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Blue Essentials (HMO-POS) 2013 — health and prescription drug coverage in one plan

About the Blue Essentials plan

Get the convenience of health and prescription drug coverage in one plan with Blue Essentials, a low-cost Medicare-approved HMO-POS plan from Blue Plus (a licensed health maintenance organization and an affiliate of Blue Cross and Blue Shield of Minnesota).

For an affordable premium, enjoy the ease of:

  • Predictable premiums, copays and coinsurance for medical services and prescription drugs
  • Access to a large provider network of doctors, clinics and hospitals and a pharmacy network ExternalLink of more than 63,000 pharmacies
  • A single ID card for medical and prescription drug coverage


Health plan benefits

  You pay:
Monthly plan premium $60; you must also continue to pay your Medicare Part B premium
Deductible $0
Doctor's office visits $25 for each primary care visit
$35 for each specialist and podiatry visit
$20 for each chiropractic visit
Inpatient hospital care Days 1-4: $275 copay per day
Days 5-90: $0
Emergency care Worldwide coverage: $65 copay
Preventive screenings and services $0 for one annual wellness visit, one physical examination and one routine eye exam
$35 copay for one routine hearing test per year
Annual out-of-pocket maximum $4,000 (combined in-network and out-of-network)



PART D DRUG plan benefits

Benefit: Member pays:
Annual deductible $0
Initial coverage, Tier 1: Preferred generic $8 copay
Initial coverage, Tier 2: Non-preferred generic $15 copay
Initial coverage, Tier 3: Preferred brand $34 copay
Initial coverage, Tier 4: Non-preferred brand 45% coinsurance


More plan information

Benefits overview (PDF)  

Plan ratings (PDF)

Prescription drug formulary (PDF)

Provider and pharmacy directory (PDF)

Summary of benefits (PDF)

Get Acrobat Reader ExternalLink


The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Limitations, copayments and restrictions may apply. You must continue to pay your Medicare Part B premium. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1 of each year. You can also view additional details in the Benefits overview (PDF) or the Summary of Benefits (PDF).

Prime Therapeutics LLC is an independent company providing pharmacy benefit management services.

Last updated March 8, 2013
H2425_002_030813_N01 CMS Approved 03/11/13

Networks, discounts and travel benefits for Blue Essentials


Find a doctor in the network

See any doctor in the large Blue Essentials network , no referral needed. You can also see doctors outside the network but you may have to pay more for those services.

Pharmacy network and prescription drug list

Blue Essentials includes Part D prescription drug coverage. Get prescriptions filled at more than 63,000 participating network pharmacies. ExternalLink The plan also provides benefits for many prescription drugs. See the drug list ExternalLink (formulary).

Discounts on health and wellness

  • Earn up to a $20 credit toward monthly health club fees when you exercise at a participating fitness center at least 12 times per month
  • Save on eyewear and hearing aids
  • Find answers to your medical questions using our health & wellness online resources. You’ll get access to health calculators, quizzes, exclusive articles and more.

Travel benefits

Travel throughout the United States for up to six months and receive plan benefits from any provider that accepts Medicare. No referrals needed. You’ll also receive emergency care nationwide.

 

Last updated March 8, 2013
H2425_002_030813_N01 CMS Approved 03/11/13

Enroll today in Blue Essentials

Eligibility
You must be a resident of Minnesota and live in the 78-county service area to enroll in Blue Essentials. You must also be entitled to Medicare Part A and enrolled in Medicare Part B. You may not be eligible to enroll if you have permanent end-stage renal disease (kidney disease requiring dialysis or a kidney transplant), unless you are currently enrolled in a Blue Cross and Blue Shield of Minnesota plan.

Choose how you’d like to enroll:

Enroll online

Get a quote, compare plans and complete an enrollment form using our online tool.

Select “Medicare Advantage” (on the first screen) to see the Blue Essentials plan. Be sure to review the Summary of Benefits when prompted.

Enroll online

Download enrollment materials

Follow these four steps to enroll in 2013 Blue Essentials:

1. Review this information:
Benefits overview (PDF)  
Plan ratings (PDF)
Summary of Benefits (PDF)

2. Complete these forms:
Blue Essentials enrollment form (PDF)

Monthly automatic withdrawal form (PDF)  – This form is optional. It is a convenient way to pay your premium. If you choose this option, return this completed form with your enrollment form to the address below.

3. Mail your form(s) to:
Blue Essentials
P.O. Box 3567
Scranton, PA 18505

4. Relax! We’ll be in touch.
Blue Plus will send you an acknowledgement letter that will let you know your plan effective date or other information.
 

Enroll by phone

Call 1-855-579-7658

8 a.m. to 8 p.m. Central Time, daily
TTY users call 711

Request an enrollment kit

We’ll mail an enrollment kit to you.

It will include all the forms you need to enroll. Order a kit ExternalLink

Last updated March 8, 2013
H2425_002_030813_N01 CMS Approved 03/11/13

Member resources for Blue Essentials


Discounts and special programs

Complimentary care and products
Enjoy discounts (up to 25 percent) on accupuncture and massage therapy at ChooseHealthy.com. ExternalLink  You can also get discounts on health & wellness products from Edgepark Medical Supplies ExternalLink  and
 Rotech Healthcare. ExternalLink

Fitness center discounts
Exercise at a participating fitness center ExternalLink at least 12 times a month to earn up to a $20 credit toward your monthly health club fees. The fitness center you can help you enroll in the program.

Hearing aids
Visit any Beltone Hearing Aid Center to receive a 25 percent discount off the price of any hearing aid.
Find a location near you (PDF) *

Vision and eyewear 
Visit a network optician (PDF) * and receive a 20 percent discount on frames, lenses and contacts not covered under the medical portion of your benefits, plus get  LASIK discounts. ExternalLink

Weight Watchers
Save $10 on a three-month membership to Weight Watchers ExternalLink online.

* Providers may join or leave the network at any time. To find out if a provider is still in the network, call customer service at the number on the back of your member ID card.


Complaints and appeals

For a complete description of the complaint, coverage determination (including exceptions) and appeals process, see Chapters 8 and 9 of the Evidence of Coverage (PDF).

You can also call member services, or send a letter to:
Blue Plus
Consumer Service Center
P.O. Box 64560
St. Paul, MN 55164

If you want to appeal your Part D prescription drug benefit coverage determination call member services.


Covered drugs and other Part D benefit information

Visit the Prime Therapeutics website ExternalLink to:

  • See the drug formulary. It lists all the generic and brand name drugs covered with your plan.
  • Get forms related to Part D drug coverage, including utilization management, prior authorization or coverage determinations (including exceptions)
  • Find information about quality assurance, medication therapy management and drug utilization

If you or your provider have questions about the prior authorization process or the status of a request, please call member services.


How to find more information

For more information about your rights and responsibilities, the service area, premiums and cost-sharing, out of network coverage and information about filing a grievance, coverage determination or appeal, review the Evidence of Coverage (PDF).

You can also call or write to us:

1-866-383-5146
8 a.m. to 8 p.m. Central Time, daily
TTY users call 711

Blue Essentials
P.O. Box 3567
Scranton, PA, 18505 

Or, visit Medicare.gov ExternalLink or call toll-free
1-800-MEDICARE (1-800-633-4227)
24 hours a day, 7 days a week
TTY users call 1-877-486-2048


Helpful resources and materials

Best Available Evidence policy ExternalLink  

Evidence of Coverage (PDF)  
(see Chapter 8 for rights and responsibilities; see Chapter 9 for grievance, coverage determination and appeals information)

LIS premium summary table for 2013 (PDF)

Medicare Ombudsman ExternalLink  

Privacy notice (PDF)

Forms and coverage information

Appoint a representative ExternalLink

Medicare complaint form ExternalLink  

Member reimbursement form (PDF)

Prescription Drug Determination Request form (PDF)

Get Acrobat Reader ExternalLink  

Last updated May 10, 2013
H2425_002_050713_N01 Pending CMS Approval MM/DD/YYYY