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The benefit information provided is a summary of what we cover and what you pay. To get a complete list of services we cover, call us and ask for the "Evidence of Coverage." To get a complete list of the drugs we cover, call us and ask for the List of Covered Drugs ("Formulary"). You may also contact your former employer's benefits administrator for the "Evidence of Coverage" and "Formulary." If you want to know more about the coverage and costs of Original Medicare, look in your current Medicare & You handbook. View it online at www.medicare,gov or get a copy by calling 1 -800 -MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. Who Can join? You and your dependent(s) can join this plan if you are a retired employee of the group, and the following conditions are met: • You and your dependent(s) are entitled to Medicare Part A and enrolled in Medicare Part B • You and your dependent(s) live in the plan service area, and • You are identified as an eligible participant by your former employer Neither you nor your dependent(s) are eligible for this plan if: • You are an active employee of the group, or • You area retired employee of the group with a dependent who is an active employee of the group and has coverage through the group's plan for active employees Our service area is nationwide. It includes all fifty states, the District of Columbia and the United States territories. Which doctors, hospitals, and pharmacies can I use? We have a network of doctors, hospitals, pharmacies, and other providers. If you use providers that are not in our network to receive medical services, you may pay more for these services. If you use pharmacies that are not in our network to fill your covered Part D drugs, the plan will generally not cover your drugs. • You can see our plan's provider and pharmacy directory on our website (www.floridablue.com/medicare. At the top navigation, click Member Resources, then click Find a Doctor or Find a Pharmacy. Or call us and we will send you a copy of the provider and pharmacy directories. Have Questions? Call Us If you are a member of this plan, call us at 1-800-926-6565, TTY: 1-800-955-8770. If you are not a member of this plan, call us at 844 -BLUE -MED (844-258-3633), TTY: 1-800-955-8770. o From October 1 through March 31, we are open seven days a week, from 8:00 a.m, to 8:00 p.m. local time, except for Thanksgiving and Christmas. o From April 1 through September 30, we are open Monday through Friday, from 8:00 a.m. to 8:00 p.m. local time, except for major holidays. Or visit our website at www.floridablue.com/medicare 2