Your Plan for Dual Eligibility | 2021 Enrollment Kit - Visit BlueCrossNC.com/Medicare - Blue Cross ...
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Your Plan for Dual Eligibility | 2021 Enrollment Kit
Visit BlueCrossNC.com/Medicare
U36089a, 8/20
H9147_9326_M CMS Accepted 09042020
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.
2
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
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.
4
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
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.
6
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
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.
8
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
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.
11Glossary
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.
12D 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.
13O
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
14Plan 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.
15Prescription 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”)
16Sample 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.
17Drug 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.
182021 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
19Summary 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.
20Summary 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.
21Summary 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.
22Summary 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.
23Summary 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.
24Summary 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.
25Frequently 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.
26Other 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.
27Other 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.
28Other 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.
29You can also read
