LEARN. COMPARE. ENROLL - 2020 Information K it Area

 
LEARN. COMPARE. ENROLL - 2020 Information K it Area
LEARN.
                                                                                                               COMPARE.
                                                                                                                ENROLL.

Medicare Advantage Plans

2020 Information Kit
in the Gem State – Area 1

     Boundary

        Bonner

    Kootenai

   Benewah
                        Shoshone

                                                                            Area 1
      Latah
                         Clearwater
    Nez Perce

                Lewis

                           Idaho

                                                  Lemhi
      Adams
                           Valley

 Washington                                                                      Clark
                                                Custer                                        Fremont
    Payette
                Gem

                        Boise
                                                                                                       Teton

                                                                                           Madison
                                                                                  Jefferson
   Ca

                                                                         Butte
     nyo

                                                                                         Bonneville
        n

                                                   Blaine
                

                Ada Elmore Camas
                                                                                  Bingham
                                                              Minidoka
                                      Gooding

                                                 Lincoln
                                                                                                 Caribou
                                                Jerome                       Power
                                                                                          Bannock
                 Owyhee               Twin                                                            Bear
                                       Falls                Cassia               Oneida                Lake
                                                                                            Franklin
                                                                                                               Powered by Blue Cross of Idaho Care Plus, Inc. | Form No. 16-600 (09-19)
LEARN. COMPARE. ENROLL - 2020 Information K it Area
IDAHO COUNTIES COVERED
BY TRUE BLUE® (HMO) PLANS
                                                                 Boundary

How We Can Serve You                                                Bonner
To join a True Blue plan, you must be entitled to Medicare
Part A, be enrolled in Medicare Part B and live in our          Kootenai

service area.                                                  Benewah
                                                                                    Shoshone

COVERED COUNTIES:
                                                                  Latah
                                                                                     Clearwater

Ada, Adams, Boise, Bonner, Boundary, Canyon, Clark,

                                                                Nez Perce
                                                                            Lewis

Elmore, Gem, Kootenai, Latah, Nez Perce, Owyhee,                                       Idaho
Payette, Shoshone, Valley and Washington counties

COVERED COUNTIES FOR TRUE BLUE RX
                                                                                                              Lemhi
                                                                  Adams
                                                                                       Valley

PREFERRED (HMO): t                                           Washington                                                                      Clark
Ada and Canyon counties                                         Payette
                                                                                                            Custer                                        Fremont

                                                                            Gem
                                                                                    Boise

                                                                                                                                                                   Teton
                                                                                                                                                       Madison
                                                                                                                                              Jefferson

                                                               Ca
                                                                                                                                     Butte
COVERED COUNTIES FOR TRUE BLUE RX

                                                                 ny
                                                                   on
                                                                                                                                                     Bonneville

                                                                     
                                                                            Ada Elmore Camas                Blaine
                                                                                                                                              Bingham
ST. LUKE’S HEALTH PARTNERS (HMO): l

                                                                                                                          Minidoka
                                                                                                  Gooding
                                                                                                             Lincoln
                                                                                                                                                             Caribou
Ada, Adams, Boise, Canyon, Elmore, Gem, Owyee,                                                              Jerome                       Power
                                                                                                                                                      Bannock
Payette, Valley and Washington counties                                      Owyhee               Twin
                                                                                                   Falls                Cassia               Oneida
                                                                                                                                                                   Bear
                                                                                                                                                                   Lake
                                                                                                                                                        Franklin

Terms to help you understand how
health plans work
PREMIUM                                          COINSURANCE
The fixed cost you pay each month to be a        A kind of cost sharing where you pay a
member of the health plan.                       percentage of the cost for some covered
                                                 services.
MEDICAL DEDUCTIBLE
The amount you pay before the health plan        MAXIMUM OUT-OF-POCKET AMOUNT
helps with medical costs. Good news for you:     A yearly limit on how much money you have
none of our plans have a medical deductible.     to spend out of your own pocket for covered
                                                 healthcare. Once you reach that limit, you don’t
COPAY
                                                 pay anything for covered care for the rest of
A kind of cost sharing where you pay a fixed
                                                 your plan year.
dollar amount for some covered services.
LEARN. COMPARE. ENROLL - 2020 Information K it Area
ENROLL TODAY. ANNUAL ENROLLMENT PERIOD IS
OCTOBER 15 THROUGH DECEMBER 7.

KNOW WHAT TO EXPECT FROM YOUR HEALTH PLAN. MAKE THE CHOICE
THAT WORKS FOR YOU.
When it comes to finding the right Medicare coverage, we know you have choices.
Choosing the right health plan can seem confusing. Understanding how to make the
best choice is the first step in choosing the right plan with the coverage you want
and the benefits you deserve.

We are here to make it easier for you so you can get on with enjoying this exciting
time in your life with less worry, less hassle and more financial peace of mind.

There’s a reason why more Idahoans trust Blue Cross of Idaho Care Plus, Inc. than
any other health insurance company in the state. We understand when to step in and
help you through the health insurance process. We also know when to get out of the
way and let you work with your provider to take control of your health. And with
one of Idaho’s largest provider networks, chances are your provider is already
working with us.

We are Idahoans who have been helping Idahoans make the most informed
healthcare decisions for over 70 years. We’ve offered Medicare Advantage plans
since the program started in 1997, so we understand the important questions you
may have about Medicare Advantage. We give you the tools you need to make
informed decisions. We understand the important questions you may have about
Medicare coverage. Whether you are new to Medicare or returning as a valued
member, we will show you how to get the most out of your health plan.

If you’re already familiar with Medicare Advantage and want to jump into enrollment
right away, turn to the When to Enroll section (page 10). Make sure you review
the Benefits at a Glance and the Summary of Benefits before you complete your
enrollment.

Peter Sorensen,
Vice President of Medicare Advantage

H1350_MK20233_M
                                                POWERED BY BLUE CROSS OF IDAHO CARE PLUS, INC.   INFORMATION KIT   1
LEARN. COMPARE. ENROLL - 2020 Information K it Area
TAB LE OF CONTENTS
2 0 2 0 ME D I C A R E A D VA NTAGE P LANS

Here’s what’s inside:
Discover how Medicare works for you ................... 5
Learn how Medicare works and why choosing a Medicare Advantage plan
over Original Medicare can get you the coverage you need and the benefits
you deserve.

HELPFUL RESOURCES .................................................................................. 6
Formulary listing, latest doctor listing, latest participating pharmacies
listings, etc.

WHAT YOU NEED TO KNOW ABOUT MEDICARE ......................................... 7
Learn why Medicare Advantage is a good choice over Original Medicare,
how HMOs work and terms to help you understand the benefits and more.

WHEN TO ENROLL .................................................................................... 10
A checklist to help you prepare in enrolling for a Medicare Advantage plan.

FREQUENTLY ASKED QUESTIONS ............................................................. 11
Answers you need to enroll in a Medicare Advantage plan.

DETAILS ABOUT THE EXTRAS .................................................................... 13
Get more than Original Medicare.

2020 PRE-ENROLLMENT CHECKLIST ......................................................... 16
A helpful checklist to guide you to the right plan.

TRUE BLUE (HMO) SUMMARY OF BENEFITS .............................................. 17
In an easy-to-read chart, take a good look at our plans and what they cover.

FIND A DOCTOR, PHARMACY NETWORKS, DRUG LIST ............................. 39
We partnered with doctors and clinics all over Idaho to bring you high-quality care
you need and expect. Find a primary care provider (PCP) here. You can find dental
providers as well. We also offer you a convenient way to search for pharmacies
nearest you, and an easy way to look up prescription drugs in our formulary
(drug list).

                                                          POWERED BY BLUE CROSS OF IDAHO CARE PLUS, INC.   INFORMATION KIT   3
LEARN. COMPARE. ENROLL - 2020 Information K it Area
Discover how Medicare works for you

   Explore your options and
   make the right choice
   Learn how Medicare works and why choosing a Medicare Advantage plan over
   Original Medicare can get you the coverage you need and the benefits you
   deserve.

                                              POWERED BY BLUE CROSS OF IDAHO CARE PLUS, INC.   INFORMATION KIT   5
LEARN. COMPARE. ENROLL - 2020 Information K it Area
Helpful Resources
             We make it easy to get answers to your questions and concerns about health
             plans and benefits. Here are some helpful online resources and phone numbers to
             direct you to the information you need. If you are looking for a network provider or
             covered prescriptions, you can find it here.

                           1-888-494-2583
                           Calls to this number are free. October 1 to March 31, you can call us seven
                           days a week from 8 a.m. to 8 p.m. April 1 to September 30, you can call us
              CALL
                           Monday – Friday from 8 a.m. to 8 p.m.
                           Customer Service also has free language interpreter services available for
                           non-English speakers.
                           1-800-377-1363
                           This number requires special telephone equipment and is only for people
              TTY          who have difficulties with hearing or speaking.
                           Calls to this number are free. We are available from 8 a.m. to 8 p.m.,
                           seven days a week.
              FAX          1-208-387-6811
                           Blue Cross of Idaho Care Plus, Inc.
              WRITE        PO Box 8406
                           Boise, ID 83707
                           medicare.bcidaho.com
                           bcidaho.com/FindTrueBlueDoctors
              USEFUL
                           bcidaho.com/FindTrueBluePreferredDoctors
              WEBSITES
                           bcidaho.com/FindTrueBlueStLukesHealthPartnersDoctors
                           bcidaho.com/DrugList

              CENTERS      medicare.gov
              FOR          If you want to know more about the coverage and costs of Original
              MEDICARE     Medicare, look in your current “Medicare & You” handbook. View it online or
              AND          get a copy by calling toll-free 1-800-MEDICARE (1-800-633-4227), 24 hours a
              MEDICAID     day, seven days a week. TTY users should call 1-877-486-2048.
                           Find your level of Extra Help (Part D)
                           medicare.gov/your-medicare-costs/get-help-paying-costs/find-your-level-
              EXTRA HELP
                           of-extra-help-part-d
                           1-800-772-1213 (TTY 1-800-325-0778)

6   INFORMATION KIT
LEARN. COMPARE. ENROLL - 2020 Information K it Area
What you need to know about
Medicare
Original Medicare doesn’t cover everything

                           Original Medicare

                            Part A       +     Part B

 Original Medicare is a government insurance program. It helps cover your
 hospital, medical and benefits if you are 65 or older, have certain disabilities
 or end-stage renal (kidney) disease. But Original Medicare covers only about
 80 percent of your medical and hospital expenses.

 You are responsible for paying the other 20 percent of your medical and
 hospital costs – and 100 percent of your prescription drug costs.

 Original Medicare doesn’t set a limit on your out-of-pocket expenses, so it’s
 difficult to predict your financial risk. Your expenses could be more difficult
 to manage without additional coverage. Original Medicare doesn’t offer
 prescription drug coverage, so you’ll need to purchase a plan that has Part D
 prescription drug coverage included.

             MEDICARE ADVANTAGE PLANS
 Original Medicare

  Part A    +    Part B     +      Part D
                                (most often)
                                                +        Extra
                                                        Benefits
                                                                            =       Medicare
                                                                                   Advantage
                                                                                    (Part C)

                                                POWERED BY BLUE CROSS OF IDAHO CARE PLUS, INC.   INFORMATION KIT   7
LEARN. COMPARE. ENROLL - 2020 Information K it Area
What You Need to Understand about the Parts
            of Medicare
            These plans provide all of the benefits you are entitled to under Medicare – plus
            extra benefits, including Medicare Part D prescription drug coverage. Medicare
            Advantage plans provide these benefits through a contract with the government.
            These plans are offered by companies such as Blue Cross of Idaho Care Plus, Inc.

                                                       Part B is medical coverage. Most Medicare
             Part A is                                 beneficiaries pay a premium for Part B
             hospital                                  coverage.

             coverage.
                                                       Part B is
             Part A helps cover your inpatient
                                                       medical
             care in hospitals, or nursing             coverage.
             facilities, home health and hospice
             care. Most people automatically           Medicare Part B also covers a limited
             get Part A without having to pay a        number of outpatient prescription
             monthly premium.                          drugs like chemotherapy (under limited
                                                       conditions). These are usually drugs given
                                                       directly by a doctor in an outpatient
                                                       hospital setting.

                              IMPORTANT: If you don’t sign up for Part B during your Initial
                              Enrollment Period, you may pay a permanent late enrollment
                              penalty of 10% for every year that you delay.

8   INFORMATION KIT
LEARN. COMPARE. ENROLL - 2020 Information K it Area
Medicare Part C and Part D are important options that can help you pay some
of the out-of-pocket costs not covered by Original Medicare. Blue Cross of Idaho
Care Plus, Inc. has a contract with Medicare to provide Part C and Part D coverage
in your community.
                                           Part D is
Part C is                                  prescription
also known                                 drug coverage.
as Medicare
Advantage.                                Part D coverage is designed to help
                                          lower your prescription drug costs. Part
Part C coverage is provided by            D coverage is available in stand-alone
Medicare Advantage plans and              plans or may be included with a Medicare
includes all of Part A and Part B         Advantage plan.
coverage as well as extra benefits.
For some plans, you pay a monthly
premium.

Medicare Advantage plans include Medicare Part D coverage. You will pay a monthly
premium for Medicare Part D coverage unless you qualify for financial assistance.

You’ll likely pay less for your prescription, and often simply pay a copay or
coinsurance for your drug. Part D has four stages of coverage. In each stage you pay
a different share of the cost.

                 If you do not enroll for Part D prescription coverage when you
                 first become eligible for Medicare, you may be subject to a
                 late-enrollment penalty. The cost of the late enrollment penalty
                 depends on how long you went without Part D or creditable
                 prescription drug coverage. Visit medicare.gov for more
                 details.

                                                POWERED BY BLUE CROSS OF IDAHO CARE PLUS, INC.   INFORMATION KIT   9
LEARN. COMPARE. ENROLL - 2020 Information K it Area
When to Enroll

              You may enroll in a Medicare Advantage or Part D
              prescription drug plan as early as 3 months before
                                                                     If you are ready to
              the month you turn 65. This is called the Initial
              Enrollment Period.                                     enroll in a Medicare

              Your Initial Enrollment Period lasts for 7 months –    Advantage plan, simply
              starting 3 months before the month you turn 65         turn the page.
              and ending 3 months after the month you turn
              65. You should sign up for Medicare three months
              before you turn 65 even if you don’t plan to retire    You’ll find everything
              at 65.
                                                                     you need to get started,
              It’s important to choose a plan that includes
                                                                     including an enrollment
              Medicare Part D prescription drug coverage
              during your Initial Enrollment Period. If you don’t,   form, Medicare Star
              you may be subject to a late enrollment penalty if     Ratings for our plans,
              you decide you want this coverage later.
                                                                     and a pre-paid return
              After your Initial Enrollment Period, you’ll have at
                                                                     envelope.
              least one opportunity each year to enroll or make
              new choices during Medicare’s Annual Enrollment
              Period, which is from October 15 through
                                                                     If you need help, please
              December 7.
                                                                     give us a call at
              Except under special circumstances, you may
              only choose or change your Part C Medicare             1-888-494-2583, or
              Advantage plan or Part D prescription drug plan        TTY 1-800-377-1363.
              each fall, during the Medicare Annual Enrollment
                                                                     You can also contact
              Period (AEP).
                                                                     your independent
              The choices you make during the Annual
              Enrollment Period take effect January 1 of the         insurance agent
              upcoming year. This includes additional coverage       for assistance.
              you may need.

10   INFORMATION KIT
Frequently Asked Questions

Why choose a Medicare Advantage plan over
Original Medicare?
•   Original Medicare (Parts A and B) only pays 80 percent for covered services.
•   Original Medicare does not cap annual out-of-pocket expenses for covered
    services.
If you have a year in which you need a lot of services, or multiple hospital stays, you
could end up paying tens of thousands of dollars – because there is no cap on your
financial responsibility.

With our Medicare Advantage plans, you will have the protection and peace of
mind knowing there is an annual out-of pocket maximum. If you reach the maximum
amount, you pay nothing for covered medical services for the rest of the year.

A few other questions to consider:
ARE MY DOCTORS IN YOUR NETWORK?
We contract with one of the largest provider networks in Idaho. There is a very good
chance that your doctors, hospitals and other providers are part of the True Blue
network. For the most up-to-date listing, please visit bcidaho.com/FindAProvider.

WHAT DO YOU COVER AND WHAT WILL I PAY?
We cover everything Original Medicare covers – and more! Review the Benefits at a
Glance brochure that came with this booklet. It provides a brief comparison of our
plans, letting you know what services are covered and what you will pay. See the
Summary of Benefits section of this booklet if you need more information on what
you pay for covered services.

ARE MY DRUGS COVERED?
Our Formulary (or list of covered drugs) has a wide range of generic and brand name
drugs to meet your needs. Our plans that include Part D coverage offer preferred
generic drugs at no cost from preferred network pharmacies. To see what drugs
we cover, and what pharmacies are part of our network, please visit bcidaho.com/
FindAPharmacy.

                                                  POWERED BY BLUE CROSS OF IDAHO CARE PLUS, INC.   INFORMATION KIT   11
WHY SHOULD I PICK A PRIMARY CARE PROVIDER (PCP)?
              Our True Blue HMO (Health Maintenance Organization) plans require you to choose
              a primary care provider (PCP). They are responsible for helping you navigate and
              access health plan services.

              NO REFERRALS REQUIRED.
              None of our HMO plans require you to have a referral from your doctor to see in-
              network providers of your choice. Some specialists might have their own policy to
              ask you for a referral before you can see them.

              COPAYS MAKE IT EASY.
              One of the main features of HMO plans is that they generally feature predictable
              copays for most services, rather than coinsurance ($20 copay versus 20 percent
              coinsurance).

              AM I COVERED WHEN I LEAVE IDAHO?
              All of our plans feature worldwide coverage for urgent and emergency services.

              Most of our HMO plans come with a Convenience Care benefit while seeing a
              provider outside of Idaho.

              Ask us for more details on coverage limits and restrictions

12   INFORMATION KIT
Benefits with our True Blue plans
Below, we’ve listed some of the benefits you get with our Medicare Advantage plans.
The copay or coinsurance for each benefit depends on the plan you pick.

 ROUTINE EYEWEAR                 NEW FOR 2020                       NURSE ADVICE LINE
                                   MDLIVE®*

 $35 copay, complete             Easy, on-demand                       Call 24-hours a day,
    pair of glasses                doctor visits                       seven days a week

     WELLNESS                   CONVENIENCE                              HEARING AIDS
     PROGRAM                       CARE*

 $50 annual copay for          $2,500 maximum for                         Copays of $999
  gym membership                each calendar year                           or less

OVER-THE-COUNTER              Optional Supplemental Dental Plans
                              HEALTHY SMILES BASIC
                              If you enroll in True Blue Rx, True Blue no Rx,
                              True Blue Rx Gem, True Blue Rx Preferred or
$40 every three months        True Blue Rx St. Luke’s Health Partners, you can
  on approved items           add Healthy Smiles Basic for an additional $9.40
                              per month. Basic dental services have a six-month
                              waiting period without evidence of prior continuous
                              coverage.
*Not available for
St. Luke’s Health             HEALTHY SMILES PLUS
Partners Plan.                If you enroll in True Blue Rx Option I or True Blue
                              Rx Option II, you can add Healthy Smiles Plus for
                              an additional $23.40 per month. Preventive and
                              diagnostic dental services have no waiting period;
                              basic dental services have a six-month
                              waiting period without evidence of prior
                              continuous coverage.

                                               POWERED BY BLUE CROSS OF IDAHO CARE PLUS, INC.   INFORMATION KIT   13
True Blue (HMO) Summary of Benefits

   Every important decision
   begins with information.
   On the next few pages, you can see detailed benefit information about our
   True Blue plans, including your out-of-pocket costs, your monthly premium,
   what we cover and more.

   With low office visit copays, a gym membership discount, preferred generic
   prescriptions, low out-of-pocket maximums, and no referrals for specialists
   visits, True Blue gives you an all-around approach to good health with
   healthcare services from local providers you know and trust.

                                                POWERED BY BLUE CROSS OF IDAHO CARE PLUS, INC.   INFORMATION KIT   15
2020 Pre-Enrollment Checklist
     True Blue Rx Gem, True Blue Rx, True Blue Rx Option I, True Blue Rx Option II,
     True Blue Rx Preferred, True Blue Rx St. Luke’s Health Partners, True Blue No Rx

       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 toll-free at 1-888-494-2583 (TTY 1-800-377-1363), 8 a.m. to 8 p.m., seven
       days a week from October 1 to March 31. Between April 1 to September 30, we are open
       Monday through Friday, 8 a.m. to 8 p.m.

       UNDERSTANDING YOUR BENEFITS

                       Review the full list of benefits found in the Evidence of Coverage (EOC), especially for
                       those services for which that you routinely see a doctor. Visit medicare.bcidaho.com or
                       call 1-888-494-2583 (TTY 1-800-377-1363) to view a copy of the EOC.

                       Review the Provider Directory (or ask your doctor) 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 a new
                       doctor.

                       Review the Pharmacy Directory to make sure the pharmacy you use for any prescription
                       medications 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/coinsurance may change on January 1, 2021.

                       Except in emergency or urgent situations, we do not cover services by out-of-network
                       providers (doctors who are not listed in the provider directory). Noncontracted providers
                       who are out of our network may deny care, except in an emergency or urgent situations.
                       You may be responsible for all of the cost associated with these services.

          For more information, we are available 8 a.m. to 8 p.m., seven days a week from October 1
             to March 31. Between April 1 to September 30, we are open Monday through Friday,
                   8 a.m. to 8 p.m. Call us toll-free at 1-888-494-2583 (TTY 1-800-377-1363).
                                     Or visit us at medicare.bcidaho.com.

16   INFORMATION KIT
TRUE BLUE® (HMO)
                                                                   AREA 1

    202 0 S U M MARY OF BE NE FIT S

  SERVING SELECT
  COUNTIES IN IDAHO
  Ada, Adams, Boise, Bonner,
  Boundary, Canyon, Clark,
  Elmore, Gem, Kootenai,
  Latah, Nez Perce, Owhyee,
  Payette, Shoshone, Valley
  and Washington counties

H1350_MK20068_M                Powered by Blue Cross of Idaho Care Plus, Inc. | Form No. 16-011 (09-19)
Call us to learn more
    CURRENT MEMBER? TOLL FREE                                  PROSPECTIVE MEMBER? TOLL-FREE

    1-888-494-2583                                             1-888-492-2583
    TTY 1-800-377-1363                                         TTY 1-800-377-1363
               We are available from 8 a.m. to 8 p.m. seven days a week, from October 1 to March 31.
              Between April 1 to September 30, we are open 8 a.m. to 8 p.m., Monday through Friday.

    WEBSITE                                                                 MEDICARE
    medicare.bcidaho.com                                                    medicare.gov
    FOR MORE INFORMATION
    bcidaho.com/FindTrueBlueDoctors
    bcidaho.com/FindTrueBluePreferredDoctors
    bcidaho.com/FindTrueBlueStLukesHealthPartnersDoctors
    bcidaho.com/DrugList
    Email: sales@bcidaho.com

    The benefit information provided is a summary of what we cover and what you pay. It does not
    list every service that we cover or list every limitation or exclusion. To get a complete list of
    services we cover, please request the Evidence of Coverage. You can request an Evidence of
    Coverage by calling Blue Cross of Idaho Care Plus, Inc. at the numbers listed above.

    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 medicare.gov or get a copy by calling toll-free
    1-800-MEDICARE (1-800-633-4227), TTY 1-877-486-2048, 24 hours a day, seven days a week.
2   SUMMARY OF BENEFITS   BLUE CROSS OF IDAHO CARE PLUS
IDAHO COUNTIES COVERED
BY TRUE BLUE® (HMO) PLANS
                                                                   Boundary

How We Can Serve You                                                  Bonner

To join a True Blue plan, you must be entitled to Medicare
Part A, be enrolled in Medicare Part B, and live in our           Kootenai

service area.                                                    Benewah
                                                                                      Shoshone

                                                                    Latah
COVERED COUNTIES:                                                                      Clearwater

                                                                  Nez Perce
Ada, Adams, Boise, Bonner, Boundary, Canyon, Clark,                           Lewis

Elmore, Gem, Kootenai, Latah, Nez Perce, Owyhee,                                         Idaho
Payette, Shoshone, Valley and Washington counties

COVERED COUNTIES FOR TRUE BLUE RX
                                                                                                                Lemhi
                                                                    Adams
                                                                                         Valley

PREFERRED (HMO): t                                             Washington                                                                      Clark       Fremont
Ada and Canyon counties
                                                                                                              Custer
                                                                  Payette

                                                                              Gem
                                                                                      Boise

                                                                                                                                                                     Teton
                                                                                                                                                         Madison
                                                                                                                                                Jefferson

                                                                 Ca
                                                                                                                                       Butte

                                                                   ny
COVERED COUNTIES FOR TRUE BLUE RX

                                                                     on
                                                                                                                                                       Bonneville

                                                                       
                                                                              Ada Elmore Camas                Blaine
                                                                                                                                                Bingham
ST. LUKE’S HEALTH PARTNERS (HMO): l

                                                                                                                            Minidoka
                                                                                                    Gooding
                                                                                                               Lincoln
                                                                                                                                                               Caribou
Ada, Adams, Boise, Canyon, Elmore, Gem, Owhyee,                                                               Jerome                       Power
                                                                                                                                                        Bannock

Payette, Valley and Washington counties                                        Owyhee               Twin
                                                                                                     Falls                Cassia               Oneida
                                                                                                                                                                     Bear
                                                                                                                                                                     Lake
                                                                                                                                                          Franklin

Terms to help you understand how
health plans work
PREMIUM                                          COINSURANCE
The fixed cost you pay each month to be a        A kind of cost sharing where you pay a
member of the health plan.                       percentage of the cost for some covered
                                                 services.
MEDICAL DEDUCTIBLE
The amount you pay before the health plan        MAXIMUM OUT-OF-POCKET AMOUNT
helps with medical costs. Good news for you:     A yearly limit on how much money you have
none of our plans have a medical deductible.     to spend out of your own pocket for covered
                                                 healthcare. Once you reach that limit, you don’t
COPAY
                                                 pay anything for covered care for the rest of
A kind of cost sharing where you pay a fixed
                                                 your plan year.
dollar amount for some covered services.

                                                      POWERED BY BLUE CROSS OF IDAHO CARE PLUS, INC. SUMMARY OF BENEFITS                                                     3
4   SUMMARY OF BENEFITS
Which doctors, hospitals and
pharmacies can I use?
True Blue plans 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.
Our True Blue plans come with a primary care provider (PCP). This person
serves as your personal health advisor, helping you know what care you need
and how to get it. None of our HMO plans require you to have a referral from
your PCP to see other doctors.

•   You can see our plan’s provider directory by visiting
    bcidaho.com/FindTrueBlueDoctors,
    bcidaho.com/FindTrueBluePreferredDoctors or
    bcidaho.com/FindTrueBlueStLukesHealthPartnersDoctors.
•   You can find pharmacies in our network by visiting
    bcidaho.com/FindAPharmacy.
•   Or call us and we can help you find a doctor or pharmacy, or send you a
    provider directory.

Are my prescription drugs
covered?
Almost all of our True Blue plans cover Part D drugs. We also cover Part B
drugs such as chemotherapy drugs and other medicines given directly by
your doctor.

•   Not all plans use the same list of covered drugs (formulary). This means
    covered prescription drugs for each plan with Part D prescription drug
    coverage may be different.
•   True Blue Rx St. Luke’s Health Partners (HMO), True Blue Rx (HMO),
    True Blue Rx Preferred (HMO) and True Blue Rx Gem (HMO) use the
    Standard formulary.
•   True Blue Rx Option I (HMO) and True Blue Rx Option II (HMO) use
    the Performance formulary.
•   See the complete covered drug list and any restrictions on our website
    at medicare.bcidaho.com. Choose Prescription Resources from the
    menu at the top of the page.
•   You can search for drugs and their costs at bcidaho.com/DrugList.
                                POWERED BY BLUE CROSS OF IDAHO CARE PLUS, INC. SUMMARY OF BENEFITS   5
True Blue Rx St. Luke’s        True Blue Rx               True Blue
       Premiums and Benefits
                                    Health Partners (HMO)*      Preferred (HMO)**          Rx Gem (HMO)
                     Plan Number       H1350-023-001              H1350-021-000            H1350-022-001
      Monthly Plan Premium
        You must continue to           You pay nothing           You pay nothing             You pay $15
      pay your Medicare Part
                 B premium
        Medical Deductible
     These plans do not have           You pay nothing           You pay nothing           You pay nothing
        a medical deductible
          Maximum Out-of-                  The most you pay for copays, coinsurance and other costs
       Pocket Responsibility               for covered Part A and Part B medical services for the year.
            Does not include
        prescription drugs or               $5,800                    $5,600                    $5,400
       monthly plan premium
             Inpatient Hospital         Prior authorization may be required for some services.
                     Coverage Our plans cover an unlimited number of days for an inpatient hospital stay.
                                     $275 daily – 1-5 days     $325 daily – 1-4 days     $325 daily – 1-4 days
                                      $0 daily – 6-90 days      $0 daily – 5-90 days      $0 daily – 5-90 days
          Outpatient Hospital
                    Coverage             $250 copay                 $250 copay                $300 copay
           Outpatient Hospital
                    Doctor Visits                             Tier 1 – You pay nothing
                                       You pay nothing                                         $5 copay
                    Primary Care                                 Tier 2 – $10 copay
                   Specialists
      No referral required for            $40 copay                 $40 copay                 $40 copay
              specialist visits
                Preventive Care        You pay nothing           You pay nothing           You pay nothing
               Emergency Care       If you are admitted to the hospital within 24 hours for the same condition,
                                         you do not have to pay your share of the cost for emergency care.
                                          $90 copay                 $90 copay                 $90 copay
             Urgently Needed              Cost sharing for necessary urgently needed services furnished
                      Services         out-of-network is the same as for such services furnished in-network.
                     Urgent Care                              Tier 1 – You pay nothing
                                          $40 copay                                           $40 copay
                                                                 Tier 2 – $40 copay
      Worldwide Emergency
      and Urgent Coverage
                                          $90 copay                 $90 copay                 $90 copay
            ($25,000 benefit
                  maximum)
         Diagnostic Services/        Prior authorization is required for some services by your doctor or other
               Labs/Imaging              network provider. Please contact the plan for more information.

    *True Blue Rx St. Luke’s Health Partners is only available in Ada, Adams, Boise, Canyon, Elmore, Gem,
     Owhyee, Payette, Valley and Washington counties.
    **True Blue Rx Preferred is only available in Ada and Canyon counties.
6   SUMMARY OF BENEFITS
True Blue                True Blue Rx              True Blue Rx                           True Blue
     Rx (HMO)                Option I (HMO)            Option II (HMO)                        no Rx (HMO)
  H1350-019-001              H1350-015-001             H1350-016-001                        H1350-006-000

    You pay $55               You pay $142               You pay $95                           You pay $29

  You pay nothing            You pay nothing           You pay nothing                     You pay nothing

                    The most you pay for copays, coinsurance and other costs
                    for covered Part A and Part B medical services for the year.

       $6,200                     $6,500                     $6,400                                $3,000

                     Prior authorization may be required for some services.
           Our plans cover an unlimited number of days for an inpatient hospital stay.
$295 daily – 1-6 days      $225 daily – 1-5 days     $300 daily – 1-5 days              $100 daily – 1-5 days
 $0 daily – 7-90 days       $0 daily – 6-90 days      $0 daily – 6-90 days               $0 daily – 6-90 days

    $275 copay                 $250 copay                $325 copay                            $100 copay

     $10 copay                  $5 copay                  $10 copay                             $10 copay

     $35 copay                  $30 copay                 $40 copay                             $25 copay

  You pay nothing            You pay nothing           You pay nothing                     You pay nothing
            If you are admitted to the hospital within 24 hours for the same condition,
                 you do not have to pay your share of the cost for emergency care.
     $90 copay                  $90 copay                 $90 copay                             $90 copay
                   Cost sharing for necessary urgently needed services furnished
                out-of-network is the same as for such services furnished in-network.

     $40 copay                  $25 copay                 $40 copay                             $25 copay

     $90 copay                  $90 copay                 $90 copay                             $90 copay

             Prior authorization is required for some services by your doctor or other
                 network provider. Please contact the plan for more information.

                                                         POWERED BY BLUE CROSS OF IDAHO CARE PLUS, INC. SUMMARY OF BENEFITS   7
True Blue Rx St. Luke’s        True Blue Rx               True Blue
       Premiums and Benefits
                                    Health Partners (HMO)*      Preferred (HMO)**          Rx Gem (HMO)
                     Plan Number       H1350-023-001              H1350-021-000            H1350-022-001
               Diagnostic Tests
                                       20% of the cost            20% of the cost          20% of the cost
               and Procedures
                     Lab Services                             Tier 1 – You pay nothing
                                          $15 copay                                           $10 copay
                                                                 Tier 2 – $20 copay
        Diagnostic Radiology
                                       20% of the cost            20% of the cost          20% of the cost
               (MRI, CT, PET)
                           X-rays                             Tier 1 – You pay nothing
                                          $15 copay                                           $15 copay
                                                                 Tier 2 – $15 copay
          Hearing Services
     Medicare-covered exam
      to diagnose and treat               $45 copay                 $45 copay                 $45 copay
       hearing and balance
                     issues
         Additional Hearing
                     Benefits
                                          $45 copay                 $45 copay                 $45 copay
       Annual routine hearing
                        exam
                    Hearing Aids             Up to two TruHearing-branded hearing aids every year
                                       (one per ear per year). Benefit is limited to the TruHearing Advanced
                                        and Premium hearing aids with an optional $75 additional cost per
                                                                 rechargeable aid.
                                                   Advanced $699 copay; Premium $999 copay
                Dental Services     Limited Medicare dental benefit (does not include services in connection
                                          with care, treatment, filling, removal or replacement of teeth)
                                          $40 copay                 $40 copay                 $40 copay
       Additional Preventive         $10 for routine oral       $10 for routine oral      $10 for routine oral
             Dental Benefits        exams, cleanings and       exams, cleanings and      exams, cleanings and
                                           X-rays                     X-rays                    X-rays

                                            Includes two oral exams, two cleanings, and two bitewing
                                           X-rays every year and one full mouth X-ray every three years;
                                                           $500 coverage limit per year

    *True Blue Rx St. Luke’s Health Partners is only available in Ada, Adams, Boise, Canyon, Elmore, Gem,
     Owhyee, Payette, Valley and Washington counties.
    **True Blue Rx Preferred is only available in Ada and Canyon counties.
8   SUMMARY OF BENEFITS
True Blue              True Blue Rx              True Blue Rx                           True Blue
     Rx (HMO)              Option I (HMO)            Option II (HMO)                        no Rx (HMO)
   H1350-019-001           H1350-015-001             H1350-016-001                        H1350-006-000

   20% of the cost         10% of the cost           15% of the cost                     You pay nothing

      $5 copay                $10 copay              You pay nothing                     You pay nothing

   20% of the cost         10% of the cost           15% of the cost                         $175 copay

     $15 copay                $10 copay                 $15 copay                        You pay nothing

     $45 copay                $45 copay                 $45 copay                             $45 copay

     $45 copay                $45 copay                 $45 copay                             $45 copay

                    Up to two TruHearing-branded hearing aids every year
              (one per ear per year). Benefit is limited to the TruHearing Advanced
               and Premium hearing aids with an optional $75 additional cost per
                                        rechargeable aid.
                          Advanced $699 copay; Premium $999 copay
            Limited Medicare dental benefit (does not include services in connection
                  with care, treatment, filling, removal or replacement of teeth)
     $35 copay                $25 copay                 $30 copay                             $25 copay
 $10 for routine oral                                                                  $10 for routine oral
exams, cleanings and         Not covered               Not covered                    exams, cleanings and
       X-rays                                                                                X-rays
  Includes two oral                                                                    Includes two oral
exams, two cleanings,                                                                exams, two cleanings,
  and two bitewing                                                                     and two bitewing
X-rays every year and                                                                X-rays every year and
                             Not covered               Not covered
 one full mouth X-ray                                                                 one full mouth X-ray
  every three years;                                                                   every three years;
 $500 coverage limit                                                                  $500 coverage limit
       per year                                                                             per year

                                                       POWERED BY BLUE CROSS OF IDAHO CARE PLUS, INC. SUMMARY OF BENEFITS   9
True Blue Rx St. Luke’s         True Blue Rx                True Blue
        Premiums and Benefits
                                     Health Partners (HMO)*       Preferred (HMO)**           Rx Gem (HMO)
                      Plan Number        H1350-023-001             H1350-021-000              H1350-022-001
                        Optional      Healthy Smiles Basic       Healthy Smiles Basic      Healthy Smiles Basic
                    Supplemental
                      Dental Plan

                                          $50 deductible; Basic dental services (fillings, extractions) covered
                                       at 80% of maximum allowance after deductible; $750 benefit maximum
                                             six-month waiting period for all basic services without proof
                                                            of continuous prior coverage

                Vision Services
             Medicare-covered
         eye exam to diagnose            You pay nothing           You pay nothing            You pay nothing
           & treat diseases and
                      conditions
              Additional Vision
                       Benefits
                                            $20 copay                 $20 copay                  $20 copay
             Annual routine eye
                          exam
                           Eyewear    $35 copay for one pair of glasses (lenses and frames in the VSP Genesis
                                     Collection); $50 allowance for non-Genesis frames. In lieu of glasses there is
                                          a $100 allowance towards contacts. Benefit is for every two years.
      Mental Health Services          $275 daily – 1-5 days      $325 daily – 1-4 days     $300 daily – 1-4 days
               Inpatient Visit         $0 daily – 6-90 days       $0 daily – 5-90 days      $0 daily – 5-90 days
            Outpatient Mental
                   Health Care              $20 copay                 $40 copay                  $40 copay
         (Individual and Group)
      Skilled Nursing Facility         Our plan covers up to 100 days per benefit period in a Skilled Nursing
                        (SNF)             Facility. Prior authorization may be required for some services.
                                                                $0 daily – 1-20 days        $0 daily – 1-20 days
                                       $0 daily – 1-20 days
                                                              $160 daily – 21-63 days     $160 daily – 21-63 days
                                     $175 daily – 21-100 days
                                                               $0 daily – 64-100 days      $0 daily – 64-100 days
                  Outpatient
               Rehabilitation
             Physical Therapy,              $20 copay                 $40 copay                  $40 copay
             Speech Therapy,
         Occupational Therapy

     *True Blue Rx St. Luke’s Health Partners is only available in Ada, Adams, Boise, Canyon, Elmore, Gem,
      Owhyee, Payette, Valley and Washington counties.
     **True Blue Rx Preferred is only available in Ada and Canyon counties.
10   SUMMARY OF BENEFITS
True Blue                True Blue Rx              True Blue Rx                           True Blue
       Rx (HMO)                Option I (HMO)            Option II (HMO)                        no Rx (HMO)
    H1350-019-001              H1350-015-001              H1350-016-001                       H1350-006-000
 Healthy Smiles Basic        Healthy Smiles Plus        Healthy Smiles Plus               Healthy Smiles Basic
  $50 deductible; Basic                                                          $50 deductible; Basic
 dental services (fillings,                                                     dental services (fillings,
  extractions) covered                                                           extractions) covered
   at 80% of maximum                                                              at 80% of maximum
                              Includes the benefits of Healthy Smiles Basic,
      allowance after                                                                allowance after
                               plus preventive dental services (oral exams,
deductible; $750 benefit                                                       deductible; $750 benefit
                            cleanings, & X-rays) with no deductible or benefit
  maximum six-month                                                              maximum six-month
                                      maximum for in-network care
  waiting period for all                                                         waiting period for all
 basic services without                                                         basic services without
proof of continuous prior                                                      proof of continuous prior
          coverage                                                                       coverage

   You pay nothing            You pay nothing            You pay nothing                     You pay nothing

       $20 copay                  $20 copay                  $20 copay                            $20 copay

              $35 copay for one pair of glasses (lenses and frames in the VSP Genesis
             Collection); $50 allowance for non-Genesis frames. In lieu of glasses there is
                  a $100 allowance towards contacts. Benefit is for every two years.
 $290 daily – 1-6 days      $175 daily – 1-5 days      $295 daily – 1-5 days              $100 daily – 1-5 days
 $0 daily – 7-90 days       $0 daily – 6-90 days        $0 daily – 6-90 days               $0 daily – 6-90 days

       $40 copay                  $25 copay                  $40 copay                            $25 copay

                Our plan covers up to 100 days per benefit period in a Skilled Nursing
                   Facility. Prior authorization may be required for some services.

  $0 daily – 1-20 days     $0 daily – 1-20 days     $0 daily – 1-20 days     $0 daily – 1-20 days
$175 daily – 21-100 days $175 daily – 21-100 days $175 daily – 21-100 days $150 daily – 21-100 days

       $40 copay                  $25 copay                  $40 copay                            $15 copay

                                                           POWERED BY BLUE CROSS OF IDAHO CARE PLUS, INC. SUMMARY OF BENEFITS   11
True Blue Rx St. Luke’s        True Blue Rx               True Blue
        Premiums and Benefits
                                       Health Partners (HMO)*      Preferred (HMO)**          Rx Gem (HMO)
                      Plan Number         H1350-023-001             H1350-021-000             H1350-022-001
                  Ambulance                 Prior authorization is required for non-emergency transportation.
       Ground or Air transport              $270 copay                $270 copay                $270 copay
          Ambulatory Surgery
                                                $250                      $250                      $300
                      Center
                   Transportation           Not Covered              Not Covered               Not Covered
               Medicare Part B Part B drugs are usually administered in an inpatient hospital setting, like
             Prescription Drugs chemotherapy drugs. These are not the same as Part D prescription drugs.
                                          20% of the cost           20% of the cost           20% of the cost
            Part D Prescription            True Blue Rx St. Luke’s Health Partners, True Blue Rx Preferred and
              Drug Deductible            True Blue Rx Gem have Part D Deductibles. There is no deductible for
                      Tiers 1-2                       Tier 1 and Tier 2 generic prescription drugs.
                           Tiers 3-5      $175 per year for         $150 per year for         $150 per year for
                                          prescriptions in          prescriptions in          prescriptions in
                                             Tiers 3-5                 Tiers 3-5                 Tiers 3-5
        Annual Physical Exam              You pay nothing           You pay nothing           You pay nothing
                Benefit Services
                                            Not covered                $10 copay                 $5 copay
              through MDLIVE®
            Podiatry Services            Foot exams and treatment if you have diabetes-related nerve damage
        Medicare-covered foot                              and/or meet certain conditions.
         exams and treatment                 $40 copay                 $40 copay                 $40 copay
           Additional Podiatry
                      Benefits                                    $40 copay per visit;
                                            Not covered                                         Not covered
                                                                    6 visits per year
             Routine foot care
             Medical Supplies
              Durable Medical
                                          20% of the cost           20% of the cost           20% of the cost
                   Equipment
          (wheelchairs, oxygen)
                    Prosthetics
                                          20% of the cost           20% of the cost           20% of the cost
        (braces, artificial limbs)
              Diabetes Supplies           You pay nothing           You pay nothing           You pay nothing
      Diabetes Shoes/Inserts              20% of the cost           20% of the cost           20% of the cost
            Wellness Programs                       Silver&Fit® Exercise and Healthy Aging Program
                   Silver&Fit®
                                            $50 annually              $50 annually              $50 annually
              Gym Membership
                  Silver&Fit®               $10 annually              $10 annually              $10 annually
            Home Exercise kits               for two kits              for two kits              for two kits
              Over-the-Counter          $40 allowance every       $40 allowance every       $40 allowance every
                   (OTC) Items             three months              three months              three months
     *True Blue Rx St. Luke’s Health Partners is only available in Ada, Adams, Boise, Canyon, Elmore, Gem,
      Owhyee, Payette, Valley and Washington counties. **True Blue Rx Preferred is only available in Ada
      and Canyon counties.
12   SUMMARY OF BENEFITS
True Blue                  True Blue Rx              True Blue Rx                           True Blue
       Rx (HMO)                  Option I (HMO)            Option II (HMO)                        no Rx (HMO)
    H1350-019-001                H1350-015-001             H1350-016-001                        H1350-006-000
                      Prior authorization is required for non-emergency transportation.
      $270 copay                   $250 copay                $275 copay                            $175 copay

          $275                         $250                       $325                                  $100

     Not Covered                  Not Covered               Not Covered                           Not Covered
               Part B drugs are usually administered in an inpatient hospital setting, like
              chemotherapy drugs. These are not the same as Part D prescription drugs.
    20% of the cost              20% of the cost           20% of the cost                      10% of the cost
There is no deductible for                             There is no deductible for
 Tier 1 and Tier 2 generic        No deductible         Tier 1 and Tier 2 generic                  Not covered
    prescription drugs.                                    prescription drugs.
   $100 per year for                                      $250 per year for
    prescriptions in              No deductible            prescriptions in                       Not covered
       Tiers 3-5                                              Tiers 3-5
    You pay nothing              You pay nothing           You pay nothing                     You pay nothing

       $10 copay                     $5 copay                 $10 copay                             $10 copay

                 Foot exams and treatment if you have diabetes-related nerve damage
                                   and/or meet certain conditions.
       $40 copay                    $25 copay                 $40 copay                             $25 copay

      Not covered                  Not covered               Not covered                          Not covered

    20% of the cost              20% of the cost           20% of the cost                      10% of the cost

    20% of the cost              20% of the cost           20% of the cost                      10% of the cost

    You pay nothing              You pay nothing           You pay nothing                     You pay nothing
    20% of the cost              20% of the cost           20% of the cost                      10% of the cost
                              Silver&Fit® Exercise and Healthy Aging Program

      $50 annually                 $50 annually              $50 annually                         $50 annually

      $10 annually                 $10 annually              $10 annually                         $10 annually
       for two kits                 for two kits              for two kits                         for two kits
  $40 allowance every          $40 allowance every       $40 allowance every                 $40 allowance every
     three months                 three months              three months                        three months

                                                             POWERED BY BLUE CROSS OF IDAHO CARE PLUS, INC. SUMMARY OF BENEFITS   13
How Part D Prescription Drug Coverage
     Works
     The costs you pay may change depending on the pharmacy you choose and when you enter another
     stage of the Part D benefit. For more information on your pharmacy-specific costs and the stages of
     your Part D benefit, please call us or get an Evidence of Coverage online at medicare.bcidaho.com.

        STAGE 1 – ANNUAL DEDUCTIBLE                   Tier 1 and 2 generic drugs do not have a
        You are responsible for the cost of your      deductible.
        prescription drugs until you have met the
        deductible.

        STAGE 2 – INITIAL COVERAGE PERIOD             You pay a small amount until you reach $4,020
        You are responsible for a limited             in total drug costs. See the chart at the right for
        copay or coinsurance.                         what you might pay.

        STAGE 3 – COVERAGE GAP                        In most cases, you pay 25% for covered generic
        You are responsible for a larger copay or     drugs, and 25% (plus dispensing fee) for covered
        coinsurance until you have met your           brand drugs until you meet your $6,350 in true
        true out-of-pocket costs.                     out-of-pocket costs. The amount paid by the
                                                      drug manufacturer combined with the 25% you
                                                      pay, count toward your true out-of-pocket cost.

        STAGE 4 – CATASTROPHIC COVERAGE               You pay the greater of either the copay
        You are responsible for a limited copay or    ($3.60 for generics, $8.95 for all others) or a
        coinsurance.                                  5% coinsurance for the remainder of the plan
                                                      year.

                                                                                 We pay

                                                                                                   You pay

14   SUMMARY OF BENEFITS
Part D: Your Share of the Costs
The costs you pay may change depending on the pharmacy you choose and when you enter another
stage of the Part D benefit. For more information on your pharmacy-specific costs and the stages of
your Part D benefit, please call us or get an Evidence of Coverage online at medicare.bcidaho.com.

                          True Blue Rx

                                                                                  True Blue Rx
                                           Rx Preferred

                                                                                                                        Rx Option II
                                                                                                    Rx Option I
                                            True Blue

                                                            True Blue

                                                                                                     True Blue

                                                                                                                         True Blue
                            St. Luke’s

                            Partners

                                                             Rx Gem
                             Health
    Formulary Name       Standard    Standard    Standard    Standard Performance Performance
                          $175 for    $150 for    $150 for    $100 for                $250 for
   Part D Deductible                                                         $0
                         Tiers 3,4,5 Tiers 3,4,5 Tiers 3,4,5 Tiers 3,4,5             Tiers 3,4,5
                              PREFERRED RETAIL COST – 30-DAY SUPPLY
                Tier 1
                             $0          $0          $0       $3 copay       $0       $3 copay
  (Preferred Generic)
      Tier 2 (Generic) $6 copay      $6 copay    $6 copay    $12 copay   $12 copay   $12 copay
                Tier 3
                         $31 copay $31 copay $31 copay $31 copay         $35 copay   $37 copay
    (Preferred Brand)
                Tier 4
                         $90 copay $90 copay $90 copay $90 copay         $85 copay   $90 copay
      (Non-Preferred)
Tier 5 (Specialty Tier) 29% of cost 30% of cost 30% of cost 31% of cost 33% of cost 28% of cost
                          NON-PREFERRED RETAIL COST – 30-DAY SUPPLY
                Tier 1
                         $5 copay  $15 copay $15 copay $15 copay                                  $5 copay          $10 copay
  (Preferred Generic)
      Tier 2 (Generic) $15 copay $20 copay $20 copay $20 copay                                   $20 copay          $20 copay
                Tier 3
                        $47 copay $47 copay $47 copay $47 copay                                  $45 copay          $47 copay
    (Preferred Brand)
                Tier 4
                       $100 copay $100 copay $100 copay $100 copay                               $95 copay         $100 copay
      (Non-Preferred)
Tier 5 (Specialty Tier) 29% of cost 30% of cost 30% of cost 31% of cost 33% of cost                                28% of cost
                                  MAIL ORDER COST – 90-DAY SUPPLY
                Tier 1
                           $0                $0              $0             $9 copay                  $0             $9 copay
  (Preferred Generic)
      Tier 2 (Generic) $18 copay         $18 copay        $18 copay         $36 copay            $36 copay          $36 copay
                Tier 3
                        $93 copay $93 copay $93 copay $93 copay                                  $105 copay        $111 copay
    (Preferred Brand)
                Tier 4
                       $270 copay $270 copay $270 copay $270 copay                               $255 copay        $270 copay
      (Non-Preferred)
                         29% of cost 30% of cost 30% of cost 31% of cost 33% of cost 28% of cost
               Tier 5
                           (30-day      (30-day      (30-day      (30-day      (30-day      (30-day
      (Specialty Tier)
                         supply only) supply only) supply only) supply only) supply only) supply only)

                                                                    POWERED BY BLUE CROSS OF IDAHO CARE PLUS, INC. SUMMARY OF BENEFITS   15
Benefits you get with our True Blue plans
     PLANS MAY OFFER SUPPLEMENTAL BENEFITS IN ADDITION TO PART C BENEFITS AND
     PART D BENEFITS.

     Below, we’ve listed some of the benefits you get with our Medicare Advantage plans. The copay
     or coinsurance for each benefit depends on the plan you pick.

         ROUTINE EYEWEAR                           HEARING AIDS                       OVER-THE-COUNTER

         $35 copay, complete                       Copays of $999                  $40 every three months
            pair of glasses                           or less                        on approved items

     Get low out-of-pocket                    Save big on your hearing            You also get help with over-
     costs with Vision Service                with coverage through               the-counter (OTC) products
     Plan (VSP) providers for                 TruHearing.                         such as vitamins, pain
     your yearly vision exam.                                                     relievers, cold medicine
                                              •   A hearing exam plus             and bandages.
     •    $20 copay for your                      three follow-up visits
          yearly vision exam                                                      •    $40 every three months
                                              •   Hearing aids with
                                                                                       to spend on approved
     •    $35 copay for a                         copays of $999 or
                                                                                       items
          complete pair of                        less and optional $75
          glasses from the                        additional cost per aid         •    Your allowance resets
          Genesis Collection                      for rechargeability.                 January, April, July and
          (frames and lenses)                 Call TruHearing at                       October
     Call VSP at 1-800-877-7195               1-855-205-5392 or visit
     or visit vsp.com to learn                truhearing.com for more
     more.                                    information.

                     New Benefits for 2020
                     MDLIVE®
                     Visit with a doctor privately and securely with an easy, on-demand mobile app, video
                     or phone. Visit MDLIVE at mdlive.com/bcimedicare for more information. Or call
                     1-844-296-8784 (TTY 711) any time or day. Not available for the True Blue Rx St. Luke’s
                     Health Partners plan.

16   SUMMARY OF BENEFITS
WELLNESS                     CONVENIENCE CARE                             NURSE ADVICE LINE
       PROGRAM

  $50 annual copay for              $2,500 maximum for                             Call 24-hours a day,
   gym membership                    each calendar year                            seven days a week

For only $50 a year,              For care while you are                       Any time, day or night, you
Silver&Fit gets you a             within the U.S. but outside                  can speak with a registered
membership at any                 of the state of Idaho, our                   nurse at no cost to you.
network fitness club and          Convenience Care program
                                  provides you with $2,500                     Ask questions about your
exercise centers around
                                  coverage at no additional                    prescriptions, finding a
the state and across the
                                  cost to you.                                 doctor or specialist, or
country.
                                                                               understanding a health
                                  Some restrictions apply.
If you aren’t up for                                                           condition.
                                  See the Evidence of
heading to the gym, you
                                  Coverage for complete
can get two home fitness
                                  details. Not available for
kits a year for only $10.
                                  the True Blue Rx St. Luke’s
                                  Health Partners plan.

         Optional Supplemental Dental Plans
         HEALTHY SMILES BASIC
         If you enroll in True Blue Rx, True Blue no Rx, True Blue Rx Gem, True Blue Rx Preferred
         or True Blue Rx St. Luke’s Health Partners you can add Healthy Smiles Basic for an
         additional $9.40 per month. Basic dental services have a six-month waiting period
         without evidence of prior continuous coverage.

         HEALTHY SMILES PLUS
         If you enroll in True Blue Rx Option I or True Blue Rx Option II, you can add Healthy
         Smiles Plus for an additional $23.40 per month. Preventive and diagnostic dental
         services have no waiting period; basic dental services have a six-month waiting period
         without evidence of prior continuous coverage.

                                                       POWERED BY BLUE CROSS OF IDAHO CARE PLUS, INC. SUMMARY OF BENEFITS   17
2020 Pre-Enrollment Checklist
True Blue Rx Gem, True Blue Rx, True Blue Rx Option I, True Blue Rx Option II,
True Blue Rx Preferred, True Blue Rx St. Luke’s Health Partners, True Blue No Rx

 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 toll-free at 1-888-494-2583 (TTY 1-800-377-1363), 8 a.m. to 8 p.m., seven
 days a week from October 1 to March 31. Between April 1 to September 30 we are open
 Monday through Friday, 8 a.m. to 8 p.m.

 UNDERSTANDING YOUR BENEFITS

           Review the full list of benefits found in the Evidence of Coverage (EOC), especially for
           those services for which that you routinely see a doctor. Visit medicare.bcidaho.com or
           call 1-888-494-2583 (TTY 1-800-377-1363) to view a copy of the EOC.

           Review the Provider Directory (or ask your doctor) 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 a new
           doctor.

           Review the Pharmacy Directory to make sure the pharmacy you use for any prescription
           medications 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/coinsurance may change on January 1, 2021.

           Except in emergency or urgent situations, we do not cover services by out-of-network
           providers (doctors who are not listed in the provider directory). Noncontracted providers
           who are out of our network may deny care, except in an emergency or urgent situations.
           You may be responsible for all of the cost associated with these services.

   For more information, we are available 8 a.m. to 8 p.m., seven days a week from October 1
      to March 31. Between April 1 to September 30 we are open Monday through Friday,
           8 a.m. to 8 p.m. Call us toll-free at 1-888-494-2583 (TTY 1-800-377-1363).
                             Or visit us at medicare.bcidaho.com.
DISCRIMINATION IS AGAINST THE LAW
Blue Cross of Idaho and Blue Cross of Idaho Care Plus,                   services or discriminated in another way on the basis of
Inc, (collectively referred to as Blue Cross of Idaho)                   race, color, national origin, age, disability or sex, you can
complies with applicable Federal civil rights laws and                   file a grievance with Blue Cross of Idaho’s Grievances
does not discriminate on the basis of race, color, national              and Appeals Department at:
origin, age, disability or sex. Blue Cross of Idaho does                 Manager, Grievances and Appeals
not exclude people or treat them differently because of                  3000 E. Pine Ave., Meridian, ID 83642
race, color, national origin, age, disability or sex.                    Telephone: 1-800-274-4018 ext. 3838
Blue Cross of Idaho:                                                     Fax: 208-331-7493
• Provides free aids and services to people with                         Email: grievances&appeals@bcidaho.com
   disabilities to communicate effectively with us, such as:             TTY: 1-800-377-1363
     o Qualified sign language interpreters                              You can file a grievance in person or by mail, fax,
     o Written information in other formats (large                       or email. If you need help filing a grievance, our
       print, audio, accessible electronic formats, other                Grievances and Appeals team is available to help you.
       formats)                                                          You can also file a civil rights complaint with the U.S.
• Provides free language services to people whose                        Department of Health and Human Services, Office for
   primary language is not English, such as:                             Civil Rights electronically through the Office for Civil
                                                                         Rights Complaint Portal, available at https://ocrportal.
     o Qualified interpreters
                                                                         hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
     o Information written in other languages                            U.S. Department of Health and Human Services, 200
If you need these services, contact Blue Cross of Idaho                  Independence Avenue SW., Room 509F, HHH Building,
Customer Service Department. Call 1-800-627-1188                         Washington, DC 20201, 1-800-368-1019, 800-537-7697
(TTY: 1-800-377-1363), or call the customer service                      (TTY). Complaint forms are available at
phone number on the back of your card. If you believe                    http://www.hhs.gov/ocr/office/file/index.html.
that Blue Cross of Idaho has failed to provide these
ATTENTION: If you speak Arabic, Bantu, Chinese, Farsi, French, German, Japanese, Korean, Nepali, Romanian,
Russian, Serbo-Croatian, Spanish, Tagalog, or Vietnamese, language assistance services, free of charge, are
available to you. Call 1-800-627-1188 (TTY: 1-800-377-1363).
                                                              Arabic:    Nepali:
 ‫ فإن خدمات المساعدة اللغوية‬،‫ إذا كنت تتحدث العربية اذكر اللغة‬:‫مملحوظة‬   ध्यान दिनुहोस्: तपार्इंले नेपाली बोल्नुहुन्छ भने तपार्इंको
                                                                         निम्ति भाषा सहायता सेवाहरू निःशुल्क रूपमा उपलब्ध छ
    ‫ (رقم هاتف الصم‬1-800-627-1188 ‫ اتصل برقم‬.‫تتوافر لك بالمجان‬           । फोन गर्नुहोस् 1-800-627-1188 (टिटिवाइ: 1-800-377-
                                            .(1-800-377-1363:‫والبكم‬      1363) ।
Bantu:                                                                   Romanian:
ICITONDERWA: Nimba uvuga Ikirundi, uzohabwa                              ATENȚIE: Dacă vorbiți limba română, vă stau la
serivisi zo gufasha mu ndimi, ku buntu. Woterefona                       dispoziție servicii de asistență lingvistică, gratuit.
1-800-627-1188 (TTY: 1-800-377-1363).                                    Sunați la 1-800-627-1188 (TTY: 1-800-377-1363).
Chinese:                                                                 Russian:
注意:如果您使用繁體中文,您可以免費獲得語言援                                                  ВНИМАНИЕ: Если вы говорите на русском языке, то
助服務。請致電 1-800-627-1188(TTY:1-800-377-                                    вам доступны бесплатные услуги перевода. Звоните
1363)。                                                          Farsi:   1-800-627-1188 (телетайп: 1-800-377-1363).
 ‫ تسهيالت زبانی بصورت رايگان‬،‫ اگر به زبان فارسی گفتگو می کنيد‬:‫توجه‬       Serbo-Croatian:
                          1-800-627-1188‫ با‬.‫برای شما فراهم می باشد‬       OBAVJEŠTENJE: Ako govorite srpsko-hrvatski,
                             .‫) تماس بگيريد‬TTY: 1-800-377-1363(          usluge jezičke pomoći dostupne su vam besplatno.
French:                                                                  Nazovite 1-800-627-1188 (TTY- Telefon za osobe sa
ATTENTION: Si vous parlez français, des services                         oštećenim govorom ili sluhom: 1-800-377-1363).
d’aide linguistique vous sont proposés gratuitement.                     Spanish:
Appelez le 1-800-627-1188 (ATS : 1-800-377-1363).                        ATENCIÓN: si habla español, tiene a su disposición
German:                                                                  servicios gratuitos de asistencia lingüística. Llame al
ACHTUNG: Wenn Sie Deutsch sprechen, stehen                               1-800-627-1188 (TTY: 1-800-377-1363).
Ihnen kostenlos sprachliche Hilfsdienstleistungen zur                    Tagalog:
Verfügung. Rufnummer: 1-800-627-1188 (TTY: 1-800-
377-1363).                                                               PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari
                                                                         kang gumamit ng mga serbisyo ng tulong sa wika
Japanese:                                                                nang walang bayad. Tumawag sa 1-800-627-1188
注意事項:日本語を話される場合、無料の言語支援                                                  (TTY: 1-800-377-1363).
をご利用いただけます。1-800-627-1188(TTY:1-800-
377-1363)まで、お電話にてご連絡ください。                                                Vietnamese:
                                                                         CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn
Korean:                                                                  ngữ miễn phí dành cho bạn. Gọi số 1-800-627-1188
주의: 한국어를 사용하시는 경우, 언어 지원 서비스를
무료로 이용하실 수 있습니다. 1-800-627-1188 (TTY:                                    (TTY: 1-800-377-1363).
1-800-377-1363)번으로 전화해 주십시오.                                                                                           Form No. 3-1187 (08-19)
3000 East Pine Avenue | Meridian, Idaho | 83642-5995
PO Box 8406 | Boise, Idaho | 83707-2406
Toll-Free 1-888-494-2583 | TTY 1-800-377-1363

Blue Cross of Idaho Care Plus, Inc. is an HMO health
plan with a Medicare contract. Enrollment in Blue Cross
of Idaho Care Plus, Inc. depends on contract renewal.©2019
Blue Cross of Idaho Care Plus, Inc. (“Blue Cross of Idaho Care
Plus”) is an Independent Licensee of the Blue Cross and
Blue Shield Association, with services provided by Blue Cross
of Idaho Health Service, Inc.
Out-of-network/noncontracted providers are under
no obligation to treat members, except in emergency
situations. Please call our customer service number or see
your Evidence of Coverage for more information, including
the cost-sharing that applies to out-of-network services.
With one of Idaho’s
     largest provider networks,
     we’ve got you covered.

Essential Resources
Find Providers, Pharmacies, Dentists and Formularies (Drug List)

     We partnered with doctors and clinics all over Idaho to bring you high-quality
     care you need and expect. Learn how to find primary care providers (PCP),
     specialists and dental providers. We also offer you a convenient way to search
     for pharmacies nearest you, and an easy way to look up prescription drugs in
     our formulary (drug list).

                                                  POWERED BY BLUE CROSS OF IDAHO CARE PLUS, INC.   INFORMATION KIT   37
Looking for Provider/Pharmacy Directory,
    Formulary or Dental Providers?

NETWORK PROVIDERS, PHARMACIES AND DRUG LIST
If you need help finding a network provider or pharmacy, you can call customer service at
1-888-494-2583 (TTY users call 1-800-377-1363). We are open seven days a week, 8 a.m.
to 8 p.m. October 1 through March 31. Between April 1 and September 30, we are open
Monday through Friday, 8 a.m. to 8 p.m. If you would like a copy mailed to you, you may
call the number above or request one through our website. In-network providers and
pharmacies are available on our website beginning October 1, 2019.

FIND AN IN-NETWORK PROVIDER ONLINE
bcidaho.com/FindAProvider

FIND AN IN-NETWORK PHARMACY ONLINE
bcidaho.com/FindAPharmacy

FORMULARY (DRUG LIST) ONLINE
bcidaho.com/DrugList

NETWORK DENTAL PROVIDERS

FIND A DENTIST ONLINE
bcidaho.com/FindADentist

                                                  POWERED BY BLUE CROSS OF IDAHO CARE PLUS, INC.   INFORMATION KIT   39
Our Find a Doctor/Dentist tool makes it easy
       to find in-network providers anywhere

             Blue Cross of Idaho Care Plus, Inc. works with healthcare providers who agree to
             provide services at discounted rates to help save you money. When you see an in-
             network provider, you get the most out of your health benefits. Follow the steps
             below to find an in-network provider.

          1            Visit bcidaho.com. Select
                       Find a Doctor on the homepage.

                                                                                FIND IT ONLINE:
                                                                                    IN-NETWORK
                                                                                      PROVIDER

          2            2A – Select the Log In button at the top right and            bcidaho.com/
                       log in to your member account.                               FindAProvider

                       2B – Choose your network.

                       To search for a provider without logging in, select         FOR MORE
                       a provider network from the drop down list                INFORMATION
                       (example: MAHMO – True Blue HMO).
                                                                                OR ASSISTANCE,
                                                                                   CALL US AT
                                                                                   1-888-494-2583
                                                                                (TTY: 1-800-377-1363)

                                                                                October 1 to March 31,
                                                                               seven days a week from
                                                                               8 a.m. to 8 p.m. Between
                             2A                                                April 1 to September 30,
                                                                                     you can call us
                                                                                    Monday – Friday
                                                                                 from 8 a.m. to 8 p.m.
                                                            2B

40   INFORMATION KIT
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