Your Plan for Dual Eligibility | 2021 Enrollment Kit - Visit BlueCrossNC.com/Medicare - Blue Cross ...

 
Your Plan for Dual Eligibility | 2021 Enrollment Kit - Visit BlueCrossNC.com/Medicare - Blue Cross ...
Your Plan for Dual Eligibility | 2021 Enrollment Kit

                                              Visit BlueCrossNC.com/Medicare
U36089a, 8/20
H9147_9326_M CMS Accepted 09042020
Your Plan for Dual Eligibility | 2021 Enrollment Kit - Visit BlueCrossNC.com/Medicare - Blue Cross ...
Welcome to
                                                           (HMO D-SNP)

    Thank you for your interest in Healthy Blue + Medicare from
    Blue Cross and Blue Shield of North Carolina (Blue Cross NC).
    You’ll find all the information you need to sign up today in         When you have
    this enrollment kit. If you have any questions, contact Blue         Medicare questions,
    Cross NC or your Authorized Agent. We’re ready to help.              we’ve got answers.
    Healthy Blue + Medicare offers a variety of benefits designed
                                                                         We’re ready to help.
    to help keep you healthy while protecting you from
    unexpected medical and drug costs. This booklet tells you
    what we cover, what you may pay and more. If you have
    questions, please call Blue Cross NC or your Authorized Agent.
    Our service area includes these counties in North Carolina:
    Alamance, Buncombe, Cabarrus, Cumberland, Davidson,
    Davie, Durham, Forsyth, Gaston, Guilford, Harnett,
    Mecklenburg, Orange, Rowan, Stokes, Surry, Wake and
    Yadkin.
    While the Summary of Benefits does not include every service,
    limit or exclusion, the Evidence of Coverage does. Just give
    us a call to request a copy.

             D-SNP stands for Dual-Eligible Special Needs Plan. It’s available
             to residents of the counties listed above who are eligible for both
             Medicare and Medicaid.

             Find more definitions in the glossary on page 12.

          Have Medicare questions? We’ve got answers. Contact Blue Cross NC:

           Phone: 1-800-400-8745 (toll-free), TTY users dial 711

           Hours: 7 days a week, 8 a.m. – 8 p.m.              Visit: BlueCrossNC.com/Medicare

                          Or contact your Blue Cross NC Authorized Agent.

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Your Plan for Dual Eligibility | 2021 Enrollment Kit - Visit BlueCrossNC.com/Medicare - Blue Cross ...
Table of Contents

Plan Information                                                                                                                                       4
How Medicare and Medicaid Work Together........................................................................................ 4
What is Healthy Blue + Medicare?......................................................................................................... 6
More Healthy Benefits............................................................................................................................. 8
Visiting the Doctor................................................................................................................................... 9
Plan Benefits Highlight.......................................................................................................................... 10
Glossary..................................................................................................................................................12

Plan Availability                                                                                                                                   15

Prescription Drug Coverage                                                                                                                          16
Common Drugs......................................................................................................................................17
Drug Tiers............................................................................................................................................... 18
Save Money on Your Prescriptions...................................................................................................... 18

Summary of Benefits                                                                                                                                 19
Summary of Benefits – Healthy Blue + Medicare............................................................................... 19
Frequently Asked Questions (Prescription Drug Coverage).............................................................. 26
Summary of Medicaid-Covered Benefits............................................................................................ 29

Enrollment                                                                                                                                         30
Enrollment Periods................................................................................................................................ 30
Pre-Enrollment Checklist...................................................................................................................... 31
Enrollment Steps................................................................................................................................... 32
Post-Enrollment Timeline..................................................................................................................... 33
Scope of Sales Appointment Confirmation Form (including duplicate)........................................... 35
Enrollment Form (including duplicate)................................................................................................ 39
Agent Checklist for Selling Medicare Advantage Plans (including duplicate).................................. 55

                                                                                                                                                               3
Your Plan for Dual Eligibility | 2021 Enrollment Kit - Visit BlueCrossNC.com/Medicare - Blue Cross ...
How Medicare and Medicaid Work Together

    This is a Dual-Eligible Special Needs Plan (D-SNP)
    Healthy Blue + Medicare is an HMO Medicare Advantage
    plan with prescription drug benefits that works with
    your Medicaid benefits. It includes hospital, medical and
    prescription drug benefits in one plan. To join this plan,   Take the time to learn
    you must:                                                    about how a Medicare
     • Be entitled to Medicare Part A                            and Medicaid plan
     • Be enrolled in Medicare Part B
                                                                 work together
     • Be enrolled in North Carolina Medicaid
       (the state's Medicaid program)
     • Live in one of the counties listed on page 15

    Eligibility
    Healthy Blue + Medicare is available to anyone with
    both Medicare Parts A and B who also receives medical
    assistance from North Carolina Medicaid to cover Medicare
    cost sharing.
    Information on the various Medicare Savings Programs that
    may cover some or all of your Medicare cost sharing are
    highlighted on the next page.

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Your Plan for Dual Eligibility | 2021 Enrollment Kit - Visit BlueCrossNC.com/Medicare - Blue Cross ...
Healthy Blue + Medicare                                         Medicare Coverage That
Plan members with full Medicaid coverage (Full Benefit          Goes Beyond Original

                                                                                                       Plan Information
Dual Eligible or FBDE) status are eligible for the North        Medicare
Carolina Medicaid program, which may be responsible for         • Like all Medicare Advantage
payment of their Medicare cost sharing. These members             health plans, we cover
are also eligible to receive the additional Medicaid benefits     everything that Original
described in the plan Evidence of Coverage.                       Medicare covers – Part A
                                                                  (hospital services) and Part B
Plan members with Qualified Medicare Beneficiary (QMB)
                                                                  (medical services). Our plan
status are eligible for the North Carolina Medicaid program,
                                                                  members also get more than
which is responsible for payment of their Medicare cost
                                                                  what is covered by Original
sharing. Some QMB members are also eligible to receive
                                                                  Medicare. Some of the extra
full Medicaid benefits (QMB+).
                                                                  benefits are covered in this
Plan members with Specified Low-Income Medicare                   Summary of Benefits.
Beneficiary Plus (SLMB+) status are eligible for the North      • This plan covers Medicare
Carolina Medicaid program, which is responsible for               Part D drugs and Part B
payment of their Medicare Part B premium. Members are             drugs (such as chemotherapy
also eligible to receive full Medicaid benefits.                  and some drugs administered
                                                                  by your provider). To see if
Cost Sharing Protections for All Members                          your prescription drugs are
In our plan, the state Medicaid program pays the cost             covered, follow the
sharing for Medicare-covered medical services you receive.        instructions in the
You pay no cost sharing for the Medicare-covered benefits         Prescription Drug Coverage
described later in this Summary of Benefits. You will pay         section of this booklet.
either small copayments or (potentially) no copayment
for prescriptions covered under the Medicare Part D
prescription drug benefit. When you receive health services,
the provider should only bill the plan for the cost of those
services and cost sharing amounts. The provider should not
bill you for services or cost sharing.

                                                                                                   5
Your Plan for Dual Eligibility | 2021 Enrollment Kit - Visit BlueCrossNC.com/Medicare - Blue Cross ...
What is Healthy Blue + Medicare?

    It’s Original Medicare and Much More
    Healthy Blue + Medicare is the plan for you if you are
    enrolled in Medicare and Medicaid. It is an HMO Medicare
    Advantage and prescription drug plan. It includes hospital,
                                                                       Your overall health
    medical and prescription drug benefits all in one plan.
                                                                       matters, and we’re
    To see if you are qualified to join Healthy Blue + Medicare,       here to support you.
    refer to pages 4 and 5 of this enrollment kit. You can also call
    Blue Cross NC or your Blue Cross NC Authorized Agent.
    When you join Healthy Blue + Medicare, you must use the
    plan’s network providers, except in emergency or urgent
    care situations, or for out-of-area renal dialysis. Please
    keep in mind that if you obtain routine care from out-of-
    network providers, neither Medicare nor Blue Cross NC
    will be responsible for the costs.

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Your Plan for Dual Eligibility | 2021 Enrollment Kit - Visit BlueCrossNC.com/Medicare - Blue Cross ...
Care You Can Count On

                                                                                     Plan Information
 • Preventive care
                                                   Blue Cross NC is proud
 • Prescription drug coverage (Medicare Part D)
                                                   to be one of North
 • Inpatient and outpatient services
                                                   Carolina’s leading health
 • Skilled nursing facility and home health care
                                                   insurance companies.
 • Ambulance service                               Today, more than 3.8
 • Urgent care                                     million customers rely
 • Routine eye exams                               on us for health care
 • Dental exams and hearing aids                   solutions – more than
 • Transportation benefit                          any other insurer based
 • Meal benefit                                    in North Carolina. In fact,
                                                   one of every three North
                                                   Carolinians is among our
                                                   customers.1
                                                   For more than 87 years,
                                                   North Carolinians have
                                                   trusted us for the health
                                                   care coverage they need.
                                                   We’re ready to meet
Footnote:
                                                   your Medicare needs.
1 Blue Cross NC internal membership data
   and NC Budget and Management Office
   population data as of May 2020.

                                                                                 7
Your Plan for Dual Eligibility | 2021 Enrollment Kit - Visit BlueCrossNC.com/Medicare - Blue Cross ...
More Healthy Benefits

    Our Healthy Blue + Medicare plan offers a range of extra benefits to help you maintain and
    improve your health.

            Hearing Coverage                                     Dental Coverage
            Coverage for routine exams, hearing                  Coverage for preventive services
            aids and more. See page 21 for more                  and more. See page 21 for more
            information.                                         information.

            Vision Coverage                                      Transportation Benefit
            Coverage for routine services                        Coverage for unlimited routine trips
            and more. See page 22 for more                       every year. See page 23 for more
            information.                                         information.

            Post Discharge Meals                                 Over-the-Counter (OTC)
            Provides for up to 2 meals a day                     Products Allowance
            for 7 days. See page 27 for more                     Provides $300 a quarter to spend on
            information.                                         approved over-the-counter health items.
                                                                 See page 27 for more information.

            24/7 NurseLine                                       Prescription Drug
            24/7/365 access to NurseLine. See                    Coverage
            page 28 for more information.                        Pay $0 copays for some or all of your
                                                                 medications. See pages 24-26 for
                                                                 more information.

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Your Plan for Dual Eligibility | 2021 Enrollment Kit - Visit BlueCrossNC.com/Medicare - Blue Cross ...
Visiting the Doctor

Turn to Our Network Providers

                                                                                                            Plan Information
You’ll want to choose a primary care provider (PCP)
from within the network to coordinate your care and help
you save money. Among the kinds of PCPs that may be
available are:
 • General and family practice doctor
 • Internal medicine doctor
 • Nurse practitioner
 • Physician assistant
                                                                        Visit an in-network
In-Network Value                                                        specialist at any time
With your Healthy Blue + Medicare plan, you may visit a                 without a referral.
specialist at any time without a referral. However, as with
any other doctor, you should visit an in-network specialist or
you may be responsible for more of the costs.

Virtual Appointments
A visit to the doctor doesn’t always have to mean a visit to
their office. More and more health care providers offer virtual
care. You can have a virtual visit via smart phone, computer,
tablet or other video device. What’s more, virtual visits are
covered the same as face-to-face visits according to your plan.
Virtual visits can include appointments not only with your
PCP, but also with behavioral health providers in the service
area who can deliver services via a secure video.
Call your doctor to ask about virtual appointment options               Call your doctor to
for a host of issues from allergies, headaches, and nausea
                                                                        ask about virtual
to medication management, mental health – and many more.
                                                                        appointment options.
Please remember that virtual services are not a substitute for
emergency care.

   Our Blue Medicare Advantage plans offer                              49,000 +
   you an extensive network of more than
   49,000 providers.* You'll get your health care at
   lower prices by using these in-network providers.
                                                                                  across NC*
                                                  Footnote:* Blue Cross NC internal data, July 2020.

                                                                                                        9
Your Plan for Dual Eligibility | 2021 Enrollment Kit - Visit BlueCrossNC.com/Medicare - Blue Cross ...
Plan Benefits Highlight
                                                  (HMO D-SNP)

                                 Healthy Blue + Medicare                   Original Medicare
                                     Medicare and qualifying                Medicare only eligibility
                                      Medicaid eligibility

                                    $0 plan premium. Part B
                                                                      You pay the Part B premium each
                                    premium is covered by
       Monthly Premium:                                                 month. This does not include
                                  your state’s Medicaid agency
                                                                      Part D prescription drug coverage.
                                      for D-SNP enrollees.

       Doctor Visits –
                                            $0 copay                             20% of cost
       Primary:

       Doctor Visits –
                                            $0 copay                             20% of cost
       Specialist:

                                                                       In 2020, the amounts for each
                                                                        benefit period were: $1,408
       Inpatient Hospital:                  $0 copay                     deductible for each benefit
                                                                          period; $0 for days 1-60;
                                                                            $352 for days 61-90.

                                 Preventive covers $0 copay for
                                   2 oral exams, 2 cleanings,
                                  1 dental X-ray and 1 fluoride
                                      treatment per year.
       Dental Care:              Comprehensive dental services                   Not covered
                                (basic & major) are covered up to
                                $2,500 per year. Includes services
                                  like dentures, crowns, dental
                                implants, extractions and fillings.

       Hearing Care –               $0 copay for one routine
                                                                                 Not covered
       Routine:                          exam per year

                                   $0 copay and up to $2,000
       Hearing Care –
                                   allowance for hearing aids;                   Not covered
       Hearing Aids:
                                    one aid per ear per year.

     Notes:
     •	Limitations, copayments and restrictions may apply.
     •	This information is not a complete description of benefits.
     •	Premiums, benefits and/or copayments/coinsurance may change on January 1 of each year.
10
(HMO D-SNP)

                                                                                                      Plan Information
                          Healthy Blue + Medicare                 Original Medicare
                              Medicare and qualifying              Medicare only eligibility
                               Medicaid eligibility

24/7 NurseLine:                      Included                           Not covered

Over-the-Counter           Up to $300 every quarter to
                                                                        Not covered
(OTC) Benefit:               spend on health items

Personal Emergency
Response System                      Included                           Not covered
(PERS):

Podiatry Care –           $0 copay for unlimited routine
                                                                        Not covered
Routine:                    foot care visits every year

Post-Discharge              $0 copay for up to 2 meals
                                                                        Not covered
Meals:                    a day for 7 days post discharge

                             $0 copay for prescription        Part D benefits are only covered
Prescription Drugs:          drugs on Tiers 1 and 6 at           if you enroll in a Medicare
                               preferred pharmacies            Prescription Drug Plan (PDP).

Healthy Aging and
                                     Included                           Not covered
Exercise Program:

                           $0 copay for unlimited routine
Transportation
                         transportation services every year             Not covered
Benefit:
                             to plan-approved locations

                             $0 copay for one routine
Vision Care – Exams:                                                    Not covered
                                  exam per year

Vision Care – Eyewear:       $250 allowance per year                    Not covered

Worldwide                  Up to $100,000 per year for
                                                                        Not covered
Emergency Coverage:       worldwide emergency services

  For more plan information, contact Blue Cross NC or your Authorized Agent.
                                                                                                 11
Glossary

     A                                                                 C
     Allowed amount                    Annual Enrollment               Coinsurance
     The discounted rate               Period (AEP)                    An amount you may be
     Medicare or Blue Cross NC         This is the time each year      required to pay as your
     has negotiated with doctors,      when you can enroll             share of the cost for services
     hospitals and other health        in a Medicare health            or prescription drugs.
     care providers for a covered      insurance plan. The             Coinsurance is usually a
     service to help keep costs low.   Annual Enrollment Period        percentage of the cost.
                                       is October 15 through
     Ambulatory surgical               December 7. You can also        Copayment (Copay)
     center                            disenroll during this period.   A fixed dollar amount you may
     Medical facility where                                            pay for a covered service or
     surgical procedures that                                          prescription drug at the time
     don’t require an overnight
     hospital stay are performed.      B                               you receive it. Copayments
                                                                       can vary depending on the
                                       Benefit                         service or drug.
     Annual deductible
     The amount you pay for            Medical services that are
                                                                       Cost sharing
     health care or prescriptions      covered by the plan.
                                                                       The amount you pay as your
     before a plan begins to pay.                                      share of the cost for health
     The Healthy Blue + Medicare                                       care services. Cost sharing
     plan does not have an annual                                      can include copayments,
     deductible.                                                       coinsurance and deductibles.

12
D                                 F                                 L

                                                                                                      Plan Information
Deductible                        Formulary                         Late enrollment
The amount you owe for            The list of prescription drugs    penalty
certain covered services          that are paid for in full or in   An amount added to your
during a benefit period           part by the health insurance      monthly premium for
before your Medicare health       plan you choose.                  Medicare drug coverage if
insurance begins to pay.                                            you go without creditable
Healthy Blue + Medicare                                             coverage (coverage that is
does not have a deductible.
                                  H                                 expected to pay, on average,
                                                                    at least as much as standard
Dual-Eligible Special             Health care provider              Medicare prescription drug
Needs Plan (D-SNP)                A professional or                 coverage) for a continuous
Health care available to                                            period of 63 days or more.
                                  organization, such as a
members in the service area
                                  doctor or a hospital, that
who are eligible for both
                                  provides medical services.
Medicare and Medicaid.
                                  HMO
                                                                    M
                                  HMO stands for Health             Medicaid beneficiary
E                                 Maintenance Organization.
                                  An HMO offers health
                                                                    An individual who is eligible
                                                                    to receive benefits from
Emergency services                coverage through a network        North Carolina Medicaid.
Medical care given when           of doctors and other health
your health or life is            care providers who are under      Medicare beneficiary
threatened, such as with          contract to provide covered       An individual who is
chest pain, head injury or        services at a lower cost to       entitled to benefits under
severe bleeding.                  members.                          Medicare Part A and enrolled
                                                                    in Medicare Part B, or
End-Stage Renal                                                     enrolled in both Medicare
Disease (ESRD)
When a person requires            I                                 Part A and Part B and who
                                                                    resides in the U.S.
dialysis or a kidney
                                  ID card
transplant because of kidney
                                  The identification card that
failure; people with end-
stage renal disease qualify for
                                  shows the health insurance
                                  plan you have and usually
                                                                    N
Original Medicare regardless
                                  lists your ID number and          Network or in-network
of age.
                                  other essential information.      providers
Extra Help or Low                                                   The doctors, other health care
Income Subsidy (LIS)                                                service providers, facilities,
A Medicare program that                                             suppliers and pharmacies
helps pay for prescription                                          that are in the network of
drug costs for those who                                            your plan. They’re also called
qualify.                                                            preferred providers.

                                                                                                     13
O
     Out-of-network                  Premium                         you may be eligible for a
     providers                       The amount of money you         Special Enrollment Period
     These are the doctors and       have to pay each month          include if you move outside
     other health care providers     of the year for your health     the service area, if you are
     not in your plan’s network.     insurance plan.                 getting “Extra Help” with
     Out-of-pocket costs                                             your prescription drug costs,
                                     Primary Care                    if you move into a nursing
     The health care costs you
                                     Provider (PCP)                  home or if we violate our
     must pay because the plan
                                     Your primary care provider is   contract with you. If you are
     does not cover them.
                                     the doctor or other provider    Medicaid eligible, you have
     Out-of-pocket maximum           you see first for most health   an SEP that allows for one
     The most you pay for covered    problems. They make sure        plan change per quarter for
     services during a benefit       you get the care you need to    the first three quarters of the
     period before Blue Cross NC     keep you healthy. They also     year.
     begins to pay 100% of your      may talk with other doctors
     covered services. This limit    and health care providers       Specialist
     never includes premium          about your care and refer you   Medical specialists are
     payments or services that are   to them. In many Medicare       doctors who have
     not covered.                    health plans, you must see      completed advanced
                                     your primary care provider      education and clinical
                                     before you see any other        training in a specific
     P                               health care provider.           area of medicine (their
                                                                     specialty area).
     Preferred pharmacy
     A pharmacy that is part of      S
     your network; compared
     to those at an out-of-          Service area
                                                                     U
     network pharmacy,               The North Carolina counties     Urgent care
     out-of-pocket costs are         where Healthy Blue +            Urgently needed services
     lower when you fill your        Medicare is available.          that are provided to treat a
     prescriptions at a preferred                                    non-emergency, unforeseen
                                     Special Enrollment
     pharmacy.                                                       medical illness, injury or
                                     Period (SEP) – Dual-
                                                                     condition that requires
     Preferred providers             Eligible Individuals or
                                                                     immediate medical care.
     The doctors, other health       Individuals Who Lose
     care service providers,         Their Dual-Eligibility
     facilities, suppliers and       A set time when members can
     pharmacies that are in your     change their health or drug
     plan’s network; they’re also    plans or return to Original
     called network providers.       Medicare. Situations in which

14
Plan Availability

The Healthy Blue + Medicare Service Area
The Healthy Blue + Medicare service area includes these
counties in North Carolina: Alamance, Buncombe, Cabarrus,            We offer Healthy Blue
Cumberland, Davidson, Davie, Durham, Forsyth, Gaston,                + Medicare in 18
Guilford, Harnett, Mecklenburg, Orange, Rowan, Stokes,               North Carolina
Surry, Wake and Yadkin.
                                                                     counties.
If your county is not listed above, Healthy Blue + Medicare
is not available where you live. Please contact Blue Cross NC
or your Authorized Agent to discuss our other Medicare
plan options.

                            Counties where Healthy Blue + Medicare is available.
                                                                                             15
Prescription Drug Coverage

     Healthy Blue + Medicare Includes
     Drug Coverage
     Our plan gives you access to the prescription drugs            See the following pages
     you need to maintain a healthy and active lifestyle.
                                                                    and the Summary of
     Our plan includes your health care and prescription
                                                                    Benefits on page 19 to
     drug coverage together in one plan.
                                                                    learn more about the
     The plan groups each drug into “tiers.” The amount             prescription drug coverage
     you pay depends on the tier, the stage of your
                                                                    that’s included with
     benefit, and what you qualify for with Medicaid.
                                                                    Healthy Blue + Medicare.

                         For a complete drug list, contact Blue Cross NC:

            Phone: 1-800-400-8745 (toll-free), TTY users dial 711

            Hours: 7 days a week, 8 a.m. – 8 p.m.

           Visit:   BlueCrossNC.com/Medicare (Click on “Find Doctor/Drug/Facility”)

16
Sample of Drugs Used on HMO Plans
                                                                                                                       1

A partial list of commonly prescribed drugs covered

  Drug                                     Tier    Drug                                     Tier     Drug                                      Tier

alendronate sodium...............6                 gabapentin................................. 2     montelukast sodium................. 2
allopurinol.................................. 2    gabapentin................................ 2      omeprazole............................... 2
alprazolam.................................3       glimepiride...............................6       oxybutynin chloride................... 2
amitriptyline hydrochloride........ 4              glipizide....................................6    oxycodone hydrochloride..........3
amlodipine besylate.............. 1, 2             glipizide ER..............................6       oxycodone/acetaminophen...3, 4
amoxicillin/                                       Humalog Kwikpen.....................3             pantoprazole sodium................. 2
   clavulanate potassium........2, 4               hydralazine hydrochloride......... 2              paroxetine hydrochloride.......... 4
atenolol...................................... 2   hydrochlorothiazide............... 1, 2           pioglitazone hydrochloride....6
atorvastatin calcium...............6               hydrochlorothiazide................... 1          potassium chloride ER..........2, 3
azithromycin.............................. 2       hydrocodone/acetaminophen...3                     pravastatin sodium.................6
baclofen..................................... 2    irbesartan.................................6      prednisone........................1, 2, 3
benazepril HCl.........................6           isosorbide mononitrate ER....... 2                pregabalin..................................3
bupropion                                          Januvia.......................................3   propranolol hydrochloride......... 2
   hydrochloride ER (XL).............3             Jardiance...................................3     quetiapine fumarate.................. 2
buspirone hydrochloride.......2, 3                 lamotrigine................................ 2     ramipril.....................................6

                                                                                                                                                        Prescription Drug Coverage
carvedilol................................... 2    Lantus Solostar.........................3         ropinirole HCl............................. 2
celecoxib...............................2, 3       latanoprost................................ 2     rosuvastatin calcium..............6
cephalexin.............................2, 4        levetiracetam............................ 2       sertraline HCl............................. 2
chlorthalidone............................ 2       levothyroxine sodium................ 2            simvastatin..............................6
citalopram hydrobromide...... 1, 2                 lisinopril...................................6    spironolactone........................... 2
clonazepam............................... 2        lisinopril/                                       Symbicort..................................3
clonidine HCl............................. 2       hydrochlorothiazide...............6               tamsulosin hydrochloride.......... 2
clopidogrel................................. 2     lorazepam.................................. 2     timolol maleate...................... 1, 2
diltiazem                                          losartan potassium.................6              tizanidine hydrochloride............ 2
   hydrochloride ER................3, 4            losartan potassium/                               topiramate................................. 2
donepezil HCl........................2, 3            hydrochlorothiazide............6                tramadol HCl.............................3
duloxetine hydrochloride...........3               lovastatin.................................6      trazodone hydrochloride........2, 3
Eliquis........................................3   meloxicam............................. 1, 2       triamterene/
escitalopram oxalate................. 2            memantine hydrochloride.....2, 4                     hydrochlorothiazide................ 2
ezetimibe...................................3      metformin hydrochloride.......6                   valacyclovir hydrochloride......... 2
famotidine................................. 2      metformin                                         venlafaxine HCl ER.................... 2
fenofibrate................................. 2     hydrochloride ER....................6             Ventolin HFA.............................3
finasteride.................................. 2    methotrexate...........................6          warfarin sodium........................ 2
fluoxetine hydrochloride............ 2             metoprolol succinate ER........... 2              Xarelto.......................................3
fluticasone propionate............... 2            metoprolol tartrate.................... 1         zolpidem tartrate....................... 4
furosemide............................ 1, 2        mirtazapine............................2, 3

  Key                       bold = Tier 6          lowercase = generic                Capitalized Name = brand-name

Footnote: 1 Data provided from 2020 Prime Therapeutics pharmacy data.
Notes: Some covered drugs may have additional requirements or limits on coverage. Tier 6 drugs


include select generic medications used to treat blood pressure, cholesterol, diabetes, osteoporosis and
rheumatoid arthritis. The formulary and pharmacy network may change at any time; you’ll receive notice
when necessary. For more information, contact Blue Cross NC or your Authorized Agent.
                                                                                                                                                       17
Drug Tiers                                                 Tier 1 – Preferred Generic Drugs
                                                                   Tier 2 – Generic Drugs
        The prescription drugs we cover are grouped in             Tier 3 – Preferred Brand Drugs
        tiers. Brands and generics may be in different             Tier 4 – Non-Preferred Drugs
        tiers. Different strengths of drugs may also be in         Tier 5 – Specialty Tier Drugs
        different tiers.                                           Tier 6 – Select Care Drugs

               Save Money on Your Prescriptions
     Ask for Generics
     Whenever your health care provider prescribes a medication, be                 GENERIC

     sure to ask if there’s a generic equivalent. Generics deliver exactly
     the same benefits as their corresponding brand-name medications
     but are often available at significantly lower cost.

     Use Our Preferred Pharmacy Network
     The Blue Cross NC Preferred Pharmacy Network includes many
     national pharmacy chains and local pharmacies. It’s a network
     of pharmacies that have worked with Blue Cross NC to bring
     you savings and value. With our preferred network pharmacies,
     you’ll find lower costs, better value and greater convenience.
     Chances are you already live or work near one of our network
     pharmacies: EPIC, Walgreens, AllianceRx Walgreens Prime,
     Walmart and others.

     Preferred Mail Order
     Save time when you use our preferred mail order pharmacy
     services. Prescriptions are delivered right to your door and we
     handle all the paperwork.

           You’ll find information on prescription drug coverage copayments,
           coinsurance and deductibles in the Summary of Benefits, page 19.

18
2021 Summary of Benefits

                                                   (HMO D-SNP)
H9147-001

This is a summary of health services and prescription drug coverage that is
covered under Healthy Blue + Medicare for January 1, 2021 – December 31, 2021.

Notes:
•	
  Healthy Blue + Medicare has 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 their services.
•	
  Cost sharing may vary depending on the pharmacy you choose and when you enter another phase
  of the Part D benefit. For more information on the additional pharmacy-specific cost sharing and the
  phases of the benefit, please call us or access our Evidence of Coverage online.
•	
  Blue Cross and Blue Shield of North Carolina Senior Health DBA Blue Cross and Blue Shield of
  North Carolina is an HMO D-SNP plan with a Medicare contract and a contract with the North Carolina
  Medicaid program. Enrollment in Blue Cross and Blue Shield of North Carolina Senior Health depends
  upon contract renewal.
•	
  The benefits information provided is a summary of what we cover and what you pay. This information is not
  a complete description of benefits. For more details, or to request an Evidence of Coverage, contact
  Blue Cross NC at 1-800-400-8745 (TTY: 711), access online at BlueCrossNC.com/Medicare or call
  your Blue Cross NC Authorized Agent.
• Healthy Blue + Medicare is available in these counties in North Carolina: Alamance, Buncombe,
  Cabarrus, Cumberland, Davidson, Davie, Durham, Forsyth, Gaston, Guilford, Harnett, Mecklenburg,
  Orange, Rowan, Stokes, Surry, Wake and Yadkin.

U36630, 8/20
H9147_9147_M CMS Accepted 09042020
                                                                                                              19
Summary of Benefits

                                          (HMO D-SNP)

                                                                                               H9147-001

                                             Part B premium is covered by your state’s
       Monthly Premium:                                                                            $0
                                             Medicaid agency for D-SNP enrollees.

       Deductible:                           This plan does not have a medical deductible.         $0

                                             Does not include prescription drugs.
                                             Like all Medicare Advantage health plans,
                                             our plan protects you by having yearly limits
                                             on your out-of-pocket costs for medical and
       Annual Maximum                        hospital care. Services you get from doctors        $7,550
       Out-of-Pocket Amount:                 or facilities in our plan go toward your yearly
                                             limit. If you reach the limit on out-of-pocket
                                             costs, you will not have to pay any out-of-
                                             pocket costs for covered Part A and Part B
                                             services for the rest of the year.

       Benefits

                                              Days 1–90:                                       $0 copay

       Inpatient Hospital Care:*
       (Cost share applies per day.          Our plan covers 60 “lifetime reserve days.” These are extra
       Benefit period applied                days that we cover. If your hospital stay is longer than 90
       per admission.)                       days, you can use these extra days. But once you have used
                                             up these extra 60 days, your inpatient hospital coverage will
                                             be limited to 90 days.

                                             Ambulatory Surgical Center:                       $0 copay
       Outpatient Services:*
                                             Outpatient Hospital:                              $0 copay

                                              Primary:                                         $0 copay
       Doctor Visit:
                                             Specialist:*                                      $0 copay

                                             Screenings:                                       $0 copay
       Preventive Care:
                                             Annual Physical Exam:                             $0 copay

     * May require prior authorization.
20
Summary of Benefits

                                     (HMO D-SNP)

  Benefits                                                                                 H9147-001

                                            This plan also covers emergency services
                                            when traveling outside of the United
  Emergency Care:                           States for less than six months. This          $0 copay
                                            benefit is limited to $100,000 per year
                                            for worldwide emergency services.

  Urgently Needed Services:                                                                $0 copay

  Diagnostic Services/                      Diagnostic tests, labs, radiology
                                                                                           $0 copay
  Labs/Imaging:*                            services and X-rays.

                   Medicare-Covered         Exams to diagnose and treat
                                                                                           $0 copay
                   Hearing Exam:            hearing and balance issues.

                   Routine Hearing          This plan covers 1 routine hearing exam
  Hearing
                   Exam and Hearing         and hearing aid fitting/evaluation             $0 copay
  Services:        Aid Evaluation:*         every year.

                                            $2,000 maximum plan benefit for
                   Hearing Aids:*
                                            hearing aids every year. 1 per ear per year.

                                                                                                        Summary of Benefits
                                            This does not include services for care,
                   Medicare-Covered
                                            treatment, filling, removal or replacement     $0 copay
                   Dental Services:
                                            of teeth.

                                            This plan covers: 2 oral exams, 2
                   Preventive:              cleanings, 1 dental X-ray, 1 fluoride          $0 copay
                                            treatment every year.
  Dental
                                            This plan covers up to a $2,500
  Services:*
                                            allowance for comprehensive dental
                                            services every year. We cover more
                                            dental care than Original Medicare. You
                   Comprehensive:           can use our coverage for these services        $0 copay
                                            and more: fillings, crowns, periodontal
                                            root planing and scaling, extractions and
                                            dentures. Any amount not used at the
                                            end of the calendar year will expire.

* May require prior authorization.
                                                                                                       21
Summary of Benefits

                                          (HMO D-SNP)

        Benefits                                                                            H9147-001

                        Routine Eye Exam:          1 every year.                            $0 copay

                                                   This plan covers up to $250 for
                        Routine Eyewear
                                                   eyeglasses or contact lenses every       $0 copay
                        (Lenses and Frames):
                                                   year.
        Vision
        Services:
                        Medicare-Covered           Exam to diagnose and treat diseases
                                                                                            $0 copay
                        Eye Exam:                  and conditions of the eye.

                        Eyewear After              Eyeglasses or contact lenses after
                                                                                            $0 copay
                        Cataract Surgery:          cataract surgery.

                                                   Our plan covers 90 days for an
                                                   inpatient hospital stay.
                                                   Our plan covers 60 “lifetime reserve
                                                   days.” These are extra days that we
                        Inpatient:                 cover. If your hospital stay is longer   $0 copay
        Mental                                     than 90 days, you can use these
        Health                                     extra days. But once you have used
        Services:*                                 up these extra 60 days, your inpatient
                                                   hospital coverage will be limited to
                                                   90 days.

                        Outpatient:                Individual and group therapy sessions.   $0 copay

                                                   Our plan covers up to 100 days in a
        Skilled Nursing Facility:*                 Skilled Nursing Facility (SNF).
                                                                                            $0 copay

     * May require prior authorization.
22
Summary of Benefits

                                     (HMO D-SNP)

  Benefits                                                                                 H9147-001

                                                  Provides a limit of two, one-hour
                         Cardiac (Heart):         sessions per day and a maximum of        $0 copay
                                                  36 sessions within a 36-week period.

  Outpatient
                                                  Provides a limit of two, one-hour
  Rehabilitation         Pulmonary (Lung):        sessions per day and a maximum of        $0 copay
  Services:*                                      36 sessions.

                         Occupational,
                         Physical and Speech                                               $0 copay
                         Language Therapy:

                                                  Covers medically necessary ground,
  Ambulance Services:*                            water and air ambulance services.
                                                                                           $0 copay

                         This plan offers coverage for unlimited routine transportation
                         services every year. Trips are limited to 60 miles.
                         Routine transportation coverage is limited to plan-approved       $0 copay
  Transportation:* locations (within the local service area) provided by contracted
                         transportation vendors in our plan. If you need a ride, call us

                                                                                                        Summary of Benefits
                         at least 48 hours ahead of time.

  Medicare Part B Drugs:*                                                                  $0 copay

                    To find other covered benefits, see pages 27-29.
              For prescription drug coverage information, see pages 24-26.

* May require prior authorization.
                                                                                                       23
Summary of Benefits                                         Prescription Drug Coverage

                                   (HMO D-SNP)                                                   H9147-001

     Part D, Prescription Drug Benefit Stages

     Annual             The Part D deductible does not apply to you because you get “Extra Help”
     Deductible:        from Medicare.

                        You pay the amount listed in the table on the following pages until your total
                        yearly drug costs reach $4,130. Total yearly drug costs are the total drug costs
                        paid by both you and our Part D plan.
                        You may get your covered drugs at retail pharmacies and mail order
     Initial Coverage   pharmacies in our plan. You may get your covered drugs from pharmacies not
     Limit (ICL):       in our plan only when you are unable to get your prescription drugs from a
                        pharmacy that is in our plan. If you live in a long-term care facility, you pay the
                        same as a standard retail pharmacy.
                        If you qualify for Low-Income Subsidy (LIS), also known as Medicare’s
                        “Extra Help” program, the amount you pay may be different in this stage.

                        After you enter the coverage gap, you will pay your Low-Income Subsidy (LIS)
                        level cost sharing for generic and brand name drugs unless your plan has
     Coverage           extra generic gap coverage.
     Gap:               For drugs on Tier 1 and Tier 6, you will pay: $0.
                        You will stay in the gap until your costs total $6,550, which is the end of
                        the coverage gap. Note: Not everyone will enter the coverage gap.

                        After your yearly out-of-pocket drug costs reach $6,550, the plan will pay most
     Catastrophic
                        of your Medicare covered Part D drugs for the rest of the plan year, depending
     Coverage:
                        on your Low-Income Subsidy (LIS) status.

       To find more information on prescription drug coverage, see pages 16–18.

24
Summary of Benefits                                         Prescription Drug Coverage

                                  (HMO D-SNP)                                           H9147-001

                                                                           Preferred Pharmacies
                                                                              and Mail Order

  Preferred Generic Drugs (Tier 1)                                                $0 copay

  Generic Drugs (Tier 2)                                                      $0 – $3.70 copay*

  Preferred Brand Drugs (Tier 3)                                              $0 – $9.20 copay*

  Non-Preferred Drugs (Tier 4)                                                $0 – $9.20 copay*

  Specialty Tier Drugs (Tier 5)                                               $0 – $9.20 copay*

  Select Care Drugs (Tier 6)                                                      $0 copay

                                                                                                        Summary of Benefits
    To find more information on prescription drug coverage, see pages 16–18.

  
* Depending on the level of “Extra Help” you receive.
Note: Cost sharing is the same for 30-day or long-term supply. You can determine which covered drugs
are generic by reading the plan’s Formulary.
                                                                                                       25
Frequently Asked Questions                             Prescription Drug Coverage

     Question: Which drugs are covered?
     Answer:     See the Prescription Drug Coverage section of this book, pages 16-18.

     Question: Which pharmacies can I use?
     Answer:     •	Our Preferred Pharmacy Network is a select network of national and local
                    independent pharmacies designed to help save you money on your prescriptions.
                   You may choose non-preferred pharmacies to fill prescriptions, but your costs may
                    be higher.
                 •	Our preferred pharmacy and preferred mail order pharmacy networks include:
                    EPIC, Walmart, Walgreens, AllianceRx Walgreens Prime and others.

     Question: How do I find a preferred pharmacy?
     Answer:     •	
                   To find a pharmacy near you, go to BlueCrossNC.com/Medicare
                   (Click on “Find Doctor/Drug/Facility”).

                   The formulary, pharmacy network and/or provider network may change at
                 •	
                   any time. You will receive notice when necessary.

                  For more information about Original Medicare, request the
                         Medicare & You handbook from Medicare:

           Phone: 1-800-MEDICARE (1-800-633-4227)            Hours: 7 days a week, 24 hours a day

          TTY:   1‑877‑486-2048                              Visit:   Medicare.gov

          Have Medicare questions? We’ve got answers. Contact Blue Cross NC:

                                             TTY users dial 711
          Phone: 1-800-400-8745 (toll-free), TYY

          Hours: 7 days a week, 8 a.m. – 8 p.m.              Visit: BlueCrossNC.com/Medicare

                         Or contact your Blue Cross NC Authorized Agent.

26
Other Covered Benefits

                                     (HMO D-SNP)

   Benefits                                                                                 H9147-001

                                                 Medicare coverage includes
                                                 manipulation of the spine to correct
   Chiropractic          Medicare-Covered:       a subluxation (when one or more of          $0 copay
   Services:*                                    the bones of your spine move out of
                                                 position).

                                                 Foot exams and treatment are
                                                 covered if you have diabetes-related
                         Medicare-Covered:                                                   $0 copay
   Podiatry                                      nerve damage and/or meet certain
                                                 conditions.
   Services:*

                         Routine Services:       Unlimited visits                            $0 copay

   Home Health Care:*                                                                        $0 copay

   Meals Benefit:*       Provides for up to 2 meals a day for 7 days post discharge.         $0 copay

                                                                                                            Summary of Benefits
                                                 Durable Medical Equipment
                                                                                             $0 copay
                                                 and Supplies:
   Medical Equipment
   and Supplies:*                                Prosthetics:                                $0 copay

                                                 Diabetes Supplies:                          $0 copay

   Outpatient Substance Abuse:*                  Individual & group therapy visits.          $0 copay

                         This plan covers certain approved, non-prescription, over-the-counter drugs
   Over-the-
                         and health-related items, up to $300 per quarter. Unused OTC amounts do
   Counter
                         not roll over to the next quarter. Some participating retailers are CVS, Dollar
   (OTC) Items:          General, Walgreens and Walmart.

* May require prior authorization.
                                                                                                           27
Other Covered Benefits

                                          (HMO D-SNP)

        Benefits                                                                               H9147-001

        Personal
        Emergency
        Response System Includes the monitoring device and monitoring service.                 $0 copay
        (PERS) Coverage:*

        Renal Dialysis:                                                                        $0 copay

                              The Silver&Fit program is provided by American Specialty
                              Health Fitness, Inc. (ASH Fitness), a subsidiary of American
                              Specialty Health Incorporated (ASH). All programs and
                              services are not available in all areas. Please make sure
        Silver&Fit®           to talk to a doctor before starting or changing an exercise
        Healthy Aging         routine. Silver&Fit, Fit at Home, and the Silver&Fit logo
                                                                                               $0 copay
        and Exercise          are trademarks of ASH. Other names or logos may be
        Program:              trademarks of their respective owners. Home kits are
                              subject to change. Not all YMCAs participate in the network.
                              ASH does not offer Blue Cross NC products or services. Not
                              connected with or endorsed by the US government or the
                              federal Medicare program.

        24/7 NurseLine:         24-hour access to NurseLine, 7 days a week, 365 days a year.

     * May require prior authorization.

                      For more information about Original Medicare, request the
                             Medicare & You handbook from Medicare:

             Phone: 1-800-MEDICARE (1-800-633-4227)                Hours: 7 days a week, 24 hours a day

             TTY:     1‑877‑486-2048                               Visit:   Medicare.gov

            Have Medicare questions? We’ve got answers. Contact Blue Cross NC:

                                                TTY users dial 711
             Phone: 1-800-400-8745 (toll-free), TYY

             Hours: 7 days a week, 8 a.m. – 8 p.m.                 Visit: BlueCrossNC.com/Medicare

                              Or contact your Blue Cross NC Authorized Agent.

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Other Covered Benefits
Medicaid-Covered Benefits
The following services are available through the North
Carolina Department of Health and Human Services (NC
Medicaid). Healthy Blue + Medicare may not cover or may
not fully cover the following services available through NC
Medicaid:
 • Doctors, OB/GYNs, health departments and rural
   health clinics
 • Laboratory and radiology
 • Hospitals, anesthesia and ambulatory surgical centers
 • Outpatient specialized therapy
 • Prescriptions (except prescriptions for
   Medicare beneficiaries)
 • Vision and hearing
 • Dental and orthodontia (for children)
 • Podiatry
 • Nursing home care
 • Personal care and other home health services
 • Medical equipment, such as wheelchairs
 • Orthotics and prosthetics
 • Mental and behavioral health care

                                                                Summary of Benefits
 • Transition from facilities to home-based and
   community care
 • Most medically necessary services for children under
   the age of 21
 • Medicare premiums, copayments and deductibles
Medicaid coverage is based on your eligibility. Please check
your Medicaid contract for a full list of services.

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