2014

A nonprofit independent licensee of the Blue Cross Blue Shield Association

For residents in Livingston, Monroe, Ontario, Seneca, Wayne and Yates Counties, NY.

Y0028_3565_0 Accepted

Choose a Medicare Plan That’s Perfect for You

Our plans provide for your health and peace of mind.

New Picture FPO

Empower your body. Enhance your health. Energize your mind.

24-hour Health CoachingManaging your health is all about teamwork. That’s why our Health Coaches are available 24/7 to provide member-only access to specially trained Health Coaches ready to assist you in managing your health and wellness goals. You can work with them to tailor a wellness program specifically designed for you. Manage chronic health conditions (e.g., heart disease, diabetes, arthritis), get the latest information on nutrition, weight management and more.

Silver&Fit® Fitness Program Get fit, have fun,and be happy! The Silver&Fit program allows members to choose from a variety of fitness programs sure to fit your physical needs and lifestyle. Become a member at one of our participating fitness facilities to access available classes, meet other Silver&Fit members, and join in on the fun! Select the Silver&Fit home fitness program to choose from a wide range of in-home fit-ness kits such as Yoga, Chair Exercise, and Aqua Aerobics. Or join a non-participating facility and take advantage of our annual

fitness allowance.

Preventive Care Services Excellus BlueCross BlueShield covers many preventive services to protect, promote and maintain the health and well-being of our members. Some of our covered preventive services include a routine physical exam each year, mammography, prostate, and colorectal screenings. These are just a few examples, so feel free to call us for additional information.

Opt-in to WellnessSign up for our monthly e-mails and get healthy recipes, information about preventive health tools, web resources and tips about talking to your doctor. ExcellusMedicare.com/Email.

Get Member Discounts with Blue365®

When you become a part of the BlueCross BlueShield family, you gain exclusive member-only access to leading national companies that provide special savings on a wide variety of health-related products and services including vision, hearing, fitness and nutrition products. You’ll receive discounts on health and fitness clubs, weight-loss programs, healthy travel experiences and more!

We offer several Medicare Supplement plans, also known as “Medigap” plans. Medicare Supplement plans work hand-in-hand with Original Medicare to help pay costs that Original Medicare does not, such as copayments, coinsurance, and deductibles. Please call us for more information.

Stand-alone Medicare Prescription Drug Coverage For people that only need Medicare Prescription Drug Coverage, we offer our BlueCross BlueShield Rx PDP prescription drug plan. This plan gives you the benefit of lower drug costs through our extensive list of covered generic and brand name drugs (formulary). We also have a network of over 64,000 pharmacies nationwide, including major chains you’ll find right in your neighborhood! Please call us for more information.

Medicare Supplement Plans

Eligibility and Service Area:To be eligible for enrollment, individuals must have both Part A and

Part B and reside in the service area of the Plan. (see counties on cover)

Medicare Advantage (PPO) Plans:For our PPO Plans, with the exception of an emergency or urgent care

situation, it may cost more to get care from out-of-network providers.

Medicare Advantage (HMO) Plans:You must use plan providers except in emergency or urgent care situations, or for out-of-area renal dialysis. If you obtain routine care from out-of-network providers neither Medicare nor Excellus BCBS

will be responsible for the costs.

For Part D (prescription drug) Plans:In general, you must use network pharmacies to access your prescription drug benefit, except in non-routine circumstances, and quantity limitations and restrictions may apply.

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). TTY users should call 1-877-486-2048, 24 hours a day / 7 days a week; The Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call 1-800-325-0778;

or Your State Medicaid Office.

Enrollment and Benefit Information:Individuals may enroll in our plan only during specific times of the year. Contact Excellus BCBS for more information.

This product brochure is an overview of the benefits available under our Medicare Advantage Plans. To the extent of any discrepancy between this document and your Evidence of Coverage, your Evidence of Coverage terms take priority.

*Blue Medicare Advantage PPO Visitor/Traveler Program is available in 34 states and 1 territory (in some states only portions of the state are available). You must live in our service area for 6 months out of the year to remain in our plan.

Excellus Health Plan, Inc. contracts with the federal government and is an HMO plan, PPO plan and PDP plan with a Medicare contract. Enrollment in Excellus Health Plan, Inc. depends on contract renewal.

The Silver&Fit® program is provided by American Specialty Health Fitness, Inc., a subsidiary of American Specialty Health Incorporated (ASH). All programs and services are not available in all areas. Silver&Fit is a federally registered trademark of ASH.

Access to the Doctors & Hospitals You Want You gain access to a robust network of doctors and hospitals dedicated to providing affordable, quality health care services. With our PPO plan, you have the flexibility to see any Medicare-approved provider, anytime. There’s no need to select a Primary Care Physician, and no referrals are required. With our HMO plans, you select a Primary Care Physician who will assume all of your medical care, including referrals to specialists. Additionally, our HMO-Point of Service plans give you the freedom to receive select services from doctors and hospitals that are not in our network, without having to pay the full cost yourself!

Urgent and Emergency Coverage Rest assured that whenever and wherever you travel, we offer coverage

if you ever need urgent care (U.S. only) or emergency care (worldwide).

Travelers & Snow Birds: A Plan for Every TravelerWith our PPO plan, you can use either in-network or out-of-network benefits to get care. See any Medicare-approved doctor, have lab work or diagnostic tests done, use hospital services and more. If you choose to get care from an in-network provider, your costs are usually lower.

We also have a Visitor/Traveler Program with our PPO plan which provides coverage while traveling outside of your service area. You pay the same in-network costs that you pay at home when you use a Blue Medicare Advantage PPO provider in any geographic area where the Visitor/Traveler Program is offered. Go to http://provider.bcbs.com or call 1-800-810-Blue (2583) to find a participating provider out of the area.*

For the occasional traveler, our HMO-Point of Service plans provide members with limited out of area coverage. With our HMO-Point of Service plans, you have some routine out-of-network coverage, such as doctor visits, diagnostic tests or lab services, hospital services and more. An annual dollar limit applies to this benefit. You can review our Summary of Benefits for a

complete list of covered services. If you have questions, please call us.

B-3702Y14 / 7377-13MedM

LIFE HAS A PLANSM

Questions?Call TOLL-FREE: 1-800-659-1986

TTY/TDD users: 1-800-421-1220

Hours: 8:00 a.m.– 8:00 p.m., Monday–Friday. From October 1 – February 14, representatives are available seven days a week from 8:00 a.m.– 8:00 p.m. Or visit ExcellusMedicare.com.

Exclusive Member Advantages

OUR MEDICARE ADVANTAGE PLANS Medicare Blue Choice® Value (HMO)

Medicare Blue Choice® Value Plus (HMO)

Medicare Blue Choice® Optimum (HMO-POS)

Medicare Blue Choice® Platinum (HMO-POS)

Medicare Blue® PPO Plan 201 (PPO)

SERVICE CATEGORY WHAT IS THIS? IN-NETWORK IN-NETWORK IN-NETWORK OUT-OF-NETWORK IN-NETWORK OUT-OF-NETWORK IN-NETWORK OUT-OF-NETWORK WHAT YOU SHOULD KNOWMonthly Plan Premium Fixed amount you pay per month for your coverage. $0 $80 $140 $96 $95 You must continue to pay your Medicare Part B premium.Annual Deductible Fixed amount you pay before your coverage begins. $0 $0 $0 $0 $0 This deductible is for medical services.Out of Pocket Maximum Protection The most you pay for copays, coinsurance and other

costs for medical services for the year. $5,000/annually $4,000/annually $3,600/annually $3,900/annually $5,000/annually$8,000/annually (combined in and out-of-network)

Excludes premium and Part D costs.

Point of Service Plan Coverage Limit Plan coverage $ amount for POS benefits per calendar year. N/A N/A N/A $3,000 annually N/A $3,000/annually N/A For our HMO-POS plans you have some out-of-network coverageDOCTOR VISITSPrimary Care Physician Routine check-up or visit to treat an injury or illness.

You pay a fixed $ amount in-network. $15/visit $15/visit $15/visit 30% coinsurance/visit $15/visit 30% coinsurance/visit $15/visit 30% coinsurance/visit For HMO plans, you must use network providers, except in an emergency or urgent care situations. For PPO plans, you can see any Medicare-approved provider but it may cost you more out-of-network, except in an emergency or urgent care situation.

Specialist Your regular doctor may send you to diagnose a disease or treat a condition. You pay a fixed $ amount in-network.

$45/visit $40/visit $40/visit 30% coinsurance/visit $40/visit 30% coinsurance/visit $45/visit 30% coinsurance/visit

Urgent Care Facility Treatment for an injury or illness needing immediate care but not an emergency situation. Nationwide coverage. $45/visit $40/visit $40/visit $40/visit $45/visit Treatment must be billed as having been done at an Urgent

Care Facility. HOSPITAL SERVICESInpatient Hospital Services Admission to hospital overnight ordered by doctor.

You pay a fixed $ amount in-network.Stays 1-3 = $550/stay

Stays 4+ = fully coveredStays 1-3 = $475/stay

Stays 4+ = fully coveredStays 1-3 = $425/stay

Stays 4+ = fully covered 30% coinsurance/per stay Stays 1-3 = $375/stay Stays 4+ = fully covered

30% coinsurance/ per stay

Stays 1-3 = $400/stay Stays 4+ = fully covered

30% coinsurance/ per stay

Covered for unlimited days when ordered by your doctor or other network provider for Medicare-covered stay.

Outpatient Hospital Services Same day surgical or treatment procedure. You pay a fixed $ amount in-network. $275/visit $225/visit $175/visit 30% coinsurance/visit $150/visit 30% coinsurance/visit $225/visit 30% coinsurance/visit Covers medically-necessary services you get in the outpatient

department of a hospital.Emergency Room Coverage Emergency situation for treatment of injury or serious

illness. Worldwide coverage. $65/visit $65/visit $65/visit $65/visit $65/visit Copay waived if admitted to hospital within 23 hours of ER visit.

DIAGNOSTIC SERVICESLab tests Blood work ordered by your doctor. $0/test $0/test $0/test 30% coinsurance /test $0/test 30% coinsurance/test $0/test 30% coinsurance/test Covers all Medicare-covered services. X-Ray Services X-ray to evaluate an injury or to determine treatment. $45/x-ray $40/x-ray $40/x-ray 30% coinsurance/x-ray $40/x-ray 30% coinsurance/x-ray $45/x-ray 30% coinsurance/x-ray Covers all Medicare-covered services ordered by your doctor

or other network provider.Diagnostic Radiology Services Medical imaging services (e.g. MRI/MRA, CT Scan,

Ultrasound, etc). $105/image $100/image $100/image 30% coinsurance/image $100/image 30% coinsurance/image $125/image 30% coinsurance/image Prior authorization is required for some services by your doctor or other network provider.

PRESCRIPTION DRUG COVERAGE Part D Prescription Deductible: If no deductible, your drug coverage starts immediately. No deductible No deductible No deductible

Emergency only Not covered

No deductible

Emergency Only

Generally, you must use a network pharmacy to fill your prescription. Your drug must be on our plan’s formulary. For certain prescription drugs, special rules restrict how and when the plan covers them for your safety and to keep your costs down. Check our formulary. Gap coverage for Part D drug plans: you pay a maximum of 72% of the cost for generic medications.

Part D: For a 30-day supply you pay per tier:

Tier 1 = Generics

Tier 2 = Preferred Brand

Tier 3 = Non-Preferred Brand

Tier 4 = Specialty

$5 $4 $4 $4 $45 $45 $45 $45$95 $95 $95 $95

33% coinsurance 33% coinsurance 33% coinsurance 33% coinsurancePart B Prescription Drug Coverage % of cost of drug you pay for physician administered

Part B drugs; e.g. injectables or chemotherapy. 20% coinsurance 20% coinsurance 20% coinsurance 30% coinsurance 20% coinsurance 30% coinsurance 20% coinsurance 30% coinsurance Besides your cost sharing percentage, you could be subject to an additional office/facility payment.

EXCLUSIVE MEMBER ADVANTAGES (EXTRA COVERAGE)Hearing & Vision Exam Annual Medicare-covered exam $45/exam $40/exam $40/exam 30% coinsurance/exam $40/exam 30% coinsurance/exam $45/exam 30% coinsurance/exam Covers one routine hearing and vision exam per calendar year.Eyewear Allowance Annual allowance for eye glasses or contact lenses No coverage $75 allowance $120 allowance $120 allowance No coverage Covers eye glasses or contact lenses once per calendar year.

Preventive Dental Services Class 1 = 2 oral exams, 2 cleanings, 2 x-rays per year No coverage Class 1 coverage Class 1 coverage No coverage No coverage No coverage We pay all allowable charges or dentist's charges (whichever is less), and you pay any additional amounts.

Silver&Fit® Fitness Program Choose 1 of 3: $25 annual fee for Participating Fitness Facility/$10 annual fee for Home Fitness Programs/ or $150 yearly allowance for Non-Participating Fitness Facility

Available Available Available Available AvailableSee information in this brochure about Silver&Fit.

Call TOLL-FREE: 1-800-659-1986

TTY/TDD users: 1-800-421-1220

Hours: 8:00 a.m.– 8:00 p.m., Monday–Friday. From October 1 – February 14, representatives are available seven days a week from 8:00 a.m.– 8:00 p.m. Or visit ExcellusMedicare.com.

Questions?

The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Limitations, copayments, and restrictions may apply. Benefits, formulary, pharmacy network, provider network, premium and/or copayments/co-insurance may change on January 1 of each year.

You can quickly and easily complete your application online, 24/7! Simply visit ExcellusMedicare.com and click on the “I am Ready to Enroll” button. Our easy online enrollment process will guide you through all the steps from start to finish.

One of our licensed sales advisors is here to help you every step of the way. Just call us toll-free at the numbers below.

You can attend one of our free, no obligation Medicare seminars right in your neighborhood! Just register online or call the toll-free numbers below to schedule a meeting.

Fill out a paper application and mail it to us.

Ready to Enroll? Here’s How!