2020 enrollment guide - secure health options · tier 2 (generic) $10 copay tier 3 (preferred...

2020Enrollment Guide

The plan’s service area includes:

Bay, Brevard, Charlotte, Citrus, Collier, Escambia, Lake, Lee, Manatee, Marion, Martin, Santa Rosa, Sarasota, St. Johns, St. Lucie & Sumter Counties

Y0011_34825_M 0819 CMS Accepted

BlueMedicare Classic (HMO) H1035-019

Start here to find the

Medicare Plan that fits your life and budget.

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This booklet will help make enrolling in your BlueMedicareSM plan as easy as possible. It also explains what will happen immediately after you’re enrolled, and how to start finding out just how Blue means more to you.

WelcomeCongratulations for choosing BlueMedicare!

This booklet contains:

Questions? Ask your agent or give us a call.

1-800-876-2227 (TTY: 1-800-955-8770)October 1 to March 31: 7 days a week from 8 a.m. to 8 p.m. local time, except for Thanksgiving and Christmas and from April 1 to September 30: Monday through Friday, from 8 a.m. to 8 p.m. local time

Information on what happens after you enroll in your plan and what to expect

Enrollment steps that will walk you through the process

All the forms you need to enroll in your plan

Information about your plan’s provider network and how to find a doctor

A summary of benefits included in your plan

Information on Medicare prescription drug benefits and how to save as much money as possible on prescription drugs

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About Medicare AdvantageWhat is Medicare Advantage? .......................................... 4

Important Medicare Enrollment Information ..................... 5

My BenefitsBenefits at a Glance ......................................................... 6

Summary of Benefits ........................................................ 9

Enrollment InformationReady to Sign Up? ......................................................... 18

Forms Used for Enrollment............................................. 19

Pre-Enrollment Checklist ................................................ 20

Enrollment Forms ........................................................... 21

Protected Health Information Authorization ................... 33

Scope of Sales Appointment Confirmation Form ........... 37

Enrollment Checklist ....................................................... 45

What’s Next?How to Make the Most of Your Medicare Dollars............ 50

What You Can Expect the First 90 Days ........................ 52

Non-Discrimination Notice .............................................. 53

Table of Contents

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With Original Medicare your out-of-pocket costs, like deductibles, coinsurance and copays, can add up. Medicare Advantage plans like BlueMedicare offer additional benefits and can help you pay fewer out-of-pocket costs than Original Medicare.

ORIGINAL MEDICARE MEDICARE ADVANTAGE

PRESCRIPTION DRUGS

Part C combines Part A, Part B and often Part D plus additional benefits like dental, hearing and vision. Our Florida Blue Medicare Advantage plans include Part D coverage.

Part A covers inpatient hospital and skilled nursing facility care.

Part B covers outpatient services and physician care.

Part D covers prescription drugs.

What is Medicare Advantage?Medicare Advantage plans are health plans offered by private insurers that contract with Medicare.

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Important Medicare Enrollment Information

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Open Enrollment Period (OEP)OEP runs January 1 through March 31. During this period if you are enrolled in a Medicare Advantage (MA) plan, you are allowed to make a one-time election to go to another MA plan or to Original Medicare. If you enroll in Original Medicare, you may also purchase a Medicare Supplement and/or a Prescription Drug Plan.

Note: There is no guaranteed-issue enrollment period for Medicare Supplement plans.

Annual Election Period (AEP) Every year, from October 15 through December 7, you can switch, drop or join the Medicare Advantage or Medicare Prescription Drug Plan of your choosing. You can also enroll in Original Medicare. Your plan selection becomes effective January 1 of the following year.

Initial Enrollment PeriodWhen you become eligible for Medicare, you can enroll in Original Medicare or a Medicare health or Prescription Drug Plan three months before the month you turn 65, the month of your birthday, and the three months after the month of your birthday.

Special Election Period (SEP)After certain events, such as a recent move or losing your employer or union coverage, you may be eligible for a Special Election Period. If you think you qualify, talk to your local sales agent.

Open Enrollment Period

Initial Enrollment Period*

Annual Election Period

Special Election Period

Jan. Feb. Mar. Apr. May June July Aug. Sept. Oct. Nov. Dec.

* 3 months before/after and including the month of your 65th birthday.

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Plan Costs BlueMedicare Classic H1035-019

How much is the monthly premium?

$0 You must continue to pay your Medicare Part B premium.

How much is the deductible? This plan does not have a deductible.

Is there any limit on how much I will pay for my covered services?

$5,000 for services you receive from In-Network providers.

Medical & Hospital BenefitsDoctor’s Office Visits $0 copay Primary Care Physician

$40 copay Specialist

Preventive Care $0 copay

Inpatient Hospital Care Days 1-7: $200 copay per day.

After the 7th day the plan pays 100% of covered expenses.

Outpatient Hospital $175 copay except for Observation Services

$90 copay for Observation Services

Outpatient Surgery $150 copay in an Ambulatory Surgical Center

$175 copay in an Outpatient Hospital Facility

Urgently Needed Services $15 copay at a Convenient Care Center

$45 copay at an Urgent Care Center

Emergency Room $90 copay

Ambulance $300 copay

Benefits at-a-Glance

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Additional BenefitsHearing Services $0 copay for routine hearing exam plus coverage for

hearing aids1

Dental Services $0 copay for cleanings and other preventive services1

Vision Services $0 copay for annual routine eye exam and allowance for purchase of eyewear1

Fitness Gym Membership SilverSneakers® Fitness Program1 See Summary of Benefits for more details

Part D Prescription Drug Benefits2

Tier 1 (Preferred Generic)

$0 copay

Tier 2 (Generic)

$10 copay

Tier 3 (Preferred Brand)

$40 copay

Tier 4 (Non-Preferred Brand/Drug)

$93 copay

Tier 5 (Specialty Tier)

33% coinsurance

Tier 6 (Select Care Drugs)

$0 copay

Mail Order Same copays/coinsurance as Preferred Pharmacy listed above

2 What you pay at a Preferred Pharmacy for a 31-day supply

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2020Summary of Benefits

The plan’s service area includes:Bay, Brevard, Broward, Charlotte, Citrus, Clay, Collier, Duval, Escambia, Lake, Lee, Manatee, Marion, Martin, Santa Rosa, Sarasota, St. Johns, St. Lucie and Sumter Counties

Medicare Advantage Plans with Part D Prescription Drug Coverage

BlueMedicare Classic (HMO) H1035-0191/1/2020 – 12/31/2020

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The benefit information provided is a summary of what we cover and what you pay. To get a complete list of services we cover, call us and ask for the “Evidence of Coverage.” You may also view the “Evidence of Coverage” for this plan on our website, www.floridablue.com/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 http://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.

Who Can Join?To join, you must:

be entitled to Medicare Part A; and be enrolled in Medicare Part B; and live in our service area.

Our service area includes the following counties in Florida: Bay, Brevard, Broward, Charlotte, Citrus, Clay, Collier, Duval, Escambia, Lake, Lee, Manatee, Marion, Martin, Santa Rosa, Sarasota, St. Johns, St. Lucie and Sumter.

Which doctors, hospitals, and pharmacies can I use?We have a network of doctors, hospitals, pharmacies, and other providers. If you use 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 our website

(www.floridablue.com/medicare). Or call us and we will send you a copy of the provider and pharmacy directories.

Have Questions? Call Us If you are a member of this plan, call us at 1-800-926-6565, TTY: 1-800-955-8770. If you are not a member of this plan, call us at 1-855-601-9465, TTY: 1-800-955-8770.

o We are available October 1 to March 31, 7 days a week from 8:00 a.m. to 8:00 p.m. local time, except for Thanksgiving and Christmas.

o From April 1 to September 30, we are open Monday through Friday, from 8:00 a.m. to 8:00 p.m. local time.

Or visit our website at www.floridablue.com/medicare

Important InformationThrough this document you will see the symbols below.

* Services with this symbol may require approval in advance (a referral) from your Primary Care Doctor(PCP) in order for the plan to cover them.

◊ Services with this symbol may require prior authorization from the plan before you receive services.

If you do not get a referral or prior authorization when required, you may have to pay the full cost of the services. Please contact your PCP or refer to the Evidence of Coverage (EOC) for more information about services that require a referral and/or prior authorization from the plan.

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The benefit information provided is a summary of what we cover and what you pay. To get a complete list of services we cover, call us and ask for the “Evidence of Coverage.” You may also view the “Evidence of Coverage” for this plan on our website, www.floridablue.com/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 http://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.

Who Can Join?To join, you must:

be entitled to Medicare Part A; and be enrolled in Medicare Part B; and live in our service area.

Our service area includes the following counties in Florida: Bay, Brevard, Broward, Charlotte, Citrus, Clay, Collier, Duval, Escambia, Lake, Lee, Manatee, Marion, Martin, Santa Rosa, Sarasota, St. Johns, St. Lucie and Sumter.

Which doctors, hospitals, and pharmacies can I use?We have a network of doctors, hospitals, pharmacies, and other providers. If you use 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 our website

(www.floridablue.com/medicare). Or call us and we will send you a copy of the provider and pharmacy directories.

Have Questions? Call Us If you are a member of this plan, call us at 1-800-926-6565, TTY: 1-800-955-8770. If you are not a member of this plan, call us at 1-855-601-9465, TTY: 1-800-955-8770.

o We are available October 1 to March 31, 7 days a week from 8:00 a.m. to 8:00 p.m. local time, except for Thanksgiving and Christmas.

o From April 1 to September 30, we are open Monday through Friday, from 8:00 a.m. to 8:00 p.m. local time.

Or visit our website at www.floridablue.com/medicare

Important InformationThrough this document you will see the symbols below.

* Services with this symbol may require approval in advance (a referral) from your Primary Care Doctor(PCP) in order for the plan to cover them.

◊ Services with this symbol may require prior authorization from the plan before you receive services.

If you do not get a referral or prior authorization when required, you may have to pay the full cost of the services. Please contact your PCP or refer to the Evidence of Coverage (EOC) for more information about services that require a referral and/or prior authorization from the plan.

Monthly Premium, Deductible and LimitsMonthly Plan Premium $0

You must continue to pay your Medicare Part B premium

Deductible This plan does not have a deductible

Maximum Out-of-Pocket Responsibility $5,000 is the most you pay for copays, coinsurance and other costs for Medicare-covered medical services from in-network providers for the year

Medical and Hospital Benefits

Inpatient Hospital Care ◊ $200 copay per day, days 1-7 $0 copay per day after day 7

Outpatient Hospital Care $175 copay per visit for Medicare-covered services ◊ $90 copay per visit for Medicare-covered observation services

Ambulatory Surgery Center ◊

$150 copay for surgery services provided at an Ambulatory Surgery Center

Doctor’s Office Visits $0 copay per primary care visit $40 copay per specialist* visit

Preventive Care $0 copay for Medicare-covered services Abdominal aortic aneurysm

screening Alcohol misuse screening and

counseling Annual Wellness Visit Bone mass measurements Breast cancer screening

(mammograms) Cardiovascular disease screening

and intensive behavioral therapy Cervical and vaginal cancer

screening Colorectal cancer screening Depression screening Diabetes screening and self-

management training Glaucoma screening Hepatitis B and C screening HIV screening Intensive Behavioral Therapy for

Obesity Lung cancer screening

Medical nutrition therapy Prostate cancer screening Sexually transmitted infections -

screening and high-intensitybehavioral counseling to prevent them

Smoking and tobacco use cessation counseling

Vaccines for influenza, pneumonia and Hepatitis B

Welcome to Medicare preventive visit

Any additional preventive services approved by Medicare during the contract year will be covered.

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Emergency Care Medicare-Covered Emergency Care $90 copay per visit, in- or out-of-networkThis copay is waived if you are admitted to the hospital within 48 hours of an emergency room visit.Worldwide Emergency Care Services $125 copay for Worldwide Emergency Care $25,000 combined yearly limit for Worldwide Emergency Care and

Worldwide Urgently Needed ServicesDoes not include emergency transportation.

Urgently Needed Services Medicare-Covered Urgently Needed ServicesUrgently needed services are provided to treat a non-emergency, unforeseen medical illness, injury or condition that requires immediate medical attention. $45 copay at an Urgent Care Center, in- or out-of-networkConvenient Care Services are outpatient services for non-emergency injuries and illnesses that need treatment when most family physician offices are closed.

$15 copay at a Convenient Care Center, in- or out-of-networkWorldwide Urgently Needed Services $125 copay for Worldwide Urgently Needed Services $25,000 combined yearly limit for Worldwide Emergency Care and

Worldwide Urgently Needed ServicesDoes not include emergency transportation.

Diagnostic Services/ Labs/Imaging*◊

Laboratory Services $0 copay at an Independent Clinical Laboratory $50 copay at an outpatient hospital facilityX-Rays $0 copay at an Independent Diagnostic Testing Facility (IDTF) $100 copay at an outpatient hospital facilityAdvanced Imaging Services Includes services such as Magnetic Resonance Imaging (MRI), Positron Emission Tomography (PET), and Computer Tomography (CT) Scan. $25 copay at a specialist’s office or at an IDTF $225 copay at an outpatient hospital facilityRadiation Therapy 20% coinsurance

Hearing Services Medicare-Covered Hearing Services* $40 copay for exams to diagnose and treat hearing and balance issues

Additional Hearing Services $0 copay for one routine hearing exam per year $0 copay for evaluation and fitting of hearing aids $699 or $999 copay per aid (two hearing aids per year)

Dental Services Medicare-Covered Dental Services $40 copay for non-routine dental care ◊Additional Dental Services $0 copay for covered preventive dental services $0 copay for covered comprehensive dental services

Vision Services Medicare-Covered Vision Services $40 copay for physician services to diagnose and treat eye diseases and

conditions* $0 copay for glaucoma screening (once per year for members at high

risk of glaucoma) $0 copay for one diabetic retinal exam per year $0 copay for one pair of eyeglasses or contact lenses after each cataract

surgery

Additional Vision Services $0 copay for an annual routine eye examination $100 maximum allowance per year towards the purchase of lenses,

frames or contact lenses

Mental Health Care ◊ Inpatient Mental Health Services $300 copay per day for days 1-5 $0 copay per day for days 6-90 190-day lifetime benefit maximum in a psychiatric hospitalOutpatient Mental Health Services $40 copay

Skilled Nursing Facility (SNF) ◊

$0 copay per day for days 1-20 $160 copay per day days 21-100 Our plan covers up to 100 days in a SNF per benefit period.

Physical Therapy*◊ $35 copay per visit

Ambulance ◊ $300 copay for each Medicare-covered trip (one-way)

Transportation Not covered

Medicare Part B Drugs ◊ $5 copay for allergy injections 20% coinsurance for chemotherapy drugs and other Medicare Part B-

covered drugs

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Part D Prescription Drug BenefitsDeductible StageThis plan does not have a deductible.

Initial Coverage StageYou begin in this stage when you fill your first prescription of the year. During this stage, the plan pays its share of the cost of your drugs and you pay your share of the cost.

You remain in this stage until your total yearly drug costs (total drug costs paid by you and any Part D plan) reach $4,020. You may get your drugs at network retail pharmacies and mail order pharmacies. Cost sharing below applies to a one-month (31 day) supply.

Preferred Retail Standard Retail Mail Order

Tier 1 -Preferred Generic $0copay $10 copay $0 copay

Tier 2 -Generic $10copay $15 copay $10 copay

Tier 3 - Preferred Brand $40copay $47 copay $40 copay

Tier 4 - Non-Preferred Brand/Drug $93copay $100 copay $93 copay

Tier 5 - Specialty Tier 33%of the cost 33%of the cost 33%of the cost

Tier 6 –Select Care Drugs $0copay $0 copay $0 copay

Coverage Gap StageMost Medicare drug plans have a coverage gap (also called the "donut hole"). This means that there's a temporary change in what you will pay for your drugs. The Coverage Gap Stage begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $4,020. You stay in this stage until your year-to-date “out-of-pocket” costs reach a total of $6,350.During the Coverage Gap Stage: You pay the same copays that you paid in the Initial Coverage Stage for drugs in Tier 1 (Preferred

Generic) and Tier 6 (Select Care Drugs) – or 25%of the cost, whichever is lower For generic drugs in all other tiers, you pay 25%of the cost For brand-name drugs, you pay 25%of the cost (plus a portion of the dispensing fee)

Catastrophic Coverage StageAfter your yearly out-of-pocket drug costs reach $6,350, you pay the greater of: $3.60 copay for generic drugs in all tiers (including brand drugs treated as generic) and a $8.95 copay

for all other drugs in all tiers, or 5% of the cost.

Additional Drug Coverage Please 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 you request and the plan approves a formulary exception, you will pay Tier 4 (Non-Preferred Brand/Drug) cost sharing.

Your cost-sharing may be different if you use a Long-Term Care pharmacy, a home infusion pharmacy, or an out-of-network pharmacy, or if you purchase a long-term supply (up to 90 days) of a drug.

Additional Benefits

Diabetic Supplies ◊ $0 copay at your network retail or mail-order pharmacy for Diabetic Supplies such as:

• Needles• Syringes• Lifescan (One Touch®) Glucose Meters• Lancets• Test Scripts

Medicare Diabetes Prevention Program

$0 copay for Medicare-covered services

Podiatry $30 copay for each Medicare-covered podiatry visit

Chiropractic $20 copay for each Medicare-covered chiropractic visit

Medical Equipment and Supplies ◊

20% coinsurance for all plan approved, Medicare-covered motorized wheelchairs and electric scooters

0% coinsurance for all other plan approved, Medicare-covered durable medical equipment

Outpatient Occupational and Speech Therapy *◊ $35 copay per visit

You Get More with BlueMedicare

HealthyBlue Rewards Your BlueMedicare plan rewards you for taking care of your health. Redeem gift card rewards for completing and reporting preventive care and screenings

SilverSneakers®Fitness Program

College Save: As a SilverSneakers member, you can accumulate tuition discount points for savings on college tuition (up to one year off full tuition) for students that you designate

Gym membership and classes available at 16,000+ fitness locations across the country, including national chains and local gyms

Access to exercise equipment and other amenities, classes for all levels and abilities, social events, and more

Classes such as line dance and Latin-style dance, indoor and outdoor boot camp, walking groups, and many more

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DisclaimersFlorida Blue Medicare is an HMO plan with a Medicare contract. Enrollment in Florida Blue Medicare depends on contract renewal. This information is not a complete description of benefits. Call 1-855-601-9465 (TTY: 1-800-955-8770) for more information. If you have any questions please contact our Member Services at 1-800-926-6565. (TTY users should call 1-800-955-8770.) Hours are 8:00 a.m. – 8:00 p.m. local time, seven days a week, from October 1 – March 31, except for Thanksgiving and Christmas. From April 1 to September 30, we are open Monday – Friday, 8:00 a.m. – 8:00 p.m. local time.

ATTENTION: If you speak Spanish, language assistance services, free of charge, are available to you. Call 1-800-926-6565 (TTY: 1-800-955-8770). ATENCIÓN: Si habla español, hay servicios de traducción, libre de cargos, disponibles para usted. Llame al 1-800-926-6565 (TTY: 1-877-955-8773).

HMO coverage is offered by Florida Blue Medicare, Inc., dba Florida Blue Medicare, an Independent Licensee of the Blue Cross and Blue Shield Association.

Plans may offer supplemental benefits in addition to Part C benefits and Part D benefits.

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DisclaimersFlorida Blue Medicare is an HMO plan with a Medicare contract. Enrollment in Florida Blue Medicare depends on contract renewal. This information is not a complete description of benefits. Call 1-855-601-9465 (TTY: 1-800-955-8770) for more information. If you have any questions please contact our Member Services at 1-800-926-6565. (TTY users should call 1-800-955-8770.) Hours are 8:00 a.m. – 8:00 p.m. local time, seven days a week, from October 1 – March 31, except for Thanksgiving and Christmas. From April 1 to September 30, we are open Monday – Friday, 8:00 a.m. – 8:00 p.m. local time.

ATTENTION: If you speak Spanish, language assistance services, free of charge, are available to you. Call 1-800-926-6565 (TTY: 1-800-955-8770). ATENCIÓN: Si habla español, hay servicios de traducción, libre de cargos, disponibles para usted. Llame al 1-800-926-6565 (TTY: 1-877-955-8773).

HMO coverage is offered by Florida Blue Medicare, Inc., dba Florida Blue Medicare, an Independent Licensee of the Blue Cross and Blue Shield Association.

Plans may offer supplemental benefits in addition to Part C benefits and Part D benefits.

EnrollmentForms

Steps that will walk you through the process and all the forms you need to enroll in your plan

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Ready to sign up?

Helpful tips for filling out your enrollment form.

Paper: Use the paper enrollment form that is included in this enrollment kit. Once you are done filling it out, you can mail the form to Florida Blue. (One form must be filled out for each person who enrolls.)

Online: Use the online form at floridablue.com/medicare. You’ll be guided through the process of completing and submitting the enrollment form and the system will prompt you if you left anything missing or incomplete.

Licensed Sales Agent: An agent can help you choose the best plan for YOU and can also offer you help in filling out and submitting the enrollment form. The agent will be employed by or contracted with Florida Blue and may be paid based on your enrollment in a plan.

Have your Medicare ID card handy, and let’s get started!

3 No matter which way you choose to enroll, make sure you don’t skip any sections. If you leave out information, it may delay your start date.

3 When choosing a plan, select only ONE plan name.3 Where requested, be sure to fill in the Part A and Part B effective dates from your Medicare ID card.3 If you choose an HMO plan, write in your choice for a primary care physician (PCP). If you do not

write in your choice for a PCP, one will be assigned to you. 3 If you are not signing up between October 15 and December 7, be sure to complete the “Attestation

of Eligibility for an Enrollment Period” section.

• Visit your local Florida Blue Center or agent; or

• Call and speak with one of our agents at 1-800-876-2227 (TTY 1-800-955-8770.)

Choose the way to enroll that’s best for you.

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Forms Used for Enrollment

1 Pre-Enrollment Checklist

This form provides important information you need to know before purchasing a plan.

2 Individual Enrollment Form

This is the form you complete to enroll in a Florida Blue Medicare Advantage plan. This booklet contains two enrollment forms.

3 Protected Health Information Authorization for Customer Service Inquiries

Complete this form if you need to give us permission to release your health information to someone. Send the original, not a photocopy, with your enrollment form. Otherwise, we will protect this information and release it only to you.

4 Scope of Sales Appointment (SOA) Confirmation Form

According to Medicare guidelines, agents can talk to you only about products you choose to discuss. Medicare asks you to complete an SOA form that shows which Medicare Advantage and/or Medicare Prescription Drug plans you wish to discuss. The form is intended to protect you. Completing the form does not mean you have enrolled in a plan. Your agent can complete this form with you by phone instead of using a paper copy.

5 Enrollment Verification Checklist

When you meet with an agent to enroll in a plan, the agent will look up how your plan covers medications that you take (including cost, tier and requirements/limitations). Your agent will also look up providers you use to see if they are in your network. Your agent will fill out this information on an enrollment verification checklist they provide and that you can take with you.

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1

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Pre-Enrollment Checklist

Before making an enrollment decision, it is important that you fully understand our benefits and rules. If you have any questions, you can call and speak to a customer service representative at 1-855-601-9465 (TTY: 1-800-955-8770).

Understanding the Benefits

Review the full list of benefits found in the Evidence of Coverage (EOC), especially for those services that you routinely receive from a doctor. Visit floridablue.com/medicare or call 1-855-601-9465 (TTY:1-800-955-8770) to view a copy of the EOC.

Review the provider directory (or ask your doctors) to make sure the doctors you see now are in the network. If they are not listed, it means you will likely have to select new doctors.

Review the pharmacy directory to make sure the pharmacy you use for prescription medicines is in the network. If the pharmacy is not listed, you will likely have to select a new pharmacy for your prescriptions.

Understanding Important Rules

In addition to your monthly plan premium, you must continue to pay your Medicare Part B premium. This premium is normally taken out of your Social Security check each month.

Benefits, premiums and/or copayments/co-insurance may change on January 1, 2021.

Except in emergency or urgent situations, we do not cover services provided by out-of-network providers (doctors who are not listed in the provider directory).

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2


P.O. Box 45296 | Jacksonville, FL 32232-5296

BlueMedicareSM Classic (HMO)BlueMedicareSM Classic Plus (HMO)

BlueMedicareSM Premier (HMO)BlueMedicareSM Saver (HMO)

Please contact BlueMedicare Classic, BlueMedicare Classic Plus, BlueMedicare Premier or BlueMedicare Saver if you need information in another language or format (Braille).

To Enroll in BlueMedicare Classic, BlueMedicare Classic Plus, BlueMedicare Premier or BlueMedicare Saver, please provide the following information:

Please check which plan you want to enroll in: BlueMedicare Classic (HMO) $0 per month BlueMedicare Classic Plus (HMO) $0 per month BlueMedicare Premier (HMO) $0 per month BlueMedicare Saver (HMO) $0 per month

Last Name: First Name: Middle Initial: Mr. Mrs. Ms.

Birth Date:

Sex: M F

Home Phone Number:( )

Alternate Phone Number:( )

Permanent Residence Street Address (P.O. Box is not allowed):

City: County: State: ZIP Code:

Mailing Address (only if different from your Permanent Residence Address):Street Address: City: State: ZIP Code:

E-mail Address:

Please provide your Medicare insurance information:Please take out your red, white and blue Medicare card to complete this section.

• Fill out this information as it appears on your Medicare card.

- OR -

• Attach a copy of your Medicare card or your letter from Social Security or the Railroad Retirement Board.

Name (as it appears on your Medicare card): ____________________________________________

Medicare Number:____________________________________________

Is Entitled To Effective DateHOSPITAL (PART A) _____________

MEDICAL (PART B) _____________You must have Medicare Part A and Part B to join a Medicare Advantage plan.

Individual Enrollment FormA Medicare Advantage Health Care Plan

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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 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, 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 the RRB. DO NOT pay BlueMedicare Classic, BlueMedicare Classic Plus, BlueMedicare Premier or BlueMedicare Saver 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 co-insurance. 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 1-800-772-1213. TTY users should call 1-800-325-0778. 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 bill

Electronic Funds Transfer (EFT) from your bank account each month. Please enclose a VOIDED check or provide the following:Account holder name: ____________________________________________________________________________Bank routing number: ___________________________ Bank account number: ___________________________Account type: Checking Saving

Automatic deduction from your monthly Social Security or Railroad Retirement Board (RRB) benefit check

I get monthly benefits from: Social Security RRB(The Social Security/RRB deduction may take two or more months to begin after Social Security or RRB approves the deduction. In most cases, if Social Security or RRB accepts your request for automatic deduction, the first deduction from your Social Security or RRB benefit check will include all premiums due from your enrollment effective date up to the point withholding begins. If Social Security or RRB does not approve your request for automatic deduction, we will send you a paper bill for your monthly premiums.)

Please read and answer these important questions:1. Do you have End-Stage Renal Disease (ESRD)? Yes No

If you have had a successful kidney transplant and/or you don’t need regular dialysis any more, please attach a note or records from your doctor showing you have had a successful kidney transplant or you don’t need dialysis; otherwise we may need to contact you to obtain additional information.

2. Some individuals may have other drug coverage, including other private insurance, TRICARE, Federal employee health benefits coverage, VA benefits, or State pharmaceutical assistance programs.Will you have other prescription drug coverage in addition to BlueMedicare Classic, BlueMedicare Classic Plus, BlueMedicare Premier or BlueMedicare Saver? Yes NoIf “yes,” please list your other coverage and your identification (ID) number(s) for this coverage:Name of other coverage ID # for this coverage: Group # for this coverage: ______________________________________ ___________________________ ___________________________

– 22 – – 23 –Y0011_34977_M 0819 CMS Accepted

3. Are you a resident in a long-term care facility, such as a nursing home? Yes NoIf “yes,” please provide the following information:

Name of Institution: ___________________________________________________________________________________

Address & Phone Number of Institution (number and street): _____________________________________________________________________________________________________________________________________________________

4. Are you enrolled in your State Medicaid program? Yes NoIf “yes,” please provide your Medicaid number: _____________________________________________________________

5. Do you or your spouse work? Yes NoPlease choose the name of a Primary Care Physician (PCP), clinic or health center: ___________________________________________________________________________________________________________________________________

Please check one of the boxes below if you would prefer us to send you information in a language other than English or in an accessible format: Spanish Braille, audio tape, large print

Please contact BlueMedicare Classic, BlueMedicare Classic Plus, BlueMedicare Premier or BlueMedicare Saver at 1-800-926-6565 if you need information in an accessible format or language other than what is listed above. Our office hours are 8 a.m. - 8 p.m. local time, seven days a week from October 1 - March 31, except for Thanksgiving and Christmas. However, from April 1 - September 30, our hours are 8 a.m. - 8 p.m. local time, five days a week. You will have to leave a message on Saturdays, Sundays and Federal holidays. We will return your call within one business day. TTY users should call 1-800-955-8770.

Please Read This Important Information

If you currently have health coverage from an employer or union, joining BlueMedicare Classic, BlueMedicare Classic Plus, BlueMedicare Premier or BlueMedicare Saver could affect your employer or union health benefits. You could lose your employer or union health coverage if you join BlueMedicare Classic, BlueMedicare Classic Plus, BlueMedicare Premier or BlueMedicare Saver. Read the communications your employer or union sends you. If you have questions, visit their website, or contact the office listed in their communications. If there isn’t any information on whom to contact, your benefits administrator or the office that answers questions about your coverage can help.

Attestation of Eligibility for an Enrollment PeriodTypically, you may enroll in a Medicare Advantage plan only during the annual enrollment period from October 15 through December 7 of each year. There are exceptions that may allow you to enroll in a Medicare Advantage plan outside of this period. Please read the following statements carefully and check the box if the statement applies to you. By checking any of the following boxes, you are certifying that, to the best of your knowledge, you are eligible for an Enrollment Period. If we later determine that this information is incorrect, you may be disenrolled.

I am new to Medicare. I am enrolled in a Medicare Advantage plan and want to make a change during the Medicare Advantage Open Enrollment Period (MA OEP).

I recently moved outside of the service area for my current plan or I recently moved and this plan is a new option for me. I moved on (insert date):

I recently was released from incarceration. I was released on (insert date): I recently returned to the United States after living permanently outside of the U.S. I returned to the U.S. on (insert date):

– 24 – – 25 –Y0011_34977_M 0819 CMS Accepted

I recently obtained lawful presence status in the United States. I got this status on (insert date): I recently had a change in my Medicaid (newly got Medicaid, had a change in level of Medicaid assistance, or lost Medicaid). on (insert date):

I recently had a change in my Extra Help paying for Medicare prescription drug coverage (newly got Extra Help, had a change in the level of Extra Help, or lost Extra Help) on (insert date):

I have both Medicare and Medicaid (or my state helps pay for my Medicare premiums) or I get Extra Help paying for my Medicare prescription drug coverage, but I haven’t had a change.

I am moving into, live in, or recently moved out of a Long-Term Care Facility (for example, a nursing home or long-term care facility). I moved/will move into/out of the facility on (insert date):

I recently left a PACE program on (insert date): I recently involuntarily lost my creditable prescription drug coverage (coverage as good as Medicare’s). I lost my drug coverage on (insert date):

I am leaving employer or union coverage on (insert date): I belong to a pharmacy assistance program provided by my state. My plan is ending its contract with Medicare, or Medicare is ending its contract with my plan. I was enrolled in a plan by Medicare (or my state) and I want to choose a different plan. My enrollment in that plan started on (insert date):

I was enrolled in a Special Needs Plan (SNP) but I have lost the special needs qualification required to be in that plan. I was disenrolled from the SNP on (insert date):

I was affected by a weather-related emergency or major disaster (as declared by the Federal Emergency Management Agency (FEMA)). One of the other statements here applied to me, but I was unable to make my enrollment because of the natural disaster.

If none of these statements applies to you or you’re not sure, please contact BlueMedicare Classic, BlueMedicare Classic Plus, BlueMedicare Premier or BlueMedicare Saver at 1-800-876-2227 (TTY users should call 1-800-955-8770) to see if you are eligible to enroll. We are open 8 a.m. - 8 p.m. local time, 7 days a week from October 1 - March 31, except for Thanksgiving and Christmas. From April 1 - September 30, we are open Monday - Friday, 8 a.m. - 8 p.m. and Saturday 8:30 a.m. - 4:30 p.m. local time.

Please Read and Sign BelowBy completing this enrollment application, I agree to the following:BlueMedicare Classic, BlueMedicare Classic Plus, BlueMedicare Premier or BlueMedicare Saver is a Medicare Advantage plan and has a contract with the Federal government. I will need to keep my Medicare Parts A and B. I can be in only one Medicare Advantage plan at a time, and I understand that my enrollment in this plan will automatically end my enrollment in another Medicare health plan or prescription drug plan. It is my responsibility to inform you of any prescription drug coverage that I have or may get in the future. Enrollment in this plan is generally for the entire year. Once I enroll, I may leave this plan or make changes only at certain times of the year when an enrollment period is available (Example: October 15 - December 7 of every year), or under certain special circumstances.BlueMedicare Classic, BlueMedicare Classic Plus, BlueMedicare Premier or BlueMedicare Saver serves a specific service area. If I move out of the area that BlueMedicare Classic, BlueMedicare Classic Plus, BlueMedicare Premier or BlueMedicare Saver serves, I need to notify the plan so I can disenroll and find a new plan in my new area. Once I am a member of BlueMedicare Classic, BlueMedicare Classic Plus, BlueMedicare Premier or BlueMedicare Saver, I have the right to appeal plan decisions about payment or services if I disagree. I will read the Evidence of Coverage document from BlueMedicare Classic, BlueMedicare Classic Plus, BlueMedicare Premier or BlueMedicare Saver when I get it to know which rules I must follow to get coverage with this Medicare Advantage Plan. I understand that people with Medicare aren’t usually covered under Medicare while out of the country except for limited coverage near the U.S. border. I understand that beginning on the date BlueMedicare Classic, BlueMedicare Classic Plus, BlueMedicare Premier or BlueMedicare Saver coverage begins, I must get all of my health care from BlueMedicare Classic, BlueMedicare Classic Plus, BlueMedicare Premier or BlueMedicare Saver, except for emergency or urgently needed services or out-of-area dialysis

– 24 – – 25 –Y0011_34977_M 0819 CMS Accepted

services. Services authorized by BlueMedicare Classic, BlueMedicare Classic Plus, BlueMedicare Premier or BlueMedicare Saver and other services contained in my BlueMedicare Classic, BlueMedicare Classic Plus, BlueMedicare Premier or BlueMedicare Saver Evidence of Coverage document (also known as a member contract or subscriber agreement) will be covered. Without authorization, NEITHER MEDICARE NOR BLUEMEDICARE CLASSIC, BLUEMEDICARE CLASSIC PLUS, BLUEMEDICARE PREMIER OR BLUEMEDICARE SAVER WILL PAY FOR THE SERVICES.I understand that if I am getting assistance from a sales agent, broker, or other individual employed by or contracted with BlueMedicare Classic, BlueMedicare Classic Plus, BlueMedicare Premier or BlueMedicare Saver, he/she may be paid based on my enrollment in BlueMedicare Classic, BlueMedicare Classic Plus, BlueMedicare Premier or BlueMedicare Saver. Release of Information: By joining this Medicare health plan, I acknowledge that BlueMedicare Classic, BlueMedicare Classic Plus, BlueMedicare Premier or BlueMedicare Saver will release my information to Medicare and other plans as is necessary for treatment, payment and health care operations. I also acknowledge that BlueMedicare Classic, BlueMedicare Classic Plus, BlueMedicare Premier or BlueMedicare Saver 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 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 Number: - - Relationship to Enrollee: _______________________________________________________________________________

Office Use Only:Name of staff member/agent/broker (if assisted in enrollment):_________________________________________________Plan ID #: _________________________________________Effective Date of Coverage: ___________________________ICEP/IEP: ________________________________________AEP: ____________________________________________SEP (type): _______________________________________Not Eligible: _______________________________________

Entity Name:_______________________________________________ Five digit Entity ID number (if known):

Date Received by agent: __________________________Florida Blue Agent ID #: ___________________________Agent State License #: ____________________________Agent Confirmation #: ____________________________

PCP First Name: ________________________________PCP Last Name: ________________________________PCP’s FL Blue Provider ID Number

- (ie: 12345 or 12345A)PCP’s 10-digit National Provider ID (NPI) Number:

Is enrollee currently a patient of this PCP? Yes No

Physician Group Name: _______________________________________________Physician Group’s FL Blue Provider ID Number

- (ie: 12345 or 12345A)Physician Group’s 10-digit National Provider ID (NPI) Number: Is enrollee currently a patient of this Physician Group?

Yes No

– 26 – – 27 –

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– 26 – – 27 –

2


P.O. Box 45296 | Jacksonville, FL 32232-5296

BlueMedicareSM Classic (HMO)BlueMedicareSM Classic Plus (HMO)

BlueMedicareSM Premier (HMO)BlueMedicareSM Saver (HMO)

Please contact BlueMedicare Classic, BlueMedicare Classic Plus, BlueMedicare Premier or BlueMedicare Saver if you need information in another language or format (Braille).

To Enroll in BlueMedicare Classic, BlueMedicare Classic Plus, BlueMedicare Premier or BlueMedicare Saver, please provide the following information:

Please check which plan you want to enroll in: BlueMedicare Classic (HMO) $0 per month BlueMedicare Classic Plus (HMO) $0 per month BlueMedicare Premier (HMO) $0 per month BlueMedicare Saver (HMO) $0 per month

Last Name: First Name: Middle Initial: Mr. Mrs. Ms.

Birth Date:

Sex: M F

Home Phone Number:( )

Alternate Phone Number:( )

Permanent Residence Street Address (P.O. Box is not allowed):

City: County: State: ZIP Code:

Mailing Address (only if different from your Permanent Residence Address):Street Address: City: State: ZIP Code:

E-mail Address:

Please provide your Medicare insurance information:Please take out your red, white and blue Medicare card to complete this section.

• Fill out this information as it appears on your Medicare card.

- OR -

• Attach a copy of your Medicare card or your letter from Social Security or the Railroad Retirement Board.

Name (as it appears on your Medicare card): ____________________________________________

Medicare Number:____________________________________________

Is Entitled To Effective DateHOSPITAL (PART A) _____________

MEDICAL (PART B) _____________You must have Medicare Part A and Part B to join a Medicare Advantage plan.

Individual Enrollment FormA Medicare Advantage Health Care Plan

– 28 – – 29 –Y0011_34977_M 0819 CMS Accepted

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 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, 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 the RRB. DO NOT pay BlueMedicare Classic, BlueMedicare Classic Plus, BlueMedicare Premier or BlueMedicare Saver 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 co-insurance. 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 1-800-772-1213. TTY users should call 1-800-325-0778. 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 bill

Electronic Funds Transfer (EFT) from your bank account each month. Please enclose a VOIDED check or provide the following:Account holder name: ____________________________________________________________________________Bank routing number: ___________________________ Bank account number: ___________________________Account type: Checking Saving

Automatic deduction from your monthly Social Security or Railroad Retirement Board (RRB) benefit check

I get monthly benefits from: Social Security RRB(The Social Security/RRB deduction may take two or more months to begin after Social Security or RRB approves the deduction. In most cases, if Social Security or RRB accepts your request for automatic deduction, the first deduction from your Social Security or RRB benefit check will include all premiums due from your enrollment effective date up to the point withholding begins. If Social Security or RRB does not approve your request for automatic deduction, we will send you a paper bill for your monthly premiums.)

Please read and answer these important questions:1. Do you have End-Stage Renal Disease (ESRD)? Yes No

If you have had a successful kidney transplant and/or you don’t need regular dialysis any more, please attach a note or records from your doctor showing you have had a successful kidney transplant or you don’t need dialysis; otherwise we may need to contact you to obtain additional information.

2. Some individuals may have other drug coverage, including other private insurance, TRICARE, Federal employee health benefits coverage, VA benefits, or State pharmaceutical assistance programs.Will you have other prescription drug coverage in addition to BlueMedicare Classic, BlueMedicare Classic Plus, BlueMedicare Premier or BlueMedicare Saver? Yes NoIf “yes,” please list your other coverage and your identification (ID) number(s) for this coverage:Name of other coverage ID # for this coverage: Group # for this coverage: ______________________________________ ___________________________ ___________________________

– 28 – – 29 –Y0011_34977_M 0819 CMS Accepted

3. Are you a resident in a long-term care facility, such as a nursing home? Yes NoIf “yes,” please provide the following information:

Name of Institution: ___________________________________________________________________________________

Address & Phone Number of Institution (number and street): _____________________________________________________________________________________________________________________________________________________

4. Are you enrolled in your State Medicaid program? Yes NoIf “yes,” please provide your Medicaid number: _____________________________________________________________

5. Do you or your spouse work? Yes NoPlease choose the name of a Primary Care Physician (PCP), clinic or health center: ___________________________________________________________________________________________________________________________________

Please check one of the boxes below if you would prefer us to send you information in a language other than English or in an accessible format: Spanish Braille, audio tape, large print

Please contact BlueMedicare Classic, BlueMedicare Classic Plus, BlueMedicare Premier or BlueMedicare Saver at 1-800-926-6565 if you need information in an accessible format or language other than what is listed above. Our office hours are 8 a.m. - 8 p.m. local time, seven days a week from October 1 - March 31, except for Thanksgiving and Christmas. However, from April 1 - September 30, our hours are 8 a.m. - 8 p.m. local time, five days a week. You will have to leave a message on Saturdays, Sundays and Federal holidays. We will return your call within one business day. TTY users should call 1-800-955-8770.

Please Read This Important Information

If you currently have health coverage from an employer or union, joining BlueMedicare Classic, BlueMedicare Classic Plus, BlueMedicare Premier or BlueMedicare Saver could affect your employer or union health benefits. You could lose your employer or union health coverage if you join BlueMedicare Classic, BlueMedicare Classic Plus, BlueMedicare Premier or BlueMedicare Saver. Read the communications your employer or union sends you. If you have questions, visit their website, or contact the office listed in their communications. If there isn’t any information on whom to contact, your benefits administrator or the office that answers questions about your coverage can help.

Attestation of Eligibility for an Enrollment PeriodTypically, you may enroll in a Medicare Advantage plan only during the annual enrollment period from October 15 through December 7 of each year. There are exceptions that may allow you to enroll in a Medicare Advantage plan outside of this period. Please read the following statements carefully and check the box if the statement applies to you. By checking any of the following boxes, you are certifying that, to the best of your knowledge, you are eligible for an Enrollment Period. If we later determine that this information is incorrect, you may be disenrolled.

I am new to Medicare. I am enrolled in a Medicare Advantage plan and want to make a change during the Medicare Advantage Open Enrollment Period (MA OEP).

I recently moved outside of the service area for my current plan or I recently moved and this plan is a new option for me. I moved on (insert date):

I recently was released from incarceration. I was released on (insert date): I recently returned to the United States after living permanently outside of the U.S. I returned to the U.S. on (insert date):

– 30 – – 31 –Y0011_34977_M 0819 CMS Accepted

I recently obtained lawful presence status in the United States. I got this status on (insert date): I recently had a change in my Medicaid (newly got Medicaid, had a change in level of Medicaid assistance, or lost Medicaid). on (insert date):

I recently had a change in my Extra Help paying for Medicare prescription drug coverage (newly got Extra Help, had a change in the level of Extra Help, or lost Extra Help) on (insert date):

I have both Medicare and Medicaid (or my state helps pay for my Medicare premiums) or I get Extra Help paying for my Medicare prescription drug coverage, but I haven’t had a change.

I am moving into, live in, or recently moved out of a Long-Term Care Facility (for example, a nursing home or long-term care facility). I moved/will move into/out of the facility on (insert date):

I recently left a PACE program on (insert date): I recently involuntarily lost my creditable prescription drug coverage (coverage as good as Medicare’s). I lost my drug coverage on (insert date):

I am leaving employer or union coverage on (insert date): I belong to a pharmacy assistance program provided by my state. My plan is ending its contract with Medicare, or Medicare is ending its contract with my plan. I was enrolled in a plan by Medicare (or my state) and I want to choose a different plan. My enrollment in that plan started on (insert date):

I was enrolled in a Special Needs Plan (SNP) but I have lost the special needs qualification required to be in that plan. I was disenrolled from the SNP on (insert date):

I was affected by a weather-related emergency or major disaster (as declared by the Federal Emergency Management Agency (FEMA)). One of the other statements here applied to me, but I was unable to make my enrollment because of the natural disaster.

If none of these statements applies to you or you’re not sure, please contact BlueMedicare Classic, BlueMedicare Classic Plus, BlueMedicare Premier or BlueMedicare Saver at 1-800-876-2227 (TTY users should call 1-800-955-8770) to see if you are eligible to enroll. We are open 8 a.m. - 8 p.m. local time, 7 days a week from October 1 - March 31, except for Thanksgiving and Christmas. From April 1 - September 30, we are open Monday - Friday, 8 a.m. - 8 p.m. and Saturday 8:30 a.m. - 4:30 p.m. local time.

Please Read and Sign BelowBy completing this enrollment application, I agree to the following:BlueMedicare Classic, BlueMedicare Classic Plus, BlueMedicare Premier or BlueMedicare Saver is a Medicare Advantage plan and has a contract with the Federal government. I will need to keep my Medicare Parts A and B. I can be in only one Medicare Advantage plan at a time, and I understand that my enrollment in this plan will automatically end my enrollment in another Medicare health plan or prescription drug plan. It is my responsibility to inform you of any prescription drug coverage that I have or may get in the future. Enrollment in this plan is generally for the entire year. Once I enroll, I may leave this plan or make changes only at certain times of the year when an enrollment period is available (Example: October 15 - December 7 of every year), or under certain special circumstances.BlueMedicare Classic, BlueMedicare Classic Plus, BlueMedicare Premier or BlueMedicare Saver serves a specific service area. If I move out of the area that BlueMedicare Classic, BlueMedicare Classic Plus, BlueMedicare Premier or BlueMedicare Saver serves, I need to notify the plan so I can disenroll and find a new plan in my new area. Once I am a member of BlueMedicare Classic, BlueMedicare Classic Plus, BlueMedicare Premier or BlueMedicare Saver, I have the right to appeal plan decisions about payment or services if I disagree. I will read the Evidence of Coverage document from BlueMedicare Classic, BlueMedicare Classic Plus, BlueMedicare Premier or BlueMedicare Saver when I get it to know which rules I must follow to get coverage with this Medicare Advantage Plan. I understand that people with Medicare aren’t usually covered under Medicare while out of the country except for limited coverage near the U.S. border. I understand that beginning on the date BlueMedicare Classic, BlueMedicare Classic Plus, BlueMedicare Premier or BlueMedicare Saver coverage begins, I must get all of my health care from BlueMedicare Classic, BlueMedicare Classic Plus, BlueMedicare Premier or BlueMedicare Saver, except for emergency or urgently needed services or out-of-area dialysis

– 30 – – 31 –Y0011_34977_M 0819 CMS Accepted

services. Services authorized by BlueMedicare Classic, BlueMedicare Classic Plus, BlueMedicare Premier or BlueMedicare Saver and other services contained in my BlueMedicare Classic, BlueMedicare Classic Plus, BlueMedicare Premier or BlueMedicare Saver Evidence of Coverage document (also known as a member contract or subscriber agreement) will be covered. Without authorization, NEITHER MEDICARE NOR BLUEMEDICARE CLASSIC, BLUEMEDICARE CLASSIC PLUS, BLUEMEDICARE PREMIER OR BLUEMEDICARE SAVER WILL PAY FOR THE SERVICES.I understand that if I am getting assistance from a sales agent, broker, or other individual employed by or contracted with BlueMedicare Classic, BlueMedicare Classic Plus, BlueMedicare Premier or BlueMedicare Saver, he/she may be paid based on my enrollment in BlueMedicare Classic, BlueMedicare Classic Plus, BlueMedicare Premier or BlueMedicare Saver. Release of Information: By joining this Medicare health plan, I acknowledge that BlueMedicare Classic, BlueMedicare Classic Plus, BlueMedicare Premier or BlueMedicare Saver will release my information to Medicare and other plans as is necessary for treatment, payment and health care operations. I also acknowledge that BlueMedicare Classic, BlueMedicare Classic Plus, BlueMedicare Premier or BlueMedicare Saver 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 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 Number: - - Relationship to Enrollee: _______________________________________________________________________________

Office Use Only:Name of staff member/agent/broker (if assisted in enrollment):_________________________________________________Plan ID #: _________________________________________Effective Date of Coverage: ___________________________ICEP/IEP: ________________________________________AEP: ____________________________________________SEP (type): _______________________________________Not Eligible: _______________________________________

Entity Name:_______________________________________________ Five digit Entity ID number (if known):

Date Received by agent: __________________________Florida Blue Agent ID #: ___________________________Agent State License #: ____________________________Agent Confirmation #: ____________________________

PCP First Name: ________________________________PCP Last Name: ________________________________PCP’s FL Blue Provider ID Number

- (ie: 12345 or 12345A)PCP’s 10-digit National Provider ID (NPI) Number:

Is enrollee currently a patient of this PCP? Yes No

Physician Group Name: _______________________________________________Physician Group’s FL Blue Provider ID Number

- (ie: 12345 or 12345A)Physician Group’s 10-digit National Provider ID (NPI) Number: Is enrollee currently a patient of this Physician Group?

Yes No

– 32 – – 33 –


– 32 – – 33 –

Please complete this entire form and return to:

Florida Blue Access Authorization Unit P.O. Box 45296 Jacksonville, FL 32232

PurposeI am the member listed in Section I. This authorization is at my request to permit Blue Cross and Blue Shield of Florida, Inc., Health Options, Inc., and Florida Blue Medicare, Inc. (together, “Florida Blue”) to respond to customer service inquiries regarding my Protected Health Information regarding health, dental and long-term care products.

Section IPlease provide the following information regarding the person whose Protected Health Information is to be released.Member Name: ______________________________________________________Member Number: _____________________________________________________Group Number: ______________________Date of Birth: _____________________

Section III authorize Florida Blue to release, orally and/or in writing, the following Protected Health Information concerning me:• Identifying information (e.g., name, address, age, gender); • Health care coverage information (i.e., general & plan-specific benefit information); • Past, present and future claims information (except for any period of time during

which a Confidential Communication address1 was in effect); and• Coordination of Benefit Information.

Section IIIPlease identify the person(s) to whom the member’s Protected Health Information may be released and their relationship, i.e., sales agent, employer health benefit representative, parent, family member, friend, corporation, organization, law firm, vendor.My information may be given to the person(s) listed below. Please Print:Name: _________________________ Relationship to Member: _______________Name: _________________________ Relationship to Member: _______________Name: _________________________ Relationship to Member: _______________

Section IVBy law, this authorization must indicate that persons other than Florida Blue receiving member’s Protected Health Information may not have to obey federal health information privacy laws and member’s Protected Health Information may be further released by those persons.

Protected Health Information Authorizationfor Customer Service Inquiries

3

– 34 – – 35 –

3

Y0011_30871 0719 C: 07/2019

I further understand that if I have identified a sales agent or an employer health benefit representative in Section III to whom my Protected Health Information may be released, Florida Blue will have no further liability as to the further release of my Protected Health Information by those designated persons.

This authorization is voluntary and is not a condition of enrollment in a health plan, eligibility for benefits or payment of claims.

Section VThis authorization will expire:

____________/___________/__________Month Day Year OR

______________________ The date member’s Florida Blue health coverage ends

It is advised that you place a specific expiration date on this authorization if you are designating a sales agent or employer as an authorized representative, or any other person for whom you may have designated to assist you with a specific, short-term task.

Section VICopy of Authorization Please keep a copy of your signed authorization. A photocopy is as valid as the original.

Section VIIRight to Withdraw Authorization I understand that I may withdraw this authorization at any time by giving written notice to the address listed on page 1 of this form. I further understand that withdrawal of this authorization will not affect any action taken by Florida Blue in reliance on this authorization prior to receiving my written notice of withdrawal.

Section VIIISignature

Member Signature:

____________________________________________

Date: _________________

If a legal representative signs this authorization form on behalf of the member, please complete the following information:

Legal Representative’s Name2:

____________________________________________

Date Signed: _________________

Relationship to the member:

____________________________________________

1��A�Confidential�Communication�address�is�one�specified�by�an�adult�(age�18�or�older)�that�is�different�than�the�address�where�the�subscriber�receives�his�or�her�mail.�

2��Please�provide�written�documentation�to�support�your�status�as�a�guardian�or�other�legal�representative.�

Health�insurance�is�offered�by�Blue�Cross�and�Blue�Shield�of�Florida,�D/B/A�Florida�Blue.�HMO�coverage�is�offered�by�Health�Options,�Inc.,�D/B/A�Florida�Blue�HMO�and�Florida�Blue�Medicare,�Inc,�HMO�subsidiaries�of�Florida�Blue.�These�companies�are�independent�licensees�of�the�Blue�Cross�and�Blue�Shield�Association.

Protected Health Information Authorizationfor Customer Service Inquiries (continued)

– 34 – – 35 –

Please complete this entire form and return to:

Florida Blue Access Authorization Unit P.O. Box 45296 Jacksonville, FL 32232

PurposeI am the member listed in Section I. This authorization is at my request to permit Blue Cross and Blue Shield of Florida, Inc., Health Options, Inc., and Florida Blue Medicare, Inc. (together, “Florida Blue”) to respond to customer service inquiries regarding my Protected Health Information regarding health, dental and long-term care products.

Section IPlease provide the following information regarding the person whose Protected Health Information is to be released.Member Name: ______________________________________________________Member Number: _____________________________________________________Group Number: ______________________Date of Birth: _____________________

Section III authorize Florida Blue to release, orally and/or in writing, the following Protected Health Information concerning me:• Identifying information (e.g., name, address, age, gender); • Health care coverage information (i.e., general & plan-specific benefit information); • Past, present and future claims information (except for any period of time during

which a Confidential Communication address1 was in effect); and• Coordination of Benefit Information.

Section IIIPlease identify the person(s) to whom the member’s Protected Health Information may be released and their relationship, i.e., sales agent, employer health benefit representative, parent, family member, friend, corporation, organization, law firm, vendor.My information may be given to the person(s) listed below. Please Print:Name: _________________________ Relationship to Member: _______________Name: _________________________ Relationship to Member: _______________Name: _________________________ Relationship to Member: _______________

Section IVBy law, this authorization must indicate that persons other than Florida Blue receiving member’s Protected Health Information may not have to obey federal health information privacy laws and member’s Protected Health Information may be further released by those persons.

Protected Health Information Authorizationfor Customer Service Inquiries

3

– 36 – – 37 –

3

Y0011_30871 0719 C: 07/2019

I further understand that if I have identified a sales agent or an employer health benefit representative in Section III to whom my Protected Health Information may be released, Florida Blue will have no further liability as to the further release of my Protected Health Information by those designated persons.

This authorization is voluntary and is not a condition of enrollment in a health plan, eligibility for benefits or payment of claims.

Section VThis authorization will expire:

____________/___________/__________Month Day Year OR

______________________ The date member’s Florida Blue health coverage ends

It is advised that you place a specific expiration date on this authorization if you are designating a sales agent or employer as an authorized representative, or any other person for whom you may have designated to assist you with a specific, short-term task.

Section VICopy of Authorization Please keep a copy of your signed authorization. A photocopy is as valid as the original.

Section VIIRight to Withdraw Authorization I understand that I may withdraw this authorization at any time by giving written notice to the address listed on page 1 of this form. I further understand that withdrawal of this authorization will not affect any action taken by Florida Blue in reliance on this authorization prior to receiving my written notice of withdrawal.

Section VIIISignature

Member Signature:

____________________________________________

Date: _________________

If a legal representative signs this authorization form on behalf of the member, please complete the following information:

Legal Representative’s Name2:

____________________________________________

Date Signed: _________________

Relationship to the member:

____________________________________________

1��A�Confidential�Communication�address�is�one�specified�by�an�adult�(age�18�or�older)�that�is�different�than�the�address�where�the�subscriber�receives�his�or�her�mail.�

2��Please�provide�written�documentation�to�support�your�status�as�a�guardian�or�other�legal�representative.�

Health�insurance�is�offered�by�Blue�Cross�and�Blue�Shield�of�Florida,�D/B/A�Florida�Blue.�HMO�coverage�is�offered�by�Health�Options,�Inc.,�D/B/A�Florida�Blue�HMO�and�Florida�Blue�Medicare,�Inc,�HMO�subsidiaries�of�Florida�Blue.�These�companies�are�independent�licensees�of�the�Blue�Cross�and�Blue�Shield�Association.

Protected Health Information Authorizationfor Customer Service Inquiries (continued)

– 36 – – 37 –

Stand-alone Medicare Prescription Drug Plans (Part D)

Medicare Prescription Drug Plan (PDP) — A stand-alone drug plan that adds prescription drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private-Fee-for-Service Plans, and Medicare Medical Savings Account Plans.

Please initial below beside the type of product(s) you want the agent to discuss.

Medicare Advantage Plans (Part C) and Cost Plans

Medicare Health Maintenance Organization (HMO) — A Medicare Advantage Plan that provides all Original Medicare Part A and Part B health coverage and sometimes covers Part D prescription drug coverage. In most HMOs, you can only get your care from doctors or hospitals in the plan’s network (except in emergencies).

Medicare Preferred Provider Organization (PPO) Plan — A Medicare Advantage Plan that provides all Original Medicare Part A and Part B health coverage and sometimes covers Part D prescription drug coverage. PPOs have network doctors and hospitals but you can also use out-of-network providers, usually at a higher cost.

Medicare Private Fee-For-Service (PFFS) Plan — A Medicare Advantage Plan in which you may go to any Medicare approved doctor, hospital and provider that accepts the plan’s payment, terms and conditions and agrees to treat you – not all providers will. If you join a PFFS Plan that has a network, you can see any of the network providers who have agreed to always treat plan members. You will usually pay more to see out-of-network providers.

Medicare Special Needs Plan (SNP) — A Medicare Advantage Plan that has a benefit package designed for people with special health care needs. Examples of the specific groups served include people who have both Medicare and Medicaid, people who reside in nursing homes, and people who have certain chronic medical conditions.

Medicare Medical Savings Account (MSA) Plan — MSA Plans combine a high deductible health plan with a bank account. The plan deposits money from Medicare into the account. You can use it to pay your medical expenses until your deductible is met.

Medicare Cost Plan — In a Medicare Cost Plan, you can go to providers both in and out of network. If you get services outside of the plan’s network, your Medicare-covered services will be paid for under Original Medicare but you will be responsible for Medicare coinsurance and deductibles.

The Centers for Medicare & Medicaid Services requires agents to document the scope of a marketing appointment prior to any face-to-face sales meeting to ensure understanding of what will be discussed between the agent and the Medicare beneficiary (or their authorized representative). All information provided on this form is confidential and should be completed by each person with Medicare or his/her authorized representative.

Scope of Sales AppointmentConfirmation Form

4

– 38 – – 39 –

4

By signing this form, you agree to a meeting with a sales agent to discuss the types of products you initialed above. Please note, the person who will discuss the products is either employed or contracted by a Medicare plan. They do not work directly for the Federal government. This individual may also be paid based on your enrollment in a plan.

Signing this form does NOT obligate you to enroll in a plan, affect your current enrollment, or enroll you in a Medicare plan.

Beneficiary or Authorized Representative Signature and Signature Date:

Signature: _______________________________________________________________________

Signature Date: ___________________________________________________________________

If you are the authorized representative, please sign above and print below:

Representative’s Name: ____________________________________________________________

Your Relationship to the Beneficiary: __________________________________________________

To be completed by Agent:

Agent Name: Agent Phone:

Beneficiary Name: Beneficiary Phone (Optional):

Beneficiary Address (Optional):

Plan(s) the agent represented during this meeting:

Date Appointment Completed:

Plan Use Only:

Initial Method of Contact: (Indicate here if beneficiary was a walk-in.)

Agent’s Signature:

Scope�of�Appointment�documentation�is�subject�to�CMS�record�retention�requirements

Health�coverage�is�offered�by�Blue�Cross�and�Blue�Shield�of�Florida,�DBA�Florida�Blue.�HMO�coverage�is�offered�by�Florida�Blue�Medicare�Inc.,�which�is�an�affiliate�of�Blue�Cross�and�Blue�Shield�of�Florida,�Inc.�These�companies�are�Independent�licensees�of�the�Blue�Cross�and�Blue�Shield�Association.

– 38 – – 39 –Y0011_33320 0719 C: 07/2019

Agent, if the form was signed by the beneficiary at time of appointment, provide written explanation below why SOA was not documented prior to meeting:

Scope of Sales AppointmentConfirmation Form (continued)

Florida�Blue�is�a�PPO,�RPPO�and�Rx�(PDP)�Plan�with�a�Medicare�contract.�Florida�Blue�Medicare�is�an�HMO�plan�with�a�Medicare�contract.�Enrollment�in�Florida�Blue�or�Florida�Blue�Medicare�depends�on�contract�renewal.

– 40 – – 41 –


– 40 – – 41 –

Stand-alone Medicare Prescription Drug Plans (Part D)

Medicare Prescription Drug Plan (PDP) — A stand-alone drug plan that adds prescription drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private-Fee-for-Service Plans, and Medicare Medical Savings Account Plans.

Please initial below beside the type of product(s) you want the agent to discuss.

Medicare Advantage Plans (Part C) and Cost Plans

Medicare Health Maintenance Organization (HMO) — A Medicare Advantage Plan that provides all Original Medicare Part A and Part B health coverage and sometimes covers Part D prescription drug coverage. In most HMOs, you can only get your care from doctors or hospitals in the plan’s network (except in emergencies).

Medicare Preferred Provider Organization (PPO) Plan — A Medicare Advantage Plan that provides all Original Medicare Part A and Part B health coverage and sometimes covers Part D prescription drug coverage. PPOs have network doctors and hospitals but you can also use out-of-network providers, usually at a higher cost.

Medicare Private Fee-For-Service (PFFS) Plan — A Medicare Advantage Plan in which you may go to any Medicare approved doctor, hospital and provider that accepts the plan’s payment, terms and conditions and agrees to treat you – not all providers will. If you join a PFFS Plan that has a network, you can see any of the network providers who have agreed to always treat plan members. You will usually pay more to see out-of-network providers.

Medicare Special Needs Plan (SNP) — A Medicare Advantage Plan that has a benefit package designed for people with special health care needs. Examples of the specific groups served include people who have both Medicare and Medicaid, people who reside in nursing homes, and people who have certain chronic medical conditions.

Medicare Medical Savings Account (MSA) Plan — MSA Plans combine a high deductible health plan with a bank account. The plan deposits money from Medicare into the account. You can use it to pay your medical expenses until your deductible is met.

Medicare Cost Plan — In a Medicare Cost Plan, you can go to providers both in and out of network. If you get services outside of the plan’s network, your Medicare-covered services will be paid for under Original Medicare but you will be responsible for Medicare coinsurance and deductibles.

The Centers for Medicare & Medicaid Services requires agents to document the scope of a marketing appointment prior to any face-to-face sales meeting to ensure understanding of what will be discussed between the agent and the Medicare beneficiary (or their authorized representative). All information provided on this form is confidential and should be completed by each person with Medicare or his/her authorized representative.

Scope of Sales AppointmentConfirmation Form

4

– 42 – – 43 –

4

By signing this form, you agree to a meeting with a sales agent to discuss the types of products you initialed above. Please note, the person who will discuss the products is either employed or contracted by a Medicare plan. They do not work directly for the Federal government. This individual may also be paid based on your enrollment in a plan.

Signing this form does NOT obligate you to enroll in a plan, affect your current enrollment, or enroll you in a Medicare plan.

Beneficiary or Authorized Representative Signature and Signature Date:

Signature: _______________________________________________________________________

Signature Date: ___________________________________________________________________

If you are the authorized representative, please sign above and print below:

Representative’s Name: ____________________________________________________________

Your Relationship to the Beneficiary: __________________________________________________

To be completed by Agent:

Agent Name: Agent Phone:

Beneficiary Name: Beneficiary Phone (Optional):

Beneficiary Address (Optional):

Plan(s) the agent represented during this meeting:

Date Appointment Completed:

Plan Use Only:

Initial Method of Contact: (Indicate here if beneficiary was a walk-in.)

Agent’s Signature:

Scope�of�Appointment�documentation�is�subject�to�CMS�record�retention�requirements

Health�coverage�is�offered�by�Blue�Cross�and�Blue�Shield�of�Florida,�DBA�Florida�Blue.�HMO�coverage�is�offered�by�Florida�Blue�Medicare�Inc.,�which�is�an�affiliate�of�Blue�Cross�and�Blue�Shield�of�Florida,�Inc.�These�companies�are�Independent�licensees�of�the�Blue�Cross�and�Blue�Shield�Association.

– 42 – – 43 –

Agent, if the form was signed by the beneficiary at time of appointment, provide written explanation below why SOA was not documented prior to meeting:

Y0011_33320 0719 C: 07/2019

Scope of Sales AppointmentConfirmation Form (continued)

Florida�Blue�is�a�PPO,�RPPO�and�Rx�(PDP)�Plan�with�a�Medicare�contract.�Florida�Blue�Medicare�is�an�HMO�plan�with�a�Medicare�contract.�Enrollment�in�Florida�Blue�or�Florida�Blue�Medicare�depends�on�contract�renewal.

– 44 – – 45 –


– 44 – – 45 –

For Medicare Advantage plans

Yes No Do you understand that you have applied for a Medicare Advantage plan? This plan is not a Medicare Supplement “Medigap” plan. This plan replaces Original Medicare.

Yes No Do you understand that to enroll you must be “entitled” to Part A and enrolled in Part B?

Yes No Do you understand you must continue to pay your Medicare Part B premium (unless it is paid for you by Medicaid or another third party)?

For Part D Prescription Drug plans

Yes No Did the sales agent fully explain the prescription deductible associated with the plan (if applicable), and the amount?

Yes No Did the sales agent tell you about the Preferred pharmacies in the network?Yes No Do you understand you have applied for a Part D Prescription Drug plan?Yes No Do you understand to enroll you must have Medicare Part A and/or Part B?

For All plansYes No Did the sales agent fully explain your premium, benefits, copays, and coinsurance amounts?Yes No Did the sales agent show you the Summary of Benefits and give you a copy?Yes No Did the sales agent give you their contact information? (name, phone or business card)Yes No Did the sales agent explain the plan’s drug list (also referred to as a formulary) and drug tiers?Yes No Did the sales agent explain the coverage gap, sometimes referred to as the doughnut hole?Yes No Do you understand that in most cases you must use a pharmacy in our drug plan network?Yes No Did the sales agent confirm that your prescription drugs are covered under the plan’s drug list?

Yes No Do you understand if you enroll in a Medicare Advantage plan and later decide to make a change, under most circumstances you are able to do so during the Annual Election Period, October 15 -December 7 each year?

Drug Name Covered Tier Cost B vs. D* PA Qty Limits Step TherapyYes No Yes No Yes No Yes No

Florida Blue is required by Medicare to contact you within 15 days of receiving your enrollment application. Within the next 15 days you will receive a letter from Florida Blue to verify that the Medicare Advantage or Part D Prescription Drug plan was fully explained. This will not affect your ability to enroll in the plan.Your sales agent will review the following questions with you to verify that the Medicare Advantage or Part D Prescription Drug plan was fully explained. Check Yes or No as appropriate.

*Some�drugs�may�be�covered�under�Medicare�Part�B�or�Part�D.�To�determine�coverage�under�the�appropriate�Medicare�benefit,�your�doctor�is�required�to�submit�a�Medicare�Part�B�vs.�D�coverage�determination�form�to�Florida�Blue�to�obtain�prior�approval�for�these�medications�before�the�prescription�is�filled.

Enrollment Checklist

5

– 46 – – 47 –

5

33429 0719

Only for HMO & PPO plans

Yes No Did the sales agent fully explain the medical deductible associated with the plan, (if applicable), and the amount?

Yes No Do you understand that you must use in-network health care providers to get the in-network benefits, copays and coinsurances?

Yes No Do you understand that if you use out-of-network health care providers you will likely pay higher out-of-pocket costs? (Note: HMO members are not covered out-of-network, except in emergencies, urgent care and out-of-area dialysis.)

Yes No Did the sales agent confirm that your doctor(s) is(are) in-network for the plan that you selected?

Provider’s Name Par/Non-Par Provider’s Complete Address

Acknowledgement

My agent and I have reviewed all my doctor(s), hospital(s) and prescription drug(s) that I have provided today. We have discussed each provider’s participating status within my plan as well as my cost share and any requirements or limits regarding my prescription drug(s). I understand that some network providers may be added or removed from the network at any time. For any additional providers or to get the most up-to-date information about my plan’s network providers for my area or my prescription drugs, I will visit floridablue.com/medicare or call the Member Services Department at 1-800-926-6565, 8 a.m. – 8 p.m. local time, seven days a week from October 1 - March 31, except for Thanksgiving and Christmas. From April 1 - September 30, we are open Monday - Friday, 8 a.m. - 8 p.m. local time except for Federal holidays. (TTY users should call 1-800-955-8770.)

Applicant’s Signature_________________________________ Date ______________________

Agent’s Signature____________________________________ Date ______________________

This�information�is�available�for�free�in�other�languages.�Please�call�our�Customer�Service�number�at�1-855-601-9465.� (TTY�users�should�call�1-800-955-8770.)�Hours�are�8�a.m.�-�8�p.m.�local�time,�seven�days�a�week�from�October�1�to�March�31,�except�for�Thanksgiving�and�Christmas.�From�April�1�to�September�30,�we�are�open�Monday�-�Friday,�8�a.m.�-�8�p.m.,�local�time.

Esta�información�está�disponible�de�manera�gratuita�en�otros�idiomas.�Comuníquese�con�Atención�al�cliente�al� 1-855-601-9465.�(�Usuarios�de�equipo�telescritor�TTY�llamen�al�1-800-955-8770.)�Estamos�abiertos�de�8�a.m.�a�8�p.m.�hora�local�los�siete�días�de�la�semana,�desde�el�1�de�octubre�hasta�el�31�de�marzo,�excepto�el�día�de�Acción�de�Gracias�(Thanksgiving)�y�el�día�de�Navidad.�Desde�el�1�de�abril�al�30�de�septiembre,�estamos�abiertos�de�lunes�a�viernes�de� 8:00�a.m.�a�8:00�p.m.�hora�local.

Florida�Blue�is�a�PPO,�RPPO�and�Rx�(PDP)�Plan�with�a�Medicare�contract.�Florida�Blue�Medicare�is�an�HMO�Plan�with�a�Medicare�contract.�Enrollment�in�Florida�Blue�or�Florida�Blue�Medicare�depends�on�contract�renewal.

Health�coverage�is�offered�by�Blue�Cross�and�Blue�Shield�of�Florida,�D/B/A�Florida�Blue.�HMO�coverage�is�offered�by�Florida�Blue�Medicare,�Inc.,�an�HMO�affiliate�of�Florida�Blue.�These�companies�are�independent�licensees�of�the�Blue�Cross�and�Blue�Shield�Association.

– 46 – – 47 –

For Medicare Advantage plans

Yes No Do you understand that you have applied for a Medicare Advantage plan? This plan is not a Medicare Supplement “Medigap” plan. This plan replaces Original Medicare.

Yes No Do you understand that to enroll you must be “entitled” to Part A and enrolled in Part B?

Yes No Do you understand you must continue to pay your Medicare Part B premium (unless it is paid for you by Medicaid or another third party)?

For Part D Prescription Drug plans

Yes No Did the sales agent fully explain the prescription deductible associated with the plan (if applicable), and the amount?

Yes No Did the sales agent tell you about the Preferred pharmacies in the network?Yes No Do you understand you have applied for a Part D Prescription Drug plan?Yes No Do you understand to enroll you must have Medicare Part A and/or Part B?

For All plansYes No Did the sales agent fully explain your premium, benefits, copays, and coinsurance amounts?Yes No Did the sales agent show you the Summary of Benefits and give you a copy?Yes No Did the sales agent give you their contact information? (name, phone or business card)Yes No Did the sales agent explain the plan’s drug list (also referred to as a formulary) and drug tiers?Yes No Did the sales agent explain the coverage gap, sometimes referred to as the doughnut hole?Yes No Do you understand that in most cases you must use a pharmacy in our drug plan network?Yes No Did the sales agent confirm that your prescription drugs are covered under the plan’s drug list?

Yes No Do you understand if you enroll in a Medicare Advantage plan and later decide to make a change, under most circumstances you are able to do so during the Annual Election Period, October 15 -December 7 each year?

Drug Name Covered Tier Cost B vs. D* PA Qty Limits Step TherapyYes No Yes No Yes No Yes No

Florida Blue is required by Medicare to contact you within 15 days of receiving your enrollment application. Within the next 15 days you will receive a letter from Florida Blue to verify that the Medicare Advantage or Part D Prescription Drug plan was fully explained. This will not affect your ability to enroll in the plan.Your sales agent will review the following questions with you to verify that the Medicare Advantage or Part D Prescription Drug plan was fully explained. Check Yes or No as appropriate.

*Some�drugs�may�be�covered�under�Medicare�Part�B�or�Part�D.�To�determine�coverage�under�the�appropriate�Medicare�benefit,�your�doctor�is�required�to�submit�a�Medicare�Part�B�vs.�D�coverage�determination�form�to�Florida�Blue�to�obtain�prior�approval�for�these�medications�before�the�prescription�is�filled.

Enrollment Checklist

5

– 48 –33429 0719

Only for HMO & PPO plans

Yes No Did the sales agent fully explain the medical deductible associated with the plan, (if applicable), and the amount?

Yes No Do you understand that you must use in-network health care providers to get the in-network benefits, copays and coinsurances?

Yes No Do you understand that if you use out-of-network health care providers you will likely pay higher out-of-pocket costs? (Note: HMO members are not covered out-of-network, except in emergencies, urgent care and out-of-area dialysis.)

Yes No Did the sales agent confirm that your doctor(s) is(are) in-network for the plan that you selected?

Provider’s Name Par/Non-Par Provider’s Complete Address

Acknowledgement

My agent and I have reviewed all my doctor(s), hospital(s) and prescription drug(s) that I have provided today. We have discussed each provider’s participating status within my plan as well as my cost share and any requirements or limits regarding my prescription drug(s). I understand that some network providers may be added or removed from the network at any time. For any additional providers or to get the most up-to-date information about my plan’s network providers for my area or my prescription drugs, I will visit floridablue.com/medicare or call the Member Services Department at 1-800-926-6565, 8 a.m. – 8 p.m. local time, seven days a week from October 1 - March 31, except for Thanksgiving and Christmas. From April 1 - September 30, we are open Monday - Friday, 8 a.m. - 8 p.m. local time except for Federal holidays. (TTY users should call 1-800-955-8770.)

Applicant’s Signature_________________________________ Date ______________________

Agent’s Signature____________________________________ Date ______________________

This�information�is�available�for�free�in�other�languages.�Please�call�our�Customer�Service�number�at�1-855-601-9465.� (TTY�users�should�call�1-800-955-8770.)�Hours�are�8�a.m.�-�8�p.m.�local�time,�seven�days�a�week�from�October�1�to�March�31,�except�for�Thanksgiving�and�Christmas.�From�April�1�to�September�30,�we�are�open�Monday�-�Friday,�8�a.m.�-�8�p.m.,�local�time.

Esta�información�está�disponible�de�manera�gratuita�en�otros�idiomas.�Comuníquese�con�Atención�al�cliente�al� 1-855-601-9465.�(�Usuarios�de�equipo�telescritor�TTY�llamen�al�1-800-955-8770.)�Estamos�abiertos�de�8�a.m.�a�8�p.m.�hora�local�los�siete�días�de�la�semana,�desde�el�1�de�octubre�hasta�el�31�de�marzo,�excepto�el�día�de�Acción�de�Gracias�(Thanksgiving)�y�el�día�de�Navidad.�Desde�el�1�de�abril�al�30�de�septiembre,�estamos�abiertos�de�lunes�a�viernes�de� 8:00�a.m.�a�8:00�p.m.�hora�local.

Florida�Blue�is�a�PPO,�RPPO�and�Rx�(PDP)�Plan�with�a�Medicare�contract.�Florida�Blue�Medicare�is�an�HMO�Plan�with�a�Medicare�contract.�Enrollment�in�Florida�Blue�or�Florida�Blue�Medicare�depends�on�contract�renewal.

Health�coverage�is�offered�by�Blue�Cross�and�Blue�Shield�of�Florida,�D/B/A�Florida�Blue.�HMO�coverage�is�offered�by�Florida�Blue�Medicare,�Inc.,�an�HMO�affiliate�of�Florida�Blue.�These�companies�are�independent�licensees�of�the�Blue�Cross�and�Blue�Shield�Association.

– 48 –

What’s Next?Information on what happens after you enroll in your plan and what to expect

– 50 – – 51 –92217 0719

How to find out which doctors, hospitals and pharmacies are in your plan’s network:

Stay In-Network

Be sure to select a doctor in your network. Except for emergency care, urgent care and dialysis services, you must go to in-network doctors to be covered. This is true even when the care you receive is medically necessary. Avoid unpredictable costs and have peace of mind by staying in your network.

There are a few ways to find out which doctors, hospital and pharmacies are in a plan’s network. You can ask your agent for help, call Customer Service (see contact information on the Welcome page), or you can visit floridablue.com/medicare and follow these steps:

How to make the mostof your Medicare Dollars

Select Find a DoctorClick on

Member Resources

Enter the name of the doctor, hospital or pharmacy you’re looking for

– 50 – – 51 –

Provider�and�pharmacy�networks�can�change�at�any�time.�You�will�receive�notice�when�necessary.

Choosing Your Primary Care Doctor Is Important

As a new member, one of your first—and most important—decisions is choosing a primary care doctor (PCP). Your PCP manages your overall health and coordinates specialized care and most covered services. Your PCP and any specialists you see work together as a team of professionals focused on you.

Florida Blue Medicare Plans give you preferred pharmacy options. As a Florida Blue member you can fill your prescription drugs at one of our preferred pharmacies to save even more on most prescriptions.

Our preferred pharmacy network includes:

Use a Preferred Pharmacy

Choose Generic or Lower-Tier Drugs

Reduce the amount you pay at the pharmacy by choosing generic or lower-tier drugs. New generic drugs become available nearly every day. Most generics, and many drugs in lower-cost tiers, work just as well as the brand or drugs in a higher-cost tier. Check with your doctor and discuss what options are best for you.

You can find all covered drugs in the formulary, the list of drugs that your plan covers. It’s also called a drug list or medication guide. To see our formulary, visit floridablue.com/medicare.

How to find out which drugs are covered:

Select Find a Form

Click on Member Resources

Choose the formulary for your plan in the list

– 52 – – 53 –92058 0719

What you can expectin the first 90 days

During your first 90 days of enrollment, you can get up and running quickly. Here are some things to look for.

To assure you that your application has been received and accepted, you will receive:

3 Notification of Receipt of Application

3 Notice That You Have Been Enrolled

You’ll receive several items to keep all year:

3 BlueMedicare member ID card3 Evidence of Coverage (EOC), a complete description of your coverage

3 Formulary, a list of the prescription drugs your plan covers

You may also receive a welcome call from Florida Blue to help you get more from your plan.

Throughout the year, we’ll stay in touch. You’ll receive:

3 Explanations of Benefits to keep you up to date on any services and supplies you may have received during the previous month

3 Quarterly Newsletters with health tips and advice on getting more from your plan

3 Calls from our Care Team from time to time to help you stay on top of your health needs

3 Surveys to let us know how we’re doing

Want less mail? Sign up for a secure member account at floridablue.com/medicare. You’ll need your Florida Blue Medicare ID card to get started. Access your plan documents, check your out-of-pocket spending, and do more with your secure member account.

– 52 – – 53 –87768 0719R1

We 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:

• Qualified sign language interpreters• Written information in other formats (large print, audio, accessible electronic formats, other formats)

● 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: ● Health and vision coverage: 1-800-352-2583 ● Dental, life, and disability coverage: 1-888-223-4892 ● Federal Employee Program: 1-800-333-2227

If you believe that we have 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:

Health and vision coverage (including FEP members):Section 1557 Coordinator4800 Deerwood Campus Parkway, DCC 1-7Jacksonville, FL 322461-800-477-3736 x290701-800-955-8770 (TTY)Fax: [email protected]

Dental, life, and disability coverage:Civil Rights Coordinator17500 Chenal ParkwayLittle Rock, AR 722231-800-260-03311-800-955-8770 (TTY)[email protected]

You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Section 1557 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, by mail or phone at:

U.S. Department of Health and Human Services200 Independence Avenue, SWRoom 509F, HHH BuildingWashington, D.C. 202011-800-368-10191-800-537-7697 (TDD)Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html

Section 1557 Notification:Discrimination is Against the Law

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ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-352-2583 (TTY: 1-877-955-8773). FEP: Llame al 1-800-333-2227

ATANSYON: Si w pale Kreyòl ayisyen, ou ka resevwa yon èd gratis nan lang pa w. Rele 1-800-352-2583 (pou moun ki pa tande byen: 1-800-955-8770). FEP: Rele 1-800-333-2227

CHÚ Ý: Nếu bạn nói Tiếng Việt, có dịch vụ trợ giúp ngôn ngữ miễn phí dành cho bạn. Hãy gọi số 1-800-352-2583 (TTY: 1-800-955-8770). FEP: Gọi số 1-800-333-2227

ATENÇÃO: Se você fala português, utilize os serviços linguísticos gratuitos disponíveis. Ligue para 1-800-352-2583 (TTY: 1-800-955-8770). FEP: Ligue para 1-800-333-2227

注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電1-800-352-2583（TTY: 1-800-955-8770)。FEP：請致電1-800-333-2227

ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-800-352-2583 (ATS : 1-800-955-8770). FEP : Appelez le 1-800-333-2227

PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-800-352-2583 (TTY: 1-800-955-8770). FEP: Tumawag sa 1-800-333-2227

ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-800-352-2583 (телетайп: 1-800-955-8770). FEP: Звоните 1-800-333-2227

)رقم هاتف الصم 008-253-3852-1اتصل برقم ملحوظة: إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. .7222-333-008-1. اتصل برقم 008-559-0778-1والبكم:

ATTENZIONE: Qualora fosse l'italiano la lingua parlata, sono disponibili dei servizi di assistenza linguistica gratuiti. Chiamare il numero 1-800-352-2583 (TTY: 1-800-955-8770). FEP: chiamare il numero 1-800-333-2227

ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: +1-800-352-2583 (TTY: +1-800-955-8770). FEP: Rufnummer +1-800-333-2227

주의: 한국어 사용을 원하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-800-352-2583 (TTY: 1-800-955-8770) 로 전화하십시오. FEP: 1-800-333-2227 로 연락하십시오.

UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-800-352-2583 (TTY: 1-800-955-8770). FEP: Zadzwoń pod numer 1-800-333-2227.

સચુના: જો તમ ેગજુરાતી બોલતા હો, તો નન:શલુ્ક ભાષા સહાય સવેા તમારા માટ ેઉપલબ્ધ છે. ફોન કરો 1-800-352-2583 (TTY: 1-800-955-8770). FEP: ફોન કરો 1-800-333-2227

ประกาศ:ถา้คุณพดูภาษาไทย คุณสามารถใชบ้ริการช่วยเหลือทางภาษาไดฟ้รี โดยติดต่อหมายเลขโทรฟรี 1-800-352-2583 (TTY: 1-800-955-8770) หรือ FEP โทร 1-800-333-2227

注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1-800-352-2583（TTY: 1-800-955-8770）まで、お電話にてご連絡ください。FEP: 1-800-333-2227

صحبت می کنید، تسهیالت زبانی رایگان در دسترس شما خواهد بود. فارسی : اگر به زبانتوجهتماس بگیريد. 2227-333-800-1با شماره :FEPتماس بگیريد. (TTY: 1-800-955-8770) 2583-352-800-1با شماره

Baa ákonínzin: Diné bizaad bee yáníłti’go, saad bee áká anáwo’, t’áá jíík’eh, ná hólǫ́. Kojį’ hodíílnih 1-800-352-2583 (TTY: 1-800-955-8770). FEP ígíí éí kojį’ hodíílnih 1-800-333-2227.

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Notes

HMO coverage is offered by Florida Blue Medicare, Inc., an affiliate of Blue Cross and Blue Shield of Florida, Inc., DBA Florida Blue. These companies are Independent Licensees of the

Blue Cross and Blue Shield Association.

2020 enrollment guide - secure health options · tier 2 (generic) $10 copay tier 3 (preferred...

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