Booklet Contents...Forever Blue (PPO) (H5526) Summary of Benefits Optional Supplemental Dental Benefits ... Tips for comparing your Medicare choices ... • Obesity screening and therapy

7

Mental Health Services1

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 Inpatient In-network

bull You pay a $295 copay for days 1-4 bull You pay nothing per day for days 7 through 90

Outpatient group therapy visit

bull In-network You pay a $40 copay

Outpatient individual therapy visit bull In-network You pay a $40 copay

Your annual in-network out-of-pocket limit (what you pay) for inpatient mental health care is $1180 After your limit has been reached you pay nothing for the remainder of the year

Skilled Nursing Facility (SNF) 1

Our plan covers up to 100 days in a SNF In-network

bull You pay nothing per day for days 1 through 20 bull You pay a $178 copay per day for days 21 through 100

Our plan benefit period applies for any SNF stay This means that if you are discharged from the SNF for more than 60 days and readmitted a new benefit period starts The plan covers up to 100 days each benefit period In this situation the cost sharing applied starts at day one If you are readmitted to the SNF within 60 days from your discharge date you are still considered to be in the same benefit period If you are transferred from one SNF to another within 60 days you are still considered to be in the same benefit period In these situations you pay the ldquoper day copayrdquo that was in effect on the last day of the discharge or transfer

Physical Therapy

bull In-network You pay a $40 copay

Ambulance1 You pay a $250 copay

Transportation Not covered

Medicare Part B Drugs 1

For Part B drugs such as chemotherapy drugs bull In-network You pay 20 coinsurance

Other Part B drugs

bull In-network You pay 20 coinsurance

8

Prescription Drug Benefits Part D Drug Deductible

During this stage the plan pays its share of the cost of your Tier 1 Preferred Generic Drugs and Tier 2 Generic Drugs and you pay your share of the cost During this stage you pay the full cost of your Tier 3 Preferred Brand Drugs Tier 4 Non-Preferred Drugs and Tier 5 Specialty Drugs You stay in this stage until you have paid $100 for your Tier 3 Preferred Brand Drugs Tier 4 Non-Preferred Drugs and Tier 5 Specialty Drugs ($100 is the amount of your Tier 3 Preferred Brand Drugs Tier 4 Non-Preferred Drugs and Tier 5 Specialty Drugs deductible)

Initial Coverage

Tier

One-month supply Preferred (up to a 30-day supply)

One-month supply Standard (up to a 30-day supply)

Three-month supply Mail-Order (up to a 90-day supply)

Tier 1 (Preferred Generic) $000 copay $500 copay $000 copay

Tier 2 (Generic) $500 copay $1000 copay $1250 copay

Tier 3 (Preferred Brand) $4200 copay $4700 copay $10500 copay

Tier 4 (Non-Preferred Drug)

$9400 copay $10000 copay $23500 copay

Tier 5 (Specialty Tier) 31 coinsurance 31 coinsurance 31 coinsurance

After you (or others on your behalf) have met your Tier 3 Preferred Brand Drugs Tier 4 Non-Preferred Drugs and Tier 5 Specialty Drugs deductible the plan pays its share of the costs of your Tier 3 Preferred Brand Drugs Tier 4 Non-Preferred Drugs and Tier 5 Specialty Drugs and you pay your share Your cost-share for a three-month supply at retail is 3 times the cost (except for Tier 5) for the applicable one-month supply (Preferred or Standard) Cost-Sharing may differ based on pharmacy type or status (eg preferrednon-preferred mail order long term care (LTC) or home infusion and 30 or 90 day supply) In limited circumstances you may get drugs from an out-of-network pharmacy and pay the standard retail copaycoinsurance plus the difference between the out-of-network billed charge and the standard retail allowable You stay in this stage until your year-to-date ldquototal drug costsrdquo (your payments plus any Part D planrsquos payments) total $4020

8

Prescription Drug Benefits Part D Drug Deductible

During this stage the plan pays its share of the cost of your Tier 1 Preferred Generic Drugs and Tier 2 Generic Drugs and you pay your share of the cost During this stage you pay the full cost of your Tier 3 Preferred Brand Drugs Tier 4 Non-Preferred Drugs and Tier 5 Specialty Drugs You stay in this stage until you have paid $100 for your Tier 3 Preferred Brand Drugs Tier 4 Non-Preferred Drugs and Tier 5 Specialty Drugs ($100 is the amount of your Tier 3 Preferred Brand Drugs Tier 4 Non-Preferred Drugs and Tier 5 Specialty Drugs deductible)

Initial Coverage

Tier

One-month supply Preferred (up to a 30-day supply)

One-month supply Standard (up to a 30-day supply)

Three-month supply Mail-Order (up to a 90-day supply)

Tier 1 (Preferred Generic) $000 copay $500 copay $000 copay

Tier 2 (Generic) $500 copay $1000 copay $1250 copay

Tier 3 (Preferred Brand) $4200 copay $4700 copay $10500 copay

Tier 4 (Non-Preferred Drug)

$9400 copay $10000 copay $23500 copay

Tier 5 (Specialty Tier) 31 coinsurance 31 coinsurance 31 coinsurance

After you (or others on your behalf) have met your Tier 3 Preferred Brand Drugs Tier 4 Non-Preferred Drugs and Tier 5 Specialty Drugs deductible the plan pays its share of the costs of your Tier 3 Preferred Brand Drugs Tier 4 Non-Preferred Drugs and Tier 5 Specialty Drugs and you pay your share Your cost-share for a three-month supply at retail is 3 times the cost (except for Tier 5) for the applicable one-month supply (Preferred or Standard) Cost-Sharing may differ based on pharmacy type or status (eg preferrednon-preferred mail order long term care (LTC) or home infusion and 30 or 90 day supply) In limited circumstances you may get drugs from an out-of-network pharmacy and pay the standard retail copaycoinsurance plus the difference between the out-of-network billed charge and the standard retail allowable You stay in this stage until your year-to-date ldquototal drug costsrdquo (your payments plus any Part D planrsquos payments) total $4020

9

Coverage Gap When you are in the Coverage Gap Stage the Medicare Coverage Gap Discount Program provides manufacturer discounts on brand name drugs You pay 25 of the negotiated price and a portion of the dispensing fee for brand name drugs Both the amount you pay and the amount discounted by the manufacturer count toward your out-of-pocket costs as if you had paid them and moves you through the coverage gap

You also receive some coverage for generic drugs You pay no more than 25 of the cost for generic drugs and the plan pays the rest For generic drugs the amount paid by the plan (75) does not count toward your out-of-pocket costs Only the amount you pay counts and moves you through the coverage gap

Catastrophic Coverage

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $6350 you pay the greater of bull 5 of the cost or bull a $360 copay for generic (including brand-name drugs treated as generic) and an

$895 copayment for all other drugs

Additional Benefits Chiropractic Care

Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine moves out of position)

bull In-network You pay a $20 copay

Diabetes Supplies and Services

Diabetes monitoring supplies bull In-network You pay nothing

Diabetes self-management training

bull In-network You pay nothing Therapeutic shoes or inserts

bull In-network You pay nothing

10

Durable Medical Equipment 1 (wheelchairs oxygen etc)

bull In-network You pay 20 of the cost depending on the equipment

You pay nothing for compression stockings in-network

Foot Care (Podiatry Services)

Foot exams and treatment if you have diabetes-related nerve damage andor meet certain conditions

bull In-network You pay a $30 copay

Routine foot care (for up to 3 visit(s) every year) bull In-network You pay a $30 copay

Home Health Care

bull In-network You pay nothing

Hospice When you enroll in a Medicare-certified hospice program your hospice services and your Medicare Part A and B services related to your diagnosis are paid for by Original Medicare not BlueShield Freedom Premier

Outpatient Rehabilitation

Cardiac (heart) rehab services bull In-network You pay a $15 copay

Occupational therapy visit

bull In-network You pay a $40 copay Physical therapy and speech and language therapy visit

bull In-network You pay a $40 copay

Outpatient Substance Abuse 1

Group therapy visit bull In-network You pay 50 coinsurance

Individual therapy visit

bull In-network You pay 50 coinsurance

11

Over-The-Counter (OTC) Items

You have $25 every quarter (3 months) to spend on plan-approved mail order Over-The-Counter (OTC) products Our mail order provider will deliver these items directly to your door Your coverage includes non-prescription OTC health related items like vitamins pain relievers and cough medicines

Prosthetic Devices 1 (braces artificial limbs etc)

Prosthetic devices bull In-network You pay $0 for diabetic shoesinserts 20 of the cost of all other

items

Renal Dialysis bull In-network You pay 20 coinsurance bull Out-of-network Inside service area Not covered for non-participating

providers Outside service area You pay 20 for non-participating providers

Telemedicine bull In-network You pay nothing

Wellness Programs (eg fitness)

bull In-network There is no charge to participate in our Health and Wellness Education Programs

bull There is no charge for the SilverSneakersreg Fitness Program

This information is not a complete description of benefits Call us at 1-800-329-2792 (TTY 711) we are available 8 am to 8 pm 7 days a week from October 1 to March 31 and 8 am to 8 pm Monday ndash Friday from April 1 to September 30 for more information You can get prescription drugs shipped to your home through the network mail-order delivery program You should expect to receive your mail-order prescriptions 14-21 calendar days after the pharmacy initially receives the order Please call the Pharmacy Services number located on the back of your member ID card if you do not receive your prescription within the appropriate amount of days BlueShield of Northeastern New York is a Medicare Advantage HMO with a Medicare contract and enrollment depends on contract renewal Other PharmaciesPhysiciansProviders are available in our network This document is available in other formats such as Braille large print or audio BlueShield of Northeastern New York is a division of HealthNow New York Inc an independent licensee of the Blue Cross and Blue Shield Association

Summary of Benefits

H3384

2020 Senior Blue HMO

1 Y0086_COM533_M

BlueShield Senior Blue 652 (HMO) 2020 Summary of Benefits

January 1 2020 ndash December 31 2020 This booklet gives you a summary of what we cover and what you pay The benefit information provided does not list every service that we cover or list every limitation or exclusion To get a complete list of services call us and ask for the ldquoEvidence of Coveragerdquo Plans may offer supplemental benefits in addition to Part C benefits and Part D benefits Tips for comparing your Medicare choices This Summary of Benefits booklet gives you a summary of what BlueShield Senior Blue 652 covers and what you pay

bull If you want to know more about the coverage and costs of Original Medicare look in your current ldquoMedicare amp Yourdquo handbook View it online at httpwwwmedicaregov 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

BlueShield Senior Blue 652 Phone Numbers and Website

bull If you are a member of this plan call toll-free 1-800-329-2792 (TTY 711) We are available October 1 to March 31 7 days a week from 8 am to 8 pm and from April 1 to September 30 Monday through Friday from 8 am to 8 pm

bull If you are not a member of this plan call toll-free 1-877-258-7453 (TTY 711) We are available October 1 to December 31 7 days a week from 8 am to 8 pm and from January 1 to September 30 Monday through Friday 8 am to 8 pm

bull Our website wwwbsnenycommedicare Who can join To join BlueShield Senior Blue 652 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 New York State

Albany Columbia Fulton Greene Montgomery Rensselaer Saratoga Schenectady Warren Washington

Which doctors hospitals and pharmacies can I use BlueShield Senior Blue 652 has a network of doctors hospitals pharmacies and other providers Except in emergencies if you use the providers that are not in our network the plan may not pay for these services

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

bull Some of our network pharmacies have preferred cost-sharing You may pay less if you use these pharmacies

bull You can see our plans provider and pharmacy directory at our website wwwbsnenycommedicare

bull Or call us and we can look up your providers or send you a copy of the provider and pharmacy directories