2022 Summary of Benefits - Medicare Advantage Plans with Part D Prescription Drug Coverage Complete (HMO D-SNP) H1035-029
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2022 Summary of Benefits
Medicare Advantage Plans with Part D Prescription Drug Coverage
BlueMedicare Complete (HMO D-SNP) H1035-029
BlueMedicare Complete (HMO D-SNP) H1035-030
1/1/2022 – 12/31/2022
The plans’ service area includes:
Brevard, Hillsborough, Lake, Orange, Osceola, Polk, Seminole, and Sumter Counties
Y0011_FBM0762 2021_MThe benefit information provided is a summary of what we cover and what you pay. To get a complete list
of services we cover, call us and ask for the “Evidence of Coverage.” You may also view the “Evidence
of Coverage” for this plan on our website, www.floridablue.com/medicare.
If you want to know more about the coverage and costs of Original Medicare, look in your current 2022
"Medicare & You" handbook. View it online at www.medicare.gov or get a copy by calling 1-800-
MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.
Who Can Join?
To join, you must:
be entitled to Medicare Part A; and
be enrolled in Medicare Part B; and
receive any level of assistance from the Florida Medical Assistance Program (Medicaid). If you
receive both Medicare and Medicaid benefits, this means you are a dual-eligible. BlueMedicare
Complete (HMO D-SNP) may enroll dual-eligibles who are in the SMLB, SLMB Plus, QMB, QMB
Plus, FBDE, QI and QDWI programs; and
live in our service area.
Our H1035-029 service area includes the following counties in Florida: Brevard, Lake, Orange,
Osceola, Seminole and Sumter
Our H1035-030 service area includes the following counties in Florida: Hillsborough and Polk
Which doctors, hospitals, and pharmacies can I use?
We have a network of doctors, hospitals, pharmacies, and other providers. If you use 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 on our website
(www.floridablue.com/medicare). Or call us and we will send you a copy of the provider and
pharmacy directories.
Have Questions? Call Us
If you are a member of this plan, call us at 1-800-926-6565, TTY: 1-800-955-8770.
If you are not a member of this plan, call us at 1-855-601-9465, TTY: 1-800-955-8770.
o From October 1 through March 31, we are open seven days a week, from 8:00 a.m. to 8:00
p.m. local time, except for Thanksgiving and Christmas.
o From April 1 through September 30, we are open Monday through Friday, from 8:00 a.m. to
8:00 p.m. local time, except for major holidays.
Or visit our website at www.floridablue.com/medicare.
Important Information
Through this document you will see the symbols below.
* Services with this symbol may require approval in advance (a referral) from your Primary Care Doctor
(PCP) in order for the plan to cover them.
◊ Services with this symbol may require prior authorization from the plan before you receive services.
If you do not get a referral or prior authorization when required, you may have to pay the full cost of the
services. Please contact your PCP or refer to the Evidence of Coverage (EOC) for more information about
services that require a referral and/or prior authorization from the plan.
2Monthly Premium, Deductible and Limits
BlueMedicare Complete (HMO D-SNP) BlueMedicare Complete (HMO D-SNP)
Brevard, Lake, Orange, Hillsborough and Polk
Osceola, Seminole and Sumter H1035-030
H1035-029
Monthly Plan $0 or up to $34.30 $0 or up to $34.30
Premium There may be some situations in which There may be some situations in which
your premium increases. You will never your premium increases. You will never
pay more than a premium of $34.30. You pay more than a premium of $34.30. You
must continue to pay your Medicare Part must continue to pay your Medicare Part
B premium. B premium.
Deductible $0 per year for health care services $0 per year for health care services
$0 or up to $480 per year for Part D $0 or up to $480 per year for Part D
prescription drugs (does not apply to Tier prescription drugs (does not apply to Tier
1 (Preferred Generic) and Tier 2 1 (Preferred Generic) and Tier 2
(Generic)) (Generic))
Maximum $2,500 is the most you pay for copays, $1,500 is the most you pay for copays,
Out-of-Pocket coinsurance and other costs for Medicare- coinsurance and other costs for Medicare-
Responsibility covered medical services from in-network covered medical services from in-network
providers for the year providers for the year
Medical and Hospital Benefits
BlueMedicare Complete (HMO D-SNP) BlueMedicare Complete (HMO D-SNP)
Brevard, Lake, Orange, Hillsborough and Polk
Osceola, Seminole and Sumter H1035-030
H1035-029
Inpatient This Plan This Plan
Hospital Care ◊ $0 copay $0 copay
Medicaid Medicaid
$3 copay, per visit, if not exempt from $3 copay, per visit, if not exempt from
cost-sharing cost-sharing
Outpatient This Plan This Plan
Hospital Care $0 copay, per visit for Medicare $0 copay, per visit for Medicare
covered services ◊ covered services ◊
$0 copay, per visit for observation $0 copay, per visit for observation
services services
Medicaid Medicaid
$3 copay, per visit, if not exempt from $3 copay, per visit, if not exempt from
cost-sharing cost-sharing
3BlueMedicare Complete (HMO D-SNP) BlueMedicare Complete (HMO D-SNP)
Brevard, Lake, Orange, Hillsborough and Polk
Osceola, Seminole and Sumter H1035-030
H1035-029
Ambulatory ◊ This Plan This Plan
Surgery Center $0 copay $0 copay
Medicaid Medicaid
$3 copay for Medicaid-covered $3 copay for Medicaid-covered
services. services.
Doctor’s Office This Plan This Plan
Visits $0 copay per primary care visit $0 copay per primary care visit
$0 copay per specialist visit* $0 copay per specialist visit*
Medicaid Medicaid
$2 copay per provider or group $2 copay per provider or group
provider, per day, if not exempt from provider, per day, if not exempt from
cost-sharing cost-sharing
$3 copay for practitioner services $3 copay for practitioner services
provided at a Rural Health Center provided at a Rural Health Center
(RHC) or Federally Qualified Health (RHC) or Federally Qualified Health
Center (FQHC) only, per clinic, per Center (FQHC) only, per clinic, per
day, if not exempt from cost-sharing day, if not exempt from cost-sharing
Preventive Care This Plan This Plan
$0 copay for Medicare-covered services $0 copay for Medicare-covered services
Abdominal aortic aneurysm Abdominal aortic aneurysm
screening screening
Annual wellness visit Annual wellness visit
Bone mass measurement Bone mass measurement
Breast cancer screening Breast cancer screening
(mammograms) (mammograms)
Cardiovascular disease risk reduction Cardiovascular disease risk reduction
visit (therapy for cardiovascular visit (therapy for cardiovascular
disease) disease)
Cardiovascular disease testing Cardiovascular disease testing
Cervical and vaginal cancer Cervical and vaginal cancer
screening screening
Colorectal cancer screening Colorectal cancer screening
Depression screening Depression screening
Diabetes screening Diabetes screening
Diabetes self-management training, Diabetes self-management training,
diabetic services and supplies diabetic services and supplies
Health and wellness education Health and wellness education
programs programs
Hepatitis C Screening Hepatitis C Screening
HIV screening HIV screening
Immunizations Immunizations
Medical nutrition therapy Medical nutrition therapy
Medicare Diabetes Prevention Medicare Diabetes Prevention
Program (MDPP) Program (MDPP)
4BlueMedicare Complete (HMO D-SNP) BlueMedicare Complete (HMO D-SNP)
Brevard, Lake, Orange, Hillsborough and Polk
Osceola, Seminole and Sumter H1035-030
H1035-029
Obesity screening and therapy to Obesity screening and therapy to
promote sustained weight loss promote sustained weight loss
Prostate cancer screening exams Prostate cancer screening exams
Screening and counseling to reduce Screening and counseling to reduce
alcohol misuse alcohol misuse
Screening for lung cancer with low Screening for lung cancer with low
dose computed tomography (LDCT) dose computed tomography (LDCT)
Screening for sexually transmitted Screening for sexually transmitted
infections (STIs) and counseling to infections (STIs) and counseling to
prevent STIs prevent STIs
Smoking and tobacco use cessation Smoking and tobacco use cessation
(counseling to stop smoking or (counseling to stop smoking or
tobacco use) tobacco use)
Vision care: Glaucoma screening Vision care: Glaucoma screening
“Welcome to Medicare” preventive “Welcome to Medicare” preventive
visit visit
Medicaid Medicaid
$3 copay for covered preventive $3 copay for covered preventive
screenings provided at a Rural Health screenings provided at a Rural Health
Center (RHC) or Federally Qualified Center (RHC) or Federally Qualified
Health Center (FQHC) only, per clinic, per Health Center (FQHC) only, per clinic, per
day, if not exempt from cost-sharing. day, if not exempt from cost-sharing.
Emergency This Plan This Plan
Care $0 copay per visit, in- or out-of- $0 copay per visit, in- or out-of-
network network
Medicaid Medicaid
$3 copay, per visit, if not exempt from $3 copay, per visit, if not exempt from
cost-sharing cost-sharing
5% coinsurance up to the first $300 5% coinsurance up to the first $300
of Medicaid payment for each visit in of Medicaid payment for each visit in
the emergency room for non- the emergency room for non-
emergency services, not to exceed emergency services, not to exceed
$15 $15
Urgently This Plan This Plan
Needed $0 copay at an Urgent Care Center or $0 copay at an Urgent Care Center or
Services Convenient Care Center, in- or out-of- Convenient Care Center, in- or out-of-
network network
Medicaid Medicaid
$2 copay for services in a practitioner $2 copay for services in a practitioner
office setting, per provider or group office setting, per provider or group
provider, per day, if not exempt from provider, per day, if not exempt from
cost-sharing cost-sharing
5BlueMedicare Complete (HMO D-SNP) BlueMedicare Complete (HMO D-SNP)
Brevard, Lake, Orange, Hillsborough and Polk
Osceola, Seminole and Sumter H1035-030
H1035-029
Convenient Care Services are Convenient Care Services are
outpatient services for non-emergency outpatient services for non-emergency
injuries and illnesses that need injuries and illnesses that need
treatment when most family physician treatment when most family physician
offices are closed. Urgently needed offices are closed. Urgently needed
services are provided to treat a non- services are provided to treat a non-
emergency, unforeseen medical emergency, unforeseen medical
illness, injury or condition that requires illness, injury or condition that requires
immediate medical attention. immediate medical attention.
Diagnostic This Plan This Plan
Services/
Laboratory Services Laboratory Services
Labs/Imaging ◊*
$0 copay $0 copay
X-Rays X-Rays
$0 copay $0 copay
Advanced Imaging Services Advanced Imaging Services
Includes services such as Magnetic Includes services such as Magnetic
Resonance Imaging (MRI), Positron Resonance Imaging (MRI), Positron
Emission Tomography (PET), and Emission Tomography (PET), and
Computer Tomography (CT) Scan Computer Tomography (CT) Scan
$0 copay $0 copay
Radiation Therapy Radiation Therapy
0% coinsurance 0% coinsurance
Medicaid Medicaid
$1 copay for independent laboratory $1 copay for independent laboratory
services per provider, per day, if not services per provider, per day, if not
exempt from cost-sharing exempt from cost-sharing
$1 copay for portable X-Ray services $1 copay for portable X-Ray services
per provider, per day, if not exempt per provider, per day, if not exempt
from cost-sharing from cost-sharing
$2 copay per provider or group $2 copay per provider or group
provider, per day, if not exempt from provider, per day, if not exempt from
cost-sharing. cost-sharing.
$3 copay for services provided at a $3 copay for services provided at a
Rural Health Center (RHC) or Rural Health Center (RHC) or
Federally Qualified Health Center Federally Qualified Health Center
(FQHC) only, per clinic, per day, if not (FQHC) only, per clinic, per day, if not
exempt from cost-sharing exempt from cost-sharing
Hearing This Plan This Plan
Services
Medicare-Covered Hearing Services* Medicare-Covered Hearing Services*
$0 copay for exams to diagnose and $0 copay for exams to diagnose and
treat hearing and balance issues treat hearing and balance issues
6BlueMedicare Complete (HMO D-SNP) BlueMedicare Complete (HMO D-SNP)
Brevard, Lake, Orange, Hillsborough and Polk
Osceola, Seminole and Sumter H1035-030
H1035-029
Additional Hearing Services Additional Hearing Services
$0 copay for one routine hearing exam $0 copay for one routine hearing exam
per year per year
$0 copay for evaluation and fitting of $0 copay for evaluation and fitting of
hearing aids hearing aids
$1,500 per ear. You pay a $0 copay $1,500 per ear. You pay a $0 copay
for up to 2 hearing aids every year with for up to 2 hearing aids every year with
a maximum benefit allowance of a maximum benefit allowance of
$1,500 per ear. $1,500 per ear.
NOTE: Hearing aids must be NOTE: Hearing aids must be
purchased through our participating purchased through our participating
provider to have access to the benefit. provider to have access to the benefit.
Member is responsible for any amount Member is responsible for any amount
after the benefit allowance has been after the benefit allowance has been
applied. Subject to benefit maximum. applied. Subject to benefit maximum.
Medicaid Medicaid
$0 copay for recipients who have $0 copay for recipients who have
moderate hearing loss or greater, including moderate hearing loss or greater,
the following services: including the following services:
One new, complete, (not refurbished) One new, complete, (not refurbished)
hearing aid device per ear, every three hearing aid device per ear, every three
years, per recipient years, per recipient
Up to three pairs of ear molds per year, Up to three pairs of ear molds per year,
per recipient per recipient
One fitting and dispensing service per One fitting and dispensing service per
ear, every three years, per recipient ear, every three years, per recipient
Dental Services This Plan This Plan
Medicare-Covered Dental Services ◊ Medicare-Covered Dental Services ◊
$0 copay for non-routine dental care $0 copay for non-routine dental care
Additional Dental Services Additional Dental Services
$0 copay for covered preventive dental $0 copay for covered preventive dental
services services
$0 copay for covered comprehensive $0 copay for covered comprehensive
dental services dental services
Medicaid Medicaid
$2 copay for oral and maxillofacial $2 copay for oral and maxillofacial
surgery services per practitioner office surgery services per practitioner office
visit, per day visit, per day
$3 copay for dental services provided at $3 copay for dental services provided
a Federally Qualified Health Center at a Federally Qualified Health Center
7BlueMedicare Complete (HMO D-SNP) BlueMedicare Complete (HMO D-SNP)
Brevard, Lake, Orange, Hillsborough and Polk
Osceola, Seminole and Sumter H1035-030
H1035-029
(FQHC) only, per clinic, per day, if not (FQHC) only, per clinic, per day, if not
exempt from cost-sharing exempt from cost-sharing
Covered Adult Services (Ages 21 and Covered Adult Services (Ages 21 and
Over) Over)
One comprehensive evaluation every One comprehensive evaluation every
three years, per recipient. For recipients three years, per recipient. For
age 21 years and older, a recipients age 21 years and older, a
comprehensive evaluation is comprehensive evaluation is
reimbursed for determining the need for reimbursed for determining the need
full or partial dentures, or problem for full or partial dentures, or problem
focused services focused services
Limited evaluations, as medically Limited evaluations, as medically
indicated indicated
One complete series of intraoral One complete series of intraoral
radiographs every three years, per radiographs every three years, per
recipient. recipient.
One panoramic radiograph every three One panoramic radiograph every three
years, per recipient years, per recipient
Prosthodontic services to diagnose, Prosthodontic services to diagnose,
plan, rehabilitate, fabricate, and plan, rehabilitate, fabricate, and
maintain dentures as follows: maintain dentures as follows:
One upper, lower, or complete set of One upper, lower, or complete set of
full or removable partial dentures per full or removable partial dentures
recipient per recipient
One reline, per denture, per 366 One reline, per denture, per 366
days, per recipient days, per recipient
Traditional Florida Medicaid reimburses for Traditional Florida Medicaid reimburses for
emergency dental services for recipients emergency dental services for recipients
age 21 years and older to alleviate pain, age 21 years and older to alleviate pain,
infection, or both, and procedures infection, or both, and procedures
essential to prepare the mouth for essential to prepare the mouth for
dentures. dentures.
Vision Services This Plan This Plan
Medicare-Covered Vision Services Medicare-Covered Vision Services
$0 copay for physician services to $0 copay for physician services to
diagnose and treat eye diseases and diagnose and treat eye diseases and
conditions * conditions *
$0 copay for glaucoma screening (once $0 copay for glaucoma screening
per year for members at high risk of (once per year for members at high
glaucoma) risk of glaucoma)
$0 copay for one diabetic retinal exam $0 copay for one diabetic retinal exam
per year per year
8BlueMedicare Complete (HMO D-SNP) BlueMedicare Complete (HMO D-SNP)
Brevard, Lake, Orange, Hillsborough and Polk
Osceola, Seminole and Sumter H1035-030
H1035-029
$0 copay for one pair of eyeglasses or $0 copay for one pair of eyeglasses or
contact lenses after each cataract contact lenses after each cataract
surgery surgery
Additional Vision Services Additional Vision Services
$0 copay for an annual routine eye $0 copay for an annual routine eye
examination. examination
$500 maximum allowance per year $500 maximum allowance per year
towards the purchase of lenses, frames towards the purchase of lenses,
or contact lenses frames or contact lenses
Member responsible for costs Member responsible for costs
exceeding the annual maximum plan exceeding the annual maximum plan
benefit allowance. benefit allowance.
Medicaid Medicaid
$0 copay for visual aid services $0 copay for visual aid services
$3 copay for optometrist services $3 copay for optometrist services
provided at a Rural Health Center provided at a Rural Health Center
(RHC) or Federally Qualified Health (RHC) or Federally Qualified Health
Center (FQHC) only, per clinic, per Center (FQHC) only, per clinic, per
day. day.
Mental Health This Plan This Plan
Services ◊
Inpatient Mental Health Services Inpatient Mental Health Services
$0 copay $0 copay
190-day lifetime benefit maximum in a 190-day lifetime benefit maximum in a
psychiatric hospital psychiatric hospital
Outpatient Mental Health Services Outpatient Mental Health Services
$0 copay $0 copay
Medicaid Medicaid
$2 copay per provider, per day, if not $2 copay per provider, per day, if not
exempt from cost-sharing exempt from cost-sharing
$3 copay for outpatient mental health $3 copay for outpatient mental health
services provided at a Rural Health services provided at a Rural Health
Center (RHC) or Federally Qualified Center (RHC) or Federally Qualified
Health Center (FQHC) only, per clinic, Health Center (FQHC) only, per clinic,
per day, if not exempt from cost- per day, if not exempt from cost-
sharing sharing
9BlueMedicare Complete (HMO D-SNP) BlueMedicare Complete (HMO D-SNP)
Brevard, Lake, Orange, Hillsborough and Polk
Osceola, Seminole and Sumter H1035-030
H1035-029
Skilled Nursing This Plan This Plan
Facility (SNF) ◊
$0 copay $0 copay
Our plan covers up to 100 days in a SNF Our plan covers up to 100 days in a SNF
per benefit period. per benefit period.
Medicaid Medicaid
$0 copay $0 copay
Once Medicare services for each benefit Once Medicare services for each benefit
period are exhausted, coverage will period are exhausted, coverage will
continue for days 101 through 120 under continue for days 101 through 120 under
your eligibility for Medicaid. your eligibility for Medicaid.
Physical This Plan This Plan
Therapy ◊*
$0 copay $0 copay
Medicaid Medicaid
Physical Therapy, Occupational Therapy, Physical Therapy, Occupational Therapy,
Respiratory Therapy, and Speech- Respiratory Therapy, and Speech-
Language Pathology services. Language Pathology services.
$0 copay for respiratory system $0 copay for respiratory system
services services
$0 copay for physical therapy services $0 copay for physical therapy services
$2 copay per provider, per day, for $2 copay per provider, per day, for
outpatient rehabilitation services outpatient rehabilitation services
provided in an office setting, if not provided in an office setting, if not
exempt from cost-sharing exempt from cost-sharing
$3 copay for outpatient rehabilitation $3 copay for outpatient rehabilitation
services provided at a Rural Health services provided at a Rural Health
Center (RHC) or Federally Qualified Center (RHC) or Federally Qualified
Health Center (FQHC) only, per clinic, Health Center (FQHC) only, per clinic,
per day, if not exempt from cost- per day, if not exempt from cost-
sharing sharing
$3 copay, per visit to an outpatient $3 copay, per visit to an outpatient
hospital, if not exempt from cost- hospital, if not exempt from cost-
sharing sharing
Ambulance ◊ This Plan This Plan
$0 copay for each Medicare-covered $0 copay for each Medicare-covered
trip (one-way) trip (one-way)
Medicaid Medicaid
$0 copay for Medicaid-covered $0 copay for Medicaid-covered
services services
10BlueMedicare Complete (HMO D-SNP) BlueMedicare Complete (HMO D-SNP)
Brevard, Lake, Orange, Hillsborough and Polk
Osceola, Seminole and Sumter H1035-030
H1035-029
Transportation This Plan This Plan
$0 copay for unlimited one-way trips for $0 copay for unlimited one-way trips
rides to your doctor, hospital or for rides to your doctor, hospital or
pharmacy pharmacy
These services can accommodate These services can accommodate
wheelchairs, walkers, oxygen tanks and wheelchairs, walkers, oxygen tanks
service animals and service animals
Medicaid Medicaid
$1 copay per one-way trip. $1 copay per one-way trip.
Non-Emergency Medical Non-Emergency Medical
Transportation (NEMT) services are Transportation (NEMT) services are
available only to eligible beneficiaries available only to eligible beneficiaries
who cannot obtain transportation who cannot obtain transportation
through any other means (such as through any other means (such as
family, friends or community family, friends or community
resources). resources).
Medicare Part B This Plan This Plan
Drugs
$0 copay for allergy injections $0 copay for allergy injections
0% coinsurance for chemotherapy 0% coinsurance for chemotherapy
drugs and other Medicare Part B- drugs and other Medicare Part B-
covered drugs ◊ covered drugs ◊
Medicaid Medicaid
$0 copay for prescription drugs $0 copay for prescription drugs
obtained through the Prescription Drug obtained through the Prescription Drug
Services program Services program
$2 copay for practitioner services, per $2 copay for practitioner services, per
provider or group provider, per day, if provider or group provider, per day, if
not exempt from cost-sharing not exempt from cost-sharing
$3 copay for Part B prescription drug $3 copay for Part B prescription drug
administration provided at a Rural administration provided at a Rural
Health Center (RHC) or Federally Health Center (RHC) or Federally
Qualified Health Center (FQHC) only, Qualified Health Center (FQHC) only,
per clinic, per day, if not exempt from per clinic, per day, if not exempt from
cost-sharing cost-sharing
11Part D Prescription Drug Benefits
Most of our members qualify for and are getting “Extra Help” from Medicare to pay for their
prescription drug plan costs. If you are in the “Extra Help” program, this information about the
costs for Part D prescription drugs does not apply to you. We sent you a separate insert, called the
“Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs” (also
known as the “Low Income Subsidy Rider” or the “LIS Rider”), which tells you about your drug
coverage.
Deductible Stage
The deductible does not apply to Tier 1 (Preferred Generic) and Tier 2 (Generic). In most cases you
will pay $0 or $99. The deductible for those who do not qualify for “Extra Help” is $480.
Initial Coverage Stage
You begin in this stage when you fill your first prescription of the year. During this stage, the plan pays its
share of the cost of your drugs and you pay your share of the cost.
You remain in this stage until your total yearly drug costs (total drug costs paid by you and any Part D plan)
reach $4,430. You may get your drugs at network retail pharmacies and mail order pharmacies. Cost-
sharing below applies to a one-month (31-day) supply.
BlueMedicare Complete (HMO D-SNP) BlueMedicare Complete (HMO D-SNP)
Brevard, Lake, Orange, Hillsborough and Polk
Osceola, Seminole and Sumter H1035-030
H1035-029
Preferred Retail/Mail Standard Preferred Retail/Mail Standard
Order/LTC Retail/Mail Order Order/LTC Retail/Mail Order
(31-day supply) (31-day supply) (31-day supply) (31-day supply)
Tier 1 - $0 $0 or $10 copay $0 $0 or $10 copay
Preferred depending on the level of depending on the level of “Extra
Generic “Extra Help” you receive. Help” you receive.
$0 $0 or $ 11 $0 $0 or $11 copay
Tier 2 - depending on the level of depending on the level of “Extra
Generic “Extra Help” you receive. Help” you receive.
Tier 3 - $0 or $40 copay $0 or $47 copay $0 or $40 copay $0 or $47 copay
Preferred depending on the level of depending on the level of depending on the level of depending on the level of “Extra
Brand “Extra Help” you receive. “Extra Help” you receive. “Extra Help” you receive. Help” you receive.
Tier 4 - $0 or $92 copay $0 or $99 copay $0 or $92 copay $0 or $99 copay
Non- depending on the level of depending on the level of depending on the level of depending on the level of “Extra
Preferred “Extra Help” you receive. “Extra Help” you receive. “Extra Help” you receive. Help” you receive.
Drug
$0 copay or up to 25%, $0 copay or up to 25%, $0 copay or up to 25%, $0 copay or up to 25%,
Tier 5 -
depending on the level of depending on the level of depending on the level of depending on the level of “Extra
Specialty
“Extra Help” you receive. “Extra Help” you receive. “Extra Help” you receive. Help” you receive.
Tier
12Coverage Gap Stage
Most Medicare drug plans have a coverage gap (also called the "donut hole"). This means that there's a
temporary change in what you will pay for your drugs. The Coverage Gap Stage begins after the total
yearly drug cost (including total drug costs paid by you and any Part D plan) reaches $4,430. You stay in
this stage until your year-to-date “out-of-pocket” costs reach a total of $7,050.
BlueMedicare Complete (HMO D-SNP) BlueMedicare Complete (HMO D-SNP)
Brevard, Lake, Orange, Hillsborough and Polk
Osceola, Seminole and Sumter H1035-030
H1035-029
You pay the same copays that you You pay the same copays that you paid
During the
paid in the Initial Coverage Stage for in the Initial Coverage Stage for
Coverage Gap
drugs in Tier 1 (Preferred Generic) drugs in Tier 1 (Preferred Generic) and
Stage:
and Tier 2 (Generic) – or 25% of the Tier 2 (Generic) – or 25% of the
cost, whichever is lower cost, whichever is lower
For generic drugs in all other tiers, For generic drugs in all other tiers,
you pay 25% of the cost you pay 25% of the cost
For brand-name drugs, you pay 25% For brand-name drugs, you pay 25%
of the cost (plus a portion of the of the cost (plus a portion of the
dispensing fee) dispensing fee)
Catastrophic Coverage Stage
After your yearly out-of-pocket drug costs reach $7,050, you pay the greater of:
$3.95 copay for generic drugs in all tiers (including brand drugs treated as generic) and a $9.85 copay
for all other drugs in all tiers, or 5% of the cost.
Additional Drug Coverage
Please call us or see the plan’s “Evidence of Coverage” on our website
(www.floridablue.com/medicare) for complete information about your costs for covered drugs. If you
request and the plan approves a formulary exception, you will pay Tier 4 (Non-Preferred Drug) cost-
sharing.
Your cost-sharing may be different if you use a Long-Term Care (LTC) pharmacy, a home infusion
pharmacy, or an out-of-network pharmacy, or if you purchase a long-term supply (up to 90 days) of a
drug.
13Additional Benefits
BlueMedicare Complete (HMO D-SNP) BlueMedicare Complete (HMO D-SNP)
Brevard, Lake, Orange, Hillsborough and Polk
Osceola, Seminole and Sumter H1035-030
H1035-029
At Home Care We offer this benefit through our We offer this benefit through our
partnership with our participating provider partnership with our participating provider
who connects college students to older who connects college students to older
adults who require assistance with adults who require assistance with
transportation, companionship, household transportation, companionship, household
chores, use of electronic devices, and chores, use of electronic devices, and
exercise and activity. exercise and activity.
Benefits include the following: Benefits include the following:
At Home Care, 60 hours per year. At Home Care, 60 hours per year.
Services include support with Activities of Services include support with Activities of
Daily Living (ADL) and Instrumental Daily Living (ADL) and Instrumental
Activities of Daily Living (IADL). Activities of Daily Living (IADL).
Caregiver
Provides coverage for coaching, education Provides coverage for coaching,
Support
and support services such as counseling education and support services such as
for Member
and training courses for caregivers of counseling and training courses for
enrollees. Benefits include: caregivers of enrollees. Benefits include:
A web-based tool that contains A web-based tool that contains
educational content covering topics on educational content covering topics on
health, wealth, senior living, in-home health, wealth, senior living, in-home
care and lifestyle care and lifestyle
Access for caregivers and family Access for caregivers and family
members to post updates and videos; members to post updates and videos;
tools to manage documents, stay tools to manage documents, stay
organized and on top of upcoming organized and on top of upcoming
tasks and appointments. Search tools tasks and appointments. Search tools
(i.e., senior housing search and in- (i.e., senior housing search and in-
home care search) home care search)
See the “Evidence of Coverage” for benefit See the “Evidence of Coverage” for
details. benefit details.
Diabetic $0 copay at your network retail or mail- $0 copay at your network retail or mail-
Supplies order pharmacy for Diabetic Supplies order pharmacy for Diabetic Supplies
such as: such as:
• Lifescan (One Touch®) Glucose • Lifescan (One Touch®)
Meters Glucose Meters
• Lancets • Lancets
• Test Strips • Test Strips
Important Note: Insulin, insulin Important Note: Insulin, insulin
syringes and needles for self- syringes and needles for self-
administration in the home are administration in the home are
14BlueMedicare Complete (HMO D-SNP) BlueMedicare Complete (HMO D-SNP)
Brevard, Lake, Orange, Hillsborough and Polk
Osceola, Seminole and Sumter H1035-030
H1035-029
obtained from a retail or mail order obtained from a retail or mail order
pharmacy and are covered under your pharmacy and are covered under your
Medicare Part D pharmacy Medicare Part D pharmacy
benefit. Applicable Part D co-pays and benefit. Applicable Part D co-pays and
deductibles apply. deductibles apply.
Medicare $0 copay for Medicare-covered $0 copay for Medicare-covered
Diabetes services services
Prevention
Program
Podiatry This Plan This Plan
$0 copay $0 copay
Medicaid Medicaid
$2 copay per provider, per day $2 copay per provider, per day
Chiropractic This Plan This Plan
$0 copay $0 copay
Medicaid Medicaid
$1 copay per provider/group, per day $1 copay per provider/group, per day
Medical This Plan This Plan
Equipment and
0% coinsurance for all plan approved, 0% coinsurance for all plan approved,
Supplies ◊
Medicare-covered motorized Medicare-covered motorized
wheelchairs and electric scooters wheelchairs and electric scooters
0% coinsurance for all other plan 0% coinsurance for all other plan
approved, Medicare-covered durable approved, Medicare-covered durable
medical equipment medical equipment
Medicaid Medicaid
$0 copay $0 copay
Outpatient This Plan This Plan
Occupational
$0 copay $0 copay
and Speech
Therapy ◊* Medicaid Medicaid
Physical Therapy, Occupational Therapy, Physical Therapy, Occupational Therapy,
Respiratory Therapy, and Speech- Respiratory Therapy, and Speech-
Language Pathology services. Language Pathology services.
$0 copay for respiratory system $0 copay for respiratory system
services services
$0 copay for physical therapy services $0 copay for physical therapy services
$2 copay per provider, per day, for $2 copay per provider, per day, for
outpatient rehabilitation services outpatient rehabilitation services
provided in an office setting, if not provided in an office setting, if not
exempt from cost-sharing exempt from cost-sharing
15BlueMedicare Complete (HMO D-SNP) BlueMedicare Complete (HMO D-SNP)
Brevard, Lake, Orange, Hillsborough and Polk
Osceola, Seminole and Sumter H1035-030
H1035-029
$3 copay for outpatient rehabilitation $3 copay for outpatient rehabilitation
services provided at a Rural Health services provided at a Rural Health
Center (RHC) or Federally Qualified Center (RHC) or Federally Qualified
Health Center (FQHC) only, per clinic, Health Center (FQHC) only, per clinic,
per day, if not exempt from cost- per day, if not exempt from cost-
sharing sharing
$3 copay, per visit to an outpatient $3 copay, per visit to an outpatient
hospital, if not exempt from cost- hospital, if not exempt from cost-
sharing sharing
This Plan This Plan
Telehealth ◊*
$0 copay for Urgently Needed $0 copay for Urgently Needed
Services Services
$0 copay for Primary Care Services $0 copay for Primary Care Services
$0 copay for Occupational $0 copay for Occupational
Therapy/Physical Therapy/Speech Therapy/Physical Therapy/Speech
Therapy at a freestanding location Therapy at a freestanding location
$0 copay Occupational $0 copay Occupational
Therapy/Physical Therapy/Speech Therapy/Physical Therapy/Speech
Therapy at an outpatient hospital Therapy at an outpatient hospital
$0 copay for Dermatology Services $0 copay for Dermatology Services
$0 copay for individual sessions for $0 copay for individual sessions for
outpatient Mental Health Specialty outpatient Mental Health Specialty
Services Services
$0 copay for individual sessions for $0 copay for individual sessions for
outpatient Psychiatry Specialty outpatient Psychiatry Specialty
Services Services
$0 copay for Opioid Treatment Program $0 copay for Opioid Treatment
Services Program Services
$0 copay for individual sessions for $0 copay for individual sessions for
outpatient Substance Abuse Specialty outpatient Substance Abuse Specialty
Services Services
$0 copay for Diabetes Self- $0 copay for Diabetes Self-
Management Training Management Training
$0 copay for Dietician Services $0 copay for Dietician Services
Medicaid Medicaid
$0 copay $0 copay
Special Members diagnosed as having one or a Members diagnosed as having one or a
Supplemental combination of Coronary Artery Disease combination of Coronary Artery Disease
Benefits for the (CAD), Congestive Heart Failure (CHF), (CAD), Congestive Heart Failure (CHF),
Chronically Ill Chronic Obstructive Pulmonary Disease Chronic Obstructive Pulmonary Disease
(COPD), and/or Diabetes may receive the (COPD), and/or Diabetes may receive the
(SSBCI) ◊
following additional benefit: following additional benefit:
Healthy Food Benefit - $50 per month to Healthy Food Benefit - $50 per month
your Blue Dollars card to purchase to your Blue Dollars card to purchase
16BlueMedicare Complete (HMO D-SNP) BlueMedicare Complete (HMO D-SNP)
Brevard, Lake, Orange, Hillsborough and Polk
Osceola, Seminole and Sumter H1035-030
H1035-029
healthy food and produce at a plan healthy food and produce at a plan
approved location. Any unused amount approved location. Any unused amount
does not roll over to the next month. does not roll over to the next month.
See the “Evidence of Coverage” for full See the “Evidence of Coverage” for full
eligibility requirements. eligibility requirements.
You Get More with BlueMedicare
BlueMedicare Complete (HMO D-SNP) BlueMedicare Complete (HMO D-SNP)
Brevard, Lake, Orange, Hillsborough and Polk
Osceola, Seminole and Sumter H1035-030
H1035-029
meQuilibrium’s digital coaching meQuilibrium’s digital coaching
Health Education
platform delivers clinically validated platform delivers clinically validated
and highly personalized resilience and highly personalized resilience
solutions to help people improve their solutions to help people improve
ability to manage stress and their ability to manage stress and
successfully cope with life’s successfully cope with life’s
challenges. To get started go to challenges. To get started go to
FloridaBlue.com/Medicare log in, FloridaBlue.com/Medicare log in,
click on My Health and select click on My Health and select
HealthyBlue Rewards. HealthyBlue Rewards.
Over-the-Counter $100 monthly allowance for the $100 monthly allowance for the
Items purchase of non-prescription items purchase of non-prescription items
such as vitamins and aspirin such as vitamins and aspirin
Any balance not used for a month Any balance not used for a month
will not carry over to the next month will not carry over to the next month
Your BlueMedicare plan rewards Your BlueMedicare plan rewards
Healthy Blue
you for taking care of your health. you for taking care of your health.
Rewards
Redeem gift card rewards for Redeem gift card rewards for
completing and reporting preventive completing and reporting
care and screenings preventive care and screenings
Gym membership and classes Gym membership and classes
SilverSneakers®
available at fitness locations across available at fitness locations across
Fitness Program
the country, including national the country, including national
chains and local gyms chains and local gyms
Access to exercise equipment and Access to exercise equipment and
other amenities, classes for all levels other amenities, classes for all
and abilities, social events, and levels and abilities, social events,
more and more
17BlueMedicare Complete (HMO D-SNP) BlueMedicare Complete (HMO D-SNP)
Brevard, Lake, Orange, Hillsborough and Polk
Osceola, Seminole and Sumter H1035-030
H1035-029
Meal Benefit 10 meals after each hospital 10 meals after each hospital
discharge discharge
Disclaimers
Florida Blue Medicare is an HMO plan with a Medicare contract. Enrollment in Florida Blue Medicare
depends on contract renewal.
If you have any questions, please contact our Member Services at 1-800-926-6565. (TTY users should call
1-800-955-8770.) Our hours are 8:00 a.m. to 8:00 p.m. local time, seven days a week, from October 1
through March 31, except for Thanksgiving and Christmas. From April 1 through September 30, our hours
are 8:00 a.m. to 8:00 p.m. local time, Monday through Friday, except for major holidays.
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.
Plans may offer supplemental benefits in addition to Part C benefits and Part D benefits.
SSBCI benefits are part of special supplemental benefits and not all members will qualify.
© 2021 Blue Cross and Blue Shield of Florida, Inc., DBA Florida Blue. All rights reserved.
18Section 1557 Notification: Discrimination is Against the Law
We comply with applicable Federal civil rights laws and do not discriminate on the basis of race, color,
national origin, age, disability, or sex. We do not exclude people or treat them differently because of race,
color, national origin, age, disability, or sex.
We provide:
• Free aids and services to people with disabilities to communicate effectively with us, such as:
o Qualified sign language interpreters
o Written information in other formats (large print, audio, accessible electronic formats, other
formats)
• Free language services to people whose primary language is not English, such as:
o Qualified interpreters
o Information written in other languages
If you need these services, contact:
• Health and vision coverage: 1-800-352-2583
• Dental, life, and disability coverage: 1-888-223-4892
• Federal Employee Program: 1-800-333-2227
If you believe that we have failed to provide these services or discriminate on the basis of race, color,
national origin, disability, age, sex, gender identity or sexual orientation, you can file a grievance with:
Health and vision coverage (including FEP Dental, life, and disability coverage:
members): Civil Rights Coordinator
Section 1557 Coordinator 17500 Chenal Parkway
4800 Deerwood Campus Parkway, DCC 1-7 Little Rock, AR 72223
Jacksonville, FL 32246 1-800-260-0331
1-800-477-3736 x29070 1-800-955-8770 (TTY)
1-800-955-8770 (TTY) civilrightscoordinator@fclife.com
Fax: 1-904-301-1580
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 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
1-877-696-67751-800-537-7697 (TDD)
Complaint forms are available at www.hhs.gov/ocr/office/file/index.html.
19ATENCIÓN: 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 ھﺎﺗف اﻟﺻم واﻟﺑﻛم1-800-352-2583 اﺗﺻل ﺑرﻗم. ﻓﺈن ﺧدﻣﺎت اﻟﻣﺳﺎﻋدة اﻟﻠﻐوﯾﺔ ﺗﺗواﻓر ﻟك ﺑﺎﻟﻣﺟﺎن، إذا ﻛﻧت ﺗﺗﺣدث اذﻛر اﻟﻠﻐﺔ:ﻣﻠﺣوظﺔ
.1-800-333-2227 اﺗﺻل ﺑرﻗم.1-800-955-8770
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 િન: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:ถ ้าคุณพูดภาษาไทย คุณสามารถใช ้บริการช่วยเหลือทางภาษาได ้ฟรี โดยติดต่อหมายเลขโทรฟรี 1-800-352-2583
(TTY: 1-800-955-8770) หรือ FEP โทร 1-800-333-2227
注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1-800-352-2583（TTY: 1-
800-955-8770）まで、お電話にてご連絡ください。FEP: 1-800-333-2227
. ﺗﺳﮭﯾﻼت زﺑﺎﻧﯽ راﯾﮕﺎن در دﺳﺗرس ﺷﻣﺎ ﺧواھد ﺑود، اﮔر ﺑﮫ زﺑﺎن ﻓﺎرﺳﯽ ﺻﺣﺑت ﻣﯽ ﮐﻧﯾد:ﺗوﺟﮫ
. ﺗﻣﺎس ﺑﮕﯾرﯾد1-800-333-2227 ﺑﺎ ﺷﻣﺎره:FEP . ﺗﻣﺎس ﺑﮕﯾرﯾد1-800-352-2583 (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.
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