U14314 2018 Medicare Advantage Onboarding Guide R001
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Medicare Advantage Member Guide
Y0079_8181_C PA 09092018
U14314, 7/18
1
Making the most of your plan
Thanks for choosing a Medicare Advantage plan from Blue Cross and Blue Shield of
North Carolina (Blue Cross NC).
Understanding your Member ID Card
Your Member ID card holds important information
about your plan. Be sure to present it whenever you
visit your doctor or any other health care provider.
1
Member ID –
This is your personal
Blue Medicare HMO
or PPO ID number; it
begins with a series of
letters (ABCD in this
example).
2
Your plan’s name –
This is the name of your
Blue Medicare plan.
3
Member website –
Visit this website for
complete information
on your coverage and
much more.
4
Customer Service
phone number –
Call this number when
you have questions
or concerns about
billing, claims or any
other issues.
5
Mailing address –
This is the address to
use whenever you want
to send us something
in writing.
2
Essential
Member Name
1
JOHN DOE
Member ID#
ABCD123456789
Plan (80840) XXXXXXXXXX
Group No
No
011800
mm-dd-yyyy
Card Issued
Rx BIN
Rx
015905
Rx PCN
Rx
HMONC
Rx Group
Rx
NCPARTD
3
North Carolina Hospitals or
physicians file claims to:
P.O. Box 17509
Winston-Salem, NC 27116
Hospitals or physicians outside of
North Carolina, file your claims to
your local BlueCross and/or Blue
Shield Plan.
Contract# H3449 XXX
www.BlueCrossNC.com/Member-Members
Customer Service:
TTY:
Provider Line:
Mental HealthSA:
4
1-888-310-4110
1-888-451-9957
1-888-296-9790
1-800-266-6167
Members send
Correspondence to:
Blue Medicare HMO
P.O. Box 17509
Winston-Salem, NC 27116
5
Members: See your Evidence of Coverage
IEOCI for covered services.
An independent licensee of the Blue Cross
and Blue Shield Association.
2
What To Do First
Sign up for Blue Connect
Just visit www.BlueCrossNC.com/Welcome to register for
Blue Connect SM. It’s your secure, personalized member website.
You will find information on your health coverage at your
fingertips, 24 hours a day, 7 days a week.
Get the app and connect on the go
Download the Blue Connect Mobile SM app. It's free through
the iTunes App Store and Google Play. With the Blue Connect
mobile app, you can manage your health plan whenever and
wherever it’s convenient for you.
Enroll in Auto Pay
Make paying your premium easy: Have your premium
automatically withdrawn from your bank account with
Auto Pay.
• F
ill out the information on the back of your bill or print
and complete an Authorization for Automatic Bank Draft
form by visiting www.BlueCrossNC.com/MedicareMembers – just click on "All Medicare Forms" and then
click on "Enrollment Forms."
Make an appointment for your Annual Wellness
Visit and complete your Health Assessment
Be sure to make an appointment to see your doctor for your
Annual Wellness Visit – available to you at no additional cost.
It’s your chance to discuss your plan of preventive care for
the year. Complete your Health Assessment questionnaire –
it gives you an overall picture of your health and can provide
ideas on what to discuss with your doctor during your Wellness
Visit. (Your Health Assessment is confidential. It will not impact
your plan options or rate.)
As a member
of a Medicare
Advantage plan
from Blue Cross
NC, you’ll have
access to Blue
Connect, our
member website.
Complete
information on
your health
coverage is at
your fingertips,
24 hours a day,
7 days a week.
Questions?
Contact Customer Service or your Blue Cross NC Authorized Agent.
Blue Medicare HMO: 1-888-310-4110
TTY/TDD:
1-888-451-9957
Blue Medicare PPO: 1-877-494-7647
Hours:
Mon. – Sun., 8 a.m. – 8 p.m.
3
Managing Your Plan
Learn about your benefits
The best way to find out more about the benefits of your
plan is to read over the Medical Benefits Chart in your Evidence
of Coverage (EOC). The EOC Benefits Chart lists the services
your plan covers and what you pay out-of-pocket for each
service. New members will receive their EOC in the mail. All
members can find their EOC by visiting www.BlueCrossNC.
com/Medicare-Members – then clicking on the Medical
Benefits tab and scrolling down to Evidence of Coverage.
Find a Doctor
To find a doctor or facility that’s part of your plan’s network,
search by name or location at www.BlueCrossNC.com/
Medicare-Members and through the Blue Connect mobile app.
Simply click on “Find a Doctor/Drug/Facility.” You can also
read reviews of doctors and find our online Provider Directory.
After you go to a doctor or other health care provider, you’ll
receive an Explanation of Benefits (EOB) from us. Please
remember: an EOB is not a bill. You'll want to compare
the amount you may owe on the EOB to your bill from
the health care provider. If the amounts don't match, call us.
Our customer service phone number is on the back of your
member ID card. You can see all your EOBs online by visiting
www.BlueCrossNC.com/Medicare-Members, logging into
Blue Connect and clicking on the Claims tab.
4
Care that you
can count on
Our Medicare Advantage
plans offer you an extensive
network of more than
41,000 providers.1 You'll
get your health care at
lower prices by using these
in-network providers.
41,000
across NC 1
Footnote:
1 Blue Cross NC internal data,
April 2018.
Explanation of Benefits – Medical Sample
Provider XYZ
Claim Number: 123456789
(In-network provider)
OFFICE OR OTHER
OUTPATIENT VISIT FOR
THE EVALUATION AND
MANAGEMENT OF XYZ
(billing code xxxx)
Date of
service
Amount Amount Amount
Billed Allowed Plan Paid
by Plan
mm/dd/yy $274.00
TOTALS:
$274.00
1 Amount billed – The amount your
doctor (or other health care provider,
such as a hospital) charged for a
service.
2
3
2
1
Amount allowed by plan – The
amount Blue Cross NC allows for
the service. The allowed amount is a
discounted price that Blue Cross NC
has negotiated with providers to help
members save money.
4
5
Amount
Denied
Your Share
$24.96
$0.00
$24.96
Member
not covered
on date of
service
(Pleaselook
for your
appeal
rights at the
end of this
document.)
$24.96
A pre-service
determination
was made on
your behalf and
was denied. The
provider may
bill you for these
services
$24.96
$0.00
$24.96
$24.96
3
4
5
Amount plan paid – The amount Blue
Cross NC paid for the service.
Amount denied – This may be an
amount for a service not covered by
your plan or an amount above the
allowed amount.
Amount you may owe – The amount
you may have to pay; this amount
should match the amount, if any, on
the bill you receive from your provider.
You’ll have coverage when you travel
Blue Medicare PPO and Blue Medicare HMO members are covered for emergency
services in the United States and around the world. In addition, the Blue Medicare PPO Travel
Program enables Blue Medicare PPO members traveling in certain states and Puerto Rico to use the
networks of other participating Blue Cross and Blue Shield Medicare Advantage PPO plans. And if
you’re traveling outside the United States, you’ll have access to international providers. For more
information, visit www.BlueCrossNC.com/Medicare-Members, click on the Medical Benefits tab and
scroll down to PPO Travel Program.
Take advantage of member discounts
Our Blue365® program can help you save money while you stay healthy. Get deals on things like
gym memberships, hearing aids, vision care, travel, healthy eating and more! See all the savings
at www.BlueCrossNC.com/Blue365.
5
Understanding the Pharmacy Benefit
Find a drug or pharmacy
To find a drug or a pharmacy near you, visit www BlueCrossNC.
com/Medicare-Members, log into Blue Connect, click on Go
to Blue Connect Home and then click on the Prescriptions tab.
You'll find that our online Pharmacy Directory and Formulary are
located on our website as well.
The Preferred Pharmacy Network is a select network of national
and local independent pharmacies that can help you save
money on your prescriptions. You may choose non-preferred
pharmacies, but your costs may be higher.
Ask about generic drugs
If your doctor prescribes a medicine, be sure to ask if it’s a
generic. Generic medicines work the same way as their
brand-name versions and almost always cost less.
Save with mail-order prescriptions
You can save time by ordering prescription medications
through the mail. Our plan’s preferred mail-order service
allows you to order up to a 90-day supply for most drugs.
• V
isit www.BlueCrossNC.com/Medicare-Members,
log into Blue Connect, click on Go to Blue Connect Home,
then click on the Prescriptions tab, and from there, click on
Prescriptions by Mail.
• You can also call AllianceRx Walgreens Prime Mail Home
Delivery at 1-877-277-5457 (TTY users 711) 24 hours
a day, 7 days a week and a member service representative
will help get you started with prescriptions by mail.
Easily manage your medications
Some Preferred retail pharmacies offer home delivery. For
example, with PillPackTM, you'll receive your medication
packaged by the dose and labeled with the date and time
you need to take it. You won’t have to sort your pills, and
it’s easy to stay on track. Shipping is free and medication is
delivered to your door. For more information, call PillPack
at 1-(855) 210-2445, 9 a.m. to 9 p.m. Monday – Friday, and
10 a.m. – 6 p.m. Saturday, Eastern Time. TTY users should
call 711, and have your Blue Cross NC member ID card and
medication information available.
6
People with limited
incomes may
qualify for extra
help in paying for
their prescription
drugs. See the
"Check if you
qualify for Extra
Help" section at
the back of this
guide for more
information.
Filling Prescriptions
When you fill a prescription, you will receive a monthly Part D Explanation of Benefits that tells
you the total amount you’ve spent and the total amount we’ve paid for each of your prescriptions
during the month. Our plan keeps track of the costs and the payments you’ve made so we can
tell you when you have moved from one drug payment stage to the next.
Understanding the Coverage Gap Stage ("Donut Hole")
When you are in the Coverage Gap Stage, the Medicare Coverage Gap Discount Program provides
manufacturer discounts on brand-name drugs. You pay a portion of the negotiated price and a
portion of the dispensing fee for brand-name drugs. The amount you pay counts toward your
out-of-pocket costs. In addition, the amount discounted by the manufacturer also counts toward
your out-of-pocket costs – just as if you had paid that amount. All this helps you through the
coverage gap with lower costs.
Coverage Gap Example
COVERAGE
ENDS
DECEMBER 31
COVERAGE
BEGINS
JANUARY 1
COVERAGE
GAP
Deductible
(if applicable)
Initial
Coverage
By your plan,
you pay just
copays for
your
prescriptions
Less Coverage
you pay a higher
percentage for your
prescriptions
Catastrophic
Coverage
kicks back in
(Catastrophic
Coverage
begins)
Catastrophic
Coverage
continues
through
year's end
7
Check if you qualify for Extra Help
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 will not
be subject to the coverage gap or a late enrollment penalty. 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 can also apply for extra help online at
www.socialsecurity.gov/prescriptionhelp.
Get in touch, stay in touch
It is easy to see the details of your plan:
Go to www.BlueCrossNC.com/Medicare-Members and log in to Blue Connect
or use the Blue Connect mobile app. Check on claims, manage billing
and payments, find a doctor, pharmacy or drug, and more!
Contact Customer Service or your Blue Cross NC Authorized Agent
Blue Medicare HMO: 1-888-310-4110
1-888-451-9957
TTY/TDD:
Blue Medicare PPO: 1-877-494-7647
Hours:
Mon. – Sun., 8 a.m. – 8 p.m.
For local retail store locations, please visit:
www.BlueCrossNC.com/Contact-Us/Retail-Stores
or visit us in person at one of our offices:
Durham office:
1965 Ivy Creek Blvd
Durham, NC 27707
Hours:
Mon. – Fri.,
8 a.m. – 5 p.m.
These hours exclude company holidays.
Winston-Salem 5660 University Pkwy
office:
Winston-Salem, NC 27105
Hours:
Mon. – Fri.,
8 a.m. – 5 p.m.
These hours exclude company holidays.
Blue Cross and Blue Shield of North Carolina is an HMO, PDP and PPO plan with a Medicare contract.
Enrollment in Blue Cross and Blue Shield of North Carolina depends on contract renewal.
®, SM Marks of the Blue Cross and Blue Shield Association. All other marks and trade names are the
property of their respective owners. Blue Cross and Blue Shield of North Carolina is an independent
licensee of the Blue Cross and Blue Shield Association.
8
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