Blue Shield 65 Plus Choice Plan summary of benefits by DNathan

VIEWS: 318 PAGES: 50

									Blue Shield 65 Plus Choice Plan
     summary of benefits



       Los Angeles and Orange Counties
     January 1, 2009 to December 31, 2009



     An HMO with a Medicare Contract (H0504)
          CMS Approval Date: 09192008




                                                       H0504-08.093B1 RA 09192008
                                         blueshieldca.com/findamedicareplan.com
                                               Medicare health plan, like Blue Shield    We also offer more benefits, which may
SECTION I - INTRODUCTION TO THE                65 Plus.                                  change from year to year.
SUMMARY OF BENEFITS
                                               You may have other options too. You       Where Is Blue Shield 65 Plus Choice
Blue Shield 65 Plus Choice PlanSM              make the choice. No matter what you       Plan and Blue Shield 65 Plus
                                               decide, you are still in the Medicare     Available?
January 1, 2009 through                        Program.
December 31, 2009                                                                        There is more than one plan listed in this
                                               You may join or leave a plan only at      Summary of Benefits. If you are enrolled in
Thank you for your interest in Blue Shield     certain times. Please call Blue Shield    one plan and wish to switch to another
65 Plus Choice Plan and Blue Shield 65         65 Plus Choice Plan or Blue Shield 65     plan, you may do so only during certain
Plus. Our plan is offered by California        Plus at the telephone number listed at    times of the year. Please call Blue Shield
Physicians’ Service/Blue Shield of             the end of this introduction or 1-800-    65 Plus Choice Plan or Blue Shield 65 Plus
California, a Medicare Advantage Health        MEDICARE (1-800-633-4227) for             for more information.
Maintenance Organization (HMO).                more information. TTY users should
                                               call 1-877-486-2048. You can call this    The service area for Blue Shield 65 Plus
This Summary of Benefits tells you some        number 24 hours a day, 7 days a week.     Choice Plan includes: Los Angeles* and
features of our plans. It doesn't list every                                             Orange* counties, CA.
service that we cover or list every            How Can I Compare My
limitation or exclusion.                       Options?                                  * Los Angeles and Orange are partial
                                                                                         counties.
To get a complete list of our benefits,        You can compare Blue Shield 65 Plus
please call Blue Shield 65 Plus Choice Plan    Choice Plan, Blue Shield 65 Plus and      The service area for Los Angeles County
or Blue Shield 65 Plus and ask for the         the Original Medicare Plan using this     includes only the ZIP Codes listed below.
Evidence of Coverage.                          Summary of Benefits. The charts in        You must live in one of these ZIP Codes to
                                               this booklet list some important health   join the plan.
You Have Choices In Your Health                benefits. For each benefit, you can see
Care                                           what our plan covers and what the         90001    90002    90003    90011
                                               Original Medicare Plan covers.            90022    90023    90031    90032
                                                                                         90033    90040    90044    90058
As a Medicare beneficiary, you can choose                                                90059    90061    90063    90189
from different Medicare options. One           Our members receive all of the benefits
                                                                                         90201    90202    90220    90221
option is the Original (fee-for-service)       that the Original Medicare Plan offers.   90222    90239    90240    90241
Medicare Plan. Another option is a                                                       90242    90255    90262    90270


                                                                  1
90280    90601    90602    90603             92825    92831    92832     92833         with End Stage Renal Disease are generally
90604    90605    90606    90607             92834    92835    92837     92838         not eligible to enroll in Blue Shield 65 Plus
90608    90609    90610    90612                                                       Choice Plan or Blue Shield 65 Plus unless
90637    90638    90639    90640             92850    92870    92871     92885
90650    90651    90652    90659             92886    92887    92899                   they are members of our organization and
90660    90661    90662    90665                                                       have been since their dialysis began.
90670    90671    90701    90702             The service area for Blue Shield
90703    90706    90707    90711             65 Plus includes: Los Angeles* and        Can I Choose My Doctors?
90712    90713    90714    90715
90716    90723    90745    90746
                                             Orange counties, CA.
                                                                                       Blue Shield 65 Plus Choice Plan and Blue
90747    90749    90801    90802
                                             * Los Angeles is a partial county.        Shield 65 Plus has formed a network of
90803    90804    90805    90806
90807    90808    90810    90813                                                       doctors, specialists, and hospitals. You can
90814    90815    90822    90831             The service area for Los Angeles          only use doctors who are part of our
90832    90833    90834    90835             County includes all ZIP codes except      network. The health providers in our
90840    90842    90844    90845             for the ZIP codes listed below. You       network can change at any time. You can
90846    90847    90848    90853                                                       ask for a current Provider Directory for an
90888    90899    91731    91732             must live in an area other than the
                                             following ZIP Codes to join the plan:     up-to-date list or visit us at
91733    91744    91745    91746
91747    91748    91749    91754                                                       www.blueshieldca.com. Our customer
91755    91765    91770    91776             93510    93532    93534    93535          service number is listed at the end of this
91788    91789    91795    91801             93536    93539    93543    93544          introduction.
91803                                        93550    93551    93552    93553
                                             93563    93584    93586    93590          What Happens If I Go To A Doctor
The service area for Orange County           93591    93599                            Who's Not In Your Network?
includes only the ZIP Codes listed below.
You must live in one of these ZIP Codes to                                             If you choose to go to a doctor outside of
join the plan.                                                                         our network, you must pay for these
                                             Who Is Eligible To Join Blue Shield
                                             65 Plus Choice Plan or Blue               services yourself. Neither Blue Shield of
90620    90621    90622    90623                                                       California nor the Original Medicare Plan
                                             Shield 65 Plus?
90624    90630    90631    90632                                                       will pay for these services.
90633    90720    90721    90740             You can join Blue Shield 65 Plus
92801    92802    92803    92804             Choice Plan or Blue Shield 65 Plus if
92805    92806    92807    92808             you are entitled to Medicare Part A and
92812    92814    92815    92816             enrolled in Medicare Part B and live in
92817    92821    92822    92823             the service area. However, individuals


                                                                2
                                             insurance. You may go to a non-              alternative drug listed on our formulary
Does My Plan Cover Medicare                  preferred pharmacy, but you may have         with your physician's help. Call us to see if
Part B Or Part D Drugs?                      to pay more for your prescription            you can get a temporary supply of the drug
                                             drugs.                                       or for more details about our drug
Blue Shield 65 Plus Choice Plan and Blue                                                  transition policy.
Shield 65 Plus do cover both Medicare Part   What Is A Prescription Drug
B prescription drugs and Medicare Part D     Formulary?                                   How Can I Get Extra Help With
prescription drugs.                                                                       Prescription Drug Plan Costs?
                                             Blue Shield 65 Plus Choice Plan and
Where Can I Get My Prescriptions If I        Blue Shield 65 Plus use a formulary. A       If you qualify for extra help with your
Join This Plan?                              formulary is a list of drugs covered by      Medicare prescription drug plan costs, your
                                             your plan to meet patient needs. We          premium and costs at the pharmacy will be
Blue Shield 65 Plus Choice Plan and Blue     may periodically add, remove, make           lower.
Shield 65 Plus have formed a network of      changes to coverage limitations on
pharmacies. You must use a network           certain drugs or change how much you         When you join Blue Shield 65 Plus Choice
pharmacy to receive plan benefits.           pay for a drug.                              Plan or Blue Shield 65 Plus, Medicare will
                                                                                          tell us how much extra help you are
We may not pay for your prescriptions if     If we make any formulary change that         getting. Then we will let you know the
you use an out-of-network pharmacy,          limits our members' ability to fill their    amount you will pay. If you are not getting
except in certain cases.                     prescriptions, we will notify the            this extra help you can see if you qualify
                                             affected enrollees before the change is      by calling 1-800-MEDICARE (1-800-633-
The pharmacies in our network can change     made. We will send a formulary to you        4227), TTY users should call 1-877-486-
at any time. You can ask for a Pharmacy      and you can see our complete                 2048.
Directory or visit us at                     formulary on our Web site at
www.blueshieldca.com/medicarepartdplans      https://www.blueshieldca.com/medicar         You can call this number 24 hours a day, 7
/pharmacydirectory/. Our customer service    epartdplans/formulary/.                      days a week.
number is listed at the end of this
introduction.                                If you are currently taking a drug that is
                                             not on our formulary or subject to
Blue Shield 65 Plus Choice Plan and Blue     additional requirements or limits, you
Shield 65 Plus have a list of preferred      may be able to get a temporary supply
pharmacies. At these pharmacies, you may     of the drug. You can contact us to
get your drugs at a lower co-pay or co-      request an exception or switch to an


                                                                 3
What Are My Protections In This                  that is not on our list of covered drugs     you take full advantage of this covered
Plan?                                            or believe you should get a non-             service if you are selected. Contact Blue
                                                 preferred drug at a lower out-of-pocket      Shield 65 Plus Choice Plan or Blue Shield
All Medicare Advantage Plans agree to            cost.                                        65 Plus for more details.
stay in the program for a full year at a time.
Each year, the plans decide whether to           You can also ask for an exception to         What Types of Drugs May be
continue for another year.                       cost utilization rules, such as a limit on   Covered Under Medicare Part B?
                                                 the quantity of a drug. If you think you
Even if a Medicare Advantage Plan leaves         need an exception, you should contact        Some outpatient prescription drugs may be
the program, you will not lose Medicare          us before you try to fill your               covered under Medicare Part B. These may
coverage. If a plan decides not to continue,     prescription at a pharmacy. Your             include, but are not limited to, the
it must send you a letter at least 90 days       doctor must provide a statement to           following types of drugs. Contact Blue
before your coverage will end. The letter        support your exception request. If we        Shield 65 Plus Choice Plan for more
will explain your options for Medicare           deny coverage for your prescription          details.
coverage in your area.                           drug(s), you have the right to appeal
                                                 and ask us to review our decision.           -- Some Antigens: If they are prepared by
As a member of Blue Shield 65 Plus                                                            a doctor and administered by a properly
Choice Plan or Blue Shield 65 Plus, you          Finally, you have the right to file a        instructed person (who could be the
have the right to request a coverage             grievance if you have any type of            patient) under doctor supervision.
determination, which includes the right to       problem with us or one of our network         -- Osteoporosis Drugs: Injectable drugs
request an exception, the right to file an       pharmacies that does not involve             for osteoporosis for certain women with
appeal if we deny coverage for a                 coverage for a prescription drug.            Medicare.
prescription drug, and the right to file a
grievance.                                       What Is A Medication Therapy                   -- Erythropoietin (Epoetin alpha or
                                                 Management (MTM) Program?                    Epogen®): By injection if you have end-
You have the right to request a coverage                                                      stage renal disease (permanent kidney
determination if you want us to cover a          A Medication Therapy Management                failure requiring either dialysis or
Part D drug that you believe should be           (MTM) Program is a free service we           transplantation) and need this drug to treat
covered.                                         may offer. You may be invited to             anemia.
                                                 participate in a program designed for         -- Hemophilia Clotting Factors: Self-
An exception is a type of coverage               your specific health and pharmacy            administered clotting factors if you have
determination. You may ask us for an             needs. You may decide not to                 hemophilia.
exception if you believe you need a drug         participate but it is recommended that


                                                                     4
                                              Please call Blue Shield of California for   Current members should call toll-free
 -- Injectable Drugs: Most injectable drugs   more information about Blue Shield          (800)-776-4466 for questions related to the
administered incident to a physician’s        65 Plus Choice Plan or Blue Shield          Medicare Part D Prescription Drug
service.                                      65 Plus.                                    program. (TTY/TDD (800)-794-1099)
  -- Immunosuppressive Drugs:
Immunosuppressive drug therapy for            Visit us at www.blueshieldca.com or,        Prospective members should call toll-free
transplant patients if the transplant was     call us:                                    (800)-488-8000 for questions related to the
paid for by Medicare, or paid by a private                                                Medicare Part D Prescription Drug
insurance that paid as a primary payer to     Customer Service Hours:                     program. (TTY/TDD (888)-595-0000)
your Medicare Part A coverage, in a           Sunday, Monday, Tuesday,
Medicare-certified facility.                  Wednesday, Thursday, Friday,                Current members should call locally
                                              Saturday, 7:00 a.m. – 8:00 p.m. Pacific     (800)-776-4466 for questions related to the
 -- Some Oral Cancer Drugs: If the same                                                   Medicare Part D Prescription Drug
drug is available in injectable form.         Current members should call toll-free       program. (TTY/TDD (800)-794-1099)
 -- Oral Anti-Nausea Drugs: If you are        (800)-776-4466 for questions related to
part of an anti-cancer chemotherapeutic       the Medicare Advantage program.             Prospective members should call locally
regimen. Inhalation and infusion drugs        (TTY/TDD (800)-794-1099)                    (800)-488-8000 for questions related to the
provided through DME.                                                                     Medicare Part D Prescription Drug
                                              Prospective members should call toll-       program. (TTY/TDD (888)-595-0000)
Contact Blue Shield 65 Plus Choice Plan or    free (800)-488-8000 for questions
Blue Shield 65 Plus for more details.         related to the Medicare Advantage           For more information about Medicare,
                                              program. (TTY/TDD (888)-595-0000)           please call Medicare at 1-800-MEDICARE
                                                                                          (1-800-633-4227).
                                              Current members should call locally         TTY users should call 1-877-486-2048.
                                              (800)-776-4466 for questions related to     You can call 24 hours a day, 7 days a
                                              the Medicare Advantage program.             week.
                                              (TTY/TDD (800)-794-1099)                    Or, visit www.medicare.gov on the web.

                                              Prospective members should call             If you have special needs, this document
                                              locally (800)-488-8000 for questions        may be available in other formats.
                                              related to the Medicare Advantage
                                              program. (TTY/TDD (888)-595-0000)




                                                                 5
If you have any questions about this plan’s benefits or costs, please contact Blue Shield of California at (800) 488-8000.


SECTION II - SUMMARY OF BENEFITS
Benefit Category           Original Medicare                                  Blue Shield 65 Plus               Blue Shield 65 Plus Choice
                                                                              Los Angeles & Orange County       Plan
                                                                              Plan
Important Information

1 – Premium and Other               In 2009 the monthly Part B         General                                  General
   Important Information            Premium is $96.40 and the yearly
                                    Medicare Part B deductible         $0 monthly plan premium in               $0 monthly plan premium in
                                    amount is $135.                    addition to your monthly                 addition to your monthly
                                                                       Medicare Part B Premium.                 Medicare Part B Premium.
                                    If a doctor or supplier does not
                                    accept assignment, their costs are
                                    often higher, which means you
                                    pay more.




2 – Doctor and Hospital Choice      You may go to any doctor,                 In-Network                        In-Network
                                    specialist or hospital that accepts
                                    Medicare.                                 You must go to network doctors,   You must go to network doctors,
 (For more information, see
                                                                              specialists and hospitals.        specialists and hospitals.
 Emergency Care – #15 and
 Urgently Needed Care – #16.)                                                 Referral required for network     Referral required for network
                                                                              hospitals and specialists (for    hospitals and specialists (for
                                                                              certain benefits).                certain benefits).
                                                                              You may have to pay a separate    You may have to pay a separate
                                                                              copay for certain doctor office   copay for certain doctor office
                                                                              visits.                           visits.




                                                                          6
If you have any questions about this plan’s benefits or costs, please contact Blue Shield of California at (800) 488-8000.


Benefit Category                    Original Medicare                        Blue Shield 65 Plus                  Blue Shield 65 Plus Choice
                                                                             Los Angeles & Orange County          Plan
                                                                             Plan
Inpatient Care
3 – Inpatient Hospital Care          In 2009 the amounts for each            In-Network                           In-Network
                                     benefit period are:                     $0 copay                             $0 copay
 (includes Substance Abuse and
                                     - Days 1-60: $1,068 deductible
 Rehabilitation Services)                                                    No limit to the number of days       No limit to the number of days
                                     - Days 61-90: $267 per day              covered by the plan each benefit     covered by the plan each benefit
                                     - Days 91-150: $534 per lifetime        period.                              period.
                                     reserve day                             Except in an emergency, your         Except in an emergency, your
                                     Call 1-800-MEDICARE                     doctor must tell the plan that you   doctor must tell the plan that you
                                     (1-800-633-4227) for                    are going to be admitted to the      are going to be admitted to the
                                     information about lifetime              hospital.                            hospital.
                                     reserve days.
                                     Lifetime reserve days can only
                                     be used once.
                                     A “benefit period” starts the day
                                     you go into a hospital or skilled
                                     nursing facility. It ends when
                                     you go for 60 days in a row
                                     without hospital or skilled
                                     nursing care. If you go into the
                                     hospital after one benefit period
                                     has ended, a new benefit period
                                     begins. You must pay the
                                     inpatient hospital deductible for
                                     each benefit period. There is no
                                     limit to the number of benefit
                                     periods you can have.


                                                                         7
If you have any questions about this plan’s benefits or costs, please contact Blue Shield of California at (800) 488-8000.


Benefit Category                    Original Medicare                      Blue Shield 65 Plus                  Blue Shield 65 Plus Choice
                                                                           Los Angeles & Orange County          Plan
                                                                           Plan
Inpatient Care
4 – Inpatient Mental Health Care     Same deductible and copay as          In-Network                           In-Network
                                     inpatient hospital care (see          $0 copay                             $0 copay
                                     “Inpatient Hospital Care”
                                     above).                               $900 out of pocket limit every       $900 out of pocket limit every
                                                                           stay.                                stay.
                                     190 day lifetime limit in a
                                     Psychiatric Hospital.                 You get up to 190 days in a          You get up to 190 days in a
                                                                           Psychiatric Hospital in a            Psychiatric Hospital in a
                                                                           lifetime.                            lifetime.
                                                                           Except in an emergency, your         Except in an emergency, your
                                                                           doctor must tell the plan that you   doctor must tell the plan that you
                                                                           are going to be admitted to the      are going to be admitted to the
                                                                           hospital.                            hospital.




                                                                       8
If you have any questions about this plan’s benefits or costs, please contact Blue Shield of California at (800) 488-8000.


Benefit Category                    Original Medicare                         Blue Shield 65 Plus               Blue Shield 65 Plus Choice
                                                                              Los Angeles & Orange County       Plan
                                                                              Plan
Inpatient Care
5 – Skilled Nursing Facility         In 2009 the amounts for each             General                           General
                                     benefit period after at least a 3-       Authorization rules may apply.    Authorization rules may apply.
 (in a Medicare-certified skilled    day covered hospital stay are:
 nursing facility)
                                     - Days 1-20: $0 per day
                                                                              In-Network                        In-Network
                                     - Days 21-100: $133.50 per day
                                                                              For SNF stays:                    For SNF stays:
                                     100 days for each benefit period.
                                                                              - Days 1-20: $0 copay per day     - Days 1-20: $0 copay per day
                                     A “benefit period” starts the day
                                                                              - Days 21-100: $85 copay per      - Days 21-100: $40 copay per
                                     you go into a hospital or SNF. It
                                                                              day                               day
                                     ends when you go for 60 days in
                                     a row without hospital or skilled        Plan covers up to 100 days each   Plan covers up to 100 days each
                                     nursing care. If you go into the         benefit period.                   benefit period.
                                     hospital after one benefit period        No prior hospital stay is         No prior hospital stay is
                                     has ended, a new benefit period          required.                         required.
                                     begins.
                                     You must pay the inpatient
                                     hospital deductible for each
                                     benefit period.
                                     There is no limit to the number
                                     of benefit periods you can have.




                                                                          9
If you have any questions about this plan’s benefits or costs, please contact Blue Shield of California at (800) 488-8000.


Benefit Category                      Original Medicare                  Blue Shield 65 Plus                  Blue Shield 65 Plus Choice
                                                                         Los Angeles & Orange County          Plan
                                                                         Plan
Inpatient Care
6 – Home Health Care                  $0 copay.                             General                           General
                                                                            Authorization rules may apply.    Authorization rules may apply.
 (includes medically necessary
 intermittent skilled nursing
 care, home health aide services,                                           In-Network                        In-Network
 and rehabilitation services, etc.)                                         $0 copay for each Medicare-       $0 copay for:
                                                                            covered home health visit.        - Medicare-covered home health
                                                                                                              visits
                                                                                                              - respite care
7 – Hospice                           You pay part of the cost for          General                           General
                                      outpatient drugs and inpatient        You must get care from a          You must get care from a
                                      respite care.                         Medicare-certified hospice.       Medicare-certified hospice.
                                      You must get care from a
                                      Medicare-certified hospice.




                                                                       10
If you have any questions about this plan’s benefits or costs, please contact Blue Shield of California at (800) 488-8000.


Benefit Category                    Original Medicare                    Blue Shield 65 Plus                  Blue Shield 65 Plus Choice
                                                                         Los Angeles & Orange County          Plan
                                                                         Plan
Outpatient Care
8 – Doctor Office Visits             20% coinsurance.                       General                           General
                                                                            See “Physical Exams,” for more    See “Physical Exams,” for more
                                                                            information.                      information.
                                                                            Authorization rules may apply.    Authorization rules may apply.


                                                                            In-Network                        In-Network
                                                                            $0 copay for each primary care    $0 copay for each primary care
                                                                            doctor visit for Medicare-        doctor visit for Medicare-
                                                                            covered benefits.                 covered benefits.
                                                                            $25 copay for each in-area,       $0 copay for each in-area,
                                                                            network urgent care Medicare-     network urgent care Medicare-
                                                                            covered visit.                    covered visit.
                                                                            $10 copay for each specialist     $0 copay for each specialist visit
                                                                            visit for Medicare-covered        for Medicare-covered benefits.
                                                                            benefits.




                                                                       11
If you have any questions about this plan’s benefits or costs, please contact Blue Shield of California at (800) 488-8000.


Benefit Category                    Original Medicare                       Blue Shield 65 Plus                   Blue Shield 65 Plus Choice
                                                                            Los Angeles & Orange County           Plan
                                                                            Plan
Outpatient Care
9 – Chiropractic Services            Routine care not covered.                  General                           General
                                     20% coinsurance for manual                 Authorization rules may apply.    Authorization rules may apply.
                                     manipulation of the spine to               In-Network                        In-Network
                                     correct subluxation (a
                                                                                $10 copay for Medicare-covered    $0 copay for Medicare-covered
                                     displacement or misalignment of
                                                                                visits.                           visits.
                                     a joint or body part) if you get it
                                     from a chiropractor or other               Medicare-covered chiropractic     Medicare-covered chiropractic
                                     qualified provider.                        visits are for manual             visits are for manual
                                                                                manipulation of the spine to      manipulation of the spine to
                                                                                correct a displacement or         correct a displacement or
                                                                                misalignment of a joint or body   misalignment of a joint or body
                                                                                part.                             part.


10 – Podiatry Services               Routine care not covered.                  General                           General
                                     20% coinsurance for medically              Authorization rules may apply.    Authorization rules may apply.
                                     necessary foot care, including             In-Network                        In-Network
                                     care for medical conditions
                                                                                $10 copay for each Medicare-      $0 copay for Medicare-covered
                                     affecting the lower limbs.
                                                                                covered visit.                    visits.
                                                                                Medicare-covered podiatry         Up to 12 routine visits every
                                                                                benefits are for medically-       year.
                                                                                necessary foot care.              Medicare-covered podiatry
                                                                                                                  benefits are for medically-
                                                                                                                  necessary foot care.




                                                                           12
If you have any questions about this plan’s benefits or costs, please contact Blue Shield of California at (800) 488-8000.


Benefit Category                    Original Medicare                    Blue Shield 65 Plus                  Blue Shield 65 Plus Choice
                                                                         Los Angeles & Orange County          Plan
                                                                         Plan
Outpatient Care
11 – Outpatient Mental Health        50% coinsurance for most               General                           General
     Care                            outpatient mental health               Authorization rules may apply.    Authorization rules may apply.
                                     services.
                                                                            In-Network                        In-Network
                                                                            $30 copay for each Medicare-      $30 copay for each Medicare-
                                                                            covered individual or group       covered individual or group
                                                                            therapy visit.                    therapy visit.
12 – Outpatient Substance            20% coinsurance.                       General                           General
     Abuse Care                                                             Authorization rules may apply.    Authorization rules may apply.
                                                                            In-Network                        In-Network
                                                                            $30 copay for Medicare-covered    $30 copay for Medicare-covered
                                                                            individual or group visits.       individual or group visits.
13 – Outpatient                      20% coinsurance for the doctor.        General                           General
     Services/Surgery                20% of outpatient facility             Authorization rules may apply.    Authorization rules may apply.
                                     charges.                               In-Network                        In-Network
                                                                            $0 copay for each Medicare-       $0 copay for each Medicare-
                                                                            covered ambulatory surgical       covered ambulatory surgical
                                                                            center visit.                     center visit.
                                                                            $0 copay for each Medicare-       $0 copay for each Medicare-
                                                                            covered outpatient hospital       covered outpatient hospital
                                                                            facility visit.                   facility visit.
                                                                                                              Additional facility charges
                                                                                                              apply.



                                                                       13
If you have any questions about this plan’s benefits or costs, please contact Blue Shield of California at (800) 488-8000.


Benefit Category                    Original Medicare                    Blue Shield 65 Plus                   Blue Shield 65 Plus Choice
                                                                         Los Angeles & Orange County           Plan
                                                                         Plan
Outpatient Care
14 – Ambulance Services              20% coinsurance.                        General                           General
                                                                             Authorization rules may apply.    Authorization rules may apply.
 (medically necessary
 ambulance services)                                                         In-Network                        In-Network
                                                                             $100 copay for Medicare-          $60 copay for Medicare-covered
                                                                             covered ambulance benefits.       ambulance benefits.
                                                                                                               If you are admitted to the
                                                                                                               hospital, you pay $0 for
                                                                                                               Medicare-covered ambulance
                                                                                                               benefits.




15 – Emergency Care                  20% coinsurance for the doctor.     In-Network                            In-Network
                                                                         $50 copay for Medicare-covered        $50 copay for Medicare-covered
                                     20% of facility charge, or a set    emergency room visits.                emergency room visits.
 (You may go to any emergency
                                     copay per emergency room visit.
 room if you reasonably believe
 you need emergency care.)           You don’t have to pay the           Out-of-Network                        Out-of-Network
                                     emergency room copay if you         $10,000 limit for emergency           $10,000 limit for emergency
                                     are admitted to the hospital for    services outside the U.S. every       services outside the U.S. every
                                     the same condition within 3 days    year.                                 year.
                                     of the emergency room visit.
                                                                         In and Out-of-Network                 In and Out-of-Network
                                     NOT covered outside the U.S.        If you are admitted to the hospital   If you are admitted to the hospital
                                     except under limited                within 24-hours for the same          within 24-hours for the same
                                     circumstances.                      condition, you pay $0 for the         condition, you pay $0 for the
                                                                         emergency room visit.                 emergency room visit.


                                                                        14
If you have any questions about this plan’s benefits or costs, please contact Blue Shield of California at (800) 488-8000.


Benefit Category                     Original Medicare                   Blue Shield 65 Plus                    Blue Shield 65 Plus Choice
                                                                         Los Angeles & Orange County            Plan
                                                                         Plan
Outpatient Care
16 – Urgently Needed Care            20% coinsurance, or a set copay.        General                            General
                                     NOT covered outside the                 $25 to $50 copay for Medicare-     $0 to $50 copay for Medicare-
 (This is NOT emergency care
                                     U.S. except under limited               covered urgently needed care       covered urgently needed care
 and, in most cases, is out of the
 service area.)                      circumstances.                          visits.                            visits.
                                                                             If you are admitted to the         If you are admitted to the
                                                                             hospital within 24-hours for the   hospital within 24-hours for the
                                                                             same condition, $0 for the         same condition, $0 for the
                                                                             urgent-care visit.                 urgent-care visit.


                                                                             See page 46 for additional         See page 46 for additional
                                                                             information about urgently         information about urgently
                                                                             needed care.                       needed care.
17 – Outpatient Rehabilitation       20% coinsurance.                        General                            General
     Services                                                                Authorization rules may apply.     Authorization rules may apply.
 (Occupational Therapy,                                                      In-Network                         In-Network
 Physical Therapy, Speech and                                                $10 copay for Medicare-covered     $0 copay for Medicare-covered
 Language Therapy)                                                           Occupational Therapy visits.       Occupational Therapy visits.

                                                                             $10 copay for Medicare-covered     $0 copay for Medicare-covered
                                                                             Physical and/or                    Physical and/or
                                                                             Speech/Language Therapy            Speech/Language Therapy
                                                                             visits.                            visits.




                                                                        15
If you have any questions about this plan’s benefits or costs, please contact Blue Shield of California at (800) 488-8000.


Benefit Category                    Original Medicare                      Blue Shield 65 Plus                  Blue Shield 65 Plus Choice
                                                                           Los Angeles & Orange County          Plan
                                                                           Plan
Outpatient Medical Services and Supplies
18 – Durable Medical                 20% coinsurance.                          General                          General
     Equipment                                                                 Authorization rules may apply.   Authorization rules may apply.
 (includes wheelchairs, oxygen,                                                In-Network                       In-Network
 etc.)                                                                         20% of the cost for Medicare-    0% to 20% of the cost for
                                                                               covered items.                   Medicare-covered items.
19 – Prosthetic Devices              20% coinsurance.                          General                          General
                                                                               Authorization rules may apply.   Authorization rules may apply.
 (includes braces, artificial
 limbs and eyes, etc.)                                                         In-Network                       In-Network
                                                                               20% of the cost for Medicare-    $0 copay for Medicare-covered
                                                                               covered items.                   items.
20 – Diabetes Self-Monitoring        20% coinsurance.                          General                          General
     Training, Nutrition Therapy                                               Authorization rules may apply.   Authorization rules may apply.
     and Supplies
                                     Nutrition therapy is for people           In-Network                       In-Network
 (includes coverage for glucose      who have diabetes or kidney               $0 copay for Diabetes self-      $0 copay for Diabetes self-
 monitors, test strips, lancets,     disease (but aren’t on dialysis or        monitoring training.             monitoring training.
 screening tests and self-           haven’t had a kidney transplant)
                                                                               $0 copay for Nutrition Therapy   $0 copay for Nutrition Therapy
 management training)                when referred by a doctor. These
                                                                               for Diabetes.                    for Diabetes.
                                     services can be given by a
                                     registered dietitian or include a         20% of the cost for Diabetes     $0 copay for Diabetes supplies.
                                     nutritional assessment and                supplies.
                                     counseling to help you manage
                                     your diabetes or kidney disease.




                                                                          16
If you have any questions about this plan’s benefits or costs, please contact Blue Shield of California at (800) 488-8000.


Benefit Category                    Original Medicare                    Blue Shield 65 Plus                     Blue Shield 65 Plus Choice
                                                                         Los Angeles & Orange County             Plan
                                                                         Plan
Outpatient Medical Services and Supplies
21 – Diagnostic Tests, X-Rays,       20% coinsurance for diagnostic          General                             General
     and Lab Services                tests and x-rays.                       Authorization rules may apply.      Authorization rules may apply.
                                     $0 copay for Medicare-covered
                                     lab services.                           In-Network                          In-Network
                                                                             $0 copay for Medicare-covered:      $0 copay for Medicare-covered:
                                     Lab Services: Medicare covers           - lab services                      - lab services
                                     medically necessary diagnostic
                                     lab services that are ordered by        - diagnostic procedures and tests   - diagnostic procedures and tests
                                     your treating doctor when they
                                     are provided by a Clinical              0% of the cost for Medicare-        0% of cost for Medicare-covered
                                     Laboratory Improvement                  covered X-rays.                     X-rays.
                                     Amendments (CLIA) certified             20% of the cost for Medicare-       20% of the cost for Medicare-
                                     laboratory that participates in         covered diagnostic radiology        covered diagnostic radiology
                                     Medicare. Diagnostic lab                services.                           services.
                                     services are done to help your          20% of the cost for Medicare-       20% of the cost for Medicare-
                                     doctor diagnose or rule out a           covered therapeutic radiology       covered therapeutic radiology
                                     suspected illness or condition.         services.                           services.
                                     Medicare does not cover most
                                     routine screening tests, like           See page 46 for more                See page 46 for more
                                     checking your cholesterol.              information about Diagnostic        information about Diagnostic
                                                                             Services.                           Services.




                                                                        17
If you have any questions about this plan’s benefits or costs, please contact Blue Shield of California at (800) 488-8000.


Benefit Category                    Original Medicare                    Blue Shield 65 Plus                  Blue Shield 65 Plus Choice
                                                                         Los Angeles & Orange County          Plan
                                                                         Plan
Preventive Services
22 – Bone Mass Measurement           20% coinsurance.                       General                           General
                                                                            Authorization rules may apply.    Authorization rules may apply.
 (for people with Medicare who
 are at risk)                        Covered once every 24 months           In-Network                        In-Network
                                     (more often if medically               $0 copay for Medicare-covered     $0 copay for Medicare-covered
                                     necessary) if you meet certain         bone mass measurement.            bone mass measurement.
                                     medical conditions.
23 – Colorectal Screening            20% coinsurance.                       General                           General
     Exams                                                                  Authorization rules may apply.    Authorization rules may apply.
 (for people with Medicare           Covered when you are high risk         In-Network                        In-Network
 age 50 and older)                   or when you are age 50 and             $0 copay for Medicare-covered     $0 copay for Medicare-covered
                                     older.                                 colorectal screenings.            colorectal screenings.


24 – Immunizations                   $0 copayment for Flu and               General                           General
                                     Pneumonia vaccines.                    Authorization rules may apply.    Authorization rules may apply.
 (Flu vaccine, Hepatitis B
                                     20% coinsurance for Hepatitis B        In-Network                        In-Network
 vaccine – for people with
 Medicare who are at risk,           vaccine.
                                                                            $0 copay for Flu and Pneumonia    $0 copay for Flu and Pneumonia
 Pneumonia vaccine)                  You may only need the                  vaccines.                         vaccines.
                                     Pneumonia vaccine once in your
                                                                            $0 copay for Hepatitis B          $0 copay for Hepatitis B
                                     lifetime. Call your doctor for
                                                                            vaccine.                          vaccine.
                                     more information.
                                                                            No referral needed for Flu and    No referral needed for Flu and
                                                                            Pneumonia vaccines.               Pneumonia vaccines.




                                                                       18
If you have any questions about this plan’s benefits or costs, please contact Blue Shield of California at (800) 488-8000.


Benefit Category                    Original Medicare                    Blue Shield 65 Plus                  Blue Shield 65 Plus Choice
                                                                         Los Angeles & Orange County          Plan
                                                                         Plan
Preventive Services
25 – Mammograms (Annual              20% coinsurance.                       In-Network                        In-Network
     Screening)                      No referral needed.                    $0 copay for Medicare-covered     $0 copay for Medicare-covered
                                     Covered once a year for all            screening mammograms.             screening mammograms.
 (for women with Medicare
 age 40 and older)                   women with Medicare age 40
                                     and older. One baseline
                                     mammogram covered for
                                     women with Medicare between
                                     age 35 and 39.

26 – Pap Smears and Pelvic           $0 copay for pap smears.               In-Network                        In-Network
     Exams                           Covered once every 2 years.            $0 copay for Medicare-covered     $0 copay for Medicare-covered
                                     Covered once a year for women          pap smears and pelvic exams.      pap smears and pelvic exams.
 (for women with Medicare)
                                     with Medicare at high risk.
                                     20% coinsurance for pelvic
                                     exams.
27 – Prostate Cancer Screening       20% coinsurance for the digital        General                           General
     Exams                           rectal exam.                           Authorization rules may apply.    Authorization rules may apply.
                                     $0 for the PSA test; 20%
 (for men with Medicare
 age 50 and older)                   coinsurance for other related
                                                                            In-Network                        In-Network
                                     services.
                                                                            $0 copay for Medicare-covered     $0 copay for Medicare-covered
                                     Covered once a year for all men
                                                                            prostate cancer screening.        prostate cancer screening.
                                     with Medicare over age 50.




                                                                       19
If you have any questions about this plan’s benefits or costs, please contact Blue Shield of California at (800) 488-8000.


Benefit Category                    Original Medicare                      Blue Shield 65 Plus                  Blue Shield 65 Plus Choice
                                                                           Los Angeles & Orange County          Plan
                                                                           Plan
Preventive Services
28 – End-Stage Renal Disease         20% coinsurance for dialysis.             General                          General
                                     20% coinsurance for Nutrition             Authorization rules may apply.   Authorization rules may apply.
                                     Therapy for End-Stage Renal
                                     Disease.
                                                                               In-Network
                                     Nutrition therapy is for people
                                                                               10% of the cost for renal        In-Network
                                     who have diabetes or kidney
                                                                               dialysis.                        $25 copay for renal dialysis.
                                     disease (but aren’t on dialysis or
                                     haven’t had a kidney transplant)          $0 copay for Nutrition Therapy   $0 copay for Nutrition Therapy
                                     when referred by a doctor. These          for End-Stage Renal Disease.     for End-Stage Renal Disease.
                                     services can be given by a
                                     registered dietitian or include a
                                     nutritional assessment and
                                     counseling to help you manage
                                     your diabetes or kidney disease.
29 – Prescription Drugs              Most drugs not covered under              Drugs covered under              Drugs covered under
                                     Original Medicare.                        Medicare Part B                  Medicare Part B
                                                                               General                          General
                                                                               20% of the cost for Part B-      20% of the cost for Part B-
                                                                               covered drugs (not including     covered drugs (not including
                                                                               Part B-covered chemotherapy      Part B-covered chemotherapy
                                                                               drugs.)                          drugs.)
                                                                               20% of the cost for Part B-      20% of the cost for Part B-
                                                                               covered chemotherapy drugs.      covered chemotherapy drugs.




                                                                          20
If you have any questions about this plan’s benefits or costs, please contact Blue Shield of California at (800) 488-8000.


Benefit Category                    Original Medicare                    Blue Shield 65 Plus                        Blue Shield 65 Plus Choice
                                                                         Los Angeles & Orange County                Plan
                                                                         Plan
Preventive Services
29 – Prescription Drugs -            You can add prescription drug           Drugs covered under                    Drugs covered under
continued                            coverage to Original Medicare           Medicare Part D                        Medicare Part D
                                     by joining a Medicare                   General                                General
                                     Prescription Drug Plan, or you
                                                                             This plan uses a formulary.            This plan uses a formulary.
                                     can get all your Medicare
                                                                             The plan will send you the             The plan will send you the
                                     coverage, including prescription
                                                                             formulary. You can also see the        formulary. You can also see the
                                     drug coverage, by joining a
                                                                             formulary at                           formulary at
                                     Medicare Advantage Plan or a
                                                                             https://www.blueshieldca.com           https://www.blueshieldca.com
                                     Medicare Cost Plan that offers
                                                                             /medicarepartdplans/formulary/         /medicarepartdplans/formulary/
                                     prescription drug coverage.
                                                                             on the web.                            on the web.
                                                                             Different out-of-pocket costs          Different out-of-pocket costs
                                                                             may apply for people who               may apply for people who
                                                                             - have limited incomes,                - have limited incomes,
                                                                             - live in long term care facilities,   - live in long term care facilities,
                                                                             or                                     or
                                                                             - have access to Indian/ Tribal/       - have access to Indian/ Tribal/
                                                                             Urban (Indian Health Services).        Urban (Indian Health Services).


                                                                             The plan offers national               The plan offers national
                                                                             in-network prescription coverage       in-network prescription coverage
                                                                             (i.e., this would include 50 states    (i.e., this would include 50 states
                                                                             and DC).                               and DC).




                                                                        21
If you have any questions about this plan’s benefits or costs, please contact Blue Shield of California at (800) 488-8000.


Benefit Category                    Original Medicare                    Blue Shield 65 Plus                    Blue Shield 65 Plus Choice
                                                                         Los Angeles & Orange County            Plan
                                                                         Plan
Preventive Services
29 – Prescription Drugs -                                                   This means that you will pay the    This means that you will pay the
continued                                                                   same cost-sharing amount for        same cost-sharing amount for
                                                                            your prescription drugs if you      your prescription drugs if you
                                                                            get them at an in-network           get them at an in-network
                                                                            pharmacy outside of the plan’s      pharmacy outside of the plan’s
                                                                            service area (for instance when     service area (for instance when
                                                                            you travel).                        you travel).
                                                                            Total yearly drug costs are the     Total yearly drug costs are the
                                                                            total drug costs paid by both you   total drug costs paid by both you
                                                                            and the plan.                       and the plan.
                                                                            The plan may require you to first   The plan may require you to first
                                                                            try one drug to treat your          try one drug to treat your
                                                                            condition before it will cover      condition before it will cover
                                                                            another drug for that condition.    another drug for that condition.
                                                                            Some drugs have quantity limits.    Some drugs have quantity limits.
                                                                            Your provider must get prior        Your provider must get prior
                                                                            authorization from Blue Shield      authorization from Blue Shield
                                                                            65 Plus for certain drugs.          65 Plus Choice Plan for certain
                                                                                                                drugs.
                                                                            You must go to certain              You must go to certain
                                                                            pharmacies for a very limited       pharmacies for a very limited
                                                                            number of drugs, due to the         number of drugs, due to the
                                                                            special handling, provider          special handling, provider
                                                                            coordination, or patient            coordination, or patient



                                                                       22
If you have any questions about this plan’s benefits or costs, please contact Blue Shield of California at (800) 488-8000.


Benefit Category                    Original Medicare                    Blue Shield 65 Plus                       Blue Shield 65 Plus Choice
                                                                         Los Angeles & Orange County               Plan
                                                                         Plan
Preventive Services
29 – Prescription Drugs -                                                   education requirements of these        education requirements of these
continued                                                                   drugs that cannot be met by            drugs that cannot be met by
                                                                            most pharmacies in your                most pharmacies in your
                                                                            network.                               network.


                                                                            These drugs are listed on the          These drugs are listed on the
                                                                            plan’s website, formulary, and         plan’s website, formulary, and
                                                                            printed materials, as well as on       printed materials, as well as on
                                                                            the Medicare Prescription Drug         the Medicare Prescription Drug
                                                                            Plan Finder on Medicare.gov.           Plan Finder on Medicare.gov.
                                                                            If the actual cost of a drug is less   If the actual cost of a drug is less
                                                                            than the normal copay amount           than the normal copay amount
                                                                            for that drug, you will pay the        for that drug, you will pay the
                                                                            actual cost, not the higher cost-      actual cost, not the higher cost-
                                                                            sharing amount.                        sharing amount.


                                                                            In-Network                             In-Network
                                                                            $0 deductible.                         $0 deductible.
                                                                            Some covered drugs don’t count         Some covered drugs don’t count
                                                                            toward your out-of-pocket drug         toward your out-of-pocket drug
                                                                            costs.                                 costs.




                                                                       23
If you have any questions about this plan’s benefits or costs, please contact Blue Shield of California at (800) 488-8000.


Benefit Category                    Original Medicare                    Blue Shield 65 Plus                    Blue Shield 65 Plus Choice
                                                                         Los Angeles & Orange County            Plan
                                                                         Plan
Preventive Services
29 – Prescription Drugs -
continued                                                                   Initial Coverage                    Initial Coverage
                                                                            You pay the following until total   You pay the following until total
                                                                            yearly drug costs reach $2,700:     yearly drug costs reach $2,700:


                                                                            Retail Pharmacy                     Retail Pharmacy


                                                                            Formulary Generic                   Formulary Insulin and Generics
                                                                            - $6 copay for a one-month (30-     - $0 copay for a one-month (30-
                                                                            day) supply of drugs in this tier   day) supply of drugs in this tier
                                                                            from a preferred pharmacy           from a preferred pharmacy
                                                                            - $12 copay for a three-month       - $0 copay for a three-month
                                                                            (90-day) supply of drugs in this    (90-day) supply of drugs in this
                                                                            tier from a preferred pharmacy      tier from a preferred pharmacy
                                                                            - $6 copay for a one-month (30-     - $0 copay for a one-month (30-
                                                                            day) supply of drugs in this tier   day) supply of drugs in this tier
                                                                            from a non-preferred pharmacy       from a non-preferred pharmacy
                                                                            - $18 copay for a three-month       - $0 copay for a three-month
                                                                            (90-day) supply of drugs in this    (90-day) supply of drugs in this
                                                                            tier from a non-preferred           tier from a non-preferred
                                                                            pharmacy                            pharmacy




                                                                       24
If you have any questions about this plan’s benefits or costs, please contact Blue Shield of California at (800) 488-8000.


Benefit Category                    Original Medicare                    Blue Shield 65 Plus                   Blue Shield 65 Plus Choice
                                                                         Los Angeles & Orange County           Plan
                                                                         Plan
Preventive Services
29 – Prescription Drugs -
continued                                                                   Formulary Brand                    Formulary Brand
                                                                            - $25 copay for a one-month        - $15 copay for a one-month
                                                                            (30-day) supply of drugs in this   (30-day) supply of drugs in this
                                                                            tier from a preferred pharmacy     tier from a preferred pharmacy
                                                                            - $50 copay for a three-month      - $30 copay for a three-month
                                                                            (90-day) supply of drugs in this   (90-day) supply of drugs in this
                                                                            tier from a preferred pharmacy     tier from a preferred pharmacy
                                                                            - $25 copay for a one-month        - $15 copay for a one-month
                                                                            (30-day) supply of drugs in this   (30-day) supply of drugs in this
                                                                            tier from a non-preferred          tier from a non-preferred
                                                                            pharmacy                           pharmacy
                                                                            - $75 copay for a three-month      - $45 copay for a three-month
                                                                            (90-day) supply of drugs in this   (90-day) supply of drugs in this
                                                                            tier from a non-preferred          tier from a non-preferred
                                                                            pharmacy                           pharmacy




                                                                       25
If you have any questions about this plan’s benefits or costs, please contact Blue Shield of California at (800) 488-8000.


Benefit Category                    Original Medicare                    Blue Shield 65 Plus                   Blue Shield 65 Plus Choice
                                                                         Los Angeles & Orange County           Plan
                                                                         Plan
Preventive Services
29 – Prescription Drugs -
continued                                                                   Non-Preferred Brand                Non-Preferred Brand
                                                                            - $60 copay for a one-month        - $60 copay for a one-month
                                                                            (30-day) supply of drugs in this   (30-day) supply of drugs in this
                                                                            tier from a preferred pharmacy     tier from a preferred pharmacy
                                                                            - $120 copay for a three-month     - $120 copay for a three-month
                                                                            (90-day) supply of drugs in this   (90-day) supply of drugs in this
                                                                            tier from a preferred pharmacy     tier from a preferred pharmacy
                                                                            - $60 copay for a one-month        - $60 copay for a one-month
                                                                            (30-day) supply of drugs in this   (30-day) supply of drugs in this
                                                                            tier from a non-preferred          tier from a non-preferred
                                                                            pharmacy                           pharmacy
                                                                            - $180 copay for a three-month     - $180 copay for a three-month
                                                                            (90-day) supply of drugs in this   (90-day) supply of drugs in this
                                                                            tier from a non-preferred          tier from a non-preferred
                                                                            pharmacy                           pharmacy




                                                                       26
If you have any questions about this plan’s benefits or costs, please contact Blue Shield of California at (800) 488-8000.


Benefit Category                    Original Medicare                    Blue Shield 65 Plus                    Blue Shield 65 Plus Choice
                                                                         Los Angeles & Orange County            Plan
                                                                         Plan
Preventive Services
29 – Prescription Drugs -
continued                                                                   Injectables                         Injectables
                                                                            - 33% coinsurance for a one-        - 33% coinsurance for a one-
                                                                            month (30-day) supply of drugs      month (30-day) supply of drugs
                                                                            in this tier from a preferred       in this tier from a preferred
                                                                            pharmacy                            pharmacy
                                                                            - 33% coinsurance for a three-      - 33% coinsurance for a three-
                                                                            month (90-day) supply of drugs      month (90-day) supply of drugs
                                                                            in this tier from a preferred       in this tier from a preferred
                                                                            pharmacy                            pharmacy
                                                                            - 33% coinsurance for a one-        - 33% coinsurance for a one-
                                                                            month (30-day) supply of drugs      month (30-day) supply of drugs
                                                                            in this tier from a non-preferred   in this tier from a non-preferred
                                                                            pharmacy                            pharmacy
                                                                            - 33% coinsurance for a three-      - 33% coinsurance for a three-
                                                                            month (90-day) supply of drugs      month (90-day) supply of drugs
                                                                            in this tier from a non-preferred   in this tier from a non-preferred
                                                                            pharmacy                            pharmacy




                                                                       27
If you have any questions about this plan’s benefits or costs, please contact Blue Shield of California at (800) 488-8000.


Benefit Category                    Original Medicare                    Blue Shield 65 Plus                    Blue Shield 65 Plus Choice
                                                                         Los Angeles & Orange County            Plan
                                                                         Plan
Preventive Services
29 – Prescription Drugs -
continued                                                                   Formulary Specialty (Unique         Formulary Specialty (Unique
                                                                            High Cost Drugs)                    High Cost Drugs)
                                                                            - 33% coinsurance for a one-        - 33% coinsurance for a one-
                                                                            month (30-day) supply of drugs      month (30-day) supply of drugs
                                                                            in this tier from a preferred       in this tier from a preferred
                                                                            pharmacy                            pharmacy
                                                                            - 33% coinsurance for a three-      - 33% coinsurance for a three-
                                                                            month (90-day) supply of drugs      month (90-day) supply of drugs
                                                                            in this tier from a preferred       in this tier from a preferred
                                                                            pharmacy                            pharmacy
                                                                            - 33% coinsurance for a one-        - 33% coinsurance for a one-
                                                                            month (30-day) supply of drugs      month (30-day) supply of drugs
                                                                            in this tier from a non-preferred   in this tier from a non-preferred
                                                                            pharmacy                            pharmacy
                                                                            - 33% coinsurance for a three-      - 33% coinsurance for a three-
                                                                            month (90-day) supply of drugs      month (90-day) supply of drugs
                                                                            in this tier from a non-preferred   in this tier from a non-preferred
                                                                            pharmacy                            pharmacy




                                                                       28
If you have any questions about this plan’s benefits or costs, please contact Blue Shield of California at (800) 488-8000.


Benefit Category                    Original Medicare                    Blue Shield 65 Plus                  Blue Shield 65 Plus Choice
                                                                         Los Angeles & Orange County          Plan
                                                                         Plan
Preventive Services
29 – Prescription Drugs -                                                   Long Term Care Pharmacy           Long Term Care Pharmacy
continued
                                                                            Formulary Generic                 Formulary Insulin and Generics
                                                                            - $6 copay for a one-month        - $0 copay for a one-month
                                                                              (34-day) supply of drugs in       (34-day) supply of drugs in this
                                                                              this tier                       tier
                                                                            Formulary Brand                   Formulary Brand
                                                                            - $25 copay for a one-month       - $15 copay for a one-month
                                                                              (34-day) supply of drugs in       (34-day) supply of drugs in
                                                                            this tier                         this tier
                                                                            Non-Preferred Brand               Non-Preferred Brand
                                                                            - $60 copay for a one-month       - $60 copay for a one-month
                                                                              (34-day) supply of drugs in       (34-day) supply of drugs in
                                                                            this tier                         this tier
                                                                            Injectables                       Injectables
                                                                            - 33% coinsurance for a           - 33% coinsurance for a
                                                                              one-month (34-day) supply of      one-month (34-day) supply of
                                                                              drugs in this tier                drugs in this tier
                                                                            Formulary Specialty (Unique       Formulary Specialty (Unique
                                                                            High Cost Drugs)                  High Cost Drugs)
                                                                            - 33% coinsurance for a           - 33% coinsurance for a
                                                                              one-month (34-day) supply of      one-month (34-day) supply of
                                                                              drugs in this tier                drugs in this tier



                                                                       29
If you have any questions about this plan’s benefits or costs, please contact Blue Shield of California at (800) 488-8000.


Benefit Category                    Original Medicare                    Blue Shield 65 Plus                   Blue Shield 65 Plus Choice
                                                                         Los Angeles & Orange County           Plan
                                                                         Plan
Preventive Services
29 – Prescription Drugs -                                                   Mail Order                         Mail Order
continued
                                                                            Formulary Generic                  Formulary Insulin and Generics
                                                                            - $12 copay for a three-month      - $0 copay for a three-month
                                                                            (90-day) supply of drugs in this   (90-day) supply of drugs in this
                                                                            tier                               tier
                                                                            Formulary Brand                    Formulary Brand
                                                                            - $50 copay for a three-month      - $30 copay for a three-month
                                                                            (90-day) supply of drugs in this   (90-day) supply of drugs in this
                                                                            tier                               tier
                                                                            Non-Preferred Brand                Non-Preferred Brand
                                                                            - $120 copay for a three-month     - $120 copay for a three-month
                                                                            (90-day) supply of drugs in this   (90-day) supply of drugs in this
                                                                            tier                               tier
                                                                            Injectables                        Injectables
                                                                            - 33% coinsurance for a three-     - 33% coinsurance for a three-
                                                                            month (90-day) supply of drugs     month (90-day) supply of drugs
                                                                            in this tier                       in this tier
                                                                            Formulary Specialty (Unique        Formulary Specialty (Unique
                                                                            High Cost Drugs)                   High Cost Drugs)
                                                                            - 33% coinsurance for a three-     - 33% coinsurance for a three-
                                                                            month (90-day) supply of drugs     month (90-day) supply of drugs
                                                                            in this tier                       in this tier



                                                                       30
If you have any questions about this plan’s benefits or costs, please contact Blue Shield of California at (800) 488-8000.


Benefit Category                    Original Medicare                    Blue Shield 65 Plus                   Blue Shield 65 Plus Choice
                                                                         Los Angeles & Orange County           Plan
                                                                         Plan
Preventive Services
29 – Prescription Drugs -                                                   Coverage Gap                       Coverage Gap
continued                                                                   The plan covers All Preferred      The plan covers All Preferred
                                                                            Generics, All Preferred Brands     Generics, All Preferred Brands
                                                                            through the coverage gap.          through the coverage gap.
                                                                            You pay the following:             You pay the following:


                                                                            Retail Pharmacy                    Retail Pharmacy
                                                                            Formulary Generic                  Formulary Insulin and Generics
                                                                            - $6 copay for a one-month (30-    - $0 copay for a one-month (30-
                                                                            day) supply of drugs covered in    day) supply of drugs covered in
                                                                            this tier from a preferred         this tier from a preferred
                                                                            pharmacy                           pharmacy
                                                                            - $12 copay for a three-month      - $0 copay for a three-month
                                                                            (90-day) supply of drugs           (90-day) supply of drugs
                                                                            covered in this tier from a        covered in this tier from a
                                                                            preferred pharmacy                 preferred pharmacy
                                                                            - $6 copay for a one-month (30-    - $0 copay for a one-month (30-
                                                                            day) supply of drugs covered in    day) supply of drugs covered in
                                                                            this tier from a non-preferred     this tier from a non-preferred
                                                                            pharmacy                           pharmacy
                                                                            - $18 copay for a three-month      - $0 copay for a three-month
                                                                            (90-day) supply of drugs           (90-day) supply of drugs
                                                                            covered in this tier from a non-   covered in this tier from a non-
                                                                            preferred pharmacy                 preferred pharmacy


                                                                       31
If you have any questions about this plan’s benefits or costs, please contact Blue Shield of California at (800) 488-8000.


Benefit Category                    Original Medicare                    Blue Shield 65 Plus                    Blue Shield 65 Plus Choice
                                                                         Los Angeles & Orange County            Plan
                                                                         Plan
Preventive Services
29 – Prescription Drugs -                                                   Coverage Gap, continued             Coverage Gap, continued
continued
                                                                            Formulary Brand                     Formulary Brand
                                                                            - 50% coinsurance for a one-        - $15 copay for a one-month
                                                                            month (30-day) supply of all        (30-day) supply of drugs in this
                                                                            drugs covered in this tier from a   tier from a preferred pharmacy
                                                                            preferred pharmacy
                                                                                                                - $30 copay for a three-month
                                                                            - 50% coinsurance for a three-      (90-day) supply of drugs in this
                                                                            month (90-day) supply of all        tier from a preferred pharmacy
                                                                            drugs covered in this tier from a
                                                                                                                - $15 copay for a one-month
                                                                            preferred pharmacy
                                                                                                                (30-day) supply of drugs in this
                                                                            - 55% coinsurance for a one-        tier from a non-preferred
                                                                            month (30-day) supply of all        pharmacy
                                                                            drugs you get at a non-preferred
                                                                                                                - $45 copay for a three-month
                                                                            pharmacy
                                                                                                                (90-day) supply of drugs in this
                                                                            - 55% coinsurance for a three-      tier from a non-preferred
                                                                            month (90-day) supply of all        pharmacy
                                                                            drugs covered in this tier from a
                                                                            non-preferred pharmacy




                                                                       32
If you have any questions about this plan’s benefits or costs, please contact Blue Shield of California at (800) 488-8000.


Benefit Category                    Original Medicare                    Blue Shield 65 Plus                     Blue Shield 65 Plus Choice
                                                                         Los Angeles & Orange County             Plan
                                                                         Plan
Preventive Services
29 – Prescription Drugs -                                                   Long Term Care Pharmacy              Long Term Care Pharmacy
continued                                                                   Formulary Generic                    Formulary Insulin and Generics
                                                                            - $6 copay for a one-month           - $0 copay for a one-month
                                                                            (34-day) supply of drugs             (34-day) supply of drugs
                                                                            Formulary Brand                      Formulary Brand
                                                                            - 50% coinsurance for a one-         - $15 copay for a one-month
                                                                            month (34-day) supply of all         (34-day) supply of all drugs
                                                                            drugs covered in this tier
                                                                                                                 Mail Order
                                                                            Mail Order                           Formulary Insulin and Generics
                                                                            Formulary Generic                    - $0 copay for a three-month
                                                                            - $12 copay for a three-month        (90-day) supply of all drugs
                                                                            (90-day) supply of drugs             covered in this tier
                                                                            Formulary Brand                      Formulary Brand
                                                                            - 50% coinsurance for a three-       - $30 copay for a three-month
                                                                            month (90 day) supply of all         (90-day) supply of all drugs
                                                                            drugs covered in this tier           covered in this tier


                                                                            For all other covered drugs, after   For all other covered drugs, after
                                                                            your total yearly drug costs         your total yearly drug costs
                                                                            reach $2,700, you pay 100%           reach $2,700, you pay 100%
                                                                            until your yearly out-of-pocket      until your yearly out-of-pocket
                                                                            drug costs reach $4,350.             drug costs reach $4,350.



                                                                       33
If you have any questions about this plan’s benefits or costs, please contact Blue Shield of California at (800) 488-8000.


Benefit Category                    Original Medicare                    Blue Shield 65 Plus                    Blue Shield 65 Plus Choice
                                                                         Los Angeles & Orange County            Plan
                                                                         Plan
Preventive Services
29 – Prescription Drugs -                                                   Catastrophic Coverage               Catastrophic Coverage
continued
                                                                            After your yearly out-of-pocket     After your yearly out-of-pocket
                                                                            drug costs reach $4,350, you pay    drug costs reach $4,350, you pay
                                                                            the greater of:                     the greater of:
                                                                            - A $2.40 copay for generic         - A $2.40 copay for generic
                                                                            (including brand drugs treated as   (including brand drugs treated as
                                                                            generic) and a $6.00 copay for      generic) and a $6.00 copay for
                                                                            all other drugs, or                 all other drugs, or
                                                                            - 5% coinsurance                    - 5% coinsurance




                                                                       34
If you have any questions about this plan’s benefits or costs, please contact Blue Shield of California at (800) 488-8000.


Benefit Category                    Original Medicare                    Blue Shield 65 Plus                     Blue Shield 65 Plus Choice
                                                                         Los Angeles & Orange County             Plan
                                                                         Plan
Preventive Services
29 – Prescription Drugs -                                                   Out-of-Network                       Out-of-Network
continued
                                                                            Plan drugs may be covered in         Plan drugs may be covered in
                                                                            special circumstances, for           special circumstances, for
                                                                            instance, illness while traveling    instance, illness while traveling
                                                                            outside of the plan’s service area   outside of the plan’s service area
                                                                            where there is no network            where there is no network
                                                                            pharmacy. You may have to pay        pharmacy. You may have to pay
                                                                            more than your normal cost-          more than your normal cost-
                                                                            sharing amount if you get your       sharing amount if you get your
                                                                            drugs at an out-of-network           drugs at an out-of-network
                                                                            pharmacy. In addition, you will      pharmacy. In addition, you will
                                                                            likely have to pay the               likely have to pay the
                                                                            pharmacy’s full charge for the       pharmacy’s full charge for the
                                                                            drug and submit documentation        drug and submit documentation
                                                                            to receive reimbursement from        to receive reimbursement from
                                                                            Blue Shield 65 Plus.                 Blue Shield 65 Plus Choice
                                                                                                                 Plan.




                                                                       35
If you have any questions about this plan’s benefits or costs, please contact Blue Shield of California at (800) 488-8000.


Benefit Category                    Original Medicare                    Blue Shield 65 Plus                    Blue Shield 65 Plus Choice
                                                                         Los Angeles & Orange County            Plan
                                                                         Plan
Preventive Services
29 – Prescription Drugs -                                                   Out-of-Network Initial              Out-of-Network Initial
continued                                                                   Coverage                            Coverage
                                                                            You will be reimbursed up to the    You will be reimbursed up to the
                                                                            full cost of the drug minus the     full cost of the drug minus the
                                                                            following for drugs purchased       following for drugs purchased
                                                                            out-of-network until total yearly   out-of-network until total yearly
                                                                            drug costs reach $2,700:            drug costs reach $2,700:

                                                                            Out-of-Network Pharmacy             Out-of-Network Pharmacy
                                                                            Formulary Generic                   Formulary Insulin and Generics
                                                                            - $6 copay for a one-month          - $0 copay for a one-month
                                                                            (30-day) supply of drugs in this    (30-day) supply of drugs in this
                                                                            tier                                tier
                                                                            Formulary Brand                     Formulary Brand
                                                                            - $25 copay for a one-month         - $15 copay for a one-month
                                                                            (30-day) supply of drugs in this    (30-day) supply of drugs in this
                                                                            tier                                tier
                                                                            Non-Preferred Brand                 Non-Preferred Brand
                                                                            - $60 copay for a one-month         - $60 copay for a one-month
                                                                            (30-day) supply of drugs in this    (30-day) supply of drugs in this
                                                                            tier                                tier




                                                                       36
If you have any questions about this plan’s benefits or costs, please contact Blue Shield of California at (800) 488-8000.


Benefit Category                    Original Medicare                    Blue Shield 65 Plus                   Blue Shield 65 Plus Choice
                                                                         Los Angeles & Orange County           Plan
                                                                         Plan
Preventive Services
29 – Prescription Drugs -                                                   Out-of-Network Pharmacy,           Out-of-Network Pharmacy,
continued                                                                   continued                          continued
                                                                            Injectables                         Injectables
                                                                            - 33% coinsurance for              - 33% coinsurance for
                                                                            a one-month (30-day) supply of     a one-month (30-day) supply of
                                                                            drugs in this tier                 drugs in this tier
                                                                            Formulary Specialty (Unique        Formulary Specialty (Unique
                                                                            High Cost Drugs)                   High Cost Drugs)
                                                                            - 33% coinsurance for              - 33% coinsurance for
                                                                            a one-month (30-day) supply of     a one-month (30-day) supply of
                                                                            drugs in this tier                 drugs in this tier


                                                                            Out-of-Network Coverage            Out-of-Network Coverage
                                                                            Gap                                Gap
                                                                            The plan covers All Preferred      The plan covers All Preferred
                                                                            Generics, All Preferred Brands     Generics, All Preferred Brands
                                                                            through the gap.                   through the gap.
                                                                            You will be reimbursed for these   You will be reimbursed for these
                                                                            drugs purchased out-of-network     drugs purchased out-of-network
                                                                            up to the full cost of the drug    up to the full cost of the drug
                                                                            minus the following:               minus the following:
                                                                            Formulary Generic                  Formulary Insulin and Generics
                                                                            - $6 copay for a one-month         - $0 copay for a one-month
                                                                            (30-day) supply of drugs           (30-day) supply of drugs


                                                                       37
If you have any questions about this plan’s benefits or costs, please contact Blue Shield of California at (800) 488-8000.


Benefit Category                    Original Medicare                    Blue Shield 65 Plus                  Blue Shield 65 Plus Choice
                                                                         Los Angeles & Orange County          Plan
                                                                         Plan
Preventive Services
29 – Prescription Drugs -                                                   Out-of-Network Coverage           Out-of-Network Coverage
continued                                                                   Gap, continued                    Gap, continued
                                                                            Formulary Brand                   Formulary Brand
                                                                         - 50% coinsurance for a one-         - $15 copay for a one-month
                                                                         month (30-day) supply of all         (30-day) supply of all drugs
                                                                         drugs covered in this tier           covered in this tier


                                                                         Non-Preferred Brand                  Non-Preferred Brand
                                                                         - After your total yearly drug       - After your total yearly drug
                                                                         costs reach $2,700, you pay          costs reach $2,700, you pay
                                                                         100% of the pharmacy’s full          100% of the pharmacy’s full
                                                                         charge for drugs purchased out-      charge for drugs purchased out-
                                                                         of-network until your yearly out-    of-network until your yearly out-
                                                                         of-pocket drug costs reach           of-pocket drug costs reach
                                                                         $4,350. You will not be              $4,350. You will not be
                                                                         reimbursed by Blue Shield            reimbursed by Blue Shield
                                                                         65 Plus for out-of-network           65 Plus Choice Plan for out-of-
                                                                         purchases when you are in the        network purchases when you are
                                                                         coverage gap. However, you           in the coverage gap. However,
                                                                         should still submit                  you should still submit
                                                                         documentation to Blue Shield         documentation to Blue Shield
                                                                         65 Plus so we can add the            65 Plus Choice Plan so we can
                                                                         amounts you spent out-of-            add the amounts you spent out-
                                                                         network to your total out-of-        of-network to your total out-of-
                                                                         pocket costs for the year.           pocket costs for the year.


                                                                       38
If you have any questions about this plan’s benefits or costs, please contact Blue Shield of California at (800) 488-8000.


Benefit Category                    Original Medicare                    Blue Shield 65 Plus                  Blue Shield 65 Plus Choice
                                                                         Los Angeles & Orange County          Plan
                                                                         Plan
Preventive Services
29 – Prescription Drugs -                                                   Out-of-Network Coverage           Out-of-Network Coverage
continued                                                                   Gap, continued                    Gap, continued


                                                                         Injectables                          Injectables
                                                                         - After your total yearly drug       - After your total yearly drug
                                                                         costs reach $2,700, you pay          costs reach $2,700, you pay
                                                                         100% of the pharmacy’s full          100% of the pharmacy’s full
                                                                         charge for drugs purchased out-      charge for drugs purchased out-
                                                                         of-network until your yearly out-    of-network until your yearly out-
                                                                         of-pocket drug costs reach           of-pocket drug costs reach
                                                                         $4,350. You will not be              $4,350. You will not be
                                                                         reimbursed by Blue Shield            reimbursed by Blue Shield
                                                                         65 Plus for out-of-network           65 Plus Choice Plan for out-of-
                                                                         purchases when you are in the        network purchases when you are
                                                                         coverage gap. However, you           in the coverage gap. However,
                                                                         should still submit                  you should still submit
                                                                         documentation to Blue Shield         documentation to Blue Shield
                                                                         65 Plus so we can add the            65 Plus Choice Plan so we can
                                                                         amounts you spent out-of-            add the amounts you spent out-
                                                                         network to your total out-of-        of-network to your total out-of-
                                                                         pocket costs for the year.           pocket costs for the year.




                                                                       39
If you have any questions about this plan’s benefits or costs, please contact Blue Shield of California at (800) 488-8000.


Benefit Category                    Original Medicare                    Blue Shield 65 Plus                  Blue Shield 65 Plus Choice
                                                                         Los Angeles & Orange County          Plan
                                                                         Plan
Preventive Services
29 – Prescription Drugs -                                                   Out-of-Network Coverage           Out-of-Network Coverage
continued                                                                   Gap, continued                    Gap, continued


                                                                         Formulary Specialty (Unique          Formulary Specialty (Unique
                                                                         High Cost Drugs)                     High Cost Drugs)
                                                                         - After your total yearly drug       - After your total yearly drug
                                                                         costs reach $2,700, you pay          costs reach $2,700, you pay
                                                                         100% of the pharmacy’s full          100% of the pharmacy’s full
                                                                         charge for drugs purchased out-      charge for drugs purchased out-
                                                                         of-network until your yearly out-    of-network until your yearly out-
                                                                         of-pocket drug costs reach           of-pocket drug costs reach
                                                                         $4,350. You will not be              $4,350. You will not be
                                                                         reimbursed by Blue Shield            reimbursed by Blue Shield
                                                                         65 Plus for out-of-network           65 Plus for out-of-network
                                                                         purchases when you are in the        purchases when you are in the
                                                                         coverage gap. However, you           coverage gap. However, you
                                                                         should still submit                  should still submit
                                                                         documentation to Blue Shield         documentation to Blue Shield
                                                                         65 Plus so we can add the            65 Plus so we can add the
                                                                         amounts you spent out-of-            amounts you spent out-of-
                                                                         network to your total out-of-        network to your total out-of-
                                                                         pocket costs for the year.           pocket costs for the year.




                                                                       40
If you have any questions about this plan’s benefits or costs, please contact Blue Shield of California at (800) 488-8000.


Benefit Category                    Original Medicare                    Blue Shield 65 Plus                    Blue Shield 65 Plus Choice
                                                                         Los Angeles & Orange County            Plan
                                                                         Plan
Preventive Services
29 – Prescription Drugs -                                                Out-of-Network Catastrophic            Out-of-Network Catastrophic
continued                                                                Coverage                               Coverage


                                                                            After your yearly out-of-pocket     After your yearly out-of-pocket
                                                                            drug costs reach $4,350, you        drug costs reach $4,350, you
                                                                            will be reimbursed for drugs        will be reimbursed for drugs
                                                                            purchased out-of-network up to      purchased out-of-network up to
                                                                            the full cost of the drug minus     the full cost of the drug minus
                                                                            the following:                      the following:
                                                                            - A $2.40 copay for generic         - A $2.40 copay for generic
                                                                            (including brand drugs treated as   (including brand drugs treated as
                                                                            generic) and a $6.00 copay for      generic) and a $6.00 copay for
                                                                            all other drugs, or                 all other drugs, or
                                                                            - 5% coinsurance                    - 5% coinsurance




                                                                       41
If you have any questions about this plan’s benefits or costs, please contact Blue Shield of California at (800) 488-8000.


Benefit Category                    Original Medicare                    Blue Shield 65 Plus                   Blue Shield 65 Plus Choice
                                                                         Los Angeles & Orange County           Plan
                                                                         Plan
Preventive Services
30 – Dental Services                 Preventive dental services (such        In-Network                        In-Network
                                     as cleaning) not covered.               In general, preventive dental     $0 copay for Medicare-covered
                                                                             benefits (such as cleaning) not   dental benefits.
                                                                             covered.                          - $5 to $15 for oral exams
                                                                             $10 copay for Medicare-covered    - $20 copay for up to 1 cleaning
                                                                             dental benefits.                  every six months
                                                                                                               - $5 copay for up to 1 fluoride
                                                                                                               treatment every six months
                                                                                                               - $0 to $10 copay for up to 1
                                                                                                               dental x-ray visit every two
                                                                                                               years
                                                                                                               Plan offers additional
                                                                                                               comprehensive dental benefits.
31 – Hearing Services                Routine hearing exams and               General                           General
                                     hearing aids not covered.               Authorization rules may apply.    Authorization rules may apply.
                                     20% coinsurance for diagnostic
                                     hearing exams.
                                                                             In-Network                        In-Network
                                                                             Hearing aids not covered.         Hearing aids not covered.
                                                                             $0 copay for diagnostic hearing   $0 copay for diagnostic hearing
                                                                             exams                             exams
                                                                             - routine hearing tests           - routine hearing tests




                                                                        42
If you have any questions about this plan’s benefits or costs, please contact Blue Shield of California at (800) 488-8000.


Benefit Category                    Original Medicare                      Blue Shield 65 Plus                   Blue Shield 65 Plus Choice
                                                                           Los Angeles & Orange County           Plan
                                                                           Plan
Preventive Services
32 – Vision Services                 20% coinsurance for diagnosis             General                           General
                                     and treatment of diseases and             Authorization rules may apply.    Authorization rules may apply.
                                     conditions of the eye.
                                     Routine eye exams and glasses
                                                                               In-Network                        In-Network
                                     not covered.
                                                                               - $0 copay for one pair of        - $0 copay for one pair of
                                     Medicare pays for one pair of
                                                                               eyeglasses or contact lenses      eyeglasses or contact lenses
                                     eyeglasses or contact lenses after
                                                                               after cataract surgery.           after cataract surgery.
                                     cataract surgery.
                                                                               - $10 copay for exams to          - $0 copay for exams to
                                     Annual glaucoma screenings
                                                                               diagnose and treat diseases and   diagnose and treat diseases and
                                     covered for people at risk.
                                                                               conditions of the eye.            conditions of the eye.
                                                                               - $10 copay for up to 1 routine   - $10 copay for up to 1 routine
                                                                               eye exam every year               eye exam every year
                                                                               - $20 copay for up to 1 pair of   - $15 copay for up to 1 pair of
                                                                               lenses every year                 lenses every year
                                                                               - $20 copay for up to 1 frame     - $0 copay for up to 1 frame
                                                                               every two years                   every two years
                                                                               - $75 limit for eye wear every    - $90 limit for eye wear every
                                                                               two years.                        two years.




                                                                          43
If you have any questions about this plan’s benefits or costs, please contact Blue Shield of California at (800) 488-8000.


Benefit Category                    Original Medicare                    Blue Shield 65 Plus                    Blue Shield 65 Plus Choice
                                                                         Los Angeles & Orange County            Plan
                                                                         Plan
Preventive Services
33 – Physical Exams                  20% coinsurance for one exam            General                            General
                                     within the first 12 months of           Authorization rules may apply.     Authorization rules may apply.
                                     your new Medicare Part B
                                     coverage.
                                                                             In-Network                         In-Network
                                     When you get Medicare Part B,
                                     you can get a one time physical         $0 copay for routine exams.        $0 copay for routine exams.
                                     exam within the first 12 months         Limited to 1 exam every year.      Limited to 1 exam every year.
                                     of your new Part B coverage.
                                     The coverage does not include
                                     lab tests.
34 – Health/Wellness Education       Smoking Cessation:                      In-Network                         In-Network
                                     Covered if ordered by your              This plan covers health/wellness   This plan covers health/wellness
                                     doctor. Includes two counseling         education benefits:                education benefits:
                                     attempts within a 12-month              - Written health education         - Written health education
                                     period if you are diagnosed with        materials, including Newsletters   materials, including Newsletters
                                     a smoking-related illness or are        - Health Club Membership /         - Health Club Membership /
                                     taking medicine that may be             Fitness Classes                    Fitness Classes
                                     affected by tobacco. Each
                                                                             - Nursing Hotline                  - Nursing Hotline
                                     counseling attempt includes up
                                     to four face-to-face visits. You
                                     pay coinsurance, and Part B
                                     deductible applies.




                                                                        44
If you have any questions about this plan’s benefits or costs, please contact Blue Shield of California at (800) 488-8000.


Benefit Category                    Original Medicare                    Blue Shield 65 Plus                   Blue Shield 65 Plus Choice
                                                                         Los Angeles & Orange County           Plan
                                                                         Plan
Preventive Services
35 – Transportation (Routine)        Not covered.                           In-Network                         In-Network
                                                                            This plan does not cover routine   $0 copay for up to 5 one-way
                                                                            transportation.                    trips to plan-approved location
                                                                                                               every three months.
36 – Acupuncture                     Not covered.                           In-Network                         In-Network
                                                                            This plan does not cover           This plan does not cover
                                                                            Acupuncture.                       Acupuncture.




                                                                       45
If you have any questions about this plan’s benefits or costs, please contact Blue Shield of California at (800) 488-8000.


Additional Benefit Information                                                                       You have a $500 cost-sharing cap per
                                                  For Blue Shield 65 Plus Choice Plan and            Diagnostic Radiology Service, which
Emergency Care and Urgently                       Blue Shield 65 Plus, you have a $10,000            means once your out-of-pocket expenses
Needed Care                                       combined annual limit for covered                  reach $500 for each service, you won’t
                                                  emergency or urgently needed services              pay any more than the $500.
Benefit Categories 15 &16 on
                                                  outside of the United States.
pages 14 & 15
                                                                                                     3) You will pay 20% of the Medicare-
                                                                                                     allowed amount for Therapeutic
Emergency Care
                                                  Diagnostic Tests, X-Rays, and Lab                  Radiology Services regardless of what
You pay $50 for each visit to an                  Services –                                         your out-of-pocket expenses are. Services
emergency room. (Waived if admitted to            Benefit Category 21 on page 17                     including, but not limited to: radiation
                                                                                                     therapy chemotherapy, radium and
the Hospital within 24 hours for the same
                                                  Whether you pay $0 or 20% coinsurance              isotope therapy.
condition.)
                                                  depends on the type of services obtained.
                                                                                                     If these services are administered in an
Urgently Needed Care
                                                  1) You will pay $0 for Diagnostic Tests,           urgent care center, emergency room, or
                                                  X-ray Services, Supplies, Blood and                physician office that is outside your plan
For Blue Shield 65 Plus Choice Plan, you
                                                  Laboratory Services. These services                service area, you pay a $50 copayment.
pay $0 for each visit to an urgent care
center within you Plan Service Area.              require prior authorization (approval in
                                                  advance) from your Physician Group or
For Blue Shield 65 Plus, you pay $25 for          Blue Shield 65 Plus Choice Plan to be
each visit to an urgent care center within        covered, except for emergency and urgent
your Plan Service Area. (Waived if                out-of-area services.
admitted to the Hospital within 24 hours
for the same condition.)                          2) You will pay 20% of the Medicare-
                                                  allowed amount for Diagnostic Radiology
For Blue Shield 65 Plus Choice Plan and           Services, including but not limited to:
Blue Shield 65 Plus, you pay $50 for each         MRI scans, PET scans, Nuclear Medicine
visit to an urgent care center, emergency         studies, CT scans, EKGs, Cardiac Stress
room or physician office that is outside          Tests, SPECT, PET, Myelogram,
your Plan Service Area.                           Cystogram and Angiogram..
(Waived if admitted to the Hospital within
24 hours for the same condition.)


                                                                       46
                                                                                                H0504-08.08.093B1 RA 09192008
contact us
Enrollment

If you are interested in enrolling in Blue Shield 65 Plus Choice Plan or Blue Shield 65 Plus,




                                                                                                MR15773 (10/08)
please call us at:

1-800-488-8000
1-888-595-0000 (TTY/TDD)
8 a.m. to 8 p.m., 7 days a week

Or call your local Authorized Blue Shield Agent

6300 Canoga Ave.
Woodland Hills, CA 91367-2555

Member Assistance

If you are a member and need assistance, please call our Member Services representatives at:

1-800-776-4466
1-800-794-1099 (TTY/TDD)
7 a.m. to 8 p.m., 7 days a week

								
To top