Community Blue Medicare HMO and Security Blue HMO 2016 ... · Security Blue HMO ValueRx (HMO),...

Community Blue Medicare HMO and Security Blue HMO

2016 Summary of Benefits Western Pennsylvania

H3957_15_0265 Accepted

SUMMARY OF BENEFITS January 1, 2016 - December 31, 2016

This booklet gives you a summary of what we cover and what you pay. It doesn't list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, call us and ask for the "Evidence of Coverage."

YOU HAVE CHOICES ABOUT HOW TO GET YOUR MEDICARE BENEFITS 1 One choice is to get your Medicare benefits through Original Medicare (fee-for-service Medicare). Original

Medicare is run directly by the Federal government. 1 Another choice is to get your Medicare benefits by joining a Medicare health plan (such as Community Blue

Medicare HMO Signature (HMO), Community Blue Medicare HMO Prestige (HMO), Security Blue HMO Basic (HMO), Security Blue HMO ValueRx (HMO), Security Blue HMO Standard (HMO), and Security Blue HMO Deluxe (HMO)).

TIPS FOR COMPARING YOUR MEDICARE CHOICES This Summary of Benefits booklet gives you a summary of what Community Blue Medicare HMO Signature (HMO), Community Blue Medicare HMO Prestige (HMO), Security Blue HMO Basic (HMO), Security Blue HMO ValueRx (HMO), Security Blue HMO Standard (HMO), and Security Blue HMO Deluxe (HMO) covers and what you pay.

1 If you want to compare our plans with other Medicare health plans, ask the other plans for their Summary of Benefits booklets. Or, use the Medicare Plan Finder on http://www.medicare.gov.

1 If you want to know more about the coverage and costs of Original Medicare, look in your current "Medicare & You" handbook. View it online at http://www.medicare.gov or get a copy by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.

SECTIONS IN THIS BOOKLET 1 Things to Know About Community Blue Medicare HMO Signature (HMO), Community Blue Medicare

HMO Prestige (HMO), Security Blue HMO Basic (HMO), Security Blue HMO ValueRx (HMO), Security Blue HMO Standard (HMO), and Security Blue HMO Deluxe (HMO)

1 Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services 1 Covered Medical and Hospital Benefits 1 Prescription Drug Benefits

This document is available in other formats such as Braille and large print.

This document may be available in a non-English language. For additional information, call Community Blue Medicare HMO Signature (HMO) or Community Blue Medicare HMO Prestige (HMO) at 1-888-234-5397 (TTY/TDD 711) or Security Blue HMO Basic (HMO), Security Blue HMO ValueRx (HMO), Security Blue HMO Standard (HMO), or Security Blue HMO Deluxe (HMO) at 1-800-935-2583 (TTY/TDD 711).

2

http://www.medicare.govhttp://www.medicare.gov

THINGS TO KNOW ABOUT COMMUNITY BLUE MEDICARE HMO SIGNATURE (HMO), COMMUNITY BLUE MEDICARE HMO PRESTIGE (HMO), SECURITY BLUE HMO BASIC (HMO), SECURITY BLUE HMO VALUERX (HMO), SECURITY BLUE HMO STANDARD (HMO), AND SECURITY BLUE HMO DELUXE (HMO)

HOURS OF OPERATION You can call us 7 days a week from 8:00 a.m. to 8:00 p.m. Eastern time.

COMMUNITY BLUE MEDICARE HMO SIGNATURE (HMO), COMMUNITY BLUE MEDICARE HMO PRESTIGE (HMO), SECURITY BLUE HMO BASIC (HMO), SECURITY BLUE HMO VALUERX (HMO), SECURITY BLUE HMO STANDARD (HMO), AND SECURITY BLUE HMO DELUXE (HMO) PHONE NUMBERS AND WEBSITE 1 If you are a member of Community Blue Medicare HMO Signature (HMO) or Community Blue Medicare

HMO Prestige (HMO) , call toll-free 1-888-234-5397 (TTY/TDD 711). 1 If you are a member of Security Blue HMO Basic (HMO), Security Blue HMO ValueRx (HMO), Security

Blue HMO Standard (HMO), or Security Blue HMO Deluxe (HMO), call toll-free 1-800-935-2583 (TTY/ TDD 711).

1 If you are not a member of Community Blue Medicare HMO Signature (HMO) or Community Blue Medicare HMO Prestige (HMO), call toll-free 1-866-687-3182 (TTY/TDD (1-800-227-8210).

1 If you are not a member of Security Blue HMO Basic (HMO), Security Blue HMO ValueRx (HMO), Security Blue HMO Standard (HMO), or Security Blue HMO Deluxe (HMO), call toll-free 1-866-670-5844 (TTY/ TDD 1-800-227-8210).

1 Our website: http://www.highmarkblueshield.com/medicare

WHO CAN JOIN? To join Security Blue HMO Basic (HMO), Security Blue HMO ValueRx (HMO), Security Blue HMO Standard (HMO) and Security Blue HMO Deluxe (HMO), you must be entitled to Medicare Part A, be enrolled in Medicare Part B, and live in our service area.

Our service area includes the following counties in Pennsylvania: Allegheny, Armstrong, Beaver, Butler, Cambria, Fayette, Greene, Indiana, Lawrence, Washington, and Westmoreland in Southwestern PA and Bedford, Blair, Cameron, Clarion, Clearfield, Crawford, Elk, Erie, Forest, Huntingdon, Jefferson, McKean, Mercer, Potter, Somerset, Venango, and Warren in West Central PA.

To join Community Blue Medicare HMO Signature (HMO) or Community Blue Medicare HMO Prestige (HMO), you must be entitled to Medicare Part A, be enrolled in Medicare Part B, and live in our service area.

Our service area includes the following counties in Pennsylvania: Allegheny, Armstrong, Beaver, Bedford, Butler, Cambria, Cameron, Clarion, Clearfield, Crawford, Elk, Erie, Fayette, Forest, Greene, Huntingdon, Indiana, Jefferson, Lawrence, McKean, Mercer, Somerset, Venango, Warren, Washington and Westermoreland.

WHICH DOCTORS, HOSPITALS, AND PHARMACIES CAN I USE? Community Blue Medicare HMO Signature (HMO), Community Blue Medicare HMO Prestige (HMO), Security Blue HMO Basic (HMO), Security Blue HMO ValueRx (HMO), Security Blue HMO Standard (HMO), and Security Blue HMO Deluxe (HMO) have a network of doctors, hospitals, pharmacies, and other providers. If you use the providers that are not in our network, the plan may not pay for these services.

You must generally use network pharmacies to fill your prescriptions for covered Part D drugs.

You can see our plan's provider and pharmacy directory at our website (www.highmarkblueshield.com/medicare).

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http://www.highmarkblueshield.com/medicarehttp://www.highmarkblueshield.com/medicare

Or, call us and we will send you a copy of the provider and pharmacy directories.

WHAT DO WE COVER? Like all Medicare health plans, we cover everything that Original Medicare covers - and more.

1 Our plan members get all of the benefits covered by Original Medicare. For some of these benefits, you may pay more in our plan than you would in Original Medicare. For others, you may pay less.

1 Our plan members also get more than what is covered by Original Medicare. Some of the extra benefits are outlined in this booklet.

We cover Part D drugs for Community Blue Medicare HMO Signature (HMO), Community Blue Medicare HMO Prestige (HMO), Security Blue HMO ValueRx (HMO), Security Blue HMO Standard (HMO), and Security Blue HMO Deluxe (HMO). In addition, we cover Part B drugs such as chemotherapy and some drugs administered by your provider.

1 You can see the complete plan formulary (list of Part D prescription drugs) and any restrictions on our website, client.formularynavigator.com/clients/hm/default.html.

1 Or, call us and we will send you a copy of the formulary.

Security Blue HMO Basic (HMO) covers Part B drugs including chemotherapy and some drugs administered by your provider. However, this plan does not cover Part D prescription drugs.

HOW WILL I DETERMINE MY DRUG COSTS? Community Blue Medicare HMO Signature (HMO), Community Blue Medicare HMO Prestige (HMO), Security Blue HMO ValueRx (HMO), Security Blue HMO Standard (HMO), and Security Blue HMO Deluxe (HMO) group each medication into one of five "tiers." You will need to use your formulary to locate what tier your drug is on to determine how much it will cost you. The amount you pay depends on the drug's tier and what stage of the benefit you have reached. Later in this document we discuss the benefit stages that occur: Initial Coverage, Coverage Gap, and Catastrophic Coverage.

Highmark Choice Company is a HMO plan with a Medicare contract. Enrollment in Highmark Choice Company depends on contract renewal.

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http://client.formularynavigator.com/clients/hm/default.html

SUMMARY OF BENEFITS

January 1, 2016 - December 31, 2016

Community Blue Medicare HMO Prestige (HMO)

Community Blue Medicare HMO Signature (HMO)BENEFIT CATEGORY

MONTHLY PREMIUM, DEDUCTIBLE, AND LIMITS ON HOW MUCH YOU PAY FOR COVERED SERVICES

How much is the monthly premium?

How much is the deductible?

Is there any limit on how much Iwill pay for my covered services?

$0 per month. In addition, you must keep paying your Medicare Part B premium. Highmark Choice Company will reduce your Medicare Part B premium by up to $3.

This plan does not have a deductible. This plan does not have a deductible.

$193.50 per month. In addition, you must keep paying your Medicare Part B premium.

Is there a limit on how much the plan will pay?

Yes. Like all Medicare health plans, our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care. Your yearly limit(s) in this plan: 1 $6,700 for services you receive

from in-network providers. If you reach the limit on out-of-pocket costs, you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year. Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs.

Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply.

Yes. Like all Medicare health plans, our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care. Your yearly limit(s) in this plan: 1 $6,700 for services you receive

from in-network providers. If you reach the limit on out-of-pocket costs, you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year. Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs.


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Security Blue HMO Deluxe (HMO)

Security Blue HMO Standard (HMO)

Security Blue HMO ValueRx (HMO)

Security Blue HMO Basic (HMO)

$214.50 - 269.50 per month. In addition, you

$174.50 - 195.50 per month. In addition, you

$49.50 - 59.50 per month. In addition, you must keep

$44.00 - 49.00 per month. In addition, you must keep

must keep paying your Medicare Part B premium.

must keep paying your Medicare Part B premium.

paying your Medicare Part B premium.

paying your Medicare Part B premium.

Please refer to the Premium Table to find out the premium in your area.




This plan does not have a deductible.




Yes. Like all Medicare health plans, our plan




protects you by having protects you by having protects you by having protects you by having yearly limits on your yearly limits on your yearly limits on your yearly limits on your out-of-pocket costs for medical and hospital care.

out-of-pocket costs for medical and hospital care.



Your yearly limit(s) in this plan:




1111 $6,700 for services you receive from in-network providers.

$6,700 for services you receive from in-network providers.



If you reach the limit on out-of-pocket costs, you




keep getting covered hospital and medical




services and we will pay the full cost for the rest of the year.




Please note that you will still need to pay your



Please note that you will still need to pay your monthly premiums. monthly premiums and

cost-sharing for your Part D prescription drugs.

monthly premiums and cost-sharing for your Part D prescription drugs.

monthly premiums and cost-sharing for your Part D prescription drugs.





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Community Blue Medicare BENEFIT CATEGORY HMO Signature (HMO)

COVERED MEDICAL AND HOSPITAL BENEFITS Note: 1 Services with a 1 may require prior authorization.

OUTPATIENT CARE AND SERVICES

Acupuncture For up to 5 visit(s) every year: $30 copay

$100 copay $300 copay Ambulance

Chiropractic Care1 Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): $20 copay Routine chiropractic visit (for up to 6 every year): $20 copay

Dental Services1 Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): $45-350 copay, depending on the service Preventive dental services: 1 Dental x-ray(s) (for up to 1): $25

copay Dental services: $30 copay for a single office visit that includes: 1 Cleaning (for up to 1 every year) 1 Oral exam (for up to 1 every

year)

Diabetes Supplies and Services1 Diabetes monitoring supplies: 0-20% of the cost, depending on the supply Diabetes self-management training: You pay nothing Therapeutic shoes or inserts: 20% of the cost


For up to 5 visit(s) every year: $30 copay

Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): $20 copay Routine chiropractic visit (for up to 8 every year): $20 copay

Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): $10-50 copay, depending on the service Preventive dental services: 1 Dental x-ray(s) (for up to 1): $20

copay Dental services: $20 copay for a single office visit that includes: 1 Cleaning (for up to 1 every six

months) 1 Oral exam (for up to 1 every six

months)

Diabetes monitoring supplies: 0-20% of the cost, depending on the supply Diabetes self-management training: You pay nothing Therapeutic shoes or inserts: 20% of the cost

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Security Blue HMO Security Blue HMO Security Blue HMO Security Blue HMO Basic (HMO) ValueRx (HMO) Standard (HMO) Deluxe (HMO)

Not covered Not covered Not covered Not covered

$100 copay $125 copay $200 copay $125 copay


Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): $30-200 copay, depending on the service Preventive dental services: 1 Dental x-ray(s) (for up

to 1): $25 copay Dental services: $30 copay for a single office visit that includes: 1 Cleaning (for up to 1

every year) 1 Oral exam (for up to 1

every year)






every year)






every year)






every year)


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Community Blue Medicare HMO Signature (HMO)

Diagnostic radiology services (such as MRIs, CT scans): $200 copay Diagnostic tests and procedures: $5-20 copay, depending on the service Lab services: $5-20 copay, depending on the service Outpatient x-rays: $50 copay Therapeutic radiology services (such as radiation treatment for cancer): You pay nothing

Primary care physician visit: You pay nothing Specialist visit: $45 copay

20% of the cost 20% of the cost Durable Medical Equipment (wheelchairs, oxygen, etc.)1

$75 copay If you are admitted to the hospital within 3 days, you do not have to pay your share of the cost for emergency care. See the "Inpatient Hospital Care" section of this booklet for other costs. Emergency Care is covered worldwide.

Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: $45 copay Routine foot care (for up to 8 visit(s) every year): $45 copay

BENEFIT CATEGORY

Diagnostic Tests, Lab andRadiology Services, and X-Rays (Costs for these services may varybased on place of service)1

Doctor's Office Visits

Emergency Care

Foot Care (podiatry services)


Diagnostic radiology services (such as MRIs, CT scans): $35 copay Diagnostic tests and procedures: You pay nothing Lab services: You pay nothing Outpatient x-rays: $10 copay Therapeutic radiology services (such as radiation treatment for cancer): You pay nothing

Primary care physician visit: You pay nothing Specialist visit: $10 copay



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Primary care physician visit: $5 copay

Specialist visit: $25 copay Specialist visit: $30 copay Specialist visit: $35 copay Specialist visit: $30 copay







20% of the cost 20% of the cost 20% of the cost 20% of the cost









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BENEFIT CATEGORY

Hearing Services

Mental Health Care1


Exam to diagnose and treat hearing and balance issues: $45 copay Routine hearing exam (for up to 1 every year): $45 copay Hearing aid fitting/evaluation (for up to 1 every year): $45 copay Hearing aid: $699-999 copay for each hearing aid, depending on the type Copayment for hearing aids applies only to TruHearing Chime products. TruHearing is the exclusive provider of the Chime 500 and Chime 900 hearing aids. Up to two Chime hearing aids once every calendar year.

Inpatient visit: Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The


Exam to diagnose and treat hearing and balance issues: $10 copay Routine hearing exam (for up to 1 every year): $10 copay Hearing aid fitting/evaluation (for up to 1 every year): $10 copay Hearing aid: $499-799 copay for each hearing aid, depending on the type Copayment for hearing aids applies only to TruHearing Chime products. TruHearing is the exclusive provider of the Chime 500 and Chime 900 hearing aids. Up to two Chime hearing aids once every calendar year.

Inpatient visit: Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The

You pay nothing You pay nothing Home Health Care1

inpatient hospital care limit does not inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital. Our plan covers 90 days for an inpatient hospital stay. Our plan also covers 60 "lifetime reserve days." These are "extra" days that we cover. If your hospital stay is longer than 90 days, you can use

apply to inpatient mental services provided in a general hospital. Our plan covers 90 days for an inpatient hospital stay. Our plan also covers 60 "lifetime reserve days." These are "extra" days that we cover. If your hospital stay is longer than 90 days, you can use

these extra days. But once you have these extra days. But once you have used up these extra 60 days, your used up these extra 60 days, your inpatient hospital coverage will be inpatient hospital coverage will be limited to 90 days. limited to 90 days. 1 $275 copay per day for days 1 1 $100 copay per stay

through 5 Outpatient group therapy visit: $10 copay

12





Exam to diagnose and treat hearing and balance issues: $30 copay Routine hearing exam (for up to 1 every year): $30 copay Hearing aid fitting/ evaluation (for up to 1 every year): $30 copay Hearing aid: $699-999 copay for each hearing aid, depending on the type Copayment for hearing aids applies only to TruHearing Chime products. TruHearing is the exclusive provider of the Chime 500 and Chime 900 hearing aids. Up to two Chime hearing aids once every calendar year.

Inpatient visit: Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital. Our plan covers 90 days for an inpatient hospital stay. Our plan also covers 60 "lifetime reserve days."







You pay nothing You pay nothing You pay nothing You pay nothing

These are "extra" days that These are "extra" days that These are "extra" days that These are "extra" days that we cover. If your hospital we cover. If your hospital we cover. If your hospital we cover. If your hospital stay is longer than 90 days, stay is longer than 90 days, stay is longer than 90 days, stay is longer than 90 days, you can use these extra you can use these extra you can use these extra you can use these extra days. But once you have days. But once you have days. But once you have days. But once you have

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BENEFIT CATEGORY

Mental Health Care1

(continued)

Outpatient Rehabilitation1

Outpatient Substance Abuse1

Outpatient Surgery1

Over-the-Counter Items

Prosthetic Devices (braces,artificial limbs, etc.)1

Renal Dialysis


1 You pay nothing per day for days 6 through 90

Outpatient group therapy visit: $40 copay Outpatient individual therapy visit: $40 copay

Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): You pay nothing Occupational therapy visit: $40 copay Physical therapy and speech and language therapy visit: $40 copay

Group therapy visit: $40 copay Individual therapy visit: $40 copay

Ambulatory surgical center: $350 copay Outpatient hospital: $350 copay

Not Covered

Prosthetic devices: 20% of the cost Related medical supplies: 20% of the cost

You pay nothing


Outpatient individual therapy visit: $10 copay

Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): You pay nothing Occupational therapy visit: $10 copay Physical therapy and speech and language therapy visit: $10 copay



Not Covered


You pay nothing

14





used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days. 1 $350 copay per stay


Cardiac (heart) rehab services (for a maximum

of 2 one-hour sessions per of 2 one-hour sessions per of 2 one-hour sessions per of 2 one-hour sessions per

used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days. 1 $200 copay per day for

days 1 through 7 1 You pay nothing per

day for days 8 through 90









day for up to 36 sessions up to 36 weeks): You pay nothing Occupational therapy visit: $30 copay Physical therapy and speech and language therapy visit: $30 copay



Not Covered


You pay nothing




Not Covered


You pay nothing




Not Covered


You pay nothing




Not Covered


You pay nothing

15

Community Blue Medicare Community Blue Medicare BENEFIT CATEGORY HMO Signature (HMO) HMO Prestige (HMO)

$40 copay $40 copay Transportation

$50 copay. $50 copay. Urgently Needed Services

Not waived if admitted. Not waived if admitted. Urgently Needed Services are covered worldwide.

Urgently Needed Services are covered worldwide.

Vision Services Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): $0-45 copay, depending on the service Routine eye exam (for up to 1 every year): $0 copay Contact lenses (for up to 1 every year): $0 copay 1 Our plan pays up to $100 every

year for contact lenses.

Eyeglass frames (for up to 1 every year): $0 copay 1 Our plan pays up to $100 every

year for eyeglass frames.

Eyeglass lenses (for up to 1 every year): $0 copay 1 Our plan pays up to $100 every

year for eyeglass lenses.

Eyeglasses or contact lenses after cataract surgery: $0 copay 1 A $200 benefit max applies to

upgrades to post-cataract surgery eyewear that are not medically necessary. Available following cataract surgery once per operated eye.

Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): $0-10 copay, depending on the service Routine eye exam (for up to 1 every year): $0 copay Contact lenses (for up to 1 every year): $0 copay 1 Our plan pays up to $100 every

year for contact lenses.

Eyeglass frames (for up to 1 every year): $0 copay 1 Our plan pays up to $100 every

year for eyeglass frames.

Eyeglass lenses (for up to 1 every year): $0 copay 1 Our plan pays up to $100 every

year for eyeglass lenses.

Eyeglasses or contact lenses after cataract surgery: $0 copay 1 A $200 benefit max applies to

upgrades to post-cataract surgery eyewear that are not medically necessary. Available following cataract surgery once per operated eye.

16

$40 copay $40 copay $40 copay $40 copay

$50 copay. $50 copay. $50 copay. $50 copay. Not waived if admitted. Not waived if admitted. Not waived if admitted. Not waived if admitted. Urgently Needed Services are covered worldwide.





Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): $0-30 copay, depending on the service

Routine eye exam (for up to 1 every year): $0 copay

Contact lenses (for up to 1 every year): $0 copay 1 Our plan pays up to

$100 every year for contact lenses.

Eyeglass frames (for up to 1 every year): $0 copay 1 Our plan pays up to

$100 every year for eyeglass frames.

Eyeglass lenses (for up to 1 every year): $0 copay 1 Our plan pays up to

$100 every year for eyeglass lenses.

Eyeglasses or contact lenses after cataract surgery: $0 copay































17

BENEFIT CATEGORY

Preventive Care


You pay nothing Our plan covers many preventive services, including: 1 Abdominal aortic aneurysm

screening 1 Alcohol misuse counseling 1 Bone mass measurement 1 Breast cancer screening

(mammogram) 1 Cardiovascular disease

(behavioral therapy) 1 Cardiovascular screenings 1 Cervical and vaginal cancer

screening 1 Colorectal cancer screenings

(Colonoscopy, Fecal occult blood test, Flexible sigmoidoscopy)

1 Depression screening 1 Diabetes screenings 1 HIV screening 1 Medical nutrition therapy

services 1 Obesity screening and

counseling 1 Prostate cancer screenings (PSA) 1 Sexually transmitted infections

screening and counseling 1 Tobacco use cessation

counseling (counseling for people with no sign of tobacco-related disease)

1 Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots

1 "Welcome to Medicare" preventive visit (one-time)


You pay nothing Our plan covers many preventive services, including: 1 Abdominal aortic aneurysm

screening 1 Alcohol misuse counseling 1 Bone mass measurement 1 Breast cancer screening

(mammogram) 1 Cardiovascular disease

(behavioral therapy) 1 Cardiovascular screenings 1 Cervical and vaginal cancer

screening 1 Colorectal cancer screenings

(Colonoscopy, Fecal occult blood test, Flexible sigmoidoscopy)

1 Depression screening 1 Diabetes screenings 1 HIV screening 1 Medical nutrition therapy

services 1 Obesity screening and

counseling 1 Prostate cancer screenings (PSA) 1 Sexually transmitted infections

screening and counseling 1 Tobacco use cessation

counseling (counseling for people with no sign of tobacco-related disease)



Vision Services (continued)

18





1 111A $200 benefit max applies to upgrades to post-cataract surgery eyewear that are not medically necessary. Available following cataract surgery once per operated eye.

A $200 benefit max applies to upgrades to post-cataract surgery eyewear that are not medically necessary. Available following cataract surgery once per operated eye.



You pay nothing You pay nothing You pay nothing You pay nothing Our plan covers many Our plan covers many Our plan covers many Our plan covers many preventive services, preventive services, preventive services, preventive services, including: including: including: including: 1 Abdominal aortic 1 Abdominal aortic 1 Abdominal aortic 1 Abdominal aortic

aneurysm screening aneurysm screening aneurysm screening aneurysm screening 1 Alcohol misuse 1 Alcohol misuse 1 Alcohol misuse 1 Alcohol misuse

counseling counseling counseling counseling 1 Bone mass 1 Bone mass 1 Bone mass 1 Bone mass

measurement measurement measurement measurement 1 Breast cancer 1 Breast cancer 1 Breast cancer 1 Breast cancer

screening screening screening screening (mammogram) (mammogram) (mammogram) (mammogram)

1 Cardiovascular disease 1 Cardiovascular disease 1 Cardiovascular disease 1 Cardiovascular disease (behavioral therapy) (behavioral therapy) (behavioral therapy) (behavioral therapy)

1 Cardiovascular 1 Cardiovascular 1 Cardiovascular 1 Cardiovascular screenings screenings screenings screenings

1 Cervical and vaginal 1 Cervical and vaginal 1 Cervical and vaginal 1 Cervical and vaginal cancer screening cancer screening cancer screening cancer screening

1 Colorectal cancer 1 Colorectal cancer 1 Colorectal cancer 1 Colorectal cancer screenings screenings screenings screenings (Colonoscopy, Fecal (Colonoscopy, Fecal (Colonoscopy, Fecal (Colonoscopy, Fecal occult blood test, occult blood test, occult blood test, occult blood test, Flexible Flexible Flexible Flexible sigmoidoscopy) sigmoidoscopy) sigmoidoscopy) sigmoidoscopy)

1 Depression screening 1 Depression screening 1 Depression screening 1 Depression screening 1 Diabetes screenings 1 Diabetes screenings 1 Diabetes screenings 1 Diabetes screenings 1 HIV screening 1 HIV screening 1 HIV screening 1 HIV screening 1 Medical nutrition 1 Medical nutrition 1 Medical nutrition 1 Medical nutrition

therapy services therapy services therapy services therapy services 1 Obesity screening and 1 Obesity screening and 1 Obesity screening and 1 Obesity screening and

counseling counseling counseling counseling 1 Prostate cancer 1 Prostate cancer 1 Prostate cancer 1 Prostate cancer

screenings (PSA) screenings (PSA) screenings (PSA) screenings (PSA) 1 Sexually transmitted 1 Sexually transmitted 1 Sexually transmitted 1 Sexually transmitted

infections screening infections screening infections screening infections screening and counseling and counseling and counseling and counseling

19

BENEFIT CATEGORY

Preventive Care (continued)

Hospice


1 Yearly "Wellness" visit Any additional preventive services approved by Medicare during the contract year will be covered.

You pay nothing for hospice care from a Medicare-certified hospice. You may have to pay part of the costs for drugs and respite care. Hospice is covered outside of our plan. Please contact us for more details.




INPATIENT CARE

Our plan covers an unlimited number of days for an inpatient hospital stay.

Our plan covers an unlimited number of days for an inpatient hospital stay.

Inpatient Hospital Care1

11 $100 copay per stay $275 copay per day for days 1 through 5 1 You pay nothing per day for

days 91 and beyond 1 You pay nothing per day for days 6 through 90

1 You pay nothing per day for days 91 and beyond

For inpatient mental health care, see the "Mental Health Care" section of this booklet.


Inpatient Mental Health Care

20





1 Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease)





Our plan covers an unlimited number of days for an inpatient hospital stay. 1 $350 copay per stay 1 You pay nothing per

day for days 91 and beyond







Our plan covers an unlimited number of days for an inpatient hospital stay. 1 $200 copay per day for

days 1 through 7 1 You pay nothing per


1 You pay nothing per day for days 91 and beyond


















21


Our plan covers up to 100 days in a SNF. 1 You pay nothing per day for

days 1 through 20 1 $160 copay per day for days 21

through 100

PRESCRIPTION DRUG BENEFITS

For Part B drugs such as chemotherapy drugs1: 0-20% of the cost depending on the drug Other Part B drugs1: 0-20% of the cost depending on the drug

You pay the following until your total yearly drug costs reach $3,310. Total yearly drug costs are the total drug costs paid by both you and our Part D plan. You may get your drugs at network retail pharmacies and mail order pharmacies. Standard Retail Cost-Sharing

Three-month supply

One-month supplyTier

$0$0 Tier 1 (Preferred Generic)

$60 copay $20 copay Tier 2 (Generic)

$141 copay $47 copay Tier 3 (Preferred Brand)

45% of the cost

45% of the cost

Tier 4 (Non-Preferred Brand)

Three-month supply


$9 copay$3 copay Tier 1 (Preferred Generic)

$45 copay $15 copay Tier 2 (Generic)

$126 copay $42 copay Tier 3 (Preferred Brand)

45% of the cost

45% of the cost


BENEFIT CATEGORY

Skilled Nursing Facility (SNF)1

How much do I pay?

Initial Coverage


Our plan covers up to 100 days in a SNF. 1 You pay nothing per day for

days 1 through 20 1 $160 copay per day for days 21

through 100



22


Our plan covers up to 100 days in a SNF. 1 You pay nothing per


1 $160 copay per day for days 21 through 100













For Part B drugs such as chemotherapy drugs1: 0-20% of the cost depending on the drug Other Part B drugs1: 0-20% of the cost depending on the drug Our plan does not cover Part D prescription drug.



45% of 45% of (Non-the cost the cost

Tier 4

PreferredBrand)

One- Three-month month

Tier supply supply Tier 1 $3 $9(Preferredcopay copayGeneric) Tier 2 $15 $45 (Generic)copay copay Tier 3 $47 $141(Preferredcopay copayBrand)




Tier 4

PreferredBrand)






Tier 4

PreferredBrand)



23

BENEFIT CATEGORY

Initial Coverage (continued)

gap begins after the total yearly drug gap begins after the total yearly drug


Not Offered 33% of the (Specialty costTier 5

Tier)

Three-One-monthmonth

Tier supply supply

Standard Mail Order Cost-Sharing

Tier Tier 1 (Preferred Generic)

Tier 3 (Preferred Brand) Tier 4 (Non-Preferred Brand)

$50 copay Not OfferedTier 2 (Generic)

Three-One-monthmonth supply supply

Not Offered$0

$117.50 Not Offered copay

45% of the Not Offered cost

Not Offered 33% of the cost Tier 5 (Specialty Tier)

If you reside in a long-term care facility, you pay the same as at a retail pharmacy. You may get drugs from an out-of-network pharmacy, but may pay more than you pay at an in-network pharmacy.

Most Medicare drug plans have a coverage gap (also called the "donut hole"). This means that there's a temporary change in what you will pay for your drugs. The coverage


Three-month supply




Three-month supply


$7.50 copay Not OfferedTier 1 (Preferred Generic)

$37.50 copay Not Offered

Tier 2 (Generic)

$105 copay Not OfferedTier 3 (Preferred Brand)

45% of the costNot Offered




Most Medicare drug plans have a coverage gap (also called the "donut hole"). This means that there's a temporary change in what you will pay for your drugs. The coverage

Coverage Gap

cost (including what our plan has paid and what you have paid) reaches $3,310. After you enter the coverage gap, you pay 45% of the plan's cost for

cost (including what our plan has paid and what you have paid) reaches $3,310. After you enter the coverage gap, you pay 45% of the plan's cost for

24





Three-month supply


Not Offered

33% of the cost

Tier 5 (Specialty Tier)

Three-month supply


Not Offered

33% of the cost



Three-month supply


$7.50 copay

Not Offered

Tier 1 (Preferred Generic)

$37.50 copay

Not Offered

Tier 2 (Generic)

$112.50 copay

Not Offered

Tier 3 (Preferred Brand)

45% of the cost

Not Offered


Not Offered

33% of the cost



Most Medicare drug plans have a coverage gap (also called the "donut hole"). This means that there's a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what


Three-month supply


$7.50 copay

Not Offered


$37.50 copay

Not Offered

Tier 2 (Generic)

$117.50 copay

Not Offered


45% of the cost

Not Offered


Not Offered

33% of the cost




Three-month supply


Not Offered

33% of the cost



Three-month supply


$7.50 copay

Not Offered


$37.50 copay

Not Offered

Tier 2 (Generic)

$105 copay

Not Offered


45% of the cost

Not Offered


Not Offered

33% of the cost




our plan has paid and what our plan has paid and what our plan has paid and what you have paid) reaches you have paid) reaches you have paid) reaches $3,310. $3,310. $3,310.

25

BENEFIT CATEGORY

Coverage Gap (continued)

Catastrophic Coverage


covered brand name drugs and 58% of the plan's cost for covered generic drugs until your costs total $4,850, which is the end of the coverage gap. Not everyone will enter the coverage gap.

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4,850, you pay the greater of:


covered brand name drugs and 58% of the plan's cost for covered generic drugs until your costs total $4,850, which is the end of the coverage gap. Not everyone will enter the coverage gap. Under this plan, you may pay even less for the brand and generic drugs on the formulary. Your cost varies by tier. You will need to use your formulary to locate your drug's tier. See the chart that follows to find out how much it will cost you. Standard Retail Cost-Sharing

Three-month supply

One-month supply

DrugsCovered Tier

$9 copay $3 copayAll Tier 1 (Preferred Generic)

$45 copay

$15 copay All

Tier 2 (Generic)


Three-month supply

One-month supply

DrugsCovered Tier

$7.50 copay

Not Offered All


$37.50 copay

Not Offered All

Tier 2 (Generic)

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4,850, you pay the greater of:

26



After you enter the coverage gap, you pay 45% of the plan's cost for covered brand name drugs and 58% of the plan's cost for covered generic drugs until your costs total $4,850, which is the end of the coverage gap. Not everyone will enter the coverage gap.

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through


After you enter the coverage gap, you pay


After you enter the coverage gap, you pay

45% of the plan's cost for 45% of the plan's cost for covered brand name drugs covered brand name drugs and 58% of the plan's cost for covered generic drugs until your costs total $4,850, which is the end of the coverage gap. Not everyone will enter the coverage gap.


and 58% of the plan's cost for covered generic drugs until your costs total $4,850, which is the end of the coverage gap. Not everyone will enter the coverage gap. Under this plan, you may pay even less for the brand and generic drugs on the formulary. Your cost varies by tier. You will need to use your formulary to locate your drug's tier. See the chart that follows to find out how much it will cost you. Standard Retail Cost-Sharing

Three-month supply

One-month supply

DrugsCovered Tier

$9 copay

$3 copay All


$45 copay

$15 copay All

Tier 2 (Generic)


Three-month supply

One-month supply

DrugsCovered Tier

$7.50 copay

Not Offered All


$37.50 copay

Not Offered All

Tier 2 (Generic)


27


Community Blue Medicare HMO Signature (HMO)BENEFIT CATEGORY

Catastrophic Coverage (continued)

11 5% of the cost, or 5% of the cost, or 1 1$2.95 copay for generic

(including brand drugs treated as generic) and a $7.40 copayment for all other drugs.

$2.95 copay for generic (including brand drugs treated as generic) and a $7.40 copayment for all other drugs.

28





mail order) reach $4,850, you pay the greater of: 1 5% of the cost, or 1 $2.95 copay for

generic (including brand drugs treated as generic) and a $7.40 copayment for all other drugs.





29

PREMIUM TABLE

As a member of our plan, you pay a monthly plan premium. The table below shows the monthly plan premium amount for each region we serve.

The service area for Community Blue Medicare HMO Signature (HMO) and Community Blue Medicare HMO Prestige (HMO) includes the following counties: Allegheny, Armstrong, Beaver, Bedford, Butler, Cambria, Cameron, Clarion, Clearfield, Crawford, Elk, Erie, Fayette, Forest, Greene, Huntingdon, Indiana, Jefferson, Lawrence, McKean, Mercer, Somerset, Venango, Warren, Washington and Westmoreland.

Premium Plan Name $0Community Blue Medicare HMO Signature (HMO) $193.50Community Blue Medicare HMO Prestige (HMO)

The service area for Security Blue HMO Basic (HMO), Security Blue HMO ValueRx (HMO), Security Blue HMO Standard (HMO), and Security Blue HMO Deluxe (HMO) in Southwestern, PA includes the following counties: Allegheny, Armstrong, Beaver, Butler, Cambria, Fayette, Greene, Indiana, Lawrence, Washington and Westmoreland.

The service area for Security Blue HMO Basic (HMO), Security Blue HMO ValueRx (HMO), Security Blue HMO Standard (HMO), and Security Blue HMO Deluxe (HMO) in West Central, PA includes the following counties: Bedford, Blair, Cameron, Clarion, Clearfield, Crawford, Elk, Erie, Forest, Huntingdon, Jefferson, McKean, Mercer, Potter, Somerset, Venango and Warren.

West Central, PA Premium Southwestern, PA Premium Plan Name $44.00$49.00Security Blue HMO Basic (HMO) $49.50$59.50Security Blue HMO ValueRx (HMO) $174.50$195.50Security Blue HMO Standard (HMO) $214.50$269.50Security Blue HMO Deluxe (HMO)

30

Highmark Choice Company and Highmark Blue Cross Blue Shield are independent licensees of the Blue Cross and Blue Shield Association. Blue Cross, Blue Shield and the Cross and Shield symbols are registered service marks of the Blue Cross and Blue Shield Association. Community Blue and Security Blue are service marks of the Blue Cross and Blue Shield Association. Highmark is a registered mark of Highmark Inc.

25962 (R9/15)

Community Blue Medicare HMO and Security Blue HMO 2016 Summary of Benefits Western PennsylvaniaYOU HAVE CHOICES ABOUT HOW TO GET YOUR MEDICARE BENEFITSTIPS FOR COMPARING YOUR MEDICARE CHOICESSECTIONS IN THIS BOOKLETTHINGS TO KNOW ABOUT COMMUNITY BLUE MEDICARE HMO SIGNATURE (HMO), COMMUNITY BLUE MEDICARE HMO PRESTIGE (HMO), SECURITY BLUE HMO BASIC (HMO), SECURITY BLUE HMO VALUERX (HMO), SECURITY BLUE HMO STANDARD (HMO), AND SECURITY BLUE HMO DELUXE (HMO)HOURS OF OPERATIONCOMMUNITY BLUE MEDICARE HMO SIGNATURE (HMO), COMMUNITY BLUE MEDICARE HMO PRESTIGE (HMO), SECURITY BLUE HMO BASIC (HMO), SECURITY BLUE HMO VALUERX (HMO), SECURITY BLUE HMO STANDARD (HMO), AND SECURITY BLUE HMO DELUXE (HMO) PHONE NUMBERS AND WEBSITEWHO CAN JOIN?WHICH DOCTORS, HOSPITALS, AND PHARMACIES CAN I USE?WHAT DO WE COVER?HOW WILL I DETERMINE MY DRUG COSTS?

MONTHLY PREMIUM, DEDUCTIBLE, AND LIMITS ON HOW MUCH YOU PAY FOR COVERED SERVICESHow much is the monthly premium?How much is the deductible?Is there any limit on how much I will pay for my covered services?Is there a limit on how much the plan will pay?

COVERED MEDICAL AND HOSPITAL BENEFITSOUTPATIENT CARE AND SERVICESAcupunctureAmbulanceChiropractic Care1Dental Services1Diabetes Supplies and Services1Diagnostic Tests, Lab andRadiology Services, and X-Rays (Costs for these services may varybased on place of service)1Doctor's Ofﬁce VisitsDurable Medical Equipment (wheelchairs, oxygen, etc.)1Emergency CareFoot Care (podiatry services)Hearing ServicesHome Health Care1Mental Health Care1Outpatient Rehabilitation1Outpatient Substance Abuse1Outpatient Surgery1Over-the-Counter ItemsProsthetic Devices (braces,artiﬁcial limbs, etc.)1Renal DialysisTransportationUrgently Needed ServicesVision ServicesPreventive CareHospice

INPATIENT CAREInpatient Hospital Care1Inpatient Mental Health CareSkilled Nursing Facility (SNF)1

PRESCRIPTION DRUG BENEFITSHow much do I pay?Initial CoverageStandard Retail Cost-SharingStandard Mail Order Cost-SharingStandard Retail Cost-SharingStandard Mail Order Cost-SharingStandard Retail Cost-SharingStandard Mail Order Cost-SharingStandard Retail Cost-SharingStandard Mail Order Cost-SharingStandard Retail Cost-SharingStandard Mail Order Cost-Sharing

Coverage GapStandard Retail Cost-SharingStandard Mail Order Cost-SharingStandard Retail Cost-SharingStandard Mail Order Cost-Sharing

Catastrophic Coverage

PREMIUM TABLE

Community Blue Medicare HMO and Security Blue HMO 2016 ... · Security Blue HMO ValueRx (HMO),...

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