2014 Blue Essentials (HMO-POS) — health and prescription drug coverage in one plan

About the 2014 Blue Essentials plan

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

Enjoy the convenience of:

Predictable premiums, copays and coinsurance for medical services and prescription drugs

Access to a large provider network of doctors, clinics and hospitals (PDF) and a pharmacy network ExternalLink of more than 64,000 pharmacies

A single ID card for medical and prescription drug coverage


Health plan benefits

  You pay:
Monthly plan premium $93.60; you must 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 In network: $4,000
Combined in and out of network: $6,500



PART D DRUG plan benefits

Benefit: Member pays:
Annual deductible $160
Initial coverage, Tier 1: Preferred generic $7 copay
Initial coverage, Tier 2: Non-preferred generic $14 copay
Initial coverage, Tier 3: Preferred brand $40 copay
Initial coverage, Tier 4: Non-preferred brand 45% coinsurance

 

More plan information

Benefits overview (PDF)

Annual Notice of Changes - Blue Essentials

Plan ratings (PDF)

Prescription drug formulary (PDF)

Provider directory (PDF)

Pharmacy network ExternalLink

Summary of Benefits (PDF)

Get Acrobat Reader ExternalLink


Blue Essentials is an HMO-POS plan with a Medicare contract. Enrollment in Blue Essentials depends on contract renewal. 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 5, 2014
H2425_002_020614_N06 CMS Approved 03/05/2014

Networks, discounts and travel benefits for 2014 Blue Essentials

Find a doctor in the network

See any doctor in the large Blue Essentials network (PDF), 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 64,000 participating network pharmacies. ExternalLink The plan also provides benefits for many prescription drugs. See the drug list ExternalLink (formulary).

Discounts on health and wellness

  • With your Silver&Fit® membership, ExternalLink you have access to fitness equipment, classes and health tools for a $50 annual membership fee, or home fitness kits geared to older adults for a $10 annual membership fee.
  • Save on eyewear and hearing aids.
  • Find answers to your medical questions using our health and 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.

 

The Silver&Fit program is a product of American Specialty Health Fitness, Inc., a subsidiary of American Specialty Health Incorporated (ASH), an independent company providing personal health and wellness programs. Silver&Fit is a federally registered trademark of ASH and used with permission herein.

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.

Last updated October 1, 2013
H2425_002_091913_N04 CMS Approved 10/22/2013

Enroll today in 2014 Blue Essentials

Eligibility
You must be a resident of Minnesota 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

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

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

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

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

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

Request an enrollment kit

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

Last updated October 1, 2013
H2425_002_091913_N04 CMS Approved 10/22/2013

Member resources for 2014 Blue Essentials

Discounts and special programs

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

Silver&Fit® Exercise and Healthy Aging Program
Your Silver&Fit membership gives you access to:

  • Exercise equipment weights and specially designed fitness classes at facilities participating with Silver&Fit for a $50 annual membership fee (where available)
  • Fitness advisors at your facility to help you get the most out of your membership
  • Tools to help you track your fitness goals and achievements
  • Choice of home exercise kits for a $10 annual membership fee instead of membership with a facility
  • Healthy aging classes online or via mail

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

Discharge Preparation Checklist (PDF) – What to do before you leave the hospital

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 2014 (PDF)

Medicare Ombudsman ExternalLink

Personal Health Record - Prepare for your next medical visit

Privacy notice (PDF)


Forms and coverage information

Appoint a representative ExternalLink

Integrated denial form (PDF)

Medicare complaint form ExternalLink

Member reimbursement form (PDF)

Prescription Drug Determination Request form (PDF)

Get Acrobat Reader ExternalLink


The Silver&Fit program is a product of American Specialty Health Fitness, Inc., a subsidiary of American Specialty Health Incorporated (ASH), an independent company providing personal health and wellness programs. Silver&Fit is a federally registered trademark of ASH and used with permission herein.

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.

Last updated December 26, 2013
H2425_002_122413_N01 CMS Approved 12/29/2013