Northeastern PennsylvaniaCentral and Northeastern Pennsylvania

FREEDOM BLUE PPO

Summary of Benefits January 1, 2017 – December 31, 2017

Service Area Our service area includes the following counties in Pennsylvania: Adams, Berks, Bradford, Carbon, Centre, Clinton, Columbia, Cumberland, Dauphin, Franklin, Fulton, Juniata, Lackawanna, Lancaster, Lebanon, Lehigh, Luzerne, Lycoming, Mifflin, Monroe, Montour, Northampton, Northumberland, Perry, Pike, Schuylkill, Snyder, Sullivan, Susquehanna, Tioga, Union, Wayne, Wyoming, and York.

To join Freedom Blue PPO Basic, Freedom Blue PPO ValueRx, Freedom Blue PPO Standard, or Freedom Blue PPO Deluxe, you must be entitled to Medicare Part A, be enrolled in Medicare Part B, and live in our service area.

H3916_16_0474 Accepted

Freedom Blue PPO

This booklet gives you a summary of what we cover and what you pay. It doesn’t list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, call us and ask for the “Evidence of Coverage.”

This document is available in other formats such as Braille and large print.

How to Contact

CALL FREEDOM BLUE PPO

1-866-743-5478 (TTY/TDD 1-800-227-8210), 8:00 a.m.– 8:00 p.m., 7 days a week

How to Find a Provider or Pharmacy

Freedom Blue PPO Basic, Freedom Blue PPO ValueRx, Freedom Blue PPO Standard, and Freedom Blue PPO Deluxe have a network of doctors, hospitals, pharmacies, and other providers. If you use the providers that are not in our network, the plan may not pay for these services.

You can see our plan’s provider and pharmacy directory at www.highmarkblueshield.com/ medicare.

OR VISIT

www.highmarkblueshield.com/medicare

Or, call us and we will send you a copy of the provider and pharmacy directories.

You can see the complete plan formulary (list of Part D prescription drugs) and any restrictions on our website, client.formularynavigator.com/ clients/hm/default.html.

Or, call us and we will send you a copy of the formulary.

HIGHMARK HOUSE CALL PROGRAMOffers a free preventive health assessment, provided by a certified nurse practitioner, in the comfort of your own home.

More About Original Medicare

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 www.medicare.gov or get a copy by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.

Every Highmark Medicare Advantage Plan Includes:

SILVERSNEAKERS® GYM MEMBERSHIP Gives you access to over 13,000 participating facilities nationwide –with cardio and weight equipment, pools, saunas, and more.

ANNUAL WELLNESS VISIT Encourages you to talk with your doctor about your overall health and to create a personal prevention plan for the year.

HIGHMARK HOUSE CALL PROGRAM Offers a free preventive health assessment, provided by a certified nurse practitioner, in the comfort of your own home.

BLUES ON CALL Provides 24/7 access to a registered nurse who can help you understand a diagnosis, review your symptoms, and much more.

Freedom Blue PPO Freedom Blue PPO Basic Freedom Blue PPO ValueRx HE

ALTH

Premium1 $93.00 $75.00

Deductible $0 $0

Network Max Out Of Pocket $6,700 $6,700

Inpatient Hospital Stay $350/admit $275/day (days 1-5)/admit

PCP Office Visit PCP:$15 In -/ $30 Out-of-network Copay, Specialist: $35 In-/ $45 Out-of-network Copay

PCP: $15 In-/ $30 Out-of-network Copay, Specialist: $40 In-/ $50 Out-of-network Copay

Preventive/Screening Covered in Full (Office visit Copay may apply)

Emergency Room $75 Copay $75 Copay

Urgently Needed Care $50 $50

Lab & Diagnostic Tests Office/Lab: $0 Copay Outpatient: $20 Copay

Office/Lab:$0 Copay Outpatient: $20 Copay

X-Rays/Advanced Imaging $30 X-Ray/$150 Advanced Imaging $30 X-Ray/$200 Advanced Imaging

Routine Hearing Aids (2 hearing aids per year)

TruHearing Flyte 700:$699 Copay Per Aid; TruHearing Flyte 900: $999 Copay Per Aid

TruHearing Flyte 700: $699 Copay Per Aid; TruHearing Flyte 900: $999 Copay Per Aid

Routine Dental (per calendar year) Office Visit: $30 Copay X-Ray: $25 Copay

Office Visit: $30 Copay X-Ray: $25 Copay

Routine Vision (annually) $0 Copay for routine eye exam. Standard Eyeglass lenses and frames or contact lenses

are covered in full. A $100 benefit maximum applies to non-standard frames and a $100 benefit maximum for specialty contact lenses. $200 benefit maximum for post cataract eyewear.

Mental Health Services Inpatient: $350/admit Outpatient: $35 Copay

Inpatient:$275/day (days 1-5)/admit Outpatient: $40 Copay

Skilled Nursing Facility (days 1-100 per benefit period/admit)

$0/day (days 1-20); $164.50/day (days 21-100)

$0/day (days 1-20); $164.50/day (days 21-100)

Outpatient Rehab $35 Copay $40 Copay

Ambulance (per one-way trip) $125 Copay $200 Copay

Transportation (wheelchair van up-to 24 one-way trips) $10 Copay $10 Copay

Routine Podiatry $35 Copay (10 visits) $40 Copay (10 visits)

Durable Medical Equipment (including oxygen) 20% Coinsurance 20% Coinsurance

Wellness Programs SilverSneakers SilverSneakers

Part B Drugs 20% Coinsurance; 10% (Office/Ambulatory Infusion Center)

20% Coinsurance; 10% (Office/Ambulatory Infusion Center)

Freedom Blue PPO Standard Freedom Blue PPO Deluxe

$190.50 $293.50

$0 $0

$6,700 $6,700

$500/admit $250/admit

PCP: $10 In-/ $30 Out-of-network Copay, Specialist: $35 In-/ $45 Out-of-network Copay

PCP: $5 In-/ $30 Out-of-network Copay, Specialist: $30 In-/ $40 Out-of-network Copay

Covered in Full (Office visit Copay may apply)

$75 Copay $75 Copay

$50 $50

Office/Lab: $0 Copay Outpatient: $15 Copay

Office/Lab: $0 Copay Outpatient: $10 Copay

$20 X-Ray/$125 Advanced Imaging $10 X-Ray/$100 Advanced Imaging

TruHearing Flyte 700: $699 Copay Per Aid; TruHearing Flyte 900: $999 Copay Per Aid

TruHearing Flyte 700: $499 Copay Per Aid; TruHearing Flyte 900: $799 Copay Per Aid

Office Visit: $30 Copay X-Ray: $25 Copay

Office Visit: $20 Copay X-Ray: $20 Copay

$0 Copay for routine eye exam. Standard Eyeglass lenses and frames or contact lenses are covered in full. A $100 benefit maximum applies to non-standard frames and a $100 benefit

maximum for specialty contact lenses. $200 benefit maximum for post cataract eyewear.

Inpatient: $500/admit Outpatient: $35 Copay

Inpatient: $250/admit Outpatient: $30 Copay

$0/day (days 1-20); $164.50/day (days 21-100)

$0/day (days 1-20); $164.50/day (days 21-100)

$35 Copay $30 Copay

$175 Copay $150 Copay

$10 Copay $10 Copay

$35 Copay (10 visits) $30 Copay (10 visits)

20% Coinsurance 20% Coinsurance

SilverSneakers SilverSneakers

20% Coinsurance; 10% (Office/Ambulatory Infusion Center)

20% Coinsurance; 10% (Office/Ambulatory Infusion Center)

Freedom Blue PPO ValueRx

DRUG

You will pay the following until your total yearly drug costs reach $3,700.Total yearly drug costs are the total drug costs paid by both you and your Part D plan.

Initial Coverage

Standard Retail Cost-Sharing

Tier 30 Day Supply 90 Day Supply

Tier 1 (Preferred Generic) $3 Copay $9 CopayTier 2 (Generic) $20 Copay $60 CopayTier 3 (Preferred Brand) $47 Copay $141 CopayTier 4 (Non-Preferred Brand) 45% of the cost 45% of the costTier 5 (Specialty Tier) 33% of the cost 33% of the cost

Standard Mail Cost-Sharing

Tier 30 Day Supply 90 Day SupplyTier 1 (Preferred Generic) Not Offered $7.50 CopayTier 2 (Generic) Not Offered $50 CopayTier 3 (Preferred Brand) Not Offered $117.50 CopayTier 4 (Non-Preferred Brand) Not Offered 45% of the costTier 5 (Specialty Tier) 33% of the cost Not Offered

Coverage Gap

The coverage gap begins after the yearly drug cost(including what our plan has paid and what you have paid) reaches $3,700.

After you enter the coverage gap, you pay 40% of the plan’s cost for covered brand-name drugsand 51% of the plan’s cost for covered generic drugs until your costs total $4,950,which is the end of the coverage gap. Not everyone will enter the coverage gap.

Generics (51% coinsurance) Brand (40% coinsurance including 50% discount)

Catastrophic Coverage

Catastrophic Coverage Description: After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reaches $4,950, you pay the greater of: 5% of the cost, or $3.30 Copay for generics

and a $8.25 Copayment for all other drugs.

Greater of: 5% or $3.30 Generic/Preferred Multi Source or $8.25 for all others

Freedom Blue PPO

Freedom Blue PPO Basic

DRUG

Initial Coverage Not Covered

Coverage Gap Not Covered

Catastrophic Coverage Not Covered

If you reside in a long-term care facility, you pay the same as at a retail pharmacy.

Freedom Blue PPO ValueRx

DRUG

You will pay the following until your total yearly drug costs reach $3,700. Total yearly drug costs are the total drug costs paid by both you and your Part D plan.

Initial Coverage

Standard Retail Cost-Sharing

Tier 30 Day Supply 90 Day Supply

Tier 1 (Preferred Generic) $3 Copay $9 Copay Tier 2 (Generic) $20 Copay $60 Copay Tier 3 (Preferred Brand) $47 Copay $141 Copay Tier 4 (Non-Preferred Brand) 45% of the cost 45% of the cost Tier 5 (Specialty Tier) 33% of the cost 33% of the cost

Standard Mail Cost-Sharing

Tier 30 Day Supply 90 Day Supply Tier 1 (Preferred Generic) Not Offered $7.50 Copay Tier 2 (Generic) Not Offered $50 Copay Tier 3 (Preferred Brand) Not Offered $117.50 Copay Tier 4 (Non-Preferred Brand) Not Offered 45% of the cost Tier 5 (Specialty Tier) 33% of the cost Not Offered

Coverage Gap

The coverage gap begins after the yearly drug cost (including what our plan has paid and what you have paid) reaches $3,700.

After you enter the coverage gap, you pay 40% of the plan’s cost for covered brand-name drugs and 51% of the plan’s cost for covered generic drugs until your costs total $4,950, which is the end of the coverage gap. Not everyone will enter the coverage gap.

Generics (51% coinsurance) Brand (40% coinsurance including 50% discount)

Catastrophic Coverage

Catastrophic Coverage Description: After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reaches $4,950, you pay the greater of: 5% of the cost, or $3.30 Copay for generics

and a $8.25 Copayment for all other drugs.

Greater of: 5% or $3.30 Generic/Preferred Multi Source or $8.25 for all others

If you reside in a long-term care facility, you pay the same as at a retail pharmacy.

Additional Plan Benefits Continued on Next Page

Freedom Blue PPO Deluxe

DRUG

You will pay the following until your total yearly drug costs reach $3,700.Total yearly drug costs are the total drug costs paid by both you and your Part D plan.

Initial Coverage

Standard Retail Cost-Sharing

Tier 30 Day Supply 90 Day Supply

Tier 1 (Preferred Generic) $3 Copay $9 CopayTier 2 (Generic) $20 Copay $60 CopayTier 3 (Preferred Brand) $47 Copay $141 CopayTier 4 (Non-Preferred Brand) 45% of the cost 45% of the costTier 5 (Specialty Tier) 33% of the cost 33% of the cost

Standard Mail Cost-Sharing

Tier 30 Day Supply 90 Day SupplyTier 1 (Preferred Generic) Not Offered $7.50 CopayTier 2 (Generic) Not Offered $50 CopayTier 3 (Preferred Brand) Not Offered $117.50 CopayTier 4 (Non-Preferred Brand) Not Offered 45% of the costTier 5 (Specialty Tier) 33% of the cost Not Offered

Coverage Gap

The coverage gap begins after the yearly drug cost(including what our plan has paid and what you have paid) reaches $3,700.

After you enter the coverage gap, you pay 40% of the plan’s cost for covered brand-name drugsand 51% of the plan’s cost for covered generic drugs until your costs total $4,950,which is the end of the coverage gap. Not everyone will enter the coverage gap.

See Table Below

Catastrophic Coverage

Catastrophic Coverage Description: After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reaches $4,950, you pay the greater of: 5% of the cost, or $3.30 Copay for generics

and a $8.25 Copayment for all other drugs.

Greater of: 5% or $3.30 Generic/Preferred Multi Source or $8.25 for all others

Freedom Blue PPO

Freedom Blue PPO Standard

DRUG

You will pay the following until your total yearly drug costs reach $3,700. Total yearly drug costs are the total drug costs paid by both you and your Part D plan.

Initial Coverage

Standard Retail Cost-Sharing

Tier 30 Day Supply 90 Day Supply

Tier 1 (Preferred Generic) $3 Copay $9 Copay Tier 2 (Generic) $20 Copay $60 Copay Tier 3 (Preferred Brand) $47 Copay $141 Copay Tier 4 (Non-Preferred Brand) 45% of the cost 45% of the cost Tier 5 (Specialty Tier) 33% of the cost 33% of the cost

Standard Mail Cost-Sharing

Tier 30 Day Supply 90 Day Supply Tier 1 (Preferred Generic) Not Offered $7.50 Copay Tier 2 (Generic) Not Offered $50 Copay Tier 3 (Preferred Brand) Not Offered $117.50 Copay Tier 4 (Non-Preferred Brand) Not Offered 45% of the cost Tier 5 (Specialty Tier) 33% of the cost Not Offered

Coverage Gap

The coverage gap begins after the yearly drug cost (including what our plan has paid and what you have paid) reaches $3,700.

After you enter the coverage gap, you pay 40% of the plan’s cost for covered brand-name drugs and 51% of the plan’s cost for covered generic drugs until your costs total $4,950, which is the end of the coverage gap. Not everyone will enter the coverage gap.

Generics (51% coinsurance) Brand (40% coinsurance including 50% discount)

Catastrophic Coverage

Catastrophic Coverage Description: After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reaches $4,950, you pay the greater of: 5% of the cost, or $3.30 Copay for generics

and a $8.25 Copayment for all other drugs.

Greater of: 5% or $3.30 Generic/Preferred Multi Source or $8.25 for all others

If you reside in a long-term care facility, you pay the same as at a retail pharmacy.

Freedom Blue PPO Deluxe

DRUG

You will pay the following until your total yearly drug costs reach $3,700. Total yearly drug costs are the total drug costs paid by both you and your Part D plan.

Initial Coverage

Standard Retail Cost-Sharing

Tier 30 Day Supply 90 Day Supply

Tier 1 (Preferred Generic) $3 Copay $9 Copay Tier 2 (Generic) $20 Copay $60 Copay Tier 3 (Preferred Brand) $47 Copay $141 Copay Tier 4 (Non-Preferred Brand) 45% of the cost 45% of the cost Tier 5 (Specialty Tier) 33% of the cost 33% of the cost

Standard Mail Cost-Sharing

Tier 30 Day Supply 90 Day Supply Tier 1 (Preferred Generic) Not Offered $7.50 Copay Tier 2 (Generic) Not Offered $50 Copay Tier 3 (Preferred Brand) Not Offered $117.50 Copay Tier 4 (Non-Preferred Brand) Not Offered 45% of the cost Tier 5 (Specialty Tier) 33% of the cost Not Offered

Coverage Gap

The coverage gap begins after the yearly drug cost (including what our plan has paid and what you have paid) reaches $3,700.

After you enter the coverage gap, you pay 40% of the plan’s cost for covered brand-name drugs and 51% of the plan’s cost for covered generic drugs until your costs total $4,950, which is the end of the coverage gap. Not everyone will enter the coverage gap.

See Table Below

Catastrophic Coverage

Catastrophic Coverage Description: After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reaches $4,950, you pay the greater of: 5% of the cost, or $3.30 Copay for generics

and a $8.25 Copayment for all other drugs.

Greater of: 5% or $3.30 Generic/Preferred Multi Source or $8.25 for all others

FREEDOM BLUE PPO DELUXE COVERAGE GAP TABLE

STANDARD NETWORK

Standard Retail Cost Sharing

Tier Drugs Covered One-month supply Three-month supply

Tier 1 (Preferred Generic) All $3 Copay $9 Copay

Tier 2 (Generic) All $20 Copay $60 Copay

STANDARD NETWORK

Standard Mail Order Cost Sharing

Tier Drugs Covered One-month supply Three-month supply

Tier 1 (Preferred Generic) All Not Offered $7.50 Copay

Tier 2 (Generic) All Not Offered $50 Copay

If you reside in a long-term care facility, you pay the same as at a retail pharmacy.

1You must continue to pay your Medicare Part B premium. 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 co-payments/co-insurance may change on January 1 of each year. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.

Highmark Senior Health Company is a PPO plan with a Medicare contract. Enrollment in Highmark Senior Health Company depends on contract renewal. Highmark Blue Shield and Highmark Senior Health Company are independent licensees of the Blue Cross and Blue Shield Association.

Out-of-network/non-contracted providers are under no obligation to treat Freedom Blue PPO members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.

TruHearing is a registered trademark of TruHearing, Inc.

SilverSneakers is a registered mark of Healthways, Inc. Healthways, Inc., is a separate company that administers the SilverSneakers program.

Discrimination is Against the Law

The Plan complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Plan does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Plan:

• Provides free aids and services to people with disabilities to communicate effectively with us, such as:

– Qualified sign language interpreters

– Written information in other formats (large print, audio, accessible electronic formats, other formats)

• Provides free language services to people whose primary language is not English, such as:

– Qualified interpreters

– Information written in other languages

If you need these services, contact the Civil Rights Coordinator.

If you believe that the Plan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

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