2018 Summary of Benefits

BlueMedicare Complete (HMO SNP) H1026-065,066

Orange and Polk

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

Sponsored by Health Options, Inc., d/b/a Florida Blue HMO and the State of Florida, Agency for
Health Care Administration.

Y0011_33833 0817 CMS Accepted

BlueMedicare Complete (HMO SNP) Summary of Benefits
January 1, 2018 - December 31, 2018

This booklet provides a summary of what BlueMedicare Complete (HMO SNP) plans cover. It also explains
what you pay for covered services and supplies. To get a complete list of services we cover, contact your local
agent or call our Customer Service Department. You may also view the “Evidence of Coverage” for these plans
on our website, www.BlueMedicareFL.com. The Evidence of Coverage includes a complete list of services
we cover.
Things to Know About BlueMedicare Complete (HMO SNP) Plans
Eligibility requirements
To join these plans, you must:
• be entitled to Medicare Part A; and
• be enrolled in Medicare Part B;
• live in our service area; and
• receive certain levels of assistance from the Florida Medical Assistance Program (Medicaid). If you receive
both Medicare and Medicaid benefits, this means you are a dual eligible.
Our service area includes the following counties in Florida: Orange (H1026-065) and Polk (H1026-066).

BlueMedicare Complete (HMO SNP) may enroll dual eligibles who are SMLB, SLMB Plus, QMB, QMB Plus,
FBDE, QI and QDWI.
NOTE: You cannot be enrolled in both a Medicaid Managed Care plan and a DSNP plan in Florida. For
members protected by the State Medicaid Program from cost sharing, Medicaid pays coinsurance, copays and
deductibles for Original Medicare covered services.
________________________________________________________________________________________

Which doctors, hospitals and pharmacies can I use?

We have a network of doctors, hospitals and other providers. In most cases, you must receive care from network
providers. Your plan generally does not cover care you receive from out-of-network providers. There are three
exceptions to this requirement:
• We cover emergency care and urgently needed services you receive from out-of-network providers.
• If providers in our network cannot provide a type of Medicare-covered care you need, we will cover the care
if you receive it from an out-of-network provider. You must receive approval from our plan before seeking
care from an out-of-network provider in this situation.
• We will cover care you receive at a Medicare-certified dialysis facility when you are temporarily not in our
service area.
In most situations, you must use our network pharmacies to fill your prescriptions for covered Part D drugs.
You can also use mail order to have your prescription delivered to your home.
Find doctors, pharmacies and our comprehensive formulary (list of covered Part D drugs) on our website,
www.BlueMedicareFL.com.
________________________________________________________________________________________
What do we cover?
Our plan includes all of the benefits covered by Original Medicare. For some of these benefits, you may pay
more in our plan than you would in Original Medicare. For others, you may pay less. Our plan members also
get more than what is covered by Original Medicare. Some of the extra benefits are outlined in this booklet. We
cover Part D drugs. In addition, we cover Part B drugs, such as chemotherapy and certain other drugs your
doctor gives you.

1
Hours of Operation
From October 1 to February14 we’re open 8 a.m. – 8 p.m. local time, 7 days a week.
From February 15 to September 30 we’re open 8 a.m. – 8 p.m. local time, Monday through Friday.

Phone Numbers and Websites

1-855-601-9465 TTY users: Call 1-800-955-8770
Our website: www.BlueMedicareFL.com
For the most current Florida Medicaid coverage information, please visit the Florida Medicaid website at
http://ahca.myflorida.com/ or call the Medicaid Hotline at 1-888-419-3456.
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.

This document is available in other formats such as Braille and large print.
This information is available for free in other languages. Please call our Member Services number at 1-800-
926-6565. (TTY users should call 1-800-955-8770.) Hours are 8:00 a.m. – 8:00 p.m. local time, seven days a
week from October 1 to February 14, except for Thanksgiving and Christmas. From February 15 to September
30, we are open Monday - Friday, 8:00 a.m. – 8:00 p.m., local time.
Esta información está disponible de manera gratuita en otros idiomas. Comuníquese con Atención al cliente al
1-800-926-6565. (Usuarios de equipo telescritor TTY llamen al 1-877-955-8773.) Estamos abiertos de 8:00
a.m. a 8:00 p.m. hora local los siete días de la semana, desde el 1 de octubre hasta el 14 de febrero, excepto
el día de Acción de Gracias (Thanksgiving) y el día de Navidad. Desde el 15 de febrero al 30 de septiembre,
estamos abiertos de lunes a viernes de 8:00 a.m. a 8:00 p.m. hora local.
Florida Blue HMO is an HMO plan with a Medicare contract and a contract with the Florida Agency for Health
Care Administration (AHCA) Medicaid Program. Enrollment in Florida Blue HMO depends on contract
renewal.
This information is not a complete description of benefits. Contact the plan for more information. Limitations,
copayments, and restrictions may apply. Benefits, premiums and/or copayments/coinsurance may change on
January 1 of each year.
You must continue to pay your Medicare Part B premium. If you meet certain eligibility requirements for both
Medicare and Medicaid, your Part B premiums may be covered in full.
Premiums, copays, coinsurance and deductibles may vary based on the level of Extra Help you receive.
Please contact Florida Blue HMO for details.
The formulary and/or pharmacy network and/or provider network may change at any time. You will receive
notice when necessary.

2
Monthly Premium, Deductible and Limits
BlueMedicare Complete (HMO SNP) BlueMedicare Complete (HMO SNP)
Orange County Polk County

Monthly Plan The plan premium is $29.10 per month.
Premium Depending on your level of assistance,
you may not pay a monthly plan premium.
You must continue to pay your Medicare
Part B premium (unless your Part B
premium is paid for you by Medicaid or
another third party).
The plan premium is $29.10 per month.
Depending on your level of assistance,
you may not pay a monthly plan premium.
You must continue to pay your Medicare
Part B premium (unless your Part B
premium is paid for you by Medicaid or
another third party).

Deductible This plan does not have a deductible. This plan does not have a deductible.

Maximum Out-of- Your yearly limit(s) in this plan: Your yearly limit(s) in this plan:
Pocket • $6,700 for services from in-network • $6,700 for services from in-network
Responsibility providers. providers.
(does not include
prescription drugs) If you reach the limit on out-of-pocket If you reach the limit on out-of-pocket
costs, we will pay the full cost of covered costs, we will pay the full cost of covered
medical services and supplies for the rest medical services and supplies for the rest
of the year. of the year.

Covered Medical and Hospital Benefits

The benefit chart below shows the benefits you will receive from Florida Blue and how Medicaid covers your
cost sharing for those plan benefits. The chart also lists some benefits you could receive from Medicaid if you
are eligible for full Medicaid benefits. If you are entitled to Medicare benefits, your care coordinator will work
with you to assist you in understanding and accessing the Medicare and Medicaid benefits you may be
entitled to.

Premiums and BlueMedicare Complete BlueMedicare Complete Traditional Florida

Benefits (HMO SNP) Orange (HMO SNP) Polk County Medicaid
County (Medicaid Managed
Care plan benefits may
be different)

Inpatient Hospital You pay nothing You pay nothing $0 copay per admission
Coverage for Medicaid-covered
services.
Under
BlueMedicare
Complete Prior
Authorization is
required for non-
emergency
Inpatient Hospital
stays.

Services marked with a 1 may require approval in advance (a referral) from your Primary Care Provider (PCP)
in order for the plan to cover them. If you do not get a referral for these services, you may have to pay the full
cost of them.
3
 Premiums and BlueMedicare Complete BlueMedicare Complete Traditional Florida
Benefits (HMO SNP) Orange (HMO SNP) Polk County Medicaid
County (Medicaid Managed
Care plan benefits may
be different)

Outpatient $0 copay $0 copay $3 copayment, per visit,

Hospital Coverage if not exempt from cost
sharing.
Under
BlueMedicare
Complete Prior
Authorization may
be required. Please
contact the plan for
details.

Doctor Visits You pay nothing per primary
visit
You pay nothing per
specialist1 visit
You pay nothing per primary
visit
You pay nothing per
specialist1 visit
$2 copayment per
provider or group
provider, per day, if not
exempt from cost
sharing.
$3 copayment for
practitioner services
provided at a Rural
Health Center (RHC) or
Federally Qualified
Health Center (FQHC)
only, per clinic, per day, if
not exempt from cost
sharing.

Preventive Care You pay nothing. You pay nothing. $3 copayment for
Covered preventive services Covered preventive services covered preventive
include: include: screenings provided at a
• Alcohol misuse screening Rural Health Center
• Alcohol misuse screening
and counseling (RHC) or Federally
and counseling
Qualified Health Center
• Annual “Wellness” visit • Annual “Wellness” visit (FQHC) only, per clinic,
• Bone mass • Bone mass per day, if not exempt
measurements measurements from cost sharing.
• Cardiovascular disease • Cardiovascular disease
screening tests screening tests
• Colorectal cancer • Colorectal cancer
screening screening
• Counseling to prevent • Counseling to prevent
Tobacco use Tobacco use
• Depression screening • Depression screening
• Diabetes screening • Diabetes screening
• Diabetes self- • Diabetes self-
management training management training
Preventive Care • Glaucoma screening • Glaucoma screening
Services marked with a 1 may require approval in advance (a referral) from your Primary Care Provider (PCP)
in order for the plan to cover them. If you do not get a referral for these services, you may have to pay the full
cost of them.
4
 Premiums and BlueMedicare Complete
Benefits (HMO SNP) Orange
County
(continued) • Hepatitis B Virus
screening
• Hepatitis B Virus vaccine
and administration
• Hepatitis C Virus
screening
• Human Immunodeficiency
Virus screening
• Influenza virus vaccine
and administration
• Initial preventive physical
examination
• Intensive behavioral
therapy for cardiovascular
disease
• Intensive behavioral
therapy for obesity
• Lung cancer screening
• Medical nutrition therapy
• Pneumococcal vaccine
and administration
• Prostate cancer screening
• Screening for Cervical
Cancer with human
Papillomavirus tests
• Screening for sexually
transmitted infections
(STIs) and HIBC to
prevent STIs
• Screening mammography
• Screening pap tests
• Screening pelvic
examinations
• Ultrasound screening
abdominal aortic
aneurysm
Any additional preventive
services approved by
Medicare during the contract
year will be covered by our
plan or original Medicare.
Services marked with a 1 may require approval in advance (a referral) from your Primary Care Provider (PCP)
in order for the plan to cover them. If you do not get a referral for these services, you may have to pay the full
cost of them.
BlueMedicare Complete Traditional Florida
(HMO SNP) Polk County Medicaid
(Medicaid Managed
Care plan benefits may
be different)
• Hepatitis B Virus
screening
• Hepatitis B Virus vaccine
and administration
• Hepatitis C Virus
screening
• Human Immunodeficiency
Virus screening
• Influenza virus vaccine
and administration
• Initial preventive physical
examination
• Intensive behavioral
therapy for cardiovascular
disease
• Intensive behavioral
therapy for obesity
• Lung cancer screening
• Medical nutrition therapy
• Pneumococcal vaccine
and administration
• Prostate cancer screening
• Screening for Cervical
Cancer with human
Papillomavirus tests
• Screening for sexually
transmitted infections
(STIs) and HIBC to
prevent STIs
• Screening mammography
• Screening pap tests
• Screening pelvic
examinations
• Ultrasound screening
abdominal aortic
aneurysm
Any additional preventive
services approved by
Medicare during the contract
year will be covered by our
plan or original Medicare.
5
 Premiums and BlueMedicare Complete
Benefits (HMO SNP) Orange
County
Emergency Care You pay nothing per visit
Under
BlueMedicare
Complete, if you
are immediately
admitted to the
hospital, you do not
have to pay your
share of the cost for
emergency care.
Urgently Needed You pay nothing at a
Services Convenient Care Center or
Urgent Care Center.
Diagnostic Laboratory Services
Services/Labs/ • You pay nothing at an
Imaging 1 Independent Clinical
Laboratory or outpatient
Under
hospital facility
BlueMedicare
Complete Prior X-Rays
Authorization is
• You pay nothing at an
required for certain
services. Independent Diagnostic
Testing Facility (IDTF) or
outpatient hospital facility
Advanced Imaging
Services (e.g., Magnetic
Resonance Imaging [MRI],
Positron Emission
Tomography [PET],
Computer Tomography [CT]
Scan)
• You pay nothing at a
specialist’s office, IDTF or
outpatient hospital facility
Radiation Therapy
• You pay nothing
Services marked with a 1 may require approval in advance (a referral) from your Primary Care Provider (PCP)
in order for the plan to cover them. If you do not get a referral for these services, you may have to pay the full
cost of them.
BlueMedicare Complete
(HMO SNP) Polk County
You pay nothing per visit
You pay nothing at a
Convenient Care Center or
Urgent Care Center.
Laboratory Services
• You pay nothing at an
Independent Clinical
Laboratory or outpatient
hospital facility
X-Rays
• You pay nothing at an
Independent Diagnostic
Testing Facility (IDTF) or
outpatient hospital facility
Advanced Imaging
Services (e.g., Magnetic
Resonance Imaging [MRI],
Positron Emission
Tomography [PET],
Computer Tomography [CT]
Scan)
• You pay nothing at a
specialist’s office, IDTF or
outpatient hospital facility
Radiation Therapy
• You pay nothing
6
Traditional Florida
Medicaid
(Medicaid Managed
Care plan benefits may
be different)
$3 copayment, per visit, if
not exempt from cost
sharing.
5% coinsurance up to the
first $300.00 of Medicaid
payment for each visit in
the emergency room for
non-emergency
services, not to exceed
$15.00.
$2 copayment for
services in a practitioner
office setting, per
provider or group
provider, per day, if not
exempt from cost
sharing.
$1 copayment for
independent laboratory
services per provider, per
day, if not exempt from
cost sharing.
$1 copayment for
portable X-Ray services
per provider, per day, if
not exempt from cost
sharing.
$2 copayment per
provider or group
provider, per day, if not
exempt from cost
sharing.
$3 copayment for
services provided at a
Rural Health Center
(RHC) or Federally
Qualified Health Center
(FQHC) only, per clinic,
per day, if not exempt
from cost sharing.
 Premiums and BlueMedicare Complete
Benefits (HMO SNP) Orange
County
Hearing Services1 Medicare-Covered Hearing
Services
Exams to diagnose and treat
hearing and balance issues
• You pay nothing
Routine Hearing Services
• You pay nothing for one
hearing exam per year.
• $1,000 allowance per year
toward any model hearing
aid.
• $0 copay for one
evaluation and fitting of
hearing aids per year.
Dental Services Medicare-Covered Dental
Services (non-routine dental
Under
care such as setting
BlueMedicare
fractures of the jaw or facial
Complete Prior
bones, jaw surgery,
Authorization is
required for extraction of teeth to
prepare for radiation therapy,
Medicare-covered
services covered when
comprehensive
provided by a physician)
dental services.
• You pay nothing
Additional Dental Services
(cleanings, oral exams, X-
rays, extraction of erupted
tooth or exposed root,
adjustment of complete or
partial denture, dentures,
crowns, and other dental
benefits)
• You pay nothing up to a
$6,000 annual maximum
Services marked with a 1 may require approval in advance (a referral) from your Primary Care Provider (PCP)
in order for the plan to cover them. If you do not get a referral for these services, you may have to pay the full
cost of them.
BlueMedicare Complete
(HMO SNP) Polk County
Medicare-Covered Hearing
Services
Exams to diagnose and treat
hearing and balance issues
• You pay nothing
Routine Hearing Services
• You pay nothing for one
hearing exam per year.
• $1,000 allowance per year
toward any model hearing
aid.
• $0 copay for one
evaluation and fitting of
hearing aids per year.
Medicare-Covered Dental
Services (non-routine dental
care such as setting
fractures of the jaw or facial
bones, jaw surgery,
extraction of teeth to
prepare for radiation therapy,
services covered when
provided by a physician)
• You pay nothing
Additional Dental Services
(cleanings, oral exams, X-
rays, extraction of erupted
tooth or exposed root,
adjustment of complete or
partial denture, dentures,
crowns, and other dental
benefits)
• You pay nothing up to a
$6,000 annual maximum
7
Traditional Florida
Medicaid
(Medicaid Managed
Care plan benefits may
be different)
$0 copay for Medicaid-
covered services.
For recipients who have
moderate hearing loss or
greater, including the
following services:
• One new, complete,
(not refurbished)
hearing aid device per
ear, every three years,
per recipient
• Up to three pairs of ear
molds per year, per
recipient
• One fitting and
dispensing service per
ear, every three years,
per recipient
$2 copayment for oral
and maxillofacial surgery
services per practitioner
office visit, per day
$3 copayment for dental
services provided at a
Federally Qualified
Health Center (FQHC)
only, per clinic, per day, if
not exempt from cost
sharing.
Covered Adult Services
(Ages 21 and Over)
• One comprehensive
evaluation every three
years, per recipient. For
recipients age 21 years
and older, a
comprehensive
evaluation is
reimbursed for the
purpose of determining
the need for full or
partial dentures, or
problem focused
services
 Premiums and BlueMedicare Complete BlueMedicare Complete Traditional Florida
Benefits (HMO SNP) Orange (HMO SNP) Polk County Medicaid
County (Medicaid Managed
Care plan benefits may
be different)

• Limited evaluations, as
medically indicated
• One complete series of
intraoral radiographs
every three years, per
recipient
• One panoramic
radiograph every three
years, per recipient
• Prosthodontic services
to diagnose, plan,
rehabilitate, fabricate,
and maintain dentures
as follows:
• One upper, lower, or
complete set of full or
removable partial
dentures per recipient
• One reline, per denture,
per 366 days, per
recipient
Traditional Florida
Medicaid reimburses for
emergency dental
services for recipients
age 21 years and older
to alleviate pain,
infection, or both, and
procedures essential to
prepare the mouth for
dentures.
Covered Children
Services (Ages under
21)
The Medicaid children's
dental services program
may provide
reimbursement for
adjunctive general
services, diagnostic
services, diagnostic
imaging, preventive
treatment, restorative,
endodontic, periodontal,
surgical procedures and
Services marked with a 1 may require approval in advance (a referral) from your Primary Care Provider (PCP)
in order for the plan to cover them. If you do not get a referral for these services, you may have to pay the full
cost of them.
8
 Premiums and BlueMedicare Complete
Benefits (HMO SNP) Orange
County
Vision Services1 Medicare-Covered Vision
Services
Under
BlueMedicare You pay nothing for the
Complete Prior following services:
Authorization is • physician services to
required for diagnose and treat eye
Medicare-covered diseases and conditions
comprehensive • glaucoma screening (once
vision services. per year for members at
high risk of glaucoma).
• diabetic retinal exams.
• one pair of eyeglasses or
contact lenses after each
cataract surgery.
Additional Vision Services Additional Vision Services not exempt from cost
• You pay nothing for one • You pay nothing for one
routine eye exam every 12
months.
• $200 Allowance per year • $200 Allowance per year
towards the purchase of
lenses, frames or contacts
Mental Health Inpatient Mental Health
Services Services
Limited to 190 days in a
Under
BlueMedicare lifetime for inpatient mental
health care in a psychiatric
Complete Prior
Authorization is hospital. This limit does not
required for non- apply to inpatient mental
emergency health services provided in a
services. general hospital.
• You pay nothing
Outpatient Mental Health
Services
• You pay nothing
Services marked with a 1 may require approval in advance (a referral) from your Primary Care Provider (PCP)
in order for the plan to cover them. If you do not get a referral for these services, you may have to pay the full
cost of them.
BlueMedicare Complete Traditional Florida
(HMO SNP) Polk County Medicaid
(Medicaid Managed
Care plan benefits may
be different)
extractions,
prosthodontic and
orthodontic treatment,
including complete and
partial dentures.
Medicare-Covered Vision $0 copayment for visual
Services aid services.
You pay nothing for the $2 copayment for
following services: optometrist services, per
• physician services to provider or group
diagnose and treat eye provider, per day, if not
diseases and conditions exempt from cost
• glaucoma screening (once sharing.
per year for members at
$3 copayment for
high risk of glaucoma).
optometrist services
• diabetic retinal exams.provided at a Rural
Health Center (RHC) or
• one pair of eyeglasses or
Federally Qualified
contact lenses after each
cataract surgery. Health Center (FQHC)
only, per clinic, per day, if
sharing.
routine eye exam every 12 Florida Medicaid covers
months. one frame every two
years and two lenses
towards the purchase of every 365 days.
lenses, frames or contacts
Inpatient Mental Health $2 copayment per
Services provider, per day, if not
Limited to 190 days in a exempt from cost
sharing.
lifetime for inpatient mental
health care in a psychiatric
$3 copayment for
hospital. This limit does not outpatient mental health
apply to inpatient mental services provided at a
health services provided in a Rural Health Center
general hospital. (RHC) or Federally
• You pay nothing Qualified Health Center
Outpatient Mental Health (FQHC) only, per clinic,
Services per day, if not exempt
from cost sharing.
• You pay nothing
9
 Premiums and BlueMedicare Complete
Benefits (HMO SNP) Orange
County
Skilled Nursing Our plan covers up to 100
Facility (SNF) days in a SNF per benefit
period.
Under
BlueMedicare • You pay nothing
Complete Prior
Authorization is
required for SNF
stays.
Physical Therapy1 Occupational, physical
therapy and speech and
Under
language therapy visits
BlueMedicare
• You pay nothing for
Complete Prior
Authorization is services received in a
specialist’s office, a free-
required for all
standing facility or
therapy services.
outpatient hospital facility
A $1,980 yearly Medicare
limit applies to outpatient
physical and speech
therapy services. This limit
is for 2017 and may change
in 2018.
A separate $1,980 yearly
Medicare limit applies to
outpatient occupational
therapy services. This limit is
for 2017 and may change in
2018.
Services marked with a 1 may require approval in advance (a referral) from your Primary Care Provider (PCP)
in order for the plan to cover them. If you do not get a referral for these services, you may have to pay the full
cost of them.
10
BlueMedicare Complete
(HMO SNP) Polk County
Our plan covers up to 100
days in a SNF per benefit
period.
• You pay nothing
Occupational, physical
therapy and speech and
language therapy visits
• You pay nothing for
services received in a
specialist’s office, a free-
standing facility or
outpatient hospital facility
A $1,980 yearly Medicare
limit applies to outpatient
physical and speech
therapy services. This limit
is for 2017 and may change
in 2018.
A separate $1,980 yearly
Medicare limit applies to
outpatient occupational
therapy services. This limit is
for 2017 and may change in
2018.
Traditional Florida
Medicaid
(Medicaid Managed
Care plan benefits may
be different)
$0 copay for Medicaid-
covered services.
Medicaid-covered
services include:
Physical Therapy,
Occupational Therapy,
Respiratory Therapy, and
Speech-Language
Pathology services
$0 copayment for
respiratory system
services.
$0 copayment for
physical therapy
services.
$2 copayment per
provider, per day, for
outpatient rehabilitation
services provided in an
office setting, if not
exempt from cost
sharing.
$3 copayment for
outpatient rehabilitation
services provided at a
Rural Health Center
(RHC) or Federally
Qualified Health Center
(FQHC) only, per clinic,
per day, if not exempt
from cost sharing.
$3 copayment, per visit
to an outpatient hospital,
if not exempt from cost
sharing.
 Premiums and BlueMedicare Complete BlueMedicare Complete Traditional Florida
Benefits (HMO SNP) Orange (HMO SNP) Polk County Medicaid
County (Medicaid Managed
Care plan benefits may
be different)

Ambulance In- and Out-of-Network In- and Out-of-Network $0 copay for Medicaid-
covered services.
Under • You pay nothing for each • You pay nothing for each
BlueMedicare Medicare-covered trip Medicare-covered trip
Complete Prior (one-way) (one-way)
Authorization is
required for non-
emergency
ambulance
services.

Transportation You pay nothing
(Routine)
Unlimited one-way trips per
calendar year to plan-
approved locations for
scheduled medical-related
services and prescriptions
transportation within your
service area.
You pay nothing
Unlimited one-way trips per
calendar year to plan-
approved locations for
scheduled medical-related
services and prescriptions
transportation within your
service area.
$1 copay per one way
trip
Non-Emergency Medical
Transportation (NEMT)
services are available
only to eligible
beneficiaries who cannot
obtain transportation
through any other means
(such as family, friends
or community resources).

Medicare Part B In-Network In-Network $0 copayment for

Drugs prescription drugs
• You pay nothing for allergy • You pay nothing for allergy obtained through the
Under injections injections
Prescription Drug
BlueMedicare
Complete Prior • You pay nothing for • You pay nothing for Services program.
Authorization is chemotherapy drugs and chemotherapy drugs and
$2 copayment for
other Medicare Part B- other Medicare Part B-
required for practitioner services, per
Medicare Part B- covered drugs covered drugs provider or group
covered provider, per day, if not
prescription drugs exempt from cost
except for allergy sharing.
injections.
$3 copayment for Part B
prescription drug
administration provided
at a Rural Health Center
(RHC) or Federally
Qualified Health Center
(FQHC) only, per clinic,
per day, if not exempt
from cost sharing.

Services marked with a 1 may require approval in advance (a referral) from your Primary Care Provider (PCP)
in order for the plan to cover them. If you do not get a referral for these services, you may have to pay the full
cost of them.
11
 Premiums and BlueMedicare Complete BlueMedicare Complete Traditional Florida
Benefits (HMO SNP) Orange (HMO SNP) Polk County Medicaid
County (Medicaid Managed
Care plan benefits may
be different)

Foot Care (podiatry Diagnosis and treatment of
services) injuries and diseases of the
feet. Routine care for
members with certain
conditions affecting the lower
limbs.
• You pay nothing
Diagnosis and treatment of
injuries and diseases of the
feet. Routine care for
members with certain
conditions affecting the lower
limbs.
• You pay nothing
$2 copayment per
provider or group
provider, per day, if not
exempt from cost
sharing.
$3 copayment for
podiatry services
provided at a Rural
Health Center (RHC) or
Federally Qualified
Health Center (FQHC)
only, per clinic, per day, if
not exempt from cost
sharing.

Medical Durable Medical Durable Medical $0 copay for Medicaid-

Equipment/ Equipment Equipment covered services.
Supplies You pay nothing for the You pay nothing for the
Under following: following:
BlueMedicare
Complete Prior • equipment • equipment
Authorization is • motorized wheelchairs • motorized wheelchairs
required for certain and electric scooters. and electric scooters.
equipment/supplies. • Prosthetics • Prosthetics
• Diabetic supplies • Diabetic supplies

Wellness • SilverSneakers® fitness • SilverSneakers® fitness Not Applicable.

Programs program by Tivity Health.
• Diabetes Prevention
Program - An evidence-
based program designed to
delay or prevent
participants’ progression to
type 2 diabetes.
You pay nothing to
participate in these
programs.
program by Tivity Health.
• Diabetes Prevention
Program - An evidence-
based program designed to
delay or prevent
participants’ progression to
type 2 diabetes.
You pay nothing to
participate in these
programs.

Services marked with a 1 may require approval in advance (a referral) from your Primary Care Provider (PCP)
in order for the plan to cover them. If you do not get a referral for these services, you may have to pay the full
cost of them.
12
 Premiums and BlueMedicare Complete BlueMedicare Complete Traditional Florida
Benefits (HMO SNP) Orange (HMO SNP) Polk County Medicaid
County (Medicaid Managed
Care plan benefits may
be different)

Outpatient You pay nothing in an You pay nothing in an $2 copayment for

Surgery ambulatory surgical center or ambulatory surgical center or services in a practitioner
outpatient hospital facility. outpatient hospital facility. office setting, per
Under
provider or group
BlueMedicare
provider, per day, if not
Complete Prior
Authorization is exempt from cost
required for certain sharing.
services. $3 copayment for
services at an outpatient
hospital facility, per visit,
if not exempt from cost
sharing.
$0 copayment for
ambulatory surgical
center (ASC) services.

Over-the-Counter $100 maximum benefit every
(OTC) Benefits quarter. Unused balance
does not roll over to the next
quarter.
$100 maximum benefit every
quarter. Unused balance
does not roll over to the next
quarter.
$0 copay for select Over-
the-Counter items,
contained in the
Medicaid formulary.
The drugs and supplies
must be prescribed by
licensed practitioners.

Meals You pay nothing for up to 10 You pay nothing for up to 10 Not Applicable
home delivered meals after home delivered meals after
each discharge from a each discharge from a
facility facility

Prescription Please see the Part D Please see the Part D $0 copay for Medicaid-
Drugs information below. information below. covered prescription
drugs not covered by a
Medicare Prescription
Drug Plan.

Services marked with a 1 may require approval in advance (a referral) from your Primary Care Provider (PCP)
in order for the plan to cover them. If you do not get a referral for these services, you may have to pay the full
cost of them.
13
Part D Prescription Drug Benefits
Dual eligible members receiving Extra Help assistance with Part D prescription drug costs will have
reduced cost sharing from that shown here, based on the level of assistance received.

Premiums and BlueMedicare Complete (HMO SNP) BlueMedicare Complete (HMO SNP)
Benefits Orange County Polk County

Deductible Stage Cost-Sharing for a one-month supply Cost-Sharing for a one-month supply (up
(up to 31 days) of a covered Part D to 31 days) of a covered Part D
Deductible amount
is $405. This applies prescription drug) prescription drug)
to Tiers 3, 4 and 5 Tier Standard Mail Order Tier Standard Mail Order
only. Retail Retail
You begin in this
payment stage when Tier 1 (Preferred Tier 1 (Preferred
$0 copay $0 copay $0 copay $0 copay
you fill your first Generic) Generic)
prescription of the
year for drugs in Tiers Tier 2 (Generic) $0 copay $0 copay Tier 2 (Generic) $0 copay $0 copay
3, 4 and 5.
Tier 3 (Preferred Tier 3 (Preferred
$47 copay $47 copay $47 copay $47 copay
During this stage, you Brand) Brand)
pay the full cost of
Tier 4 (Non-
your drugs. $100 copay $100 copay Tier 4 (Non- $100 copay $100 copay
PreferredBrand) PreferredBrand)
You stay in this stage
until you have paid Tier 5 (Specialty 25% of the 25% of the Tier 5 (Specialty 25% of the 25% of the
$405 for your drugs Drugs) cost cost Drugs) cost cost
Initial Coverage Tier 6 Tier 6
Stage (Supplemental $0 copay $0 copay (Supplemental $0 copay $0 copay
You begin in this Drugs) Drugs)
stage when you fill The cost-sharing information shown The cost-sharing information shown
your first prescription above is for a one-month supply of a above is for a one-month supply of a
of the year. covered Part D prescription drug covered Part D prescription drug
During this stage, the purchased at a retail pharmacy and purchased at a retail pharmacy and
plan pays its share of through our mail order pharmacy. Your through our mail order pharmacy. Your
the cost of your drugs cost-sharing may be different if you use a cost-sharing may be different if you use a
and you pay your Long Term Care pharmacy, a home Long Term Care pharmacy, a home
share of the cost. infusion pharmacy, or an out-of-network infusion pharmacy, or an out-of-network
pharmacy, or if you purchase a long-term pharmacy, or if you purchase a long-term
You remain in this supply (up to 100) days) of a drug. supply (up to 100) days) of a drug.
stage until your total
yearly drug costs Please call us or see the plan’s Please call us or see the plan’s “Evidence
(total drug costs paid “Evidence of Coverage” on our website of Coverage” on our website
by you and any Part (www.BlueMedicareFL.com) for complete (www.BlueMedicareFL.com) for complete
D plan) reach $3,750. information about your costs for covered information about your costs for covered
drugs. drugs.
You may get your
drugs at network
retail pharmacies and
mail order
pharmacies.

Services marked with a 1 may require approval in advance (a referral) from your Primary Care Provider (PCP)
in order for the plan to cover them. If you do not get a referral for these services, you may have to pay the full
cost of them.
14
Premiums and BlueMedicare Complete (HMO SNP)
Benefits Orange County
Coverage Gap The Coverage Gap Stage begins after
Stage total yearly drug costs (what any Part D
plan has paid and what you have paid)
reach $3,750.
During the Coverage Gap Stage:
You pay the same copays that you paid
in the Initial Coverage Stage for generic
drugs in Tier 1 (Preferred Generics),
Tier 2 (Generics) and Tier 6
(Supplemental Drugs) or 44% of the
cost, whichever is lower; and
For all other drugs, you pay 35% of the
cost for covered brand name drugs (plus
a portion of the dispensing fee) and 44%
of the plan's cost for covered generic
drugs.
You stay in this stage until your year-to-
date “out-of-pocket costs” (your
payments) reach a total of $5,000.
Catastrophic After your yearly out-of-pocket drug costs
Coverage Stage reach $5,000, you pay the greater of:
• 5% of the cost, or
• $3.35 copay for generic (including
brand drugs treated as generic) and
an $8.35 copay for all other drugs
Services marked with a 1 may require approval in advance (a referral) from your Primary Care Provider (PCP)
in order for the plan to cover them. If you do not get a referral for these services, you may have to pay the full
cost of them.
15
BlueMedicare Complete (HMO SNP)
Polk County
The Coverage Gap Stage begins after
total yearly drug costs (what any Part D
plan has paid and what you have paid)
reach $3,750.
During the Coverage Gap Stage:
You pay the same copays that you paid
in the Initial Coverage Stage for generic
drugs in Tier 1 (Preferred Generics),
Tier 2 (Generics) and Tier 6
(Supplemental Drugs) or 44% of the
cost, whichever is lower; and
For all other drugs, you pay 35% of the
cost for covered brand name drugs (plus
a portion of the dispensing fee) and 44%
of the plan's cost for covered generic
drugs.
You stay in this stage until your year-to-
date “out-of-pocket costs” (your
payments) reach a total of $5,000.
After your yearly out-of-pocket drug costs
reach $5,000, you pay the greater of:
• 5% of the cost, or
• $3.35 copay for generic (including
brand drugs treated as generic) and an
$8.35 copay for all other drugs
 Section 1557 Notification: Discrimination is Against the Law

Florida Blue, Florida Blue HMO, Florida Blue Preferred HMO (collectively, “Florida Blue”), Florida
Combined Life and the Blue Cross and Blue Shield Federal Employee Program® (FEP) 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.

Florida Blue, Florida Blue HMO, Florida Blue Preferred HMO, Florida Combined Life and FEP:
 Provide free aids and services to people with disabilities to communicate effectively with us, such as:
o Qualified sign language interpreters
o Written information in other formats (large print, audio, accessible electronic formats, other formats)
 Provide free language services to people whose primary language is not English, such as:
o Qualified interpreters
o Information written in other languages

If you need these services, contact:

 Florida Blue (health and vision coverage): 1-800-352-2583
 Florida Combined Life (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:
Florida Blue (including FEP members): Florida Combined Life:
Section 1557 Coordinator Civil Rights Coordinator
4800 Deerwood Campus Parkway, DCC 1-7 17500 Chenal Parkway
Jacksonville, FL 32246 Little Rock, AR 72223
1-800-477-3736 x29070 1-800-260-0331
1-800-955-8770 (TTY) 1-800-955-8770 (TTY)
Fax: 1-904-301-1580 civilrightscoordinator@fclife.com
section1557coordinator@floridablue.com

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 Services

200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019
1-800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html

87768 0217R
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 الصم‬3852-253-008-1 ‫ اتصل برقم‬.‫ فإن خدمات المساعدة اللغوية تتوافر لك بالمجان‬،‫ إذا كنت تتحدث اذكر اللغة‬:‫ملحوظة‬
.7222-333-008-1 ‫ اتصل برقم‬.0778-559-008-1 :‫والبكم‬
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.

સુચના: જો તમે ગુજરાતી બોલતા હો, તો નન:શુલ્ક ભાષા સહાય સેવા તમારા માટે ઉપલબ્ધ છે .
ફોન કરો 1-800-352-2583 (TTY: 1-800-955-8770). FEP: ફોન કરો 1-800-333-2227

ประกาศ:ถ้าคุณพูดภาษาไทย คุณสามารถใช้บริ การช่วยเหลือทางภาษาได้ฟรี โดยติดต่อหมายเลขโทรฟรี 1-800-352-2583 (TTY: 1-800-955-8770)

หรื อ 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

.‫ تسهیالت زبانی رایگان در دسترس شما خواهد بود‬،‫ اگر به زبان فارسی صحبت می کنید‬:‫توجه‬
.‫ تماس بگیريد‬1-800-333-2227 ‫ با شماره‬:FEP .‫ تماس بگیريد‬1-800-352-2583 (TTY: 1-800-955-8770) ‫با 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.