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Benefits at-a-Glance BlueMedicare Classic (HMO)

BlueMedicare Premier (HMO)

H1035-018

H1035-022

Service Area

Palm Beach

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.

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

$4,500 for services you receive from In-Network providers.

$3,400 for services you receive from In-Network providers.

Plan Costs & Details

Medical & Hospital Benefits Doctor’s Office Visits

$0 copay Primary Care Physician

$35 copay Specialist

$15 copay Specialist

Preventive Care

$0 copay

Inpatient Hospital Care

Days 1-8: $225 copay per day.

Days 1-8: $75 copay per day.

After the 8th day the plan pays 100% of covered expenses.

Outpatient Hospital

$175 copay except for Observation Services

$75 copay except for Observation Services

$90 copay for Observation Services

$100 copay for Observation Services

$150 copay in an Ambulatory Surgical Center

$40 copay in an Ambulatory Surgical Center

$175 copay in an Outpatient Hospital Facility

$75 copay for in an Outpatient Hospital Facility

$50 copay at a Convenient Care Center

$10 copay at a Convenient Care Center

$50 copay at an Urgent Care Center

$10 copay at an Urgent Care Center

Emergency Room

$90 copay

$100 copay

Ambulance

$295 copay

$300 copay

Outpatient Surgery

Urgently Needed Services

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Part D Prescription Drug Benefits1 Tier 1

$0 copay

Tier 2

$2 copay

$0 copay

Tier 3

$35 copay

Tier 4

$93 copay

Tier 5

33% coinsurance

Tier 6

$0 copay

Not Applicable

Mail Order

Same copays/coinsurance as Preferred Pharmacy listed above

(Preferred Generic) (Generic) (Preferred Brand) (Non-Preferred) (Specialty) (Select Care)

What you pay at a Preferred Pharmacy for a 31-day supply

Additional Benefits Acupuncture

$20 copay

Vision Services

$0 copay for annual routine eye exam

$100 allowance per year towards the purchase of lenses, frames or contact lenses

$300 allowance per year towards the purchase of lenses, frames or contact lenses

$0 copay for one routine hearing exam per year

$0 copay for evaluation and fitting of hearing aids

$350 maximum allowance for each hearing aid. Up to 2 hearing aids every year.

$600 maximum allowance for each hearing aid. Up to 2 hearing aids every year.

Hearing Services and Hearing Aids

Hearing aids must be purchased Hearing aids must be purchased through NationsHearing. through NationsHearing.

Additional Benefits (continued) Dental Services

$0 copay for the following services • 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)

Telehealth

$0 copay for Primary Care services and most Medicare-covered Preventive services. See the Summary of Benefits for more information about Telehealth. • Available 24/7 • Able to prescribe medications, except controlled substances

At Home Care

60 hours per year We 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. See the Summary of Benefits for more information on Papa services.

HealthyBlue Rewards

• R edeem gift card rewards for completing and reporting preventive care and screenings

SilverSneakers® Fitness Program

• G ym membership and classes available at 16,000+ fitness locations across the country, including national chains and local gyms • A ccess to exercise equipment and other amenities, classes for all levels and abilities, social events, and more

Additional Benefits Exclusively for BlueMedicare Premier (HMO) H1035-022 Over-the-Counter Items

$60 quarterly allowance for the purchase of non-prescription items, such as vitamins and aspirin. What you need to know: • A ny balance not used for a quarter will not carry over to the next quarter • Y ou must use your full benefit in one order • Y our order total may not exceed your benefit amount

Transportation Services

$0 copay for 48 one-way trips annually for rides to your doctor, hospital or pharmacy These services can accommodate wheelchairs, walkers, oxygen tanks and service animals

Caregiver Support for Member

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.)

Special Supplemental Benefits for the Chronically Ill

Members diagnosed as having one or a combination of Coronary Artery Disease (CAD), Congestive Heart Failure (CHF), Chronic Obstructive Pulmonary Disease (COPD), and/or Diabetes may receive additional benefits for: • 20 meals per month, home delivered • 3 telephone consultations for nutritional therapy and planning with a Dietary Counselor, per year • An additional $50 allowance per quarter toward the purchase of Over-the-Counter (OTC) items • Enhanced fitness training with 5 personal trainer sessions and specialized fitness classes through SilverSneakers • 12 one-way additional routine transportation trips. These additional trips do not require clinical criteria and may be used for social purposes.

Florida Blue Medicare is an HMO plan with a Medicare contract. Enrollment in Florida Blue Medicare depends on contract renewal. HMO coverage is offered by Florida Blue Medicare, Inc., DBA Florida Blue Medicare, an Independent Licensee of the Blue Cross and Blue Shield Association. Tivity Health and SilverSneakers are registered trademarks or trademarks of Tivity Health, Inc., and/or its subsidiaries and/or affiliates in the USA and/or other countries. We comply with applicable Federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability, or gender. ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-855-601-9465 (TTY: 1-877-955-8773). ATANSYON: Si w pale Kreyòl Ayisyen, gensèvis èd pou lang ki disponib gratis pou ou. Rele 1-855-601-9465 (TTY: 1-800-955-8770). © 2020 Blue Cross and Blue Shield of Florida, Inc., DBA Florida Blue. All rights reserved.

Benefits at-a-Glance BlueMedicare Complete (HMO)

BlueMedicare Complete (HMO)

H1035-027

H1035-028

Service Area

Miami-Dade

Broward & Palm Beach

How much is the monthly premium?

$30.80 You may pay a lower premium or no premium based on your level of assistance. In addition, you must keep paying your Medicare Part B premium.

How much is the deductible?

This plan does not have a deductible for medical services and supplies. $445 per year for Part D prescription drugs. Not applicable to Tiers 1 and 2.

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

$500 for services you receive from In-Network providers.

$2,500 for services you receive from In-Network providers.

Plan Costs

Medical & Hospital Benefits Doctor’s Office Visits

$0 copay Primary Care Physician

$0 copay Specialist

Preventive Care

$0 copay

Inpatient Hospital Care

$0 copay per stay

Outpatient Hospital

$0 copay

Outpatient Surgery

$0 copay in an Ambulatory Surgical Center or Outpatient Hospital Facility

Urgently Needed Services

$0 copay at a Convenient Care Center

$0 copay at an Urgent Care Center

Emergency Room

$0 copay

Ambulance

$0 copay

$0 copay Y0011_FBM0211 0820_M

Part D Prescription Drug Benefits1 Tier 1

$0 copay

Tier 2

$0 copay

Tier 3

Deductible then $40 copay

Tier 4

Deductible then $92 copay

Tier 5

Deductible then 25% coinsurance

Mail Order

Same copays/coinsurance as Preferred Pharmacy listed above

(Preferred Generic) (Generic) (Preferred Brand)

(Non-Preferred)

(Specialty)

What you pay at a Preferred Pharmacy for a 31-day supply

Additional Benefits Acupuncture

$0 copay

Vision Services

$0 copay for annual routine eye exam

$400 allowance per year towards the purchase of lenses, frames or contact lenses

$0 copay for one routine hearing exam per year

$0 copay for evaluation and fitting of hearing aids

$1,250 maximum allowance for each hearing aid. Up to 2 hearing aids every year.

$1,000 maximum allowance for each hearing aid. Up to 2 hearing aids every year.

Hearing aids must be purchased through NationsHearing.

Hearing Services and Hearing Aids

Additional Benefits (continued) Dental Services

$0 copay for the services below. • 2 cleanings per year (one every six months) • Oral exams and X-rays • S urgery and extractions • C omplete or partial dentures, including adjustments and repairs • F illings, crowns and root canals

Over-the-Counter Items

$100 monthly allowance for the purchase of non-prescription items, such as vitamins and aspirin. What you need to know: • A ny balance not used for a month will not carry over to the next month

Telehealth

$0 copay for Primary Care services, Urgently Needed services, Outpatient Occupational, Physical and Speech Therapy, Dermatology, and most Medicare-covered Preventive services. See the Summary of Benefits for more information about Telehealth. • Available 24/7 • Able to prescribe medications, except controlled substances

At Home Care

Transportation Services

$0 copay for unlimited one-way trips annually for rides to your doctor, hospital or pharmacy

These services can accommodate wheelchairs, walkers, oxygen tanks and service animals Discharge Meals

Members discharged from a hospital following an acute hospital admission will qualify for a total of 10 home-delivered meals

Additional Benefits (continued) HealthyBlue Rewards

• R edeem gift card rewards for completing and reporting preventive care and screenings

SilverSneakers® Fitness Program

Florida Blue Medicare is an HMO plan with a Medicare contract. Enrollment in Florida Blue Medicare depends on contract renewal. HMO coverage is offered by Florida Blue Medicare, Inc., DBA Florida Blue Medicare, an Independent Licensee of the Blue Cross and Blue Shield Association. Sponsored by Florida Blue Medicare, Inc., d/b/a Florida Blue Medicare, and the State of Florida, Agency for Health Care Administration. Tivity Health and SilverSneakers are registered trademarks or trademarks of Tivity Health, Inc., and/or its subsidiaries and/or affiliates in the USA and/or other countries. We comply with applicable Federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability, or gender. ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-855-601-9465 (TTY: 1-877-955-8773). ATANSYON: Si w pale Kreyòl Ayisyen, gensèvis èd pou lang ki disponib gratis pou ou. Rele 1-855-601-9465 (TTY: 1-800-955-8770). © 2020 Blue Cross and Blue Shield of Florida, Inc., DBA Florida Blue. All rights reserved.

Benefits at-a-Glance Plan Costs & Details

BlueMedicare Select (PPO) H5434-002

Service Area

Bay, Broward, Charlotte, Collier, Duval, Escambia, Highlands, Hillsborough, Lee, Manatee, Marion, Orange, Osceola, Palm Beach, Pinellas, Santa Rosa & St. Lucie Counties

How much is the monthly premium?

$146.80 You must continue to pay your Medicare Part B premium.

How much is the deductible?

This plan does not have a deductible for medical services and supplies. $305 per year for Part D prescription drugs. Not applicable to Tier 6.

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

$5,900 In-Network providers. $10,000 in and Out-of-Network providers combined.

Medical & Hospital Benefits Doctor’s Office Visits

In-Network $5 copay Primary Care Physician

Out-of-Network 40% coinsurance

$45 copay Specialist Preventive Care

In-Network $0 copay

Out-of-Network 40% coinsurance

Inpatient Hospital Care

In-Network Days 1-7: $225 copay per day

Out-of-Network Days 1-27: $200 copay per day.

After the 7th day the plan pays 100% of covered expenses.

Days 28-90: $0 copay per day

In-Network $130 copay except for Observation Services

Out-of-Network 40% coinsurance

Outpatient Hospital

$90 copay for Observation Services

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Medical & Hospital Benefits (continued) Outpatient Surgery

In-Network $150 copay in an Ambulatory Surgical Center

Out-of-Network 40% coinsurance

$130 copay in an Outpatient Hospital Facility Urgently Needed Services

In- and Out-of-Network $25 copay at a Convenient Care Center $25 copay at an Urgent Care Center

Emergency Room

In- and Out-of-Network $90 copay

Ambulance

In- and Out-of-Network $150 copay

Part D Prescription Drug Benefits1 Tier 1

Deductible then $3 copay

Tier 2

Deductible then $10 copay

Tier 3

Deductible then $40 copay

Tier 4

Deductible then $93 copay

Tier 5

Deductible then 27% coinsurance

Tier 6

$0 copay

Mail Order

Same copays/coinsurance as Preferred Pharmacy listed above

(Preferred Generic) (Generic) (Preferred Brand) (Non-Preferred) (Specialty) (Select Care)

What you pay at a Preferred Pharmacy for a 31-day supply

Additional Benefits Acupuncture2

In-Network $20 copay

Vision Services2

In-Network $0 copay for annual routine eye exam $100 allowance per year towards the purchase of lenses, frames or contact lenses

Additional Benefits (continued) Hearing Services and Hearing Aids2

In-Network $0 copay for one routine hearing exam per year $0 copay for evaluation and fitting of hearing aids $350 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 cleanings and other preventive services

Telehealth2

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

At Home Care2

HealthyBlue Rewards

• R edeem gift card rewards for completing and reporting preventive care and screenings

SilverSneakers® Fitness Program

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

Florida Blue is a PPO Plan with a Medicare contract. Enrollment in Florida Blue depends on contract renewal. 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. Tivity Health and SilverSneakers are registered trademarks or trademarks of Tivity Health, Inc. and/or its subsidiaries and/or affiliates in the USA and/or other countries. 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. We comply with applicable Federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability, or gender. ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-855-601-9465 (TTY: 1-877-955-8773). ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-855-601-65 (TTY: 1-800-955-8770).© 2020 Blue Cross and Blue Shield of Florida, Inc., DBA Florida Blue. All rights reserved.

Benefits at-a-Glance BlueMedicare Value (PPO)

BlueMedicare Value (PPO)

H5434-026

H5434-032

Service Area

Broward, Indian River, Martin, Palm Beach & St. Lucie

Miami-Dade

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 medical services and supplies.

$1,000 Out-of-Network (OON) deductible for medical services and supplies.

Plan Costs

$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?

$3,900 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 Benefits Doctor’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 Specialist

Preventive Care

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 Specialist

Out-of-Network 50% coinsurance

Out-of-Network OON deductible then 50% coinsurance

In-Network $0 copay

Out-of-Network 50% coinsurance

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Medical & Hospital Benefits (continued) Inpatient Hospital Care

Outpatient Hospital

In-Network Days 1-8 $250 copay per day

In-Network Days 1-6: $325 copay per day

After the 8th day the plan pays 100% of covered expenses.

After the 6th day the plan pays 100% of covered expenses.

Out-of-Network 50% coinsurance

Out-of-Network OON deductible then 50% coinsurance

In-Network $200 copay except for Observation Services $90 copay for Observation Services

In-Network $250 copay except for Observation Services $90 copay for Observation Services

Out-of-Network 50% coinsurance

Out-of-Network OON deductible then 50% coinsurance

In-Network $132 copay in an Ambulatory Surgical Center

In-Network $140 copay in an Ambulatory Surgical Center

$200 copay in an Outpatient Hospital Facility

$250 copay for in an Outpatient Hospital Facility

Out-of-Network 50% coinsurance

Out-of-Network OON deductible then 50% coinsurance

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

$50 copay at an Urgent Care Center

Emergency Room

In- and Out-of-Network $90 copay

Ambulance

In- and Out-of-Network $325 copay

Outpatient Surgery

Urgently Needed Services

Part D Prescription Drug Benefits1 Tier 1

$0 copay

$2 copay

Tier 2

$8 copay

$10 copay

Tier 3

Deductible then $47 copay

$47 copay

(Preferred Generic) (Generic) (Preferred Brand)

Part D Prescription Drug Benefits1 (continued) Tier 4

Deductible then $100 copay

$100 copay

Tier 5

(Specialty)

Deductible then 30% coinsurance

33% coinsurance

Tier 6

$0 copay

Mail Order

Same copays/coinsurance as listed above

(Non-Preferred)

(Select Care)

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

Additional Benefits Acupuncture2

In-Network $20 copay

Vision Services2

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

Hearing Services and Hearing Aids2

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

Out-of- Network 50% coinsurance for one routine hearing exam per year $1,000 maximum allowance for each hearing aid. Up to 2 hearing aids every year. Hearing aids must be purchased through NationsHearing.

Out-of- Network 50% coinsurance for one routine hearing exam per year $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: • A ny balance not used for a quarter will not carry over to the next quarter • Y ou must use your full benefit in one order • Y our order total may not exceed your benefit amount

Additional Benefits (continued)

Telehealth2

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

At Home Care2

Caregiver Support for Member2

HealthyBlue Rewards

• R edeem gift card rewards for completing and reporting preventive care and screenings

SilverSneakers® Fitness Program

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