2012 Medicare plans (Switch plan year)

Grievance, coverage determinations, and appeals

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You have certain rights guaranteed by federal Law. If you have problems or concerns you may make a formal complaint. There are specific guidelines set by the Medicare program about how you can make a complaint, how the complaint must be classified and the timelines in which we must address and respond to your complaint.

You can call us to request a coverage determination by telephone or you may submit the Coverage Determination form by fax or mail.

You will not be disenrolled from Medicare Plus Blue PPOSM or Prescription Blue PDPSM or penalized if you initiate a complaint. Your complaint will always be handled fairly and investigated within the guidelines of the Medicare program.

Contact Member Services first

Our Member Services representatives are here to assist you with any concerns, questions or problems you have about Medicare Plus Blue PPOSM or Prescription Blue PDPSM or care that you have received.

To locate the correct telephone number for Member Services, simply reference the back of your Medicare Plus Blue PPOSM or Prescription Blue PDPSM ID card.

If our Member Services department is not able to resolve your concern or your issue requires handling by our Grievance and Appeals Department, a Member Services representative will help you get started. Other information and links further below may be helpful to you as well.

Member Services representatives can assist you with:

Other helpful information

Note: To request a list of grievances, appeals and exceptions filed with us, please contact us by:

Phone: 1-877-241-2583 (TTY: 1-800-579-0235),
from 8 a.m. to 8 p.m. Eastern time, seven days a week.

Fax: 1-877-348-2251

Mail:
Blue Cross Blue Shield of Michigan
Grievance and Appeals Department
P.O. Box 2627
Detroit, MI 48231-2627

For process and status questions, members and providers can contact us at the numbers listed above.

H9572 S5584_W_12BCBSMAdvantageWebR2 CMS Approved 04262012

People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If eligible, Medicare could pay for up to seventy-five (75) percent of drug costs including monthly prescription drug premiums, annual deductibles, and co-insurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don't even know it. For more information about the Extra Help program, contact your local Social Security office or call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, seven days per week. TTY users should call 1-877-486-2048.

Important information about these plans

Medicare Plus Blue PPOSM is a health plan with a Medicare contract. Prescription Blue PDPSM is a stand-alone prescription drug plan with a Medicare contract.

Medicare Plus Blue PPO

Medicare Plus Blue PPO is available to all Medicare beneficiaries who are Michigan residents and are entitled to receive services under Medicare Part A and enrolled in Part B.

With the exception of emergency or urgent care, it will cost more to get care from non-plan or non-preferred providers. Your responsibility will be greater out-of-network when the out-of-network coinsurance is based on the Medicare allowed amount and the contracted amount is lower. You may receive services from any provider who accepts Original Medicare. Your out-of-pocket costs will be lower if you choose a network provider. To find a network provider, visit www.bcbsm.com/medicare/provdirectory.shtml.

Prescription Blue PDP

Prescription Blue PDP is available to all Medicare beneficiaries who are Michigan residents entitled to receive services under Medicare Part A and/or enrolled in Part B.

Medicare Plus Blue PPO and Prescription Blue PDP

Premiums vary by county. You must continue to pay your Medicare Part B premium.

Limitations, copayments and restrictions may apply.

Our network includes approximately 2,300 Michigan retail pharmacies, of which 86 percent are network pharmacies. Nationwide, most chain pharmacies are in our network, as well as long-term care and home infusion pharmacies and Indian/Tribal/Urban (Indian Health Service) pharmacies.

In general, benefits are only available at contracted network pharmacies. Plan drugs may be covered in special circumstances, for instance, illness while traveling outside of the plan's service area where there is no network pharmacy. You may have to pay more than your normal cost sharing amount if you get your drugs at an out-of-network pharmacy. Quantity limitation and restrictions may apply. In addition, you will likely have to pay the pharmacy's full charge for the drug and submit documentation to receive reimbursement from Blue Cross Blue Shield of Michigan. For additional information on network pharmacies, please call Member Services at 1-877-469-2583, 8 a.m. to 8 p.m. seven days a week. TTY users should call 1-800-481-8704. You may also write to: Blue Cross Blue Shield of Michigan, 600 E. Lafayette Blvd., Mail Code X435, Detroit, MI 48226.

If you decide to have your plan premium withheld from your Social Security check or deducted from your checking or savings account, it may take up to three months for the automatic deduction to begin. If your premium amount is currently withheld from your Social Security check or deducted from your checking or savings account and you wish to receive a monthly bill instead, the change may also take up to three months to become effective. During this time, you will be responsible for paying your premium.

The benefit information provided herein is a brief summary, not a comprehensive description of benefits. For more information contact the plan. Benefits, formulary, pharmacy network, premium and/or co-payments/co-insurance may change on Jan. 1, 2013.

Medicare beneficiaries may enroll in Medicare Plus Blue PPO, BCN Advantage HMO-POS or Prescription Blue PDP through the CMS Medicare Online Enrollment Center located at http://www.medicare.gov. For more information, please contact Blue Cross Blue Shield of Michigan at 1-877-469-2583, 8 a.m. to 8 p.m. seven days a week. TTY users should call 1-800-481-8704.

You may only enroll in Medicare Plus Blue PPOSM or Prescription Blue PDPSM during specific times of the year. To learn more about enrollment periods, please contact Member Services.