Summary of Benefits for Blue Cross Senior Secure Plan I and...
32
Summary of Benefits for Blue Cross Senior Secure Plan I and Plan II Available in California in Select Counties This plan is an HMO with a Medicare contract. Blue Cross of California is an independent licensee of the Blue Cross Association. The Blue Cross name and symbol are registered marks of the Blue Cross Association. Si usted necesita asistencia en español para poder entender este documento, podrá requerirla sin costo alguno llamándonos gratis al numero telefónico que se muestra en este material. SCASB0001FM (9/07) H0564 006, 009 M0013_08_053 09/2007 M0013_08_014 07/2007
Transcript of Summary of Benefits for Blue Cross Senior Secure Plan I and...
Summary of Benefits forBlue Cross Senior Secure Plan I and Plan II
Available in California in Select Counties
This plan is an HMO with a Medicare contract.Blue Cross of California is an independent licensee of the Blue Cross Association. The Blue Cross name and symbol are registered marks of the Blue Cross Association.
Si usted necesita asistencia en español para poder entender este documento, podrá requerirla sin costo alguno llamándonos gratis al numero telefónico que se muestra en este material.
SCASB0001FM (9/07)H0564 006, 009
M0013_08_053 09/2007 M0013_08_014 07/2007
ed
CLICK HERE
ed
Call Me
Blue Cross Senior Secure Plan I and II Summary of Benefits – Section 1 – 2008 – SCASB0001FM 1
Section 1
Introduction to the Summary of Benefitsfor Blue Cross Senior Secure
January 1, 2008 - December 31, 2008
Thank you for your interest in Blue Cross SeniorSecure. Our plan is offered by Blue Cross of California,a Medicare Advantage Health MaintenanceOrganization (HMO). This Summary of Benefits tells yousome features of our plan. It doesn’t list every servicethat we cover or list every limitation or exclusion. Toget a complete list of our benefits, please call BlueCross Senior Secure and ask for the “Evidenceof Coverage.”
Blue Cross Senior Secure Plan I and II Summary of Benefits – Section 1 – 2008 – SCASB0001FM 2
You Have Choicesin Your Health CareAs a Medicare beneficiary, you can choose fromdifferent Medicare options. One option is theOriginal (fee-for-service) Medicare Plan. Anotheroption is a Medicare health plan, like Blue CrossSenior Secure. You may have other options too. Youmake the choice. No matter what you decide, youare still in the Medicare Program.
You may join or leave a plan only at certaintimes. Please call Blue Cross Senior Secure atthe telephone number listed at the end of thisintroduction or 1-800-MEDICARE(1-800-633-4227) for more information.TTY users should call 1-877-486-2048. You cancall this number 24 hours a day, 7 days a week.
How Can I Compare My Options?You can compare Blue Cross Senior Secure and theOriginal Medicare Plan using this Summary ofBenefits. The charts in this booklet list someimportant health benefits. For each benefit, you cansee what our plan covers and what the OriginalMedicare Plan covers.
Our members receive all of the benefits that theOriginal Medicare Plan offers. We also offer morebenefits, which may change from year to year.
Where Is Blue CrossSenior Secure Available?The service area for Blue Cross Senior SecurePlan I includes: Riverside*, San Bernardino*, Kern,Los Angeles, Orange counties, CA. You must live inone of these areas to join the plan.
The service area for Blue Cross Senior SecurePlan II includes: Santa Barbara*, Orange, SanDiego counties, CA. You must live in one of theseareas to join the plan.
Who Is Eligible to JoinBlue Cross Senior Secure?You can join Blue Cross Senior Secure if youare entitled to Medicare Part A and enrolled inMedicare Part B and live in the service area.However, individuals with End-Stage Renal
Disease are generally not eligible to enroll inBlue Cross Senior Secure unless they are membersof our organization and have been since theirdialysis began.
Can I Choose My Doctors?Blue Cross Senior Secure has formed a network ofdoctors, specialists, and hospitals. You can only usedoctors who are part of our network. The healthproviders in our network can change at any time.
You can ask for a current Provider Directory for anup-to-date list or visit us at www.bluecrossca.com.Our customer service number is listed at the end ofthis introduction.
What Happens if I Go to a DoctorWho’s Not in Your Network?If you choose to go to a doctor outside of ournetwork, you must pay for these services yourself.Neither Blue Cross of California nor the OriginalMedicare Plan will pay for these services.
Does My Plan Cover MedicarePart B or Part D Drugs?Blue Cross Senior Secure does cover both MedicarePart B prescription drugs and Medicare Part Dprescription drugs.
Where Can I Get MyPrescriptions if I Join This Plan?Blue Cross Senior Secure has formed a network ofpharmacies. You must use a network pharmacy toreceive plan benefits. We may not pay for yourprescriptions if you use an out-of-networkpharmacy, except in certain cases. The pharmaciesin our network can change at any time.
You can ask for a current Pharmacy NetworkList or visit us at www.bluecrossca.com. Ourcustomer service number is listed at the endof this introduction.
Blue Cross of California has a list of preferredpharmacies. At these pharmacies, you may get yourdrugs at a lower co pay or co insurance. You may goto a non-preferred pharmacy, but you may have topay more for your prescription drugs.
Blue Cross Senior Secure Plan I and II Summary of Benefits – Section 1 – 2008 – SCASB0001FM 3
What Is a PrescriptionDrug Formulary?Blue Cross Senior Secure uses a formulary. Aformulary is a list of drugs covered by your plan tomeet patient needs. We may periodically add,remove or make changes to coverage limitationson certain drugs, or change how much you pay fora drug.
If we make any formulary change that limits ourmembers’ ability to fill their prescriptions, we willnotify the affected enrollees before the change ismade. We will send a formulary to you, and youcan see our complete formulary on our Web site atwww.bluecrosscamedicarerx.com.
If you are currently taking a drug that is not on ourformulary or subject to additional requirements orlimits, you may be able to get a temporary supply ofthe drug. You can contact us to request anexception or switch to an alternative drug listed onour formulary with your physician’s help. Call us tosee if you can get a temporary supply of the drug orfor more details about our drug transition policy.
How Can I Get Extra HelpWith Prescription Drug Plan Costs?If you qualify for extra help with your Medicareprescription drug plan costs, your premium andcosts at the pharmacy will be lower. When you joinBlue Cross Senior Secure, Medicare will tell us howmuch extra help you are getting. Then we will letyou know the amount you will pay.
If you are not getting this extra help, you can see ifyou qualify by calling 1-800-MEDICARE(1-800-633-4227). TTY users should call1-877-486-2048. You can call this number24 hours a day, 7 days a week.
What Are MyProtections in This Plan?All Medicare Advantage Plans agree to stay in theprogram for a full year at a time. Each year, theplans decide whether to continue for another year.Even if a Medicare Advantage Plan leaves theprogram, you will not lose Medicare coverage. If aplan decides not to continue, it must send you aletter at least 90 days before your coverage will end.
The letter will explain your options for Medicarecoverage in your area.
As a member of Blue Cross Senior Secure, you havethe right to request a coverage determination, whichincludes the right to request an exception, the rightto file an appeal if we deny coverage for aprescription drug, and the right to file a grievance.You have the right to request a coveragedetermination if you want us to cover a Part D drugthat you believe should be covered.
An exception is a type of coverage determination.You may ask us for an exception if you believe youneed a drug that is not on our list of covered drugsor believe you should get a non-preferred drug at alower out-of-pocket cost. You can also ask for anexception to cost utilization rules, such as a limit onthe quantity of a drug.
If you think you need an exception, you shouldcontact us before you try to fill your prescription ata pharmacy. Your doctor must provide a statementto support your exception request.
If we deny coverage for your prescription drug(s),you have the right to appeal and ask us to reviewour decision. Finally, you have the right to file agrievance if you have any type of problem with usor one of our network pharmacies that does notinvolve coverage for a prescription drug.
What Is a Medication TherapyManagement (MTM) Program?A Medication Therapy Management (MTM)Program is a free service we may offer. You may beinvited to participate in a program designed foryour specific health and pharmacy needs.
You may decide not to participate but it isrecommended that you take full advantage of thiscovered service if you are selected. Contact BlueCross Senior Secure for more details.
Blue Cross Senior Secure Plan I and II Summary of Benefits – Section 1 – 2008 – SCASB0001FM 4
Please call Blue Cross of California for more informationabout these plans.
Visit us at www.bluecrossca.com or call us:
Customer Service Hours: Sunday, Monday, Tuesday, Wednesday,Thursday, Friday, Saturday, 8 a.m. to 8 p.m.
Current members should call1-888-230-7338 for questions relatedto the Medicare Advantage program(TTY/TDD: 1-888-877-5378).
Prospective members should call1-888-211-9813 for questions relatedto the Medicare Advantage program(TTY/TDD: 1-800-297-1538).
Current members should call1-888-230-7338 for questions related tothe Medicare Part D Prescription Drugprogram (TTY/TDD: 1-888-877-5378).
Prospective members should call1-888-211-9813 for questions related tothe Medicare Part D Prescription Drugprogram (TTY/TDD: 1-800-297-1538).
For more information about Medicare, please call Medicare at 1-800-MEDICARE(1-800-633-4227). TTY users should call 1-877-486-2048. You can call 24 hours a day,7 days a week. Or, visit www.medicare.gov on the web.
If you have special needs, this document may be available in other formats.
Blu
e C
ross
Sen
ior
Secu
re P
lan
I an
d II
Sum
mar
y of
Ben
efit
s –
Sect
ion
2 –
2008
– S
CA
SB00
01FM
5
Sec
tion
2
Sum
mar
y of
Ben
efit
s fo
r B
lue
Cro
ss S
enio
r S
ecur
e Pl
an I
and
II
If y
ou h
ave
any
ques
tion
s ab
out
this
pla
n’s
bene
fits
or
cost
s, p
leas
e co
ntac
t B
lue
Cro
ss o
f C
alif
orni
a fo
r de
tails
.
Ben
efit
Cat
egor
yO
rigi
nal
Med
icar
eB
lue
Cro
ss S
enio
r S
ecur
ePl
an I
Blu
e C
ross
Sen
ior
Sec
ure
Plan
II
Impo
rtan
t In
form
atio
n
1. P
rem
ium
and
Oth
erIm
port
ant
Info
rmat
ion
You
pay
the
Med
icar
e Pa
rt B
pre
miu
mea
ch m
onth
. (T
his
amou
nt is
$93
.50
in 2
007,
and
it m
ay c
hang
e in
200
8.)
Mos
t peo
ple
will
pay
the
stan
dard
mon
thly
Par
t B p
rem
ium
. How
ever
,so
me
peop
le w
ill h
ave
to p
ay a
hig
her
prem
ium
bec
ause
of t
heir
yea
rly
inco
me.
For
mor
e in
form
atio
n on
Par
tB
pre
miu
ms
base
d on
inco
me,
cal
lSo
cial
Sec
urit
y at
1-8
00-7
72-1
213.
TT
Y u
sers
sho
uld
call
1-80
0-32
5-07
78.
If a
doc
tor
or s
uppl
ier
does
not
acc
ept
assi
gnm
ent,
thei
r co
sts
are
ofte
nhi
gher
, whi
ch m
eans
you
pay
mor
e.
Gen
eral
$0 m
onth
ly p
lan
prem
ium
in a
ddit
ion
to y
our
mon
thly
Med
icar
e Pa
rt B
prem
ium
. (T
his
amou
nt is
$93
.50
in20
07, a
nd it
may
cha
nge
in 2
008.
)
In-N
etw
ork
$500
out
-of-
pock
et li
mit
.
Con
tact
the
plan
for
serv
ices
that
appl
y.
Out
-of-
Net
wor
kU
nles
s ot
herw
ise
note
d, o
ut-o
f-ne
twor
k se
rvic
es n
ot c
over
ed.
See
p. 2
6 fo
r ad
ditio
nal i
nfor
mat
ion
abou
t Pre
miu
m a
nd O
ther
Im
port
ant
Info
rmat
ion.
Gen
eral
$0 m
onth
ly p
lan
prem
ium
in a
ddit
ion
to y
our
mon
thly
Med
icar
e Pa
rt B
prem
ium
. (T
his
amou
nt is
$93
.50
in20
07, a
nd it
may
cha
nge
in 2
008.
)
In-N
etw
ork
$3,0
00 o
ut-o
f-po
cket
lim
it
$2,0
00 y
earl
y de
duct
ible
.
Con
tact
the
plan
for
serv
ices
that
appl
y.
Out
-of-
Net
wor
kU
nles
s ot
herw
ise
note
d, o
ut-o
f-ne
twor
k se
rvic
es n
ot c
over
ed.
See
p. 2
6 fo
r ad
ditio
nal i
nfor
mat
ion
abou
t Pre
miu
m a
nd O
ther
Im
port
ant
Info
rmat
ion.
Blu
e C
ross
Sen
ior
Secu
re P
lan
I an
d II
Sum
mar
y of
Ben
efit
s –
Sect
ion
2 –
2008
– S
CA
SB00
01FM
6
Ben
efit
Cat
egor
yO
rigi
nal
Med
icar
eB
lue
Cro
ss S
enio
r S
ecur
ePl
an I
Blu
e C
ross
Sen
ior
Sec
ure
Plan
II
2. D
octo
r an
d H
ospi
tal
Cho
ice
(For
mor
e in
form
atio
n,se
e E
mer
genc
y -
#15
and
Urg
entl
y N
eede
d C
are
-#1
6.)
You
may
go
to a
ny d
octo
r, s
peci
alis
t or
hosp
ital
that
acc
epts
Med
icar
e.In
-Net
wor
kY
ou m
ust g
o to
net
wor
k do
ctor
s,sp
ecia
lists
, and
hos
pita
ls.
Ref
erra
l req
uire
d fo
r ne
twor
k ho
spit
als
and
spec
ialis
ts (
for
cert
ain
bene
fits)
.
You
may
hav
e to
pay
a s
epar
ate
copa
yfo
r ce
rtai
n do
ctor
off
ice
visi
ts.
See
p. 2
6 fo
r ad
ditio
nal i
nfor
mat
ion
abou
t Doc
tor
and
Hos
pita
l Cho
ice.
In-N
etw
ork
You
mus
t go
to n
etw
ork
doct
ors,
spec
ialis
ts, a
nd h
ospi
tals
.
Ref
erra
l req
uire
d fo
r ne
twor
k ho
spit
als
and
spec
ialis
ts (
for
cert
ain
bene
fits)
.
You
may
hav
e to
pay
a s
epar
ate
copa
yfo
r ce
rtai
n do
ctor
off
ice
visi
ts.
See
p. 2
6 fo
r ad
ditio
nal i
nfor
mat
ion
abou
t Doc
tor
and
Hos
pita
l Cho
ice.
Inpa
tien
t C
are
3. I
npat
ient
Hos
pita
lC
are
(inc
lude
s Su
bsta
nce
Abu
se a
ndR
ehab
ilita
tion
Ser
vice
s)
For
each
ben
efit
per
iod3 :
D
ays
1 -
60: a
n in
itia
l ded
ucti
ble
of$9
92 in
200
7 D
ays
61 -
90:
$24
8 pe
r da
y in
200
7 D
ays
91 -
150
: $49
6 pe
r lif
etim
ere
serv
e da
y in
200
7
The
se a
mou
nts
may
cha
nge
in 2
008.
Plea
se c
all 1
-800
-ME
DIC
AR
E(1
-800
-633
-422
7) fo
r in
form
atio
nab
out l
ifeti
me
rese
rve
days
.4
Life
tim
e re
serv
e da
ys c
an o
nly
be u
sed
once
.
In-N
etw
ork
For
Med
icar
e-co
vere
d ho
spit
al s
tays
:
D
ays
1 -
5: $
50 c
opay
per
day
D
ays
6 -
90: $
0 co
pay
per
day
The
am
ount
you
pay
for
each
Med
icar
e-co
vere
d st
ay m
ay v
ary
depe
ndin
g on
whi
ch h
ospi
tal
you
go to
.
$0 c
opay
for
addi
tion
al h
ospi
tal d
ays
In-N
etw
ork
For
pref
erre
d ne
twor
k ho
spit
als:
$0
cop
ay o
nce
the
$2,0
00 y
earl
yde
duct
ible
is m
et
For
non-
pref
erre
d ne
twor
k ho
spit
als:
$5
00 c
opay
per
day
The
re is
a $
3,25
0 ou
t-of
-poc
ket
max
imum
for
inpa
tien
t ser
vice
sre
ceiv
ed a
t a n
on-p
refe
rred
net
wor
kho
spit
al.
Inpa
tien
t ser
vice
s pr
ovid
ed a
t non
-pr
efer
red
netw
ork
hosp
ital
s do
not
appl
y to
the
plan
yea
rly
dedu
ctib
le a
ndpl
an o
ut-o
f-po
cket
lim
it.
3 A b
enef
it p
erio
d be
gins
the
day
you
go to
a h
ospi
tal o
r sk
illed
nur
sing
faci
lity.
The
ben
efit
per
iod
ends
whe
n yo
u ha
ve n
ot r
ecei
ved
hosp
ital
or
skill
ednu
rsin
g ca
re fo
r 60
day
s in
a r
ow. I
f you
go
into
the
hosp
ital
aft
er o
ne b
enef
it p
erio
d en
ded,
a n
ew b
enef
it p
erio
d be
gins
. You
mus
t pay
the
inpa
tien
tho
spit
al d
educ
tibl
e fo
r ea
ch b
enef
it p
erio
d. T
here
is n
o lim
it to
the
num
ber
of b
enef
it p
erio
ds y
ou c
an h
ave.
4 Life
tim
e re
serv
e da
ys c
an o
nly
be u
sed
once
.
Blu
e C
ross
Sen
ior
Secu
re P
lan
I an
d II
Sum
mar
y of
Ben
efit
s –
Sect
ion
2 –
2008
– S
CA
SB00
01FM
7
Ben
efit
Cat
egor
yO
rigi
nal
Med
icar
eB
lue
Cro
ss S
enio
r S
ecur
ePl
an I
Blu
e C
ross
Sen
ior
Sec
ure
Plan
II
A “
bene
fit p
erio
d” s
tart
s th
e da
y yo
ugo
into
a h
ospi
tal o
r sk
illed
nur
sing
faci
lity.
It e
nds
whe
n yo
u go
for
60da
ys in
a r
ow w
itho
ut h
ospi
tal o
rsk
illed
nur
sing
car
e. I
f you
go
into
the
hosp
ital
aft
er o
ne b
enef
it p
erio
d ha
sen
ded,
a n
ew b
enef
it p
erio
d be
gins
.Y
ou m
ust p
ay th
e in
pati
ent h
ospi
tal
dedu
ctib
le fo
r ea
ch b
enef
it p
erio
d.T
here
is n
o lim
it to
the
num
ber
ofbe
nefit
per
iods
you
can
hav
e.
No
limit
to th
e nu
mbe
r of
day
sco
vere
d by
the
plan
eac
h be
nefit
peri
od.
Exc
ept i
n an
em
erge
ncy,
you
r do
ctor
mus
t tel
l the
pla
n th
at y
ou a
re g
oing
to b
e ad
mit
ted
to th
e ho
spit
al.
See
p. 2
7 fo
r ad
ditio
nal i
nfor
mat
ion
abou
t Inp
atie
nt H
ospi
tal C
are.
No
limit
to th
e nu
mbe
r of
day
sco
vere
d by
the
plan
eac
h be
nefit
peri
od.
Exc
ept i
n an
em
erge
ncy,
you
r do
ctor
mus
t tel
l the
pla
n th
at y
ou a
re g
oing
to b
e ad
mit
ted
to th
e ho
spit
al.
See
p. 2
7 fo
r ad
ditio
nal i
nfor
mat
ion
abou
t Inp
atie
nt H
ospi
tal C
are.
4. I
npat
ient
Men
tal
Hea
lth
Car
eSa
me
dedu
ctib
le a
nd c
opay
as
inpa
tien
t hos
pita
l car
e (S
ee “
Inpa
tien
tH
ospi
tal C
are”
abo
ve.)
190-
day
limit
in a
Psy
chia
tric
Hos
pita
l
In-N
etw
ork
For
hosp
ital
sta
ys:
D
ays
1 -
5: $
50 c
opay
per
day
D
ays
6 -
90: $
0 co
pay
per
day
You
get
up
to 1
90 d
ays
in a
Psyc
hiat
ric
Hos
pita
l in
a lif
etim
e.E
xcep
t in
an e
mer
genc
y, y
our
doct
orm
ust t
ell t
he p
lan
that
you
are
goi
ngto
be
adm
itte
d to
the
hosp
ital
.
In-N
etw
ork
For
pref
erre
d ne
twor
k ho
spit
als:
$0
cop
ay o
nce
the
$2,0
00 y
earl
yde
duct
ible
is m
etFo
r no
n-pr
efer
red
netw
ork
hosp
ital
s:
$5
00 c
opay
per
day
The
re is
a $
3,25
0 ou
t-of
-poc
ket
max
imum
for
inpa
tien
t ser
vice
sre
ceiv
ed a
t a n
on-p
refe
rred
net
wor
kho
spit
al.
Inpa
tien
t ser
vice
s pr
ovid
ed a
t non
-pr
efer
red
netw
ork
hosp
ital
s do
not
appl
y to
the
plan
yea
rly
dedu
ctib
le a
ndpl
an o
ut-o
f-po
cket
lim
it.
You
get
up
to 1
90 d
ays
in a
Psyc
hiat
ric
Hos
pita
l in
a lif
etim
e.
Exc
ept i
n an
em
erge
ncy,
you
r do
ctor
mus
t tel
l the
pla
n th
at y
ou a
re g
oing
to b
e ad
mit
ted
to th
e ho
spit
al.
Blu
e C
ross
Sen
ior
Secu
re P
lan
I an
d II
Sum
mar
y of
Ben
efit
s –
Sect
ion
2 –
2008
– S
CA
SB00
01FM
8
Ben
efit
Cat
egor
yO
rigi
nal
Med
icar
eB
lue
Cro
ss S
enio
r S
ecur
ePl
an I
Blu
e C
ross
Sen
ior
Sec
ure
Plan
II
5. S
kille
d N
ursi
ngFa
cilit
y
(in
a M
edic
are-
cert
ifie
dSk
illed
Nur
sing
Fac
ility
)
For
each
ben
efit
per
iod3 a
fter
at l
east
a3-
day
cove
red
hosp
ital
sta
y:
D
ays
1 -
20: $
0 pe
r da
y in
200
7 D
ays
21 -
100
: $12
4 pe
r da
y in
2007
The
se a
mou
nts
may
cha
nge
in 2
008.
100
days
for
each
ben
efit
per
iod
A “
bene
fit p
erio
d” s
tart
s th
e da
y yo
ugo
into
a h
ospi
tal o
r SN
F. I
t end
sw
hen
you
go fo
r 60
day
s in
a r
oww
itho
ut h
ospi
tal o
r sk
illed
nur
sing
care
.
If y
ou g
o in
to th
e ho
spit
al a
fter
one
bene
fit p
erio
d ha
s en
ded,
a n
ewbe
nefit
per
iod
begi
ns. Y
ou m
ust p
ayth
e in
pati
ent h
ospi
tal d
educ
tibl
e fo
rea
ch b
enef
it p
erio
d. T
here
is n
o lim
itto
the
num
ber
of b
enef
it p
erio
ds y
ouca
n ha
ve.
Gen
eral
Prio
r au
thor
izat
ion
is r
equi
red.
In-N
etw
ork
For
SNF
stay
s:
D
ays
1 -
20: $
0 co
pay
per
day
D
ays
21 -
100
: $65
cop
ay p
er d
ay
100
days
cov
ered
for
each
ben
efit
peri
od
No
prio
r ho
spit
al s
tay
is r
equi
red.
See
p. 2
7 fo
r ad
ditio
nal i
nfor
mat
ion
abou
t Ski
lled
Nur
sing
Faci
lity.
Gen
eral
Prio
r au
thor
izat
ion
is r
equi
red.
In-N
etw
ork
$0 c
opay
for
SNF
serv
ices
100
days
cov
ered
for
each
ben
efit
peri
odN
o pr
ior
hosp
ital
sta
y is
req
uire
d.
See
p. 2
7 fo
r ad
ditio
nal i
nfor
mat
ion
abou
t Ski
lled
Nur
sing
Faci
lity.
6. H
ome
Hea
lth
Car
e
(inc
lude
s m
edic
ally
nece
ssar
y, in
term
itte
ntsk
illed
nur
sing
car
e,ho
me
heal
th a
ide
serv
ices
, and
reh
abil-
itat
ion
serv
ices
, etc
.)
$0 c
opay
Gen
eral
Aut
hori
zati
on r
ules
may
app
ly.
In-N
etw
ork
$0 c
opay
for
Med
icar
e-co
vere
d ho
me
heal
th v
isit
s.
See
p. 2
7 fo
r ad
ditio
nal i
nfor
mat
ion
abou
t Hom
e H
ealth
Car
e.
Gen
eral
Aut
hori
zati
on r
ules
may
app
ly.
In-N
etw
ork
$0 c
opay
for
Med
icar
e-co
vere
d ho
me
heal
th v
isit
s.
See
p. 2
7 fo
r ad
ditio
nal i
nfor
mat
ion
abou
t Hom
e H
ealth
Car
e.
3 A b
enef
it p
erio
d be
gins
the
day
you
go to
a h
ospi
tal o
r sk
illed
nur
sing
faci
lity.
The
ben
efit
per
iod
ends
whe
n yo
u ha
ve n
ot r
ecei
ved
hosp
ital
or
skill
ednu
rsin
g ca
re fo
r 60
day
s in
a r
ow. I
f you
go
into
the
hosp
ital
aft
er o
ne b
enef
it p
erio
d en
ded,
a n
ew b
enef
it p
erio
d be
gins
. You
mus
t pay
the
inpa
tien
tho
spit
al d
educ
tibl
e fo
r ea
ch b
enef
it p
erio
d. T
here
is n
o lim
it to
the
num
ber
of b
enef
it p
erio
ds y
ou c
an h
ave.
Blu
e C
ross
Sen
ior
Secu
re P
lan
I an
d II
Sum
mar
y of
Ben
efit
s –
Sect
ion
2 –
2008
– S
CA
SB00
01FM
9
Ben
efit
Cat
egor
yO
rigi
nal
Med
icar
eB
lue
Cro
ss S
enio
r S
ecur
ePl
an I
Blu
e C
ross
Sen
ior
Sec
ure
Plan
II
7. H
ospi
ceY
ou p
ay p
art o
f the
cos
t for
out
pati
ent
drug
s an
d in
pati
ent r
espi
te c
are.
You
mus
t get
car
e fr
om a
Med
icar
e-ce
rtifi
ed h
ospi
ce.
In-N
etw
ork
You
mus
t get
car
e fr
om a
Med
icar
e-ce
rtifi
ed h
ospi
ce.
In-N
etw
ork
You
mus
t get
car
e fr
om a
Med
icar
e-ce
rtifi
ed h
ospi
ce.
Out
pati
ent
Car
e
8. D
octo
r O
ffic
eV
isit
s20
% c
oins
uran
ce1,
2G
ener
alSe
e “R
outi
ne P
hysi
cal E
xam
s” fo
rm
ore
info
rmat
ion.
Aut
hori
zati
on r
ules
may
app
ly.
In-N
etw
ork
$10
copa
y fo
r ea
ch p
rim
ary
care
doct
or v
isit
for
Med
icar
e-co
vere
dbe
nefit
s.$1
0 co
pay
for
each
spe
cial
ist v
isit
for
Med
icar
e-co
vere
d be
nefit
s.Se
e p.
27
for
addi
tiona
l inf
orm
atio
nab
out D
octo
r O
ffice
Visi
ts.
Gen
eral
See
“Rou
tine
Phy
sica
l Exa
ms”
for
mor
e in
form
atio
n.A
utho
riza
tion
rul
es m
ay a
pply
.
In-N
etw
ork
$15
copa
y fo
r ea
ch p
rim
ary
care
doct
or v
isit
for
Med
icar
e-co
vere
dbe
nefit
s.$2
5 co
pay
for
each
spe
cial
ist v
isit
for
Med
icar
e-co
vere
d be
nefit
s.Se
e p.
27
for
addi
tiona
l inf
orm
atio
nab
out D
octo
r O
ffice
Visi
ts.
9. C
hiro
prac
tic
Serv
ices
20%
coi
nsur
ance
1,2
Rou
tine
car
e no
t cov
ered
20%
coi
nsur
ance
for
man
ual
man
ipul
atio
n of
the
spin
e to
cor
rect
subl
uxat
ion
if yo
u ge
t it f
rom
ach
irop
ract
or o
r ot
her
qual
ified
prov
ider
Gen
eral
Aut
hori
zati
on r
ules
may
app
ly.
In-N
etw
ork
$20
copa
y fo
r M
edic
are-
cove
red
visi
ts.
Med
icar
e-co
vere
d ch
irop
ract
ic v
isit
sar
e fo
r m
anua
l man
ipul
atio
n of
the
spin
e to
cor
rect
a d
ispl
acem
ent o
rm
isal
ignm
ent o
f a jo
int o
r bo
dy p
art.
Gen
eral
Aut
hori
zati
on r
ules
may
app
ly.
In-N
etw
ork
$25
copa
y fo
r M
edic
are-
cove
red
visi
ts.
Med
icar
e-co
vere
d ch
irop
ract
ic v
isit
sar
e fo
r m
anua
l man
ipul
atio
n of
the
spin
e to
cor
rect
a d
ispl
acem
ent o
rm
isal
ignm
ent o
f a jo
int o
r bo
dy p
art.
1 Eac
h ye
ar, y
ou p
ay a
tota
l of o
ne d
educ
tibl
e. I
n 20
07, t
his
dedu
ctib
le is
$13
1, a
nd it
may
cha
nge
in 2
008.
2 If a
doc
tor
or s
uppl
ier
choo
ses
not t
o ac
cept
ass
ignm
ent,
thei
r co
sts
are
ofte
n hi
gher
, whi
ch m
eans
you
pay
mor
e.
Blu
e C
ross
Sen
ior
Secu
re P
lan
I an
d II
Sum
mar
y of
Ben
efit
s –
Sect
ion
2 –
2008
– S
CA
SB00
01FM
10
Ben
efit
Cat
egor
yO
rigi
nal
Med
icar
eB
lue
Cro
ss S
enio
r S
ecur
ePl
an I
Blu
e C
ross
Sen
ior
Sec
ure
Plan
II
10. P
odia
try
Serv
ices
20%
coi
nsur
ance
1,2
Rou
tine
car
e no
t cov
ered
20%
coi
nsur
ance
for
med
ical
lyne
cess
ary
foot
car
e, in
clud
ing
care
for
med
ical
con
diti
ons
affe
ctin
g th
e lo
wer
limbs
Gen
eral
Aut
hori
zati
on r
ules
may
app
ly.
In-N
etw
ork
$20
copa
y fo
r ea
ch M
edic
are-
cove
red
visi
t.
$20
copa
y fo
r up
to 1
2 ro
utin
e vi
sit(
s)ev
ery
year
Med
icar
e-co
vere
d po
diat
ry b
enef
its
are
for
med
ical
ly n
eces
sary
foot
car
e.
See
p. 2
7 fo
r ad
ditio
nal i
nfor
mat
ion
abou
t Pod
iatr
y Se
rvic
es.
Gen
eral
Aut
hori
zati
on r
ules
may
app
ly.
In-N
etw
ork
$25
copa
y fo
r ea
ch M
edic
are-
cove
red
visi
t.
$25
copa
y fo
r up
to 1
2 ro
utin
e vi
sit(
s)ev
ery
year
Med
icar
e-co
vere
d po
diat
ry b
enef
its
are
for
med
ical
ly n
eces
sary
foot
car
e.
See
p. 2
7 fo
r ad
ditio
nal i
nfor
mat
ion
abou
t Pod
iatr
y Se
rvic
es.
11. O
utpa
tien
t M
enta
lH
ealt
h C
are
50%
coi
nsur
ance
for
mos
t out
pati
ent
men
tal h
ealth
ser
vice
s1,2
Gen
eral
Aut
hori
zati
on r
ules
may
app
ly.
In-N
etw
ork
$20
copa
y fo
r ea
ch M
edic
are-
cove
red
indi
vidu
al o
r gr
oup
ther
apy
visi
t.
Gen
eral
Aut
hori
zati
on r
ules
may
app
ly.
In-N
etw
ork
$25
copa
y fo
r ea
ch M
edic
are-
cove
red
indi
vidu
al o
r gr
oup
ther
apy
visi
t.
12. O
utpa
tien
tSu
bsta
nce
Abu
se C
are
20%
coi
nsur
ance
1,2
Gen
eral
Aut
hori
zati
on r
ules
may
app
ly.
In-N
etw
ork
$20
copa
y fo
r M
edic
are-
cove
red
indi
vidu
al o
r gr
oup
visi
ts.
Gen
eral
Aut
hori
zati
on r
ules
may
app
ly.
In-N
etw
ork
$25
copa
y fo
r M
edic
are-
cove
red
indi
vidu
al o
r gr
oup
visi
ts.
1 Eac
h ye
ar, y
ou p
ay a
tota
l of o
ne d
educ
tibl
e. I
n 20
07, t
his
dedu
ctib
le is
$13
1, a
nd it
may
cha
nge
in 2
008.
2 If a
doc
tor
or s
uppl
ier
choo
ses
not t
o ac
cept
ass
ignm
ent,
thei
r co
sts
are
ofte
n hi
gher
, whi
ch m
eans
you
pay
mor
e.
Blu
e C
ross
Sen
ior
Secu
re P
lan
I an
d II
Sum
mar
y of
Ben
efit
s –
Sect
ion
2 –
2008
– S
CA
SB00
01FM
11
Ben
efit
Cat
egor
yO
rigi
nal
Med
icar
eB
lue
Cro
ss S
enio
r S
ecur
ePl
an I
Blu
e C
ross
Sen
ior
Sec
ure
Plan
II
13. O
utpa
tien
tSe
rvic
es/S
urge
ry20
% c
oins
uran
ce fo
r th
e do
ctor
1,2
20%
of o
utpa
tien
t fac
ility
1,2
Gen
eral
Aut
hori
zati
on r
ules
may
app
ly.
In-N
etw
ork
$75
copa
y fo
r ea
ch M
edic
are-
cove
red
ambu
lato
ry s
urgi
cal c
ente
r vi
sit.
$5 to
$10
0 co
pay
for
each
Med
icar
e-co
vere
d ou
tpat
ient
hos
pita
l fac
ility
visi
t.
See
p. 2
7 fo
r ad
ditio
nal i
nfor
mat
ion
abou
t Out
patie
nt S
ervi
ces/S
urge
ry.
Gen
eral
Aut
hori
zati
on r
ules
may
app
ly.
In-N
etw
ork
$0 c
opay
for
each
Med
icar
e-co
vere
dam
bula
tory
sur
gica
l cen
ter
visi
t.
$0 to
$10
cop
ay fo
r ea
ch M
edic
are-
cove
red
outp
atie
nt h
ospi
tal f
acili
tyvi
sit.
See
p. 2
7 fo
r ad
ditio
nal i
nfor
mat
ion
abou
t Out
patie
nt S
ervi
ces/S
urge
ry.
14. A
mbu
lanc
e Se
rvic
es
(med
ical
ly n
eces
sary
ambu
lanc
e se
rvic
es)
20%
coi
nsur
ance
1,2
Gen
eral
Aut
hori
zati
on r
ules
may
app
ly.
In-N
etw
ork
$100
cop
ay fo
r M
edic
are-
cove
red
ambu
lanc
e be
nefit
s.
See
p. 2
7 fo
r ad
ditio
nal i
nfor
mat
ion
abou
t Am
bula
nce
Serv
ices
.
Gen
eral
Aut
hori
zati
on r
ules
may
app
ly.
In-N
etw
ork
$0 c
opay
for
Med
icar
e-co
vere
dam
bula
nce
bene
fits.
See
p. 2
7 fo
r ad
ditio
nal i
nfor
mat
ion
abou
t Am
bula
nce
Serv
ices
.
15. E
mer
genc
y C
are
(You
may
go
to a
nyem
erge
ncy
room
if y
oure
ason
ably
bel
ieve
you
need
em
erge
ncy
care
.)
20%
coi
nsur
ance
for
the
doct
orco
insu
ranc
e1,2
20%
of f
acili
ty c
harg
e or
a s
et c
opay
per
emer
genc
y ro
om v
isit
1,2
You
don
’t ha
ve to
pay
the
emer
genc
yro
om c
opay
if y
ou a
re a
dmit
ted
to th
eho
spit
al fo
r th
e sa
me
cond
itio
n w
ithi
n3
days
of t
he e
mer
genc
y ro
om v
isit
.
In-N
etw
ork
$50
copa
y fo
r M
edic
are-
cove
red
emer
genc
y ro
om v
isit
s.
Out
-of-
Net
wor
kW
orld
wid
e co
vera
ge.
In-N
etw
ork
$50
copa
y fo
r M
edic
are-
cove
red
emer
genc
y ro
om v
isit
s.
Out
-of-
Net
wor
kW
orld
wid
e co
vera
ge.
1 Eac
h ye
ar, y
ou p
ay a
tota
l of o
ne d
educ
tibl
e. I
n 20
07, t
his
dedu
ctib
le is
$13
1, a
nd it
may
cha
nge
in 2
008.
2 If a
doc
tor
or s
uppl
ier
choo
ses
not t
o ac
cept
ass
ignm
ent,
thei
r co
sts
are
ofte
n hi
gher
, whi
ch m
eans
you
pay
mor
e.
Blu
e C
ross
Sen
ior
Secu
re P
lan
I an
d II
Sum
mar
y of
Ben
efit
s –
Sect
ion
2 –
2008
– S
CA
SB00
01FM
12
Ben
efit
Cat
egor
yO
rigi
nal
Med
icar
eB
lue
Cro
ss S
enio
r S
ecur
ePl
an I
Blu
e C
ross
Sen
ior
Sec
ure
Plan
II
NO
T c
over
ed o
utsi
de th
e U
.S. e
xcep
tun
der
limit
ed c
ircu
mst
ance
sIn
- an
d O
ut-o
f-N
etw
ork
If y
ou a
re a
dmit
ted
to th
e ho
spit
alw
ithi
n 72
hou
rs fo
r th
e sa
me
cond
itio
n, y
ou p
ay $
0 fo
r th
eem
erge
ncy
room
vis
it.
See
p. 2
8 fo
r ad
ditio
nal i
nfor
mat
ion
abou
t Em
erge
ncy
Car
e.
In-
and
Out
-of-
Net
wor
kIf
you
are
adm
itte
d to
the
hosp
ital
wit
hin
72 h
ours
for
the
sam
eco
ndit
ion,
you
pay
$0
for
the
emer
genc
y ro
om v
isit
.
See
p. 2
8 fo
r ad
ditio
nal i
nfor
mat
ion
abou
t Em
erge
ncy
Car
e.
16. U
rgen
tly
Nee
ded
Car
e
(Thi
s is
NO
T e
mer
genc
yca
re, a
nd in
mos
t ca
ses,
is o
ut o
f th
e se
rvic
ear
ea.)
20%
coi
nsur
ance
or
a se
t cop
ay1,
2
NO
T c
over
ed o
utsi
de th
e U
.S. e
xcep
tun
der
limit
ed c
ircu
mst
ance
s
Gen
eral
$30
copa
y fo
r M
edic
are-
cove
red
urge
ntly
nee
ded
care
vis
its.
If y
ou a
re a
dmit
ted
to th
e ho
spit
alw
ithi
n 72
hou
rs fo
r th
e sa
me
cond
itio
n: $
0 fo
r th
e ur
gent
car
e vi
sit.
Gen
eral
$30
copa
y fo
r M
edic
are-
cove
red
urge
ntly
nee
ded
care
vis
its.
If y
ou a
re a
dmit
ted
to th
e ho
spit
alw
ithi
n 72
hou
rs fo
r th
e sa
me
cond
itio
n: $
0 fo
r th
e ur
gent
car
e vi
sit.
17. O
utpa
tien
tR
ehab
ilita
tion
Ser
vice
s
(Occ
upat
iona
l The
rapy
,P
hysi
cal T
hera
py,
Spee
ch a
nd L
angu
age
The
rapy
)
20%
coi
nsur
ance
1,2
Gen
eral
Aut
hori
zati
on r
ules
may
app
ly.
In-N
etw
ork
$20
copa
y fo
r M
edic
are-
cove
red
Occ
upat
iona
l The
rapy
vis
its.
$20
copa
y fo
r M
edic
are-
cove
red
Phys
ical
and
/or
Spee
ch/L
angu
age
The
rapy
vis
its.
Gen
eral
Aut
hori
zati
on r
ules
may
app
ly.
In-N
etw
ork
$25
copa
y fo
r M
edic
are-
cove
red
Occ
upat
iona
l The
rapy
vis
its.
$25
copa
y fo
r M
edic
are-
cove
red
Phys
ical
and
/or
Spee
ch/L
angu
age
The
rapy
vis
its.
1 Eac
h ye
ar, y
ou p
ay a
tota
l of o
ne d
educ
tibl
e. I
n 20
07, t
his
dedu
ctib
le is
$13
1, a
nd it
may
cha
nge
in 2
008.
2 If a
doc
tor
or s
uppl
ier
choo
ses
not t
o ac
cept
ass
ignm
ent,
thei
r co
sts
are
ofte
n hi
gher
, whi
ch m
eans
you
pay
mor
e.
Blu
e C
ross
Sen
ior
Secu
re P
lan
I an
d II
Sum
mar
y of
Ben
efit
s –
Sect
ion
2 –
2008
– S
CA
SB00
01FM
13
Ben
efit
Cat
egor
yO
rigi
nal
Med
icar
eB
lue
Cro
ss S
enio
r S
ecur
ePl
an I
Blu
e C
ross
Sen
ior
Sec
ure
Plan
II
Out
pati
ent
Med
ical
Ser
vice
s an
d Su
ppli
es
18. D
urab
le M
edic
alE
quip
men
t
(inc
lude
s w
heel
chai
rs,
oxyg
en, e
tc.)
20%
coi
nsur
ance
1,2
Gen
eral
Aut
hori
zati
on r
ules
may
app
ly.
In-N
etw
ork
20%
of t
he c
ost f
or M
edic
are-
cove
red
item
s.
See p
. 28
for a
dditi
onal
info
rmat
ion
abou
t Dur
able
Med
ical E
quip
men
t.
Gen
eral
Aut
hori
zati
on r
ules
may
app
ly.
In-N
etw
ork
$0 c
opay
for
Med
icar
e-co
vere
d it
ems.
See p
. 28
for a
dditi
onal
info
rmat
ion
abou
t Dur
able
Med
ical E
quip
men
t.
19. P
rost
heti
c D
evic
es
(inc
lude
s br
aces
,ar
tifi
cial
lim
bs a
nd e
yes,
etc.
)
20%
coi
nsur
ance
1, 2
Gen
eral
Aut
hori
zati
on r
ules
may
app
ly.
In-N
etw
ork
20%
of t
he c
ost f
or M
edic
are-
cove
red
item
s.
See p
. 28
for a
dditi
onal
info
rmat
ion
abou
t Pro
sthet
ic D
evice
s.
Gen
eral
Aut
hori
zati
on r
ules
may
app
ly.
In-N
etw
ork
$0 c
opay
for
Med
icar
e-co
vere
d it
ems.
See p
. 28
for a
dditi
onal
info
rmat
ion
abou
t Pro
sthet
ic D
evice
s.
20. D
iabe
tes
Self
-M
onit
orin
g T
rain
ing,
Nut
riti
on T
hera
py, a
ndSu
pplie
s (i
nclu
des
cove
rage
for
glu
cose
mon
itor
s, t
est
stri
ps,
lanc
ets,
scr
eeni
ng t
ests
,an
d se
lf-m
anag
emen
ttr
aini
ng)
20%
coi
nsur
ance
1, 2
Gen
eral
Aut
hori
zati
on r
ules
may
app
ly.
In-N
etw
ork
$0 c
opay
for
Dia
bete
s se
lf-m
onit
orin
gtr
aini
ng.
$0 c
opay
for
Nut
riti
on T
hera
py fo
rD
iabe
tes.
20%
of t
he c
ost f
or D
iabe
tes
supp
lies.
Gen
eral
Aut
hori
zati
on r
ules
may
app
ly.
In-N
etw
ork
$0 c
opay
for
Dia
bete
s se
lf-m
onit
orin
gtr
aini
ng.
$0 c
opay
for
Nut
riti
on T
hera
py fo
rD
iabe
tes.
$0 c
opay
for
Dia
bete
s su
pplie
s
1 Eac
h ye
ar, y
ou p
ay a
tota
l of o
ne d
educ
tibl
e. I
n 20
07, t
his
dedu
ctib
le is
$13
1, a
nd it
may
cha
nge
in 2
008.
2 If a
doc
tor
or s
uppl
ier
choo
ses
not t
o ac
cept
ass
ignm
ent,
thei
r co
sts
are
ofte
n hi
gher
, whi
ch m
eans
you
pay
mor
e.
Blu
e C
ross
Sen
ior
Secu
re P
lan
I an
d II
Sum
mar
y of
Ben
efit
s –
Sect
ion
2 –
2008
– S
CA
SB00
01FM
14
Ben
efit
Cat
egor
yO
rigi
nal
Med
icar
eB
lue
Cro
ss S
enio
r S
ecur
ePl
an I
Blu
e C
ross
Sen
ior
Sec
ure
Plan
IISe
e p.
28
for
addi
tiona
l inf
orm
atio
nab
out D
iabe
tes S
elf-
Mon
itori
ngT
rain
ing,
Nut
ritio
n T
hera
py a
ndSu
pplie
s.
See
p. 2
8 fo
r ad
ditio
nal i
nfor
mat
ion
abou
t Dia
bete
s Sel
f-M
onito
ring
Tra
inin
g, N
utri
tion
The
rapy
and
Supp
lies.
21. D
iagn
osti
c T
ests
,X
-Ray
s, a
nd L
ab S
ervi
ces
20%
coi
nsur
ance
for
diag
nost
ic te
sts
and
X-r
ays1,
2
$0 c
opay
for
Med
icar
e-co
vere
d la
bse
rvic
es
Lab
Serv
ices
: Med
icar
e co
vers
med
ical
ly n
eces
sary
dia
gnos
tic
lab
serv
ices
that
are
ord
ered
by
your
trea
ting
doc
tor
whe
n th
ey a
re p
rovi
ded
by a
Clin
ical
Lab
orat
ory
Impr
ovem
ent
Am
endm
ents
(C
LIA
) ce
rtifi
edla
bora
tory
that
par
tici
pate
s in
Med
icar
e. D
iagn
osti
c la
b se
rvic
es a
redo
ne to
hel
p yo
ur d
octo
r di
agno
se o
rru
le o
ut a
sus
pect
ed il
lnes
s or
cond
itio
n. M
edic
are
does
not
cov
erm
ost r
outi
ne s
cree
ning
test
s, li
kech
ecki
ng y
our
chol
este
rol.
Gen
eral
Aut
hori
zati
on r
ules
may
app
ly.
In-N
etw
ork
0% o
f the
cos
t for
Med
icar
e-co
vere
dla
b se
rvic
es.
0% to
20%
of t
he c
ost f
or M
edic
are-
cove
red
diag
nost
ic p
roce
dure
s an
dte
sts.
0% to
20%
of t
he c
ost f
or M
edic
are-
cove
red
X-r
ays.
0% to
20%
of t
he c
ost f
or M
edic
are-
cove
red
diag
nost
ic r
adio
logy
ser
vice
s.0%
to 2
0% o
f the
cos
t for
Med
icar
e-co
vere
d th
erap
euti
c ra
diol
ogy
serv
ices
.Se
e p.
28
for
addi
tiona
l inf
orm
atio
nab
out D
iagn
ostic
Tes
ts, X
-Ray
s and
Lab
Serv
ices
.
Gen
eral
Aut
hori
zati
on r
ules
may
app
ly.
In-N
etw
ork
0% o
f the
cos
t for
Med
icar
e-co
vere
dla
b se
rvic
es.
0% to
20%
of t
he c
ost f
or M
edic
are-
cove
red
diag
nost
ic p
roce
dure
s an
dte
sts.
0% to
20%
of t
he c
ost f
or M
edic
are-
cove
red
X-r
ays.
0% to
20%
of t
he c
ost f
or M
edic
are-
cove
red
diag
nost
ic r
adio
logy
ser
vice
s.0%
to 2
0% o
f the
cos
t for
Med
icar
e-co
vere
d th
erap
euti
c ra
diol
ogy
serv
ices
.Se
e p.
28
for
addi
tiona
l inf
orm
atio
nab
out D
iagn
ostic
Tes
ts, X
-Ray
s and
Lab
Serv
ices
.
Pre
vent
ive
Serv
ices
22. B
one
Mas
sM
easu
rem
ent
(for
peo
ple
wit
h M
edic
are
who
are
at r
isk)
20%
coi
nsur
ance
1, 2
Cov
ered
onc
e ev
ery
24 m
onth
s (m
ore
ofte
n if
med
ical
ly n
eces
sary
) if
you
mee
t cer
tain
med
ical
con
diti
ons
Gen
eral
Aut
hori
zati
on r
ules
may
app
ly.
In-N
etw
ork
$0 c
opay
for
Med
icar
e-co
vere
d bo
nem
ass
mea
sure
men
t
Gen
eral
Aut
hori
zati
on r
ules
may
app
ly.
In-N
etw
ork
$0 c
opay
for
Med
icar
e-co
vere
d bo
nem
ass
mea
sure
men
t
1 Eac
h ye
ar, y
ou p
ay a
tota
l of o
ne d
educ
tibl
e. I
n 20
07, t
his
dedu
ctib
le is
$13
1, a
nd it
may
cha
nge
in 2
008.
2 If a
doc
tor
or s
uppl
ier
choo
ses
not t
o ac
cept
ass
ignm
ent,
thei
r co
sts
are
ofte
n hi
gher
, whi
ch m
eans
you
pay
mor
e.
Blu
e C
ross
Sen
ior
Secu
re P
lan
I an
d II
Sum
mar
y of
Ben
efit
s –
Sect
ion
2 –
2008
– S
CA
SB00
01FM
15
Ben
efit
Cat
egor
yO
rigi
nal
Med
icar
eB
lue
Cro
ss S
enio
r S
ecur
ePl
an I
Blu
e C
ross
Sen
ior
Sec
ure
Plan
II
23. C
olor
ecta
l Scr
eeni
ngE
xam
s (f
or p
eopl
e w
ith
Med
icar
e ag
e 50
and
olde
r)
20%
coi
nsur
ance
1,2
Cov
ered
whe
n yo
u ar
e hi
gh r
isk
orw
hen
you
are
age
50 a
nd o
lder
Gen
eral
Aut
hori
zati
on r
ules
may
app
ly.
In-N
etw
ork
$0 c
opay
for
Med
icar
e-co
vere
dco
lore
ctal
scr
eeni
ngs.
Gen
eral
Aut
hori
zati
on r
ules
may
app
ly.
In-N
etw
ork
$0 c
opay
for
Med
icar
e-co
vere
dco
lore
ctal
scr
eeni
ngs.
24. I
mm
uniz
atio
ns
(Flu
vac
cine
, Hep
atit
is B
vacc
ine
– fo
r pe
ople
wit
hM
edic
are
who
are
at
risk
, Pne
umon
iava
ccin
e)
$0 c
opay
for
Flu
and
Pneu
mon
iava
ccin
es
20%
coi
nsur
ance
for
Hep
atit
is B
vacc
ine1,
2
You
may
onl
y ne
ed th
e Pn
eum
onia
vacc
ine
once
in y
our
lifet
ime.
Cal
lyo
ur d
octo
r fo
r m
ore
info
rmat
ion.
Gen
eral
Aut
hori
zati
on r
ules
may
app
ly.
In-N
etw
ork
$0 c
opay
for
Flu
and
Pneu
mon
iava
ccin
es.
$0 c
opay
for
Hep
atit
is B
vac
cine
.
No
refe
rral
nee
ded
for
Flu
and
Pneu
mon
ia v
acci
nes.
Ref
erra
l nee
ded
for
othe
rim
mun
izat
ions
.
Gen
eral
Aut
hori
zati
on r
ules
may
app
ly.
In-N
etw
ork
$0 c
opay
for
Flu
and
Pneu
mon
iava
ccin
es.
$0 c
opay
for
Hep
atit
is B
vac
cine
.
No
refe
rral
nee
ded
for
Flu
and
Pneu
mon
ia v
acci
nes.
Ref
erra
l nee
ded
for
othe
rim
mun
izat
ions
.
25. M
amm
ogra
ms
(Ann
ual S
cree
ning
)
(for
wom
en w
ith
Med
icar
e ag
e 40
and
olde
r)
20%
coi
nsur
ance
2
No
refe
rral
nee
ded
Cov
ered
onc
e a
year
for
all w
omen
wit
h M
edic
are
age
40 a
nd o
lder
. One
base
line
mam
mog
ram
cov
ered
for
wom
en w
ith
Med
icar
e be
twee
n ag
e 35
and
39
Gen
eral
Aut
hori
zati
on r
ules
may
app
ly.
In-N
etw
ork
$0 c
opay
for
Med
icar
e-co
vere
dsc
reen
ing
mam
mog
ram
s.
Gen
eral
Aut
hori
zati
on r
ules
may
app
ly.
In-N
etw
ork
$0 c
opay
for
Med
icar
e-co
vere
dsc
reen
ing
mam
mog
ram
s.
1 Eac
h ye
ar, y
ou p
ay a
tota
l of o
ne d
educ
tibl
e. I
n 20
07, t
his
dedu
ctib
le is
$13
1, a
nd it
may
cha
nge
in 2
008.
2 If a
doc
tor
or s
uppl
ier
choo
ses
not t
o ac
cept
ass
ignm
ent,
thei
r co
sts
are
ofte
n hi
gher
, whi
ch m
eans
you
pay
mor
e.
Blu
e C
ross
Sen
ior
Secu
re P
lan
I an
d II
Sum
mar
y of
Ben
efit
s –
Sect
ion
2 –
2008
– S
CA
SB00
01FM
16
Ben
efit
Cat
egor
yO
rigi
nal
Med
icar
eB
lue
Cro
ss S
enio
r S
ecur
ePl
an I
Blu
e C
ross
Sen
ior
Sec
ure
Plan
II
26. P
ap S
mea
rs a
ndP
elvi
c E
xam
s
(for
wom
en w
ith
Med
icar
e)
$0 c
opay
for
Pap
smea
rs
Cov
ered
onc
e ev
ery
2 ye
ars.
Cov
ered
once
a y
ear
for
wom
en w
ith
Med
icar
eat
hig
h ri
sk
20%
coi
nsur
ance
for
Pelv
ic E
xam
s
Gen
eral
Aut
hori
zati
on r
ules
may
app
ly.
In-N
etw
ork
$0 c
opay
for
Med
icar
e-co
vere
d Pa
psm
ears
and
pel
vic
exam
s.
Gen
eral
Aut
hori
zati
on r
ules
may
app
ly.
In-N
etw
ork
$0 c
opay
for
Med
icar
e-co
vere
d Pa
psm
ears
and
pel
vic
exam
s.
27. P
rost
ate
Can
cer
Scre
enin
g E
xam
s
(for
men
wit
h M
edic
are
age
50 a
nd o
lder
)
20%
coi
nsur
ance
for
the
digi
tal r
ecta
lex
am
$0 fo
r th
e PS
A te
st; 2
0% c
oins
uran
cefo
r ot
her
rela
ted
serv
ices
Cov
ered
onc
e a
year
for
all m
en w
ith
Med
icar
e ov
er a
ge 5
0
Gen
eral
Aut
hori
zati
on r
ules
may
app
ly.
In-N
etw
ork
$0 c
opay
for
Med
icar
e-co
vere
dpr
osta
te c
ance
r sc
reen
ing.
Gen
eral
Aut
hori
zati
on r
ules
may
app
ly.
In-N
etw
ork
$0 c
opay
for
Med
icar
e-co
vere
dpr
osta
te c
ance
r sc
reen
ing.
28. E
SRD
20%
coi
nsur
ance
for
dial
ysis
1,2
Gen
eral
Aut
hori
zati
on r
ules
may
app
ly.
Out
-of-
area
Ren
al D
ialy
sis
serv
ices
do
not r
equi
re A
utho
riza
tion
.
In-N
etw
ork
20%
of t
he c
ost f
or in
- an
d ou
t-of
-are
adi
alys
is.
$0 c
opay
for
Nut
riti
on T
hera
py fo
rR
enal
Dis
ease
.
Gen
eral
Aut
hori
zati
on r
ules
may
app
ly.
Out
-of-
area
Ren
al D
ialy
sis
serv
ices
do
not r
equi
re A
utho
riza
tion
.
In-N
etw
ork
20%
of t
he c
ost f
or in
- an
d ou
t-of
-are
adi
alys
is.
$0 c
opay
for
Nut
riti
on T
hera
py fo
rR
enal
Dis
ease
.
1 Eac
h ye
ar, y
ou p
ay a
tota
l of o
ne d
educ
tibl
e. I
n 20
07, t
his
dedu
ctib
le is
$13
1, a
nd it
may
cha
nge
in 2
008.
2 If a
doc
tor
or s
uppl
ier
choo
ses
not t
o ac
cept
ass
ignm
ent,
thei
r co
sts
are
ofte
n hi
gher
, whi
ch m
eans
you
pay
mor
e.
Blu
e C
ross
Sen
ior
Secu
re P
lan
I an
d II
Sum
mar
y of
Ben
efit
s –
Sect
ion
2 –
2008
– S
CA
SB00
01FM
17
Ben
efit
Cat
egor
yO
rigi
nal
Med
icar
eB
lue
Cro
ss S
enio
r S
ecur
ePl
an I
Blu
e C
ross
Sen
ior
Sec
ure
Plan
II
29. P
resc
ript
ion
Dru
gsM
ost d
rugs
not
cov
ered
(You
can
add
pre
scri
ptio
n dr
ugco
vera
ge to
Ori
gina
l Med
icar
e by
join
ing
a M
edic
are
Pres
crip
tion
Dru
gPl
an.)
Dru
gs C
over
ed U
nder
Med
icar
e Pa
rt B
Gen
eral
20%
of t
he c
ost f
or P
art B
-cov
ered
drug
s (n
ot in
clud
ing
Part
B-c
over
edch
emot
hera
py d
rugs
).
20%
of t
he c
ost f
or P
art B
-cov
ered
chem
othe
rapy
dru
gs.
Dru
gs C
over
ed U
nder
Med
icar
e Pa
rt D
Gen
eral
Thi
s pl
an u
ses
a fo
rmul
ary.
The
pla
n w
ill s
end
you
the
form
ular
y.
You
can
als
o se
e th
e fo
rmul
ary
atw
ww
.blu
ecro
ssca
med
icar
erx.
com
on
the
web
.
Diff
eren
t out
-of-
pock
et c
osts
may
appl
y fo
r pe
ople
who
ha
ve li
mit
ed in
com
es,
liv
e in
long
-ter
m c
are
faci
litie
s, o
r ha
ve a
cces
s to
Ind
ian/
Tri
bal/
Urb
an(I
ndia
n H
ealth
Ser
vice
).
The
pla
n of
fers
nat
iona
l in-
netw
ork
pres
crip
tion
cov
erag
e. T
his
mea
ns th
atyo
u w
ill p
ay th
e sa
me
amou
nt fo
r yo
urpr
escr
ipti
on d
rugs
if y
ou g
et th
em a
tan
in-n
etw
ork
phar
mac
y ou
tsid
e of
the
plan
’s se
rvic
e ar
ea (
for
inst
ance
whe
nyo
u tr
avel
).
Dru
gs C
over
ed U
nder
Med
icar
e Pa
rt B
Gen
eral
20%
of t
he c
ost f
or P
art B
-cov
ered
drug
s (n
ot in
clud
ing
Part
B-c
over
edch
emot
hera
py d
rugs
).
20%
of t
he c
ost f
or P
art B
-cov
ered
chem
othe
rapy
dru
gs.
Dru
gs C
over
ed U
nder
Med
icar
e Pa
rt D
Gen
eral
Thi
s pl
an u
ses
a fo
rmul
ary.
The
pla
n w
ill s
end
you
the
form
ular
y.
You
can
als
o se
e th
e fo
rmul
ary
atw
ww
.blu
ecro
ssca
med
icar
erx.
com
on
the
web
.
Diff
eren
t out
-of-
pock
et c
osts
may
appl
y fo
r pe
ople
who
ha
ve li
mit
ed in
com
es,
liv
e in
long
-ter
m c
are
faci
litie
s, o
r ha
ve a
cces
s to
Ind
ian/
Tri
bal/
Urb
an(I
ndia
n H
ealth
Ser
vice
).
The
pla
n of
fers
nat
iona
l in-
netw
ork
pres
crip
tion
cov
erag
e. T
his
mea
ns th
atyo
u w
ill p
ay th
e sa
me
amou
nt fo
r yo
urpr
escr
ipti
on d
rugs
if y
ou g
et th
em a
tan
in-n
etw
ork
phar
mac
y ou
tsid
e of
the
plan
’s se
rvic
e ar
ea (
for
inst
ance
whe
nyo
u tr
avel
).
Blu
e C
ross
Sen
ior
Secu
re P
lan
I an
d II
Sum
mar
y of
Ben
efit
s –
Sect
ion
2 –
2008
– S
CA
SB00
01FM
18
Ben
efit
Cat
egor
yO
rigi
nal
Med
icar
eB
lue
Cro
ss S
enio
r S
ecur
ePl
an I
Blu
e C
ross
Sen
ior
Sec
ure
Plan
II
Tot
al y
earl
y dr
ug c
osts
are
the
tota
ldr
ug c
osts
pai
d by
bot
h yo
u an
d th
epl
an.
Som
e dr
ugs
have
qua
ntit
y lim
its.
You
r pr
ovid
er m
ust g
et p
rior
auth
oriz
atio
n fr
om B
lue
Cro
ss S
enio
rSe
cure
Pla
n I
for
cert
ain
drug
s.
If th
e ac
tual
cos
t of a
dru
g is
less
than
the
norm
al c
opay
am
ount
for
that
drug
, you
will
pay
the
actu
al c
ost,
not
the
high
er c
opay
am
ount
.
In-N
etw
ork
$0 d
educ
tibl
e.
Som
e co
vere
d dr
ugs
don’
t cou
ntto
war
d yo
ur o
ut-o
f-po
cket
dru
g co
sts.
Init
ial C
over
age
You
pay
the
follo
win
g un
til t
otal
year
ly d
rug
cost
s re
ach
$2,5
10:
Ret
ail P
harm
acy
Gen
eric
s $8
cop
ay fo
r a
one-
mon
th (
30-d
ay)
supp
ly o
f dru
gs $2
4 co
pay
for
a th
ree-
mon
th(9
0-da
y) s
uppl
y of
dru
gs
Pre
ferr
ed B
rand
$3
0 co
pay
for
a on
e-m
onth
(30
-day
)su
pply
of d
rugs
$9
0 co
pay
for
a th
ree-
mon
th(9
0-da
y) s
uppl
y of
dru
gs
Tot
al y
earl
y dr
ug c
osts
are
the
tota
ldr
ug c
osts
pai
d by
bot
h yo
u an
d th
epl
an.
Som
e dr
ugs
have
qua
ntit
y lim
its.
You
r pr
ovid
er m
ust g
et p
rior
auth
oriz
atio
n fr
om B
lue
Cro
ss S
enio
rSe
cure
Pla
n II
for
cert
ain
drug
s.
If th
e ac
tual
cos
t of a
dru
g is
less
than
the
norm
al c
opay
am
ount
for
that
drug
, you
will
pay
the
actu
al c
ost,
not
the
high
er c
opay
am
ount
.
In-N
etw
ork
$0 d
educ
tibl
e.
Som
e co
vere
d dr
ugs
don’
t cou
ntto
war
d yo
ur o
ut-o
f-po
cket
dru
g co
sts.
Init
ial C
over
age
You
pay
the
follo
win
g un
til t
otal
year
ly d
rug
cost
s re
ach
$2,5
10:
Ret
ail P
harm
acy
Gen
eric
s $8
cop
ay fo
r a
one-
mon
th (
30-d
ay)
supp
ly o
f dru
gs $2
4 co
pay
for
a th
ree-
mon
th(9
0-da
y) s
uppl
y of
dru
gs
Pre
ferr
ed B
rand
$3
0 co
pay
for
a on
e-m
onth
(30
-day
)su
pply
of d
rugs
$9
0 co
pay
for
a th
ree-
mon
th(9
0- d
ay)
supp
ly o
f dru
gs
Blu
e C
ross
Sen
ior
Secu
re P
lan
I an
d II
Sum
mar
y of
Ben
efit
s –
Sect
ion
2 –
2008
– S
CA
SB00
01FM
19
Ben
efit
Cat
egor
yO
rigi
nal
Med
icar
eB
lue
Cro
ss S
enio
r S
ecur
ePl
an I
Blu
e C
ross
Sen
ior
Sec
ure
Plan
II
Non
-Pre
ferr
ed B
rand
$6
4 co
pay
for
a on
e-m
onth
(30
-day
)su
pply
of d
rugs
$1
92 c
opay
for
a th
ree-
mon
th(9
0-da
y) s
uppl
y of
dru
gs
Non
-Spe
cial
ty I
njec
tabl
es 33
% c
oins
uran
ce fo
r a
one-
mon
th(3
0-da
y) s
uppl
y of
dru
gs 33
% c
oins
uran
ce fo
r a
thre
e-m
onth
(90-
day)
sup
ply
of d
rugs
Spec
ialt
y 33
% c
oins
uran
ce fo
r a
one-
mon
th(3
0-da
y) s
uppl
y of
dru
gs
Lon
g-T
erm
Car
e P
harm
acy
Gen
eric
s $8
cop
ay fo
r a
one-
mon
th (
34-d
ay)
supp
ly o
f dru
gs
Pre
ferr
ed B
rand
$3
0 co
pay
for
a on
e-m
onth
(34
-day
)su
pply
of d
rugs
Non
-Pre
ferr
ed B
rand
$6
4 co
pay
for
a on
e-m
onth
(34
-day
)su
pply
of d
rugs
Non
-Spe
cial
ty I
njec
tabl
es 33
% c
oins
uran
ce fo
r a
one-
mon
th(3
4-da
y) s
uppl
y of
dru
gs
Spec
ialt
y 33
% c
oins
uran
ce fo
r a
one-
mon
th(3
4-da
y) s
uppl
y of
dru
gs
Non
-Pre
ferr
ed B
rand
$6
4 co
pay
for
a on
e-m
onth
(30
-day
)su
pply
of d
rugs
$1
92 c
opay
for
a th
ree-
mon
th(9
0-da
y) s
uppl
y of
dru
gs
Non
-Spe
cial
ty I
njec
tabl
es 33
% c
oins
uran
ce fo
r a
one-
mon
th(3
0-da
y) s
uppl
y of
dru
gs 33
% c
oins
uran
ce fo
r a
thre
e-m
onth
(90-
day)
sup
ply
of d
rugs
Spec
ialt
y 33
% c
oins
uran
ce fo
r a
one-
mon
th(3
0-da
y) s
uppl
y of
dru
gs
Lon
g-T
erm
Car
e P
harm
acy
Gen
eric
s $8
cop
ay fo
r a
one-
mon
th (
34-d
ay)
supp
ly o
f dru
gs
Pre
ferr
ed B
rand
$3
0 co
pay
for
a on
e-m
onth
(34
-day
)su
pply
of d
rugs
Non
-Pre
ferr
ed B
rand
$6
4 co
pay
for
a on
e-m
onth
(34
-day
)su
pply
of d
rugs
Non
-Spe
cial
ty I
njec
tabl
es 33
% c
oins
uran
ce fo
r a
one-
mon
th(3
4-da
y) s
uppl
y of
dru
gs
Spec
ialt
y 33
% c
oins
uran
ce fo
r a
one-
mon
th(3
4-da
y) s
uppl
y of
dru
gs
Blu
e C
ross
Sen
ior
Secu
re P
lan
I an
d II
Sum
mar
y of
Ben
efit
s –
Sect
ion
2 –
2008
– S
CA
SB00
01FM
20
Ben
efit
Cat
egor
yO
rigi
nal
Med
icar
eB
lue
Cro
ss S
enio
r S
ecur
ePl
an I
Blu
e C
ross
Sen
ior
Sec
ure
Plan
II
Mai
l Ord
erG
ener
ics
$1
2 co
pay
for
a th
ree-
mon
th(9
0-da
y) s
uppl
y of
dru
gs fr
om a
pref
erre
d m
ail-
orde
r ph
arm
acy.
$2
4 co
pay
for
a th
ree-
mon
th(9
0-da
y) s
uppl
y of
dru
gs fr
om a
non
-pr
efer
red
mai
l-or
der
phar
mac
y.
Pre
ferr
ed B
rand
$7
5 co
pay
for
a th
ree-
mon
th(9
0-da
y) s
uppl
y of
dru
gs fr
om a
pref
erre
d m
ail-
orde
r ph
arm
acy.
$9
0 co
pay
for
a th
ree-
mon
th(9
0-da
y) s
uppl
y of
dru
gs fr
om a
non
-pr
efer
red
mai
l-or
der
phar
mac
y.
Non
-Pre
ferr
ed B
rand
$1
60 c
opay
for
a th
ree-
mon
th(9
0-da
y) s
uppl
y of
dru
gs fr
om a
pref
erre
d m
ail-
orde
r ph
arm
acy.
$1
92 c
opay
for
a th
ree-
mon
th(9
0-da
y) s
uppl
y of
dru
gs fr
om a
non
-pr
efer
red
mai
l-or
der
phar
mac
y.
Non
-Spe
cial
ty I
njec
tabl
es 33
% c
oins
uran
ce fo
r a
thre
e-m
onth
(90-
day)
sup
ply
of d
rugs
from
apr
efer
red
mai
l-or
der
phar
mac
y. 33
% c
oins
uran
ce fo
r a
thre
e-m
onth
(90-
day)
sup
ply
of d
rugs
from
a n
on-
pref
erre
d m
ail-
orde
r ph
arm
acy.
Spec
ialt
y 33
% c
oins
uran
ce fo
r a
one-
mon
th(3
0-da
y) s
uppl
y of
dru
gs fr
om a
pref
erre
d m
ail-
orde
r ph
arm
acy.
Mai
l Ord
erG
ener
ics
$1
2 co
pay
for
a th
ree-
mon
th(9
0-da
y) s
uppl
y of
dru
gs fr
om a
pref
erre
d m
ail-
orde
r ph
arm
acy.
$2
4 co
pay
for
a th
ree-
mon
th(9
0-da
y) s
uppl
y of
dru
gs fr
om a
non
-pr
efer
red
mai
l-or
der
phar
mac
y.
Pre
ferr
ed B
rand
$7
5 co
pay
for
a th
ree-
mon
th(9
0-da
y) s
uppl
y of
dru
gs fr
om a
pref
erre
d m
ail-
orde
r ph
arm
acy.
$9
0 co
pay
for
a th
ree-
mon
th(9
0-da
y) s
uppl
y of
dru
gs fr
om a
non
-pr
efer
red
mai
l-or
der
phar
mac
y.
Non
-Pre
ferr
ed B
rand
$1
60 c
opay
for
a th
ree-
mon
th(9
0-da
y) s
uppl
y of
dru
gs fr
om a
pref
erre
d m
ail-
orde
r ph
arm
acy.
$1
92 c
opay
for
a th
ree-
mon
th(9
0-da
y) s
uppl
y of
dru
gs fr
om a
non
-pr
efer
red
mai
l-or
der
phar
mac
y.
Non
-Spe
cial
ty I
njec
tabl
es 33
% c
oins
uran
ce fo
r a
thre
e-m
onth
(90-
day)
sup
ply
of d
rugs
from
apr
efer
red
mai
l-or
der
phar
mac
y. 33
% c
oins
uran
ce fo
r a
thre
e-m
onth
(90-
day)
sup
ply
of d
rugs
from
a n
on-
pref
erre
d m
ail-
orde
r ph
arm
acy.
Spec
ialt
y 33
% c
oins
uran
ce fo
r a
one-
mon
th(3
0-da
y) s
uppl
y of
dru
gs fr
om a
pref
erre
d m
ail-
orde
r ph
arm
acy.
Blu
e C
ross
Sen
ior
Secu
re P
lan
I an
d II
Sum
mar
y of
Ben
efit
s –
Sect
ion
2 –
2008
– S
CA
SB00
01FM
21
Ben
efit
Cat
egor
yO
rigi
nal
Med
icar
eB
lue
Cro
ss S
enio
r S
ecur
ePl
an I
Blu
e C
ross
Sen
ior
Sec
ure
Plan
II
33
% c
oins
uran
ce fo
r a
one-
mon
th(3
0-da
y) s
uppl
y of
dru
gs fr
om a
non
-pr
efer
red
mai
l-or
der
phar
mac
y.
Cov
erag
e G
apY
ou p
ay th
e fo
llow
ing:
The
pla
n co
vers
onl
y se
lect
Gen
eric
sth
roug
h th
e ga
p.
Ret
ail P
harm
acy
Gen
eric
s $8
cop
ay fo
r a
one-
mon
th (
30-d
ay)
supp
ly o
f dru
gs $2
4 co
pay
for
a th
ree-
mon
th(9
0-da
y) s
uppl
y of
dru
gs
Lon
g-T
erm
Car
e P
harm
acy
Gen
eric
s $8
cop
ay fo
r a
one-
mon
th (
34-d
ay)
supp
ly o
f dru
gs
Mai
l Ord
erG
ener
ics
$1
2 co
pay
for
a th
ree-
mon
th(9
0-da
y) s
uppl
y of
dru
gs fr
om a
pref
erre
d m
ail o
rder
$2
4 co
pay
for
a th
ree-
mon
th(9
0-da
y) s
uppl
y of
dru
gs fr
om a
non
-pr
efer
red
mai
l ord
er
For
all o
ther
cov
ered
dru
gs, a
fter
you
rto
tal y
earl
y dr
ug c
osts
rea
ch $
2,51
0,yo
u pa
y 10
0% u
ntil
your
yea
rly
out-
of-p
ocke
t dru
g co
sts
reac
h $4
,050
.
33
% c
oins
uran
ce fo
r a
one-
mon
th(3
0-da
y) s
uppl
y of
dru
gs fr
om a
non
-pr
efer
red
mai
l-or
der
phar
mac
y.
Cov
erag
e G
apY
ou p
ay th
e fo
llow
ing:
The
pla
n co
vers
onl
y se
lect
Gen
eric
sth
roug
h th
e ga
p.
Ret
ail P
harm
acy
Gen
eric
s $8
cop
ay fo
r a
one-
mon
th (
30-d
ay)
supp
ly o
f dru
gs $2
4 co
pay
for
a th
ree-
mon
th(9
0-da
y) s
uppl
y of
dru
gs
Lon
g-T
erm
Car
e P
harm
acy
Gen
eric
s $8
cop
ay fo
r a
one-
mon
th (
34-d
ay)
supp
ly o
f dru
gs
Mai
l Ord
erG
ener
ics
$1
2 co
pay
for
a th
ree-
mon
th(9
0-da
y) s
uppl
y of
dru
gs fr
om a
pref
erre
d m
ail o
rder
$2
4 co
pay
for
a th
ree-
mon
th(9
0-da
y) s
uppl
y of
dru
gs fr
om a
non
-pr
efer
red
mai
l ord
er
For
all o
ther
cov
ered
dru
gs, a
fter
you
rto
tal y
earl
y dr
ug c
osts
rea
ch $
2,51
0,yo
u pa
y 10
0% u
ntil
your
yea
rly
out-
of-p
ocke
t dru
g co
sts
reac
h $4
,050
.
Blu
e C
ross
Sen
ior
Secu
re P
lan
I an
d II
Sum
mar
y of
Ben
efit
s –
Sect
ion
2 –
2008
– S
CA
SB00
01FM
22
Ben
efit
Cat
egor
yO
rigi
nal
Med
icar
eB
lue
Cro
ss S
enio
r S
ecur
ePl
an I
Blu
e C
ross
Sen
ior
Sec
ure
Plan
II
Cat
astr
ophi
c C
over
age
Aft
er y
our
year
ly o
ut-o
f-po
cket
dru
gco
sts
reac
h $4
,050
, you
pay
the
grea
ter
of:
$2
.25
copa
y fo
r ge
neri
c (i
nclu
ding
bran
d dr
ugs
trea
ted
as g
ener
ic)
and
$5.6
0 co
pay
for
all o
ther
dru
gs, o
r 5%
coi
nsur
ance
.
Out
-of-
Net
wor
kPl
an d
rugs
may
be
cove
red
in s
peci
alci
rcum
stan
ces,
for
inst
ance
, illn
ess
whi
le tr
avel
ing
outs
ide
of th
e pl
an’s
serv
ice
area
whe
re th
ere
is n
o ne
twor
kph
arm
acy.
You
may
pay
mor
e th
an th
eco
pay
if yo
u ge
t you
r dr
ugs
at a
n ou
t-of
-net
wor
k ph
arm
acy.
Out
-of-
Net
wor
k In
itia
l Cov
erag
eY
ou p
ay th
e fo
llow
ing
unti
l tot
alye
arly
dru
g co
sts
reac
h $2
,510
:
Out
-of-
Net
wor
k P
harm
acy
Gen
eric
s $8
cop
ay fo
r a
one-
mon
th (
30-d
ay)
supp
ly o
f dru
gs
Pre
ferr
ed B
rand
$3
0 co
pay
for
a on
e-m
onth
(30
-day
)su
pply
of d
rugs
Non
-Pre
ferr
ed B
rand
$6
4 co
pay
for
a on
e-m
onth
(30
-day
)su
pply
of d
rugs
Cat
astr
ophi
c C
over
age
Aft
er y
our
year
ly o
ut-o
f-po
cket
dru
gco
sts
reac
h $4
,050
, you
pay
the
grea
ter
of:
$2
.25
copa
y fo
r ge
neri
c (i
nclu
ding
bran
d dr
ugs
trea
ted
as g
ener
ic)
and
$5.6
0 co
pay
for
all o
ther
dru
gs, o
r 5%
coi
nsur
ance
.
Out
-of-
Net
wor
kPl
an d
rugs
may
be
cove
red
in s
peci
alci
rcum
stan
ces,
for
inst
ance
, illn
ess
whi
le tr
avel
ing
outs
ide
of th
e pl
an’s
serv
ice
area
whe
re th
ere
is n
o ne
twor
kph
arm
acy.
You
may
pay
mor
e th
an th
eco
pay
if yo
u ge
t you
r dr
ugs
at a
n ou
t-of
-net
wor
k ph
arm
acy.
Out
-of-
Net
wor
k In
itia
l Cov
erag
eY
ou p
ay th
e fo
llow
ing
unti
l tot
alye
arly
dru
g co
sts
reac
h $2
,510
:
Out
-of-
Net
wor
k P
harm
acy
Gen
eric
s $8
cop
ay fo
r a
one-
mon
th (
30-d
ay)
supp
ly o
f dru
gs
Pre
ferr
ed B
rand
$3
0 co
pay
for
a on
e-m
onth
(30
-day
)su
pply
of d
rugs
Non
-Pre
ferr
ed B
rand
$6
4 co
pay
for
a on
e-m
onth
(30
-day
)su
pply
of d
rugs
Blu
e C
ross
Sen
ior
Secu
re P
lan
I an
d II
Sum
mar
y of
Ben
efit
s –
Sect
ion
2 –
2008
– S
CA
SB00
01FM
23
Ben
efit
Cat
egor
yO
rigi
nal
Med
icar
eB
lue
Cro
ss S
enio
r S
ecur
ePl
an I
Blu
e C
ross
Sen
ior
Sec
ure
Plan
II
Non
-Spe
cial
ty I
njec
tabl
es 33
% c
oins
uran
ce fo
r a
one-
mon
th(3
0-da
y) s
uppl
y of
dru
gsSp
ecia
lty
33
% c
oins
uran
ce fo
r a
one-
mon
th(3
0-da
y) s
uppl
y of
dru
gs
Out
-of-
Net
wor
k C
over
age
Gap
You
pay
the
follo
win
g:
Gen
eric
s $8
cop
ay fo
r a
one-
mon
th (
30-d
ay)
supp
ly o
f dru
gs
Out
-of-
Net
wor
kC
atas
trop
hic
Cov
erag
eA
fter
you
r ye
arly
out
-of-
pock
et d
rug
cost
s re
ach
$4,0
50, y
ou p
ay th
e gr
eate
rof
:
$2
.25
copa
y fo
r ge
neri
c (i
nclu
ding
bran
d dr
ugs
trea
ted
as g
ener
ic)
and
$5.6
0 co
pay
for
all o
ther
dru
gs, o
r 5%
coi
nsur
ance
.
See
p. 2
8 fo
r ad
ditio
nal i
nfor
mat
ion
abou
t Pre
scri
ptio
n D
rugs
.
Non
-Spe
cial
ty I
njec
tabl
es 33
% c
oins
uran
ce fo
r a
one-
mon
th(3
0-da
y) s
uppl
y of
dru
gsSp
ecia
lty
33
% c
oins
uran
ce fo
r a
one-
mon
th(3
0-da
y) s
uppl
y of
dru
gs
Out
-of-
Net
wor
k C
over
age
Gap
You
pay
the
follo
win
g:
Gen
eric
s $8
cop
ay fo
r a
one-
mon
th (
30-d
ay)
supp
ly o
f dru
gs
Out
-of-
Net
wor
kC
atas
trop
hic
Cov
erag
eA
fter
you
r ye
arly
out
-of-
pock
et d
rug
cost
s re
ach
$4,0
50, y
ou p
ay th
e gr
eate
rof
:
$2
.25
copa
y fo
r ge
neri
c (i
nclu
ding
bran
d dr
ugs
trea
ted
as g
ener
ic)
and
$5.6
0 co
pay
for
all o
ther
dru
gs, o
r 5%
coi
nsur
ance
.
See
p. 2
8 fo
r ad
ditio
nal i
nfor
mat
ion
abou
t Pre
scri
ptio
n D
rugs
.
30. D
enta
l Ser
vice
sPr
even
tive
den
tal s
ervi
ces
(suc
h as
clea
ning
) no
t cov
ered
In-N
etw
ork
$0 c
opay
for
Med
icar
e-co
vere
d de
ntal
bene
fits
$0
cop
ay fo
r up
to 1
ora
l exa
m e
very
year
$3
0 to
$40
cop
ay fo
r up
to 2
clea
ning
s ev
ery
year
$0
to $
30 c
opay
for
up to
1 d
enta
lX
-ray
vis
it
In-N
etw
ork
$0 c
opay
for
Med
icar
e-co
vere
d de
ntal
bene
fits
$0
cop
ay fo
r up
to 1
ora
l exa
m e
very
year
$3
0 to
$40
cop
ay fo
r up
to 2
clea
ning
s ev
ery
year
$0 to
$30
cop
ay fo
r up
to 1
den
tal X
-ra
y vi
sit
Blu
e C
ross
Sen
ior
Secu
re P
lan
I an
d II
Sum
mar
y of
Ben
efit
s –
Sect
ion
2 –
2008
– S
CA
SB00
01FM
24
Ben
efit
Cat
egor
yO
rigi
nal
Med
icar
eB
lue
Cro
ss S
enio
r S
ecur
ePl
an I
Blu
e C
ross
Sen
ior
Sec
ure
Plan
II
See
p. 2
9 fo
r ad
ditio
nal i
nfor
mat
ion
abou
t Den
tal S
ervi
ces.
See
p. 2
9 fo
r ad
ditio
nal i
nfor
mat
ion
abou
t Den
tal S
ervi
ces.
31. H
eari
ng S
ervi
ces
Rou
tine
hea
ring
exa
ms
and
hear
ing
aids
not
cov
ered
20%
coi
nsur
ance
for
diag
nost
iche
arin
g ex
ams1,
2
Gen
eral
Aut
hori
zati
on r
ules
may
app
ly.
In-N
etw
ork
Hea
ring
aid
s no
t cov
ered
.
$2
0 co
pay
for
diag
nost
ic h
eari
ngex
ams
$2
0 co
pay
for
up to
1 r
outi
nehe
arin
g te
st e
very
yea
r
Gen
eral
Aut
hori
zati
on r
ules
may
app
ly.
In-N
etw
ork
Hea
ring
aid
s no
t cov
ered
.
$2
5 co
pay
for
diag
nost
ic h
eari
ngex
ams
$2
5 co
pay
for
up to
1 r
outi
nehe
arin
g te
st e
very
yea
r
32. V
isio
n Se
rvic
es20
% c
oins
uran
ce fo
r di
agno
sis
and
trea
tmen
t of d
isea
ses
and
cond
itio
ns o
fth
e ey
e1,2
Rou
tine
eye
exa
ms
and
glas
ses
not
cove
red
Med
icar
e pa
ys fo
r on
e pa
ir o
fey
egla
sses
or
cont
act l
ense
s af
ter
cata
ract
sur
gery
1,2
Ann
ual g
lauc
oma
scre
enin
gs c
over
edfo
r pe
ople
at r
isk1,
2
Gen
eral
Aut
hori
zati
on r
ules
may
app
ly.
In-N
etw
ork
20
% o
f the
cos
t for
one
pai
r of
eyeg
lass
es o
r co
ntac
t len
ses
afte
r ea
chca
tara
ct s
urge
ry.
$2
0 co
pay
for
exam
s to
dia
gnos
e an
dtr
eat d
isea
ses
and
cond
itio
ns o
f the
eye.
$2
0 co
pay
for
up to
1 r
outi
ne e
yeex
am e
very
yea
r 0%
of t
he c
ost f
or u
p to
1 p
air(
s) o
fco
ntac
ts e
very
two
year
s 0%
of t
he c
ost f
or u
p to
1 p
air(
s) o
fle
nses
eve
ry tw
o ye
ars
0%
of t
he c
ost f
or u
p to
1 fr
ame(
s)ev
ery
two
year
s
Gen
eral
Aut
hori
zati
on r
ules
may
app
ly.
In-N
etw
ork
$0 c
opay
for
on
e pa
ir o
f eye
glas
ses
or c
onta
ctle
nses
aft
er e
ach
cata
ract
sur
gery
. up
to 1
pai
r(s)
of c
onta
cts
ever
y tw
oye
ars
up
to 1
pai
r(s)
of l
ense
s ev
ery
two
year
s up
to 1
fram
e(s)
eve
ry tw
o ye
ars
$2
5 co
pay
for
exam
s to
dia
gnos
e an
dtr
eat d
isea
ses
and
cond
itio
ns o
f the
eye.
$2
0 to
$25
cop
ay fo
r up
to 1
rou
tine
eye
exam
(s)
ever
y ye
ar
1 Eac
h ye
ar, y
ou p
ay a
tota
l of o
ne d
educ
tibl
e. I
n 20
07, t
his
dedu
ctib
le is
$13
1, a
nd it
may
cha
nge
in 2
008.
2 If a
doc
tor
or s
uppl
ier
choo
ses
not t
o ac
cept
ass
ignm
ent,
thei
r co
sts
are
ofte
n hi
gher
, whi
ch m
eans
you
pay
mor
e.
Blu
e C
ross
Sen
ior
Secu
re P
lan
I an
d II
Sum
mar
y of
Ben
efit
s –
Sect
ion
2 –
2008
– S
CA
SB00
01FM
25
Ben
efit
Cat
egor
yO
rigi
nal
Med
icar
eB
lue
Cro
ss S
enio
r S
ecur
ePl
an I
Blu
e C
ross
Sen
ior
Sec
ure
Plan
II
$95
limit
for
eye
wea
r ev
ery
two
year
s.
See
p. 2
9 fo
r ad
ditio
nal i
nfor
mat
ion
abou
t Visi
on S
ervi
ces.
$95
limit
for
eye
wea
r ev
ery
two
year
s.
See
p. 2
9 fo
r ad
ditio
nal i
nfor
mat
ion
abou
t Visi
on S
ervi
ces.
33. P
hysi
cal E
xam
s20
% c
oins
uran
ce fo
r on
e ex
am w
ithi
nth
e fir
st 6
mon
ths
of y
our
new
Med
icar
e Pa
rt B
cov
erag
e1,2
Whe
n yo
u ge
t Med
icar
e Pa
rt B
, you
can
get a
one
-tim
e ph
ysic
al e
xam
wit
hin
the
first
6 m
onth
s of
you
r ne
wPa
rt B
cov
erag
e. T
he c
over
age
does
not i
nclu
de la
b te
sts.
Gen
eral
Aut
hori
zati
on r
ules
may
app
ly.
In-N
etw
ork
$5 c
opay
for
rout
ine
exam
s.
Lim
ited
to 1
exa
m(s
) ev
ery
year
.
$5 c
opay
for
Med
icar
e-co
vere
dbe
nefit
s.
Gen
eral
Aut
hori
zati
on r
ules
may
app
ly.
In-N
etw
ork
$10
copa
y fo
r ro
utin
e ex
ams.
Lim
ited
to 1
exa
m(s
) ev
ery
year
.
$10
copa
y fo
r M
edic
are-
cove
red
bene
fits.
Hea
lth/
Wel
lnes
sE
duca
tion
Not
cov
ered
In-N
etw
ork
Thi
s pl
an c
over
s he
alth
/wel
lnes
sed
ucat
ion
bene
fits.
W
ritt
en h
ealth
edu
cati
on m
ater
ials
,in
clud
ing
New
slet
ters
H
ealth
Clu
b M
embe
rshi
p/Fi
tnes
sC
lass
es N
ursi
ng H
otlin
e O
ther
Wel
lnes
s B
enef
its
See p
. 29
for a
dditi
onal
info
rmat
ion
abou
t Hea
lth/W
ellne
ss Ed
ucat
ion
Bene
fits.
In-N
etw
ork
Thi
s pl
an c
over
s he
alth
/wel
lnes
sed
ucat
ion
bene
fits.
W
ritt
en h
ealth
edu
cati
on m
ater
ials
,in
clud
ing
New
slet
ters
H
ealth
Clu
b M
embe
rshi
p/Fi
tnes
sC
lass
es N
ursi
ng H
otlin
e O
ther
Wel
lnes
s B
enef
its
See p
. 29
for a
dditi
onal
info
rmat
ion
abou
t Hea
lth/W
ellne
ss Ed
ucat
ion
Bene
fits.
1 Eac
h ye
ar, y
ou p
ay a
tota
l of o
ne d
educ
tibl
e. I
n 20
07, t
his
dedu
ctib
le is
$13
1, a
nd it
may
cha
nge
in 2
008.
2 If a
doc
tor
or s
uppl
ier
choo
ses
not t
o ac
cept
ass
ignm
ent,
thei
r co
sts
are
ofte
n hi
gher
, whi
ch m
eans
you
pay
mor
e.
Blue Cross Senior Secure Summary of Benefits – Section 3 – 2008 – SCASB0001FM 26
Section 3
2008 Summary of Benefits forBlue Cross Senior Secure
It’s important that you understand your benefits soyou can get the most out of your health careservices, and we can serve you better. We want yourbenefit information to be easy to understand andsimple for you to use.
Your plan was created to provide Medicarebeneficiaries with coverage for medically-necessaryhospital and doctor services with low or no monthlyplan premiums. Your plan also may includeMedicare Part D Prescription Drug Coverage. Italso may include coverage for routine vision care,dental care, and hearing examinations.
This section provides important additionalinformation about some of the benefits listed earlierin Section 2.
Out-of-Pocket Maximum/AnnualDeductible (see #1 in Section 2)
Out-of-Pocket Maximum
Blue Cross Senior Secure Plan I features a $500 out-of-pocket maximum and Blue Cross Senior SecurePlan II features a $3,000 out-of-pocket maximumon the following services:Inpatient Services
Medicare-covered inpatient hospital care andassociated charges.
Medicare-covered inpatient mental healthcare.
Outpatient Services
Medicare-covered ambulance services.
Medicare-covered emergency room visits.
Medicare-covered urgently-needed care visits.
Annual Deductible (Blue Cross Senior SecurePlan II only):
This plan has a $2,000 annual deductible, whichapplies only to the following covered services. Youmust pay all costs for these services until you havemet your annual deductible.Inpatient Services
Medicare-covered inpatient hospital care andassociated charges (at a preferred hospital).
Medicare-covered inpatient mental healthcare.
Medicare-covered skilled nursing facility care.
Outpatient Services
Home healthcare.
Durable medical equipment. Prosthetic devices.
Diabetes self-monitoring supplies.
Medicare-covered ambulance services.
Outpatient surgery in an ambulatory surgicalcenter or outpatient hospital facility.
Please note that copayment or coinsurance amountsare based on the plan’s contracted rate, or, for non-contracted providers, the Medicare-allowed amount.
Doctor and Hospital Choice(see #2 in Section 2)
Your primary care physician or primary medicalgroup must be a participating provider in one of thenetwork medical groups or Independent ProfessionalAssociations (IPAs) in order for you to fully accessyour benefits. See your provider directory for a list ofnetwork medical groups and IPAs.
The provider list is subject to change with priornotice during the contract year. For updatedprovider information, please contactCustomer Service.
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Inpatient Hospital Care(see #3 in Section 2)
For Blue Cross Senior Secure Plan I, if you use apreferred network hospital, you pay a $50 copay perday for days 1-5 for Medicare-covered inpatienthospital care. If you use a non-preferred networkhospital, you pay up to $500 per day for days 1-15.
For Blue Cross Senior Secure Plan II, if you use apreferred network hospital, you pay all costs forMedicare-covered inpatient hospital services untilyou have reached the annual deductible amount of$2,000. If you use a non-preferred networkhospital, you pay up to $500 per day for days 1-15,and this copay does not apply to your annualdeductible.
For both Blue Cross Senior Secure Plan I and PlanII members, if you use a hospital that is not apreferred or non-preferred hospital for your plan,you will be responsible for all costs – except inemergency or urgent situations. See the providerdirectory for a list of preferred and non-preferredhospitals. The list of preferred and non-preferrednetwork hospitals is subject to change with priornotice during the year. For information on currentpreferred and non-preferred hospitals, you cancontact Customer Service.
Skilled Nursing Facility(see #5 in Section 2)
Blue Cross Senior Secure Plan II: You pay all costsfor Medicare-covered skilled nursing facility careuntil you have met your annual deductible.
Home Health Care(see #6 in Section 2)
Blue Cross Senior Secure Plan II: You pay all costsfor Medicare-covered home healthcare until youhave met your annual deductible.
Screening Services (see #8 in Section 2)
You do not pay a copayment for the followingscreening services, but you may pay an appropriateoffice visit copayment: colorectal screenings, screeningmammograms, bone mass measurement, Pap smearsand pelvic exams, and prostate cancer screening exams.
If a colorectal screening exam includes biopsy orremoval of a growth, the procedure will beconsidered outpatient surgery and your benefits foroutpatient surgery will apply.
Podiatry Services (see #10 in Section 2)
Your plan allows you to self-refer to a networkpodiatrist up to 12 times per year for routinepodiatry services. You are responsible for a specialistcopayment for each visit. Medicare-covered servicesare not covered under routine podiatry. Routinepodiatry includes removal or cutting of corns orcalluses and trimming of nails in the absence oflocalized illness, injury or symptoms involving thefeet. Additional visits or referrals for medically-necessary foot care may be arranged and approvedby your primary care physician.
Outpatient Surgery/Services(see #13 in Section 2)
Blue Cross Senior Secure Plan I: Your office visitcopayment will apply for any nonsurgical physicianservices in an outpatient hospital facility. Inaddition, the outpatient surgery copayment appliesfor covered elective, scheduled (nonurgent,nonemergency) surgeries performed in anoutpatient hospital or ambulatory surgical center.
Blue Cross Senior Secure Plan II: You pay allfacility fee charges until you reach your $2,000annual deductible for elective, scheduled(nonurgent, nonemergency) Medicare-coveredsurgeries when performed in an outpatient hospitalor ambulatory surgical center.
Ambulance Services(see #14 in Section 2)
Blue Cross Senior Secure Plan I: You pay yourambulance copayment for each medically-necessarytrip to the hospital or dialysis center, from thehospital or dialysis center, or between facilities.
Blue Cross Senior Secure Plan II: You pay all costsfor Medicare-covered ambulance services until yourannual deductible has been met. Ambulance servicesare covered for each medically-necessary trip to thehospital or dialysis center, from the hospital ordialysis center, or between facilities.
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Emergency Care(see #15 in Section 2)
You pay your emergency room (ER) copayment foreach covered ER visit. If you are admitted to ahospital from an ER for the same or a relatedcondition within the time frame described inSection 2, you will not pay your ER copayment, butyou will pay your inpatient hospital copayment, ifyou have one.
Durable Medical Equipment andProsthetic Devices(see #18 and #19 in Section 2)
Durable Medical Equipment includes items such asoxygen, wheelchairs, walkers, and hospital beds forhome use.
Prosthetic Devices include arm, leg, back, and neckbraces; artificial eyes; artificial limbs (and theirreplacement parts); breast prostheses (aftermastectomy); and prosthetic devises needed toreplace an internal body part or function, includingMedicare-covered therapeutic shoes.
Blue Cross Senior Secure Plan II: You must meetyour deductible before you’re eligible for benefitsfor Durable Medical Equipment (DME) andprosthetic devices. After you meet your deductible,the plan covers 100% of eligible expenses formedically necessary Durable Medical Equipmentand Prosthetic Devices.
Diabetes Self-Monitoring Training,Nutrition Therapyand Supplies(see #20 in Section 2)
There is no copayment for diabetes self-monitoringtraining, however a copayment may apply for anassociated office visit.
If your plan includes Medicare Part D PrescriptionDrug coverage, supplies associated with theinjection of insulin (specifically syringes, needles,alcohol swabs, and gauze) are covered underMedicare Part D and not under Medicare Part B.
Diagnostic Tests, X-Rays and LabServices (see #21 in Section 2)
You do not pay a copayment for most clinical ordiagnostic lab services, however you may pay anoffice visit copayment if you are charged for anoffice visit.
You pay a 20% coinsurance for complex diagnostictests. These tests include MRIs, PET scans, CTscans, nuclear medicine studies, EKGs and cardiacstress tests. You may pay an office visit copayment ifyou are charged for an office visit.
You pay a 20% coinsurance for radiologicaltherapeutic lab services (radiation therapy), renaldialysis and chemotherapy regardless of place oftreatment. You may pay an office visit copayment ifyou are charged for an office visit.
Prescription Drugs(see #29 in Section 2)
Your plan provides benefits for MedicarePart B-covered drugs with 20% coinsurance.
Your plan includes Medicare Part D PrescriptionDrug Benefits. If you are already enrolled inanother Part D Plan, you will be disenrolledautomatically from your old plan and enrolled inthis plan.
Our plans also cover generic barbiturates andbenzodiazepines. These classes of generic drugs arenot required to be covered by Medicare Part Dplans. A list of these drugs is included in ourformulary. Your copayments for barbiturates andbenzodiazepines do not count toward your InitialCoverage Limit or yearly out-of-pocket maximum(also known as the “true out-of-pocket maximum”or TrOOP.) Brand-name barbiturates andbenzodiazepines are not covered.
You can buy a 90-day supply of a prescription drugthrough a network mail-order pharmacy or fromcertain retail pharmacies that contracted with theplan to provide 90-day supplies. These retailpharmacies are identified in the provider directorywith an asterisk (*).
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Dental Care (see #30 in Section 2)
Your plan covers the following preventive careservices from network dentists:
one office visit (consisting of an oralexamination and one set of bite-wingX-rays) per year for a $0 copayment; and
one teeth cleaning per year for a $30copayment; and
a second teeth cleaning in the same year for a$40 copayment; and
a full set of X-rays every five years for a $30copayment.
Vision Care (see #32 in Section 2)
You may receive one routine eye examination peryear through a Blue View Vision provider for a $20copayment. Routine eye exams are for the purposeof prescribing, fitting, changing eyeglasses (andcontact lenses) or determining the refractive state ofthe eyes. We offer coverage for one pair of standardeyeglass lenses (including single vision, bifocal andtrifocal lenses) and up to $75 for one pair ofstandard frames every two years OR up to $95 forone pair of contact lenses (every two years).
Please note that if you select a pair of eyeglassframes that are more than $75 or contact lenses thatare more than $95, you will be responsible for anyamounts over the $75 for frames or the $95 forcontact lenses. There may be an additional chargefor cosmetic lens options selected by the member,such as progressive multifocal lenses, lens coatingsand lens tinting.
Health/Wellness Education(see p. 25 in Section 2)
You can enroll in the Forever FitSM program — afitness plan designed especially for Medicare-eligibleindividuals. The Forever FitSM program includes:
complimentary basic membership in a participatingfitness center in your area. You can use all theservices available to fitness center members with abasic membership.
discounts for exercise and movement programs,such as yoga, Pilates, Tai Chi, Qi Gong andpersonal training.
discounts on selected health and fitnessmagazines and access to online education tools.
There is not a separate charge for this program, aslong as you only use services available with basicfitness center memberships.
After you enroll in this Medicare Advantage plan,you will receive a brochure that shows theparticipating fitness centers in your area anddescribes how to enroll in Forever Fit.SM
Contact Customer Service for more information onthis program, or visit www.WholeHealthMD.com.
Foreign TravelIf you are traveling outside the United States for lessthan six months, your plan covers medicallynecessary care in an emergency room, urgent carecenter or physician’s office. If you have a deductible,you first must meet your deductible. Then you areresponsible for a $50 copayment per visit.
Your inpatient copayment applies for emergency orurgent inpatient admissions while you are travelingoutside the United States. This benefit is limited to60 inpatient days per lifetime.
Precertification/PriorAuthorizationChiropractic Services: You must contact the planfor precertification for in-network chiropractic visitsafter the fifth visit.
Diagnostic Tests, X-Rays, and Lab Services: Youmust contact the plan for prior authorization beforehaving high-tech imaging, radiation oncologytreatment, and other select diagnostic services,including, but not limited to, injectable/infusiblemedications.
