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Summary of Benefits

January 1, 2017–December 31, 2017

Medicare HMO Blue Medicare HMO Blue Medicare HMO Blue
ValueRx (HMO) PlusRx (HMO) FlexRx (HMO-POS)
Monthly Plan $39 per month. In $295 per month. In $99 per month. In
Premium addition, you must keep addition, you must keep addition, you must keep
paying your Medicare paying your Medicare paying your Medicare
Part B premium. Part B premium. Part B premium.

Deductible
Medical: This plan does not have This plan does not have This plan does not have
a deductible a deductible a deductible

Prescription Drugs: $320 per year for $200 per year for $260 per year for
Tiers 3, 4, 5 Tiers 3, 4, 5 Tiers 3, 4, 5

Maximum Out-of- Your yearly limit(s) Your yearly limit(s) Your yearly limit(s)
Pocket in this plan: in this plan: in this plan:
Responsibility • $4,900 for services you • $3,400 for services you • $3,900 for services you
(does not include receive from receive from receive from
prescription drugs) in-network providers. in-network providers. in-network providers.
If you reach the limit on If you reach the limit on • $9,900 for services you
out-of-pocket costs, you out-of-pocket costs, you receive from out-of-
keep getting covered keep getting covered network providers.
hospital and medical hospital and medical If you reach the limit on
services and we will pay services and we will pay out-of-pocket costs, you
the full cost for the rest the full cost for the rest keep getting covered
of the year. of the year. hospital and medical
Please note that you will Please note that you will services and we will pay
still need to pay your still need to pay your the full cost for the rest
monthly premiums and monthly premiums and of the year.
cost-sharing for your Part cost-sharing for your Part Please note that you will
D prescription drugs. D prescription drugs. still need to pay your
monthly premiums and
cost-sharing for your Part
D prescription drugs.

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