Member Kit MEDICARE + YOU

Member Kit MEDICARE + YOUMember Kit
MEDICARE + YOU
INSTRUCTIONS ................................................................................................................................... 5
ONLINE RESOURCES .......................................................................................................................... 6
Outlines important links on our website and how to find them
PLAN SELECTION FORM .................................................................................................................... 7
Use this form to transfer from your existing Premera Blue Cross Medicare Advantage plan to a new one that better meets your needs
SUPPLEMENTAL BENEFITS GUIDE ..................................................................................................11
A snapshot of some of the supplemental benefits our plans offer
BENEFIT HIGHLIGHTS .......................................................................................................................17
A snapshot of our most popular plans and how they compare
SUMMARY OF BENEFITS...................................................................................................................29
A comprehensive overview of all Premera Medicare Advantage plan rates, cost shares, and benefits
CVS CAREMARK MAIL ORDER PHARMACY FAQ AND FORM.........................................................65
Have prescriptions mailed directly to your home by ordering them online or filling out the form included here
MEDICARE STAR RATINGS ...............................................................................................................69
Star Ratings are assessed annually to help you compare our plans’ performance to other plans
Introduction
Dear Member,
Supporting your whole-body health and well-being is our focus. And you deserve peace of mind about your Medicare Advantage (HMO) plan coverage. This kit includes everything you need to understand any changes or enhancements made to your current plan.
Because we believe your good health is everything, your plan covers the following head-to-toe benefits to help support the whole you:
• Rite Aid is now a preferred pharmacy along with CVS Pharmacy and Bartell Drugs
• $0 co-pay for a 90-day supply of Tier 1 preferred generics through our mail-order pharmacy*
• 5% copay on diabetic supplies
• Lower copays for PCP, specialist, and telehealth** visits
• Embedded preventive and NEW comprehensive dental services
• Enhanced coverage for chiropractic visits and NEW acupuncture coverage
• Routine hearing benefits with a $1,000 per ear per year hearing aid allowance through Hearing Care Solutions
• Routine vision benefits with up to a $300 annual eyewear allowance
• Up to $50 credit per quarter for over-the-counter supplies, shipped to your home
• No-cost, live, daily workouts on Facebook Live and YouTube through Silver&Fit®
• Convenient in-home testing kits for cancer screening, diabetes management, and other chronic disease management for eligible members
• Healthy Rewards program for eligible members who can earn rewards for maintaining their health by getting recommended preventive screenings, chronic disease management, participating in a fitness class, and more
continued on next page
You can also attend a virtual Member Information Meeting to learn about any changes to your plan firsthand from your local Premera Medicare Specialist. They’ll answer any questions you have and help ensure you’re taking advantage of all the perks available to you as part of your membership. Go to premera.com/member-meeting or call 888-850-8526 (TTY: 711) to find a meeting and RSVP***.
We appreciate your continued membership.
Sincerely,
Vice President and General Manager, Senior Markets
*Not included on the Alpine HMO plan. **When offered through your provider. ***Reservations are encouraged, but not required.
On behalf of Premera Blue Cross, The Silver&Fit® program is provided by American Specialty Health Fitness, Inc., a subsidiary of American Specialty Health Incorporated (ASH). Silver&Fit is a federally registered trademark of ASH and used with permission herein. Other names may be trademarks of their respective owners. Kits are subject to change.
On behalf of Premera Blue Cross, CVS Health, its subsidiaries and affiliates, including Over The Counter Health Solutions, is an independent provider of pharmacy benefit management services.
On behalf of Premera Blue Cross, Hearing Care Solutions is an independent company that provides the hearing aid benefit.
For accommodations of persons with special needs at meetings call <888-868-7767> (TTY: 711).
Enrollment Instructions
If you’re happy with the plan you’re on, you don’t have to do anything!
However, if your needs have changed, this kit includes the other plans we offer that may be a better fit. To transfer your membership to a different Premera Blue Cross Medicare Advantage plan:
Print, fill out, and mail the form on pages 7 through 10 to: Premera Blue Cross PO Box 262548 Plano, TX 75026
Call us at 888-868-7767 (TTY/TDD: 711) for help in choosing the best option. Customer Service representatives are ready to assist you in this paperless enrollment process. Our hours of operation are: October 1 – March 31: 8 a.m. – 8 p.m., 7 days a week April 1 – September 30: 8 a.m. – 8 p.m., Monday – Friday
Connect with a local Premera Medicare specialist Our Medicare specialists can answer all of your questions regarding our plans and help you enroll. You can:
• Visit premera.com/member-meeting to find a member meeting and RSVP.
• Or contact the specialist listed who serves your county.
Kirsten Keneipp 425-367-8054 [email protected]
Kitsap San Juan Skagit Snohomish Whatcom
Lesley Quick 509-280-0181 [email protected]
Spokane Stevens Walla Walla
Premera Blue Cross is an HMO plan with a Medicare contract. Enrollment in Premera Blue Cross depends on contract renewal.
Premera Blue cross in an HMO plan with Medicare conract. Enrollment in Premera Blue Cross
depends on contract renewal. Premera is an Independent Licensee of the Blue Cross Blue Shield
Association.
Online resources
The Premera Blue Cross Medicare Advantage (HMO) website contains many resources to help you use your plan. Please see below for commonly requested items available free on our website, premera.com/ma.
Find a doctor, dentist or hospital To find a medical provider or dental provider in your area, go to premera.com/ma and click on Find a doctor.
Find a pharmacy To find a pharmacy in your area, go to premera.com/ma and click on Find a pharmacy.
Formulary (list of covered drugs) To see what drugs are covered, go to premera.com/ma and click on See covered drugs.
Evidence of Coverage To view a copy of the Evidence of Coverage for your plan, go to premera.com/ma. Select Plan documents from the Products & Services tab.
You can also call Premera Blue Cross Medicare Advantage Customer Service at 888-850-8526
(TTY/TDD: 711), April 1 – September 30, Monday – Friday, 8 a.m. - 8 p.m. (October 1 – March
31, 7 days a week, 8 a.m. – 8 p.m.) to receive a paper copy of the above materials.
Plan Selection Form To be used by current Premera members only.
Please contact us at 888-868-7767 (TTY/TDD: 711) if you need PO Box 262548 help with your enrollment. Monday–Friday, 8 a.m. to 8 p.m. Plano, TX 75026 (or 7 days a week, 8 a.m. to 8 p.m., October 1–March 31). Fax: 800-381-4837
YOUR INFORMATION
Email address:
Street address:
Street address:
PCP location:
PAPER APP MAILED TO AGENT EFFECTIVE DATE:
SEMINAR (DATE / LOCATION): SEP TYPE:
PBP: PLAN #: CONTRACT #: GROUP #:
Y0134_PBC3017_M 042630 (10-05-2021) 1
CHOOSE YOUR MEDICARE ADVANTAGE PLAN
I am currently a member of the plan in Premera Blue Cross Medicare Advantage, and my current monthly premium is $ . I want to transfer from my current Premera Blue Cross Medicare Advantage plan to the Premera Blue Cross Medicare Advantage plan I have selected below. I agree to allow Premera Blue Cross to use my personal information on file from my current Premera Blue Cross plan to complete my enrollment request. I understand that this plan may have a different provider network and that I must pay the monthly premium (if any) in addition to any Medicare Part A and Part B premiums I may owe. I understand that this plan has different health benefits and a monthly premium of $ . If this form is received by the end of the month, my new plan will generally be effective the 1st of the following month.
KING • PIERCE • SNOHOMISH • THURSTON • WHATCOM
Sound + Rx (HMO) - $35
Charter + Rx (HMO) - $110
HMO - $0
Peak + Rx (HMO) - $0
HMO - $0 Classic (HMO) - $55
SPOKANE • WALLA WALLA
Classic (HMO) - $55 (not available in Spokane)
STEVENS
PAYING YOUR PLAN PREMIUM
If we determine that you owe a late enrollment penalty (or if you currently have a late enrollment penalty), we need to know how you would prefer to pay it. You can pay your monthly plan premium, including any late enrollment penalty that you currently have or may owe, by mail or electronic funds transfer (EFT) each month. You can also choose to pay your premium by automatic deduction from your Social Security or Railroad Retirement Board (RRB) benefit check each month. If you are assessed a Part D-Income Related Monthly Adjustment Amount (Part D-IRMAA), you will be notified by the Social Security Administration. You will be responsible for paying this extra amount in addition to your plan premium. You will either have the amount withheld from your Social Security benefit check or be billed directly by Medicare or RRB. DO NOT pay Premera Blue Cross the Part D-IRMAA. People with limited incomes may qualify for extra help to pay for their prescription drug costs. If eligible, Medicare could pay for 75% 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. For more information about this extra help, contact your local Social Security office, or call Social Security at 800-772-1213. TTY/TDD users should call 800-325-0778. You can also apply for extra help online at www.socialsecurity.gov/prescriptionhelp. If you qualify for extra help with your Medicare prescription drug coverage costs, Medicare will pay all or part of your plan premium. If Medicare pays only a portion of this premium, we will bill you for the amount that Medicare doesn‘t cover. If you don’t select a payment option, you will get a bill each month.
Please select a premium payment option:
Get a monthly bill
Electronic funds transfer (EFT) from your bank account each month. Please enclose a VOIDED check or provide the following:
Account Holder Name: Account type: Checking Savings
Bank Routing #: Bank Account #:
Automatic deduction from your monthly Social Security or Railroad Retirement Board (RRB)benefit check. Please note: The Social Security/RRB deduction may take two or more months to begin after Social Security or RRB approves the deduction. Before the deduction begins, you may receive invoices for your premium. You will be responsible for paying your monthly premium directly to Premera from your effective date until the date your withholding begins. Invoices will stop once the deduction is approved. If Social Security or RRB does not approve your request for automatic deduction, we will send you a letter and paper bill for your monthly premiums.
I get monthly benefits from: Social Security Railroad Retirement Board
Please check the box if you would prefer us to send you information in a language other than English or in another format: Spanish Braille
Please contact Premera Blue Cross at 888-850-8526 (TTY/TDD: 711) if you need information in another format or language than what is listed above. Our office hours are seven days a week, between 8 a.m. and 8 p.m.
Y0134_PBC3017_M please continue to the next page — 3
STOP — READ THIS IMPORTANT INFORMATION
PLEASE READ AND SIGN BELOW
Premera Blue Cross is a Medicare Advantage plan that has a contract with the Federal government.
I understand that if I am getting assistance from a sales agent, broker, or other individual employed by or contracted with Premera Blue Cross, he/she may be paid based on my enrollment in a Premera Blue Cross Medicare Advantage plan.
Release of Information: By joining this Medicare health plan, I acknowledge that the Medicare health plan will release my information to Medicare and other plans as is necessary for treatment, payment and health care operations. I also acknowledge that Premera Blue Cross will release my information including my prescription drug event data to Medicare, who may release it for research and other purposes which follow all applicable Federal statutes and regulations. The information on this enrollment form is correct to the best of my knowledge. I understand that if I intentionally provide false information on this form, I will be disenrolled from the plan. I understand that people with Medicare aren’t covered under Medicare while out of the country except for limited coverage near the U.S. border.
I understand that beginning on the date my Premera Blue Cross Medicare Advantage coverage begins, I must get all of my health care from Premera Blue Cross, except for emergency or urgently needed services or out-of-area dialysis services. Services authorized by Premera Blue Cross and other services contained in my Premera Blue Cross Medicare Advantage Evidence of Coverage document (also known as a member contract or subscriber agreement) will be covered. WITHOUT AUTHORIZATION, NEITHER MEDICARE NOR PREMERA BLUE CROSS MEDICARE ADVANTAGE PLANS WILL PAY FOR THE SERVICES.
I understand that my signature (or the signature of the person authorized to act on my behalf under the laws of the State where I live) on this application means that I have read and understand the contents of this application. If signed by an authorized individual (as described above), this signature certifies that: 1) this person is authorized under State law to complete this enrollment and 2) documentation of this authority is available upon request from Medicare.
Signature: Today’s date:
If you are the authorized representative, you must sign above and provide the following information:
Name: Address: Phone: Relationship to enrollee:
Once you have completed this form, please mail it to this address:
Premera Blue Cross Medicare Advantage Plans PO Box 262548, Plano, TX 75026 or fax it to 800-381-4387
Premera Blue Cross is an HMO plan with a Medicare contract. Enrollment in Premera depends on contract renewal.
Y0134_PBC3017_M 4
Additional Benefits
MEDICARE ADVANTAGE (HMO)
From the top of your head to the tip of your toes,
your health matters. The Silver&Fit® Program All Premera Medicare Advantage members can stay active with their no-cost Silver&Fit membership. Membership includes:
• Access to our network that includes more than 16,500 local and national fitness centers like select YMCA locations, LA Fitness, Snap Fitness, and others
• Healthy aging coaching – coaches can answer questions related to healthy eating and nutrition, sleep, self-advocacy, coping with isolation, starting a home fitness routine, and other lifestyle questions
• Home Fitness Kits – pick one kit per benefit year. Choose from a Wearable Fitness Tracker, Pilates, Strength, Swim, or Yoga Kit options.
• No-cost, live, daily workouts on Facebook Live and YouTube
• Access to over 8,000 digital workout videos available via the Silver&Fit ASHConnect™ mobile app or website
• Access to a national social club network of over 120,000 locations with activities such as walking, chess, bridge, AM radio, cooking, and more
To use this benefit, visit silverandfit.com or call 877-427-4788 (TTY/TDD 711).
24- Hour NurseLine
Help is only a call away.
All Premera Medicare Advantage members have access to free confidential help from a nurse 24 hours a day, 7 days a week, 365 days a year. Nurses are available through this service to answer questions about medications, help you decide when and where to seek care, or simply provide reassurance when you need it.
To use this benefit, call 855-339-8123.
Call 911 or go to the emergency room in the case of a life-threatening emergency, such as a heart attack or stroke.
your health matters. Hearing Services with Hearing Care Solutions (HCS)*
Premera Medicare Advantage plans help you keep your retirement money safe by paying for costs not covered by Original Medicare alone, like hearing aids.
Hearing Care Solutions delivers quality hearing care and hearing instruments at the greatest value to meet your lifestyle needs and includes an annual benefit of $1,000 per ear per year toward hearing aids.
Through Hearing Care Solutions, members receive:
• A hearing aid fitting at no cost
• A 60-day evaluation period to make sure everything feels right
• 1 year of follow-up care at no charge, with the original provider
All instruments purchased through Hearing Care Solutions receive:
• 12-month, interest-free financing, available to qualified applicants
• 2-year supply of batteries for nonrechargeable devices (up to 64 cells per ear, per year)
• 3-year manufacturer’s warranty, including loss, damage, and repair
To use this benefit, call Hearing Care Solutions at 866-344-7756.
From the top of your head to the tip of your toes,
your health matters. Dental Benefits Keep your mouth looking and feeling young! All 2022 plans have preventive and comprehensive dental embedded. You can expect the following, and more:
• a $0 copay for preventive and comprehensive dental services
• an annual comprehensive deductible applies for in-network and out-of-network services
• a maximum annual allowance ranging from $1,000-1500 depending on plan choice
Vision Maintain your vision and eye health as you age with Premera vision benefits. Vision plans include:
• a routine eye exam once per calendar year
• a diabetic retinopathy screening once per calendar year
• Up to a $300 hardware reimbursement allowance on select plans
90-day Prescription Mail Order*
Enjoy the convenience of having long-term drugs delivered right to your home! Through the CVS mail- order pharmacy home delivery service, pay a $0 copay for a 90-day supply of preferred generic drugs. To use this benefit, visit caremark.com, complete the paper form found on premera.com/ma, or call us at the number on your member ID card.
Over the Counter (OTC) Receive up to a $50 quarterly benefit for over-the-counter health and wellness products available through OTC Health Solutions. This benefit provides you with an easy way to get:
• generic personal care items
• bath and safety supplies
• hearing aid batteries and more.
To use this benefit, browse the OTC Health Solutions catalog premera.com/ma. Then, place your order over the phone at 888-628-2770, or online at cvs.com/otchs/premera.
*Not included with all plans. Check the Summary of Benefits to see what is included in your plan. The Silver&Fit program is provided by American Specialty Health Fitness, Inc. (ASH Fitness), a subsidiary of American Specialty Health Incorporated (ASH). Silver&Fit and Silver&Fit Connected! are trademarks of ASH and used with permission herein. The people in this piece are not Silver&Fit members. Kits are subject to change. Participating facilities and fitness chains may vary by location and are subject to change. Other names may be trademarks of their respective owners.
Visit premera.com/ma/benefits for more information on how to use these benefits as a member.
October 1–March 31
7 days a week, 8 a.m. to 8 p.m.
April 1–September 30 Monday through Friday, 8 a.m. to 8 p.m.
visit premera.com/ma
On behalf of Premera Blue Cross, CVS Health, its subsidiaries and affiliates, including CVS Caremark Part D Services, LLC, is an independent provider of pharmacy benefit management services.
On behalf of Premera Blue Cross, the Silver&Fit program is provided by American Specialty Health Fitness, inc., (ASH Fitness), a subsidiary of American Specialty Health Incorporated (ASH), and is an independent company
which provides the Healthy Aging and Exercise program.
Premera Blue Cross is an (HMO) plan with a Medicare contract. Enrollment depends on contract renewal.
Y0134_PBC3155_M
053019 (10-01-2021)
Discrimination is against the law. Premera Blue Cross Medicare Advantage complies with applicable Federal and Washington state civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, gender identity, or sexual orientation. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 888-850-8526 (TTY: 711). : 888-850-8526 (TTY : 711) ° 049795(07-01-2021)
HMO $0 ($0 premium)................................................................................................................................. Page 2
Walla Walla
HMO $0 ($0 premium)................................................................................................................................. Page 2
Classic HMO ($55 premium)...................................................................................................................... Page 3
HMO $0 ($0 premium)................................................................................................................................. Page 2
Peak + Rx ($0 premium).............................................................................................................................. Page 4
Sound + Rx ($35 premium)......................................................................................................................... Page 5
REGION TWO: Island, Lewis, San Juan, Skagit, Kitsap, Cowlitz
HMO $0 ($0 premium)................................................................................................................................. Page 2
Always in your corner
At Premera Blue Cross, it’s our customers who drive us to innovate and improve with each new day. Our employees work hard to make
healthcare work better—so we are at our best when you need us most.
Enrolling is easy—you can:
CONTACT your producer or local sales representative
ENROLL BY PHONE: Call toll free 888-868-7767 (TTY/TDD: 711) October 1–March 31
7 days a week, 8 a.m. to 8 p.m.
April 1–September 30
ENROLL ONLINE: Go to premera.com/ma
ENROLL BY MAIL: Return your paper application to: Premera Blue Cross PO Box 262548 Plano, TX 75026
MEDICAL SERVICES
Plan Cost
Office Visit
Prescription mail order
Dental
Hearing
Vision
Premium $24 Maximum out of pocket $5,000
Provider (PCP) visit copay $0 Specialist visit copay $30
Labs/ x-rays $0/ $10 Testing/ radiology $30/ $160
Ambulatory benefits $250
$10
Ambulance copay (ground/air each one-way trip) $370 Emergency care copay (waived if admitted) $90, worldwide
Urgent care (waived if admitted) $45 in US, $50 worldwide Inpatient hospital
no copay if readmitted within 60 days Days 1-4 /days 5+ $350/$0
Days 1-20 $0 Skilled nursing (waived 3-day prior hospital) Days 21-60 $160
Days 61-100 $0
Drug deductible No deductible
Advair and Shingrix included in T1 Tier 1 copay $2/$12 Tier 2 copay $10/$20 Tier 3 copay $40/$47 Tier 4 copay $100 Tier 5 copay 33%
Tier 1 Preferred Generic, 90-day supply $0
Max copay for 30-day supply of select diabetic insulins $35
Preventive and comprehensive Included Annual maximum $1,500
Routine copay/comprehensive deductible $0/ $75 Routine hearing exam (1 per year) $0–$30
Hearing aids* *$0 copay; (*toward the purchase of hearing aids $1,000 annual limit per earthrough Hearing Care Solutions)
Routine eye exam (1 per year) $0 Hardware reimbursement allowance –
every 12 months $200
Per quarter allowance (mail order only) $50 Routine visit – 10 for each service per year $20 per visit
6 visits per year $30 per visit
Cowlitz, Island, King, Kitsap, Lewis, Pierce, San Juan, Skagit, Snohomish, Spokane, Thurston, Walla Walla and Whatcom Counties Medicare Advantage (HMO) – Dental embedded on all plans
MEDICAL SERVICES
Plan Cost
Office Visit
Dental
Hearing
Vision
Premium $0
Days 61-100 $0
Maximum out of pocket $6,500 Provider (PCP) visit copay $5
Specialist visit copay $40 Labs/ x-rays $15/ $15
Testing/ radiology $60/ $180 Ambulatory benefits $250
Outpatient surgery $350 Outpatient hospital observation $90
$20
Drug deductible $160 Deductible waived for T1, T2
NA NA
Cowlitz, Island, King, Kitsap, Lewis, Pierce, San Juan, Skagit, Snohomish, Thurston, Walla Walla, and Whatcom Counties Medicare Advantage Classic (HMO) – Dental embedded on all plans
MEDICAL SERVICES
Plan Cost
Office Visit
Dental
Hearing
Vision
$10
Days 61-100 $0
King, Pierce, Snohomish, Thurston, and Whatcom Counties Medicare Advantage Sound + Rx (HMO) – Dental embedded on all plans
MEDICAL SERVICES
Plan Cost
Office Visit
Dental
Hearing
Vision
$35
Days 61-100 $0
Hearing aids* *$0 copay;(*toward the purchase of hearing aids $1,000 annual limit per earthrough Hearing Care Solutions)
NA NA
King, Pierce, Snohomish, Thurston, and Whatcom Counties Medicare Advantage Peak + Rx (HMO) – Dental embedded on all plans
MEDICAL SERVICES
Plan Cost
Office Visit
Dental
Hearing
Vision
$20
Days 61-100 $0
Drug deductible $160 Deductible waived for T1, T2
NA NA
MEDICAL SERVICES
Plan Cost
Office Visit
Dental
Hearing
Vision
$35
Days 61-100 $0
Drug deductible No Part D
Advair and Shingrix included in T1 Tier 1 copay NA Tier 2 copay NA Tier 3 copay NA Tier 4 copay NA Tier 5 copay NA
Tier 1 Preferred Generic, 90-day supply NA
Max copay for 30-day supply of select diabetic insulins NA
Your doctors. Our network. ACCESS WHEN AND WHERE YOU NEED IT
You can find doctors and hospitals across our service area.
This is a partial list of providers in the Medicare Advantage network.
Western Washington • Associates in Family Medicine • Pacific Medical Centers • CHI Franciscan Health • PeaceHealth • The Everett Clinic • Physicians of Southwest Washington (PSW) • EvergreenHealth • The Polyclinic • Family Care Network (FCN) • Providence Health and Services • Morton Medical Center • Skagit Valley Hospital • MultiCare Health System • Swedish Medical Center • Northwest Physicians Network (NPN) • UW Medicine • Overlake Medical Center • Virginia Mason Medical Center
Eastern Washington • The Doctors Clinic • Providence Holy Family Hospital • Multicare Deaconess Hospital • Providence Sacred Heart Medical Center • MultiCare Rockwood Clinic • Vivacity Care Center • MultiCare Valley Hospital • Walla Walla Clinic • Providence Health and Services
As a Premera Medicare Advantage HMO customer, you can receive care from any doctor or hospital in our Medicare Advantage network, even if they are located outside your county. Just ask your primary care physician (PCP) for a referral to the provider you wish to see.
Top 5 tips for choosing the plan that’s right for you
All of our Medicare Advantage plans include extra benefits, like dental, vision, hearing, and fitness. They also include routine chiropractic and acupuncture coverage.
Make a list of the medications you’re taking. Then check the list of covered drugs (also called a formulary) to see if all your drugs are covered on the plan you like. Search the Premera Medicare Advantage formulary at premera.com/ma.
Premera has thousands of doctors and hospitals in our Medicare Advantage network. So, chances are your doctor is in our network. You can search our provider directory at premera.com/ma.
A Premera Medicare Advantage plan helps keep your retirement money safe by paying for costs not covered by Original Medicare alone. Plan premiums start as low as $0 per month.
It’s important to be able to call customer service and ask questions about your Medicare Advantage plan. Premera’s customer service team can answer most questions in just one phone call.
Medicare easy.
CALL TOLL FREE 888-868-7767 (TTY/TDD: 711)
Monday–Friday, 8 a.m.–8 p.m.
(October 1–March 31: 7 days a week, 8 a.m.–8 p.m.)
Premera Blue Cross is an HMO plan with a Medicare contract. Enrollment in Premera Blue Cross depends on contract renewal.
To join a Premera Blue Cross Medicare Advantage Plan, you must have Medicare Part A and Part B and live in the Premera Blue Cross Medicare Advantage service area
(Cowlitz, Island, King, Kitsap, Lewis, Pierce, San Juan, Skagit, Snohomish, Spokane, Stevens, Thurston, Walla Walla, and Whatcom counties in Washington).
Members must select a PCP from the Premera Blue Cross Medicare Advantage Plans provider network.
Y0134_PBC3173_M 048849 (10-10-2021)
1
2022 Summary of Benefits PAGES 4–15 PREMERA BLUE CROSS MEDICARE ADVANTAGE (HMO)
PREMERA BLUE CROSS MEDICARE ADVANTAGE CLASSIC (HMO) PREMERA BLUE CROSS MEDICARE ADVANTAGE TOTAL HEALTH (HMO)
PAGES 16–24 PREMERA BLUE CROSS MEDICARE ADVANTAGE PEAK + RX (HMO) PREMERA BLUE CROSS MEDICARE ADVANTAGE SOUND + RX (HMO)
PAGES 25–36 PREMERA BLUE CROSS MEDICARE ADVANTAGE ALPINE (HMO) PREMERA BLUE CROSS MEDICARE ADVANTAGE CHARTER + RX (HMO) PREMERA BLUE CROSS MEDICARE ADVANTAGE CLASSIC PLUS (HMO)
Y0134_PBC3025_M 037040 (10-10-2021)
2022 Summary of Benefits
PREMERA BLUE CROSS MEDICARE ADVANTAGE (HMO) H7245-001 PREMERA BLUE CROSS MEDICARE ADVANTAGE CLASSIC (HMO) H7245-002 PREMERA BLUE CROSS MEDICARE ADVANTAGE TOTAL HEALTH (HMO) H7245-005 PREMERA BLUE CROSS MEDICARE ADVANTAGE PEAK + RX (HMO) H9302-011 PREMERA BLUE CROSS MEDICARE ADVANTAGE SOUND + RX (HMO) H9302-007 PREMERA BLUE CROSS MEDICARE ADVANTAGE ALPINE (HMO) H9302-004 PREMERA BLUE CROSS MEDICARE ADVANTAGE CHARTER + RX (HMO) H9302-003 PREMERA BLUE CROSS MEDICARE ADVANTAGE CLASSIC PLUS (HMO) H7245-003
This is a summary of drug and health services covered by Premera Blue Cross Medicare Advantage (HMO), Premera Blue Cross Medicare Advantage Classic (HMO), Premera Blue Cross Medicare Advantage Total Health (HMO), Premera Blue Cross Medicare Advantage Peak + Rx (HMO), Premera Blue Cross Medicare Advantage Sound + Rx (HMO), Premera Blue Cross Medicare Advantage Alpine (HMO), Premera Blue Cross Medicare Advantage Charter + Rx (HMO), and Premera Blue Cross Medicare Advantage Classic Plus (HMO) January 1, 2022 to December 31, 2022.
2
Premera Blue Cross Medicare Advantage (HMO), Premera Blue Cross Medicare Advantage Classic (HMO), Premera Blue Cross Medicare Advantage Total Health (HMO), Premera Blue Cross Medicare Advantage Peak + Rx (HMO), Premera Blue Cross Medicare Advantage Sound + Rx (HMO), Premera Blue Cross Medicare Advantage Alpine (HMO), Premera Blue Cross Medicare Advantage Charter + Rx (HMO), and Premera Blue Cross Medicare Advantage Classic Plus (HMO) are plans with a Medicare contract. Enrollment in these plans depends on contract renewal.
The benefit information provided does not list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, please request the “Evidence of Coverage” by calling customer service or accessing it on our website: premera.com/ma.
To join Premera Blue Cross Medicare Advantage (HMO), Premera Blue Cross Medicare Advantage Classic (HMO), Premera Blue Cross Medicare Advantage Total Health (HMO), Premera Blue Cross Medicare Advantage Peak + Rx (HMO), Premera Blue Cross Medicare Advantage Sound + Rx (HMO), Premera Blue Cross Medicare Advantage Alpine (HMO), Premera Blue Cross Medicare Advantage Charter + Rx (HMO), or Premera Blue Cross Medicare Advantage Classic Plus (HMO), you must be entitled to Medicare Part A, be enrolled in Medicare Part B, and live in our service area. Our service area includes the following counties in Washington: Cowlitz, Island, King, Kitsap, Lewis, Pierce, San Juan, Skagit, Snohomish, Spokane, Stevens, Thurston, Walla Walla, and Whatcom.
If you use providers that are not in our network, we may not pay for these services.
For 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). TTY/TDD users should call 1-877-486-2048.
This document is available in other formats, including Braille and Spanish.
For more information, please call us at 888-850-8526 (TTY/TDD: 711), or visit us at premera.com/ma.
Representatives are available: October 1 - March 31, 8 a.m. to 8 p.m., 7 days a week April 1 – Sept 30, 8 a.m. to 8 p.m., Monday through Friday.
Premium and Benefits Premera Blue Cross Medicare Premera Blue Cross Medicare Premera Blue Cross Medicare Advantage (HMO) Advantage Classic (HMO) Advantage Total Health (HMO)
Monthly Plan Premium You pay $0 per month. You must continue to pay your Medicare Part B premium.
You pay $55 per month. You must continue to pay your Medicare Part B premium.
Part C Deductible No deductible. No deductible. No deductible. Part D Deductible $160 per year for Part D
prescription drugs except for drugs listed on Tier 1 and Tier 2, which are excluded from the deductible.
No deductible. No deductible.
Maximum Out-of-Pocket Responsibility (does not include prescription drugs)
You pay no more than $6,500 annually. Includes copays and other costs for medical services for the year.
Inpatient Hospital Coverage You pay a $450 copay per day for days 1–4. You pay a $0 copay per day for days 5 and beyond.
You pay a $350 copay per day for days 1–4. You pay a $0 copay per day for days 5 and beyond.
Outpatient Hospital Coverage $350 $300 $275 Outpatient Hospital Observation Coverage
$90 $90 $90
Ambulatory Surgery Center You pay a $250 copay for each Medicare-covered ambulatory surgical center visit.
You pay a $250 copay for each Medicare-covered ambulatory surgical center visit.
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Doctor Visits Primary care providers You pay a $5 copay per
office visit. You pay a $0 copay per telehealth visit.
You pay a $0 copay per office visit. You pay a $0 copay per telehealth visit.
Specialists You pay a $40 copay per office visit (referral required). You pay a $35 copay per telehealth visit.
You pay a $30 copay per office visit (referral required). You pay a $25 copay per telehealth visit.
Preventive Care You pay nothing. You pay nothing. You pay nothing. (such as flu vaccine, diabetic screenings)
Other preventive services are available. There are some covered services that have a cost.
Emergency Care You pay a $90 copay per visit. Waived, if you are admitted to the hospital within 24 hours. Includes worldwide coverage.
You pay a $90 copay per visit. Waived, if you are admitted to the hospital within 24 hours. Includes worldwide coverage.
You pay a $90 copay per visit. Waived, if you are admitted to the hospital within 24 hours. Includes worldwide coverage.
Urgently Needed Services You pay a $35 copay per visit. Includes worldwide coverage with a $50 copay.
You pay a $35 copay per visit. Includes worldwide coverage with a $50 copay.
You pay a $45 copay per visit. Includes worldwide coverage with a $50 copay.
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Counties Cowlitz, Island, King, Kitsap, Lewis, Pierce, San Juan, Skagit, Snohomish, Spokane, Thurston, Walla Walla, and Whatcom
Cowlitz, Island, King, Kitsap, Lewis, Pierce, San Juan, Skagit, Snohomish, Thurston, Walla Walla, and Whatcom
Spokane, Stevens, and Walla Walla
Premium and Benefits Premera Blue Cross Medicare Advantage (HMO)
Premera Blue Cross Medicare Advantage Classic (HMO)
Premera Blue Cross Medicare Advantage Total Health (HMO)
Diagnostic Services/Labs/ Imaging Diagnostic tests and procedures
You pay a $60 copay per service location per day.
Lab services You pay a $15 copay per service location per day.
Outpatient x-rays You pay a $15 copay per service location per day.
Therapeutic radiology services (such as radiation treatment for cancer)
You pay 20% of the total cost. If your doctor provides additional services, a separate cost sharing amount may apply.
Diagnostic radiology services $180 copay per service location per day.
$160 copay per service location per day.
$160 copay per service location per day.
Hearing Services Medicare-covered hearing exam
You pay a $35 copay per visit. You pay a $30 copay per visit. You pay a $30 copay per visit.
Routine hearing exam You pay a $0–$35 copay for one routine hearing exam per calendar year. $0 copay through Hearing Care Solutions provider; higher copay applies to exams by all other providers.
You pay a $0–$30 copay for one routine hearing exam per calendar year. $0 copay through Hearing Care Solutions provider; higher copay applies to exams by all other providers.
You pay a $0–$30 copay for one routine hearing exam per calendar year. $0 copay through Hearing Care Solutions provider; higher copay applies to exams by all other providers.
Hearing aid You pay a $0 copay. There is a $1,000 annual allowance per ear toward the purchase of hearing aids through Hearing Care Solutions.
You pay a $0 copay. There is a $1,000 annual allowance per ear toward the purchase of hearing aids through Hearing Care Solutions.
You pay a $0 copay. There is a $1,000 annual allowance per ear toward the purchase of hearing aids through Hearing Care Solutions.
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Dental Services Medicare-covered dental services
Annual maximum $1,000 $1,500 $1,500
Dental services You pay a $0 copay for preventive and comprehensive dental services.
Preventive Services • Prophylaxis (cleaning) - Two per calendar year OR Periodontal maintenance - Three per calendar year • Fluoride - Two per calendar year • Periodic oral exam - Up to two periodic oral evaluations per calendar year • Limited oral evaluation (problem focused) - One evaluation per 12 months • Comprehensive oral exam - One comprehensive exam per 36 months • Detailed and extensive oral evaluation - problem focused, by report - One per lifetime • Re-evaluation - limited, problem focused (established patient) - One per lifetime • Comprehensive periodontal exam - One per calendar year • Bitewing x-rays - One set per calendar year • Full-mouth complete set - One procedure every 60 months • Panoramic film x-ray for evaluation of the teeth and mouth - One procedure every 60 months
Annual Comprehensive Deductible (in-network and out-of-network)
You pay a one-time annual Comprehensive Services deductible of $75. Deductible is waived for preventive and Medicare-covered dental services.
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Comprehensive services • Periodontal scaling and root planning - One every two years, per quadrant • Scaling in presence of generalized moderate or severe gingival inflammation, full mouth - Once per two years • Occlusal adjustment performed with covered surgery – no limit • Gingivectomy or gingivoplasty - One surgical procedure per lifetime • Osseous surgery including flap entry and closure - One per lifetime • Pedicle or free soft tissue graft - One per set per lifetime • Full mouth debridement - One per lifetime • Intraoral x-rays: Periapical x-rays or Occlusal x-rays - One procedure code per calendar year • Restorations (fillings): amalgam (Silver) and/or Composite - One per tooth per 24 months • Recementing a crown that has fallen off - One per 12 months • Recementing bridges, inlays, onlays and crowns - After 12 months of insertion and per 12 months per
tooth thereafter • Pins when preparing a tooth for a crown - Bundle with crown code and pins (when required) • Buildup of filling around a post to prepare the tooth for a crown - One combo per tooth every 5 years • Crowns - One per tooth every 5 years • Oral surgery, including postoperative care for coronectomy, intentional partial tooth removal - One per tooth
per lifetime • Root canal – One initial root canal procedure and one retreatment procedure per tooth per lifetime • Pulpotomy – No Limit • Apicoectomy – No Limit • Retrograde fillings – Per root per lifetime • Medicine placed under fillings to promote pulp healing - Unlimited per plan year to plan annual maximum • Complete denture – maxillary (upper) or mandibular (lower) - One upper complete and/or one lower
complete denture every seven years, including routine post-delivery care • Partial Dentures: Resin or metal, maxillary (upper) or mandibular (lower) or maxillary (upper) or mandibular
(lower) - One upper and/or one lower partial denture every seven years 8
Comprehensive services • Complete denture and partial denture adjustment - Two per denture per year • Complete or Partial Denture Reline or Rebase – One relining or rebasing of existing removable dentures per
24 months (only after 24 months from date of last placement, unless an immediate prosthesis replacing at least 3 teeth).
• Recementation - One procedure per calendar year • Repair of dentures or fixed bridgework - One per denture/bridgework per 24 month • Teledentistry - Two per calendar year • Pain Management - Unlimited per plan year to plan annual maximum. Only if no services other than exam
and x-rays were performed on the same date of service. • Deep sedation/general anesthesia - Unlimited per plan year to plan annual maximum. In conjunction with
covered oral surgery or periodontal surgery. • Local anesthesia - Unlimited per plan year to plan annual maximum. In conjunction with covered oral
surgery or periodontal surgery • Intravenous moderate (conscious) sedation/analgesia - Unlimited per plan year to plan annual maximum.
In conjunction with covered oral surgery or periodontal surgery.
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Vision Services Medicare-covered You pay a $0 copay for each You pay a $0 copay for each You pay a $0 copay for each vision exam Medicare-covered diabetic
retinopathy and glaucoma screenings once per calendar year.
You pay a $20 copay for each Medicare-covered exam to diagnose and treat diseases and conditions of the eye.
Medicare-covered diabetic retinopathy and glaucoma screenings once per calendar year.
Medicare-covered diabetic retinopathy and glaucoma screenings once per calendar year.
Medicare-covered You pay a $0 copay for one pair You pay a $0 copay for one pair You pay $0 copay for one pair vision hardware of Medicare-covered eyeglasses
or contact lenses after each cataract surgery.
of Medicare-covered eyeglasses or contact lenses after each cataract surgery.
of Medicare-covered eyeglasses or contact lenses after each cataract surgery.
Routine vision exam You pay a $20 copay for one routine vision exam per calendar year for the purposes of obtaining eyeglasses or contact lenses. No referral is required for routine vision exam.
You pay a $0 copay for one routine vision exam per calendar year for the purposes of obtaining eyeglasses or contact lenses. No referral is required for routine vision exam.
Routine vision hardware There is a $150 benefit limit for routine eyeglasses (lenses and frames) or contact lenses per calendar year.
There is a $250 benefit limit for routine eyeglasses (lenses and frames) or contact lenses per calendar year.
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Mental Health Services Inpatient mental health care You pay a $390 copay per day You pay a $390 copay per day You pay a $390 copay per day
for days 1–4. for days 1–4. for days 1–4. You pay a $0 copay per day for You pay a $0 copay per day for You pay a $0 copay per day for days 5–90. days 5–90. days 5–90.
Outpatient mental health care You pay a $35 copay for each Medicare-covered individual or group therapy visit. You pay a $20 copay for each telemental health visit.
You pay a $30 copay for each Medicare-covered individual or group therapy visit. You pay a $20 copay for each telemental health visit.
Skilled Nursing Facility You pay a $0 copay per day for You pay a $0 copay per day for You pay a $0 copay per day for days 1–20. days 1–20. days 1–20. You pay a $160 copay per day You pay a $160 copay per day You pay a $160 copay per day for days 21–60. for days 21–60. for days 21–60. You pay a $0 copay per day for You pay a $0 copay per day for You pay a $0 copay per day for days 61–100. days 61–100. days 61–100.
Physical Therapy You pay a $20 copay per visit. You pay a $10 copay per visit. You pay a $10 copay per visit.
Ambulance You pay a $300 copay each way for Medicare-covered ambulance transport.
You pay a $330 copay each way for Medicare-covered ambulance transport.
You pay a $370 copay each way for Medicare-covered ambulance transport.
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Transportation Not covered. Not covered. Not covered.
Medicare Part B Drugs You pay 20% of the total cost for Medicare-covered Part B chemotherapy drugs and other Part B drugs.
You pay 20% of the total cost for Medicare-covered Part B chemotherapy drugs and other Part B drugs.
You pay 20% of the total cost for Medicare-covered Part B chemotherapy drugs and other Part B drugs.
Over the Counter (OTC) Receive a $25 quarterly benefit for over-the-counter health and wellness products available through OTC Health Solutions.
Receive a $50 quarterly benefit for over-the-counter health and wellness products available through OTC Health Solutions.
Chiropractic Services Medicare-covered copay: $20. Routine Chiropractic Services: 6 visits/ $20 copay.
Medicare-covered copay: $20. Routine Chiropractic Services: 10 visits/ $20 copay.
Acupuncture Medicare-covered copay: $40. Routine Acupuncture: 6 visits/ $20 copay.
Medicare-covered copay: $30. Routine Acupuncture: 10 visits/ $20 copay.
Routine Naturopathic Services
Not covered. 6 visits/ $30 copay 6 visits/ $30 copay
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Counties: Cowlitz, Island, King, Kitsap, Lewis, Pierce, San Juan, Skagit, Snohomish, Spokane, Thurston, Walla Walla, and Whatcom
Counties: Cowlitz, Island, King, Kitsap, Lewis, Pierce, San Juan, Skagit, Snohomish, Thurston, Walla Walla, and Whatcom
Counties: Spokane, Stevens, and Walla Walla
Premera Blue Cross Medicare Advantage (HMO)
PRESCRIPTION DRUG BENEFITS (PART D) PRESCRIPTION DRUG BENEFITS (PART D) PRESCRIPTION DRUG BENEFITS (PART D) Deductible Phase
During this stage, you pay the full cost of your Tier 3, 4, and 5 drugs. You stay in this stage until you have paid $160 for your Tier 3, 4, and 5 drugs. During this stage, your out-of-pocket costs for Select Insulins will be $35.
Deductible Phase
Because there is no deductible for the plan, this payment stage does not apply to you.
Deductible Phase
Initial Coverage Phase - You begin in this stage when you fill your first prescription of the year. You stay in the Initial Coverage Stage until your total drug costs for the year reach $4,430. During this stage, your out-of-pocket costs for Select Insulins will be $35.
Preferred Retail Standard Retail Preferred Retail Standard Retail Preferred Retail Standard Retail Cost Sharing (in Cost sharing (in Cost Sharing (in Cost sharing (in Cost Sharing (in Cost Sharing (in network) (up to network)(up to network) (up to network)(up to network) (up to network)(up to a 30-day supply) 30-day supply) a 30-day supply) 30-day supply) a 30-day supply) 30-day supply)
Tier 1: Preferred Generic
Tier 2: Generic
Tier 2: Generic
Tier 2: Generic
Tier 3: Preferred Brand
You pay a $42 copay. $35 copay for Select Insulins.
You pay a $47 copay $35 copay for Select Insulins.
Tier 4: Tier 4: Tier 4: Non- You pay a You pay a Non- You pay a You pay a Non- You pay a $100 You pay a Preferred $100 copay. $100 copay. Preferred $100 copay. $100 copay. Preferred copay. $100 copay. Drugs Drugs Drugs
Tier 5: Specialty
Tier 5: Specialty
Tier 5: Specialty
You pay 33% of the total cost. 13
Counties: Cowlitz, Island, King, Kitsap, Lewis, Pierce, San Juan, Skagit, Snohomish, Spokane, Thurston, Walla Walla, and Whatcom
Counties: Cowlitz, Island, King, Kitsap, Lewis, Pierce, San Juan, Skagit, Snohomish, Thurston, Walla Walla, and Whatcom
Counties: Spokane, Stevens, and Walla Walla
Premera Blue Cross Medicare Advantage (HMO)
Mail Order Cost Sharing (90-day supply)
Long-Term Care Cost Sharing (up to a 31-day supply)
Tier 2: Generic
Tier 2: Generic
Tier 2: Generic
Tier 4: Non- Preferred Drugs
You pay a $300 copay.
Tier 5: Specialty Not offered.
You pay 30% of the total cost.
Cost sharing may change depending on the pharmacy you choose and when you enter another of the four phases of the Part D benefit.
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Coverage Gap After you enter the Coverage Gap, you pay 25% of the costs of brand name drugs and 25% of the costs of generic drugs until your out-of-pocket costs reach $7,050, which is the end of the Coverage Gap. During this stage, your out-of-pocket costs for Select Insulins will be $35. Not everyone will reach the Coverage Gap.
Catastrophic Coverage After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $7,050, you pay whichever of these is larger: • 5% of the cost of the drug, or • $3.95 copay for a generic drug, or a drug that is treated like a generic and $9.85 copay for all other drugs.
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Counties King, Pierce, Snohomish, Thurston, and Whatcom
Premium and Benefits Premera Blue Cross Medicare Advantage Peak + Rx (HMO)
Premera Blue Cross Medicare Advantage Sound + Rx (HMO)
Part C Deductible No deductible. No deductible.
Part D Deductible $160 per year for Part D prescription drugs except for drugs listed on Tier 1 and Tier 2, which are excluded from the deductible.
There is no deductible for Sound + Rx.
Inpatient Hospital Coverage You pay a $450 per day for days 1-4. You pay a $0 copay per day for days 5 and beyond.
You pay a $450 per day for days 1-4. You pay a $0 copay per day for days 5 and beyond.
Outpatient Hospital Coverage
$90 $90
You pay a $275 copay for each Medicare- covered ambulatory surgical center visit.
Doctor Visits Primary care providers You pay a $5 copay per office visit.
You pay a $0 copay per telehealth visit. You pay a $0 copay per office visit. You pay a $0 copay per telehealth visit.
Preventive Care (such as flu vaccine, diabetic screenings)
You pay nothing. Other preventive services are available. There are some covered services that have a cost.
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Emergency Care You pay a $90 copay per visit. Waived, if admitted to the hospital within 24 hours. Includes worldwide coverage.
You pay a $90 copay per visit. Waived, if admitted to the hospital within 24 hours. Includes worldwide coverage.
Urgently Needed Services You pay a $35 copay per visit.
Includes worldwide coverage with a $50 copay.
You pay a $40 copay per visit.
Includes worldwide coverage with a $50 copay. Diagnostic Services/Labs/ Imaging Diagnostic tests and procedures
You pay a $60 copay per service location per day. You pay a $25 copay per service location per day.
Lab services You pay a $15 copay per service location per day. You pay a $5 copay per service location per day. Outpatient x-rays You pay a $15 copay per service location per day. You pay a $10 copay per service location per day. Therapeutic radiology services (such as radiation treatment for cancer)
You pay 20% of the cost.
If your doctor provides additional services, a separate cost sharing amount may apply.
You pay 20% of the cost.
Diagnostic radiology services
$180 copay per service location per day. $170 copay per service location per day.
You pay a $35 copay per visit. You pay a $45 copay per visit.
Routine hearing exam You pay a $0–$35 copay for one routine hearing exam per calendar year. $0 copay through Hearing Care Solutions provider; higher copay applies to exams performed by all other providers.
You pay a $0–$45 copay for one routine hearing exam per calendar year. $0 copay through Hearing Care Solutions provider; higher copay applies to exams performed by all other providers.
Hearing aid You pay a $0 copay. There is a $1,000 annual allowance per ear for hearing aids through Hearing Care Solutions provider.
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Dental Services Medicare-covered dental services
Annual maximum $1,000 $1,300 Dental services You pay a $0 copay for routine dental services. Preventive Services • Prophylaxis (cleaning) - Two per calendar year OR Periodontal maintenance - Three per calendar year
• Fluoride - Two per calendar year • Periodic oral exam - Up to two periodic oral evaluations per calendar year • Limited oral evaluation (problem focused) - One evaluation per 12 months • Comprehensive oral exam - One comprehensive exam per 36 months • Detailed and extensive oral evaluation - problem focused, by report - One per lifetime • Re-evaluation - limited, problem focused (established patient) - One per lifetime • Comprehensive periodontal exam - One per calendar year • Bitewing x-rays - One set per calendar year • Full-mouth complete set - One procedure every 60 months • Panoramic film x-ray for evaluation of the teeth and mouth - One procedure every 60 months
Annual Comprehensive Deductible (in-network and out-of-network)
You pay a one-time annual Comprehensive Services deductible of $75. Deductible is waived for preventive and Medicare-covered dental services.
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Comprehensive services • Periodontal scaling and root planning - One every two years, per quadrant • Scaling in presence of generalized moderate or severe gingival inflammation, full mouth - Once per two years • Occlusal adjustment performed with covered surgery – no limit • Gingivectomy or gingivoplasty - One surgical procedure per lifetime • Osseous surgery including flap entry and closure - One per lifetime • Pedicle or free soft tissue graft - One per set per lifetime • Full mouth debridement - One per lifetime • Intraoral x-rays: Periapical x-rays or Occlusal x-rays - One procedure code per calendar year • Restorations (fillings): amalgam (Silver) and/or Composite - One per tooth per 24 months • Recementing a crown that has fallen off - One per 12 months • Recementing bridges, inlays, onlays and crowns - After 12 months of insertion and per 12 months per tooth
thereafter • Pins when preparing a tooth for a crown - Bundle with crown code and pins (when required) • Buildup of filling around a post to prepare the tooth for a crown - One combo per tooth every 5 years • Crowns - One per tooth every 5 years • Oral surgery, including postoperative care for coronectomy, intentional partial tooth removal - One per tooth
per lifetime • Root canal – One initial root canal procedure and one retreatment procedure per tooth per lifetime • Pulpotomy – No Limit • Apicoectomy – No Limit • Retrograde fillings – Per root per lifetime • Medicine placed under fillings to promote pulp healing - Unlimited per plan year to plan annual maximum • Complete denture – maxillary (upper) or mandibular (lower) - One upper complete and/or one lower
complete denture every seven years, including routine post-delivery care • Partial Dentures: Resin or metal, maxillary (upper) or mandibular (lower) or maxillary (upper) or mandibular
(lower) - One upper and/or one lower partial denture every seven years • Complete denture and partial denture adjustment - Two per denture per year
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Comprehensive services • Complete or Partial Denture Reline or Rebase – One relining or rebasing of existing removable dentures per 24 months (only after 24 months from date of last placement, unless an immediate prosthesis replacing at least 3 teeth).
• Recementation - One procedure per calendar year • Repair of dentures or fixed bridgework - One per denture/bridgework per 24 months • Teledentistry - Two per calendar year • Pain Management - Unlimited per plan year to plan annual maximum. Only if no services other than exam
and x-rays were performed on the same date of service. • Deep sedation/general anesthesia - Unlimited per plan year to plan annual maximum. In conjunction with
covered oral surgery or periodontal surgery. • Local anesthesia - Unlimited per plan year to plan annual maximum. In conjunction with covered oral surgery
or periodontal surgery • Intravenous moderate (conscious) sedation/analgesia - Unlimited per plan year to plan annual maximum. In
conjunction with covered oral surgery or periodontal surgery.
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Vision Services Medicare-covered vision exam
You pay a $0 copay for each Medicare-covered diabetic retinopathy and glaucoma screenings once per calendar year.
You pay a $0 copay for each Medicare-covered diabetic retinopathy and glaucoma screenings once per calendar year.
Medicare-covered vision hardware
You pay $0 copay for one pair of Medicare-covered eyeglasses or contact lenses after each cataract surgery.
You pay $0 copay for one pair of Medicare-covered eyeglasses or contact lenses after each cataract surgery.
Routine vision exam You pay a $20 copay for one routine vision exam per calendar year for the purposes of obtaining eyeglasses or contact lenses. No referral is required for routine vision exam.
Routine vision hardware There is a $150 benefit limit for routine eyeglasses (lenses and frames) or contact lenses per calendar year.
Mental Health Services Inpatient mental health care You pay a $595 copay per day for days 1–2.
You pay $0 copay per day for days 3–90. You pay a $595 copay per day for days 1–2. You pay $0 copay per day for days 3–90.
Outpatient mental health care
Skilled Nursing Facility You pay a $0 copay per day for days 1–20. You pay a $160 copay per day for days 21–60. You pay a $0 copay per day for days 61–100.
You pay a $0 copay per day for days 1–20. You pay a $160 copay per day for days 21–60. You pay a $0 copay per day for days 61–100.
Physical Therapy You pay a $20 copay per visit. You pay a $35 copay per visit. Ambulance You pay a $280 copay each way for
Medicare-covered ambulance transport. You pay a $285 copay each way for Medicare-covered ambulance transport.
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Transportation Not covered. Not covered. Medicare Part B Drugs You pay 20% of the total cost for Medicare-covered
Part B chemotherapy drugs and other Part B drugs. You pay 20% of the total cost for Medicare-covered Part B chemotherapy drugs and other Part B drugs.
Over the Counter (OTC) Receive a $25 quarterly benefit for over-the-counter health and wellness products available through OTC Health Solutions.
Chiropractic Services Medicare-covered copay: $20. Routine Chiropractic Services: 6 visits/ $20 copay.
Acupuncture Medicare-covered copay: $40. Routine Acupuncture: 6 visits/ $20 copay.
Routine Naturopathic Services
Counties: King, Pierce, Snohomish, Thurston, and Whatcom
Premera Blue Cross Medicare Advantage Peak + Rx (HMO)
PRESCRIPTION DRUG BENEFITS (PART D) PRESCRIPTION DRUG BENEFITS (PART D) Deductible Phase
During this stage, you pay the full cost of your Tier 3, 4, and 5 drugs. You stay in this stage until you have paid $160 for your Tier 3, 4, and 5 drugs. During this stage, your out-of-pocket costs for Select Insulins will be $35.
Deductible Phase
Initial Coverage Phase - You begin in this stage when you fill your first prescription of the year. You stay in the Initial Coverage Stage until your total drug costs for the year reach $4,430. During this stage, your out-of-pocket costs for Select Insulins will be $35.
Preferred Retail Cost Sharing (in network) (up to a 30- day supply)
Standard Retail Cost Sharing (in network) (up to 30-day supply)
Long-Term Care Cost Sharing (up to a 31- day supply)
Preferred Retail Cost Sharing (in network) (up to a 30- day supply)
Standard Retail Cost Sharing (in network) (up to 30-day supply)
Long-Term Care Cost Sharing (up to a 31- day supply)
Tier 2: Generic
Tier 2: Generic
You pay $100.
You pay $100.
You pay $300.
You pay $100.
You pay $100.
You pay $100.
You pay $300.
You pay $100.
Tier 5: Specialty
Not offered.
Tier 5: Specialty
Not offered.
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Coverage Gap After you enter the Coverage Gap, you pay 25% of the costs of brand name drugs and 25% of the costs of generic drugs until your out-of-pocket costs reach $7,050, which is the end of the Coverage Gap. During this stage, your out-of-pocket costs for Select Insulins will be $35. Not everyone will reach the Coverage Gap.
Catastrophic Coverage After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $7,050, you pay whichever of these is larger: • 5% of the cost of the drug, or
• $3.95 copay for a generic drug, or a drug that is treated like a generic and $9.85 copay for all other drugs.
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $7,050, you pay whichever of these is larger: • 5% of the cost of the drug, or
• $3.95 copay for a generic drug, or a drug that is treated like a generic and $9.85 copay for all other drugs.
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Counties King, Pierce, Snohomish, Thurston, and Whatcom King, Pierce, Snohomish, and Thurston
Premium and Benefits Premera Blue Cross Medicare Advantage Alpine (HMO)
Premera Blue Cross Medicare Advantage Charter + Rx (HMO)
Premera Blue Cross Medicare Advantage Classic Plus (HMO)
Part C Deductible No deductible. No deductible. No deductible. Part D Deductible Not applicable. $160 per year for Part D
prescription drugs except for drugs listed on Tier 1 and Tier 2, which are excluded from the deductible.
$180 per year for Part D prescription drugs except for drugs listed on Tier 1 and Tier 2, which are excluded from the deductible.
Inpatient Hospital Coverage You pay a $350 copay per day for days 1-4 You pay a $0 copay per day for days 5 and beyond.
Outpatient Hospital Coverage
$350 $290 $250
$90 $290 $250
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Doctor Visits Primary care providers You pay a $0 copay per
office visit. You pay a $0 copay per telehealth visit.
Preventive Care (such as flu vaccine, diabetic screenings)
Emergency Care You pay a $90 copay per visit. Waived, if you are admitted to the hospital within 24 hours.
Includes worldwide coverage.
You pay a $90 copay per visit. Waived, if you are admitted to the hospital within 24 hours.
You pay a $90 copay per visit. Waived, if you are admitted to the hospital within 24 hours.
Urgently Needed Services You pay a $40 copay per visit.
Diagnostic Services/Labs/ Imaging Diagnostic tests and procedures
You pay 20% of the total cost per service location per day.
You pay 20% of the total cost per service location per day.
Lab services You pay a $5 copay per service location per day.
Outpatient x-rays You pay a $10 copay per service location per day.
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Counties King, Pierce, Snohomish, Thurston, and Whatcom King, Pierce, Snohomish, and Thurston
Premium and Benefits Premera Blue Cross Medicare Advantage Alpine (HMO)
Premera Blue Cross Medicare Advantage Charter + Rx (HMO)
Premera Blue Cross Medicare Advantage Classic Plus (HMO)
Therapeutic radiology services (such as radiation treatment for cancer)
Diagnostic radiology services $170 copay per service location per day.
20% of the total cost per service location per day.
20% of the total cost per service location per day.
Routine hearing exam You pay a $0–$50 copay for one routine hearing exam per calendar year. $0 copay through Hearing Care Solutions provid

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