Medicare plans that meet your needs. From a company that shares your values.

Sacramento (partial) County

Blue Shield 65 Plus (HMO) benefit overviewMedicare Advantage Prescription Drug PlanEffective January 1 through December 31, 2015

blueshieldca.com

H0504_14_158D CMS Accepted 07282014

Fairness, equality, compassion, accountability… These are the values you grew up with and still

hold dear. At Blue Shield, we share those values.

With 75 years of putting care before profit, our aim

is to provide Medicare beneficiaries with the most

affordable and comprehensive benefits in the

marketplace, along with the highest level of care,

customer service, and ethical business practices.

We’re a leading voice on affordable care for

everyone in California.

what’s inside

1. why choose Blue Shield

2. summary of 2015 medical benefits

3. summary of 2015 prescription drug coverage

4. SilverSneakers Fitness program

5. optional supplemental dental HMO plan

6. how to enroll

7. what to expect

for care, not profitSM

why choose Blue Shield 1.You may be asking yourself what to look for when picking a health plan. Or maybe you’re trying to decide between two plans that appear similar. Here are some of the things we think you should consider before enrolling.

1. Costs

Use this brochure and our Summary of Benefits to compare what you will pay with our plan versus other plans.

2. Formulary

If you currently take medication, be sure you confirm that your medication, or an acceptable alternative, is on our comprehensive formulary (list of drugs).

3. Reputation

This is where we feel our plan really stands out from the competition. Why?

• Blue Shield puts care first, not profit. Blue Shield is a not-for-profit company that’s been serving Californians for more than 75 years.

• Westrivetoupholdhighstandardsofethicalbusiness practices in our programs and products. In fact, we have been recognized as one of the World’s Most Ethical Companies for three years in a row by Ethisphere Institute.*

4. Service

• AdedicatedMemberServicesteam

• Geta90-daysupplyofdrugsforonlytwo30-daycopayswhenyouvisitoneofournetwork pharmacies that offer preferred cost-sharing, or order through our mail service pharmacy.

5. Network

We have a large network of primary care physicians and specialists, so chances are you can keep seeing your doctor. Or, if you’re ready to switch doctors, we can help you find a physician who is convenient for you.

Here’sthebottomline.Over205,000# Medicarebeneficiaries in California have trusted their healthcare coverage to Blue Shield of California. We know California, and our mission is to ensure access to high-quality health care at an affordable price, a tradition we have been building on for more than 75 years.

* March2014.FormoreaboutEthisphere,theWorld’sMostEthicalrankingmethodology,andthecompletelistoftheWorld’sMostEthicalCompanies,visithttp://www.ethisphere.com.

# BlueShieldMedicareAdvantageHMOandMedicareSupplementplanmembershipreporting asofJune2014.

for care, not profitSM

summaryof2015 medical benefits2.

EffectiveJanuary1throughDecember31,2015AvailableinselectareasofSacramentoCounty*

Benefit With Blue Shield 65 PlusSM, you pay:

Monthly plan premium (youmustcontinuetopayMedicarePart B premium)

$0

Annual out-of-pocket maximum (this is the most you would pay inayearforMedicarePartsAandBcoveredservices)

$3,400

Primary care physician visits $6 copay

“Welcome to Medicare” preventive visit and Annual Wellness Visit

$0copay

Specialist office visits (with primary care physician referral) $13 copay

Inpatient hospital care $200copay/dayfordays1to5

Outpatient surgery (when performed at an ambulatory surgical center)

$50copay

Basic outpatient diagnostic tests, EKGs, basic X-rays, and lab services (accordingtoMedicareguidelines; prior authorization required)

$0copay

MRI scans, CT scans, and other complex diagnostic radiology services

$50copay

* Refer to the Summary of Benefits for a complete description of the service area.

† Worldwidecoverage.$65copayand$10,000annuallimitforemergencycareandurgentlyneededcare outside the U.S.

‡ Abenefitperiodstartsthedayyougointoahospitalorskillednursingfacility.Itendswhenyou gofor60daysinarowwithouthospitalorskillednursingcare.Ifyougointothehospitalafterone benefit period has ended, a new benefit period begins.

Benefit With Blue Shield 65 Plus, you pay:

Diabetic test strips and lancets (see the plan’s Evidence of Coverage for a full list of what’s covered)

$0copay

Vision care – routine eye exam and refraction (once every 12-month period through network providers) Some coverage at non-network providers included

$10copay

Ambulance services $200copaypertrip,oneway

Basic gym membership/fitness program $0copay;seeSection4

Urgently needed care† $15 copay

Emergency care† $65 copay

Skilled nursing facility care (100daysperbenefitperiod‡; no prior hospitalization required with network provider)

$40copay/dayfordays1to20

$100copay/dayfordays21to100

NurseHelp 24/7SM (telephone and online support) $0copay

summaryof2015 prescription drug coverage3.

AvailableinselectareasofSacramentoCounty*

Part D prescription drug benefit(using network pharmacies) With Blue Shield 65 Plus, you pay:

Deductible $0

One-month (30-day) supply from a network pharmacy

Three-month (90-day) supply from a network pharmacy that offers preferred cost-sharing or through mail service

Tier 1: Preferred Generic Drugs $0copay/$5copay† $0copay

Tier 2: Non-Preferred Generic Drugs $5copay/$9copay† $10copay

Tier 3: Preferred Brand Drugs $40copay/$45copay† $80copay

Tier 4: Non-Preferred Brand Drugs $85copay/$90copay† $170copay

Tier 5: Injectable Drugs 25% of Blue Shield’s contracted rate

25% of Blue Shield’s contracted rate

Tier 6: Specialty Tier Drugs 33% of Blue Shield’s contracted rate

33% of Blue Shield’s contracted rate

Coverage gap (coverage for outpatient prescription drugs after the total yearly drug costs paid by both youandBlueShieldreach$2,960untilyouryearlyout-of-pocketdrugcostsreach$4,700)

Youpay45%forbranddrugs,andyoupay65%for generic drugs. Whether a drug is considered generic or brand can be determined using the plan formulary.

* Refer to your Summary of Benefits for a complete description of the service area.† The first copay shown is for covered drugs you get at a pharmacy that offers preferred cost-sharing.

The second copay shown is for covered drugs you get at a pharmacy that offers standard cost-sharing. Refer to your Summary of Benefits for a complete description of cost-sharing.

‡ Acceptse-prescribing.

Network pharmacies that offer preferred cost-sharing

You may pay less when you visit one of our network pharmacies that offer preferred cost-sharing.

• CVS/pharmacy‡ (800)865-6647[TTY:711]

• Safeway/Vons‡ (877)723-3929[TTY:711]

• Costco‡ (800)607-6861[TTY:711] You do not have to be a Costco member to use Costco Pharmacies.

SilverSneakers Fitnessprogram4.

Exercise, education, and social activities are very important to your health and well-being, which is why Blue Shield of California offers the Healthways SilverSneakers® Fitness program at no additional cost!

SilverSneakers includes the following:

• Afitnessmembershipwithaccesstomorethan11,000locations*nationwide(includingwomen-only locations) where you can use equipment and take group exercise classes

• SilverSneakersFLEX™withclasses including tai chi, yoga, dance, and walking groups offered in neighborhood locations such as parks, recreation centers, and adult-living communities

• SilverSneakersSteps®, which includes a choice of four kits – general fitness, strength, walking, and yoga – for you to use at home or when you travel

• Funsocialactivitiesandevents,includinghealth education seminars

To find your closest SilverSneakers location andFLEXclasses,orderaSilverSneakersSteps kit, or get additional information, visit silversneakers.com. Remember, when you travel you can use any SilverSneakers location in the nation! Enroll today and be one step closer to a healthier lifestyle.

*AsofJuly2014,silversneakers.com.

optional supplemental dentalHMOplan5.

Havinggoodoralhealthisimportant,particularlyasyougetolder.AccordingtotheCenterforDisease Control and Prevention, nearly 25% of people ages 65 to 75 have gum disease, which is linked to other health concerns, including increased risks of heart disease, stroke, and diabetes. Regular dental exams can play a vital role in the early detection of these conditions, as well as other health problems such as nutritional deficiencies, oral infections, and systemic diseases.

BlueShieldoffersanoptionalsupplementaldentalHMOplantoBlueShield65Plusmembersfor a low monthly premium of $12.20. This comprehensive plan provides access to a network of over 15,000dentists*.

Optional supplemental dental HMO plan potential savings

The following is a summary example of potential savings when using a network dentist.

Description

Patients without coverage (Standard list price for two preventive visits)†

Blue Shield’s optional supplemental dental HMO plan member out-of-pocket costs

Annualpremium $0.00 $146.40($12.20x12months)Annualdentalexam,teethcleaning,andX-rays

$430.00(D0120,D1110,D0210) $5.00

6-month follow-up $298.00(D0120,D0272,D1110) $5.00Molarrootcanal $1,498.00(D3330) $335.00‡

Noble metal porcelain crown $1,500.00(D2750) $275.00#

Total cost $3,726.00† $766.40Potential one-year savings $2,959.60

* Dental providers in California are available through a contracted dental plan administrator.† Thesamplecostsarebasedonthe2014FairHealth90thpercentileamountsforthe90010ZIP

code. These rates may not apply to you.‡ This amount is your copay if a general dentist performs the molar root canal. Your copay will be higher if

the molar root canal is performed by a specialist.# You pay the copayment plus the cost of precious or semi-precious metals.

Optional supplemental dental HMO plan highlights

• Awiderangeofdentalbenefits,includingmany diagnostic and preventive services at no charge to you

• Fixedcopaymentsforbasicand major services

• Nowaitingperiodformostservices

• Nodeductibles

• Specialtycareavailablewithareferralfromyour dental provider

• Virtuallynoclaimforms

Optional supplemental dental HMO plan benefits at a glance

The following is a summary of services and supplies covered by the optional supplemental dental HMOplanbenefit.

Thischartisonlyasummary.Foracompletelistofthebenefits,exclusions,andlimitations,pleaserefer to the Evidence of Coverage.

BenefitWith the optional supplemental

dental HMO plan, you pay:*Diagnostic and preventive services – Foryourannualdentalexamandsix-monthcheckup.• Comprehensiveoralexams(D0150) $5 copay• Periodicoralexams(D0120) $0copay• CompleteX-rays(D0210) $0copay• Adultprophylaxis(cleanings,every6months)(D1110) $5 copay

Minor restorative services – Keep your teeth healthy. • One-surfacecompositeresinrestoration–anterior(D2330) $11 copay• Two-surfacecompositeresinrestoration–anterior(D2331) $17 copay

Major services – Makesurethebigstuffistakencareofwhenneeded.• Crown(porcelainfusedtonoblemetal)(D2752) $275‡ copay• Osseoussurgery–fourormoreteethperquadrant(D4260) $293copay• Endodontictherapy–anteriorrootcanal(D3310) $195/268† copay• Endodontictherapy–molarrootcanal(D3330) $335/425† copay• Periodontalrootplaning–fourormoreperteethper

quadrant(D4341)$45copay

• Extraction(singleeruptedtooth)(D7140) $15 copay• Bridge-Pontic–porcelainfusedtohighnoblemetal

(perunit)(D6240)$210‡ copay

• Bridgeretainer–crown,porcelainfusedtohighnoblemetal(perunit)(D6750)

$275‡ copay

• Completedenture–upper(D5110)orlower(D5120) $285 copay• Removalofimpactedtooth(completebony)(D7240) $80copay

* Allservicesmustbeperformed,prescribed,orauthorizedbyyourdentist,chosenfromtheBlueShield Dental Provider Directory. If you need to see a specialist, you must get a referral from your dentalprovidertoreceivecoveredspecialistservices.Maximumplanpaysforyourspecialistservicesis$1,000percalendaryear.Youareresponsibleforamountsabove$1,000.

† You pay the lower amount if the benefit is provided by a general dentist. You pay the higher amount if the benefit is provided by a specialist.

‡ You pay the copayment plus the cost of precious or semi-precious metals.

how to enroll6.Applying is easy

Youhavetwooptions:

1. Work with your broker to use our online plan comparison tool, and immediately enroll online.

2. While enrolling online is faster and easier, you can also choose to fill out the paper applicationinthisbookletinstead.Here’show:

• Tearouttheapplication.

• Fillitoutcompletely.

• Besuretosignwhereindicated.

• Faxittousat(877) 251-3660. You may also mail it to the address listed at the top of page 1 of the application.

Speak with your authorized Blue Shield broker to enroll in Blue Shield 65 Plus andactivateyournewbenefitsfor2015.

what to expect once you enroll7.

1. Acknowledgementletter:Wewillnotifyyou that we received your completed enrollment form and are waiting for Medicaretoapproveyourenrollment.The letter will include a copy of your enrollment form for your records.

2. Confirmationletter:ConfirmationthatMedicarehasapprovedyourenrollmentin our plan.

3. New-memberverificationcall:Wewillcall you to verify that you understand that you’ve been enrolled in our plan and how the plan works. If we don’t reach you by phone, we’ll follow up with a letter.

4. Otherhealthinsurancesurvey:AllowsustotellMedicarewhetheryouhaveotherinsurance in addition to our plan.

5. Welcomekit:Afullexplanationofhow to use your new plan. Be sure to read the Member Handbook and the Evidence of Coverage.

6. PlanIDcard:Presentthiscardeverytime you receive healthcare services or prescription drugs.

7. Healthsurvey:Youranswerscanhelpus provide you and your doctor with information that may better help you effectively manage your health.

The Member Handbook in your welcome kit will give you more details about what to expect as a Blue Shield 65 Plus plan member. We hope to welcome you to our plan!

Blue Shield has been dedicated to offering quality healthcare coverage andmemberservicesince1939–anongoingtraditionyoucantrust.

We hope this booklet made our health plan information easy to understand. It’s one of the ways we’re working to make your health plan selection simple.

Need help?Contact your authorized Blue Shield broker.

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BlueShieldofCaliforniaisanHMOplanwithaMedicarecontract.EnrollmentinBlueShieldof California depends on contract renewal. The benefit information provided is a brief summary,notacompletedescriptionofbenefits.Formoreinformation,contacttheplan.Limitations,copayments,andrestrictionsmayapply.Benefits,formulary,providernetwork,pharmacynetwork,premium,and/orcopayments/coinsurancemaychangeonJanuary1ofeachyear.YoumustcontinuetopayyourMedicarePartBpremium.

Blue Shield and the Shield symbol are registered marks of the BlueCross BlueShield Association,anassociationofindependentBlueCrossandBlueShieldplans.

SilverSneakers is a registered mark of Healthways, Inc., independent companies that do not provide Blue Shield of California products or services.

Thisinformationisavailableforfreeinotherlanguages.PleasecontactMemberServicesat(800)776-4466[TTY:711]from7a.m.to8p.m.,sevendaysaweek,foradditionalinformation.

Esta información está disponible de forma gratuita en varios idiomas. Por favor, llame aServiciosparaMiembrosal(800)776-4466[TTY:711]de7a.m.a8p.m.,sietedíasalasemana para información adicional.