Enrolling - bluekcmemberportal.azureedge.net · To get the best savings on your covered Part D drugs, you must generally use a pharmacy in our plan. You may get your covered drugs

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Summary of Benefits

Thank you for your interest in ourPrescription Drug plans.Anthem Blue Cross and Blue Shield offers prescription drug plans designed to help you with your specific drug benefit needs and protect you from unexpected drug costs. This booklet tells you what we cover, what you may pay and more. If you have questions, please call your agent.

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Prescription Drug PlanPlan year: January 1 – December 31, 2020

KansasJohnson and Wyandotte counties

Blue MedicareRx Value (PDP)Blue MedicareRx Plus (PDP)Blue MedicareRx Enhanced (PDP)

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Hurray! You sent in your enrollment request. Here’s what happens next:

You’ll get a notice with your proposed plan start date after we get your enrollment request.

We’ll send your enrollment request to the Centers for Medicare & Medicaid Services (CMS) for approval.

You’ll get your member ID card and Plan Guide with helpful tips on how to get started as a member of our plan.

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What’s inside: • Summary of Benefits

• Medicare Overview

• Plan Star Ratings

• Enrollment Form

• Temporary Proof of Enrollment

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Summary of Benefits

Prescription Drug PlanPlan year: January 1 – December 31, 2020

KansasJohnson and Wyandotte counties

Blue MedicareRx Value (PDP)Blue MedicareRx Plus (PDP)Blue MedicareRx Enhanced (PDP)

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Thank you for your interest in our Prescription Drug plans.Blue Cross and Blue Shield of Kansas City offers prescription drug plans designed to help you with your specific drug benefit needs and protect you from unexpected drug costs. This booklet tells you what we cover, what you may pay and more. If you have questions, please call your agent.

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Blue MedicareRx Value (PDP), Blue MedicareRx Plus (PDP) and Blue MedicareRx Enhanced (PDP)Blue MedicareRx Value (PDP) and Blue MedicareRx Plus (PDP) and Blue MedicareRx Enhanced (PDP) are prescription drug plans. They include prescription drug benefits only. To join these plans, you must:

· Be entitled to Medicare Part A and/ or,

· Be enrolled in Medicare Part B and

· Live in our service area.

Our service area includes: Johnson, Wyandotte.

Have questions?

· If you are not a member of this plan, please call us toll-free 1-877-507-4649 (TTY: 711), and follow the instructions to be connected to a representative.

· If you are a member of this plan, please call us toll-free at 1-866-755-2776 (TTY: 711), 8 a.m. to 8 p.m., seven days a week (except Thanksgiving and Christmas) from October 1 through March 31, and Monday to Friday (except holidays) from April 1 through September 30.

· You can learn more about us on our website athttps://shop.partdkansascity.com/medicare.

While the Summary of Benefits does not include every service, limit or exclusion, the Evidence of Coverage does. Just give us a call to request a copy.

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Know your drug plan

For many, prescription drugs are an important part of health and wellness

Our prescription drug plans give you access to the covered drugs you need – and the ability to predict costs.

What is a formulary?

Before you get your prescriptions filled, make sure they’re covered on the plan’s formulary. The formulary is a drug list that tells you:

· Which drugs require prior authorization from your plan beforeyou fill your prescription,

· If there is a quantity limit on the frequency, amount or dosage,· If you need to try other drugs first (called step therapy),· And the cost-sharing tier a drug is in.

Our plan groups each drug into “tiers.” The amount you pay depends on the drug’s tier and what stage of the benefit you have reached (refer to “The four stages of drug coverage” located further on in this booklet).

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Know your drug plan - continued

How to find if your drugs (or an acceptable alternative) are covered and what they’ll cost:

· Visit https://shop.partdkansascity.com/medicare

1. Scroll to the Useful Tools section and choose the tab labeled Find Your Covered Drugs.

2. Enter your ZIP code, county and beginning coverage date; then select Continue.

3. Enter the name of your drug, dosage, quantity and refill frequency, and select Add Drug.

4. Select your pharmacy.

5. Select View All Plans.

6. Make sure to choose Show drug cost details to view what tier your drugs are in, specific costs and coverage details.

· You can also call Customer Service at the number on page 2 to get a copy of the Formulary.

Can I use any pharmacy to fill my covered prescriptions?

To get the best savings on your covered Part D drugs, you must generally use a pharmacy in our plan. You may get your covered drugs from pharmacies that are not in our plan, but only when you are unable to get your prescription drugs from a pharmacy that is in our plan.

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Know your drug plan - continued

Save even more money at pharmacies with preferred cost sharing

To help you save even more money on your covered drugs, we work with certain pharmacies (preferred pharmacies) to further reduce prices. At preferred pharmacies, your copays and share of the cost may be lower than pharmacies with standard cost sharing. You can use a preferred pharmacy or a pharmacy with standard cost sharing; the choice is yours.

To find a pharmacy in our plan, see our online Pharmacy Directory on our website at https://shop.partdkansascity.com/medicare (under Useful Tools, select Find a Pharmacy, and enter your location and search details). Preferred pharmacies are indicated above the pharmacy name. Or you can give us a call and we'll send you a copy.

Don't miss out on some “Extra Help”1

If you qualify for Medicare’s “Extra Help,” you can get help with paying your drug plan’s monthly payment (premium), yearly deductible, coinsurance and copays for covered prescription drugs. Plus:

· The coverage gap stage will not apply to you, and· There are no late enrollment penalties.

1You can’t get Medicare Coverage Gap Discounts on brand-name drugs if you receive “Extra Help.”

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To find out if you qualify for “Extra Help,” call:· 1-800-MEDICARE/1-800-633-4227 (TTY: 1-877-486-2048),

24 hours a day/7 days a week,· The Social Security Administration at 1-800-772-1213 (TTY:

1-800-325-0778) between 7 a.m. and 7 p.m., Monday through Friday,

· Your state Medicaid office, or· Our Customer Service number located on page 2.

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Summary of 2020 prescription drug coverage

Ways to save

· You can save money on your prescription drugs by choosing generic drugs on drug Tiers 1 & 2, when available.

· You may save money if you go to a preferred cost-sharing pharmacy. To find a pharmacy in our plan:

- Visit https://shop.partdkansascity.com/medicare (under Useful Tools, select Find a Pharmacy, and enter your location and search details). Preferred pharmacies are indicated above the pharmacy name.

Give us a call and we'll send you a copy of the Pharmacy Directory.

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The four stages of drug coverage

What you pay for your covered drugs depends, in part, on which coverage stage you are in.

Stage 1 Stage 2 Stage 3 Stage 4

Deductible InitialCoverage

Coverage Gap Catastrophic Coverage

If you have a deductible, you will pay 100% of your drug cost until you meet your deductible. (If you have no deductible, or if a specific drug tier does not apply to the deductible, you will skip to Stage 2.)

You will pay a copay or a percentage of the cost, and your plan pays the rest for your covered drugs.

In this stage, you pay a greater share of the costs. It begins after you and your plan have paid $4,020 on covered drugs during Stages 1 and 2. After you enter the coverage gap, you pay 25% of the plan’s cost for covered brand-name drugs and 25% of the plan’s cost for covered generic drugs until your costs total $6,350.Some plans have extra coverage. See the Coverage Gap section for more details.

In this stage, after your yearly out-of-pocket drug costs (including drugs purchased through mail order and your retail pharmacy) reach $6,350, the plan pays most, or in some cases all, of the cost of your covered Part D prescription drugs. See the Catastrophic Coverage section below for what you pay with this plan.

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Which coverage stage am I in?You will get an Explanation of Benefits (EOB) each month you fill a prescription. It will show which coverage stage you're in and how close you are to entering the next one.

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Blue MedicareRx Value (PDP)

Blue MedicareRx Plus (PDP)

Blue MedicareRx Enhanced (PDP)

How much is my premium (monthly payment)?

$43.10 per month $57.00 per month $26.50 per month

You must continue to pay your Medicare Part B premium.

Stage 1: How much is my deductible?

$330.00 deductible per year for Part D prescription drugs.

Drugs listed on Tier 2: Generic, Tier 3: Preferred Brand, Tier 4: Non-Preferred Drug and Tier 5: Specialty Tier are included in the Part D deductible.

This plan does not have a Part D deductible.

$300.00 deductible per year for Part D prescription drugs.

Drugs listed on Tier 3: Preferred Brand, Tier 4: Non-Preferred Drug and Tier 5: Specialty Tier are included in the Part D deductible.

Stage 2: Initial Coverage

After you pay your yearly deductible (if your plan has one), you pay the amount listed in the table on the following pages, until your total yearly drug costs reach $4,020. Total yearly drug costs are the total drug costs paid by both you and our Part D plan.



You may get your covered drugs at retail pharmacies and mail-order pharmacies

in our plan. Generally, you may get your covered drugs from pharmacies not in our plan only when you are unable to get your prescription drugs from a

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pharmacy that is in our plan. If you live in a long-term care facility, you pay the same as at a standard retail pharmacy.

If you qualify for low-income subsidy (LIS), also known as Medicare's "Extra Help" program, the amount you pay may be different in this Stage.


Preferred Retail and Mail Order Cost Sharing

Cost SharingBlue MedicareRx

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Enhanced (PDP)

Tier 1: Preferred Generic

Preferred retail one-month supply $1.00* $1.00 $1.00*

Mail order three-month supply $3.00* $3.00 $3.00*

Tier 2: Generic

Preferred retail one-month supply $3.00 $3.00 $2.00*

Mail order three-month supply $9.00 $9.00 $6.00*

Tier 3: Preferred Brand

Preferred retail one-month supply $33.00 $40.00 20%

Mail order three-month supply $99.00 $120.00 20%

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Preferred Retail and Mail Order Cost Sharing


Value (PDP)

Blue MedicareRx

Plus (PDP)

Blue MedicareRx

Enhanced (PDP)

Tier 4: Non-Preferred Drug

Preferred retail one-month supply 41% 42% 37%

Mail order three-month supply 41% 42% 37%

Tier 5: Specialty Tier

Preferred retail one-month supply 25% 33% 25%

Mail order three-month supply Not available Not available Not available

*Your deductible will not apply for these drugs.

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Standard Retail Cost Sharing


Value (PDP)

Blue MedicareRx

Plus (PDP)

Blue MedicareRx

Enhanced (PDP)

Tier 1: Preferred Generic

Standard retail one-month supply

$11.00* $9.00 $9.00*

Tier 2: Generic


$13.00 $17.00 $10.00*

Tier 3: Preferred Brand


$43.00 $47.00 22%

Tier 4: Non-Preferred Drug


50% 50% 39%

Tier 5: Specialty Tier


25% 33% 25%

*Your deductible will not apply for these drugs.

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Stage 3: Coverage Gap




You pay 25% of the plan’s cost for covered brand name drugs and 25% of the plan’s cost for covered generic drugs until your costs total $6,350, which is the end of the coverage gap. Not everyone will enter the coverage gap.

For drugs on Tier 1 you pay the same cost-sharing that is listed in Stage 2 above.

For all other drugs, you pay 25% of the plan’s cost for covered brand name drugs and 25% of the plan’s cost for covered generic drugs until your costs total $6,350, which is the end of the coverage gap. Not everyone will enter the coverage gap.

For drugs on Tier 1, Tier 2 you pay the same cost-sharing that is listed in Stage 2 above.

For all other drugs, you pay 25% of the plan’s cost for covered brand name drugs and 25% of the plan’s cost for covered generic drugs until your costs total $6,350, which is the end of the coverage gap. Not everyone will enter the coverage gap.

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Stage 4: Catastrophic Coverage




After your yearly out-of-pocket drug costs (including drugs purchased through mail order and your retail pharmacy) reach $6,350, you pay the greater of:

· 5% of the cost, or

· $3.60 copay forgeneric (includingbrand name drugstreated as generic)and an $8.95copay for all otherdrugs.







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Medicare ID cards

The Medicare plan option you choose will determine the plan ID card or cards you will need to carry with you at all times.

If you choose one of our Prescription Drug Plans (PDP):

Your PDP card is used for obtaining your prescriptions. You will need to carry another card to obtain your medical benefits, depending on what kind of medical coverage you have. (For example, your Medicare Supplement plan card, or your Medicare card.)

How can I learn more about Medicare?

Medicare & You – a helpful tool

We strongly recommend you obtain a copy of the official U.S. government’s Medicare & You handbook to get the answers to all of your questions about Medicare. If you do not have a copy, you can view it online at www.medicare.gov or call Medicare for a copy at1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week.TTY users can call 1-877-486-2048.

When you can enroll

Initial coverage period

You can sign up for a Medicare Advantage or Part D plan when you are first eligible for Medicare. Your initial enrollment phase is a 7-month period that includes the 3 months before you turn 65, the month you turn 65 and the 3 months after you turn 65.

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Annual election period - October 15 to December 7

This is the time frame each year that you can enroll in or change your Medicare Advantage or Part D plan. You may also switch to Original Medicare (Parts A and B). New coverage begins January 1 of each year, after you’ve enrolled.

Open enrollment period - January 1 to March 31

If you're enrolled in a Medicare Advantage Prescription Drug (MA-PD) plan, and you're switching to Original Medicare, you can enroll in a Part D plan during this time.

Special enrollment period

You can sign up for a Medicare Advantage or Part D plan outside of the time frame above if certain events occur in your life or if you’re eligible for low-income subsidy (also called “Extra Help”).

Avoid late-enrollment penalties

It’s important to enroll in a Medicare plan when you’re first eligible. If you don’t, you may have to pay the following penalties:

· Medicare Part A: Your monthly premium, if you have one, mayincrease by 10% per year for twice the number of years you couldhave had Part A but didn’t sign up.

· Medicare Part B: Your monthly premium may increase 10% foreach 12-month period that you could have had Part B but didn’tsign up. You’ll have to pay this penalty for as long as you have PartB.

· Medicare Part D: If you don’t sign up when you’re first eligible, youmay have to pay this penalty for as long as you are enrolled in PartD, and it may increase every year. (You may not have to pay if youreceive “Extra Help” or can provide proof of other creditablecoverage.)

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It’s important we treat you fairly That’s why we follow Federal civil rights laws in our health programs and activities. We don’t discriminate, exclude people, or treat them differently on the basis of race, color, national origin, sex, age or disability. For people with disabilities, we offer free aids and services. For people whose primary language isn’t English, we offer free language assistance services through interpreters and other written languages. Interested in these services? Call Customer Service for help (TTY: 711).

If you think we failed to offer these services or discriminated based on race, color, national origin, age, disability, or sex, you can file a complaint, also known as a grievance. You can file a complaint with our Compliance Coordinator in writing to Compliance Coordinator, 4361 Irwin Simpson Rd, Mailstop: OH0205-A537; Mason, Ohio 45040-9498. Or you can file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights at 200 Independence Avenue, SW; Room 509F, HHH Building; Washington, D.C. 20201 or by calling 1-800-368-1019 (TTY: 1- 800-537-7697) or online at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf. Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Get help in your language Separate from our language assistance program, we make documents available in alternate formats for members with visual impairments. If you need a copy of this document in an alternate format, please call the Customer Service number on the back of your ID card.

English: You have the right to get this information and help in your language for free. Call Customer Service for help.

Spanish: Tiene el derecho de obtener esta información y ayuda en su idioma de forma gratuita. Llame al número de Servicios para Miembros para obtener ayuda.

Arabic: .للمساعدة العمالء بخدمة اتصلً.مجانا بلغتك والمساعدة المعلومات ھذه على الحصول لك يحق

Armenian: Դուք իրավունք ունեք Ձեր լեզվով ստանալու այս տեղեկատվությունը և ցանկացած օգնություն` անվճար:

Օգնություն ստանալու համար զանգահարեք հաճախորդների սպասարկման կենտրոն:

Chinese: 您有權使用您的語言免費獲得該資訊和協助。請致電客戶

服務部尋求協助。

Farsi: .کنيد دريافت خودتان زبان به رايگان صورت به را کمکھا و اطالعات اين که داريد را حق اين شما .بگيريد تماس مشتريان خدمات مرکز اب مکک دريافت برای

French: Vous avez le droit d’accéder gratuitement à ces informations et à une aide dans votre langue. Pour obtenir de l’aide, veuillez appeler le service client.

Haitian: Ou gen dwa resevwa enfòmasyon sa a ak asistans nan lang ou pale a pou gratis. Rele nimewo Sèvis Kliyan an pou jwenn èd.

Italian: Ha il diritto di ricevere queste informazioni ed eventuale assistenza nella sua lingua senza alcun costo aggiuntivo. Per assistenza, chiami il Servizio clienti.

Japanese: この情報と支援を希望する言語で無料で受けることができます。サポートが必要な場合はカスタマーサービスにお電

話ください。

Korean: 귀하께는 본 정보와 도움을 비용없이 귀하의 언어로 받으실 권리가 있습니다 . 도움을 받으시려면 고객 서비스부로 연락해 주십시오 .

Polish: Masz prawo do bezpłatnego otrzymania niniejszych informacji oraz uzyskania pomocy w swoim języku. Zadzwoń pod numer Działu Obsługi Klienta w celu uzyskania pomocy.

Portuguese: Você tem o direito de receber gratuitamente estas informações e ajuda no seu idioma. Ligue para o Atendimento ao Cliente para obter ajuda.

Russian: Вы имеете право получить данную информацию и помощь на вашем языке бесплатно. Для получения помощи звоните в отдел обслуживания клиентов.

Tagalog: May karapatan kang makuha ang impormasyon at tulong na ito sa sarili mong wika ng walang kabayaran. Tumawag sa Serbisyo para sa mga Kustomer para matulungan ka.

Vietnamese: Bạn có quyền được biết về thông tin này và được hỗ trợ bằng ngôn ngữ của bạn miễn phí. Hãy liên hệ với Dịch vụ khách hàng để được hỗ trợ.

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This information is not a complete description of benefits. Call 1-866-755-2776 (TTY: 711) for more information.

Blue Cross and Blue Shield of Kansas City (Blue KC) is a PDP plan participant in a Medicare contract held by Blue Cross and Blue Shield of Kansas (BCBSKS). Enrollment in Blue KC depends on contract renewal.

Blue KC and Anthem Insurance Companies, Inc. (AICI) provide administrative services for Blue MedicareRx plans. BCBSKS is the legal entity under contract with the Centers for Medicare and Medicaid Services (CMS) to offer the Part D plans noted. BCBSKS is the risk-bearing entity licensed under applicable state law or under a federal waiver program to offer the Part D plans noted.

Blue KC's service area covers 30 counties in greater Kansas City and northwest Missouri, plus Johnson and Wyandotte counties in Kansas. Blue KC, BCBSKS and AICI are independent licensees of the Blue Cross Blue Shield Association (Association). Â® The Blue Cross Blue Shield names and symbols are registered marks of the Association.

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2020 Medicare Star Ratings*

The Medicare Program rates all health and prescription drug plans each year, based on a plan’s quality and performance. Medicare Star Ratings help you know how good a job our plan is doing. You can use these Star Ratings to compare our plan’s performance to other plans. The two main types of Star Ratings are:

1. An Overall Star Rating that combines all of our plan’s scores.2. Summary Star Rating that focuses on our medical or our prescription drug

services.

Some of the areas Medicare reviews for these ratings include:

• How our members rate our plan’s services and care;• How well our doctors detect illnesses and keep members healthy;• How well our plan helps our members use recommended and safe prescription medications.

For 2020, Blue MedicareRx (PDP) received the following Overall Star Rating from Medicare.

4 Stars

We received the following Summary Star Rating for Blue MedicareRx (PDP)'s health/drug plan services:

Health Plan Services: Not Offered

Drug Plan Services: 4 Stars

The number of stars shows how well our plan performs.

5 stars - excellent

4 stars - above average

3 stars – average

2 stars - below average

1 star - poor

Learn more about our plan and how we are different from other plans at www.medicare.gov.

We do not discriminate, exclude people, or treat them differently on the basis of race, color, national origin, sex, age or disability in our health programs and activities.

You may also contact us at 1-877-507-4649 (toll-free) or 711 (TTY), 8 a.m. to 8 p.m., seven days a week (except Thanksgiving and Christmas) from October 1 through March 31, and Monday to Friday (except holidays) from April 1 through September 30.

http://www.medicare.gov/

Current members please call 1-866-755-2776 (toll-free) or 711 (TTY).

*Medicare evaluates plans based on a 5-star rating system. Star Ratings are calculated each year and may change from one year to the next.

Blue Cross and Blue Shield of Kansas City (Blue KC) is a PDP plan participant in a Medicare contract held by Blue Cross and Blue Shield of Kansas (BCBSKS). Enrollment in Blue KC depends on contract renewal.

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Enrollment Checklist

Before making an enrollment decision, it is important that you fully understand our benefits and rules. If you have any questions, you can call and speak to a customer service representative at 1-800-243-3363 TTY: 711, 8 a.m. to 8 p.m., seven days a week (except Thanksgiving and Christmas) from October 1 through March 31, and Monday to Friday (except holidays) from April 1 through September 30.

Understanding the Benefits

Review the full list of benefits found in the Evidence of Coverage (EOC) . Visit https://shop.anthem.com/medicare or call 1-800-243-3363 to view a copy of the EOC.

Review the pharmacy directory to make sure the pharmacy you use for any prescription medicines is in the network. If the pharmacy is not listed, you will likely have to select a new pharmacy for your prescriptions.

Understanding Important Rules

In addition to your monthly plan premium, you must continue to pay your Medicare Part B

premium. This premium is normally taken out of your Social Security check each month.

Benefits, premiums and/or copayments/co-insurance may change on January 1, 2021.

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The Centers for Medicare & Medicaid Services (CMS) requires agents to document the scope of a marketing appointment prior to any face-to-face sales meeting to ensure understanding of

Please initial below beside the type of product(s) you want the agent to discuss:

______________Stand-alone Medicare Prescription Drug Plans (Part D)

______________Medicare Advantage Plans (Part C)

_________________________________________________ _________________________Signature: Signature Date:

If you are the authorized representative, please sign above and print below:

Representative’s Name: _________________________________________________________

______________________________________________

Agent Name: Agent Phone:

(Optional):

(Optional):

(Agent’s Signature:

5049201 502003MUSENMUB_0003 2020 SOA Forms Blue

Y0114_20_110361_I_C_0003 08/14/2019 502003MUSENMUB_0003

Please note, the person who will discuss the products is either employed or contracted by a Medicare plan. The person does not work directly for the federal government. This individual may also be paid based on your enrollment in a plan.

Signing this form does NOT obligate you to enroll in a plan, affect your current enrollment, or enroll you in a Medicare plan.

A stand-alone drug plan that adds prescription drug coverage to Original Medicare, some Medicare Cost plans, some Medicare Private Fee-for-Service plans, and Medicare Medical Savings Account plans.

A Medicare Advantage plan that provides all Original Medicare Part A and Part B health coverage and sometimes covers Part D prescription drug coverage. In most HMOs, you can only get your care from doctors or hospitals in the plan’s network (except in emergencies).

A Medicare Advantage plan that provides all Original Medicare Part A and Part B health coverage and sometimes covers Part D prescription drug coverage. PPOs have network doctors and hospitals but you can also use out-of-network providers, usually at a higher cost.

A special type of Medicare Advantage Plan available that

who have both Medicare and Medicaid, who reside in a nursing home, or have certain chronic medical conditions. There are plans available to anyone who has both Medical Assistance from the State and Medicare, plans for people with diabetes, and plans for anyone with Medicare living in an assisted living facility (ALF) or living at home but has complex health issues which require comprehensive care.

Scope of Appointment documentation is subject to CMS record retention requirements.

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Applicant Complete: Name and Medicare Number

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Blue Cross and Blue Shield of Kansas CityMedicare Prescription Drug PlanIndividual Enrollment Form - 2020

Be sure to complete the entire enrollment form. Fax the completed form to 1-800-833-8554 or mail the completed form to P.O. Box 659403, San Antonio TX, 78265-9714. You can also enroll online at

https://shop.partdkansascity.com/medicare. Note: Your agent/broker may provide different instructions.

Please contact Blue Cross and Blue Shield of Kansas City if you need information in another language or format (Large Print or Braille).

To enroll in Blue Cross and Blue Shield of Kansas City, please provide the following information.

o Blue MedicareRx Value (PDP)$43.10 per month

o Blue MedicareRx Plus (PDP)$57.00 per month

o Blue MedicareRx Enhanced (PDP)

$26.50 per month

Last name First name MI

Birthdate (MM/DD/YYYY) Gender Home phone number Alternate phone number

¨ M ¨ F

Permanent residence street address (P.O. Box is not allowed.)

City State ZIP code County

Mailing address (only if different from your permanent residence address)

City State ZIP code



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Please provide your Medicare insurance information

Please take out your red, white and blue Medicare card to complete this section.

· Fill out this information as it appears on your Medicare card.

-OR-

· Attach a copy of your Medicare card or your letter from Social Security or the Railroad Retirement Board.

Name (as it appears on your Medicare card):

Medicare Number:

Is Entitled To: Effective Date:

HOSPITAL (Part A)

MEDICAL (Part B)

You must have Medicare Part A or Part B (or both) to join a Medicare prescription drug plan.

Paying your plan premium

You can pay your monthly plan premium (including any late enrollment penalty you may owe) by mail or electronic funds transfer (EFT) each month. You can also choose to pay your premium by automatic deduction from your Social Security or Railroad Retirement Board (RRB) benefit check each month.

If you are assessed a Part D-Income Related Monthly Adjustment Amount (D-IRMAA), you will be notified by the Social Security Administration. You will be responsible for paying this extra amount in addition to your plan premium. You will either have the amount withheld from your Social Security or Railroad Retirement Board (RRB) benefit check or be billed directly by Medicare. Do NOT pay the Part D-IRMAA extra amount to Blue Cross and Blue Shield of Kansas City.

People with limited incomes may qualify for “Extra Help” to pay for their prescription drug costs. If eligible, Medicare could pay for 75% or more of your drug costs including monthly prescription drug premiums, annual deductibles and coinsurance. Additionally, those who qualify won't have a coverage gap or a late enrollment penalty. Many people are eligible for these savings and don’t even know it. For more information about this “Extra Help”, contact your local Social Security office, or call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. You also can apply for “Extra Help” online at www.socialsecurity.gov/prescriptionhelp.

If you qualify for “Extra Help” with your Medicare prescription drug coverage costs, Medicare will pay all or part of your plan premium. If Medicare pays only a portion of this premium, we will bill you for the amount that Medicare doesn’t cover.

If you don’t select a payment option, you will get a bill each month.

Please select a premium payment option:

o Monthly Bill: Send me a bill each month

o Automatic Bank Account Deduction: Electronic funds transfer (EFT) from my bank account each month. (Depending on when you apply, more than one month's amount might be deducted for your first payment.) Please complete steps 1 and 2 below:



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1) Account Type o Checking: Must enclose VOIDED check or letter from financial institution with account number.

o Savings: Must enclose letter from financial institution with account information.

2) Please complete the following information for your account

Account holder name Bank name

Bank routing number* Account number

(*This is the first 9 digits printed on the lower left corner of your check.)

I authorize the bank above to deduct my monthly premiums.

Automatic deduction from your monthly o Social Security or o Railroad Retirement Board (RRB) benefit check.

(The Social Security/Railroad Retirement Board (RRB) deduction may take two or more months to begin after Social Security or Railroad Retirement Board (RRB) approves the deduction. In most cases, if Social Security or Railroad Retirement Board (RRB) accepts your request for automatic deduction, the first deduction from your Social Security or Railroad Retirement Board (RRB) benefit check will include all premiums due from your enrollment effective date up to the point withholding begins. If Social Security or Railroad Retirement Board (RRB) delays or does not approve your request for automatic deduction, we will send you a paper bill for your monthly premiums.)

Please read and answer these important questions:

1. Some individuals may have other drug coverage, including other private insurance, TRICARE, Federal employee health benefits coverage, VA benefits, or State pharmaceutical assistance programs.

Will you continue to have other prescription drug coverage? o Yes o No o N/A

If "yes," please list your other coverage and your identification (ID) # for this coverage

Name of other coverage

ID # for this coverageGroup # for this coverage

2. Are you a resident in a long-term care facility, such as a nursing home? o Yes o No

If “yes,” please provide the following information:

Name of institution

Address

City State ZIP code Phone number

Please check one of the boxes below if you would prefer that we send you information in a language other than English or in an accessible format:

Assistance for the visually impaired:

¨ Voice-Enabled (Audio) PDF ¨ Large PrintPlease contact Blue Cross and Blue Shield of Kansas City at 1-877-507-4649 if you need information in an accessible format or language other than what is listed above. TTY users should call 711.

.



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STOPPlease read this important information.

If you are a member of a Medicare Advantage plan (like an HMO or PPO), you may already have Part D prescription drug coverage from your Medicare Advantage plan that will meet your needs. By joining Blue Cross and Blue Shield of Kansas City your membership in your Medicare Advantage plan may end. This will affect both your doctor and hospital coverage, as well as your prescription drug coverage. Read the information that your Medicare Advantage plan sends you and if you have questions, contact your Medicare Advantage plan.

If you currently have health coverage from an employer or union, joining Blue Cross and Blue Shield of Kansas City could affect your employer or union health benefits. You could lose your employer or union health coverage if you join Blue Cross and Blue Shield of Kansas City. Read the communications your employer or union sends you. If you have questions, visit their website, or contact the office listed in their communications. If there isn’t any information on whom to contact, your benefits administrator or the office that answers questions about your coverage can help.

Typically, you may enroll in a Medicare Prescription Drug Plan (PDP) only during the Annual Enrollment Period (AEP) between October 15 and December 7 of each year. Additionally, there are exceptions — i.e., Initial Enrollment Period (IEP) and Special Enrollment Periods (SEPs) — that may allow you to enroll in a Prescription Drug Plan outside of this period.

Please read the following statements carefully and check all of the boxes where there is a statement that applies to you. By checking any of the following boxes you are certifying that, to the best of your knowledge, you are eligible for an Enrollment Period. If we later determine that this information is incorrect, you may be disenrolled.

NOTE: You must select at least one of the options below.

o I am enrolling during the Annual Open Enrollment Period from October 15 to December 7. (AEP)

o I am new to Medicare. (IEP)

o I am turning 65 and not new to Medicare. (IEP2)

o I recently moved outside of the service area for my current plan or I recently moved and this plan is a new option for me. I moved on (insert date) .(SEP)

o I have both Medicare and Medicaid (or my state helps pay for my Medicare premiums) or I get “Extra Help” paying for my Medicare prescription drug coverage, but I haven't had a change. (SEP)

o I was enrolled in a plan by Medicare (or my state) and I want to choose a different plan. My enrollment in that plan started on (insert date) .(SEP)

o I was affected by a weather-related emergency or major disaster (as declared by the Federal Emergency Management Agency (FEMA)). One of the other statements here applied to me, but I was unable to make my enrollment because of the natural disaster. (SEP)

o I recently had a change in my Medicaid/”Extra Help” paying for my Medicare prescription drug coverage (newly got Medicaid/”Extra Help”, had a change in the level of Medicaid/”Extra Help”, or lost Medicaid/”Extra Help”) on (insert date) _________________ . (SEP)

o I am moving into, live in or recently moved out of a long-term care facility (for example, a nursing home or long-term care facility). I moved/will move into/out of the facility on (insert

date) .(SEP)

o I recently left a Program of All-inclusive Care for the Elderly (PACE®) program on (insert date).(SEP)



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o I recently involuntarily lost my creditable prescription drug coverage (coverage as good as Medicare’s). I lost my drug coverage on (insert date) .(SEP)

o I am leaving employer or union coverage on (insert date) .(SEP)

o I belong to a pharmacy assistance program provided by my state. (SEP)

o I recently returned to the United States after living permanently outside of the U.S. I returned to the U.S. on (insert date) .(SEP)

o My plan is ending its contract with Medicare or Medicare is ending its contract with my plan. (SEP)

o I was recently released from incarceration. I was released on (insert date) .(SEP)

o I recently obtained lawful presence status in the United States. I got this status on (insertdate) .(SEP)

o I am enrolled in a Medicare Advantage plan and want to make a change during the Medicare Advantage Open Enrollment Period. (MA OEP)

o Other*

*If none of these statements apply to you or you’re not sure, please contact Blue Cross and Blue Shield of Kansas City at 1-877-507-4649 (TTY users should call 711) to see if you are eligible to enroll.

C

Email Preferences

Email is the fastest, easiest way to get important information about your plan – and some fun extras, too! Please provide your email address below to sign up for our email program.

Member's email @

By giving my email address, I agree to receive emails about my benefits, health programs and other plan services.

I understand I can change my email preferences any time by calling customer service.

Please read and sign below

By completing this enrollment application, I agree to the following:

Blue MedicareRx Value (PDP) or Blue MedicareRx Plus (PDP) or Blue MedicareRx Enhanced (PDP) is a Medicare drug plan and has a contract with the Federal government. I understand that this prescription drug coverage is in addition to my coverage under Medicare; therefore, I will need to keep my Medicare Part A or Part B coverage. It is my responsibility to inform Blue Cross and Blue Shield of Kansas City of any prescription drug coverage that I have or may get in the future. I can only be in one Medicare prescription drug plan at a time – if I am currently in a Medicare prescription drug plan, my enrollment in Blue Cross and Blue Shield of Kansas City will end that enrollment. Enrollment in this plan is generally for the entire year. Once I enroll, I may leave this plan or make changes if an enrollment period is available, generally during the Annual Enrollment Period (October 15 – December 7), unless I qualify for certain special circumstances.



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Blue MedicareRx Value (PDP) or Blue MedicareRx Plus (PDP) or Blue MedicareRx Enhanced (PDP) serves a specific service area. If I move out of the area that Blue Cross and Blue Shield of Kansas City serves, I need to notify the plan so I can disenroll and find a new plan in my new area. I understand that I must use network pharmacies except in an emergency when I cannot reasonably use Blue Cross and Blue Shield of Kansas City network pharmacies. Once I am a member of Blue MedicareRx Value (PDP) or Blue MedicareRx Plus (PDP) or Blue MedicareRx Enhanced (PDP), I have the right to appeal plan decisions about payment or services if I disagree. I will read the Evidence of Coverage document from Blue Cross and Blue Shield of Kansas City when I get it to know which rules I must follow to get coverage. I understand that if I have had a prior break in creditable prescription drug coverage (as good as Medicare’s), or leave this plan and don’t have or get other Medicare prescription drug coverage or creditable prescription coverage (as good as Medicare’s), I may have to pay a late enrollment penalty in addition to my premium for Medicare prescription drug coverage in the future. I understand that if I am getting assistance from a sales agent, broker, or other individual employed by or contracted with Blue Cross and Blue Shield of Kansas City, he/she may be paid based on my enrollment in Blue MedicareRx Value (PDP) or Blue MedicareRx Plus (PDP) or Blue MedicareRx Enhanced (PDP). Counseling services may be available in my state to provide advice concerning Medicare supplement insurance or other Medicare Advantage or prescription drug plan options, medical assistance through the state Medicaid program, and the Medicare Savings Program.

Release of Information: By joining this Medicare prescription drug plan, I acknowledge that Blue Cross and Blue Shield of Kansas City will release my information to Medicare and other plans as is necessary for treatment, payment and health care operations. I also acknowledge that Blue Cross and Blue Shield of Kansas City will release my information, including my prescription drug event data, to Medicare, who may release it for research and other purposes which follow all applicable Federal statutes and regulations. The information on this enrollment form is correct to the best of my knowledge.

I understand that if I intentionally provide false information on this form, I will be disenrolled from the plan. I understand that my signature (or the signature of the person authorized to act on my behalf under State law where I live) on this application means that I have read and understand the contents of this application. If signed by an authorized individual (as described above), this signature certifies that: 1) this person is authorized under State law to complete this enrollment and 2) documentation of this authority is available upon request from Medicare.

Signature Required to process your application.

Applicant signatureX

Today’s date

Desired plan effective date*:

*Subject to Medicare election period guidelines



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Authorized Representative Information Only

All fields within this section must be completed if the application has been signed by an Authorized Representative and not the Applicant.

NameFirst Name Last Name

Address

City State ZIP code

Phone Number Relationship to Enrollee

o I have submitted Authorized Representative documentation with this application.



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Applicant: Please do not complete the following sections.Agent/Broker: Please fill in ALL fields including 'Writing Agent' and 'Agency' with your assigned

Encrypted ID, Code, or Tax ID based on your appointed brand, state AND product.

Coverage effective date PLAN ID #:

o IEP o AEP o OEP o SEP (type): o Not eligible

I helped the applicant fill out this application. o Yes o No

Was this an individual face-to-face appointment? o No o Yes (if yes, how was a scope ofappointment (SOA) collected)? o Paper o Recorded call (voice recording ID)

Print name First Name Last Name

Writing Agent TIN (10 digits)/Agent Code

Agency TIN (10 digits) or Agency Code

Agency Name

Phone

Email @

Signature Application received date1

Blue KC and Anthem Insurance Companies, Inc. (AICI) provide administrative services for Blue MedicareRx plans. BCBSKS is the legal entity under contract with the Centers for Medicare and Medicaid Services (CMS) to offer the Part D plans noted. BCBSKS is the risk-bearing entity licensed under applicable state law or under a federal waiver program to offer the Part D plans noted.

Blue KC's service area covers 30 counties in greater Kansas City and northwest Missouri, plus Johnson and Wyandotte counties in Kansas. Blue KC, BCBSKS and AICI are independent licensees of the Blue Cross Blue Shield Association (Association). ® The Blue Cross Blue Shield names and symbols are registered marks of the Association.

Enclosure – 1557 notice

Temporary Proof of Membership

Agent/Broker: Complete and leave with your soon-to-be new member.

Please keep this as proof of your enrollment request until Medicare has confirmed your

enrollment, and you receive your ID card and new member materials.

Future Blue Cross and Blue Shield of Kansas City Member

Name:

Today’s Date:

Plan Name:

Plan Type:

Rx BIN: 020115

Rx PCN: IS

Rx GRP: WM2A

Requested Plan Start Date:

Online Enrollment Confirmation Number (if applicable):

Please call your Agent/Broker if you have any questions or concerns. In addition, we’re

here to help and you can call us at the Customer Service number on the reverse side.

Agent/Broker Name:

Agent/Broker Phone:

Agent/Broker ID:

Please note: Enrollment is subject to Medicare approval. If you would like a complete copy of your

enrollment form, please call us at the Customer Service number on the reverse side.

Y0114_20_107033_I_C_0098 501999MUSENMUB_0098

Important Phone Numbers

Blue Cross and Blue Shield of Kansas City

Customer Service: 1-866-755-2776, TTY: 711

Blue KC and Anthem Insurance Companies, Inc. (AICI) provide administrative services for Blue

MedicareRx plans. BCBSKS is the legal entity under contract with the Centers for Medicare and

Medicaid Services (CMS) to offer the Part D plans noted. BCBSKS is the risk-bearing entity

licensed under applicable state law or under a federal waiver program to offer the Part D plans

noted. Blue KC's service area covers 30 counties in greater Kansas City and northwest Missouri,

plus Johnson and Wyandotte counties in Kansas. Blue KC, BCBSKS and AICI are independent

licensees of the Blue Cross Blue Shield Association (Association). ® The Blue Cross Blue Shield

names and symbols are registered marks of the Association.

20KCSS5726_20PDPCVR_10

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20INCVR_PDP

Hurray! You sent in your enrollment request. Here’s what happens next:

You’ll get a notice with your proposed plan start date after we get your enrollment request.

We’ll send your enrollment request to the Centers for Medicare & Medicaid Services (CMS) for approval.

You’ll get your member ID card and Plan Guide with helpful tips on how to get started as a member of our plan.

5027303 500842MUSENMUB PY 2020 Anthem PDP inside Cover

What’s inside: • Summary of Benefits

• Medicare Overview

• Plan Star Ratings

• Enrollment Form

• Temporary Proof of Enrollment

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Documents

Enrolling - bluekcmemberportal.azureedge.net · To get the best savings on your covered Part D drugs, you must generally use a pharmacy in our plan. You may get your covered drugs