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Dental ServicesVision ServicesBlueMedicare Classic (HMO)Bay, Brevard, Charlotte, Collier,Escambia, Lake, Lee, Manatee, Marion,Martin, Okaloosa, Santa Rosa, Sarasota,St. Johns, St. Lucie and SumterH1035-019BlueMedicare Classic Plus (HMO)Bay, Escambia, Okaloosa andSanta RosaH1035-047 Member is responsible for any amountafter the benefit allowance has beenapplied. Subject to benefit maximum. Member is responsible for any amountafter the benefit allowance has beenapplied. Subject to benefit maximum.Medicare-Covered DentalServices 40 copay for non-routine dental careMedicare-Covered DentalServices 35 copay for non-routine dental careAdditional Dental Services 0 copay for covered preventive dentalservicesAdditional Dental Services 0 copay for covered preventive dentalservices 0 copay for covered comprehensivedental services 0 copay for covered comprehensivedental servicesMedicare-Covered Vision Services 40 copay for physician services todiagnose and treat eye diseases andconditions* 0 copay for glaucoma screening(once per year for members at high riskof glaucoma) 0 copay for one diabetic retinal examper year 0 copay for one pair of eyeglasses orcontact lenses after each cataractsurgeryMedicare-Covered Vision Services 35 copay for physician services todiagnose and treat eye diseases andconditions* 0 copay for glaucoma screening(once per year for members at highrisk of glaucoma) 0 copay for one diabetic retinal examper year 0 copay for one pair of eyeglasses orcontact lenses after each cataractsurgeryAdditional Vision ServicesAdditional Vision Services 0 copay for an annual routine eyeexamination 100 maximum allowance per yeartowards the purchase of lenses, framesor contact lenses Member responsible for costsexceeding the annual maximum planbenefit allowance 0 copay for an annual routine eyeexamination 200 maximum allowance per yeartowards the purchase of lenses,frames or contact lenses Member responsible for costsexceeding the annual maximum planbenefit allowance7

BlueMedicare Classic (HMO)Bay, Brevard, Charlotte, Collier,Escambia, Lake, Lee, Manatee, Marion,Martin, Okaloosa, Santa Rosa, Sarasota,St. Johns, St. Lucie and SumterH1035-019BlueMedicare Classic Plus (HMO)Bay, Escambia, Okaloosa andSanta RosaH1035-047Inpatient Mental Health Services 300 copay per day, days 1-5 0 copay per day, days 6-90 190-day lifetime benefit maximum in apsychiatric hospitalInpatient Mental Health Services 300 copay per day, days 1-5 0 copay per day, days 6-90 190-day lifetime benefit maximum in apsychiatric hospitalOutpatient Mental Health Services 20 copayOutpatient Mental Health Services 20 copay 0 copay per day, days 1-20 160 copay per day, days 21-100Our plan covers up to 100 days in a SNFper benefit period. 0 copay per day, days 1-20 160 copay per day, days 21-100Our plan covers up to 100 days in a SNFper benefit period. 35 copay per visit 35 copay per visitAmbulance 385 copay for each Medicare-coveredtrip (one-way) 385 copay for each Medicare-coveredtrip (one-way)Transportation Not covered Not Covered 5 copay for allergy injections 5 copay for allergy injections 20% of the Medicare-allowed amountfor chemotherapy drugs and otherMedicare Part B-covered drugs 20% of the Medicare-allowed amountfor chemotherapy drugs and otherMedicare Part B-covered drugs Mental HealthServices Skilled NursingFacility (SNF) PhysicalTherapy *Medicare Part BDrugsPart D Prescription Drug BenefitsDeductible Stage 0 per year for Part D prescription drugs8

Initial Coverage StageYou begin in this stage when you fill your first prescription of the year. During this stage, the plan pays itsshare of the cost of your drugs and you pay your share of the cost.During the InitialCoverage Stage:BlueMedicare Classic (HMO)Bay, Brevard, Charlotte, Collier,Escambia, Lake, Lee, Manatee,Marion, Martin, Okaloosa, SantaRosa, Sarasota, St. Johns, St. Lucieand SumterH1035-019BlueMedicare Classic Plus (HMO)Bay, Escambia, Okaloosa andSanta RosaH1035-047 You remain in this stage untilyour total yearly drug costs (totaldrug costs paid by you and anyPart D plan) reach 4,430. Youmay get your drugs at networkretail pharmacies and mail orderpharmacies. You remain in this stage until yourtotal yearly drug costs (totaldrug costs paid by you and anyPart D plan) reach 4,430. Youmay get your drugs at networkretail pharmacies and mail orderpharmacies.BlueMedicare Classic (HMO)Bay, Brevard, Charlotte, Collier,Escambia, Lake, Lee, Manatee, Marion,Martin, Okaloosa, Santa Rosa, Sarasota,St. Johns, St. Lucie and SumterH1035-019BlueMedicare Classic Plus (HMO)Bay, Escambia, Okaloosa andSanta daysupply)(31-daysupply)(31-daysupply) 10 copay 0 copay 0 copay 10 copay 0 copay 10 copay 15 copay 30 copay 10 copay 15 copay 30 copayTier 3 - PreferredBrand 40 copay 35 copay forSelect Insulins 47 copay 35 copay forSelect Insulins 120 copay 105 copayfor SelectInsulins 40 copay 35 copay forSelect Insulins 47 copay 35 copay forSelect Insulins 120 copay 105 copay forSelect InsulinsTier 4 - NonPreferred Drug 93 copay 35 copay forSelect Insulins 100 copay 35 copay forSelect Insulins 279 copay 105 copayfor SelectInsulins 93 copay 35 copay forSelect Insulins 100 copay 35 copay forSelect Insulins 279 copay 105 copay forSelect InsulinsTier 5 - SpecialtyTier33% of thecost33% of thecostN/A33% of thecost33% of thecostN/ATier 6 - Select CareDrugs 0 copay 0 copay 0 copay 0 copay 0 copay 0 -daysupply)(31-daysupply)Tier 1 - PreferredGeneric 0 copayTier 2 - Generic9MailOrder(90-daysupply)

Coverage Gap StageMost Medicare drug plans have a coverage gap (also called the "donut hole"). This means that there's atemporary change in what you will pay for your drugs.BlueMedicare Classic (HMO)Bay, Brevard, Charlotte, Collier,Escambia, Lake, Lee, Manatee,Marion, Martin, Okaloosa, SantaRosa, Sarasota, St. Johns, St. Lucieand SumterH1035-019During the CoverageGap Stage: The Coverage Gap Stage beginsafter the total yearly drug cost (totaldrug costs paid by you and any PartD plan) reaches 4,430. You stay inthis stage until your year-to-date“out-of-pocket” costs reach a total of 7,050. You pay the same copays thatyou paid in the Initial CoverageStage for drugs in Tier 1(Preferred Generic) and Tier 6(Select Care Drugs) – or 25% ofthe cost, whichever is lower For generic drugs in all othertiers, you pay 25% of the cost For brand-name drugs, you pay25% of the cost (plus a portion of thedispensing fee) BlueMedicare Classic offersadditional gap coverage for SelectInsulins. During the Coverage Gapstage, your out-of-pocket cost forSelect Insulins will be 35.BlueMedicare Classic Plus (HMO)Bay, Escambia, Okaloosa andSanta RosaH1035-047 The Coverage Gap Stage beginsafter the total yearly drug cost(total drug costs paid by you andany Part D plan) reaches 4,430.You stay in this stage until youryear-to-date “out-of-pocket” costsreach a total of 7,050. You pay the same copays thatyou paid in the Initial CoverageStage for drugs in Tier 1(Preferred Generic) and Tier 6(Select Care Drugs) – or 25% ofthe cost, whichever is lower For generic drugs in all othertiers, you pay 25% of the cost For brand-name drugs, you pay 25% of the cost (plus a portion ofthe dispensing fee) BlueMedicare Classic Plus offersadditional gap coverage forSelect Insulins. During theCoverage Gap stage, your outof-pocket cost for Select Insulinswill be 35.Catastrophic Coverage StageAfter your yearly out-of-pocket drug costs reach 7,050, you pay the greater of: 3.95 copay for generic drugs in all tiers (including brand drugs treated as generic) and a 9.85 copayfor all other drugs in all tiers, or 5% of the cost.Additional Drug CoveragePlease call us or see the plan’s “Evidence of Coverage” on our website(www.floridablue.com/medicare) for complete information about your costs for covered drugs. If yourequest and the plan approves a formulary exception, you will pay Tier 4 (Non-Preferred Drug) costsharing. Your cost-sharing may be different if you use a Long-Term Care (LTC) pharmacy, a home infusionpharmacy, or an out-of-network pharmacy, or if you purchase a long-term supply (up to 90 days) of adrug. 10

Additional BenefitsAt Home CareCaregiverSupportfor MemberDiabeticSuppliesBlueMedicare Classic (HMO)Bay, Brevard, Charlotte, Collier,Escambia, Lake, Lee, Manatee, Marion,Martin, Okaloosa, Santa Rosa, Sarasota,St. Johns, St. Lucie and SumterH1035-019BlueMedicare Classic Plus (HMO)Bay, Escambia, Okaloosa andSanta RosaH1035-047We offer this benefit through ourpartnership with our participating providerwho connects college students to olderadults who require assistance withtransportation, companionship, householdchores, use of electronic devices, andexercise and activity.We offer this benefit through ourpartnership with our participating providerwho connects college students to olderadults who require assistance withtransportation, companionship, householdchores, use of electronic devices, andexercise and activity.Benefits include the following:Benefits include the following:At Home Care, 60 hours per year.At Home Care, 60 hours per year. Services include support with Activitiesof Daily Living (ADL) and InstrumentalActivities of Daily Living (IADL). Services include support with Activitiesof Daily Living (ADL) and InstrumentalActivities of Daily Living (IADL).Provides coverage for coaching,education and support services such ascounseling and training courses forcaregivers of enrollees. Benefits include: A web-based tool that containseducational content covering topics onhealth, wealth, senior living, in-homecare and lifestyle Access for caregivers and familymembers to post updates and videos;tools to manage documents, stayorganized and on top of upcomingtasks and appointments. Search tools(i.e., senior housing search and inhome care search)Provides coverage for coaching,education and support services such ascounseling and training courses forcaregivers of enrollees. Benefits include: A web-based tool that containseducational content covering topics onhealth, wealth, senior living, in-homecare and lifestyle Access for caregivers and familymembers to post updates and videos;tools to manage documents, stayorganized and on top of upcomingtasks and appointments. Search tools(i.e., senior housing search and inhome care search)See the “Evidence of Coverage” for benefitdetails.See the “Evidence of Coverage” forbenefit details. 0 copay at your network retail or mailorder pharmacy for Diabetic Suppliessuch as: Lifescan (One Touch ) GlucoseMetersLancetsTest Strips11 0 copay at your network retail or mailorder pharmacy for Diabetic Suppliessuch as: Lifescan (One Touch )Glucose MetersLancetsTest Strips

BlueMedicare Classic (HMO)Bay, Brevard, Charlotte, Collier,Escambia, Lake, Lee, Manatee, Marion,Martin, Okaloosa, Santa Rosa, Sarasota,St. Johns, St. Lucie and SumterH1035-019BlueMedicare Classic Plus (HMO)Bay, Escambia, Okaloosa andSanta RosaH1035-047Important Note: Insulin, insulinsyringes and needles for selfadministration in the home areobtained from a retail or mail orderpharmacy and are covered under yourMedicare Part D pharmacybenefit. Applicable Part D co-pays apply.Important Note: Insulin, insulinsyringes and needles for selfadministration in the home areobtained from a retail or mail orderpharmacy and are covered under yourMedicare Part D pharmacybenefit. Applicable Part D co-pays apply.MedicareDiabetesPreventionProgram 0 copay for Medicare-coveredservices 0 copay for Medicare-coveredservicesPodiatry 30 copay for each Medicare-coveredpodiatry visit 30 copay for each Medicare-coveredpodiatry serviceChiropractic 20 copay for each Medicare-coveredchiropractic visit 20 copay for each Medicare-coveredchiropractic serviceMedicalEquipment andSupplies 20% of the Medicare-allowed amountfor all plan approved, Medicarecovered motorized wheelchairs andelectric scooters 20% of the Medicare-allowed amountfor all plan approved, Medicarecovered motorized wheelchairs andelectric scooters 0% of the Medicare-allowed amount forall other plan approved, Medicarecovered durable medical equipment 0% of the Medicare-allowed amountfor all other plan approved, Medicarecovered durable medical equipment 35 copay per visit 35 copay per visit 45 copay for Urgently NeededServices 0 copay for Primary Care Services 35 copay for OccupationalTherapy/Physical Therapy/SpeechTherapy at a freestanding location 35 copay OccupationalTherapy/Physical Therapy/SpeechTherapy at an outpatient hospital 40 copay for Dermatology Services 20 copay for individual sessions foroutpatient Mental Health Specialty 40 copay for Urgently NeededServices 0 copay for Primary Care Services 35 copay for OccupationalTherapy/Physical Therapy/SpeechTherapy at a freestanding location 35 copay OccupationalTherapy/Physical Therapy/SpeechTherapy at an outpatient hospital 35 copay for Dermatology Services 20 copay for individual sessions foroutpatient Mental Health SpecialtyOutpatientOccupationaland SpeechTherapy *Telehealth *12

BlueMedicare Classic (HMO)Bay, Brevard, Charlotte, Collier,Escambia, Lake, Lee, Manatee, Marion,Martin, Okaloosa, Santa Rosa, Sarasota,St. Johns, St. Lucie and SumterH1035-019BlueMedicare Classic Plus (HMO)Bay, Escambia, Okaloosa andSanta RosaH1035-047Services 20 copay for individual sessions foroutpatient Psychiatry SpecialtyServices 20 copay for Opioid TreatmentProgram Services 20 copay for individual sessions foroutpatient Substance Abuse SpecialtyServices 0 copay for Diabetes SelfManagement Training 0 copay for Dietician ServicesServices 20 copay for individual sessions foroutpatient Psychiatry SpecialtyServices 20 copay for Opioid TreatmentProgram Services 20 copay for individual sessions foroutpatient Substance Abuse SpecialtyServices 0 copay for Diabetes SelfManagement Training 0 copay for Dietician ServicesYou Get More with BlueMedicareBlueMedicare Classic (HMO)Bay, Brevard, Charlotte, Collier,Escambia, Lake, Lee, Manatee,Marion, Martin, Okaloosa, SantaRosa, Sarasota, St. Johns, St.Lucie and SumterH1035-019Health EducationOver-the-CounterItems meQuilibrium’s digitalcoaching platform deliversclinically validated and highlypersonalized resiliencesolutions to help peopleimprove their ability tomanage stress andsuccessfully cope with life’schallenges. To get started goto FloridaBlue.com/Medicarelog in, click on My Health andselect HealthyBlue Rewards.Not Covered13BlueMedicare Classic Plus (HMO)Bay, Escambia, Okaloosa andSanta RosaH1035-047 meQuilibrium’s digitalcoaching platform deliversclinically validated andhighly personalizedresilience solutions to helppeople improve their abilityto manage stress andsuccessfully cope with life’schallenges. To get startedgo to FloridaBlue.com/Medicarelog in, click on My Health andselect HealthyBlue Rewards. 75 quarterly allowance for thepurchase of non-prescriptionitems such as vitamins andaspirin Any balance not used for aquarter will not carry over to thenext quarter

HealthyBlue Rewards Your BlueMedicare planrewards you for taking care ofyour health. Redeem gift cardrewards for completing andreporting preventive care andscreenings. Your BlueMedicare planrewards you for taking careof your health. Redeem giftcard rewards for completingand reporting preventivecare and screenings.SilverSneakers Fitness Program Gym membership andclasses available at fitnesslocations across the country,including national chains andlocal gyms Gym membership andclasses available at fitnesslocations across thecountry, including nationalchains and local gyms Access to exerciseequipment and otheramenities, classes for alllevels and abilities, socialevents, and more Access to exerciseequipment and otheramenities, classes for alllevels and abilities, socialevents, and moreDisclaimersFlorida Blue Medicare is an HMO plan with a Medicare contract. Enrollment in Florida Blue Medicaredepends on contract renewal.If you have any questions, please contact our Member Services number at 1-800-926-6565. (TTY usersshould call 1-800-955-8770.) Our hours are 8:00 a.m. to 8:00 p.m. local time, seven days a week, fromOctober 1 through March 31, except for Thanksgiving and Christmas. From April 1 through September 30,our hours are 8:00 a.m. to 8:00 p.m. local time, Monday through Friday, except for major holidays.HMO coverage is offered by Florida Blue Medicare, Inc., dba Florida Blue Medicare, an IndependentLicensee of the Blue Cross and Blue Shield Association.Plans may offer supplemental benefits in addition to Part C benefits and Part D benefits. 2021 Blue Cross and Blue Shield of Florida, Inc., DBA Florida Blue. All rights reserved.14

Section 1557 Notification: Discrimination is Against the LawWe comply with applicable Federal civil rights laws and do not discriminate on the basis of race, color,national origin, age, disability, or sex. We do not exclude people or treat them differently because of race,color, national origin, age, disability, or sex.We provide: Free aids and services to people with disabilities to communicate effectively with us, such as:o Qualified sign language interpreterso Written information in other formats (large print, audio, accessible electronic formats, otherformats) Free language services to people whose primary language is not English, such as:o Qualified interpreterso Information written in other languagesIf you need these services, contact: Health and vision coverage: 1-800-352-2583 Dental, life, and disability coverage: 1-888-223-4892 Federal Employee Program: 1-800-333-2227If you believe that we have failed to provide these services or discriminate on the basis of race, color,national origin, disability, age, sex, gender identity or sexual orientation, you can file a grievance with:Dental, life, and disability coverage:Civil Rights Coordinator17500 Chenal ParkwayLittle Rock, AR 722231-800-260-03311-800-955-8770 (TTY)civilrightscoordinator@fclif

Medicare Advantage Plans with Part D Prescription Drug Coverage . BlueMedicare Classic (HMO) H1035-019 . BlueMedicare Classic Plus (HMO) H1035-047 . . If you want to know more about the coverage and costs of Original Medicare, look in your current 2022 " Medicare & You" handbook. View it online at . www.medicare.gov.