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Effective January 1 – December 31, 2018Blue Shield 65 PlusChoice Plan (HMO)Medicare Advantage Prescription Drug PlanLos Angeles County(partial)/Orange CountySummaryof Benefitsblueshieldca.com/medicareH0504 17 215A1 021 Accepted 09032017
Summary of Benefits – Blue Shield 65 Plus Choice Plan (HMO) – Los Angeles County (partial)/Orange CountyWe all have the right to live a healthy, limitless lifeWe’re a California-based health plan that’s been serving Californians since 1939.We understand your healthcare coverage needs are unique, and what it takesto provide you with affordable access to care. That’s why we offer a variety ofquality coverage options and will help you find the Medicare plan that’s rightfor your specific health and financial needs. We strive to provide Medicarebeneficiaries with the most affordable and comprehensive benefits in themarketplace, and the highest level of customer service. And we will continueto be a leading voice for access to affordable, quality care for all Californians.we never stop working for you.What’s insideWhy choose Blue Shield 1Summary of 2018 medical benefits 2Summary of 2018 prescription drug coverage 6Optional supplemental dental HMO and PPO plans 8SilverSneakers Fitness program 11How to enroll 12What to expect once you enroll 12To join Blue Shield 65 PlusSM Choice Plan, you must be entitled to Medicare Part A, be enrolled inMedicare Part B and live in our service area. Our service area includes: Orange County and LosAngeles County,*The service area for Los Angeles County includes only the ZIP codes listed below.You must live in one of these ZIP codes to join the plan: 90001, 90002, 90003, 90011, 90022, 90023, 90031,90032, 90033, 90040, 90044, 90058, 90059, 90061, 90063, 90189, 90201, 90202, 90220, 90221, 90222, 90239,90240, 90241, 90242, 90255, 90262, 90270, 90280, 90601, 90602, 90603, 90604, 90605, 90606, 90607, 90608,90609, 90610, 90612, 90637, 90638, 90639, 90640, 90650, 90651, 90652, 90659, 90660, 90661, 90662, 90665,90670, 90671, 90701, 90702, 90703, 90706, 90707, 90711, 90712, 90713, 90714, 90715, 90716, 90723, 90745,90746, 90747, 90749, 90801, 90802, 90803 90804, 90805, 90806, 90807, 90808, 90810, 90813, 90814, 90815,90822, 90831, 90832, 90833, 90834, 90835, 90840, 90842, 90844, 90845, 90846, 90847, 90848, 90853, 90888,90899, 91731, 91732, 91733, 91744, 91745, 91746, 91747, 91748, 91749, 91754, 91755, 91765, 91770, 91776,91788, 91789, 91795, 91801and 91803.* Denotes partial county.
Why choose Blue ShieldYou may be asking yourself what to look for when picking a health plan. Or maybe you’re tryingto decide between two plans that appear similar. Here are some of the things we think you shouldconsider before enrolling.CostsUse this Summary of Benefits to compare what you will pay with our plan versus other plans.List of drugsIf you currently take medication, be sure you confirm that your medication, or an acceptablealternative, is on our list of drugs.Reputation and qualityThis is where we feel our plan really stands out from the competition. Why? Blue Shield puts care first, not profit. Blue Shield is a nonprofit company that’s been servingCalifornians since 1939. We strive to uphold high standards of ethical business practices in our programs and products. Blue Shield is a California original. We’re one of the first Blue Shield plans in the country and anadvocate for affordable, quality care for all Californians. We know Medicare. More than 260,000* Medicare beneficiaries in the Golden State have trustedtheir healthcare coverage to us.Service You have a California-based Member Services team dedicated to you. Save time and gas by having prescriptions delivered right to your door. Order your qualifyingongoing prescriptions through our mail service pharmacy.† You may go to any specialist within your doctor’s physician group in the following specialtieswithout a referral from your doctor for the initial visit: cardiology, gastroenterology, urology,ophthalmology, gynecology, orthopedics and podiatry.Doctors and specialistsWith our large network of primary care physicians and specialists, chances are you can keepseeing your current doctor. If you’re ready to switch doctors, we can help. Search blueshieldca.com/find-a-doctor for a plan provider, when asked if you know what plan you’re interested in, choose“Medicare Advantage – (HMO)” and then select the correct sub-plan option for your plan.* Blue Shield Medicare Advantage HMO and Medicare Supplement plan membership reporting as ofJune 2017.† Not all covered drugs are offered through mail service. See the plan formulary for more information.1
Summary of Benefits – Blue Shield 65 Plus Choice Plan (HMO) – Los Angeles County (partial)/Orange CountySummary of 2018 medical benefitsEffective January 1 through December 31, 2018This is a summary document. For a complete list of services, please refer to the appropriate planEvidence of Coverage (EOC) located on our website at blueshieldca.com/findamedicareplan.Services marked with an * may require a referral from your doctor.Premiums and benefitsWith Blue Shield 65 Plus Choice Plan, you pay:Monthly plan premium (You must continue topay your Medicare Part B premium.) 0DeductibleYou pay nothingMaximum out-of-pocket responsibility (doesnot include prescription drugs)(This is the mostyou would pay for the year for MedicareParts A and B services.) 2,400Inpatient hospital coverage (Our plan covers an unlimited number of days for an inpatient hospital stay.)You pay nothing per admissionOutpatient hospital coverage (We cover medically-necessary services you get in the outpatientdepartment of a hospital for diagnosis or treatment of an illness or injury) Services in an emergency departmentor outpatient clinic, such as observationservices or outpatient surgery 100 copay for each visit to an emergency room 150 copay for each visit to an outpatienthospital facilityOutpatient surgeryYou pay nothing for each visit to an ambulatorysurgical center 150 copay for each visit to an outpatienthospital facilityDoctor visits Primary care physicianYou pay nothing Specialists* 5 copay per visitPreventive careYou pay nothingAny additional preventive services approvedby Medicare during the contract year willbe covered.Emergency care 100 copay per visit.You pay the copay regardless of whether ornot you are admitted to a hospital for thesame condition.Worldwide coverage. 100 copay and 50,000 combined annuallimit for emergency care and urgentlyneeded services outside the United Statesand its territories.2
Premiums and benefitsWith Blue Shield 65 Plus Choice Plan, you pay:Urgently needed services 10 copay per visit.You pay the copay regardless of whether ornot you are admitted to a hospital for thesame condition.Worldwide coverage. 100 copay and 50,000 combined annuallimit for emergency care and urgentlyneeded services outside the United Statesand its territories.Diagnostic services/labs/imaging*(covered according to Medicare guidelines; prior authorization is required) Diagnostic radiology services(such as MRIs, CT scans, PET scans, etc.)You pay nothing for each diagnosticradiology service Lab servicesYou pay nothing Diagnostic tests and proceduresYou pay nothing Outpatient X-raysYou pay nothing Therapeutic radiology services (such asradiation treatment for cancer)You pay 20% of the Medicare-allowed amount.While you pay 20% for therapeutic radiologyservices, you will never pay more than your 2,400 total out-of-pocket maximum forthe year.Hearing services* Hearing examYou pay nothing if performed at your PCP’soffice; 5 copay per visit if performed at aspecialist’s officeDental services Cleaning (for up to 1 every six months) 20 copay Dental X-ray(s)† 0- 10 copay, depending on the service Fluoride treatment (for up to 2 every year) 5 copay Oral exam 5- 16 copay, depending on the serviceSee optional supplemental dental HMO andPPO plans for more information about dentalservices for an extra plan premium.† The 0- 10 copay for dental X-ray, depending on the type, is limited to either one set every 6 or24 months.3
Summary of Benefits – Blue Shield 65 Plus Choice Plan (HMO) – Los Angeles County (partial)/Orange CountySummary of 2018 medical benefits (cont’d)Services marked with an * may require a referral from your doctor.Premiums and benefitsWith Blue Shield 65 Plus Choice Plan, you pay:Vision services Exam to diagnose and treat diseases andconditions of the eye* 5 copay per visit You pay nothingYearly glaucoma screening* Routine eye exam and refraction (onceevery 12-month period through networkproviders; some coverage at non-networkproviders included; see the plan EOCfor details)You pay nothing Eyeglass frames (for up to 1 every two years) 20 copay. Our plan pays up to 100 everytwo years for eyeglass frames. Eyeglass lenses (for up to 1 every year) 20 copayMental health services* Inpatient mental health care 900 copay per stay Outpatient group therapy visit 30 copay per visit Outpatient individual therapy visit 30 copay per visitSkilled nursing facility (SNF)*(100 days per benefit period;† no priorhospitalization required with network provider)You pay nothing for days 1 through 20 75 copay per day for days 21 through 100Rehabilitation Services* Occupational therapy visit Physical therapy and speech and languagetherapy visitYou pay nothingYou pay nothing† A benefit period starts the day you go into a hospital or skilled nursing facility. It ends when you go for60 days in a row without hospital or skilled nursing care. If you go into the hospital after one benefitperiod has ended, a new benefit period begins.4
Premiums and benefitsWith Blue Shield 65 Plus Choice Plan, you pay:Ambulance 150 copay per trip (each way)TransportationYou pay nothing; limited to 24 one-way trips toplan-approved locations every 12 monthsMedicare Part B Drugs20% of the Medicare-allowed amount forchemotherapy drugs20% of the Medicare-allowed amount forother Part B drugsFoot care (podiatry services) Foot exams and treatment* 5 copay for each Medicare-covered visit Routine foot care 5 copay for each visit; limited to 1 visit permonth/12 visits per calendar yearMedical equipment/supplies* Durable medical equipment(e.g., wheelchairs, oxygen)‡20% of the Medicare-allowed amount Blood glucose monitorsYou pay nothing for ACCU-CHEK blood glucosemonitors and 20% of the Medicare-allowedamount for blood glucose monitors from allother manufacturers Prosthetics (e.g., braces, artificial limbs)You pay nothing Diabetes self-management training, diabeticservices and supplies‡You pay nothing for all training, services andsupplies except blood glucose monitors (see“Blood glucose monitors” above)Wellness program Basic gym access throughSilverSneakers FitnessYou pay nothing; see page 11NurseHelp 24/7SM (telephone and online support)You pay nothing‡ Prior authorization from the plan may be required. See the plan EOC for more information.5
Summary of Benefits – Blue Shield 65 Plus Choice Plan (HMO) – Los Angeles County (partial)/Orange CountySummary of 2018 prescription drug coveragePart D prescription drug benefitUsing a Blue Shield 65 Plus Choice Plan network pharmacy that offers preferred cost-sharing, you pay:Deductible 0One-month(up to a 30-day) supplyThree-month(up to a 90-day) supply*Tier 1: Preferred Generic Drugs 3 copay 4.50 copayTier 2: Generic Drugs 10 copay 15 copay†Tier 3: Preferred Brand Drugs 40 copay 100 copay†Tier 4: Non-Preferred Brand Drugs 95 copay 237.50 copay†Tier 5: Injectable Drugs31% coinsurance31% coinsurance†Tier 6: Specialty Tier Drugs33% coinsuranceNot offeredNetwork pharmacies that offer preferred cost-sharingYou may pay less when you visit one of our network pharmacies that offer preferred cost-sharing.Here’s just a few: CVS/pharmacy‡(including CVS pharmacy at Target)(888) 607-4287 [TTY: 711] Safeway and Vons pharmacies‡(877) 723-3929 [TTY: 711] Albertsons/Sav-on/Osco pharmacies‡(877) 932-7948 [TTY: 711] Costco‡(800) 955-2292 [TTY: 711] Ralphs,‡ Walmart‡ and many more.You do not have to be a Costco member to use Costco Pharmacies.* Three-month supply cost-sharing also applies to Blue Shield’s mail service pharmacy.† A long-term (up to a 90-day) supply is not available for select drugs. The drugs that are notavailable for a long-term supply are marked with the symbol † in our Drug List.‡ Accepts e-prescribing.6
Part D prescription drug benefitUsing a Blue Shield 65 Plus Choice Plan network pharmacy that offers standard cost-sharing, you pay:Deductible 0One-month(up to a 30-day) supplyThree-month(up to a 90-day) supply*Tier 1: Preferred Generic Drugs 8 copay 24 copayTier 2: Generic Drugs 18 copay 54 copay†Tier 3: Preferred Brand Drugs 47 copay 141 copay†Tier 4: Non-Preferred Brand Drugs 100 copay 300 copay†Tier 5: Injectable Drugs31% coinsurance31% coinsurance†Tier 6: Specialty Tier Drugs33% coinsuranceNot offeredIf you reside in a long-term care facility, you pay the same as at a standard retail cost-sharingpharmacy. You may get drugs from an out-of-network pharmacy at the same cost as anin-network standard retail cost-sharing pharmacy.For more information on the additional pharmacy-specific cost-sharing and the phases of thebenefit, please refer to the plan EOC.Coverage gap(coverage for outpatient prescription drugsafter the total yearly drug costs paid byboth you and Blue Shield reach 3,750,until your yearly out-of-pocket drug costsreach 5,000)Tier 1: Preferred Generic Drugs and Tier 2: GenericDrugs are covered at the copays describedabove. For Tiers 3-6, you pay 35% coinsurancefor brand-name drugs (plus a portion of thedispensing fee) and 44% coinsurance for genericdrugs until your costs total 5,000, which is theend of the coverage gap. Whether a drug isconsidered generic or brand can be determinedusing the plan formulary.Catastrophic CoverageAfter your yearly out-of-pocket drug costs (including drugs you bought through your retail pharmacyand through mail service) reach 5,000, you pay the greater of: 5% of the cost, or 3.35 copay for a generic drug (including brand drugs treated as generic) and an 8.35 copayfor all other drugsOur network of over 6,000 pharmacies# includes pharmacies that offer standard cost-sharingand pharmacies that offer preferred cost-sharing. You may go to either type of networkpharmacy for your covered prescription drugs. Your cost-sharing may be less at pharmacieswith preferred cost-sharing.# As of June 2017.7
Summary of Benefits – Blue Shield 65 Plus Choice Plan (HMO) – Los Angeles County (partial)/Orange CountyOptional supplemental dental HMO and PPO plansYour teeth are an important part of your overall health. Blue Shield 65 Plus Choice Plan offers dentalcoverage for many common dental procedures such as checkups, cleanings, gum care and more –all included as part of your health plan.Simply choose a network dentist who will provide and coordinate all your dental care.Key features: Comprehensive dental benefits includingdiagnostic, restorative and preventiveservices – with low copays Access to a network of general care dentists Virtually no claim forms Emergency dental coverage includedIn addition, if you’re looking for more comprehensive dental coverage, we offer two optionalsupplemental dental plans to Blue Shield 65 Plus Choice Plan members: a dental HMO planand a dental PPO plan.Which one would work best for you?Your goal: Keep costs down whilemaintaining coverageYour goal: More flexibility and choicein coverageBenefits of the optional supplementaldental HMO:Benefits of the optional supplementaldental PPO: Offers our lowest premium at 13.20 permonth with no deductibles Choose from nearly 38,000* general dentistsand specialists statewide for a monthlypremium of 34.90 Choose a dentist from our dental networkof more than 15,000* general dentistsstatewide8 See non-network dentists and specialists –including your current dentist Freedom to change your dentist wheneveryou want No referrals needed for specialist care inor out of the network Fixed copayments for basic and majorservices for easier budgeting 100% coverage for network diagnostic andpreventive services No waiting period for most services No claim forms if seeing a network dentist No annual dollar limit on general dentistry Three cleanings per year
Optional supplemental dental HMO and PPO plan benefits at a glanceHere is a summary of services and supplies covered by the optional supplemental dental HMOand PPO plans.This chart is only a summary. For a complete list of the benefits, exclusions and limitations, pleaserefer to the plan EOC.Optional supplementaldental planNetwork accessCalendar-year deductibleper member (notapplicable to diagnosticand preventive services)Calendar-year maximumper member†Waiting Periods –Major Services OnlyMonthly optionalsupplemental dentalplan premiumSummary list of servicescovered (ADA code)‡Diagnostic servicesComprehensive oralexam (D0150)Complete X-rays – onceevery 6 months (D0210)Choice PlanOptionalsupplementaldental HMOParticipatingdentists onlyParticipatingdentists onlyYou paynothingYou paynothingNoneNo waitingperiodOptionalsupplementaldental u pay 50 beforemajor services begin 1,500 for covered preventiveand comprehensive dental 1,000 forservices combined, no matter ifcoveredthe services are performed by aendodontic,participating general dentist orperiodontic anda dental specialist. Up to 1,000oral surgeryof this maximum amount may beservices whenused for covered preventive andperformed bycomprehensive dental servicesan in-networkperformed by non-participatingdental specialist.dentists in a calendar year. Youpay any amount above the 1,500calendar-year benefit maximum.No waitingSix-month waiting periodperiodfor major services onlyNone 13.20 34.90You payYou payYou payYou pay 16 copay 5 copay0%20% 5 copay 0 copay0%20%9
Summary of Benefits – Blue Shield 65 Plus Choice Plan (HMO) – Los Angeles County (partial)/Orange CountyOptional supplementaldental planNetwork accessSummary list of servicescovered (ADA code)‡Preventive careProphylaxis – adult(D1110)Restorative servicesOne surface compositeresin restoration –anterior (D2330)Crown (porcelain fusedto noble metal) (D2750)Periodontics Periodontal scaling &root planing/four ormore teethper quadrant (D4341)Endodontics Anterior root canaltherapy (D3310)Molar root canal therapy(D3330)Choice PlanOptionalsupplementaldental HMOOptionalsupplementaldental PPOParticipatingdentists onlyParticipatingdentists ou payYou payYou payYou pay 20 copay(1 cleaningevery 6 months) 5 copay(1 cleaningevery 6 months) 40 copay 11 copay20%30% 430 copay 275# copay50%50% 80 copay 45 copay50%50% 240 copay 195 copay50%50% 373 copay 335 copay50%50%0% for 320% for 3cleaningscleaningsper yearper year(1 every 4 months)* Dental providers in California are available through a contracted dental plan administrator. Networknumbers are as of June 2017† All services must be performed, prescribed or authorized by your network dentist. If you need tosee a specialist, you must get a referral from your primary dentist to receive covered specialistservices. Plan pays a maximum of 1,000 per calendar year for covered specialist services. Youare responsible for amounts above 1,000. If you are enrolled in the optional supplemental dentalPPO plan and you need to see a specialist, you may go directly to the specialist.‡ ADA codes are procedure codes established by the American Dental Association for efficientprocessing and reporting of dental claims.# You pay the copayment plus the cost of precious or semi-precious metals. Porcelain on molarcrowns is not a covered benefit. For the optional supplemental dental HMO plan, your copayment will be higher if these servicesare performed by a specialist.10
SilverSneakers FitnessExercise, education and social activities are very important to your health and well-being,which is why Blue Shield 65 Plus Choice Plan offers SilverSneakers at no additional cost!SilverSneakers helps you live the life you wantby giving you access to: Over 13,000 fitness locations* nationwidethat you can use anytime Exercise equipment and SilverSneakersclasses Social events and activities SilverSneakers FLEX classes including yoga,Latin dance and tai chiIf you’re new to fitness, that’s OK. Nearly half ofall SilverSneakers members had never been toa fitness location before joining the program.To find your closest SilverSneakers location andSilverSneakers FLEX classes, or get additionalinformation, visit silversneakers.com. You canuse more than one location at a time.* As of July 2017, silversneakers.com.At-home kits are offered for memberswho want to start working out athome or for those who can’t get toa fitness location due to injury, illnessor being homebound.11
Summary of Benefits – Blue Shield 65 Plus Choice Plan (HMO) – Los Angeles County (partial)/Orange CountyHow to enrollWhat to expect onceyou enrollApplying is easy. You havetwo options:Over the next few weeks,you will receive:1. Work with your broker or salesrepresentative to use our online plancomparison tool, and immediatelyenroll online.Acknowledgement letter: We will letyou know we received your completedenrollment form and that Medicare hasapproved your enrollment in our plan.2. Although enrolling online is faster andeasier, you can choose to fill out thepaper application in the enclosedbooklet instead. New member verification letter: We willwrite to you to verify that you understandthat you’ve been enrolled in our planand how the plan works.Here’s how: Tear out the application. Fill it out completely. Be sure to sign where indicated. Fax it to us at (877) 251-3660. You may alsomail it to the address listed at the top ofpage 1 of the application. Other health insurance survey: Pleasecomplete and return so we can tellMedicare whether you have otherinsurance in addition to our plan. Welcome kit: This kit gives you a fullexplanation of how to use your newplan. Be sure to read the MemberHandbook and the plan’s Evidenceof Coverage (EOC). Plan ID card: Present this card everytime you receive healthcare services orprescription drugs. We will also includea description of how to read the card. Health survey: Your answers can helpus provide you and your doctor withinformation that may better help youeffectively manage your health.The Member Handbook in your welcomekit will give you more details about what toexpect as a Blue Shield 65 Plus Choice Planplan member. We hope to welcome youto our plan!12
Blue Shield 65 Plus Choice Plan is available in OrangeCounty and select areas of Los Angeles County.Blue Shield 65 Plus Choice Plan memberscan select network physicians from thefollowing physician groups:*Alamitos IPAAllied Pacific of Cal IPAAppleCare Medical GroupBrookshire IPAFamily Care SpecialistsHoag Affiliated PhysiciansKorean American Medical GroupLakewood IPAMission Heritage Medical GroupMission Hospital Affiliated PhysiciansPioneer Provider NetworkPrimary Care Associates of CaliforniaSt. Joseph Heritage Medical GroupSt. Joseph Hospital Affiliated PhysiciansSt. Jude Affiliated PhysiciansSt. Jude Heritage Medical GroupSt. Mary IPALos AngelesOrange* List of network physician groups is as of August 2017. See the Blue Shield 65 Plus Choice Plan ProviderDirectory for more information about network physicians and facilities. This list is subject to change.13
Blue Shield has been dedicated to offering quality healthcare coverage andmember service since 1939 – an ongoing tradition you can trust.We hope this booklet made our health plan information easy to understand.It’s one of the ways we’re working to make your health plan selection simple.Need help?Contact Blue Shield at (800) 488-8000 [TTY: 711]Our plan Provider Directory is located on our website at blueshieldca.com/find-a-doctor.Our plan Pharmacy Directory is located on our website at blueshieldca.com/med pharmacy.To get the most complete and current information about which drugs are covered, you can visitour website at blueshieldca.com/med formulary.If you want to know more about the coverage and costs of Original Medicare, look in your current“Medicare & You” handbook. View it online at http://www.medicare.gov or get a copy by calling1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.Tivity Health, SilverSneakers and SilverSneakers FLEX are registered trademarks or trademarksof Tivity Health, Inc. and/or its subsidiaries and/or affiliates in the USA and/or other countries. 2017Tivity Health, Inc. All rights reserved.Blue Shield 65 Plus Choice Plan and NurseHelp 24/7 are service marks of Blue Shield of California.Blue Shield and the Shield symbol are registered trademarks of the BlueCross BlueShield Association,an association of independent Blue Cross and Blue Shield plans.ATTENTION: If you speak a language other than English, language assistance services, free of charge,are available to you. Call 1-800-776-4466 (TTY: 711).ATENCIÓN: Si no habla inglés, tiene a su disposición gratis el servicio de asistencia en idiomas. Llameal 1-800-776-4466 (TTY: 711).Blue Shield of California is an independent member of the Blue Shield AssociationBlue Shield of California is an HMO plan with a Medicare contract. Enrollment in Blue Shield ofCalifornia depends on contract renewal. This information is not a complete description of benefits.Contact the plan for more information. Limitations, copayments and restrictions may apply. Benefits,premiums and/or copayments/coinsurance may change on January 1 of each year. The Formulary,pharmacy network and/or provider network may change at any time. You will receive noticewhen necessary.MR15775-DS-CP (10/17)8 a.m. to 8 p.m., seven days a week, from October 1 through February 14,and 8 a.m. to 8 p.m., weekdays, from February 15 through September 30.
Los Angeles County (partial)/Orange County. Summary of Benefits - Blue Shield 65 Plus Choice Plan (HMO) - Los Angeles County (partial)/Orange County We all have the right to live a healthy, limitless life We're a California-based health plan that's been serving Californians since 1939. . plan-approved locations every 12 months .
