Reference Guide for Excellus 2016

Medicare Reference Guidebook
2016
The answers
you need,
the coverage
you want.
Y0028_4523_1 Accepted
A nonprofit independent licensee of the Blue Cross Blue Shield Association
LIFE HAS ACCESS
As a member
of Excellus
BlueCross
BlueShield you
have access
to our robust
provider network.9
It’s easy to see if your current doctor, specialist, hospital, pharmacy or other
healthcare providers are in our extensive network … or to find a new provider.
OR
To Find Providers and Pharmacies Online: Go to our website at
ExcellusMedicare.com and click the link for “Doctors - Hospitals - Pharmacies.”
Next click “View or Print a Directory.” You can select and open a
Provider/Pharmacy Directory by plan name.
Call our dedicated Medicare representatives toll-free at 1-800-659-1986,
8:00 a.m. – 8:00 p.m. Monday-Friday. From October 1 through February 14,
8:00 a.m. – 8:00 p.m., 7 days a week. (TTY/TDD users call 1-800-421-1220)
A nonprofit independent licensee of
the Blue Cross Blue Shield Association
2
The answers you need.
The coverage you want.
Excellus BlueCross BlueShield knows you have choices when it comes to your health insurance.
Our company wants to help you understand Medicare and the plan options you have with us.
Our goal is to make your experience a positive one while helping you choose a plan that is right
for you. We plan to do this by providing answers to questions we are most frequently asked by
people eligible for Medicare. This easy to use reference guide provides answers to:
• What is Medicare?
• What plans do you offer?
• Can I still see my doctors?
• Are my prescriptions covered?
• Am I covered while traveling?
• How do you support my health and well-being?
• When can I enroll?
You should choose our company for your health insurance needs because we have been in this
business for decades and it is our goal to provide high quality, affordable care to all Medicare
eligible residents in our community.
After you read this guide, if you still have questions, our licensed sales advisors can quickly
give you answers. Our licensed sales advisors are available to talk with you by phone, in-person
or at convenient meeting locations. Or you can visit our website at ExcellusMedicare.com.
to compare plans, estimate costs and more--24/7. To speak with a licensed sales advisor call
1-800-659-1986 (TTY/TDD users call 1-800-421-1220). (See our hours of operation in the back
of this guide.)
The choice is yours! Read our material, call us, write us, attend a meeting, or go online. The
information you need to know about our Medicare Advantage plans is available. We hope to
hear from you soon!
Sincerely,
Roger van Baaren
Vice President, Medicare
Table of contents
The answers you need
1
Medicare basics ............................................................................................................ 2
What plans do you have?............................................................................................... 4
Our Medicare Advantage plans offer ............................................................................. 5
Other plan features for HMO or PPO. 5
Am I eligible for a Medicare Advantage plan?................................................................ 5
Can I still see my doctors?.............................................................................................. 6
Are my prescriptions covered?........................................................................................ 7
Extra help paying for prescription drug costs......................... ........................................ 8
Understanding your prescription drug coverage............................................................. 9
Am I covered while traveling? ..................................................................................... 10
How do you support my health and well-being? ........................................................ 11
The Silver&Fit Exercise & Healthy Aging Program®........................................................ 12
The coverage you want
15
When can I enroll?....................................................................................................... 16
How do I enroll in your Medicare Advantage plan?...................................................... 17
Once I enroll, what may I expect?................................................................................ 17
Advantages of being a member of our plan................................................................. 18
For your reference
19
Coverage and initial determination information .......................................................... 20
Appeal and grievance information .............................................................................. 20
Prescription drug information....................................................................................... 22
Medical care information ............................................................................................ 23
Protected health information....................................................................................... 24
Contact information and helpful resources
27
The answers you need
1
Medicare basics
What is Medicare?
Medicare is federal health insurance for the following:
• People 65 or older
• People under 65 with certain disabilities
• People of any age with End-Stage Renal Disease (ESRD) (permanent kidney failure requiring dialysis
or a kidney transplant)
The different parts of Medicare
The different parts of Medicare help cover specific services (see below).
Medicare Part A
(Hospital Insurance Coverage):
(Medical Insurance Coverage):
• Helps cover inpatient care in hospitals
• Helps cover skilled nursing facility, hospice,
and home health care
• Helps cover doctors’ and other health care
providers’ services, outpatient care, durable
medical equipment, and home health care.
• Helps cover some preventive services to help
maintain your health and to keep certain illnesses
from getting worse.
Eligibility:
• You are eligible for Part A if you or your spouse
paid into Social Security for at least 10 years
through your employment and if you are a citizen
or permanent resident of the U.S.
Part A costs:
• Most individuals do not pay a monthly premium
for Part A because they or their spouse paid
Medicare taxes while working.
• If you aren’t eligible for premium-free Part A,
you may be able to buy Part A, if you meet
certain conditions. Call Social Security at
1-800-772-1213 (TTY number for hearing
impaired is 1-800-325-0778) between 7 a.m.
and 7 p.m. on business days, to see if you qualify
and to check the amount you will pay for your
Part A premium. If you have limited income and
resources, your state may be able to help you pay
for your Part A and/or Part B premium.
• Part A can have a substantial deductible,
copayments, and coinsurance.
2
Medicare Part B
Eligibility:
• Anyone who is eligible for free Medicare hospital
insurance (Part A) can enroll in Medicare medical
insurance (Part B) by paying a monthly premium.
• If you are not eligible for free hospital insurance,
you can buy medical insurance, without having to
buy hospital insurance, if you are age 65 or older
and you are a U.S. citizen; or a lawfully admitted
non-citizen who has lived in the United States for
at least five years. Call the Social Security Office
for more information.
Part B costs:
• Part B requires a monthly premium which most
people have deducted directly from their monthly
Social Security check. Most people will pay the
standard premium amount. Social Security will
contact you if you have to pay more based on
your income. If you don’t sign up for Part B when
you’re first eligible, you may have to pay a late
enrollment penalty.
• In addition, there is a Part B annual deductible
amount and other costs (such as copayments and
coinsurance) that may apply.
Medicare Part C
(also known as Medicare Advantage
Coverage):
• Offers health plan options run by Medicareapproved private insurance companies like ours.
• Medicare Advantage plans are a way to get the
benefits and services covered under Part A
and Part B.
• Most Medicare Advantage plans cover Medicare
prescription drug coverage (Part D).
• Some Medicare Advantage plans may include
extra benefits.
Eligibility:
• If you have Medicare Parts A and B, you can
join a Medicare Advantage plan.
Part C costs:
• In addition to paying your monthly Medicare
Part B premium, you might have to pay a monthly
premium for your Medicare Advantage plan
because of the extra benefits it offers, and there
will be some cost-sharing.
See information about our company’s Medicare
Advantage Part C plans on page 4
Medicare Part D
(Medicare Prescription Drug Coverage):
• Helps cover the cost of prescription drugs.
• May help lower your prescription drug costs and
help protect against higher costs in the future.
• Is run by Medicare-approved private insurance
companies like ours.
• There are two ways to get Medicare prescription
drug coverage: 1) through a stand-alone plan
that covers prescription drugs only, 2) through
a Medicare Advantage plan that includes health
care and prescription drug coverage.
Eligibility:
• Anyone who has Medicare hospital insurance
(Part A), medical insurance (Part B) or a Medicare
Advantage plan (Part C) is eligible for prescription
drug coverage (Part D).
Part D costs:
• Most drug plans charge a monthly fee that
varies by plan. You pay this in addition to the
Part B premium. If you belong to a Medicare
Advantage plan (like an HMO or PPO) that
includes Medicare prescription drug coverage,
the monthly premium you pay to your plan may
include an amount for prescription drug coverage.
• A small percentage of Medicare beneficiaries with
higher incomes will pay a higher monthly Part D
premium. If you must pay a higher premium, the
Social Security office will send you a letter with
your premium amount and the reason.
• In addition, there could be a yearly
deductible amount and other costs
(such as copayments or coinsurance
per prescription). Some Medicare
drug plans have different levels
or “tiers” of coinsurance or
copayments, with different costs
for different types of drugs.
3
What plans do you have?
We offer Medicare Supplement (Medigap) plans
We offer Medicare Supplement plans, which work hand-in-hand with
Original Medicare to help you pay the costs that Original Medicare does
not, such as copayments, coinsurance and deductibles. Our Medigap
plans do not include drug coverage, but you may be able to join a
Medicare Prescription Drug Plan. As a member of our plan, you will pay
a monthly premium to us (in addition to paying your monthly Medicare
Part B premium). Generally, you must have Medicare Part A and B to
buy a Medicare Supplement plan. Some people choose this type of plan
because they have the freedom to go to any Medicare participating
doctor within the United States. The premiums for these plans are
usually higher than most Medicare Advantage plans.
We have Medicare Advantage (Part C) plans.
A Medicare Advantage plan is another Medicare health plan choice you
have as part of Medicare. Medicare Advantage plans are sometimes
called “Part C” or “MA plans.” Our company offers Medicare Advantage
HMO and HMO-POS plans. If you join our Medicare Advantage plan, we
will provide all of your Part A (Hospital Insurance) and Part B (Medical
Insurance) coverage. Many of our Medicare Advantage plans offer extra
coverage; such as, prescription drugs, vision, dental, routine physicals,
hearing, and/or health and wellness programs1.
If you are a member of one of our HMO plans, you will need to
receive most or all of your health care from a participating provider
within our robust network. In addition, our HMO-POS plan gives you
the option to see out-of-network providers for some covered services.
The POS benefit coverage has annual limits (see your Summary of
Benefits for more details). Any
time you get care from an out-ofnetwork provider it may cost you
more, except in an emergency or
urgent care situation.
If you are a member of one of
our PPO plans, you may choose
to receive your health care from
either a participating provider in
our network or an out-of-network
provider. Any time you get care
from an out-of-network provider
it may cost you more, except
in an emergency or urgent
care situation.
Types of Medicare
Advantage plans we
offer at a glance.
See the chart below to review
our plan types and requirements,
like whether you need a referral
to see a specialist. For our HMO
plans, please ask your doctor
about our open-ended referrals.
With an open-ended referral you
can see an approved specialist on
a continual basis without having to get another referral—even
from year to year.
HMO
HMO-POS
PPO
Health Maintenance
Organization
Health Maintenance
Organization
Preferred Provider
Organization
Point-of-Service
4
Primary Care Physician
Primary Care Physician
No Primary Care Physician
Referrals
Referrals
No Referrals
In-Network providers3
In-Network &
Out-of-Network providers4
In-Network &
Out-of-Network providers4
Our Medicare Advantage plans offer:
• Quality health insurance
• Affordable premium plans including a $0 premium
plan in most markets1, 2
• Affordable payments for in-network benefits1
• A robust provider network9
• Built-in prescription drug coverage included in
most plans
• An extensive list (formulary) of generic prescription
drugs1, 4
• Value-added extras (e.g. vision, dental, travel
coverage, diagnostic hearing exam, etc.1)
• $0 copay for Medicare-covered in-network
preventive services1
• $0 annual deductible for medical expenses1
• A fitness benefit with your choice of a gym
membership and at-home fitness kits1
• Programs to help you when you are sick
z
Dental coverage1
Some plans cover preventive dental services for two
oral exams, two cleanings, and two dental x-rays
per year up to an allowable amount. Please refer to
the Summary of Benefits to see what dental services
may be covered.
Hearing services1
All of our plans cover Medicare-covered diagnostic
hearing exams anytime you are having a medical
problem with your ears. In addition, our plans offer
one routine hearing exam every calendar year. Please
refer to the Summary of Benefits for plan costsharing details.
Vision care1
Some of our plans cover supplemental routine eye
exams in addition to exams to diagnose and treat
diseases and conditions of the eye. A copayment
may apply for the supplemental routine exam
depending on the plan you have chosen.
Other plan features for HMO or PPO
Out-of-pocket maximums1, 4 – your Safety Net
Our plans provide a safety net to limit your total out-of-pocket costs each year. This is known as the out-ofpocket maximum. When your total payment of copays or coinsurance reaches the out-of-pocket maximum for
your plan, Excellus BCBS will pay the remaining covered charges for the rest of the year.
Only cost-sharing for medical services counts towards your out-of-pocket maximum. Any outpatient
prescription drug charges are not included in determining the amount.
Am I eligible for a
Medicare Advantage plan?
You are eligible to join one of our plans if you:
• Have Medicare Part A and B, and
• Are a legal resident in the service area of the plan, and
• Do not have End-Stage Renal Disease (ESRD) (unless you are
already a member in one of our company’s plans)
Need tips about talking
to your doctor? We’ll email
some to you. Sign up for
our monthly emails at
ExcellusMedicare.com/Email.
Our service area is the geographic area where Medicare permits us
to enroll members. You must be a resident of one of the counties
listed in the Summary of Benefits.
5
Can I still see my doctors??
We would be happy to see if your doctor is a
participating provider for you.
It’s easy to verify that your doctor is
in our network.
Important information about our provider
network4:
HMO Plans
• If you choose a Medicare Advantage HMO plan,
you will select a participating provider from our
provider network who will coordinate all your
medicare care.3 Should you find yourself in a
medical emergency either at home or while traveling, you may go “out-of-network” to receive care.
• Some of our HMO plans include a Point-of-Service
(POS) benefit. The POS benefit provides you the
flexibility to receive some services from doctors
or hospitals that are not in our provider network
without having to pay the entire cost yourself.
PPO Plans4
• When you select one of our Medicare Advantage
PPO plans, you may see any Medicare participating doctor or hospital of your choice, although to
keep your out-of-pocket costs low, you’ll want to
remain in-network.
To find out whether your doctors are in our provider
network you may:
1. Visit our Medicare website at ExcellusMedicare.
com and click on “Doctors - Hospitals Pharmacies”
2. Call one of our licensed sales advisors at
1-800-659-1986, Monday – Friday, 8:00 a.m. to
8:00 p.m. (TTY/TDD users call 1-800-421-1220).
If you are calling from October 1st to
February 14th, representatives are available to
assist you 7 days a week, 8:00 a.m. to 8:00 p.m.
When you select our plan, you gain access to a robust
network of doctors, hospitals and pharmacies.4, 9
Network providers
9
“Providers” is the term we use for doctors, other
health care professionals, hospitals, and other health
care facilities that are licensed by the state and
eligible to receive payment from Medicare. You can
read online reviews of providers and write a review
of your care. Visit ExcellusMedicare.com/Providers
and select “Review Your Provider’s Care”.
6
Are my prescription drugs covered1, 9?
Our comprehensive list of covered prescription drugs is called a “formulary.” To find out how your drugs
are covered, check our website or call our licensed sales advisors.
To determine if your drugs are covered under
our plans you may:
1. Refer to our printed Formulary (included in
this package).
2. Visit our website at ExcellusMedicare.com
and click on “I am New to Medicare” then
“Prescriptions.”
3. Call our licensed sales advisors at
1-800-659-1986, Monday – Friday, 8:00 a.m.
to 8:00 p.m. If you are calling from October 1st
to February 14th, representatives are available
to assist you seven days a week, from 8:00 a.m.
to 8:00 p.m.
The prescription drugs on our formulary are selected
in consultation with a team of doctors and pharmacists in the community dedicated to safeguarding
the pharmaceutical needs of our members.
Our formulary is reviewed by Medicare and must
always meet Medicare’s requirements. The
Centers for Medicare and Medicaid Services has
created guidelines for the types of drugs that must
be covered, setting minimum standards that must
be met, and excluding certain types of drugs from
our formulary entirely. The formulary may change
throughout the year.
To receive your Medicare Part D drug coverage, you
must use our in-network pharmacies. We do have
many network pharmacies outside of our service
area where you can get your prescriptions filled as
a member of our plan. Generally, we cover drugs
filled at an out-of-network pharmacy only under
non-routine circumstances when you are not able
to use a network pharmacy.6
Rx Formulary
The formulary uses a tiered structure. Drugs are
tiered according to price and type of drug.
Tier 1 (Preferred Generic Drugs)
Tier 2 (Generic Drugs)
Tier 3 (Preferred Brand Name Drugs)
Tier 4 (Non-Preferred Brand Name Drugs)
Tier 5 (Specialty Drugs)
Refer to page 22 and the Summary of Benefits
for additional information on prescription drugs
including requirements and coverage limits.1
7
Save money on your prescriptions
Generic drugs
A generic drug is a copy of a brand name drug, identical in dosage, safety, strength, how it is taken,
quality, performance, and intended use. The only difference is that generic drugs are sold under their
chemical or “generic” name, while brand name drugs are marketed under a specific trade name by the
pharmaceutical manufacturer. Generic drugs have the same risks and benefits as their brand name counterparts, as they have the same active ingredients and are shown to work the same way in the body. Both brand
name and generic drugs have to meet the same rigorous FDA requirements, so they are of the same quality.
This list may change monthly. Please check our website for a complete up-to-date list.
Mail Order Service
You can save money by ordering a 90-day supply of your medication through our network mail order
program. You can order and receive a 90-day supply of your long-term medications through the mail
from Express Scripts®, Walgreens and Wegmans. All of these services allow you to have your medications
delivered right to your door.*
Extra help paying for prescription drug cost
People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If you qualify,
Medicare could pay for up to 75 percent or more of your drug costs including monthly prescription drug
premiums, annual deductibles and coinsurance. Additionally, those who qualify will not be subject to the
coverage gap or a late enrollment penalty. Many people are eligible for these savings and don’t even know it.
To see if you qualify for getting Extra Help:
• Call 1-800-MEDICARE (1-800-633-4227) TTY uses should call 1-877-486-2048, 24 hours a day /
7 days a week;
• The Social Security office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday.
TTY users should call, 1-800-325-0778; or
• Your State Medicaid Office
• EPIC and the VA
You may also qualify for the Elderly Pharmaceutical Insurance Coverage (EPIC) Program. This is a New York
State sponsored prescription plan for those over 65 who need help paying for their prescriptions.
Military veterans qualify for a variety of benefits with the U.S. Department of Veterans Affairs (VA). One of
those benefits is prescription coverage. To find out if you are eligible for this benefit, you can contact your
local VA. Contact information for EPIC and the VA can be found in the back of this guide.
* To refill your mail order prescriptions, please contact us 10 days before you think the drugs you have on
hand will run out to make sure your next order is shipped to you in time. Typically, you should expect to
receive your mail order prescription drugs from 5 to 8 business days from the time that the mail order pharmacy receives the order. If you do not receive your prescription drug(s) within this time, please contact us at
1-800-499-2838 (TTY 1-800-421-1220) Monday - Friday, 8:00 a.m. - 8:00 p.m. From October 1 - February
14, 8:00 a.m. - 8:00 p.m., 7 days a week.
8
Find a pharmacy1, 9
Excellus BlueCross BlueShield has thousands of network pharmacies to choose
from. Check our website or call Customer Care to find a participating pharmacy
in your area. In general, you must use our network pharmacies to access your
prescription drug benefit except in non-routine circumstances, and quantity limits
and restrictions may apply.
Understand Your Part D Prescription Drug Coverage3
Your plan may have an annual deductible. If you have a deductible, you will pay
the full cost of your prescription medications until your plan deductible is met
and you enter the Initial Coverage stage.
PHASE 1
PHASE 3
Initial Coverage
YOU PAY: Copayment
or Coinsurance
EXCELLUS BCBS
PAYS: Remaining cost
When you are in the Initial
Coverage phase, you pay
your copay or coinsurance
for your covered medication.
Excellus BCBS pays
the remainder of your
medication costs.
You stay in Phase 1 phase
until the amount of your
year to-date total drug
costs (what you pay plus
what Excellus BCBS
pays) reaches $3,310.
Catastrophic Coverage
PHASE 2
Coverage Gap
When you are in the Coverage Gap
phase, you pay:
n 58 percent of the cost for all of your covered
generic medications.
n 45 percent at the pharmacy for your covered brand
name medications. The total cost of the medication
(before the discount) applies toward your trueout-of-pocket costs.You stay in this phase
until your true out-of-pocket costs
reach $4,850.
Refer to your plan benefits
for the copay or coinsurance
amounts you pay during
this phase.
YOU PAY: reduced
copayment /coinsurance
described below
EXCELLUS BCBS
PAYS: Remaining cost
When you are in the
Catastrophic Coverage
phase, you pay the greater
of either 5 percent
coinsurance or $2.95 for
generic drugs; or $7.40 for
all other prescription drugs.
Excellus BCBS pays
most of the cost for your
covered medications.
Once you are in this
payment stage, you stay
in it for the rest of the
calendar year (through
December 31).
9
Am I covered while traveling?
Yes, all our members are covered for
urgent care nationwide and emergent
situations worldwide. With our plans, we take
care of health situations that you do not expect.
What does that mean?
In an Emergency: We will cover you for an
emergency situation when you believe that your
health is at serious risk and your illness or injury is
life threatening if you do not receive immediate care.
This would include broken bones, severe bleeding,
chest pains, inability to breathe, or other such
symptoms. The cost of your care will generally be the
same, whether you are traveling in the United States
or traveling out of the country. For all of the plans
we offer, we will not reimburse for services outside
of the United States except for emergencies.
When you need Urgent Care: We will cover you
for urgent care while you travel within the United
States, when an illness or injury which is unforeseen
and not life threatening, requires immediate
medical care. Examples of urgent care situations
would be sprains, minor lacerations, high fevers,
etc. The cost of your care is generally a defined
copayment amount for covered services to a medical
facility or an urgent care center (other than a
physician’s office) when you seek urgent care.
In an emergency call 911 or go to the nearest hospital.
Out-of-Network medical coverage for our HMO-POS plans
If you are a member of one of our Health Maintenance Organization - Point-of-Service (HMO-POS) plans you
have the flexibility to receive select services from doctors or hospitals that are not in our network4 without
having to pay the entire cost yourself. Please see the Summary of Benefits for the annual limits and list of
covered services.
Visitor/Travel Program for PPO Members 7
Our Visitor/Traveler Program which provides coverage while traveling outside of the service area. Members
pay the same in-network costs they pay at home when they use a Blue Medicare Advantage PPO provider
in any geographic area where the Visitor/Traveler Program is offered. Go to http://provider.bcbs.com or call
1-800-810-Blue (2583) to find a participating provider out of the area.
Blue Medicare Advantage PPO Visitor/Traveler Program is
available in 35 states and 1 territory (in some states only
portions of the state are available). If you use an out-ofnetwork provider who does not participate in the Blue
Medicare Advantage PPO network, your financial
responsibility will be greater because the out-of-network
reimbursement is based on a percentage of the Medicare
allowed amount.
10
You do not need a referral when you get care from out-of-network providers; however, before getting
services from out-of-network providers you may want to confirm with us that the services you are getting
are covered by us and are medically necessary. If we later determine if the services are not covered or were
not medically necessary, we may deny coverage and you will be responsible for the entire cost.
Please note that we cannot pay a provider who has opted out of the Medicare program. Check with your
provider before receiving services to confirm that they have not opted out of Medicare.
How do you support my health and well-being?
We offer programs to help our members stay healthy plus we provide
preventive coverage.
$0 Annual Preventive Health Screening
There’s no better way to give yourself peace of mind than by getting the preventive screenings you need.
They’re completely free to Excellus BlueCross BlueShield Medicare members when performed by an
in-network provider.2
When services other than preventive are performed during a preventive screening appointment, the office visit
copayment will apply. If the service is considered diagnostic, not preventive, a copayment may apply.
Top 10 $0 copay preventive screenings used
by members1
Other $0 copay preventive screenings included
in your plan:
1. Breast cancer screening (mammograms)
• Abdominal aortic aneurysm screening
• Alcohol misuse counseling
• Cardiovascular disease testing and behavioral
therapy
• Counseling to help you stop smoking and/or
using tobacco
• Depression screening
• HIV screening
• Obesity screening and counseling
• Screening and counseling for sexually transmitted
infections (STIs)
2. Immunizations (Flu and Pneumonia vaccines)
3. Bone mass measurement (DEXA scan)
4. Colorectal cancer screening (including flexible
sigmoidoscopy, fecal occult blood test, and
screening colonoscopy)
5. Yearly “Wellness” visit (annual physical)
6. Cervical and vaginal cancer screening (pap and
pelvic exam)
7. Diabetes screening and self management
training
8. Prostate cancer screening exams
9. Medical nutrition therapy
10. “Welcome to Medicare” Preventive Visit
To learn more about preventive health screenings and tips on talking
to your doctor, visit MyExcellusMedicare.com and select “For Your Health.”
11
Online Resources For Medicare Members
As a member you’ll have access to our web tools. At
MyExcellusMedicare.com you’ll find personalized advice, tips and many tools to help you stay healthy. It’s
all available to you day or night, at your convenience.
You can learn about your plan, download and print
important forms and applications, read about preventive health, fall prevention, advance care planning
and more. You can also view your prescription drug
claims by setting up a username and password. You
will need your member ID to set that up.
You can access our Drug List and Generic Savings
Calculator. Also research health topics and preventative health tools. Or sign up for monthly health &
wellness emails that include information on health
topics, healthy recipes, prescription drug information, questions to ask your doctor and more.
Medication Therapy Management (MTM)
Our Medicare Therapy Management program is
designed for members who have specific health
and pharmacy needs. The program is available to
members with 2 or more specific chronic medical
conditions who are taking 8 or more prescription
medications. A clinical pharmacist will call you to
discuss information on effective drug treatment,
costs, and how to treat and prevent side-effects
from medications. Members are encouraged to follow up with their doctors. To see if you qualify, call
1-800-559-8426. Please leave a message and your
call will be returned within the next business day.
Silver&Fit® Exercise & Healthy Aging Program1
The Silver&Fit program gives you the power to improve your health through learning and exercise. For a low
annual member fee, you can participate in this program as part of your membership with us. We encourage
you to take part in this optional benefit. Members can choose 1 of 3 program options:
Join an in-network Silver&Fit fitness facility for only $25 a year.1
Participating Fitness Facilities. For an annual member fee of $25 you will have access to the participating fitness
facility of your choice. In most cases, you can pay a $25 fee at the facility (with some exceptions). The Silver&Fit
Program has a national network so “snowbirds” can continue to benefit from the program when traveling.
Members who travel have the opportunity to switch facilities once a month. The change would be effective at the
start of the following month. You will not have to pay another $25 annual member fee when you switch facilities.
To find participating fitness facilities online go to our website at ExcellusMedicare.com and click the link for
“Doctors - Hospitals - Pharmacies.” Next click “View or Print a Directory.” You can select and open a Provider/
Pharmacy Directory by plan name.
Choose 2 home fitness kits for only $10 for each benefit year
The Silver&Fit Home Fitness Program. For those who do not enjoy working out at a fitness club or exercise
center, the Silver&Fit Home Fitness program may better suit your needs. For an annual fee of $10, you get a
choice of up to two Home Fitness kits per year. Choose from 17 kits including Chair Pilates, Walking, Chair
Boxing, and many more.
Out-of-Network Facilities. If your fitness facility is not part of the Silver&Fit network, or you
are unable to locate a convenient participating facility, you are still eligible to participate in
the Silver&Fit program. If you select the out-of-network option, you are
eligible to receive up to $150 reimbursement annually for your fitness
facility membership dues or fees.
Note: The Silver&Fit program does not
reimburse for future months, or for services
received outside the United States.
12
Get Healthy – Resources to help you manage your health
Together, we’re better.
Your health is important to us. We have a lot of
useful information we can share about the most
common chronic conditions you face today. Chronic
conditions are illnesses that last a long time and
need to be managed on a daily basis. Together, we
can find ways for you to control your condition so
you can get the most out of your life.
13
Health management programs1
Health management programs help people learn
about ways to stay well. These programs offer tips
and information to help you while working with
your doctor. Excellus BlueCross BlueShield members
may be encouraged to participate in these programs
if you are receiving care for a chronic condition
(ex, diabetes, asthma, depression), are at risk for
developing a chronic condition, or if you want
information that will help you avoid a chronic
condition. Health management programs offer
phone access to nurse care managers, free health
information, and helpful reminders about health issues. The programs are available to you at no
additional cost.
Health Assessment1
All new Excellus BlueCross BlueShield members
receive a Health Risk Assessment (HRA) survey by
mail within 90 days of enrollment, as required by
the Centers for Medicare and Medicaid Services. To
help us with this, we have contracted with, National
Research Corporation (NRC). We encourage new
members to complete and return the survey. As a
new member this information helps us to learn more
about your health and wellness. With your consent,
a licensed health care professional will visit your
home for about an hour to review your medications
and medical history, perform a physical assessment,
and discuss your health concerns. You will receive
a summary of recommendations to review with
your physician at your next visit. If you are selected
for this program, a staff person will call you to ask
about scheduling a visit to your home at no cost.
Nurse Call Line1
Managing your health is all about teamwork. That’s
why you can contact a registered nurse by phone
anytime - 24 hours a day, seven days a week. Nurse
care managers can provide support on the phone
or through follow up educational mailings. Our
24/7 nurses provide information regarding nutrition,
medications and diagnoses. Manage chronic health
conditions (e.g. heart disease, diabetes, arthritis), get
the latest information on nutrition, general health
questions and more.
Research health topics
Our online Web research tool has information
about health topics such as hearing loss, Alzheimer’s
disease, osteoporosis, arthritis and much more.
There is plenty of information to help you stay
healthy as you get older. The library also includes
interactive videos on topics such as getting active,
maintaining a healthy weight, sleeping well,
dealing with low back pain and medicines to
treat depression.
Make the Connection
If you have a chronic or complex condition, you
may receive a call from us. Our programs have
been developed with input from doctors in the
communities we serve, and your doctor may
refer you to us. If you believe you may benefit from
our health management programs please contact
your doctor or one of our dedicated Medicare
Customer Care Advocates at 1-877-883-9577
(TTY 1-800-421-1220) for more information.
If you have questions, you may call a nurse care
manager, Monday through Friday, 8 a.m. to 4:30
p.m. 1-800-860-2619 (TTY/ TDD 1-800-421-1220).
Let us help you live healthy. Learn about
our health and wellness programs and
services through our monthly emails.
Sign up at ExcellusMedicare.com/Email.
14
The coverage you want
15
Now that you have reviewed
our plan information
I am sure you are now asking…
When can I enroll?
1. Initial Enrollment Period (IEP)
• During your IEP, you can enroll 3 months before
you turn age 65 to 3 months after the month you
turn age 65.
• If you get Medicare due to a disability, you can
join during the 3 months before to 3 months after
your 25th month of disability.
• You can join a Medicare Advantage or standalone Prescription Drug Plan.
• If you enroll during the 3 months after your birth
month, enrollment will generally take effect on
the first day of the month subsequent to your
enrollment submission request.
2. Annual Election Period (AEP)
• The AEP, also referred to as the “Fall Open
Enrollment” is from October 15th - December
7th. Your coverage will begin on January 1st.
• During the AEP you can:
- Change Medicare Advantage or stand-alone
Prescription Drug Plans
- Add or drop prescription drug coverage
- Return to Original Medicare
3. Special Election Period (SEP)
In certain situations, you may be able to join, switch
or drop a Medicare Advantage plan during a SEP.
Examples of a SEP are:
• If you lose creditable coverage (loss of employer
group coverage)
• If you make a permanent move into or out of your
plan’s service area
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••If you have both Medicare and Medicaid
• If you become approved for Low Income Subsidy
(LIS – Extra Help)
• If you qualify for any other exceptional conditions
determined by the Centers for Medicare &
Medicaid Services (CMS)
4. Medicare Advantage Disenrollment Period
(MADP)
The Medicare Advantage Disenrollment Period runs
from January 1st – February 14th each year.
During the MADP you will be able to:
• Disenroll from a Medicare Advantage plan (MA)
or Medicare Advantage Prescription Drug Plan
(MA-PD) and return to Original Medicare.
• Enroll in a stand-alone Prescription Drug Plan
(PDP), if you disenroll from an MA or MA-PD plan
during the MADP and return to Original Medicare.
How do I enroll in your
Medicare Advantage plan?
Enrolling in a Medicare Advantage plan
with us is fast and easy!
Use the Enrollment Form: (included in
this package) Start by choosing your plan
at the top of the Enrollment Form. Then
complete the following:
• Your Personal Information: Please tell us
about yourself in this section and provide all
information requested.
• Your Medicare Card Information: Fill out the
information from your red, white, and blue
Medicare card in this section.
Online anytime of the day, you can
visit our easy-to-use website at:
ExcellusMedicare.com Compare our
plans and explore options for extra help
online!
Call us: Just call one of our licensed sales
advisors to help answer your questions
and enroll over the phone. They will do
everything for you.
1-800-659-1986, Monday - Friday, 8:00 a.m. to 8:00
p.m. (TTY/TDD users call 1-800-421-1220). If you are
calling from October 1st to February 14th, representatives are available to assist you 7 days a week,
from 8:00 a.m. to 8:00 p.m.
• A Few Questions: Fill in the information as it
applies to you.
• Your Signature and Authorization: Please read
all the information on your Enrollment Form and
then sign where indicated. Another signature
may be required if someone helps you fill out
your form5. Please make a copy for your records.
Once I enroll, what may I expect?
We will welcome you to our family of
members!
We look forward to serving you today and for many
years to come. We will send you information on how
to use your benefits in healthy times and when you are
sick and need your coverage the most.
Once you enroll in our plan, you will receive
the following:
• A letter from us confirming your enrollment plus your Member ID card number so you can start
using your benefits immediately.
• An Evidence of Coverage document explaining your benefits and how to access your coverage.
• An Abridged Formulary with prescription drug coverage information.
• A Member Guidebook with information to help you use and understand the benefits you have with
your plan.
17
Advantages of being a member of our plan
We strive to give you security and peace of mind
We will give you the tools and resources you need to be a healthy member. Our benefits and programs are
designed to give you the security and peace of mind of knowing you have access to a high-quality health
insurance plan.
Your membership grants you access to our comprehensive network of doctors, hospitals, and other health
professional services. As a BlueCross BlueShield member, your member card is widely recognized and
accepted throughout the Blue’s network.
Plan highlights are:
• Access to a broad network of doctors and hospitals9
• Access to a local, Medicare–dedicated Customer Care team to answer your questions
• The Silver&Fit® Exercise and Healthy Aging program to get or keep you healthy1
• Online health and wellness resources
• Nationwide Urgent Care coverage
• Worldwide Emergency coverage
• $0 annual medical deductible for all our MA plans.1 This means your coverage begins right away
• $0 copay for Medicare-covered in-network preventive services to keep you healthy1
• Access to a Nurse Call Line 24/7, to get health advice or to be connected to other resources
• Built-in prescription drug coverage included in most plans
• A health management program to coordinate all of your plan benefits
18
For your reference
19
Coverage and initial determination information
How do I make a request for coverage, request a review of an
initial determination or voice a concern with you?
What is an initial determination?
The initial determination that we make is the
starting point for handling requests that you may
have about covering a Part D drug and/or Part C
medical care or service you need, or paying for a
Part D drug or Part C medical care or service you
have already received.
Initial decisions about Part D drugs are called,
“coverage determinations” and initial decisions
about Part C medical care or services are called,
“organization determinations.” With this decision,
we explain whether we will provide the Part D drug
and/or Part C medical care or service you are
requesting, or pay for the Part D drug and/or Part C
medical care or service you already received.
What is an exception?
An exception is a type of initial determination (also
called “coverage determination”) involving a Part D
drug. You may ask us to make an exception to our
Part D coverage rules in a number of situations. For
example, you would file an exception if you want
to ask us to cover your Part D drug even if it is not
on our formulary, to waive coverage restrictions or
quantity limits on your Part D drug, or to provide a
higher level of coverage for your Part D drug.
Appeal and Grievance
information
Appeals
Filing an appeal with the health plan,
If you do not agree with our decision to deny your
coverage, you may ask us to review the denial
decision. When we receive your request it is
reviewed by professionals within our organization,
who were not involved in making the original
determination. This process ensures that we give
your request a thorough review, independent of the
original review.
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You have the right to request a standard appeal
or a fast appeal.
Grievances
Filing a grievance with the health plan,
You would file a grievance if you have a complaint
regarding the health plan, a provider of care, or one
of our network pharmacies. For example, you would
file a grievance if you have a complaint about
circumstances such as wait times in doctors’ offices
or at the pharmacy, the way your network physician/
pharmacist or others behave, the customer service
you receive, or difficulty receiving or understanding the information you needed or requested. If
you have a grievance, we encourage you to call our
dedicated Medicare Customer Care Department
immediately. We will make every attempt to resolve
your complaint over the phone.
You may also file your grievance by mail or
in person.
You have the right to ask for a “fast” or “expedited”
grievance if waiting would significantly increase any
risk to your health.
How you voice a concern about the
quality of your care
Complaints concerning the quality of care you have
received may be made in oral or written format to us
under the grievance process, or to an independent
organization called the Quality Improvement
Organization (QIO), or to both. For example, if you
believe you were given the wrong treatment or you
believe your pharmacist provided the incorrect dose
of a prescription, you may file a complaint with the
QIO in addition to or in lieu of filing a complaint
under our grievance process. For any complaint
filed with the QIO, we must cooperate with the
QIO in resolving the complaint.
For more detailed information on the grievance
and appeals process, request an Evidence of
Coverage (EOC).
Who may file a grievance, initial
determination or appeal?
You, your doctor, the physician providing your treatment (Part C), or other prescriber (Part D), or someone you name may file a grievance, initial
determination or appeal. The person you name
would be your “representative.” You may name a
relative, friend, lawyer, advocate, doctor, or anyone
else to act for you. If you want someone to act for
you who is not already authorized by the court or
under state law, then you and that person must
sign and date a statement that gives the person
legal permission to be your representative. The
representative statement must include your name
and Medicare number.
You may use Form CMS-1696 which is available
on our website. You may also use an equivalent
notice which satisfies the requirements on Form
CMS-1696. Unless otherwise stated, your appointed
representative will have all of your rights and responsibilities during the grievance or appeals process.
Where do I file a grievance?
To file a grievance you may:
Call us: 1-877-883-9577 Monday - Friday,
8:00 a.m. to 8:00 p.m. (TTY/TDD users call
1-800-421-1220). If you are calling from
October 1st to February 14th, representatives
are available to assist you 7 days a week, from
8:00 a.m. to 8:00 p.m.
-orSend it to us by fax: 1-315-671-6656
-orSend it to us in writing:
Excellus BlueCross BlueShield
Customer Advocacy Unit
PO Box 4717
Syracuse, NY 13221
-orRegister your grievance in person:
Please call one of our dedicated Medicare
Customer Care Advocates for
information on filing your grievance
in person.
Where do I file an appeal?
To file an appeal you may:
Send it to us by fax:
1-315-671-6656
-orMail your request to:
Excellus BlueCross BlueShield
Customer Advocacy Unit
PO Box 4717
Syracuse, NY 13221
-orCall us with a fast or expedited appeal:
1-877-883-9577 Monday - Friday, 8:00 a.m. to
8:00 p.m. (TTY/TDD users call 1-800-421-1220).
If you are calling from October 1st to February
14th, representatives are available to assist you
7 days a week, from 8:00 a.m. to 8:00 p.m.
You may submit a request outside of regular
business hours and on weekends at:
1-877-444-5380.
21
Prescription drug information
Your role in drug safety
It’s important for you to ask your doctor and
pharmacist about prescription drugs and over-thecounter drugs you take. You may not realize
there can be problems with how certain drugs
interact with each other or with over-the-counter
medications, including vitamins. It’s also important
for you to continue to take the herbal supplement
medications that your doctor prescribes for you. If
you stop taking any medications without talking to
your doctor you may put yourself at risk for medical
complications. We have resources available to help
you manage your medications.
Requirements and coverage limits
For certain prescription drugs, we have additional
requirements for coverage or limits on coverage.
These requirements and limits ensure that members
use these drugs in the safest, most effective way and
also helps control drug plan costs.
Quantity Limits (QL) For certain drugs, we limit the
amount of the drug that we will cover. The same
Quantity Limit requirements apply to both mail-order
and retail pharmacies. For information on quantity
limitations and requirements call our licensed sales
advisors at 1-800-659-1986, (TTY users can call
1-800-421-1220).
Excluded Part D Drugs (*) This prescription drug is
not normally covered under Part D. The amount you
pay when you fill a prescription for this drug does
not count towards your total drug costs (that is, the
amount you pay does not help you qualify
for catastrophic coverage). In addition, if you are
receiving extra help to pay for your prescriptions,
you will not get any extra help to pay for this drug.
Prior Authorization (PA) These medications
require authorization from Excellus BCBS
before you can fill your prescription.
Verification for Part B or Part D (BD) These
medications require prior authorization only to
determine whether they qualify for payment under
Part B or Part D.
Step Therapy (STEP) In some cases, we require
you to first try certain drugs to treat your medical
condition before we will cover another drug for
that condition.
The items listed in parentheses above are indicated
in the formulary.
Information on Flu and Shingles Vaccinations
Excellus BlueCross BlueShield members are covered in full for your annual flu shot when it is provided
by an in-network doctor. You may have some costs if you choose to use a non-participating doctor.
To determine the cost of a flu shot from a non-participating provider please contact one of our
licensed sales advisors.
The shingles vaccination is covered under the Part D drug benefit and a copay1 will apply. You may find
it in our formulary by looking up “ZOSTAVAX.” You may also get a shingle’s vaccine in any in-network
pharmacy that administers immunizations. The pharmacy will only require your copay and therefore you
will not need to worry about being reimbursed for the vaccine. If you would like more information on all
covered vaccinations, please contact our licensed sales advisors or ask your doctor for the drug name of
the vaccination you would like to receive and check it on our formulary.
22
Medical care information
Utilization Management
We are committed to high quality, appropriate,
and cost-efficient medical care which is best suited
to the needs of our members. To ensure we can
continue to provide optimal health insurance, we
use a process called Utilization Management (UM)
to evaluate the health care you or your health care
provider request.
Prior Authorization
For some types of care, you or your doctor may need
to get approval in advance from us (this is called
“prior authorization”). For example, if your doctor
determines that you need a knee replacement,
he/she will need to receive prior approval for
coverage from Excellus BlueCross BlueShield before
performing the procedure. We require only certain
services be reviewed in advance to determine if
they are medically necessary, appropriate for you
and your condition, and experimental and/or
investigational.
Our medical team of health care professionals
and physicians consider the following types of
information to help determine whether your
requested medical services should be approved:
• Is the requested medical service an appropriate
course of treatment for your condition?
• Is this the only treatment option available for
your condition?
• Are there other treatment options having a
demonstrated improvement in symptoms for
individuals with the same condition or symptoms?
• Does your health plan cover the requested medical
service?
Please keep in mind that not all of the medical
services you receive will need to be reviewed,
including emergency situations.
Utilization Management Review
We conduct three types of UM reviews to determine
whether coverage for the medical services requested
is appropriate for the diagnosis and treatment of
your condition.
1. Pre-service reviews occur before you receive any
medical care. For some medical services, your
doctor will need to contact us by phone, in
writing, or by fax, to request pre-approval for
coverage of medical services. We will review the
request before you get treatment.
We will contact you, your doctor, and the doctor
that is treating you to let you know the outcome
of our UM review and whether the medical
services are covered under your health plan.
The types of services that typically have a preservice review include elective hospital admissions,
involving planned, non-emergency surgery (such
as a hip replacement procedure or back surgery)
and Skilled Nursing Facility (SNF) admissions.
2. Concurrent reviews occur while you are getting
care. Your doctor may submit a request for
coverage of additional medical services during
your course of treatment. We will review the
request and notify both you and your doctor, in
writing and by phone, of the outcome of our
UM review and whether the requested medical
services are covered under your health plan.
This type of review is also used to determine
whether you would benefit from one of our care
management programs and/or discharge planning
prior to your discharge from the hospital.
The types of services that are typically reviewed
during treatment include physical therapy;
rehabilitation care at a SNF; and, chemical
dependency care.
3. Post-service reviews occur after you have received
care. In some instances, after you have received
medical services, we will review your medical
records to ensure the care provided was adequate
and medically appropriate for your condition.
Upon completion of our review, we will notify you
and your doctor of the outcome of our review
and coverage for the medical services, if any.
23
Protected health information
How is your health information
protected?
We are fully committed to protecting the privacy
of our prospective members and members.
Protected Health Information (PHI) is any information
that can identify you as an individual as well as
any information regarding your past, present, or
potential future physical and/or mental health
condition. PHI includes information provided on
your enrollment form and claim forms. We do
not disclose your PHI to anyone unless we are
permitted to do so by law or have received a
signed authoriza­tion form from you.
How we use and disclose your information:
The following are ways we may use and disclose
your information. If we need to use or disclose your
PHI in any way other than what is described in one
of the categories below, we will contact you to
receive your signed authorization beforehand.
Treatment: We may disclose your PHI to doctors or
hospitals involved in your care in order for them to
manage, coordinate and administer your treatment.
Payment: We may use and disclose PHI to collect
premiums, assist providers in billing and collec­tion
efforts, and determine coordination of benefits with
other insurance companies. For example, if you
have health insurance through another insurance
company, we may disclose PHI to them in order to
determine which company holds the responsibility
for your claim payment.
Health care operations: We may use and disclose
PHI to perform our health care operations, such
as to determine premiums, conduct quality
assessment and improvement activities, engage
in care coordination or case management, and
determine eligibility for benefits.
24
To you: We must disclose your PHI to you. We
may also disclose your PHI to recommend possible
treatment options or alternatives or to tell you about
health-related benefits or services that may be
of interest to you. To designate one or more
individuals to receive information related to your
health insurance and PHI, you must complete a
disclosure authorization for each person.
To family and friends: If you agree or, if you are
unable to agree and the circumstance, such as an
emergency, indicates that disclosure would be in
your best interest, we may disclose PHI to a family
member, friend or other person. In an emergency
situation, we will only disclose the mini­mum amount
of information necessary.
To our business associates: A business associate is
defined as someone that assists us in the operation
of our business. For example, we may disclose PHI
to a company that performs case reviews to ensure
you receive quality care. Our business associates are
required to sign a confidentiality agreement with
us that limits their use or disclosure of the PHI they
receive.
To plan sponsors: If you are enrolled in a group
health plan, we may disclose PHI to the employer
group (plan sponsor) to permit them to perform
plan administrative functions. Before PHI is disclosed
to your plan sponsor, the plan sponsor must agree
in writing to limit their use or disclosure of this
information to plan administration functions only.
What are your rights regarding your PHI?
Access: You have the right to inspect and/or copy
your PHI with limited exceptions. For instance, in
the event that a licensed health care professional,
exercising professional judgment, determines that
providing access to such information is reasonably
likely to endanger the life, physical safety or cause
substantial harm to someone.
Disclosure accounting: You have the right to
receive a list of instances in which we or our
business associates disclosed your PHI. The list will
not include disclosures we made for the purpose
of treatment, payment, health care operations,
disclosures made with your authorization, or certain
other disclosures.
Restriction requests: You have the right to request
that we place additional restrictions on our use or
disclosure of your PHI. As permitted by law, we will
not honor these requests, as it prohibits us from
administering your benefits.
Confidential communication: You have the
right to request that we communicate with you
confidentially about your PHI. We will honor a
request to communicate to an alternative location if
you believe you would be endangered if we did not
do so. We must accommodate your request if it is
reasonable and specifies the alternative location.
Amendment: You have the right to request that we
amend your PHI. Your request must be in writing,
and it must explain why the information should be
amended. We may deny your request if we did not
create the information you want amended or if we
determine the information is ac­curate.
Safeguards: We understand how important your
personal information is and have safeguards in place
to keep all information about you confidential in
all settings. Keeping your privacy confiden­tial is so
important to us that we require our employees
sign an agreement to follow our Code of Business
Conduct and complete our privacy training program.
Questions and Complaints: If you want more
information about our privacy practices or have
questions, please view our complete privacy policy
on our Web site or contact our Medicare Customer
Care Department.
Sharing your protected health
information
You may elect to share your PHI with a family
member or any person you approve to be involved
with your health care and access your records. You
may authorize us to share your PHI with a family
member or any person you choose. To do this, you
must complete an authorization form that permits
us to disclose information to the person you have
named on the authorization form. This is completely
voluntary and you may revoke your authorization at
any time.
An Authorization to Share Protected Health
Information form is required for the person
you have elected and this form can be found on
our website.
25
26
Contact information and helpful resources
Contact information
Our licensed sales advisors
Call: 1-800-659-1986
Hours: Monday – Friday, 8:00 a.m. to 8:00 p.m. If
you are calling from October 1st to February 14th,
representatives are available to assist you seven
days a week, from 8:00 a.m. to 8:00 p.m.
TTY/TDD: 1-800-421-1220 (Requires Special
Telephone Equipment)
Fax: Write: 1-716-843-7860
Excellus BlueCross BlueShield
PO Box 546, Buffalo, NY 14201
Website: ExcellusMedicare.com
Helpful resources
Centers for Medicare and Medicaid
Services
For more information about Medicare:
1-800-MEDICARE (1-800-633-4227)
TTY/TDD: 1-877-486-2048
Hours: 24 hours a day, 7 days a week
Website: Medicare.gov
Social Security Administration (SSA)
To apply for Low-Income Subsidy (LIS):
Call: 1-800-772-1213
TTY/TDD: 1-800-325-0778
Hours: Monday - Friday, 7:00 am - 7:00 pm
Website: ssa.gov
Elderly Pharmaceutical Insurance
Coverage (EPIC)
Call: 1-800-332-3742
TTY/TDD: 1-800-290-9138
Hours: Monday - Friday, 8:00 am - 5:00 pm
Website: Health.NY.gov/health_care/epic
New York State Medicaid Help Line
1-800-541-2831
Department of Veterans Affairs
Call: 1-800-827-1000
TTY/TDD: 1-800-829-4833
Website: va.gov
27
1 This information is not a complete description of benefits. Contact the plan for more information.
Limitations, copayments and restrictions may apply. Benefits and copayments/coinsurance may change on
January 1 of each year.
2 You must continue to pay your Medicare Part B premium.
3 You must use participating plan providers except in emergency or urgent care situations or for out-of-area
renal dialysis or other services. If you obtain routine care from out-of-network providers neither Medicare
nor Excellus BlueCross BlueShield will be responsible for the costs.
4 Our plan will cover services from either in-network or out-of-network providers, as long as the services are
covered benefits and medically necessary. However, if you use an out-of-network provider, your share of the
costs for your covered services may be higher.
5 If you are receiving assistance from a sales agent, broker, or other individual employed by or contracted
with Excellus BlueCross BlueShield, he/she represents our organization, and may be paid in part based upon
your enrollment in our plan. Compensation paid to our sales representatives may vary depending upon a
number of factors, including the Medicare Advantage and/or Part D Prescription Drug Plan that you select
and the overall volume of business the sales representative produces. If you require additional information
regarding the compensation received by our sales representatives for your plan, please contact your sales
representative directly.
6 In general you must use network pharmacies to access your prescription drug benefit, except in non-routine
circumstances, and quantity limitations and restrictions may apply.
7 The Visitor Travel Program will include Blue Medicare Advantage PPO network coverage of all Part A,
Part B, and Supplemental benefits offered by your plan outside your service area in 35 states and
1 territory: Alabama, Arkansas, California, Colorado, Connecticut, Florida, Georgia, Hawaii, Idaho, Illinois,
Indiana, Kentucky, Maine, Massachusetts, Michigan, Missouri, Montana, North Carolina, Nevada, New
Hampshire, New Jersey, New Mexico, New York, Ohio, Oklahoma, Oregon, Pennsylvania, Puerto Rico,
South Carolina, Tennessee, Texas, Utah, Virginia, Washington, Wisconsin, and West Virginia. For some
states listed, MA PPO networks are only available in portions of the state.
8 Coverage limits for each prescription drug coverage level (e.g., initial coverage period, coverage gap and
catastrophic coverage period) change annually.
9 The Formulary, pharmacy network, and/or provider network may change at any time. You will receive
notice when necessary.
The Silver&Fit program is a product of American Specialty Health Fitness, Inc., (ASH Fitness), a subsidiary
of American Specialty Health Incorporated (ASH). All programs and services are not available in all areas.
Silver&Fit and the Silver&Fit logo are federally registered trademarks of ASH and are used with permission
herein.
Silver&Fit is an exercise and healthy aging program administered by American Specialty Health Fitness, Inc.,
an independent company that offers these services on behalf of Excellus BlueCross BlueShield.
Excellus BlueCross BlueShield contracts with the Federal Government and is an HMO and PPO plan with a
Medicare contract. Enrollment in Excellus BlueCross BlueShield depends on contract renewal.
28
Excellus BlueCross BlueShield has a contract with the Centers for Medicare & Medicaid Services (CMS) which
is renewed annually. Availability of coverage beyond the end of the current contract year is not guaranteed. If
the contract is not renewed by either Excellus BlueCross BlueShield or CMS this may result in the termination
of your enrollment in the plan. In addition, Excellus BlueCross BlueShield may reduce its service area and no
longer offer services in the area where you reside.
ExcellusMedicare.com
B-3678Y16/9670-15MedM EXC