2019 Community Blue Medicare PPO Summary of Benefits

Residents of the following counties: Carbon, Lehigh, Monroe, Northampton, Schuylkill,

please click here.

Residents of the following counties: Adams, Centre, Cumberland, Dauphin, Franklin, Fulton,

Juniata, Lebanon, Mifflin, Perry, York, please click here.

Residents of the following counties: Berks, Bradford, Lackawanna, Luzerne, Pike, Snyder,

Susquehanna, Union, Wayne, Wyoming, please click here.

Residents of the following county: Lancaster, please click here.

Community Blue Medicare PPO

Summary of Benefits January 1, 2019 – December 31, 2019

Central and Northeastern Pennsylvania

Service Area Our service area includes the following counties in Pennsylvania: Carbon, Lehigh, Monroe, Northampton, Schuylkill.

To join Community Blue Medicare PPO, you must be entitled to Medicare Part A, be enrolled in Medicare Part B, and live in our service area.

H3916_18_0744_M

Central and Northeastern Pennsylvania

This booklet gives you a summary of what we cover and what you pay. It doesn’t list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, call us and ask for the “Evidence of Coverage.”

This document is available in other formats such as Braille and large print.

How to Contact

Or Visit Call Community Blue Medicare PPO 1-866-687-3182 (TTY users can call 711), www.highmarkblueshield.com/medicare

8:00 a.m.– 8:00 p.m., 7 days a week.

How to Find a Provider or Pharmacy Community Blue Medicare PPO has a network of doctors, hospitals, pharmacies, and other providers. If you use the providers that are not in our network, the plan may not pay for these services.

You can see our plan’s provider and pharmacy directory at www.highmarkblueshield.com/medicare. Or, call us and we will send you a copy of the provider and pharmacy directories.

You can see the complete plan formulary (list of Part D prescription drugs) and any restrictions on our website, client.formularynavigator.com/clients/hm/default.html. Or, call us and we will send you a copy of the formulary.

Every Highmark Medicare Advantage Plan

SILVERSNEAKERS® GYM MEMBERSHIPGives you access to over 13,000 participating facilities nationwide – with cardio and weight equipment, pools, saunas, and more.

BLUES ON CALLProvides 24/7 access to a registered nurse who can help you understand a diagnosis, review your symptoms, and much more.

ANNUAL WELLNESS VISITEncourages you to talk with your doctor about your overall health and to create a personal prevention plan for the year.

HIGHMARK HOUSE CALL PROGRAMOffers a free preventive health assessment, provided by a certified nurse practitioner, in the comfort of your own home.

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.

Out-of-Network Benefit: The out-of-network (OON) benefit provides “out-of-network” coverage. You may see out-of-network providers as long as the services are covered benefits and medically necessary. You pay more for services then when you would if you used a “network provider.

More About Original Medicare

Out-of-Network Benefit

Community Blue Medicare PPO Signature

DRUG

You pay the following until your total yearly drug costs reach $3,820. Total yearly drug costs are the total drug costs paid by both you and your Part D plan.

Initial Coverage

Standard Retail Cost-Sharing

Tier 31 Day Supply 90 Day SupplyTier 1 (Preferred Generic) $5 Copay $15 CopayTier 2 (Generic) $20 Copay $60 CopayTier 3 (Preferred Brand) $47 Copay $141 CopayTier 4 (Non-Preferred Drug) $100 Copay $300 CopayTier 5 (Specialty Tier) 33% of the cost Not Offered

Standard MailCost-Sharing

Tier 31 Day Supply 90 Day SupplyTier 1 (Preferred Generic) $15 Copay $15 CopayTier 2 (Generic) $60 Copay $60 CopayTier 3 (Preferred Brand) $141 Copay $141 CopayTier 4 (Non-Preferred Drug) $300 Copay $300 CopayTier 5 (Specialty Tier) 33% of the cost Not Offered

Preferred RetailCost-Sharing

Tier 31 Day Supply 90 Day SupplyTier 1 (Preferred Generic) $0 Copay $0 CopayTier 2 (Generic) $15 Copay $45 CopayTier 3 (Preferred Brand) $42 Copay $126 CopayTier 4 (Non-Preferred Drug) $95 Copay $285 CopayTier 5 (Specialty Tier) 33% of the cost Not Offered

Preferred Mail Cost-Sharing

Tier 31 Day Supply 90 Day SupplyTier 1 (Preferred Generic) $0 Copay $0 CopayTier 2 (Generic) $40 Copay $40 CopayTier 3 (Preferred Brand) $115 Copay $115 CopayTier 4 (Non-Preferred Drug) $280 Copay $280 CopayTier 5 (Specialty Tier) 33% of the cost Not Offered

Coverage Gap

The coverage gap begins after the yearly drug cost (including what our plan has paid and what you have paid) reaches $3,820. After you enter the coverage gap, you pay 25% of the plan’s cost for covered brand name drugs and 37% of the plan’s cost for covered generic drugs until your costs total $5,100, which is the end of the coverage gap.

Not everyone will enter the coverage gap.

Generics (37% Coinsurance) Brand (25% Coinsurance including 70% discount)

Catastrophic Coverage

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reaches $5,100,

you pay the greater of: 5% of the cost, or $3.40 Copay for generics and a $8.50 Copay for all other drugs.

Greater of: 5% or $3.40 Generic / Preferred Multi-Source or $8.50 for all others

Central and Northeastern Pennsylvania Community Blue Medicare PPO Signature

HEAL

TH

Premium $13.00

Deductible $0

Network Max Out-Of-Pocket $6,700 IN/OON Max of $10,000

Inpatient Hospital Stay $275/day (days 1-5) IN Copay; $350/day (days 1-5) OON Copay

Outpatient Hospital Coverage* ASC: $300 IN Copay; $450 OON Copay

Facility: $350 IN Copay; $450 OON Copay

Doctor Office Visit PCP: $0 IN Copay; $25 OON Copay

Specialist: $40 IN Copay; $60 OON Copay

Preventive/Screening Covered in Full (Office visit Copay may apply)

Emergency Room $90 Copay

Urgently Needed Services $50 Copay

Lab & Diagnostic Tests* Office/Lab: $0 IN Copay; $40 OON Copay

Outpatient: $30 IN Copay; $40 OON Copay

X-Rays/Advanced Imaging* X-Ray: $50 IN Copay; $70 OON Copay,

Advanced Imaging: $270 IN Copay; $370 OON Copay

Hearing Services

Medicare Covered: $40 IN Copay; $60 OON Copay; Routine: $40 (1 Every Year) IN Copay; $60 OON Copay. 2 Hearing Aids Every year;

TruHearing Advanced - $699 Copay; TruHearing Premium - $999 IN Copay; $500 allowance OON

Dental Services Medicare Covered*: $40 to $350 (Depends on place of service) IN Copay; $450 OON

Copay; Routine Dental (Office Visit): $15 Copay (1 Every Six Months). Routine Dental: (X-Ray): $15 Copay (1 Every Year).

Vision Services

Medicare Covered: $40 Copay IN; $60 Copay OON; Routine: $0 Copay (1 Every Year) IN; $50 Copay OON.

Standard Eyeglass lenses and frames or contact lenses are covered in full. A $100 benefit maximum applies to non-standard frames and a $100 benefit maximum for

specialty contact lenses. $200 benefit maximum for post cataract eyewear.

Mental Health Services* Inpatient: $275/day IN Copay (Days 1-5); $350/day OON Copay (Days 1-5)

Outpatient: $40 IN Copay; $60 OON Copay Skilled Nursing Facility

(days 1-100 per benefit period/admit)* $0/day Copay (days 1-20); $172/day Copay (days 21-100)

Physical Therapy* $40 IN Copay; $60 OON Copay

Ambulance (per one-way trip)** $350 Copay

Transportation (up-to 24 one-way trips) * $10 Copay Up-to 24 One-way trips

Part B Drugs* 20% Coinsurance

Durable Medical Equipment (including oxygen)* 20% Coinsurance

Wellness Programs SilverSneakers

Routine Podiatry $40 IN Copay; $60 OON Copay (4 Visits)

Formulary Lean (Performance)

* Indicates a service that requires prior authorization. ** Indicates prior authorization needed for non-emergent trips.

Community Blue Medicare PPO Signature DR

UG

You pay the following until your total yearly drug costs reach $3,820. Total yearly drug costs are the total drug costs paid by both you and your Part D plan.

Initial Coverage

Standard Retail Cost-Sharing

Tier 31 Day Supply 90 Day Supply Tier 1 (Preferred Generic) $5 Copay $15 Copay Tier 2 (Generic) $20 Copay $60 Copay Tier 3 (Preferred Brand) $47 Copay $141 Copay Tier 4 (Non-Preferred Drug) $100 Copay $300 Copay Tier 5 (Specialty Tier) 33% of the cost Not Offered

Standard Mail Cost-Sharing

Tier 31 Day Supply 90 Day Supply Tier 1 (Preferred Generic) $15 Copay $15 Copay Tier 2 (Generic) $60 Copay $60 Copay Tier 3 (Preferred Brand) $141 Copay $141 Copay Tier 4 (Non-Preferred Drug) $300 Copay $300 Copay Tier 5 (Specialty Tier) 33% of the cost Not Offered

Preferred Retail Cost-Sharing

Tier 31 Day Supply 90 Day Supply Tier 1 (Preferred Generic) $0 Copay $0 Copay Tier 2 (Generic) $15 Copay $45 Copay Tier 3 (Preferred Brand) $42 Copay $126 Copay Tier 4 (Non-Preferred Drug) $95 Copay $285 Copay Tier 5 (Specialty Tier) 33% of the cost Not Offered

Preferred Mail Cost-Sharing

Tier 31 Day Supply 90 Day Supply Tier 1 (Preferred Generic) $0 Copay $0 Copay Tier 2 (Generic) $40 Copay $40 Copay Tier 3 (Preferred Brand) $115 Copay $115 Copay Tier 4 (Non-Preferred Drug) $280 Copay $280 Copay Tier 5 (Specialty Tier) 33% of the cost Not Offered

Coverage Gap

The coverage gap begins after the yearly drug cost (including what our plan has paid and what you have paid) reaches $3,820. After you enter the coverage gap, you pay 25% of the plan’s cost for covered brand name drugs and 37% of the plan’s cost for covered generic drugs until your costs total $5,100, which is the end of the coverage gap.

Not everyone will enter the coverage gap.

Generics (37% Coinsurance) Brand (25% Coinsurance including 70% discount)

Catastrophic Coverage

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reaches $5,100,

you pay the greater of: 5% of the cost, or $3.40 Copay for generics and a $8.50 Copay for all other drugs.

Greater of: 5% or $3.40 Generic / Preferred Multi-Source or $8.50 for all others

If you reside in a long-term care facility, you pay the same as at a standard retail pharmacy.

Highmark Senior Health Company is a PPO plan with a Medicare contract. Enrollment in Highmark Senior Health Company depends on contract renewal. Highmark Blue Shield and Highmark Senior Health Company are independent licensees of the Blue Cross and Blue Shield Association.

Out-of-network/non-contracted providers are under no obligation to treat Community Blue Medicare PPO 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.

This information is not a complete description of benefits. Call 1-866-687-3182 (TTY users may call 711) for more information.

SilverSneakers is a registered mark of Tivity Health Inc. Tivity Health Inc., is a separate company that administers the SilverSneakers program.

H3916_18_0745_M

Our service area includes the following counties in Pennsylvania: Adams, Centre, Cumberland, Dauphin, Franklin, Fulton, Juniata, Lebanon, Mifflin, Perry, York.

To join Community Blue Medicare PPO, you must be entitled to Medicare Part A, be enrolled in Medicare Part B, and live in our service area.

Service Area

Community Blue Medicare PPO

Summary of BenefitsJanuary 1, 2019 – December 31, 2019

Central and Northeastern Pennsylvania

This booklet gives you a summary of what we cover and what you pay. It doesn’t list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, call us and ask for the “Evidence of Coverage.”

This document is available in other formats such as Braille and large print.

How to Find a Provider or PharmacyCommunity Blue Medicare PPO has a network of doctors, hospitals, pharmacies, and other providers. If you use the providers that are not in our network, the plan may not pay for these services.

You can see our plan’s provider and pharmacy directory at www.highmarkblueshield.com/medicare. Or, call us and we will send you a copy of the provider and pharmacy directories.

You can see the complete plan formulary (list of Part D prescription drugs) and any restrictions on our website, client.formularynavigator.com/clients/hm/default.html. Or, call us and we will send you a copy of the formulary.

1-866-687-3182 (TTY users can call 711),

8:00 a.m.– 8:00 p.m., 7 days a week.

Call Community Blue Medicare PPO

www.highmarkblueshield.com/medicare

Or Visit

How to Contact

Central and Northeastern Pennsylvania

Every Highmark Medicare Advantage Plan

SILVERSNEAKERS® GYM MEMBERSHIPGives you access to over 13,000 participating facilities nationwide – with cardio and weight equipment, pools, saunas, and more.

BLUES ON CALLProvides 24/7 access to a registered nurse who can help you understand a diagnosis, review your symptoms, and much more.

ANNUAL WELLNESS VISITEncourages you to talk with your doctor about your overall health and to create a personal prevention plan for the year.

HIGHMARK HOUSE CALL PROGRAMOffers a free preventive health assessment, provided by a certified nurse practitioner, in the comfort of your own home.

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.

Out-of-Network Benefit: The out-of-network (OON) benefit provides “out-of-network” coverage. You may see out-of-network providers as long as the services are covered benefits and medically necessary. You pay more for services then when you would if you used a “network provider.

More About Original Medicare

Out-of-Network Benefit

* Indicates a service that requires prior authorization. ** Indicates prior authorization needed for non-emergent trips.

Community Blue Medicare PPO SignatureHE

ALTH

Premium $27.00

Deductible $0

Network Max Out-Of-Pocket $6,700 IN/OON Max of $10,000

Inpatient Hospital Stay $275/day (days 1-5) IN Copay; $350/day (days 1-5) OON Copay

Outpatient Hospital Coverage*ASC: $300 IN Copay; $450 OON Copay

Facility: $350 IN Copay; $450 OON Copay

Doctor Office VisitPCP: $0 IN Copay; $25 OON Copay

Specialist: $40 IN Copay; $60 OON Copay

Preventive/Screening Covered in Full (Office visit Copay may apply)

Emergency Room $90 Copay

Urgently Needed Services $50 Copay

Lab & Diagnostic Tests*Office/Lab: $0 IN Copay; $40 OON Copay

Outpatient: $30 IN Copay; $40 OON Copay

X-Rays/Advanced Imaging*X-Ray: $50 IN Copay; $70 OON Copay,

Advanced Imaging: $270 IN Copay; $370 OON Copay

Hearing Services

Medicare Covered: $40 IN Copay; $60 OON Copay; Routine: $40 (1 Every Year) IN Copay; $60 OON Copay. 2 Hearing Aids Every year;

TruHearing Advanced - $699 Copay; TruHearing Premium - $999 IN Copay; $500 allowance OON

Dental ServicesMedicare Covered*: $40 to $350 (Depends on place of service) IN Copay; $450 OON

Copay; Routine Dental (Office Visit): $15 Copay (1 Every Six Months). Routine Dental: (X-Ray): $15 Copay (1 Every Year).

Vision Services

Medicare Covered: $40 Copay IN; $60 Copay OON; Routine: $0 Copay (1 Every Year) IN; $50 Copay OON.

Standard Eyeglass lenses and frames or contact lenses are covered in full. A $100 benefit maximum applies to non-standard frames and a $100 benefit maximum for

specialty contact lenses. $200 benefit maximum for post cataract eyewear.

Mental Health Services*Inpatient: $275/day IN Copay (Days 1-5); $350/day OON Copay (Days 1-5)

Outpatient: $40 IN Copay; $60 OON CopaySkilled Nursing Facility

(days 1-100 per benefit period/admit)*$0/day Copay (days 1-20); $172/day Copay (days 21-100)

Physical Therapy* $40 IN Copay; $60 OON Copay

Ambulance (per one-way trip)** $350 Copay

Transportation (up-to 24 one-way trips) * $10 Copay Up-to 24 One-way trips

Part B Drugs* 20% Coinsurance

Durable Medical Equipment (including oxygen)* 20% Coinsurance

Wellness Programs SilverSneakers

Routine Podiatry $40 IN Copay; $60 OON Copay (4 Visits)

Formulary Lean (Performance)

Community Blue Medicare PPO Signature

DRUG

You pay the following until your total yearly drug costs reach $3,820. Total yearly drug costs are the total drug costs paid by both you and your Part D plan.

Initial Coverage

Standard Retail Cost-Sharing

Tier 31 Day Supply 90 Day SupplyTier 1 (Preferred Generic) $5 Copay $15 CopayTier 2 (Generic) $20 Copay $60 CopayTier 3 (Preferred Brand) $47 Copay $141 CopayTier 4 (Non-Preferred Drug) $100 Copay $300 CopayTier 5 (Specialty Tier) 33% of the cost Not Offered

Standard MailCost-Sharing

Tier 31 Day Supply 90 Day SupplyTier 1 (Preferred Generic) $15 Copay $15 CopayTier 2 (Generic) $60 Copay $60 CopayTier 3 (Preferred Brand) $141 Copay $141 CopayTier 4 (Non-Preferred Drug) $300 Copay $300 CopayTier 5 (Specialty Tier) 33% of the cost Not Offered

Preferred RetailCost-Sharing

Tier 31 Day Supply 90 Day SupplyTier 1 (Preferred Generic) $0 Copay $0 CopayTier 2 (Generic) $15 Copay $45 CopayTier 3 (Preferred Brand) $42 Copay $126 CopayTier 4 (Non-Preferred Drug) $95 Copay $285 CopayTier 5 (Specialty Tier) 33% of the cost Not Offered

Preferred Mail Cost-Sharing

Tier 31 Day Supply 90 Day SupplyTier 1 (Preferred Generic) $0 Copay $0 CopayTier 2 (Generic) $40 Copay $40 CopayTier 3 (Preferred Brand) $115 Copay $115 CopayTier 4 (Non-Preferred Drug) $280 Copay $280 CopayTier 5 (Specialty Tier) 33% of the cost Not Offered

Coverage Gap

The coverage gap begins after the yearly drug cost (including what our plan has paid and what you have paid) reaches $3,820. After you enter the coverage gap, you pay 25% of the plan’s cost for covered brand name drugs and 37% of the plan’s cost for covered generic drugs until your costs total $5,100, which is the end of the coverage gap.

Not everyone will enter the coverage gap.

Generics (37% Coinsurance) Brand (25% Coinsurance including 70% discount)

Catastrophic Coverage

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reaches $5,100,

you pay the greater of: 5% of the cost, or $3.40 Copay for generics and a $8.50 Copay for all other drugs.

Greater of: 5% or $3.40 Generic / Preferred Multi-Source or $8.50 for all others

Central and Northeastern Pennsylvania

Community Blue Medicare PPO SignatureDR

UG

You pay the following until your total yearly drug costs reach $3,820. Total yearly drug costs are the total drug costs paid by both you and your Part D plan.

Initial Coverage

Standard Retail Cost-Sharing

Tier 31 Day Supply 90 Day SupplyTier 1 (Preferred Generic) $5 Copay $15 CopayTier 2 (Generic) $20 Copay $60 CopayTier 3 (Preferred Brand) $47 Copay $141 CopayTier 4 (Non-Preferred Drug) $100 Copay $300 CopayTier 5 (Specialty Tier) 33% of the cost Not Offered

Standard MailCost-Sharing

Tier 31 Day Supply 90 Day SupplyTier 1 (Preferred Generic) $15 Copay $15 CopayTier 2 (Generic) $60 Copay $60 CopayTier 3 (Preferred Brand) $141 Copay $141 CopayTier 4 (Non-Preferred Drug) $300 Copay $300 CopayTier 5 (Specialty Tier) 33% of the cost Not Offered

Preferred RetailCost-Sharing

Tier 31 Day Supply 90 Day SupplyTier 1 (Preferred Generic) $0 Copay $0 CopayTier 2 (Generic) $15 Copay $45 CopayTier 3 (Preferred Brand) $42 Copay $126 CopayTier 4 (Non-Preferred Drug) $95 Copay $285 CopayTier 5 (Specialty Tier) 33% of the cost Not Offered

Preferred Mail Cost-Sharing

Tier 31 Day Supply 90 Day SupplyTier 1 (Preferred Generic) $0 Copay $0 CopayTier 2 (Generic) $40 Copay $40 CopayTier 3 (Preferred Brand) $115 Copay $115 CopayTier 4 (Non-Preferred Drug) $280 Copay $280 CopayTier 5 (Specialty Tier) 33% of the cost Not Offered

Coverage Gap

The coverage gap begins after the yearly drug cost (including what our plan has paid and what you have paid) reaches $3,820. After you enter the coverage gap, you pay 25% of the plan’s cost for covered brand name drugs and 37% of the plan’s cost for covered generic drugs until your costs total $5,100, which is the end of the coverage gap.

Not everyone will enter the coverage gap.

Generics (37% Coinsurance) Brand (25% Coinsurance including 70% discount)

Catastrophic Coverage

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reaches $5,100,

you pay the greater of: 5% of the cost, or $3.40 Copay for generics and a $8.50 Copay for all other drugs.

Greater of: 5% or $3.40 Generic / Preferred Multi-Source or $8.50 for all others

If you reside in a long-term care facility, you pay the same as at a standard retail pharmacy.

Highmark Senior Health Company is a PPO plan with a Medicare contract. Enrollment in Highmark Senior Health Company depends on contract renewal. Highmark Blue Shield and Highmark Senior Health Company are independent licensees of the Blue Cross and Blue Shield Association.

Out-of-network/non-contracted providers are under no obligation to treat Community Blue Medicare PPO 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.

This information is not a complete description of benefits. Call 1-866-687-3182 (TTY users may call 711) for more information.

SilverSneakers is a registered mark of Tivity Health Inc. Tivity Health Inc., is a separate company that administers the SilverSneakers program.

H3916_18_0746_M

Our service area includes the following counties in Pennsylvania: Berks, Bradford, Lackawanna, Luzerne, Pike, Snyder, Susquehanna, Union, Wayne, Wyoming.

To join Community Blue Medicare PPO, you must be entitled to Medicare Part A, be enrolled in Medicare Part B, and live in our service area.

Service Area

Community Blue Medicare PPO

Summary of BenefitsJanuary 1, 2019 – December 31, 2019

Central and Northeastern Pennsylvania

This booklet gives you a summary of what we cover and what you pay. It doesn’t list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, call us and ask for the “Evidence of Coverage.”

This document is available in other formats such as Braille and large print.

How to Find a Provider or PharmacyCommunity Blue Medicare PPO has a network of doctors, hospitals, pharmacies, and other providers. If you use the providers that are not in our network, the plan may not pay for these services.

You can see our plan’s provider and pharmacy directory at www.highmarkblueshield.com/medicare. Or, call us and we will send you a copy of the provider and pharmacy directories.

You can see the complete plan formulary (list of Part D prescription drugs) and any restrictions on our website, client.formularynavigator.com/clients/hm/default.html. Or, call us and we will send you a copy of the formulary.

1-866-687-3182 (TTY users can call 711),

8:00 a.m.– 8:00 p.m., 7 days a week.

Call Community Blue Medicare PPO

www.highmarkblueshield.com/medicare

Or Visit

How to Contact

Central and Northeastern Pennsylvania

Every Highmark Medicare Advantage Plan

SILVERSNEAKERS® GYM MEMBERSHIPGives you access to over 13,000 participating facilities nationwide – with cardio and weight equipment, pools, saunas, and more.

BLUES ON CALLProvides 24/7 access to a registered nurse who can help you understand a diagnosis, review your symptoms, and much more.

ANNUAL WELLNESS VISITEncourages you to talk with your doctor about your overall health and to create a personal prevention plan for the year.

HIGHMARK HOUSE CALL PROGRAMOffers a free preventive health assessment, provided by a certified nurse practitioner, in the comfort of your own home.

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.

Out-of-Network Benefit: The out-of-network (OON) benefit provides “out-of-network” coverage. You may see out-of-network providers as long as the services are covered benefits and medically necessary. You pay more for services then when you would if you used a “network provider.

More About Original Medicare

Out-of-Network Benefit

* Indicates a service that requires prior authorization. ** Indicates prior authorization needed for non-emergent trips.

Community Blue Medicare PPO SignatureHE

ALTH

Premium $23.00

Deductible $0

Network Max Out-Of-Pocket $6,700 IN/OON Max of $10,000

Inpatient Hospital Stay $275/day (days 1-5) IN Copay; $350/day (days 1-5) OON Copay

Outpatient Hospital Coverage*ASC: $300 IN Copay; $450 OON Copay

Facility: $350 IN Copay; $450 OON Copay

Doctor Office VisitPCP: $0 IN Copay; $25 OON Copay

Specialist: $40 IN Copay; $60 OON Copay

Preventive/Screening Covered in Full (Office visit Copay may apply)

Emergency Room $90 Copay

Urgently Needed Services $50 Copay

Lab & Diagnostic Tests*Office/Lab: $0 IN Copay; $40 OON Copay

Outpatient: $30 IN Copay; $40 OON Copay

X-Rays/Advanced Imaging*X-Ray: $50 IN Copay; $70 OON Copay,

Advanced Imaging: $270 IN Copay; $370 OON Copay

Hearing Services

Medicare Covered: $40 IN Copay; $60 OON Copay; Routine: $40 (1 Every Year) IN Copay; $60 OON Copay. 2 Hearing Aids Every year;

TruHearing Advanced - $699 Copay; TruHearing Premium - $999 IN Copay; $500 allowance OON

Dental ServicesMedicare Covered*: $40 to $350 (Depends on place of service) IN Copay; $450 OON

Copay; Routine Dental (Office Visit): $15 Copay (1 Every Six Months). Routine Dental: (X-Ray): $15 Copay (1 Every Year).

Vision Services

Medicare Covered: $40 Copay IN; $60 Copay OON; Routine: $0 Copay (1 Every Year) IN; $50 Copay OON.

Standard Eyeglass lenses and frames or contact lenses are covered in full. A $100 benefit maximum applies to non-standard frames and a $100 benefit maximum for

specialty contact lenses. $200 benefit maximum for post cataract eyewear.

Mental Health Services*Inpatient: $275/day IN Copay (Days 1-5); $350/day OON Copay (Days 1-5)

Outpatient: $40 IN Copay; $60 OON CopaySkilled Nursing Facility

(days 1-100 per benefit period/admit)*$0/day Copay (days 1-20); $172/day Copay (days 21-100)

Physical Therapy* $40 IN Copay; $60 OON Copay

Ambulance (per one-way trip)** $350 Copay

Transportation (up-to 24 one-way trips) * $10 Copay Up-to 24 One-way trips

Part B Drugs* 20% Coinsurance

Durable Medical Equipment (including oxygen)* 20% Coinsurance

Wellness Programs SilverSneakers

Routine Podiatry $40 IN Copay; $60 OON Copay (4 Visits)

Formulary Lean (Performance)

Community Blue Medicare PPO Signature

DRUG

You pay the following until your total yearly drug costs reach $3,820. Total yearly drug costs are the total drug costs paid by both you and your Part D plan.

Initial Coverage

Standard Retail Cost-Sharing

Tier 31 Day Supply 90 Day SupplyTier 1 (Preferred Generic) $5 Copay $15 CopayTier 2 (Generic) $20 Copay $60 CopayTier 3 (Preferred Brand) $47 Copay $141 CopayTier 4 (Non-Preferred Drug) $100 Copay $300 CopayTier 5 (Specialty Tier) 33% of the cost Not Offered

Standard MailCost-Sharing

Tier 31 Day Supply 90 Day SupplyTier 1 (Preferred Generic) $15 Copay $15 CopayTier 2 (Generic) $60 Copay $60 CopayTier 3 (Preferred Brand) $141 Copay $141 CopayTier 4 (Non-Preferred Drug) $300 Copay $300 CopayTier 5 (Specialty Tier) 33% of the cost Not Offered

Preferred RetailCost-Sharing

Tier 31 Day Supply 90 Day SupplyTier 1 (Preferred Generic) $0 Copay $0 CopayTier 2 (Generic) $15 Copay $45 CopayTier 3 (Preferred Brand) $42 Copay $126 CopayTier 4 (Non-Preferred Drug) $95 Copay $285 CopayTier 5 (Specialty Tier) 33% of the cost Not Offered

Preferred Mail Cost-Sharing

Tier 31 Day Supply 90 Day SupplyTier 1 (Preferred Generic) $0 Copay $0 CopayTier 2 (Generic) $40 Copay $40 CopayTier 3 (Preferred Brand) $115 Copay $115 CopayTier 4 (Non-Preferred Drug) $280 Copay $280 CopayTier 5 (Specialty Tier) 33% of the cost Not Offered

Coverage Gap

The coverage gap begins after the yearly drug cost (including what our plan has paid and what you have paid) reaches $3,820. After you enter the coverage gap, you pay 25% of the plan’s cost for covered brand name drugs and 37% of the plan’s cost for covered generic drugs until your costs total $5,100, which is the end of the coverage gap.

Not everyone will enter the coverage gap.

Generics (37% Coinsurance) Brand (25% Coinsurance including 70% discount)

Catastrophic Coverage

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reaches $5,100,

you pay the greater of: 5% of the cost, or $3.40 Copay for generics and a $8.50 Copay for all other drugs.

Greater of: 5% or $3.40 Generic / Preferred Multi-Source or $8.50 for all others

Central and Northeastern Pennsylvania

Community Blue Medicare PPO SignatureDR

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You pay the following until your total yearly drug costs reach $3,820. Total yearly drug costs are the total drug costs paid by both you and your Part D plan.

Initial Coverage

Standard Retail Cost-Sharing

Tier 31 Day Supply 90 Day SupplyTier 1 (Preferred Generic) $5 Copay $15 CopayTier 2 (Generic) $20 Copay $60 CopayTier 3 (Preferred Brand) $47 Copay $141 CopayTier 4 (Non-Preferred Drug) $100 Copay $300 CopayTier 5 (Specialty Tier) 33% of the cost Not Offered

Standard MailCost-Sharing

Tier 31 Day Supply 90 Day SupplyTier 1 (Preferred Generic) $15 Copay $15 CopayTier 2 (Generic) $60 Copay $60 CopayTier 3 (Preferred Brand) $141 Copay $141 CopayTier 4 (Non-Preferred Drug) $300 Copay $300 CopayTier 5 (Specialty Tier) 33% of the cost Not Offered

Preferred RetailCost-Sharing

Tier 31 Day Supply 90 Day SupplyTier 1 (Preferred Generic) $0 Copay $0 CopayTier 2 (Generic) $15 Copay $45 CopayTier 3 (Preferred Brand) $42 Copay $126 CopayTier 4 (Non-Preferred Drug) $95 Copay $285 CopayTier 5 (Specialty Tier) 33% of the cost Not Offered

Preferred Mail Cost-Sharing

Tier 31 Day Supply 90 Day SupplyTier 1 (Preferred Generic) $0 Copay $0 CopayTier 2 (Generic) $40 Copay $40 CopayTier 3 (Preferred Brand) $115 Copay $115 CopayTier 4 (Non-Preferred Drug) $280 Copay $280 CopayTier 5 (Specialty Tier) 33% of the cost Not Offered

Coverage Gap

The coverage gap begins after the yearly drug cost (including what our plan has paid and what you have paid) reaches $3,820. After you enter the coverage gap, you pay 25% of the plan’s cost for covered brand name drugs and 37% of the plan’s cost for covered generic drugs until your costs total $5,100, which is the end of the coverage gap.

Not everyone will enter the coverage gap.

Generics (37% Coinsurance) Brand (25% Coinsurance including 70% discount)

Catastrophic Coverage

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reaches $5,100,

you pay the greater of: 5% of the cost, or $3.40 Copay for generics and a $8.50 Copay for all other drugs.

Greater of: 5% or $3.40 Generic / Preferred Multi-Source or $8.50 for all others

If you reside in a long-term care facility, you pay the same as at a standard retail pharmacy.

Highmark Senior Health Company is a PPO plan with a Medicare contract. Enrollment in Highmark Senior Health Company depends on contract renewal. Highmark Blue Shield and Highmark Senior Health Company are independent licensees of the Blue Cross andBlue Shield Association.

Out-of-network/non-contracted providers are under no obligation to treat Community Blue Medicare PPO 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.

This information is not a complete description of benefits. Call 1-866-687-3182 (TTY users may call 711) for more information.

SilverSneakers is a registered mark of Tivity Health Inc. Tivity Health Inc., is a separate company that administers the SilverSneakers program.

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Our service area includes the following counties in Pennsylvania: Lancaster.

To join Community Blue Medicare PPO, you must be entitled to Medicare Part A, be enrolled in Medicare Part B, and live in our service area.

Service Area

Community Blue Medicare PPO

Summary of BenefitsJanuary 1, 2019 – December 31, 2019

Central Pennsylvania

This booklet gives you a summary of what we cover and what you pay. It doesn’t list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, call us and ask for the “Evidence of Coverage.”

This document is available in other formats such as Braille and large print.

How to Find a Provider or PharmacyCommunity Blue Medicare PPO has a network of doctors, hospitals, pharmacies, and other providers. If you use the providers that are not in our network, the plan may not pay for these services.

You can see our plan’s provider and pharmacy directory at www.highmarkblueshield.com/medicare. Or, call us and we will send you a copy of the provider and pharmacy directories.

You can see the complete plan formulary (list of Part D prescription drugs) and any restrictions on our website, client.formularynavigator.com/clients/hm/default.html. Or, call us and we will send you a copy of the formulary.

1-866-687-3182 (TTY users can call 711),

8:00 a.m.– 8:00 p.m., 7 days a week.

Call Community Blue Medicare PPO

www.highmarkblueshield.com/medicare

Or Visit

How to Contact

Central Pennsylvania

Every Highmark Medicare Advantage Plan

SILVERSNEAKERS® GYM MEMBERSHIPGives you access to over 13,000 participating facilities nationwide – with cardio and weight equipment, pools, saunas, and more.

BLUES ON CALLProvides 24/7 access to a registered nurse who can help you understand a diagnosis, review your symptoms, and much more.

ANNUAL WELLNESS VISITEncourages you to talk with your doctor about your overall health and to create a personal prevention plan for the year.

HIGHMARK HOUSE CALL PROGRAMOffers a free preventive health assessment, provided by a certified nurse practitioner, in the comfort of your own home.

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.

Out-of-Network Benefit: The out-of-network (OON) benefit provides “out-of-network” coverage. You may see out-of-network providers as long as the services are covered benefits and medically necessary. You pay more for services then when you would if you used a “network provider.

More About Original Medicare

Out-of-Network Benefit

* Indicates a service that requires prior authorization. ** Indicates prior authorization needed for non-emergent trips.

Community Blue Medicare PPO SignatureHE

ALTH

Premium $13.00

Deductible $0

Network Max Out-Of-Pocket $6,700 IN/OON Max of $10,000

Inpatient Hospital Stay $450/admit IN Copay; $325/day (days 1-5) OON Copay

Outpatient Hospital Coverage*ASC: $225 IN Copay; $450 OON Copay

Facility: $300 IN Copay; $450 OON Copay

Doctor Office VisitPCP: $0 IN Copay; $25 OON Copay

Specialist: $30 IN Copay; $60 OON Copay

Preventive/Screening Covered in Full (Office visit Copay may apply)

Emergency Room $90 Copay

Urgently Needed Services $50 Copay

Lab & Diagnostic Tests*Office/Lab: $0 IN Copay; $40 OON Copay

Outpatient: $30 IN Copay; $40 OON Copay

X-Rays/Advanced Imaging*X-Ray: $25 IN Copay; $50 OON Copay,

Advanced Imaging: $225 IN Copay; $350 OON Copay

Hearing Services

Medicare Covered: $30 IN Copay; $60 OON Copay; Routine: $30 (1 Every Year) IN Copay; $60 OON Copay. 2 Hearing Aids Every year;

TruHearing Advanced - $699 Copay; TruHearing Premium - $999 IN Copay; $500 allowance OON

Dental ServicesMedicare Covered*: $30 to $300 (Depends on place of service) IN Copay; $450 OON

Copay; Routine Dental (Office Visit): $0 Copay (1 Every Six Months). Routine Dental: (X-Ray): $0 Copay (1 Every Year).

Vision Services

Medicare Covered: $30 Copay IN; $60 Copay OON; Routine: $0 Copay (1 Every Year) IN; $50 Copay OON.

Standard Eyeglass lenses and frames or contact lenses are covered in full. A $100 benefit maximum applies to non-standard frames and a $100 benefit maximum for

specialty contact lenses. $200 benefit maximum for post cataract eyewear.

Mental Health Services*Inpatient: $450/admit IN Copay; $325/day OON Copay (Days 1-5)

Outpatient: $30 IN Copay; $60 OON CopaySkilled Nursing Facility

(days 1-100 per benefit period/admit)*$0/day Copay (days 1-20); $172/day Copay (days 21-100)

Physical Therapy* $30 IN Copay; $60 OON Copay

Ambulance (per one-way trip)** $275 Copay

Transportation (up-to 24 one-way trips) * $10 Copay Up-to 24 One-way trips

Part B Drugs* 20% Coinsurance

Durable Medical Equipment (including oxygen)* 20% Coinsurance

Wellness Programs SilverSneakers

Routine Podiatry $30 IN Copay; $60 OON Copay (4 Visits)

Formulary Lean (Performance)

Community Blue Medicare PPO Signature

DRUG

You pay the following until your total yearly drug costs reach $3,820. Total yearly drug costs are the total drug costs paid by both you and your Part D plan.

Initial Coverage

Standard Retail Cost-Sharing

Tier 31 Day Supply 90 Day SupplyTier 1 (Preferred Generic) $5 Copay $15 CopayTier 2 (Generic) $20 Copay $60 CopayTier 3 (Preferred Brand) $47 Copay $141 CopayTier 4 (Non-Preferred Drug) $100 Copay $300 CopayTier 5 (Specialty Tier) 33% of the cost Not Offered

Standard MailCost-Sharing

Tier 31 Day Supply 90 Day SupplyTier 1 (Preferred Generic) $15 Copay $15 CopayTier 2 (Generic) $60 Copay $60 CopayTier 3 (Preferred Brand) $141 Copay $141 CopayTier 4 (Non-Preferred Drug) $300 Copay $300 CopayTier 5 (Specialty Tier) 33% of the cost Not Offered

Preferred RetailCost-Sharing

Tier 31 Day Supply 90 Day SupplyTier 1 (Preferred Generic) $0 Copay $0 CopayTier 2 (Generic) $15 Copay $45 CopayTier 3 (Preferred Brand) $42 Copay $126 CopayTier 4 (Non-Preferred Drug) $95 Copay $285 CopayTier 5 (Specialty Tier) 33% of the cost Not Offered

Preferred Mail Cost-Sharing

Tier 31 Day Supply 90 Day SupplyTier 1 (Preferred Generic) $0 Copay $0 CopayTier 2 (Generic) $40 Copay $40 CopayTier 3 (Preferred Brand) $115 Copay $115 CopayTier 4 (Non-Preferred Drug) $280 Copay $280 CopayTier 5 (Specialty Tier) 33% of the cost Not Offered

Coverage Gap

The coverage gap begins after the yearly drug cost (including what our plan has paid and what you have paid) reaches $3,820. After you enter the coverage gap, you pay 25% of the plan’s cost for covered brand name drugs and 37% of the plan’s cost for covered generic drugs until your costs total $5,100, which is the end of the coverage gap.

Not everyone will enter the coverage gap.

Generics (37% Coinsurance) Brand (25% Coinsurance including 70% discount)

Catastrophic Coverage

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reaches $5,100,

you pay the greater of: 5% of the cost, or $3.40 Copay for generics and a $8.50 Copay for all other drugs.

Greater of: 5% or $3.40 Generic / Preferred Multi-Source or $8.50 for all others

Central Pennsylvania

Community Blue Medicare PPO SignatureDR

UG

You pay the following until your total yearly drug costs reach $3,820. Total yearly drug costs are the total drug costs paid by both you and your Part D plan.

Initial Coverage

Standard Retail Cost-Sharing

Tier 31 Day Supply 90 Day SupplyTier 1 (Preferred Generic) $5 Copay $15 CopayTier 2 (Generic) $20 Copay $60 CopayTier 3 (Preferred Brand) $47 Copay $141 CopayTier 4 (Non-Preferred Drug) $100 Copay $300 CopayTier 5 (Specialty Tier) 33% of the cost Not Offered

Standard MailCost-Sharing

Tier 31 Day Supply 90 Day SupplyTier 1 (Preferred Generic) $15 Copay $15 CopayTier 2 (Generic) $60 Copay $60 CopayTier 3 (Preferred Brand) $141 Copay $141 CopayTier 4 (Non-Preferred Drug) $300 Copay $300 CopayTier 5 (Specialty Tier) 33% of the cost Not Offered

Preferred RetailCost-Sharing

Tier 31 Day Supply 90 Day SupplyTier 1 (Preferred Generic) $0 Copay $0 CopayTier 2 (Generic) $15 Copay $45 CopayTier 3 (Preferred Brand) $42 Copay $126 CopayTier 4 (Non-Preferred Drug) $95 Copay $285 CopayTier 5 (Specialty Tier) 33% of the cost Not Offered

Preferred Mail Cost-Sharing

Tier 31 Day Supply 90 Day SupplyTier 1 (Preferred Generic) $0 Copay $0 CopayTier 2 (Generic) $40 Copay $40 CopayTier 3 (Preferred Brand) $115 Copay $115 CopayTier 4 (Non-Preferred Drug) $280 Copay $280 CopayTier 5 (Specialty Tier) 33% of the cost Not Offered

Coverage Gap

The coverage gap begins after the yearly drug cost (including what our plan has paid and what you have paid) reaches $3,820. After you enter the coverage gap, you pay 25% of the plan’s cost for covered brand name drugs and 37% of the plan’s cost for covered generic drugs until your costs total $5,100, which is the end of the coverage gap.

Not everyone will enter the coverage gap.

Generics (37% Coinsurance) Brand (25% Coinsurance including 70% discount)

Catastrophic Coverage

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reaches $5,100,

you pay the greater of: 5% of the cost, or $3.40 Copay for generics and a $8.50 Copay for all other drugs.

Greater of: 5% or $3.40 Generic / Preferred Multi-Source or $8.50 for all others

If you reside in a long-term care facility, you pay the same as at a standard retail pharmacy.

Highmark Senior Health Company is a PPO plan with a Medicare contract. Enrollment in Highmark Senior Health Company depends on contract renewal. Highmark Blue Shield and Highmark Senior Health Company are independent licensees of the Blue Cross and Blue Shield Association.

Out-of-network/non-contracted providers are under no obligation to treat Community Blue Medicare PPO 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.

This information is not a complete description of benefits. Call 1-866-687-3182 (TTY users may call 711) for more information.

SilverSneakers is a registered mark of Tivity Health Inc. Tivity Health Inc., is a separate company that administers the SilverSneakers program.