Enrollment Guide - Florida Blue Medicare Advantage · 2020. 10. 7. · Enrollment Guide...

Enrollment Guide

Y0011_FBM0172 2020_M

Start here to find the Medicare Plan that fits your life and budget.

BlueMedicare Value (PPO) H5434-033,034

Brevard, Hillsborough, Orange, Osceola, Polk & Seminole Counties

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This booklet will help make enrolling in your BlueMedicareSM plan as easy as possible. It also explains what will happen immediately after you’re enrolled, and how to start finding out just how Blue means more to you.

WelcomeCongratulations for choosing BlueMedicare!

This booklet contains:

Questions? Ask your agent or give us a call.

1-855-217-4362 (TTY: 1-800-955-8770)October 1 to March 31: 7 days a week from 8 a.m. to 8 p.m. local time and from April 1 to September 30: Monday through Saturday, from 8 a.m. to 8 p.m. local time and closed on Sundays. We are closed most Federal Holidays.

Information on what happens after you enroll in your plan and what to expect

Enrollment steps that will walk you through the process

All the forms you need to enroll in your plan

Information about your plan’s provider network and how to find a doctor

A summary of benefits included in your plan

Information on Medicare prescription drug benefits and how to save as much money as possible on prescription drugs

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Table of Contents

About Medicare AdvantageWhat is Medicare Advantage? .......................................... 4

Important Medicare Enrollment Information ..................... 5

My BenefitsBenefits at a Glance ......................................................... 6

PPO Visitor/Traveler Program ........................................ 10

Summary of Benefits .......................................................11

Enrollment InformationReady to Sign Up? ......................................................... 28

Forms Used for Enrollment............................................. 29

Pre-Enrollment Checklist ................................................ 30

Protected Health Information Authorization ................... 31

Scope of Sales Appointment Confirmation Form ........... 35

Enrollment Checklist ....................................................... 43

What’s Next?How to Make the Most of Your Medicare Dollars............ 48

What You Can Expect the First 90 Days ........................ 50

Non-Discrimination Notice .............................................. 51

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With Original Medicare your out-of-pocket costs, like deductibles, coinsurance and copays, can add up. Medicare Advantage plans like BlueMedicare offer additional benefits and can help you pay fewer out-of-pocket costs than Original Medicare.

ORIGINAL MEDICARE MEDICARE ADVANTAGE

PRESCRIPTION DRUGS

Part C combines Part A, Part B and often Part D plus additional benefits like dental, hearing and vision. Our Florida Blue Medicare Advantage plans include Part D coverage.

Part A covers inpatient hospital and skilled nursing facility care.

Part B covers outpatient services and physician care.

Part D covers prescription drugs.

Medicare Advantage plans are health plans offered by private insurers that contract with Medicare.

What is Medicare Advantage?Medicare Advantage plans are health plans offered by private insurers that contract with Medicare.

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Important Medicare Enrollment Information

92055 0719

Open Enrollment Period (OEP)OEP runs January 1 through March 31. During this period if you are enrolled in a Medicare Advantage (MA) plan, you are allowed to make a one-time election to go to another MA plan or to Original Medicare. If you enroll in Original Medicare, you may also purchase a Medicare Supplement and/or a Prescription Drug Plan.

Note: There is no guaranteed-issue enrollment period for Medicare Supplement plans.

Annual Election Period (AEP) Every year, from October 15 through December 7, you can switch, drop or join the Medicare Advantage or Medicare Prescription Drug Plan of your choosing. You can also enroll in Original Medicare. Your plan selection becomes effective January 1 of the following year.

Initial Enrollment PeriodWhen you become eligible for Medicare, you can enroll in Original Medicare or a Medicare health or Prescription Drug Plan three months before the month you turn 65, the month of your birthday, and the three months after the month of your birthday.

Special Election Period (SEP)After certain events, such as a recent move or losing your employer or union coverage, you may be eligible for a Special Election Period. If you think you qualify, talk to your local sales agent.

Open Enrollment Period

Initial Enrollment Period*

Annual Election Period

Special Election Period

Jan. Feb. Mar. Apr. May June July Aug. Sept. Oct. Nov. Dec.

* 3 months before/after and including the month of your 65th birthday.

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Plan CostsBlueMedicare Value (PPO)H5434-033

BlueMedicare Value (PPO)H5434-034

Service Area Brevard, Orange, Osceola & Seminole

Hillsborough & Polk

How much is the monthly premium?

$0 You must continue to pay your Medicare Part B premium.


How much is the deductible?

This plan does not have a deductible for medicals ervices and supplies.$150 per year for Part D prescription drugs. Not applicable to Tiers 1, 2 and 6.

This plan does not have a deductible for medicals ervices and supplies.$150 per year for Part D prescription drugs. Not applicable to Tiers 1, 2 and 6.

Is there any limit on how much I will pay for my covered services?

$4,500 In-Network providers$10,000 In- and Out-of-Network providers combined

$4,500 In-Network providers$10,000 In- and Out-of-Network providers combined

Medical & Hospital BenefitsDoctor’s Office Visits

In-Network $0 copay Level 1 Primary Care Physician$10 copay all other Primary Care Physician$35 copay Level 1 Specialist $45 copay all other SpecialistOut-of-Network 50% coinsurance

In-Network $0 copay Level 1 Primary Care Physician$10 copay all other Primary Care Physician$35 copay Level 1 Specialist $45 copay all other SpecialistOut-of-Network 50% coinsurance

Preventive Care In-Network$0 copayOut-of-Network 50% coinsurance

In-Network$0 copayOut-of-Network 50% coinsurance

Benefits at-a-Glance

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Medical & Hospital Benefits (continued)

Inpatient Hospital Care

In-NetworkDays 1-6: $325 copay per dayAfter the 6th day the plan pays 100% of covered expenses.Out-of-Network 50% coinsurance

In-NetworkDays 1-6: $275 copay per dayAfter the 6th day the plan pays 100% of covered expenses.Out-of-Network 50% coinsurance

Outpatient Hospital In-Network$250 copay except for Observation Services$90 copay for Observation ServicesOut-of-Network 50% coinsurance

In-Network$225 copay except for Observation Services$90 copay for Observation ServicesOut-of-Network 50% coinsurance

Outpatient Surgery In-Network$150 copay in an Ambulatory Surgical Center $250 copay in an Outpatient Hospital Facility Out-of-Network 50% coinsurance

In-Network$150 copay in an Ambulatory Surgical Center $225 copay for in an Outpatient Hospital Facility Out-of-Network 50% coinsurance

Urgently Needed Services

In- and Out-of-Network $50 copay at a Convenient Care Center$50 copay at an Urgent Care Center

In- and Out-of-Network $40 copay at a Convenient Care Center$40 copay at an Urgent Care Center

Emergency Room In- and Out-of-Network $90 copay

In- and Out-of-Network $90 copay

Ambulance In- and Out-of-Network $310 copay

In- and Out-of-Network $305 copay

Part D Prescription Drug Benefits1

Tier 1 (Preferred Generic)

$3 copay $3 copay

Tier 2 (Generic)

$12 copay $12 copay

Tier 3 (Preferred Brand)

Deductible then $47 copay


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Part D Prescription Drug Benefits1 (continued)

Tier 4 (Non-Preferred)



Tier 5 (Specialty)

Deductible then 30% coinsurance

Deductible then 30% coinsurance

Tier 6 (Select Care)

$0 copay $0 copay

Mail Order Same copays/coinsurance as listed above

Same copays/coinsurance as listed above

1 What you pay at a Network Retail Pharmacy for a 31-day supply

Additional BenefitsAcupuncture2 In-Network

$20 copayVision Services2 In-Network

$0 copay for annual routine eye exam $200 allowance per year towards the purchase of lenses, frames or contact lenses

Hearing Servicesand Hearing Aids2

In-Network$0 copay for one routine hearing exam per year

$0 copay for evaluation and fitting of hearing aids

$500 maximum allowance for each hearing aid. Up to 2 hearing aids every year.

Hearing aids must be purchased through NationsHearing.

Dental Services2 In-Network$0 copay for the services shown below• 2 cleanings per year (one every six months)• Oral exams and X-rays• Extraction, erupted tooth or exposed root (up to 2 per year)• Adjustment of complete or partial denture (up to 2 per year)

Over-the-Counter Items2

$50 quarterly allowance for the purchase of non-prescription items, such as vitamins and aspirin. What you need to know:• Any balance not used for a quarter will not carry over to the next

quarter• You must use your full benefit in one order• Your order total may not exceed your benefit amount

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Additional Benefits (continued)

Telehealth2 In-Network$0 copay for Level 1 Primary Care services and most Medicare-covered Preventive services. Copays vary for other services.• Available 24/7• Able to prescribe medications, except controlled substances

At Home Care2 60 hours per yearWe offer this benefit through our partnership with Papa who connects college students, known as “Papa Pals” to older adults who require assistance with house chores, technology tutoring, food shopping, pet care and companionship.

Caregiver Support for Member2

We provide coverage for coaching, education and support services such as counseling and training courses for caregivers of enrollees. Benefits include:• A web-based tool that contains educational content covering topics

on health, wealth, senior living, in-home care and lifestyle.• Access for caregivers and family members to post updates and

videos; tools to manage documents, stay organized and on top of upcoming tasks and appointments.

• Search tools (i.e. senior housing search and in-home care search.)

HealthyBlue Rewards

• Redeem gift card rewards for completing and reporting preventive care and screenings

SilverSneakers® Fitness Program

• Gym membership and classes available at 16,000+ fitness locations across the country, including national chains and local gyms

• Access to exercise equipment and other amenities, classes for all levels and abilities, social events, and more

2 See Summary of Benefits for more details including Out-of-Network coverage

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PPO Visitor/Traveler Program

Illinois

Wisconsin

Tennessee

Indiana

Home ServiceArea

Florida

PuertoRico

Kansas

Nebraska

New Mexico

Colorado

Utah

IdahoOregon

Washington

Montana

Nevada

Louisiana

Minnesota

Michigan

GeorgiaAlabama

SouthCarolina

NorthCarolina

Virginia

New Jersey

Rhode Island

Kentucky

Ohio

Missouri

WestVirginia

Pennsylvania

New York

Maine

Conn.

N.H.

Mass.

Texas

California

Hawaii

Oregon

ArkansasOklahoma

Your enrollment materials will also tell you in which states the Visitor/Traveler Program is available and how to locate provider information. In addition, you may:

Visit “Find a Doctor” at www.bcbs.com to find a Blue Medicare Advantage PPO provider; or call our Customer Service Department toll-free at 1-855-601-9465.

The Visitor/Traveler Program will include BlueMedicare Advantage PPO network coverage of all Part A, Part B, and supplemental benefits offered by your plan outside your service area in the 39 states and 1 territory shown in the map above.

When you receive services from a PPO provider in any area where the Visitor/Traveler Program is offered, you will pay the same cost-sharing amounts you pay when you receive covered benefits from network providers in your home service area.For some of the states listed, Medicare Advantage PPO networks are available only in portions of the state.

*This information is for 2020. States may be added or removed for 2021.

39 States and 1 Territory*

Call 1-800-810-BLUE (1-800-810-2583) 24 hours a day, 7 days a week, to find a BlueMedicare Advantage PPO provider (TTY: 1-800-955-8770)

We are available October 1 to March 31: 7 days a week from 8 a.m. to 8 p.m. local time, except for Thanksgiving and Christmas and from April 1 to September 30: Monday through Friday, from 8 a.m. to 8 p.m. local time

Under the Medicare Advantage rules, if you are absent from the service area for more than six (6) months, you must be disenrolled. However, in areas where we offer the Visitor/Traveler Program you may remain in the plan while out of our service area for 12 months.

Florida Blue is a PPO and RPPO Plan with a Medicare contract. Enrollment in Florida Blue depends on contract renewal.

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2021Summary of Benefits

The plans’ service area includes:

Brevard, Hillsborough, Orange, Osceola, Polk and Seminole Counties

Medicare Advantage Plans with Part D Prescription Drug Coverage

BlueMedicare Value (PPO) H5434-033 BlueMedicare Value (PPO) H5434-0341/1/2021 – 12/31/2021

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1

The benefit information provided is a summary of what we cover and what you pay. To get a complete list of services we cover, call us and ask for the “Evidence of Coverage.” You may also view the “Evidence of Coverage” for this plan on our website, www.floridablue.com/medicare. If you want to know more about the coverage and costs of Original Medicare, look in your current "Medicare & You" handbook. View it online at www.medicare.gov or get a copy by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.

Who Can Join? To join, you must:

be entitled to Medicare Part A; and be enrolled in Medicare Part B; and live in our service area.

Our H5434-033 service area includes the following counties in Florida: Brevard, Orange, Osceola and Seminole Our H5434-034 service area includes the following counties in Florida: Hillsborough and Polk

Which doctors, hospitals, and pharmacies can I use? We have a network of doctors, hospitals, pharmacies, and other providers. If you use the providers that are not in our network, you may pay more for these services.

You can see our plan's provider and pharmacy directory at our website (www.floridablue.com/medicare). Or call us and we will send you a copy of the provider and pharmacy directories.

Have Questions? Call Us If you are a member of this plan, call us at 1-800-926-6565, TTY: 1-800-955-8770. If you are not a member of this plan, call us at 1-855-601-9465, TTY: 1-800-955-8770.

o From October 1 through March 31, we are open seven days a week, from 8:00 a.m. to 8:00 p.m. local time, except for Thanksgiving and Christmas.

o From April 1 through September 30, we are open Monday through Friday, from 8:00 a.m. to 8:00 p.m. local time, except for major holidays.

Or visit our website at www.floridablue.com/medicare

Important Information Through this document you will see the “◊” symbol. Services with this symbol may require prior authorization from the plan before you receive the services from network providers. If you do not get a prior authorization when required, you may have to pay out-of-network cost-sharing, even though you received services from a network provider. Please contact your doctor or refer to the Evidence of Coverage (EOC) for more information about services that require a prior authorization from the plan.

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1

The benefit information provided is a summary of what we cover and what you pay. To get a complete list of services we cover, call us and ask for the “Evidence of Coverage.” You may also view the “Evidence of Coverage” for this plan on our website, www.floridablue.com/medicare. If you want to know more about the coverage and costs of Original Medicare, look in your current "Medicare & You" handbook. View it online at www.medicare.gov or get a copy by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.

Who Can Join? To join, you must:

be entitled to Medicare Part A; and be enrolled in Medicare Part B; and live in our service area.

Our H5434-033 service area includes the following counties in Florida: Brevard, Orange, Osceola and Seminole Our H5434-034 service area includes the following counties in Florida: Hillsborough and Polk

Which doctors, hospitals, and pharmacies can I use? We have a network of doctors, hospitals, pharmacies, and other providers. If you use the providers that are not in our network, you may pay more for these services.

You can see our plan's provider and pharmacy directory at our website (www.floridablue.com/medicare). Or call us and we will send you a copy of the provider and pharmacy directories.

Have Questions? Call Us If you are a member of this plan, call us at 1-800-926-6565, TTY: 1-800-955-8770. If you are not a member of this plan, call us at 1-855-601-9465, TTY: 1-800-955-8770.

o From October 1 through March 31, we are open seven days a week, from 8:00 a.m. to 8:00 p.m. local time, except for Thanksgiving and Christmas.

o From April 1 through September 30, we are open Monday through Friday, from 8:00 a.m. to 8:00 p.m. local time, except for major holidays.

Or visit our website at www.floridablue.com/medicare

Important Information Through this document you will see the “◊” symbol. Services with this symbol may require prior authorization from the plan before you receive the services from network providers. If you do not get a prior authorization when required, you may have to pay out-of-network cost-sharing, even though you received services from a network provider. Please contact your doctor or refer to the Evidence of Coverage (EOC) for more information about services that require a prior authorization from the plan.

2

Monthly Premium, Deductible and Limits

BlueMedicare Value (PPO) Brevard, Orange, Osceola and Seminole

H5434-033

BlueMedicare Value (PPO) Hillsborough and Polk

H5434-034

Monthly Plan Premium



Deductible $0 Out-of-Network (OON) Deductible $150 per year for Part D prescription

drugs (does not apply to Tier 1 (Preferred Generic), Tier 2 (Generic), and Tier 6 (Select Care Drugs))

$0 Out-of-Network (OON) Deductible $150 per year for Part D prescription

drugs (does not apply to Tier 1 (Preferred Generic), Tier 2 (Generic), and Tier 6 (Select Care Drugs))

Maximum Out-of-Pocket Responsibility

$4,500 is the most you pay for copays, coinsurance and other costs for Medicare-covered medical services from in-network providers for the year.

$10,000 is the most you pay for copays, coinsurance and other costs for Medicare-covered medical services you receive from in and out-of-network providers combined.

$4,500 is the most you pay for copays, coinsurance and other costs for Medicare-covered medical services from in-network providers for the year.

$10,000 is the most you pay for copays, coinsurance and other costs for Medicare-covered medical services you receive from in and out-of-network providers combined.

Medical and Hospital Benefits


H5434-033


H5434-034

Inpatient Hospital Care

In-Network ◊ $325 copay per day, days 1-6 $0 copay per day, after day 6 Out-of-Network 50% of the Medicare-allowed amount

In-Network ◊ $275 copay per day, days 1-6 $0 copay per day, after day 6 Out-of-Network 50% of the Medicare-allowed amount

Outpatient Hospital Care

In-Network $90 copay per visit for Medicare-

covered observation services $250 copay for all other services ◊ Out-of-Network 50% of the Medicare-allowed amount

In-Network $90 copay per visit for Medicare-

covered observation services $225 copay for all other services ◊ Out-of-Network 50% of the Medicare-allowed amount

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H5434-033


H5434-034

Ambulatory Surgery Center

In-Network ◊ $150 copay for surgery services provided at an Ambulatory Surgery Center Out-of-Network 50% of the Medicare-allowed amount


Doctor’s Office Visits

In-Network $0 copay per Level 1 primary

care visit $10 copay all other primary care visit $35 copay per Level 1 specialist visit $45 copay all other specialist visit Out-of-Network 50% of the Medicare-allowed amount



Preventive Care In-Network $0 copay Out-of-Network 50% of the Medicare-allowed amount

In-Network $0 copay Out-of-Network 50% of the Medicare-allowed amount

Abdominal aortic aneurysm screening

Alcohol misuse screening and counseling Annual Wellness Visit Bone mass measurements Breast cancer screening (mammograms) Cardiovascular disease screening and intensive behavioral therapy Cervical and vaginal cancer screening Colorectal cancer screening Depression screening Diabetes screening and self-management training Glaucoma screening Hepatitis B and C screening HIV screening Intensive Behavioral Therapy for Obesity Lung cancer screening Medical nutrition therapy Prostate cancer screening Sexually transmitted infections - screening and high-intensity behavioral

counseling to prevent them Smoking and tobacco use cessation counseling Vaccines for influenza, pneumonia and Hepatitis B Welcome to Medicare preventive visit Any additional preventive services approved by Medicare during the contract year will be covered.

4


H5434-033


H5434-034

Emergency Care

Medicare Covered Emergency Care $90 copay per visit, in- or out-of-

network This copay is waived if you are admitted to the hospital within 48 hours of an emergency room visit. Worldwide Emergency Care Services $125 copay for Worldwide Emergency

Care $25,000 combined yearly limit for

Worldwide Emergency Care and Worldwide Urgently Needed Services

Does not include emergency transportation.







Medicare Covered Urgently Needed Services Urgently needed services are provided to treat a non-emergency, unforeseen medical illness, injury or condition that requires immediate medical attention. $50 copay at an Urgent Care Center,

in- or out-of-network Convenient Care Services are outpatient services for non-emergency injuries and illnesses that need treatment when most family physician offices are closed. $50 copay at a Convenient Care

Center, in- or out-of-network Worldwide Urgently Needed Services $125 copay for Worldwide Urgently

Needed Services $25,000 combined yearly limit for









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H5434-033


H5434-034

Ambulatory Surgery Center



Doctor’s Office Visits





Preventive Care In-Network $0 copay Out-of-Network 50% of the Medicare-allowed amount

In-Network $0 copay Out-of-Network 50% of the Medicare-allowed amount

Abdominal aortic aneurysm screening

Alcohol misuse screening and counseling Annual Wellness Visit Bone mass measurements Breast cancer screening (mammograms) Cardiovascular disease screening and intensive behavioral therapy Cervical and vaginal cancer screening Colorectal cancer screening Depression screening Diabetes screening and self-management training Glaucoma screening Hepatitis B and C screening HIV screening Intensive Behavioral Therapy for Obesity Lung cancer screening Medical nutrition therapy Prostate cancer screening Sexually transmitted infections - screening and high-intensity behavioral

counseling to prevent them Smoking and tobacco use cessation counseling Vaccines for influenza, pneumonia and Hepatitis B Welcome to Medicare preventive visit Any additional preventive services approved by Medicare during the contract year will be covered.

4


H5434-033


H5434-034

Emergency Care
























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H5434-033


H5434-034

Diagnostic Services/ Labs/Imaging

In-Network ◊ Laboratory Services $0 copay at an Independent Clinical

Laboratory $40 copay at an outpatient hospital

facility X-Rays $15 copay at an Independent

Diagnostic Testing Facility (IDTF) $150 copay at an outpatient hospital

facility Advanced Imaging Services Includes services such as Magnetic Resonance Imaging (MRI), Positron Emission Tomography (PET), and Computer Tomography (CT) Scan $50 copay at a specialist’s office or at

an IDTF $150 copay at an outpatient hospital

facility Radiation Therapy 20% of the Medicare-allowed amount Out-of-Network 50% of the Medicare-allowed amount








6


H5434-033


H5434-034

Hearing Services

In-Network Medicare-Covered Hearing Services $45 copay for exams to

diagnose and treat hearing and balance issues

Additional Hearing Services $0 copay for one routine hearing exam

per year $0 copay for evaluation and fitting of

hearing aids $500 per ear. You pay a $0 copay

for up to 2 hearing aids every year with a maximum benefit allowance of $500 per ear. NOTE: Hearing aids must be purchased through NationsHearing to receive in-network benefits.

Member is responsible for any amount after the benefit allowance has been applied. Subject to benefit maximum.

Out-of-Network Medicare-Covered Hearing Services 50% of the Medicare-allowed amount

Additional Hearing Services Member must submit receipts for

reimbursement at 50% of maximum allowed for one routine hearing exam per year.

Member must submit receipts for reimbursement at 50% of maximum allowed for evaluation and fitting of hearing aids.

Member must submit receipts for reimbursement at 50% of maximum allowed for up to 2 hearing aids every year. Subject to benefit maximum.

Member is responsible for any amount after the benefit allowance has been applied.














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H5434-033


H5434-034

Diagnostic Services/ Labs/Imaging















6


H5434-033


H5434-034

Hearing Services



























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H5434-033


H5434-034

Dental Services

Medicare-Covered Dental Services ◊ In-Network $45 copay for non-routine dental care Out-of-Network 50% of the Medicare-allowed amount

Additional Dental Services In-Network $0 copay for covered preventive dental

services $0 copay for covered comprehensive

dental services

Out-of-Network Member pays up front and is

reimbursed 50% of non-participating rates for covered preventive dental services.

Member pays up front and is reimbursed 50% of non-participating rates for covered comprehensive dental services.




dental services




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H5434-033


H5434-034

Dental Services




dental services







dental services




8


H5434-033


H5434-034

Vision Services

Medicare-Covered Vision Services In-Network $45 copay for physician services to

diagnose and treat eye diseases and conditions

$0 copay for glaucoma screening (once per year for members at high risk of glaucoma)

$0 copay for one diabetic retinal exam per year

$0 copay for one pair of eyeglasses or contact lenses after each cataract surgery

Out-of-Network 50% of the Medicare-allowed amount

Additional Vision Services In-Network $0 copay for an annual routine eye

examination $0 copay for lenses, frames or

contacts. Subject to the annual maximum plan benefit allowance. Member responsible for any amounts in excess of the annual maximum plan benefit allowance.

$200 maximum allowance per year towards the purchase of lenses, frames or contacts.

Out-of-Network Member must pay 100% of the charges

and submit the itemized receipt(s) for reimbursement of 50% of the in-network allowed amount for an annual routine eye examination.

Member is responsible for all amounts in excess of the 50% in-network allowed amount and/or any amounts in excess of the annual maximum plan benefit allowance for lenses, frames or contacts.

Total reimbursement is subject to the annual maximum plan benefit allowance.

Medicare-Covered Vision Services In-Network $45 copay for physician services to

diagnose and treat eye diseases and conditions

$0 copay for glaucoma screening (once per year for members at high risk of glaucoma)

$0 copay for one diabetic retinal exam per year

$0 copay for one pair of eyeglasses or contact lenses after each cataract surgery


Additional Vision Services In-Network $0 copay for an annual routine eye

examination $0 copay for lenses, frames or

contacts. Subject to the annual maximum plan benefit allowance. Member responsible for any amounts in excess of the annual maximum plan benefit allowance.

$200 maximum allowance per year towards the purchase of lenses, frames or contacts.

Out-of-Network Member must pay 100% of the

charges and submit the itemized receipt(s) for reimbursement of 50% of the in-network allowed amount for an annual routine eye examination.

Member is responsible for all amounts in excess of the 50% in-network allowed amount and/or any amounts in excess of the annual maximum plan benefit allowance for lenses, frames or contacts.

Total reimbursement is subject to the annual maximum plan benefit allowance.

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H5434-033


H5434-034

Mental Health Care

Inpatient Mental Health Services In-Network ◊ $318 copay per day, days 1-5 $0 copay per day, days 6-90 190-day lifetime benefit maximum in a

psychiatric hospital Out-of-Network 50% of the Medicare-allowed amount Outpatient Mental Health Services In-Network ◊ $40 copay Out-of-Network 50% of the Medicare-allowed amount

Inpatient Mental Health Services In-Network ◊ $318 copay per day, days 1-5 $0 copay per day, days 6-90 190-day lifetime benefit maximum in a

psychiatric hospital Out-of-Network 50% of the Medicare-allowed amount Outpatient Mental Health Services In-Network ◊ $40 copay Out-of-Network 50% of the Medicare-allowed amount

Skilled Nursing Facility (SNF)

In-Network ◊ $0 copay per day, days 1-20 $160 copay per day, days 21-100 Out-of-Network 50% of the Medicare-allowed amount Our plan covers up to 100 days in a SNF per benefit period.

In-Network ◊ $0 copay per day, days 1-20 $160 copay per day, days 21-100 Out-of-Network 50% of the Medicare-allowed amount Our plan covers up to 100 days in a SNF per benefit period.

Physical Therapy

In-Network ◊ $40 copay per visit Out-of-Network 50% of the Medicare-allowed amount


Ambulance $310 copay for each Medicare-covered trip (one-way) in-network ◊ or out-of-network

$305 copay for each Medicare-covered trip (one-way) in-network ◊ or out-of-network

Transportation Not covered Not covered

Medicare Part B Drugs

In-Network ◊ $5 copay for allergy injections 20% of the Medicare-allowed amount

for chemotherapy drugs and other Medicare Part B-covered drugs


In-Network ◊ $5 copay for allergy injections 20% of the Medicare-allowed amount

for chemotherapy drugs and other Medicare Part B-covered drugs


10

Part D Prescription Drug Benefits


H5434-033


H5434-034

During the Deductible Stage:

This plan has a $150 deductible The deductible does not apply

to Tier 1 (Preferred Generic), Tier 2 (Generic), and Tier 6 (Specialty Care Drugs)



Initial Coverage Stage During this stage, the plan pays its share of the cost of your drugs and you pay your share of the cost. You remain in this stage until your total yearly drug costs (total drug costs paid by you and any Part D plan) reach $4,130. You may get your drugs at network retail pharmacies and mail order pharmacies. Cost sharing below applies to a one-month (31-day) supply.


H5434-033


H5434-034 Standard

Retail Mail

Order Standard

Retail Mail

Order

Tier 1 - Preferred Generic $3 copay $3 copay $3 copay $3 copay

Tier 2 - Generic $12 copay $12 copay $12 copay $12 copay

Tier 3 - Preferred Brand $47 copay $47 copay $47 copay $47 copay

Tier 4 - Non- Preferred Drug $100 copay $100 copay $100 copay $100 copay

Tier 5 - Specialty Tier 30% of the cost 30% of the cost 30% of the cost 30% of the cost Tier 6 - Select Care Drugs $0 copay $0 copay $0 copay $0 copay

– 20 – – 21 –10

Part D Prescription Drug Benefits


H5434-033


H5434-034

During the Deductible Stage:





Initial Coverage Stage During this stage, the plan pays its share of the cost of your drugs and you pay your share of the cost. You remain in this stage until your total yearly drug costs (total drug costs paid by you and any Part D plan) reach $4,130. You may get your drugs at network retail pharmacies and mail order pharmacies. Cost sharing below applies to a one-month (31-day) supply.


H5434-033


H5434-034 Standard

Retail Mail

Order Standard

Retail Mail

Order

Tier 1 - Preferred Generic $3 copay $3 copay $3 copay $3 copay

Tier 2 - Generic $12 copay $12 copay $12 copay $12 copay

Tier 3 - Preferred Brand $47 copay $47 copay $47 copay $47 copay

Tier 4 - Non- Preferred Drug $100 copay $100 copay $100 copay $100 copay

Tier 5 - Specialty Tier 30% of the cost 30% of the cost 30% of the cost 30% of the cost Tier 6 - Select Care Drugs $0 copay $0 copay $0 copay $0 copay

– 22 – – 23 –11

Coverage Gap Stage Most Medicare drug plans have a coverage gap (also called the "donut hole"). This means that there's a temporary change in what you will pay for your drugs. The Coverage Gap Stage begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $4,130. You stay in this stage until your year-to-date “out-of-pocket” costs reach a total of $6,550.


H5434-033


H5434-034

During the Coverage Gap Stage:

You pay the same copays that you paid in the Initial Coverage Stage for drugs in Tier 6 (Select Care Drugs) – or 25% of the cost, whichever is lower

For generic drugs in all other tiers, you pay 25% of the cost

For brand-name drugs, you pay 25% of the cost (plus a portion of the dispensing fee)

You pay the same copays that you paid in the Initial Coverage Stage for drugs in Tier 6 (Select Care Drugs) – or 25% of the cost, whichever is lower

For generic drugs in all other tiers, you pay 25% of the cost

For brand-name drugs, you pay 25% of the cost (plus a portion of the dispensing fee)

Catastrophic Coverage Stage After your yearly out-of-pocket drug costs reach $6,550, you pay the greater of: $3.70 copay for generic drugs in all tiers (including brand drugs treated as generic) and an $9.20 copay

for all other drugs in all tiers, or 5% of the cost.

Additional Drug Coverage Please call us or see the plan’s “Evidence of Coverage” on our website

(www.floridablue.com/medicare) for complete information about your costs for covered drugs. If you request and the plan approves a formulary exception, you will pay Tier 4 (Non-Preferred Brand/Drug) cost sharing.

Your cost-sharing may be different if you use a Long-Term Care pharmacy, a home infusion pharmacy, or an out-of-network pharmacy, or if you purchase a long-term supply (up to 90 days) of a drug.

12

Additional Benefits


H5434-033


H5434-034

At Home Care

We offer this benefit through our partnership with Papa who connects college students to older adults who require assistance with transportation, companionship, household chores, use of electronic devices, and exercise and activity. Benefits include the following: At Home Care, 60 hours per year. Services include support with Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL).


Caregiver Support for Member

Provides coverage for coaching, education and support services such as counseling and training courses for caregivers of enrollees. Benefits include: A web-based tool that contains

educational content covering topics on health, wealth, senior living, in-home care and lifestyle

Access for caregivers and family members to post updates and videos; tools to manage documents, stay organized and on top of upcoming tasks and appointments. Search tools (i.e., senior housing search and in-home care search

See the Evidence of Coverage for benefit details.





Diabetic Supplies

In-Network ◊ $0 copay at your network retail or mail-

order pharmacy for Diabetic Supplies such as: • Needles • Syringes • Lifescan (One Touch®) Glucose

Meters • Lancets • Test Scripts


In-Network ◊ $0 copay at your network retail or

mail-order pharmacy for Diabetic Supplies such as: • Needles • Syringes • Lifescan (One Touch®) Glucose



– 22 – – 23 –12

Additional Benefits


H5434-033


H5434-034

At Home Care



Caregiver Support for Member









Diabetic Supplies

In-Network ◊ $0 copay at your network retail or mail-

order pharmacy for Diabetic Supplies such as: • Needles • Syringes • Lifescan (One Touch®) Glucose



In-Network ◊ $0 copay at your network retail or

mail-order pharmacy for Diabetic Supplies such as: • Needles • Syringes • Lifescan (One Touch®) Glucose



– 24 – – 25 –13


H5434-033


H5434-034

Medicare Diabetes Prevention Program

In-Network $0 copay for Medicare-covered services Out-of-Network 50% of the Medicare-allowed amount

In-Network $0 copay for Medicare-covered services Out-of-Network 50% of the Medicare-allowed amount

Podiatry In-Network $35 copay for each Medicare-covered podiatry visit Out-of-Network 50% of the Medicare-allowed amount

In-Network $35 copay for each Medicare-covered podiatry visit Out-of-Network 50% of the Medicare-allowed amount

Chiropractic In-Network $20 copay for each Medicare-covered chiropractic service Out-of-Network 50% of the Medicare-allowed amount

In-Network $20 copay for each Medicare-covered chiropractic service Out-of-Network 50% of the Medicare-allowed amount

Medical Equipment and Supplies

In-Network ◊ 20% of the Medicare-allowed amount

for all plan approved, Medicare-covered motorized wheelchairs and electric scooters

0% of the Medicare-allowed amount for all other plan approved, Medicare-covered durable medical equipment


In-Network ◊ 20% of the Medicare-allowed amount

for all plan approved, Medicare-covered motorized wheelchairs and electric scooters

0% of the Medicare-allowed amount for all other plan approved, Medicare-covered durable medical equipment


Outpatient Occupational and Speech Therapy



– 24 – – 25 –14


H5434-033


H5434-034

Telehealth

In-Network $50 copay for Urgently Needed

Services Level 1 $0 copay, Level 2 $10 copay

for Primary Care Services $40 copay for Occupational

Therapy/Physical Therapy/Speech Therapy at a freestanding location

$40 copay Occupational Therapy/Physical Therapy/Speech Therapy at an outpatient hospital

Level 1 $35 copay, Level 2 $45 copay for Dermatology Services

$40 copay for individual sessions for outpatient Mental Health Specialty Services

$40 copay for individual sessions for outpatient Psychiatry Specialty Services

$40 copay for Opioid Treatment Program Services

$40 copay for individual sessions for outpatient Substance Abuse Specialty Services

$0 copay for Diabetes Self-Management Training

$0 copay for Dietician Services


In-Network $40 copay for Urgently Needed

Services Level 1 $0 copay, Level 2 $10 copay

for Primary Care Services $40 copay for Occupational

Therapy/Physical Therapy/Speech Therapy at a freestanding location

$40 copay Occupational Therapy/Physical Therapy/Speech Therapy at an outpatient hospital

Level 1 $35 copay, Level 2 $45 copay for Dermatology Services

$40 copay for individual sessions for outpatient Mental Health Specialty Services

$40 copay for individual sessions for outpatient Psychiatry Specialty Services

$40 copay for Opioid Treatment Program Services

$40 copay for individual sessions for outpatient Substance Abuse Specialty Services

$0 copay for Diabetes Self-Management Training

$0 copay for Dietician Services


– 26 –15

You Get More with BlueMedicare BlueMedicare Value (PPO)

Brevard, Orange, Osceola and Seminole H5434-033


H5434-034

Over-the-Counter Items

$50 quarterly allowance for the purchase of non-prescription items such as vitamins and aspirin

Any balance not used for a quarter will not carry over to the next quarter

$50 quarterly allowance for the purchase of non-prescription items such as vitamins and aspirin

Any balance not used for a quarter will not carry over to the next quarter

HealthyBlue Rewards

Your BlueMedicare plan rewards you for taking care of your health. Redeem gift card rewards for completing and reporting preventive care and screenings.

SilverSneakers®

Fitness Program

Gym membership and classes available at fitness locations across the country, including national chains and local gyms

Access to exercise equipment and other amenities, classes for all levels and abilities, social events, and more

Disclaimers Florida Blue is a PPO plan with a Medicare contract. Enrollment in Florida Blue depends on contract renewal.

Out-of-network/non-contracted providers are under no obligation to treat Florida Blue members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.

If you have any questions, please contact our Member Services number at 1-800-926-6565. (TTY users should call 1-800-955-8770.) Our hours are 8:00 a.m. to 8:00 p.m. local time, seven days a week, from October 1 through March 31, except for Thanksgiving and Christmas. From April 1 through September 30, our hours are 8:00 a.m. to 8:00 p.m. local time, Monday through Friday, except for major holidays.

Health coverage is offered by Blue Cross and Blue Shield of Florida, Inc., dba Florida Blue, an Independent Licensee of the Blue Cross and Blue Shield Association.

Plans may offer supplemental benefits in addition to Part C benefits and Part D benefits.

© 2020 Blue Cross and Blue Shield of Florida, Inc., DBA Florida Blue. All rights reserved.

– 26 –

EnrollmentForms

Steps that will walk you through the process and all the forms you need to enroll in your plan

– 28 – – 29 –92082 0720

Helpful tips for filling out your enrollment form.

Paper: Use the paper enrollment form provided. Once you are done filling it out, you can mail the form to Florida Blue. (One form must be filled out for each person who enrolls.)

Online: Use the online form at floridablue.com/medicare. You’ll be guided through the process of completing and submitting the enrollment form and the system will prompt you if you left anything missing or incomplete.

Licensed Sales Agent: An agent can help you choose the best plan for YOU and can also offer you help in filling out and submitting the enrollment form. The agent will be employed by or contracted with Florida Blue and may be paid based on your enrollment in a plan.

3 No matter which way you choose to enroll, make sure you don’t skip any sections. If you leave out information, it may delay your start date.

3 When choosing a plan, select only ONE plan name.3 Where requested, be sure to fill in the Part A and Part B effective dates from your Medicare ID card.3 If you choose an HMO plan, write in your choice for a primary care physician (PCP). If you do not

write in your choice for a PCP, one will be assigned to you. 3 If you are not signing up between October 15 and December 7, be sure to complete the “Attestation

of Eligibility for an Enrollment Period” section.

• Visit your local Florida Blue Center or agent; or

• Call and speak with one of our agents at 1-855-217-4362 (TTY 1-800-955-8770.)

Choose the way to enroll that’s best for you.

Ready to sign up?Have your Medicare ID card handy, and let’s get started!

– 28 – – 29 –

Forms Used for Enrollment

1 Pre-Enrollment Checklist

This form provides important information you need to know before purchasing a plan.

2 Individual Enrollment Form

This is the form you complete to enroll in a Florida Blue Medicare Advantage plan.

3 Protected Health Information Authorization for Customer Service Inquiries

Complete this form if you need to give us permission to release your health information to someone. Send the original, not a photocopy, with your enrollment form. Otherwise, we will protect this information and release it only to you.

4 Scope of Sales Appointment (SOA) Confirmation Form

According to Medicare guidelines, agents can talk to you only about products you choose to discuss. Medicare asks you to complete an SOA form that shows which Medicare Advantage and/or Medicare Prescription Drug plans you wish to discuss. The form is intended to protect you. Completing the form does not mean you have enrolled in a plan. Your agent can complete this form with you by phone instead of using a paper copy.

5 Enrollment Verification Checklist

When you meet with an agent to enroll in a plan, the agent will look up how your plan covers medications that you take (including cost, tier and requirements/limitations). Your agent will also look up providers you use to see if they are in your network. Your agent will fill out this information on an enrollment verification checklist they provide and that you can take with you.

– 30 – – 31 –

Pre-Enrollment Checklist

Before making an enrollment decision, it is important that you fully understand our benefits and rules. If you have any questions, you can call and speak to a customer service representative at 1-855-601-9465 (TTY: 1-800-955-8770).

Understanding the Benefits

Review the full list of benefits found in the Evidence of Coverage (EOC), especially looking for those services that you routinely receive from a doctor. Visit floridablue.com/medicare or call 1-855-601-9465 (TTY: 1-800-955-8770) to view a copy of the EOC.

Review the provider directory (or ask your doctors) to make sure the doctors you see now are in the network. If they are not listed, it means you will likely have to select new doctors.

Review the pharmacy directory to make sure the pharmacy you use for any prescription medicines is in the network. If the pharmacy is not listed, you will likely have to select a new pharmacy for your prescriptions.

Understanding Important Rules

In addition to your monthly plan premium, you must continue to pay your Medicare Part B premium. This premium is normally taken out of your Social Security check each month.

Benefits, premiums and/or copayments/co-insurance may change on January 1, 2022.

Our plan allows you to see providers outside of our network (non-contracted providers). However, while we will pay for covered services provided by a non-contracted provider, the provider must agree to treat you. Except in an emergency or urgent situations, non-contracted providers may deny care. In addition, you will pay a higher co-pay for services received by non-contracted providers.

93123 0720

– 30 – – 31 –

Please complete this entire form and return to:

Florida Blue Access Authorization Unit P.O. Box 45296 Jacksonville, FL 32232

PurposeI am the member listed in Section I. This authorization is at my request to permit Blue Cross and Blue Shield of Florida, Inc., Health Options, Inc., and Florida Blue Medicare, Inc. (together, “Florida Blue”) to respond to customer service inquiries regarding my Protected Health Information regarding health, dental and long-term care products.

Section IPlease provide the following information regarding the person whose Protected Health Information is to be released.Member Name: ______________________________________________________Member Number: _____________________________________________________Group Number: ______________________Date of Birth: _____________________

Section III authorize Florida Blue to release, orally and/or in writing, the following Protected Health Information concerning me:• Identifying information (e.g., name, address, age, gender); • Health care coverage information (i.e., general & plan-specific benefit information); • Past, present and future claims information (except for any period of time during

which a Confidential Communication address1 was in effect); and• Coordination of Benefit Information.

Section IIIPlease identify the person(s) to whom the member’s Protected Health Information may be released and their relationship, i.e., sales agent, employer health benefit representative, parent, family member, friend, corporation, organization, law firm, vendor.My information may be given to the person(s) listed below. Please Print:Name: _________________________ Relationship to Member: _______________Name: _________________________ Relationship to Member: _______________Name: _________________________ Relationship to Member: _______________

Section IVBy law, this authorization must indicate that persons other than Florida Blue receiving member’s Protected Health Information may not have to obey federal health information privacy laws and member’s Protected Health Information may be further released by those persons.

Protected Health Information Authorizationfor Customer Service Inquiries

– 32 – – 33 –

3

Y0011_30871 0719 C: 07/2019

I further understand that if I have identified a sales agent or an employer health benefit representative in Section III to whom my Protected Health Information may be released, Florida Blue will have no further liability as to the further release of my Protected Health Information by those designated persons.

This authorization is voluntary and is not a condition of enrollment in a health plan, eligibility for benefits or payment of claims.

Section VThis authorization will expire:

____________/___________/__________Month Day Year OR

______________________ The date member’s Florida Blue health coverage ends

It is advised that you place a specific expiration date on this authorization if you are designating a sales agent or employer as an authorized representative, or any other person for whom you may have designated to assist you with a specific, short-term task.

Section VICopy of Authorization Please keep a copy of your signed authorization. A photocopy is as valid as the original.

Section VIIRight to Withdraw Authorization I understand that I may withdraw this authorization at any time by giving written notice to the address listed on page 1 of this form. I further understand that withdrawal of this authorization will not affect any action taken by Florida Blue in reliance on this authorization prior to receiving my written notice of withdrawal.

Section VIIISignature

Member Signature:

____________________________________________

Date: _________________

If a legal representative signs this authorization form on behalf of the member, please complete the following information:

Legal Representative’s Name2:

____________________________________________

Date Signed: _________________

Relationship to the member:

____________________________________________

1��A�Confidential�Communication�address�is�one�specified�by�an�adult�(age�18�or�older)�that�is�different�than�the�address�where�the�subscriber receives his or her mail.

2 Please provide written documentation to support your status as a guardian or other legal representative.

Health insurance is offered by Blue Cross and Blue Shield of Florida, D/B/A Florida Blue. HMO coverage is offered by Health Options, Inc., D/B/A Florida Blue HMO and Florida Blue Medicare, Inc, HMO subsidiaries of Florida Blue. These companies are independent licensees of the Blue Cross and Blue Shield Association.

Protected Health Information Authorizationfor Customer Service Inquiries (continued)

– 32 – – 33 –

Please complete this entire form and return to:

Florida Blue Access Authorization Unit P.O. Box 45296 Jacksonville, FL 32232

PurposeI am the member listed in Section I. This authorization is at my request to permit Blue Cross and Blue Shield of Florida, Inc., Health Options, Inc., and Florida Blue Medicare, Inc. (together, “Florida Blue”) to respond to customer service inquiries regarding my Protected Health Information regarding health, dental and long-term care products.

Section IPlease provide the following information regarding the person whose Protected Health Information is to be released.Member Name: ______________________________________________________Member Number: _____________________________________________________Group Number: ______________________Date of Birth: _____________________

Section III authorize Florida Blue to release, orally and/or in writing, the following Protected Health Information concerning me:• Identifying information (e.g., name, address, age, gender); • Health care coverage information (i.e., general & plan-specific benefit information); • Past, present and future claims information (except for any period of time during

which a Confidential Communication address1 was in effect); and• Coordination of Benefit Information.

Section IIIPlease identify the person(s) to whom the member’s Protected Health Information may be released and their relationship, i.e., sales agent, employer health benefit representative, parent, family member, friend, corporation, organization, law firm, vendor.My information may be given to the person(s) listed below. Please Print:Name: _________________________ Relationship to Member: _______________Name: _________________________ Relationship to Member: _______________Name: _________________________ Relationship to Member: _______________

Section IVBy law, this authorization must indicate that persons other than Florida Blue receiving member’s Protected Health Information may not have to obey federal health information privacy laws and member’s Protected Health Information may be further released by those persons.

Protected Health Information Authorizationfor Customer Service Inquiries

– 34 – – 35 –

3

Y0011_30871 0719 C: 07/2019

I further understand that if I have identified a sales agent or an employer health benefit representative in Section III to whom my Protected Health Information may be released, Florida Blue will have no further liability as to the further release of my Protected Health Information by those designated persons.

This authorization is voluntary and is not a condition of enrollment in a health plan, eligibility for benefits or payment of claims.

Section VThis authorization will expire:

____________/___________/__________Month Day Year OR

______________________ The date member’s Florida Blue health coverage ends

It is advised that you place a specific expiration date on this authorization if you are designating a sales agent or employer as an authorized representative, or any other person for whom you may have designated to assist you with a specific, short-term task.

Section VICopy of Authorization Please keep a copy of your signed authorization. A photocopy is as valid as the original.

Section VIIRight to Withdraw Authorization I understand that I may withdraw this authorization at any time by giving written notice to the address listed on page 1 of this form. I further understand that withdrawal of this authorization will not affect any action taken by Florida Blue in reliance on this authorization prior to receiving my written notice of withdrawal.

Section VIIISignature

Member Signature:

____________________________________________

Date: _________________

If a legal representative signs this authorization form on behalf of the member, please complete the following information:

Legal Representative’s Name2:

____________________________________________

Date Signed: _________________

Relationship to the member:

____________________________________________

1��A�Confidential�Communication�address�is�one�specified�by�an�adult�(age�18�or�older)�that�is�different�than�the�address�where�the�subscriber receives his or her mail.

2 Please provide written documentation to support your status as a guardian or other legal representative.

Health insurance is offered by Blue Cross and Blue Shield of Florida, D/B/A Florida Blue. HMO coverage is offered by Health Options, Inc., D/B/A Florida Blue HMO and Florida Blue Medicare, Inc, HMO subsidiaries of Florida Blue. These companies are independent licensees of the Blue Cross and Blue Shield Association.

Protected Health Information Authorizationfor Customer Service Inquiries (continued)

– 34 – – 35 –

Stand-alone Medicare Prescription Drug Plans (Part D)

Medicare Prescription Drug Plan (PDP) — A stand-alone drug plan that adds prescription drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private-Fee-for-Service Plans, and Medicare Medical Savings Account Plans.

Please initial below beside the type of product(s) you want the agent to discuss.

Medicare Advantage Plans (Part C) and Cost Plans

Medicare Health Maintenance Organization (HMO) — A Medicare Advantage Plan that provides all Original Medicare Part A and Part B health coverage and sometimes covers Part D prescription drug coverage. In most HMOs, you can only get your care from doctors or hospitals in the plan’s network (except in emergencies).

Medicare Preferred Provider Organization (PPO) Plan — A Medicare Advantage Plan that provides all Original Medicare Part A and Part B health coverage and sometimes covers Part D prescription drug coverage. PPOs have network doctors and hospitals but you can also use out-of-network providers, usually at a higher cost.

Medicare Private Fee-For-Service (PFFS) Plan — A Medicare Advantage Plan in which you may go to any Medicare approved doctor, hospital and provider that accepts the plan’s payment, terms and conditions and agrees to treat you – not all providers will. If you join a PFFS Plan that has a network, you can see any of the network providers who have agreed to always treat plan members. You will usually pay more to see out-of-network providers.

Medicare Special Needs Plan (SNP) — A Medicare Advantage Plan that has a benefit package designed for people with special health care needs. Examples of the specific groups served include people who have both Medicare and Medicaid, people who reside in nursing homes, and people who have certain chronic medical conditions.

Medicare Medical Savings Account (MSA) Plan — MSA Plans combine a high deductible health plan with a bank account. The plan deposits money from Medicare into the account. You can use it to pay your medical expenses until your deductible is met.

Medicare Cost Plan — In a Medicare Cost Plan, you can go to providers both in and out of network. If you get services outside of the plan’s network, your Medicare-covered services will be paid for under Original Medicare but you will be responsible for Medicare coinsurance and deductibles.

The Centers for Medicare & Medicaid Services requires agents to document the scope of a marketing appointment prior to any face-to-face sales meeting to ensure understanding of what will be discussed between the agent and the Medicare beneficiary (or their authorized representative). All information provided on this form is confidential and should be completed by each person with Medicare or his/her authorized representative.

Scope of Sales AppointmentConfirmation Form

– 36 – – 37 –

4

By signing this form, you agree to a meeting with a sales agent to discuss the types of products you initialed above. Please note, the person who will discuss the products is either employed or contracted by a Medicare plan. They do not work directly for the Federal government. This individual may also be paid based on your enrollment in a plan.

Signing this form does NOT obligate you to enroll in a plan, affect your current enrollment, or enroll you in a Medicare plan.

Beneficiary or Authorized Representative Signature and Signature Date:

Signature: _______________________________________________________________________

Signature Date: ___________________________________________________________________

If you are the authorized representative, please sign above and print below:

Representative’s Name: ____________________________________________________________

Your Relationship to the Beneficiary: __________________________________________________

To be completed by Agent:

Agent Name: Agent Phone:

Beneficiary Name: Beneficiary Phone (Optional):

Beneficiary Address (Optional):

Plan(s) the agent represented during this meeting:

Date Appointment Completed:

Plan Use Only:

Initial Method of Contact: (Indicate here if beneficiary was a walk-in.)

Agent’s Signature:

Scope of Appointment documentation is subject to CMS record retention requirements

Health coverage is offered by Blue Cross and Blue Shield of Florida, DBA Florida Blue. HMO coverage is offered by Florida Blue Medicare�Inc.,�which�is�an�affiliate�of�Blue�Cross�and�Blue�Shield�of�Florida,�Inc.�These�companies�are�Independent�licensees�of�the Blue Cross and Blue Shield Association.

– 36 – – 37 –Y0011_33320 0719 C: 07/2019

Agent, if the form was signed by the beneficiary at time of appointment, provide written explanation below why SOA was not documented prior to meeting:

Scope of Sales AppointmentConfirmation Form (continued)

Florida Blue is a PPO, RPPO and Rx (PDP) Plan with a Medicare contract. Florida Blue Medicare is an HMO plan with a Medicare contract. Enrollment in Florida Blue or Florida Blue Medicare depends on contract renewal.

– 38 – – 39 –

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– 38 – – 39 –

Stand-alone Medicare Prescription Drug Plans (Part D)

Medicare Prescription Drug Plan (PDP) — A stand-alone drug plan that adds prescription drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private-Fee-for-Service Plans, and Medicare Medical Savings Account Plans.

Please initial below beside the type of product(s) you want the agent to discuss.

Medicare Advantage Plans (Part C) and Cost Plans

Medicare Health Maintenance Organization (HMO) — A Medicare Advantage Plan that provides all Original Medicare Part A and Part B health coverage and sometimes covers Part D prescription drug coverage. In most HMOs, you can only get your care from doctors or hospitals in the plan’s network (except in emergencies).

Medicare Preferred Provider Organization (PPO) Plan — A Medicare Advantage Plan that provides all Original Medicare Part A and Part B health coverage and sometimes covers Part D prescription drug coverage. PPOs have network doctors and hospitals but you can also use out-of-network providers, usually at a higher cost.

Medicare Private Fee-For-Service (PFFS) Plan — A Medicare Advantage Plan in which you may go to any Medicare approved doctor, hospital and provider that accepts the plan’s payment, terms and conditions and agrees to treat you – not all providers will. If you join a PFFS Plan that has a network, you can see any of the network providers who have agreed to always treat plan members. You will usually pay more to see out-of-network providers.

Medicare Special Needs Plan (SNP) — A Medicare Advantage Plan that has a benefit package designed for people with special health care needs. Examples of the specific groups served include people who have both Medicare and Medicaid, people who reside in nursing homes, and people who have certain chronic medical conditions.

Medicare Medical Savings Account (MSA) Plan — MSA Plans combine a high deductible health plan with a bank account. The plan deposits money from Medicare into the account. You can use it to pay your medical expenses until your deductible is met.

Medicare Cost Plan — In a Medicare Cost Plan, you can go to providers both in and out of network. If you get services outside of the plan’s network, your Medicare-covered services will be paid for under Original Medicare but you will be responsible for Medicare coinsurance and deductibles.

The Centers for Medicare & Medicaid Services requires agents to document the scope of a marketing appointment prior to any face-to-face sales meeting to ensure understanding of what will be discussed between the agent and the Medicare beneficiary (or their authorized representative). All information provided on this form is confidential and should be completed by each person with Medicare or his/her authorized representative.

Scope of Sales AppointmentConfirmation Form

– 40 – – 41 –

4

By signing this form, you agree to a meeting with a sales agent to discuss the types of products you initialed above. Please note, the person who will discuss the products is either employed or contracted by a Medicare plan. They do not work directly for the Federal government. This individual may also be paid based on your enrollment in a plan.

Signing this form does NOT obligate you to enroll in a plan, affect your current enrollment, or enroll you in a Medicare plan.

Beneficiary or Authorized Representative Signature and Signature Date:

Signature: _______________________________________________________________________

Signature Date: ___________________________________________________________________

If you are the authorized representative, please sign above and print below:

Representative’s Name: ____________________________________________________________

Your Relationship to the Beneficiary: __________________________________________________

To be completed by Agent:

Agent Name: Agent Phone:

Beneficiary Name: Beneficiary Phone (Optional):

Beneficiary Address (Optional):

Plan(s) the agent represented during this meeting:

Date Appointment Completed:

Plan Use Only:

Initial Method of Contact: (Indicate here if beneficiary was a walk-in.)

Agent’s Signature:

Scope of Appointment documentation is subject to CMS record retention requirements

Health coverage is offered by Blue Cross and Blue Shield of Florida, DBA Florida Blue. HMO coverage is offered by Florida Blue Medicare�Inc.,�which�is�an�affiliate�of�Blue�Cross�and�Blue�Shield�of�Florida,�Inc.�These�companies�are�Independent�licensees�of�the Blue Cross and Blue Shield Association.

– 40 – – 41 –

Agent, if the form was signed by the beneficiary at time of appointment, provide written explanation below why SOA was not documented prior to meeting:

Y0011_33320 0719 C: 07/2019

Scope of Sales AppointmentConfirmation Form (continued)

Florida Blue is a PPO, RPPO and Rx (PDP) Plan with a Medicare contract. Florida Blue Medicare is an HMO plan with a Medicare contract. Enrollment in Florida Blue or Florida Blue Medicare depends on contract renewal.

– 42 – – 43 –

This page intentionally left blank

– 42 – – 43 –

For Medicare Advantage plans

Yes No Do you understand that you have applied for a Medicare Advantage plan? This plan is not a Medicare Supplement “Medigap” plan. This plan replaces Original Medicare.

Yes No Do you understand that to enroll you must be “entitled” to Part A and enrolled in Part B?

Yes No Do you understand you must continue to pay your Medicare Part B premium (unless it is paid for you by Medicaid or another third party)?

For Part D Prescription Drug plans

Yes No Did the sales agent fully explain the prescription deductible associated with the plan (if applicable), and the amount?

Yes No Did the sales agent tell you about the Preferred pharmacies in the network?Yes No Do you understand you have applied for a Part D Prescription Drug plan?Yes No Do you understand to enroll you must have Medicare Part A and/or Part B?

For All plansYes No Did the sales agent fully explain your premium, benefits, copays, and coinsurance amounts?Yes No Did the sales agent show you the Summary of Benefits and give you a copy?Yes No Did the sales agent give you their contact information? (name, phone or business card)Yes No Did the sales agent explain the plan’s drug list (also referred to as a formulary) and drug tiers?Yes No Did the sales agent explain the coverage gap, sometimes referred to as the doughnut hole?Yes No Do you understand that in most cases you must use a pharmacy in our drug plan network?Yes No Did the sales agent confirm that your prescription drugs are covered under the plan’s drug list?

Yes No Do you understand if you enroll in a Medicare Advantage plan and later decide to make a change, under most circumstances you are able to do so during the Annual Election Period, October 15 -December 7 each year?

Drug Name Covered Tier Cost B vs. D* PA Qty Limits Step TherapyYes No Yes No Yes No Yes No

Florida Blue is required by Medicare to contact you within 15 days of receiving your enrollment application. Within the next 15 days you will receive a letter from Florida Blue to verify that the Medicare Advantage or Part D Prescription Drug plan was fully explained. This will not affect your ability to enroll in the plan.Your sales agent will review the following questions with you to verify that the Medicare Advantage or Part D Prescription Drug plan was fully explained. Check Yes or No as appropriate.

*Some�drugs�may�be�covered�under�Medicare�Part�B�or�Part�D.�To�determine�coverage�under�the�appropriate�Medicare�benefit,�your�doctor is required to submit a Medicare Part B vs. D coverage determination form to Florida Blue to obtain prior approval for these medications�before�the�prescription�is�filled.

Enrollment Checklist

– 44 – – 45 –

5

33429 0719

Only for HMO & PPO plans

Yes No Did the sales agent fully explain the medical deductible associated with the plan, (if applicable), and the amount?

Yes No Do you understand that you must use in-network health care providers to get the in-network benefits, copays and coinsurances?

Yes No Do you understand that if you use out-of-network health care providers you will likely pay higher out-of-pocket costs? (Note: HMO members are not covered out-of-network, except in emergencies, urgent care and out-of-area dialysis.)

Yes No Did the sales agent confirm that your doctor(s) is(are) in-network for the plan that you selected?

Provider’s Name Par/Non-Par Provider’s Complete Address

Acknowledgement

My agent and I have reviewed all my doctor(s), hospital(s) and prescription drug(s) that I have provided today. We have discussed each provider’s participating status within my plan as well as my cost share and any requirements or limits regarding my prescription drug(s). I understand that some network providers may be added or removed from the network at any time. For any additional providers or to get the most up-to-date information about my plan’s network providers for my area or my prescription drugs, I will visit floridablue.com/medicare or call the Member Services Department at 1-800-926-6565, 8 a.m. – 8 p.m. local time, seven days a week from October 1 - March 31, except for Thanksgiving and Christmas. From April 1 - September 30, we are open Monday - Friday, 8 a.m. - 8 p.m. local time except for Federal holidays. (TTY users should call 1-800-955-8770.)

Applicant’s Signature_________________________________ Date ______________________

Agent’s Signature____________________________________ Date ______________________

This�information�is�available�for�free�in�other�languages.�Please�call�our�Customer�Service�number�at�1-855-601-9465.� (TTY�users�should�call�1-800-955-8770.)�Hours�are�8�a.m.�-�8�p.m.�local�time,�seven�days�a�week�from�October�1�to�March�31,�except�for�Thanksgiving�and�Christmas.�From�April�1�to�September�30,�we�are�open�Monday�-�Friday,�8�a.m.�-�8�p.m.,�local�time.

Esta información está disponible de manera gratuita en otros idiomas. Comuníquese con Atención al cliente al 1-855-601-9465.�(�Usuarios�de�equipo�telescritor�TTY�llamen�al�1-800-955-8770.)�Estamos�abiertos�de�8�a.m.�a�8�p.m.�hora�local�los�siete�días�de�la�semana,�desde�el�1�de�octubre�hasta�el�31�de�marzo,�excepto�el�día�de�Acción�de�Gracias�(Thanksgiving)�y�el�día�de�Navidad.�Desde�el�1�de�abril�al�30�de�septiembre,�estamos�abiertos�de�lunes�a�viernes�de� 8:00�a.m.�a�8:00�p.m.�hora�local.

Florida Blue is a PPO, RPPO and Rx (PDP) Plan with a Medicare contract. Florida Blue Medicare is an HMO Plan with a Medicare contract. Enrollment in Florida Blue or Florida Blue Medicare depends on contract renewal.

Health coverage is offered by Blue Cross and Blue Shield of Florida, D/B/A Florida Blue. HMO coverage is offered by Florida Blue Medicare,�Inc.,�an�HMO�affiliate�of�Florida�Blue.�These�companies�are�independent�licensees�of�the�Blue�Cross�and�Blue�Shield�Association.

– 44 – – 45 –

For Medicare Advantage plans

Yes No Do you understand that you have applied for a Medicare Advantage plan? This plan is not a Medicare Supplement “Medigap” plan. This plan replaces Original Medicare.

Yes No Do you understand that to enroll you must be “entitled” to Part A and enrolled in Part B?

Yes No Do you understand you must continue to pay your Medicare Part B premium (unless it is paid for you by Medicaid or another third party)?

For Part D Prescription Drug plans

Yes No Did the sales agent fully explain the prescription deductible associated with the plan (if applicable), and the amount?

Yes No Did the sales agent tell you about the Preferred pharmacies in the network?Yes No Do you understand you have applied for a Part D Prescription Drug plan?Yes No Do you understand to enroll you must have Medicare Part A and/or Part B?

For All plansYes No Did the sales agent fully explain your premium, benefits, copays, and coinsurance amounts?Yes No Did the sales agent show you the Summary of Benefits and give you a copy?Yes No Did the sales agent give you their contact information? (name, phone or business card)Yes No Did the sales agent explain the plan’s drug list (also referred to as a formulary) and drug tiers?Yes No Did the sales agent explain the coverage gap, sometimes referred to as the doughnut hole?Yes No Do you understand that in most cases you must use a pharmacy in our drug plan network?Yes No Did the sales agent confirm that your prescription drugs are covered under the plan’s drug list?

Yes No Do you understand if you enroll in a Medicare Advantage plan and later decide to make a change, under most circumstances you are able to do so during the Annual Election Period, October 15 -December 7 each year?

Drug Name Covered Tier Cost B vs. D* PA Qty Limits Step TherapyYes No Yes No Yes No Yes No

Florida Blue is required by Medicare to contact you within 15 days of receiving your enrollment application. Within the next 15 days you will receive a letter from Florida Blue to verify that the Medicare Advantage or Part D Prescription Drug plan was fully explained. This will not affect your ability to enroll in the plan.Your sales agent will review the following questions with you to verify that the Medicare Advantage or Part D Prescription Drug plan was fully explained. Check Yes or No as appropriate.

*Some�drugs�may�be�covered�under�Medicare�Part�B�or�Part�D.�To�determine�coverage�under�the�appropriate�Medicare�benefit,�your�doctor is required to submit a Medicare Part B vs. D coverage determination form to Florida Blue to obtain prior approval for these medications�before�the�prescription�is�filled.

Enrollment Checklist

– 46 –33429 0719

Only for HMO & PPO plans

Yes No Did the sales agent fully explain the medical deductible associated with the plan, (if applicable), and the amount?

Yes No Do you understand that you must use in-network health care providers to get the in-network benefits, copays and coinsurances?

Yes No Do you understand that if you use out-of-network health care providers you will likely pay higher out-of-pocket costs? (Note: HMO members are not covered out-of-network, except in emergencies, urgent care and out-of-area dialysis.)

Yes No Did the sales agent confirm that your doctor(s) is(are) in-network for the plan that you selected?

Provider’s Name Par/Non-Par Provider’s Complete Address

Acknowledgement

My agent and I have reviewed all my doctor(s), hospital(s) and prescription drug(s) that I have provided today. We have discussed each provider’s participating status within my plan as well as my cost share and any requirements or limits regarding my prescription drug(s). I understand that some network providers may be added or removed from the network at any time. For any additional providers or to get the most up-to-date information about my plan’s network providers for my area or my prescription drugs, I will visit floridablue.com/medicare or call the Member Services Department at 1-800-926-6565, 8 a.m. – 8 p.m. local time, seven days a week from October 1 - March 31, except for Thanksgiving and Christmas. From April 1 - September 30, we are open Monday - Friday, 8 a.m. - 8 p.m. local time except for Federal holidays. (TTY users should call 1-800-955-8770.)

Applicant’s Signature_________________________________ Date ______________________

Agent’s Signature____________________________________ Date ______________________

This�information�is�available�for�free�in�other�languages.�Please�call�our�Customer�Service�number�at�1-855-601-9465.� (TTY�users�should�call�1-800-955-8770.)�Hours�are�8�a.m.�-�8�p.m.�local�time,�seven�days�a�week�from�October�1�to�March�31,�except�for�Thanksgiving�and�Christmas.�From�April�1�to�September�30,�we�are�open�Monday�-�Friday,�8�a.m.�-�8�p.m.,�local�time.

Esta información está disponible de manera gratuita en otros idiomas. Comuníquese con Atención al cliente al 1-855-601-9465.�(�Usuarios�de�equipo�telescritor�TTY�llamen�al�1-800-955-8770.)�Estamos�abiertos�de�8�a.m.�a�8�p.m.�hora�local�los�siete�días�de�la�semana,�desde�el�1�de�octubre�hasta�el�31�de�marzo,�excepto�el�día�de�Acción�de�Gracias�(Thanksgiving)�y�el�día�de�Navidad.�Desde�el�1�de�abril�al�30�de�septiembre,�estamos�abiertos�de�lunes�a�viernes�de� 8:00�a.m.�a�8:00�p.m.�hora�local.

Florida Blue is a PPO, RPPO and Rx (PDP) Plan with a Medicare contract. Florida Blue Medicare is an HMO Plan with a Medicare contract. Enrollment in Florida Blue or Florida Blue Medicare depends on contract renewal.

Health coverage is offered by Blue Cross and Blue Shield of Florida, D/B/A Florida Blue. HMO coverage is offered by Florida Blue Medicare,�Inc.,�an�HMO�affiliate�of�Florida�Blue.�These�companies�are�independent�licensees�of�the�Blue�Cross�and�Blue�Shield�Association.

– 46 –

What’s Next?Information on what happens after you enroll in your plan and what to expect

– 48 – – 49 –92825 0720

How to find out which doctors, hospitals and pharmacies are in your plan’s network:

Stay In-Network

Be sure to select a doctor in your network. Except for emergency care, urgent care and dialysis services, your out-of-pocket costs will generally be greater if you use an out-of-network provider rather than in-network provider. This is true even when the care you receive is medically necessary. Avoid unpredictable costs and have peace of mind by staying in your network.

There are a few ways to find out which doctors, hospital and pharmacies are in a plan’s network. You can ask your agent for help, call Customer Service (see contact information on the Welcome page), or you can visit floridablue.com/medicare and follow these steps:

Select Find a DoctorClick on

Member Resources

Enter the name of the doctor, hospital or pharmacy you’re looking for

How to make the mostof your Medicare Dollars

– 48 – – 49 –

Provider�and�pharmacy�networks�can�change�at�any�time.�You�will�receive�notice�when�necessary.

With BlueMedicare Value plans, members may only use certain pharmacies.

Some of our participating chain pharmacies include:

Use a Participating Pharmacy

Choose Generic or Lower-Tier Drugs

Reduce the amount you pay at the pharmacy by choosing generic or lower-tier drugs. New generic drugs become available nearly every day. Most generics, and many drugs in lower-cost tiers, work just as well as the brand or drugs in a higher-cost tier. Check with your doctor and discuss what options are best for you.

You can find all covered drugs in the formulary, the list of drugs that your plan covers. It’s also called a drug list or medication guide. To see our formulary, visit floridablue.com/medicare.

How to find out which drugs are covered:

Select Find a Form

Select Medicare Advantage Forms & Documents

Click on Member Resources

Choose your plan in the list and locate the formulary for your plan

– 50 – – 51 –92058 0720

What you can expectin the first 90 days

During your first 90 days of enrollment, you can get up and running quickly. Here are some things to look for.

To assure you that your application has been received and accepted, you will receive:

3 Notification of Receipt of Application

3 Notice That You Have Been Enrolled

You’ll receive several items to keep all year:

3 BlueMedicare member ID card3 Information on how to use your plan and how to locate plan documents

You may also receive a welcome call from Florida Blue to help you get more from your plan.

Throughout the year, we’ll stay in touch. You’ll receive:

3 Explanations of Benefits to keep you up to date on any services and supplies you may have received during the previous month

3 Quarterly Newsletters with health tips and advice on getting more from your plan

3 Calls from our Care Team from time to time to help you stay on top of your health needs

3 Surveys to let us know how we’re doing

Want less mail? Sign up for a secure member account at floridablue.com/medicare. You’ll need your Florida Blue Medicare ID card to get started. Access your plan documents, check your out-of-pocket spending, and do more with your secure member account.

– 50 – – 51 –87768 0719R1

We comply with applicable Federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability, or sex. We do not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

We provide: ● free aids and services to people with disabilities to communicate effectively with us, such as:

• Qualified sign language interpreters• Written information in other formats (large print, audio, accessible electronic formats, other formats)

● free language services to people whose primary language is not English, such as:• Qualified interpreters• Information written in other languages

If you need these services, contact: ● Health and vision coverage: 1-800-352-2583 ● Dental, life, and disability coverage: 1-888-223-4892 ● Federal Employee Program: 1-800-333-2227

If you believe that we have failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with:

Health and vision coverage (including FEP members):Section 1557 Coordinator4800 Deerwood Campus Parkway, DCC 1-7Jacksonville, FL 322461-800-477-3736 x290701-800-955-8770 (TTY)Fax: [email protected]

Dental, life, and disability coverage:Civil Rights Coordinator17500 Chenal ParkwayLittle Rock, AR 722231-800-260-03311-800-955-8770 (TTY)[email protected]

You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Section 1557 Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, by mail or phone at:

U.S. Department of Health and Human Services200 Independence Avenue, SWRoom 509F, HHH BuildingWashington, D.C. 202011-800-368-10191-800-537-7697 (TDD)Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html

Section 1557 Notification:Discrimination is Against the Law

– 52 – – 53 –

ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-352-2583 (TTY: 1-877-955-8773). FEP: Llame al 1-800-333-2227

ATANSYON: Si w pale Kreyòl ayisyen, ou ka resevwa yon èd gratis nan lang pa w. Rele 1-800-352-2583 (pou moun ki pa tande byen: 1-800-955-8770). FEP: Rele 1-800-333-2227

CHÚ Ý: Nếu bạn nói Tiếng Việt, có dịch vụ trợ giúp ngôn ngữ miễn phí dành cho bạn. Hãy gọi số 1-800-352-2583 (TTY: 1-800-955-8770). FEP: Gọi số 1-800-333-2227

ATENÇÃO: Se você fala português, utilize os serviços linguísticos gratuitos disponíveis. Ligue para 1-800-352-2583 (TTY: 1-800-955-8770). FEP: Ligue para 1-800-333-2227

注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電1-800-352-2583（TTY: 1-800-955-8770)。FEP：請致電1-800-333-2227

ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-800-352-2583 (ATS : 1-800-955-8770). FEP : Appelez le 1-800-333-2227

PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-800-352-2583 (TTY: 1-800-955-8770). FEP: Tumawag sa 1-800-333-2227

ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-800-352-2583 (телетайп: 1-800-955-8770). FEP: Звоните 1-800-333-2227

)رقم هاتف الصم 008-253-3852-1اتصل برقم ملحوظة: إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. .7222-333-008-1. اتصل برقم 008-559-0778-1والبكم:

ATTENZIONE: Qualora fosse l'italiano la lingua parlata, sono disponibili dei servizi di assistenza linguistica gratuiti. Chiamare il numero 1-800-352-2583 (TTY: 1-800-955-8770). FEP: chiamare il numero 1-800-333-2227

ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: +1-800-352-2583 (TTY: +1-800-955-8770). FEP: Rufnummer +1-800-333-2227

주의: 한국어 사용을 원하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-800-352-2583 (TTY: 1-800-955-8770) 로 전화하십시오. FEP: 1-800-333-2227 로 연락하십시오.

UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-800-352-2583 (TTY: 1-800-955-8770). FEP: Zadzwoń pod numer 1-800-333-2227.

સચુના: જો તમ ેગજુરાતી બોલતા હો, તો નન:શલુ્ક ભાષા સહાય સવેા તમારા માટ ેઉપલબ્ધ છે. ફોન કરો 1-800-352-2583 (TTY: 1-800-955-8770). FEP: ફોન કરો 1-800-333-2227

ประกาศ:ถา้คุณพดูภาษาไทย คุณสามารถใชบ้ริการช่วยเหลือทางภาษาไดฟ้รี โดยติดต่อหมายเลขโทรฟรี 1-800-352-2583 (TTY: 1-800-955-8770) หรือ FEP โทร 1-800-333-2227

注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1-800-352-2583（TTY: 1-800-955-8770）まで、お電話にてご連絡ください。FEP: 1-800-333-2227

صحبت می کنید، تسهیلات زبانی رایگان در دسترس شما خواهد بود. فارسی : اگر به زبانتوجهتماس بگیريد. 2227-333-800-1با شماره :FEPتماس بگیريد. (TTY: 1-800-955-8770) 2583-352-800-1با شماره

Baa ákonínzin: Diné bizaad bee yáníłti’go, saad bee áká anáwo’, t’áá jíík’eh, ná hólǫ́. Kojį’ hodíílnih 1-800-352-2583 (TTY: 1-800-955-8770). FEP ígíí éí kojį’ hodíílnih 1-800-333-2227.

– 52 – – 53 –

Notes

Health coverage is offered by Blue Cross and Blue Shield of Florida, Inc., DBA Florida Blue, an Independent Licensee of the Blue Cross and Blue Shield Association.

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