Choosing the Medicare Plan

That’s Right for You

H4531_S5715_MRK_TMP_SNSPPO08CMS APPROVED 11/2007

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Today you’ll get information on…

When to enroll in a Medicare-approved Prescription drug plan or Medicare Advantage Plan

Who is eligible to enroll Blue MedicareRx Plan Options Blue Medicare PPO Determining which plan is right for you How to enroll

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When is it Time to Enroll?

Annual Enrollment Period– November 15th to December 31st of each year– Coverage will be effective January 1st

Initial Enrollment Period– Turning age 65

You can enroll up to 3 months prior to the month of your 65th birthday, the month of your birthday, and up to 3 months after the month of your 65th birthday.

– Disability

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When is it Time to Enroll?

Special Enrollment Period – Some examples

A move outside the plan’s approved program service area. Enter or leave a skilled nursing facility (like a nursing home).

Open Enrollment Period (Medicare Advantage plans only)– January 1st through March 31st of each year.– Only beneficiaries who are eligible to enroll in a Medicare Advantage

or Medicare Advantage Prescription Drug plan may make a change during the Open Enrollment Period (OEP).

– Those who already have drug coverage can only change to another option with drug coverage.  Those who do not have drug coverage may not change to an option that provides drug coverage. 

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When is it Time to Enroll?

Open Enrollment Period (Medicare Advantage plans only) cont’d

– An individual who is enrolled in an MAPD plan may elect either another MAPD plan or standalone PDP plan. An individual who is enrolled in a standalone PDP plan can only enroll in an MAPD plan. Either action will generate an automatic disenrollment from whatever plan the individual currently is in.

– An individual who is enrolled in an MA plan and who does not have Part D coverage may only elect another MA plan that does not include Part D coverage, or may elect Original Medicare, or may disenroll from the MA plan.

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Why is it so important to enroll now?

This page will be intentionally left blank because depending on

the time of year the presentation is given, the reasons will vary.

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Who is eligible to enroll?

Must have Medicare Part B in order to join an MAPD plan. Individuals enrolled in an MAPD plan like Blue Medicare PPO,

must continue to pay their Medicare Part B premium if not otherwise paid for under Medicaid or by another third party.

If you are enrolled in a Medicare Advantage (MA) Plan, you may not enroll in any Medicare-approved prescription drug plan unless you have a Private Fee-for-Service (PFFS) MA Plan that does not provide Medicare prescription drug coverage, a Medical Savings Account (MSA) or an 1876 Cost Plan.

What types of plans are available?

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TYPE OF PRESCRIPTION DRUG PLAN DESCRIPTION

PDP (Prescription Drug Plan) A plan that covers prescription drugs.

MAPD (Medicare Advantage Prescription Drug)

A plan that offers both Medicare Advantage medical coverage and the Part D outpatient prescription drug benefit.

Employers/Unions Can provide coverage to either active or retired employees.

Employers who previously provided drug coverage will have multiple options to continue providing drug coverage for beneficiaries including:

• Contracting with a PDP to provide a Part D benefit• Dropping current drug coverage, advising employees (beneficiaries)

to sign up for a PDP, and possibly providing another new coverage option that supplements that Part D benefit

• Paying for part or all of Medicare PDP premiums• Continuing to provide drug coverage to retirees in lieu of Part D

coverage, which also must be at least “actuarially equivalent” in order for the employer to receive a tax-free federal subsidy

There are three plan types available for those who want to enroll in Part D prescription drug coverage

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Medicare Advantage—Part C

(Blue Medicare PPO)

Overview

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Medicare Advantage OptionsMedicare Advantage (Part C)

Name replacement for Medicare+Choice program Beneficiary choices include private health plan options, varying

by geographic location HMO PPO Private fee-for-service plans

Prescription drug benefits (equivalent to Part D) are included in MAPD plans Medicare Prescription Drug Benefits are only available to members of

the MAPD plan If a beneficiary is already enrolled in an MAPD plan, the enrollee must

receive their Medicare Prescription Drug Benefit through that plan.

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Medicare Advantage – PPO Plans

Medicare Advantage PPOs

– PPOs will cover allowable costs of care if doctors and hospitals outside of the network are used†

– PPOs generally do not require a primary care physician to authorize specialist visits

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Medicare Advantage Required Services

Requirement Includes

Physician Services Provide consultation and referral by a licensed physician

Inpatient Hospital Services

(as needed)

Medical/surgical care and supplies, intensive care, nursing services, drugs and medication, rehabilitation therapies, detoxification

Home Health Services Durable Medical Equipment and IV therapy services

Outpatient Services Diagnostic procedures such as X-ray, ambulatory care, short-term rehabilitation services and physical therapy

Medically Necessary Emergency

Treatment for both in-area and out-of-area services

Substance Abuse Treatment/Referral services and medical treatment

Preventive Health Services Periodic health evaluations, ear and eye exams, and adult immunizations

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PPO Option: Value

Please note: Coverage exists, and copay applies, only to Medicare covered items/services unless otherwise specified

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Blue Medicare PPO Value continued

In Network Out of Network

Please note: Coverage exists, and copay applies, only to Medicare covered items/services unless otherwise specified

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PPO Option: Advantage

Please note: Coverage exists, and copay applies, only to Medicare covered items/services unless otherwise specified

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Blue Medicare PPO Advantagecontinued

In Network Out of Network

Please note: Coverage exists, and copay applies, only to Medicare covered items/services unless otherwise specified

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PPO Option: Premier

Please note: Coverage exists, and copay applies, only to Medicare covered items/services unless otherwise specified

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Blue Medicare PPO Premiercontinued

In Network Out of Network

Please note: Coverage exists, and copay applies, only to Medicare covered items/services unless otherwise specified

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How Do I Enroll?

We offer two convenient ways to enroll

Complete the enrollment form.

You can also enroll on our secure Web site, www.bcbstx.com Just click on “Medicare Products” and then “Blue Medicare PPO.”

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Medicare Part DPrescription Drug Plan

(Blue MedicareRx) Overview

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Are you eligible for Blue MedicareRx?

Entitled to Part A and/or enrolled in Part B Reside permanently in the plan’s service area Not enrolled in any other Medicare Prescription Drug Plan

at the same time as Blue MedicareRx– If you are enrolled in a Medicare Advantage (MA) Plan,

you may not enroll in any Medicare-approved prescription drug plan unless you have a Private Fee-for-Service (PFFS) MA Plan that does not provide Medicare prescription drug coverage, a Medical Savings Account (MSA) or an 1876 Cost Plan.

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Blue MedicareRx Plans

We offer 3 plans to choose from Standard Value Plus

Each plan offers you affordability, savings and flexibility

Individuals enrolled in Blue MedicareRx must continue to pay their Medicare Part B premium if not otherwise paid for under Medicaid or by another third party

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Which plan is right for you?

Things to consider… How much does it cost? Are my drugs covered? What pharmacy can I use?

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How much does it cost?

What do my drug costs include? Premium Deductible, if applicable Copayment/Coinsurance Costs incurred during the coverage gap if applicable Medicare Part B premium must continue to be paid

if not otherwise paid for under Medicaid or by another third party

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Are my drugs covered?

Formulary– A listing of medications covered by the plan– Blue MedicareRx covers more than 2,600

formulary drugs – Visit www.bcbstx.com for a complete listing

Which tier are my drugs under? Generic Preferred Brand Brand Specialty

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What pharmacy can I use?

Members must use network pharmacies or the Blue MedicareRx mail-order program to receive benefits, except under emergency circumstances.

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What pharmacy can I use? (continued)

We offer one of the largest retail networks in the country with over 56,500* network pharmacies

Retail drug store chains and their affiliates CVS, H-E-B, Walgreens

Long-term care Home infusion Most independent pharmacies There are approximately 3,900 network pharmacies*

in Texas

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Preferred network pharmacies^– Pay just two and a half months of copayments instead of

three when you fill a 90-day supply of eligible prescriptions. – There are approximately 1,750 preferred network

pharmacies in Texas – Albertsons, CVS, Kmart, Kroger, Randalls, Sam’s Club,

Sav-On, Target, Tom Thumb, United Supermarket Pharmacies, Walgreens and Wal-Mart or their affiliates

What pharmacy can I use? (continued)

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For a complete list of our retail, network and preferred network pharmacies– Call 1-888-579-9373, 7 days a week, 8 a.m.-8 p.m.,

Local Time. For the hearing or speech impaired, please call 1-888-579-9375.

– Or visit www.bcbstx.com

Mail order option– You can also save on copayments with our convenient

mail-order program administered by Walgreens.

What pharmacy can I use? (continued)

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How Do I Enroll?

We offer three convenient ways to enroll1. Complete the enrollment form.

2. Via the phone. 1-888-579-9373, 7 days a week, 8 a.m.-8 p.m., Local Time. For the hearing or speech impaired, please call 1-888-579-9375.

3. You can also enroll on our secure Web site, www.bcbstx.com. Just click on “Medicare Products” and then “Blue MedicareRx Plans.”

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When choosing a plan…

Compare the Savings– $0 deductible options– Copayments as low as $5 for generics– A plan option with benefits during the “gap”

Compare the pharmacy network– Savings on copayments at preferred network

pharmacies– Savings through mail-order– One of the area’s largest pharmacy networks

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When choosing a plan… (continued)

Review the formulary

– Blue MedicareRx has a comprehensive formulary

– We cover more than 2,600 formulary drugs

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How do you apply for extra help?

You may be able to get extra help to pay for your prescription drug premiums and costs. To see if you qualify for extra help, call:– 1-800-MEDICARE (1-800-633-4227), 24 hours a day/

7 days a week. For the hearing or speech impaired, please call 1-877-486-2048.

– Social Security Administration at 1-800-722-1213 between 7 a.m. and 7 p.m., Monday – Friday. For the hearing or speech impaired, please call 1-800-325-0778.

– State Medicaid Office

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Resources

Blue Medicare PPO– Call 1-866-308-4781, 7 days a week, 8 a.m.-8 p.m., Local Time– For the hearing or speech impaired, please call 1-800-538-0380– Visit www.bcbstx.com

Medicare– Call 1-800-MEDICARE (1-800-633-4227) 24 hours a day– TTY/TDD Users: 1-877-486-2048, 24 hours a day– Visit www.medicare.gov

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Resources (continued)

Social Security – Call 1-800-772-1213, 7 a.m.- 7 p.m. Monday-Friday– TTY/TDD Users: 1-800-325-0778, 7 a.m.- 7 p.m.

Monday-Friday– Visit www.socialsecurity.gov

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Additional Information† Deductibles, coinsurance and limitations apply to out-of-network benefits. Your responsibility may be greater

since the coinsurance is based on the Medicare-allowed amount.* Per a GEO Access analysis conducted by Prime Therapeutics on 7/3/2007. ^ At a preferred network pharmacy, you may purchase a 90-day supply of eligible generic or brand prescription

drugs and pay only two and a half months of copayments. The list provided is current as of 6/20/06 and does not guarantee that a pharmacy is still in the network. Network pharmacies that are not preferred pharmacies do not offer lower copaymets for a 90-day supply.

SM Service Marks of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans

® Registered Service Marks of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans

Blue Cross and Blue Shield of New Mexico refers to HCSC Insurance Services Company, which is a wholly owned subsidiary of Health Care Service Corporation, a Mutual Legal Reserve Company. These companies are independent licensees of the Blue Cross and Blue Shield Association and offer or provide services for Medicare Advantage and Medicare Part D products under contracts H3208 and S5715 with the Centers for Medicare and Medicaid Services.