Medicare PPO, (Hearing and speech impaired
TTY/TDD: 1-888-451-9957), 7 days a week, 8 a.m.–8 p.m. Physicians should call:
336-774-5400 or 1-888-296-9790
+ Mail: BCBSNC, Attn: MAPD Exceptions Request, P.O. Box 17509,
Winston-Salem, NC 27116-7509
A specific form is not required for you to make an exception request. The request must include your prescribing physician’s statement that he/
she has determined that the preferred drug either would not be as effective for you and/or would have adverse effects for you.
Receiving an exception request decision Your exception request will be reviewed and
both you and your prescribing physician will be notified of the decision as soon as your health requires, but no later than 72 hours from the time physician’s “supporting statement” was received. Faster exception decisions are available if this 72-hour timeframe could seriously harm your health or ability to function.
If the decision is not in your favor, the notice will be given by phone followed by a written notice within three business days. The notice will tell you how to pursue your appeal rights if you are dissatisfied with the decision.
Appeals process
An appeal is your opportunity to request a re-determination of an adverse coverage determination, which includes denied exception requests.
Example of an appeal
If we deny your request for an exception to cover a non-formulary drug, then you may file an appeal of the denial. An appeal can only be filed after an exception has been requested and denied by the Plan.
Filing an appeal
If you receive a coverage determination denial, you or your appointed representative or your doctor or other prescriber may file an appeal.
A specific form is not required for you to file an appeal. An appeal must be filed within 60 calendar days of the date of the denial notice and must be in writing, unless you are filing an expedited or fast appeal. You may submit it via:
+ Mail: BCBSNC, Attn: Appeals and Grievance Unit, P.O. Box 17509, Winston-Salem, NC 27116-7509 + Fax: 336-794-8836 or 1-888-375-8836 + In person: Blue Cross and Blue Shield of
North Carolina, 5660 University Parkway, Winston-Salem, NC 27105
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Coverage determinations, appeals and
grievances for prescription drug coverage
(continued)
Receiving a decision on your appeal A standard review of your appeal will be
performed as soon as your health requires but no later than seven calendar days after your appeal is received. Requests for an expedited or fast appeal will be reviewed as soon as possible, but no later than 72 hours following the receipt of the request.
An individual who was not involved with your original coverage determination will make a decision on your appeal.
You will receive a written response to your appeal. The decision on an expedited appeal will be provided by phone followed by the written notice. If the decision is to deny the appeal, the notice will advise you of your right to submit your appeal to the Independent Review Entity (IRE) with instructions on how to do so. If timeframes are missed for claims adjudication or review of the appeal, the appeal will automatically be forwarded to the IRE for
Example of a grievance
If you are dissatisfied with the service you received from a pharmacist or plan
representative, then you may file a grievance.
Filing a grievance
The grievance must be filed within 60 days after the event or incident that caused you to be dissatisfied. A specific form is not required for you to file a grievance. You or your appointed representative may file a grievance via:
+ Phone: 1-888-310-4110 for Blue Medicare HMO or 1-877-494-7647 for Blue Medicare PPO, (Hearing and speech impaired
TTY/TDD: 1-888-451-9957), 7 days a week, 8 a.m.– 8 p.m.
+ Mail: BCBSNC, Attn: Appeals and Grievance Unit, P.O. Box 17509, Winston-Salem, NC 27116-7509 + Fax: 1-888-375-8836
+ In person: Blue Cross and Blue Shield of a decision. There may be additional levels of
appeal available to you. You will be informed of your additional rights in the notice, or you may refer to your Evidence of Coverage for further details.
Grievance process
A grievance is a complaint that you may file if you are dissatisfied with Blue Medicare HMO or Blue Medicare PPO or with a contracted provider for reasons other than a decision on a coverage determination. Grievances also include complaints regarding the timeliness, appropriateness, access to, or setting of a covered prescription drug.
North Carolina, 5660 University Parkway, Winston-Salem, NC 27105
PAGE 18 of 120
Receiving a grievance decision
The resolution of a grievance will be made as quickly as your concern requires, but no more than 30 calendar days after our receipt of the grievance. We may extend the timeframe by up to 14 calendar days if you request the extension, or if we justify a need for additional information and the delay is in your best interest. If you request a written response to an oral grievance, one will be provided within 30 days after receipt of the grievance.
A written response will be provided for all written grievances. Our decision on a grievance is final and is not subject to an appeal.
You have the right to an expedited review of a grievance concerning our refusal to grant an expedited coverage determination or expedited appeal. This type of grievance will be responded to within 24 hours after our receipt of the grievance.
Quality improvement
If you have a concern relating to the quality of services that you received through your Medicare Advantage prescription drug benefits, then, in addition to the review, you can also request review by the following organizations:
+ The Carolinas Center for Medical Excellence (CCME) Quality Improvement Organization (QIO) in North Carolina.
CCME, formerly known as Medical Review of North Carolina Inc., is a nonprofit, medical care quality improvement
organization. CCME has been designated by the Centers for Medicare & Medicaid Services as the Quality Improvement Organization (QIO) for North Carolina.
The QIO conducts case reviews to ensure that Medicare beneficiaries receive the quality of medical care that they expect and are entitled to receive. CCME serves as an independent, impartial third party to review Medicare beneficiary complaints.
Quality of care complaints filed with the QIO must be made in writing. You can write to CCME at The Carolinas Center for Medical Excellence, 100 Regency Forest Drive, Suite 200, Cary, NC 27518.
Assistance is available, Mon. through Fri., 8 a.m.–5 p.m. by calling:
+ QIO number for appeals and complaints:
1-800-682-2650
+ TTY/TDD users dial: 1-800-735-2962 + Web inquiries: www.ccmemedicare.org
Seniors’ Health Insurance Information Program (SHIIP)
SHIIP is a state consumer division of the North Carolina Department of Insurance. SHIIP assists senior citizens with Medicare, Medicare Part D, Medicare supplements, Medicare Advantage, Medicare fraud and abuse and long-term care insurance questions.
Assistance is available by calling 1-800-443-9354, Mon. through Fri., 8 a.m.–5 p.m. You may also send an e-mail to [email protected] or visit SHIIP’s Web site at www.ncshiip.com.
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PAGE 19 of 120
Coverage determinations, appeals and
grievances for prescription drug coverage
(continued)
Notice of possible contract termination Blue Cross and Blue Shield of North Carolina is an HMO and PPO plan with a Medicare contract. Enrollment in Blue Cross and Blue Shield of North Carolina depends on contract renewal. CMS is the government agency that runs Medicare. This contract renews each year. At the end of each year, the contract is reviewed and BCBSNC or CMS can decide to end it. Members will get a 90-day advance, written notice in this situation. It is also possible for our contract to end at some other time. If the contract is going to end, we will generally tell members 90 days in advance. Advance notice may
If BCBSNC decides to stop offering Medicare Advantage plans or change our service area so
that it no longer includes the area where you live, membership in Medicare Advantage plans will end for everyone in that service area, and members will have to change to a different plan. Members will continue to get services through BCBSNC until the contract ends.
The benefit information provided is a brief summary, not a complete description of benefits.
be as little as 30 days or even fewer days if CMS ends our contract in the middle of the year. In this notice, we would provide a written description of alternatives available for obtaining Medicare services within the service area. We are also required to notify the general public of a contract termination via local newspapers.
For more information contact the plan. Additional information about benefits is available to assist you in making a decision about your coverage. This is an advertisement; for more information contact the plan. Benefits, premium and/or copayment/
coinsurance may change on January 1 of each year.
Please contact BCBSNC for details. This brochure may be available in alternate formats upon request.
PAGE 20 of 120
PAG E 21 of 120
January 1, 2014 – December 31, 2014
FOR RESIDENTS OF:
Alamance, Alexander, Alleghany, Anson, Ashe, Avery, Beaufort, Bertie, Bladen, Brunswick, Buncombe, Cabarrus, Caldwell, Carteret, Caswell, Catawba, Chatham, Chowan, Cleveland, Columbus,
Cumberland, Davidson, Davie, Duplin, Durham, Edgecombe, Forsyth, Franklin, Gaston, Gates, Granville, Greene, Guilford, Halifax, Harnett, Haywood, Henderson, Hertford, Hoke, Hyde, Iredell, Johnston, Jones, Lee, Lincoln, Madison, Martin, McDowell, Mecklenburg, Mitchell, Montgomery, Nash, New Hanover,
Northampton, Onslow, Orange, Pamlico, Pender, Perquimans, Person, Pitt, Polk, Randolph, Richmond, Robeson, Rockingham, Rowan, Sampson, Scotland, Stanly, Stokes, Surry, Transylvania, Tyrrell, Union, Vance, Wake, Warren, Washington, Watauga, Wayne, Wilkes, Wilson, Yadkin and Yancey.
Y0079_6255 CMS Accepted 09152013 U5047b, 9/13
2014 Summary of Benefits
(Contract H3449, Plans 005, 012 and 013)
