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Report
Blue Shield’s 2014 Medicare sales event
H0504_13_200 08162013
S2468_13_200 08162013
1
Agenda
• Blue Shield Accomplishments
•What you need to know – updates and commissions
• MA-PD Plans
• Medicare Supplement Plans
• PDP Plans
• Specialty Benefits
•Q&A
2
Recent Accomplishments
• Affordability mission – 2% pledge
• 4 Star quality rating*
• Medicare Advantage County
Expansion
*Applies to Blue Shield’s 2013 MAPD and PDP plans. Medicare
evaluates plans based on a 5-Star rating system. Star Ratings are
calculated each year and may change from one year to the next.
3
What you need to know for the
2014 MA-PD and PDP
Annual Election Period (AEP)
4
Things to remember…..
• Annual Election Period (AEP)
 2014 MA-PD and PDP applications accepted 10/15/2013 through
12/7/2013 for a 1/1/2014 effective date
 Applications cannot be submitted prior to 10/15/2013, except for
initial coverage individuals who can submit as early as 10/1/2013
for a 1/1/2014 effective date
• Medicare Advantage Disenrollment Period (MADP)
MA plan enrollees may disenroll from 1/1/2014 through 2/14/2014
and return to Original Medicare (may also enroll in a PDP plan
during this time)
• Applications must be submitted in a timely manner
Submit to Blue Shield within 24 hours of the applicant getting it to
you
• A member packet must be provided whenever an application is
provided to a prospect
Must include Plan Rating info, Summary of Benefits and MultiLanguage insert
5
Certification and Events
• Producer must complete an annual Medicare Certification (i.e through
AHIP) as well as Blue Shield’s MA-PD and PDP product-specific training prior
to a sale (no exceptions, & no commissions will be paid to non-certified
brokers)
– In order to receive commissions on Blue Shield products, you must be
individually appointed by Blue Shield or endorsed by an agency
appointed by Blue Shield prior to submitting applications
• Get Your $100 AHIP Reimbursement
– Sell five Blue Shield MA-PD plan enrollments in order to be reimbursed a
maximum of $100. PDP & Medicare Supplement Plan Sales DO NOT
QUALIFY for reimbursement.
• Sales Event Reporting
– Please use the latest Master Sales Event template.
6
Commissions Update
7
2014 Commissions
• MA-PD – $532 new, $266 renewal
• PDP – $56 new, $28 renewal
• Medicare Supplement Plans– 20% first year, 10% renewal
Lifetime Renewals were added in 2013 for MA-PD and PDP in
addition to Medicare Supplement Plans.
8
2014 Blue Shield 65 Plus HMO
benefit changes
9
2014 Blue Shield 65 Plus HMO and Blue Shield 65 Plus
Choice Plan HMO benefit changes
For the 2014 benefit year, Blue Shield has lowered the member cost-sharing
for Skilled Nursing Care in the following plans:
Benefit:
Skilled Nursing Care (covered up to 100 days per benefit period)
Blue Shield 65 Plus HMO
Los Angeles (partial) & Orange Counties
Blue Shield 65 Plus Choice Plan HMO
Los Angeles (partial) & Orange Counties
Blue Shield 65 Plus HMO
Riverside County (partial)
Blue Shield 65 Plus HMO
San Bernardino County (partial)
Blue Shield 65 Plus HMO
Ventura County (partial)
Blue Shield 65 Plus HMO
San Diego County (full)
Blue Shield 65 Plus HMO
Sacramento County (partial)
Member cost-sharing amount
Member cost-sharing amount
2013
2014
Days 1-10: $0
Days 11-100: $85 per day
The copay is applicable per admission
Days 1-20: $0
Days 21-100: $75 per day
The copay is applicable per admission
Days 1-10: $0
Days 11-100: $75 per day
The copay is applicable per admission
Days 1-20: $0
Days 21-100: $50 per day
The copay is applicable per admission
Days 1-10: $50 per day
Days 11-100: $100 per day
The copay is applicable per admission
Days 1-20: $0 per day
Days 21-100: $100 per day
The copay is applicable per admission
Days 1-10 : $50 per day
Days 11-100: $100 per day
The copay is applicable per admission
Days 1-20: $0 per day
Days 21-100: $100 per day
The copay is applicable per admission
Days 1-10: $50 per day
Days 11-100: $100 per day
The copay is applicable per admission
Days 1-20: $0 per day
Days 21-100: $75 per day
The copay is applicable per admission
Days 1-10: $0
Days 11-100: $100 per day
The copay is applicable per admission
Days 1-20: $0
Days 21-100: $100 per day
The copay is applicable per admission
Days 1-10: $50 per day
Days 11-100: $100 per day
The copay is applicable per admission
Days 1-20: $50 per day
Days 21-100: $100 per day
The copay is applicable per admission
12
2014 Blue Shield 65 Plus HMO and Blue Shield 65 Plus
Choice Plan HMO benefit changes
For the 2014 benefit year:
• Blue Shield 65 Plus HMO members will have the option of adding an Optional
Supplemental Dental HMO Plan for a set monthly premium!
• Blue Shield 65 Plus CHOICE Plan HMO will include embedded dental benefits at no
additional cost, AND members will also have the option of adding an Optional
Supplemental Dental HMO Plan for a set monthly premium.
Benefit:
2014 MAPD Dental Plans
Embedded Dental Benefit
Optional Supplemental Dental
HMO Plan
Premium: $12.20 per month
Blue Shield 65 Plus Choice Plan HMO
Los Angeles (partial) & Orange Counties
Specific ADA codes covered.
Copay varies by ADA codes.
(See EOC for details)
Blue Shield 65 Plus HMO
ALL COUNTIES
Not Covered
13
Available for a monthly premium
Specific ADA codes covered.
Copay varies by ADA codes.
(See EOC for details)
Available for a monthly premium
Specific ADA codes covered.
Copay varies by ADA codes.
(See EOC for details)
2014 Blue Shield 65 Plus
HMO County Expansions
42
Blue Shield 65 Plus
2014 County Expansions
For the 2014 benefit year, Blue Shield 65 Plus HMO will
expand into 3 new counties with competitive
benefits:
New counties as of 2014:
–
Contra Costa County (Partial) - Blue Shield 65
Plus (HMO)
–
Fresno County- Blue Shield 65 Plus (HMO)
–
Santa Clara County (Partial) - Blue Shield 65 Plus
(HMO)
Contra Costa
Santa Clara
Fresno
43
blue shield 65 plus (HMO) benefits
For the 2014 benefit year, Blue Shield’s MAPD plans in the new
counties will include the following Maximum Out-of-Pocket
(MOOP) amounts:
Benefits
Annual out-of-pocket
maximum (Medicare Parts A
and B covered services)
Blue Shield 65 Plus (HMO)
Blue Shield 65 Plus (HMO)
Blue Shield 65 Plus (HMO)
Contra Costa County
(partial)
Fresno County
Santa Clara County
(partial)
New county as of 2014
New county as of 2014
New county as of 2014
$2,900
$2,900
$2,900
$0
$0
$0
Monthly Plan Premium
(Members must continue to
pay their monthly Medicare
Part B premium)
44
blue shield 65 plus (HMO) benefits
Benefits
Inpatient Hospital
Care
Inpatient Mental
Health Care
Skilled Nursing
Facility
Blue Shield 65 Plus (HMO)
Blue Shield 65 Plus (HMO)
Blue Shield 65 Plus (HMO)
Contra Costa County (partial)
Fresno County
Santa Clara County (partial)
New county as of 2014
New county as of 2014
New county as of 2014
Days 1-5: $125 copay/day
Days 1-5: $160 copay/day
Days 1-5: $125 copay/day
Days 6-90: $0 copay/day
Days 6-90: $0 copay/day
Days 6-90: $0 copay/day
No limit to the number of covered
days/benefit period*
No limit to the number of covered
days/benefit period*
No limit to the number of covered
days/benefit period*
$900 per stay (150 days each
benefit period up to 190-day limit)
$900 per stay (150 days each benefit
period up to 190-day limit)
$900 per stay (150 days each
benefit period up to 190-day limit)
Member pays 100% of costs for days
151 and over unless a new benefit
period begins
Member pays 100% of costs for days
151 and over unless a new benefit
period begins
Member pays 100% of costs for
days 151 and over unless a new
benefit period begins
Up to 190 days in a Medicarecertified Psychiatric Hospital in a
lifetime
Up to 190 days in a Medicarecertified Psychiatric Hospital in a
lifetime
Up to 190 days in a Medicarecertified Psychiatric Hospital in a
lifetime
Days 1-20: $0 copay/day
Days 21-100: $100 copay/day
Days 1-20: $0 copay/day
Days 21-100: $100 copay/day
Days 1-20: $0 copay/day
Days 21-100: $100 copay/day
Copays applicable per admission
Copays applicable per admission
Copays applicable per admission
100 covered days/benefit period*
No prior hospital stay is required
100 covered days/benefit period*
100 covered days/benefit period*
No prior hospital stay is required
No prior hospital stay is required
Primary Care
Physician Visits
$0 copay/visit
$0 copay/visit
$0 copay/visit
Specialist Visit
$8 copay/visit
$10 copay/visit
$9 copay/visit
*Benefit Period : A Benefit Period begins with the first day of the Medicare-covered Inpatient Hospital stay or Skilled Nursing
Facility stay and ends with the close of a period of 60 consecutive days, during which you are not an Inpatient of a Hospital or
Skilled Nursing Facility.
45
blue shield 65 plus (HMO) benefits
Benefits
Blue Shield 65 Plus (HMO)
Blue Shield 65 Plus (HMO)
Blue Shield 65 Plus (HMO)
Contra Costa County
(partial)
Fresno County
Santa Clara County
(partial)
New county as of 2014
New county as of 2014
New county as of 2014
$0 copay
$0 copay
$0 copay
(office visit copay may apply)
(office visit copay may apply)
(office visit copay may apply)
Outpatient Substance Abuse
Care
$30 copay/individual or group
session
$30 copay/individual or group
session
$30 copay/individual or group
session
Outpatient Hospital Services
$50 copay/visit at an ambulatory
surgical center
$50 copay/visit at an ambulatory
surgical center
$150 copay/visit at an outpatient
hospital facility
$150 copay/visit at an outpatient
hospital facility
$50 copay/visit at an
ambulatory surgical center
$100 copay/visit at an
outpatient hospital facility
Ambulance (each way)
$150 copay/trip
$175 copay/trip
$250 copay/trip
Emergency Care
$65 copay/visit
$65 copay/visit
$65 copay/visit
Worldwide coverage
Worldwide coverage
Worldwide coverage
$10,000 combined annual limit for
covered emergency care or
urgently needed care outside the
U.S.
$10,000 combined annual limit for
covered emergency care or
urgently needed care outside the
U.S.
$10,000 combined annual limit
for covered emergency care
or urgently needed care
outside the U.S.
Annual Wellness Visit (1 exam
every 12 months)
46
blue shield 65 plus (HMO) benefits
Benefits
Blue Shield 65 Plus (HMO)
Blue Shield 65 Plus (HMO)
Blue Shield 65 Plus (HMO)
Contra Costa County (partial)
Fresno County
Santa Clara County (partial)
New county as of 2014
New county as of 2014
New county as of 2014
$15 copay/visit (within plan service
area)
$15 copay/visit (within plan service
area)
$15 copay/visit (within plan service
area)
$15 copay/visit (outside plan
service area but within US)
$15 copay/visit (outside plan
service area but within US)
$15 copay/visit (outside plan
service area but within US)
$65 copay/visit (outside US)
$65 copay/visit (outside US)
$65 copay/visit (outside US)
Worldwide coverage $10,000
combined annual limit for covered
emergency care or urgently
needed care outside the U.S.
Worldwide coverage $10,000
combined annual limit for covered
emergency care or urgently
needed care outside the U.S.
Worldwide coverage $10,000
combined annual limit for covered
emergency care or urgently
needed care outside the U.S.
Outpatient
Rehabilitation
Services (PT/OT/ST)
$20 copay/visit
$20 copay/visit
$20 copay/visit
Durable Medical
Equipment (DME)
20% of Medicare-allowable amount
per item per month
20% of Medicare-allowable
amount per item per month
20% of Medicare-allowable
amount per item per month
Urgent Care
47
blue shield 65 plus (HMO) benefits
Benefits
Blue Shield 65 Plus (HMO)
Blue Shield 65 Plus (HMO)
Blue Shield 65 Plus (HMO)
Contra Costa County (partial)
Fresno County
New county as of 2014
New county as of 2014
Santa Clara County
(partial)
Chiropractic (Medicarecovered)
$8 copay/visit
$10 copay/visit
$9 copay/visit
Podiatry (Routine)
Not covered
Not covered
Not covered
$8 copay/visit
$10 copay/visit
$9 copay/visit
$30 copay/ individual or group
therapy visit
$30 copay/ individual or group
therapy visit
$30 copay/ individual or group
therapy visit
$0 copay
$0 copay
$0 copay
(office visit copay may apply)
(office visit copay may apply)
(office visit copay may apply)
$50 copay
$50 copay
$50 copay
(office visit copay may apply)
(office visit copay may apply)
(office visit copay may apply)
Podiatry (Medicare-covered)
Outpatient Mental Health
Care
Basic Diagnostic Tests, X-Rays,
Supplies, Blood, & Lab
(Including EKGs)
Diagnostic Radiology
Services (e.g., MRIs, PET
scans, CT scans, Nuclear
Medicine studies,
Myelogram, Cardiac Stress
Tests, Cystogram, Angiogram,
SPECT)
48
New county as of 2014
blue shield 65 plus (HMO) benefits
Benefits
Diabetes Self-Management
Training
Diabetes Supplies
Therapeutic Radiology
Services (e.g., radiation
therapy, radium and isotope
therapy, chemotherapy)
Blue Shield 65 Plus (HMO)
Blue Shield 65 Plus (HMO)
Blue Shield 65 Plus (HMO)
Contra Costa County
(partial)
Fresno County
Santa Clara County
(partial)
New county as of 2014
New county as of 2014
New county as of 2014
$0 copay
$0 copay
$0 copay
$0 copay
$0 copay
(regardless of where the
supplies are obtained)
(regardless of where the supplies
are obtained)
(regardless of where the supplies
are obtained)
20% of the Medicare-allowable
amount
20% of the Medicare-allowable
amount
20% of the Medicare-allowable
amount
(office visit copay may apply)
(office visit copay may apply)
(office visit copay may apply)
10% of the Medicare-allowable
amount/treatment
20% of the Medicare-allowable
amount for drugs
used/treatment
10% of the Medicare-allowable
amount/treatment
20% of the Medicare-allowable
amount for drugs used/treatment
10% of the Medicare-allowable
amount/treatment
20% of the Medicare-allowable
amount for drugs
used/treatment
Dialysis Treatments
49
$0 copay
blue shield 65 plus (HMO) benefits
Benefits
Blue Shield 65 Plus (HMO)
Blue Shield 65 Plus (HMO)
Contra Costa County
(partial)
Fresno County
New county as of 2014
New county as of 2014
$0 copay
$0 copay
$0 copay
(office visit copay may apply)
(office visit copay may apply)
(office visit copay may
apply)
$20 copay (1 every year)
$20copay (1 every year)
$20 copay (1 every year)
Medicare-covered Eye Wear
$0 copay
$0 copay
$0 copay
Eyeglass Lenses (one set of
medically necessary uncoated
lenses or standard anti-reflective
lenses every 12 months)
$20 copay
$20 copay
$20 copay
Eyeglass Frames (one set of
frames every 24 months)
$20 copay (up to $75 retail
value)
$20 copay (up to $75 retail
value)
$20 copay (up to $75 retail
value)
SilverSneakers Fitness Program
Basic health club
membership/fitness classes
Basic health club
membership/fitness classes
Basic health club
membership/fitness classes
$0 copay
$0 copay
$0 copay
$0 copay
$0 copay
$0 copay
Medicare-covered Hearing Exam
Routine Eye Exam
NurseHelp 24/7
50
Blue Shield 65 Plus
(HMO)
Santa Clara County
(partial)
New county as of 2014
blue shield 65 plus (HMO) benefits
Benefits
Blue Shield 65 Plus
(HMO)
Blue Shield 65 Plus
(HMO)
Blue Shield 65
Plus (HMO)
Contra Costa
County (partial)
Fresno County
Santa Clara
County (partial)
New county as of
2014
New county as of
2014
New county as of
2014
Retail In-Network Preferred or Other Network Pharmacy 30-day Supply
Tier 1: Preferred Generic Drugs
$5 copay
$5 copay
$5 copay
Tier 2: Preferred Brand Drugs
$45 copay
$45 copay
$45 copay
Tier 3: Non-Preferred Brand Drugs
$90 copay
$90 copay
$90 copay
Tier 4: Injectable Drugs
25% of Blue Shield's
contracted rate
25% of Blue Shield's
contracted rate
25% of Blue
Shield's
contracted rate
Tier 5: Specialty Tier Drugs
33% of Blue Shield's
contracted rate
33% of Blue Shield's
contracted rate
33% of Blue
Shield's
contracted rate
*Part D drug formularies vary by plan. Refer to Blue Shield 65 Plus HMO and Blue Shield 65 Plus Choice HMO plan formulary lists for
details.
52
blue shield 65 plus (HMO) benefits
Benefits
Gap Coverage (for all plans)
Blue Shield 65 Plus
(HMO)
Blue Shield 65 Plus
(HMO)
Contra Costa
County (partial)
Fresno County
New county as of
2014
New county as of
2014
Blue Shield 65 Plus (HMO)
Santa Clara County (partial)
New county as of 2014
Tier 1- Preferred Generic Drugs: members will pay the same copayments
referenced in previous slides.
Generic Drugs in Tiers 2-5, : members are responsible for 72% coinsurance
through the Medicare Coverage Gap Discount Program
Brand Name Drugs in Tiers 2 through 5: members are responsible for 47.5%
coinsurance through the Medicare Coverage Gap Discount Program
Catastrophic Coverage - For
drug costs after member's true
out of pocket (TrOOP) costs
reach $4,750.
The greater of $2.55
for generic
(including brand
drugs treated as
generic) and $6.35
for all other drugs, or
5% coinsurance
The greater of $2.55
for generic
(including brand
drugs treated as
generic) and $6.35
for all other drugs, or
5% coinsurance
58
The greater of $2.55 for
generic (including brand
drugs treated as generic) and
$6.35 for all other drugs, or 5%
coinsurance
Blue Shield
Medicare Supplement Plans
‹#›
2014 Blue Shield Medicare Supplement plans
Blue Shield offers 7 of the 2010
standardized plans:
A, C, D, F, & K
High Deductible F &N
–Affordable monthly rates
–A wide choice of plans
–The freedom to select their own doctors
–Plans are age banded in pricing
–All plans include the basic core benefit
–Blue Shield offers the SilverSneakers Fitness
Program at no additional cost
60
Welcome to Medicare rate savings
New to Medicare? Then we want to welcome you!
•Beginning December 1st, 2012, new member can save $15 each
month for the first 12 months* on the Blue Shield Medicare
Supplement plan rates if he/she is new to Medicare Part B
To qualify:
•The member must be age 65 or older
•Blue Shield must receive the application within 6 months of the
date he/she first enrolled for benefits under Medicare Part B
Welcome to Medicare Rate Savings is
available for all Medicare Supplement
plans offered by Blue Shield
*These additional monthly savings are due to increased efficiencies from administering Medicare Supplement plans under
this program/service are passed on to the subscriber.
For more information, refer to the Producer Information Booklet or contact your Blue Shield of California Regional Sales
Manager
61
Easy$PaySM Program
• No checks to write
• No postage to pay
• If your clients choose to use our Easy$PaySM method of
automatic deductions for payment of their monthly
dues, they save $3 per month*
Note: Automatic deductions are available through checking or savings
accounts only.
• Current Easy$PaySM members will automatically
receive the $3 savings**
*These additional monthly savings are due to increased efficiencies from administering
Medicare Supplement plans under this program/service are passed on to the subscriber.
**For more information, refer to the Producer Information Booklet or contact your Blue
Shield of California Regional Sales Manager
62
Blue Shield extends its Medicare Supplement Plan
Special Open Enrollment Period
• Blue Shield of California is pleased to extend its Medicare
Supplement plan Special Open Enrollment period through June 30,
2014.
• Your clients currently enrolled in a Medicare Supplement plan qualify,
and may transfer to any open Medicare Supplement plan offering
benefits equal to or lesser than those provided in their current plan
without going through underwriting.
• Individuals enrolled in another carrier’s plan just submit a new
application without having to complete a health questionnaire*.
Current Blue Shield members must simply complete the Guaranteed
Acceptance Application Form to take advantage of this special
open enrollment period.
*Individuals currently enrolled in a Medicare Supplement plan from another carrier must submit a replacement of
coverage form along with the new application.
63
2014 Blue Shield
Medicare Prescription Drug Plans
(PDP)
‹#›
2014 Blue Shield Part D (PDP) Plan
changes
Effective January 1, 2014, Blue Shield will
continue to offer two PDP plans:

Blue Shield Medicare Enhanced Plan

Blue Shield Medicare Basic Plan
65
Blue Shield Medicare Prescription Drug Plans (PDP)
•Blue Shield Medicare Enhanced Plan (PDP)
•Blue Shield Medicare Basic Plan (PDP)
Benefit
Monthly Plan Premium
Annual Deductible
Blue Shield
Medicare Enhanced
Plan (PDP)
Blue Shield Medicare
Basic Plan (PDP)
6 Tiers
6 Tiers
$74.40
$42.80
(2013: $72.50)
(2013: $53.40)
$0
$310
(2013: $325)
* Blue Shield Medicare Prescription Drug Plans have different Part D drug formularies. Refer to the Blue Shield
Medicare Enhanced Plan and Blue Shield Medicare Basic Plan formulary lists for details.
66
Blue Shield Medicare Prescription Drug Plans (PDP)
Blue Shield
Medicare
Enhanced Plan
(PDP)
Blue Shield
Medicare Basic
Plan (PDP)
Tier 1: Preferred Generic Drugs
Retail 30-day supply – preferred or other network
pharmacy
Retail 90-day supply – preferred network
pharmacy
Retail 90-day supply – other network pharmacy
Retail 30-day supply – out-of-network pharmacy
Long Term Care pharmacy 31-day supply
Mail Service 90-day supply
67
$2 copay
$0 copay
(2013: $5 copay)
(2013: $4 copay)
$4 copay
$0 copay
(2013: $10 copay)
(2013: $8 copay)
$6 copay
$0 copay
(2013: $15 copay)
(2013: $12 copay)
$2 copay
$0 copay
(2013: $5 copay)
(2013: $4 copay)
$2 copay
$0 copay
(2013: $5 copay)
(2013: $4 copay)
$4 copay
$0 copay
(2013: $10 copay)
(2013: $8 copay)
Blue Shield Medicare Prescription Drug Plans (PDP)
Blue Shield Medicare
Enhanced Plan (PDP)
Blue Shield
Medicare Basic
Plan (PDP)
Tier 2: Non-Preferred Generic Drugs
Retail 30-day supply – preferred or other
network pharmacy
Retail 90-day supply – preferred network
pharmacy
Retail 90-day supply – other network
pharmacy
Retail 30-day supply – out-of-network
pharmacy
Long Term Care pharmacy 31-day supply
Mail Service 90-day supply
68
$6 copay
$5 copay
(2013: $5 copay)
(2013: $4 copay)
$12 copay
$10 copay
(2013: $10 copay)
(2013: $8 copay)
$18 copay
$15 copay
(2013: $15 copay)
(2013: $12 copay)
$6 copay
$5 copay
(2013: $5 copay)
(2013: $4 copay)
$6 copay
$5 copay
(2013: $5 copay)
(2013: $4 copay)
$12 copay
$10 copay
(2013: $10 copay)
(2013: $8 copay)
Blue Shield Medicare Prescription Drug Plans (PDP)
Blue Shield Medicare
Enhanced Plan (PDP)
Blue Shield
Medicare Basic
Plan (PDP)
Tier 3: Preferred Brand Drugs
Retail 30-day supply – preferred or other
network pharmacy
Retail 90-day supply – preferred network
pharmacy
Retail 90-day supply – other network
pharmacy
Retail 30-day supply – out-of-network
pharmacy
Long Term Care pharmacy 31-day supply
Mail Service 90-day supply
69
$40 copay
$45 copay
(2013: $45 copay)
(2013: $37 copay)
$80 copay
$90 copay
(2013: $90 copay)
(2013: $74 copay)
$120 copay
$135 copay
(2013: $135 copay)
(2013: $111 copay)
$40 copay
$90 copay
(2013: $45 copay)
(2013: $74 copay)
$40 copay
$45 copay
(2013: $45 copay)
(2013: $37copay)
$80 copay
$90 copay
(2013: $90 copay)
(2013: $74 copay)
Blue Shield Medicare Prescription Drug Plans (PDP)
Blue Shield Medicare
Enhanced Plan (PDP)
Blue Shield
Medicare Basic
Plan (PDP)
Tier 4: Non-Preferred Brand Drugs
Retail 30-day supply – preferred or other
network pharmacy
Retail 90-day supply – preferred network
pharmacy
Retail 90-day supply – other network
pharmacy
Retail 30-day supply – out-of-network
pharmacy
Long Term Care pharmacy 31-day supply
Mail Service 90-day supply
70
$88 copay
$90 copay
(2013: $90 copay)
(2013: $76 copay)
$176 copay
$180 copay
(2013: $180 copay)
(2013: $152 copay)
$264 copay
$270 copay
(2013: $270 copay)
(2013: $228 copay)
$88 copay
$90 copay
(2013: $90 copay)
(2013: $76 copay)
$88 copay
$90 copay
(2013: $90 copay)
(2013: $76 copay)
$176 copay
$180 copay
(2013: $180 copay)
(2013: $152 copay)
Blue Shield Medicare Prescription Drug Plans (PDP)
PLAN
Blue Shield Medicare
Enhanced Plan (PDP)
Blue Shield Medicare
Basic Plan (PDP)
Tiers 1-6: Members are
responsible for no more
than 72% of the cost for
generic drugs and 47.5%
of negotiated price
through manufacturer
discounts on brand
name drugs
Tiers 1-6: Members are
responsible for no more
than 72% of the cost for
generic drugs and 47.5%
of negotiated price
through manufacturer
discounts on brand
name drugs
Benefit
Coverage Gap
(after total yearly drug costs reach
$2,850)
74
•
•
New Optional Supplemental Dental HMO plan
As part of Blue Shield 65 Plus in 2014, we will be offering a NEW optional supplemental Dental HMO
plan for a low monthly premium of $12.20.
Benefit Summary (see Evidence of Coverage for a complete list of covered services, exclusions and
limitations):
2014 – Optional Supplemental Dental HMO Plan
ADA Code
Diagnostic services
Office visit
Comprehensive oral exams
X-rays – intraoral complete series (including bitewings) –
once every 24 months
Preventive care
Prophylaxis (cleanings, one every 6 months)
Restorative services
One-surface composite (filling)
Crown (porcelain fused to noble metal)
Endodontics
Anterior root canal
Molar root canal
ADA Code*
Member Copay1
None
D0150
D0210
$0
$5
$0
D1110
$5
D2330
D2750
$11
$2752
D3310
$1953
D3330
$3353
*ADA codes are procedure codes established by the American Dental Association for efficient processing and reporting of
dental claims
1All services must be performed, prescribed or authorized by a network Dentist. If a member needs to see a specialist, they must
get a referral from their dentist to receive covered services.
2 Members will pay the copayment plus the cost of precious or semi-precious metals. Porcelain on molar crowns is not a covered
benefit.
3Member copayment will be higher if this service is performed by a specialist.
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New Optional Supplemental Dental HMO plan
•
Benefit Summary, continued (see Evidence of Coverage for a complete list of covered
services, exclusions and limitations):
2014 – Optional Supplemental Dental HMO Plan
ADA Code
Periodontics
Osseous surgery/four or more teeth per
quadrant
Periodontal root planing/four or more teeth per
quadrant
Prosthetics
Bridge pontic/false tooth – porcelain fused to
high noble metal (per unit)
Bridge retainer – porcelain fused to high noble
metal (per unit)
Complete denture (upper or lower)
Oral surgery
Extraction (single tooth)
Removal of impacted tooth (complete bony)
ADA Code*
Member Copay1
D4260
$293
D4341
$45
D6240
$2102
D6750
$2752
D5110/D5120
$285
D7111
D7240
$10
$80
*ADA codes are procedure codes established by the American Dental Association for efficient processing and reporting of
dental claims
1All
services must be performed, prescribed or authorized by a network Dentist. If a member needs to see a specialist, they must
get a referral from their dentist to receive covered services.
2 Members
will pay the copayment plus the cost of precious or semi-precious metals. Porcelain on molar crowns is not a
covered benefit.
3Member copayment will be higher if this service is performed by a specialist.
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