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HomeMy WebLinkAbout2025-142A& Blue 0V. In the pursuit of health' BLUEMEDICARE GROUP MASTER AGREEMENT SECTION 1: INTRODUCTION This B1ueMedicare Group Master Agreement (this "Agreement") describes the rights and obligations which you and Blue Cross and Blue Shield of Florida, Inc. ("Florida Blue") have with respect to the group Medicare Advantage, Medicare Advantage Prescription Drug Plan, and/or standalone Medicare Prescription Drug Plan (hereinafter, "Medicare Plan(s)") coverage to be provided by us to your Covered Retirees and Covered Dependents. References to "we", "us", "our," and Florida Blue throughout this Agreement refer to Blue Cross and Blue Shield of Florida, Inc. In exchange for your payment of the Premium, we agree to provide the coverage and/or benefits specified in the Evidence of Coverage for the Medicare Plan(s) ("Evidence of Coverage"), a copy of which is attached to this Agreement. The coverage to be provided by us under the Group Plan which you have established is described in the Evidence of Coverage. SECTION 2: DEFIMTIONS Certain terms defined in the Agreement are also used and defined (for the convenience of Covered Persons) in the Evidence of Coverage. If a word or phrase starts with a capital letter, it is either the first word in a sentence, a proper name, a title, or a defined term. The following defined terms apply to this Agreement: Anniversary Date means the date one year after the Effective Date of coverage and subsequent annual anniversaries or such other date as mutually agreed to in writing by the parties. Appeal means a request submitted by or on behalf of a Covered Person for a review of our decision to deny a request for coverage of health care services or prescription drugs or payment for services or drugs. CMS means the Centers for Medicare and Medicaid Services. CMS Requirements means the provisions of Parts C and D of Title XVIII of the Social Security Act, CMS Medicare Part C and D regulations at 42 C.F.R. Parts 422 and 423, the CMS Managed Care and Prescription Drug Benefit Manuals, other CMS instructions and guidance and the provisions of Florida Blue's contracts with CMS to offer the Medicare Plans. Covered Dependent means an Eligible Dependent who continues to meet all applicable eligibility requirements described in the Evidence of Coverage and who is enrolled, and actually covered, under the Agreement other than as a Covered Retiree. Covered Person means a Covered Retiree or a Covered Dependent. Covered Retiree means an Eligible Retiree, who continues to meet all applicable eligibility requirements described in the Evidence of Coverage and who is enrolled, and actually covered, under the Agreement other than as a Covered Dependent. Effective Date for the Group means 12:01 a.m. on the date specified on the last page of this Agreement and for Covered Persons means 12:01 a.m. on the date coverage will begin as specified in the Evidence of Coverage. Eligible Dependent means an individual who meets and continues to meet all of the eligibility requirements described in the Evidence of Coverage. Eligible Retiree means an individual who meets and continues to meet all of the eligibility requirements set forth in the Evidence of Coverage and is eligible to enroll as a Covered Retiree. An Eligible Retiree is not a Covered Retiree until actually enrolled and accepted for coverage as a Covered Retiree by us. Enrollment Forms means those forms, electronic or paper, which are approved by us and used to maintain accurate enrollment files under the Agreement. Grace Period means the sixty (60) calendar day period beginning on the date the Premium is due. Grievance means a type of complaint submitted by a Covered Person (or other person eligible under CMS Requirements to submit a Grievance) about us or one of our network providers or pharmacies, including a complaint concerning the quality of care. This type of complaint does not involve coverage or payment disputes. Group means the employer, labor union, association, partnership, corporation, department, other organization or entity through which coverage and benefits are issued by us. Note: References to "you" or "your" throughout the first part of this Agreement also refer to the Group. References to "you" or "your" in the Evidence of Coverage refer to Eligible Retirees, Eligible Dependents, Covered Retirees and/or Covered Dependents depending on the context and intent of the specific provision. Group Master Agreement or Agreement means the written document which is evidence of the entire agreement between the Group and Florida Blue whereby coverage and benefits are provided to Covered Persons. Late Enrollment Penalty ("LEP") means an amount added to the Part D Premium of an individual who did not have Part D coverage or other creditable prescription drug plan when the individual first became eligible for Part D or who had a break in Part D or other creditable prescription drug coverage for at least 63 days. Low Income Subsidy ("LIS") means the premium subsidy amount paid to us by CMS for qualifying Covered Persons with Medicare Part D coverage. Medicare Plan means the group Medicare Advantage Plan, Medicare Advantage Prescription Drug Plan, and/or standalone Medicare Prescription Drug Plan that you select. Premium means the amount required to be paid by the Group to us for coverage under this Agreement. Service Area means a geographic area where a Medicare Plan accepts members. SECTION 3: ELIGIBILITY. ENROLLMENT, AND DISENROLLMENT A. Eligibility Determination Determination of whether an individual is an Eligible Retiree or Eligible Dependent will be a two-step process: 1. You will determine whether the individual is eligible to participate in the retiree group health benefit plan that you sponsor. For individuals meeting your eligibility criteria, you will promptly forward completed applications to us. You are responsible for complying with all applicable laws and regulations, including but not limited to the Employee Retirement Income Security Act (ERISA) and the Internal Revenue Code, in making this eligibility determination. You must also comply with all eligibility guidelines included in the benefit administrative guide and Evidence of Coverage. 2. After receiving a complete application, we will process the application in accordance with CMS Requirements. An application must be approved by us and accepted by CMS for an individual to be enrolled in a Medicare Plan. B. Distribution of Enrollment Materials You may only distribute materials describing the Medicare Plan that we have provided to you or that we have approved in writing. You will distribute any pre -enrollment materials that we provide to you to each potential enrollee before collecting enrollment applications. Nothing in this Section will preclude you from making additional disclosures about your group health benefit plan as applicable to comply with ERISA, such as a wrap-around summary plan description or other plan document. If applicable, you are solely responsible for compliance with ERISA disclosure requirements in connection with the Medicare Plan(s). C. Group Disenrollment If you decide to disenroll all Covered Persons from a Medicare Plan, you must: 1. Notify all beneficiaries that you intend to disenroll them from the Medicare Plan. You will provide this notice at least twenty one (21) calendar days before the disenrollment. This notice will explain how to contact Medicare for information about other plan options that may be available. You will include language provided by Florida Blue in this notice to meet specific CMS Requirements for notice contents. 2. Provide us with all information necessary to submit a complete disenrollment request transaction to CMS in accordance with CMS Requirements. 3. In the event of termination of this Agreement, provide advanced notice in accordance with Section 4 of this Agreement. D. Individual Covered Person Disenrollment Covered Persons may be disenrolled from a Medicare Plan by Florida Blue if they become ineligible for continued enrollment. Covered Persons may also be disenrolled if this Agreement terminates or if you inform us that they are no longer eligible to participate in your retiree group health plan. If Florida Blue determines that a Covered Person is ineligible for continued enrollment or if you instruct us to disenroll an individual, you must: 1. Provide us with at least thirty (30) calendar days advanced notice of the ineligibility or disenrollment election of an individual; and 2. Provide the Covered Person(s) who will be disenrolled with at least twenty one (21) calendar days advanced notice of the termination and of other insurance options that are available to them. You will include language provided by Florida Blue in this notice to meet specific CMS Requirements for notice contents. The Covered Person will have the opportunity to elect another plan offered by us or by you, join Original Medicare, or join another carrier's Medicare Plan (by submitting an enrollment request to that organization). SECTION 4: TERM AND TERMINATION A. Term of Agreement and Renewal Process This Agreement shall become effective as of the Effective Date provided: (1) that we accept your Croup Application; and (2) that you pay the required initial Premium specified by us. This Agreement shall continue in effect until the first Anniversary Date following the Effective Date unless terminated earlier as permitted by its terms. After the initial term, this Agreement shall automatically renew each succeeding year on the Anniversary Date for an additional one-year period unless: 1. At least sixty (60) calendar days prior to such Anniversary Date, you notify us that you do not want the Agreement to automatically renew; or 2. It is terminated as permitted by its terms. At least ninety (90) calendar days before each Anniversary Date, we will provide you with notice of changes in Premium and benefits under the Medicare Plan for the upcoming year (the "Renewal Notice"). If this Agreement renews as specified above, all of its terms and provisions (including the Premium due) shall be amended to include the terns of the Renewal Notice, and the amended Agreement shall govern coverage as of the Anniversary Date. Payment of the new charges shall constitute acceptance of the change in Premium rates. This Agreement is conditionally renewable. This means that it automatically renews each year on your Anniversary Date unless terminated earlier in accordance with its terms. B. Termination by Group The Group may cancel this Agreement on its Anniversary Date by giving written notice to us at least sixty (60) calendar days in advance, unless we have initiated a termination for any of the reasons stated below. C. Termination by Florida Blue We may terminate this Agreement or refuse to renew for the following reasons: 4 1. Failure to Pay Premiums. You do not pay Premiums in accordance with its terms or we have not received timely Premium payments prior to the end of the Grace Period. Termination of this Agreement for failure to pay premiums shall be effective as of the end of the Grace Period. In the event of such termination, you are obligated to pay the following: a. Any portion of the Premium due for coverage provided by us prior to termination; and b. Any amounts otherwise due us. 2. Fraud or Intentional Misrepresentation of Material Fact. You perform an act, or engage in any practice, that constitutes fraud or make an intentional misrepresentation of material fact. 3. Group Contribution and Participation and CMS Rules. You do not comply with: (1) a material provision which relates to rules for Group contributions or Covered Person participation; or (2) any provision in this Agreement which relates to LIS or other CMS Requirements. 4. Service Area. There is no longer any Covered Person who lives, resides, or works in the Service Area. 5. Termination or Non -renewal of the CMS Contract. We will provide you with at least ninety (90) calendar days' notice upon termination or non -renewal of our contract with CMS. Except as specifically provided in this Subsection 4.C, if we decide to terminate or not renew the Agreement based on one or more of the circumstances mentioned above, we will give you at least forty- five (45) calendar days advance written notice. D. Notification of Termination to Covered Retirees It is your obligation to immediately notify each Covered Person of any such termination of this Agreement for any reason, consistent with the requirements of Section 3 of this Agreement. E. Representations Made By, and Obligations of, the Group In agreeing to provide coverage in accordance with the terms of this Agreement, we rely on the representations you made when you applied for coverage with us and your representation that you have authority to act on behalf of all Covered Persons with respect to this Agreement. Consequently, every act by, agreement with, or notice given to, you will be binding on all Covered Persons. You agree that you shall offer to all Eligible Retirees the opportunity to become a Covered Person under this Agreement. You agree that, if requested by us, you will distribute the Evidence of Coverage and other coverage materials to Covered Persons. SECTION S: PAYMENT PROVISIONS A. Monthly Invoice We will prepare a monthly invoice of the Premium due on or before the due date. This monthly invoice will also reflect any prorated charges and credits resulting from changes in the number of Covered Persons and changes in the types of coverage that took place in the previous or current month. If you become aware that a Covered Person will become ineligible, you must provide us with written notice of such ineligibility as described in Section 3 of this Agreement. You shall be liable to us for the Premium due for each individual enrolled in a Medicare Plan under this Agreement until the effective date of disenrollment, which is set by CMS Requirements. You must pay the total amount of the invoice. Do not add names to an invoice, change coverage or pay for a retiree or dependent whose name does not appear on the invoice. No changes can be made to a Group invoice unless a signed application form is on file and submitted to Florida Blue. Payment shall be for the total amount of the Group invoice. B. Payment Due Date The first Premium payment is due before the Effective Date of the Agreement. Each following payment is due monthly unless you agree with us in writing on some other method and/or frequency of payment. The Premium is due and payable on or before the first day of each succeeding calendar month to which such payments apply. C. Grace Period This Agreement has a sixty (60) calendar day Premium payment Grace Period, which begins on the date the Premium payment is due. If we do not receive the required Premium payment on or before the date it is due, it may be paid during this Grace Period. Coverage will stay in force during the Grace Period. If Premium payments are not received by the end of the Grace Period, we will terminate this Agreement and proceed with the disenrollment of Covered Persons as described in Section 3 of this Agreement. D. Changes in Premium Premium rates may be changed on your Anniversary Date as described in Section 4.A above regarding renewal. E. Other Rules Regarding the Payment of Premiums 1. CMS rules govern the effective date of any disenrollment of a Covered Person under this Agreement, and we are not required to retroactively terminate this Agreement or coverage for any Covered Person. 2. If full payment of the Premium is not paid when due, this Agreement may be terminated as described in Section 4 of this Agreement. F. Premium Subsidization You may subsidize Premium amounts charged to Eligible Retirees. You are responsible for compliance with all applicable laws and regulations relating to your subsidy of Premiums, including ERISA and CMS Requirements, as applicable. You acknowledge and agree that Premium subsidization may vary for different classes of Eligible Retirees only if such classes are reasonable and based on objective business criteria. You represent and warrant that you will not vary Premium subsidization based on any Covered Person's eligibility for LIS. Further, you will not vary Premium subsidization for individuals within a given class of Eligible Retirees. In no case will you charge an Eligible Retiree more than the sum of the monthly Premium that we charge you for the Medicare Plan benefits. 6 G. Low Income Subsidy You will comply with the following requirements in connection with LIS: 1. You are required to pass through any LIS payments received from CMS to reduce the Premium amount that the Covered Retiree pays. You will first apply any LIS amounts to a Covered Person's share of Premium. You may not benefit from any LIS amount until the Premium for a Covered Person (including amounts for the non -drug benefits in a combined Medicare Advantage Prescription Drug Plan) paid by a Covered Retiree is reduced to zero ($0.00). 2. You are responsible for reducing up -front Premium contributions that you collect from Covered Retirees for any Covered Persons eligible for LIS. In limited situations where you are unable to reduce the up -front Premium contribution (e.g. if LIS is awarded retroactively), you will directly refund the LIS amount to the Eligible Retiree within fifteen (15) calendar days of the date you receive the LIS amount from Florida Blue. H. Late Enrollment Penalty (LEP) The Premium for an individual Covered Person may be higher if the Covered Person is assessed an LEP for not enrolling in Part B in a timely manner. This higher Premium will be reflected on the bill you receive from us. I. Premium Billing You will be responsible for the payment of the "Total Monthly Premium per Covered Retiree" of all Group members. The Total Monthly Premium may be less for Covered Persons who qualify for LIS as defined by CMS. You will also be responsible for any LEP charges that Group members have been assessed by CMS. The first Premium charge is payable before the Effective Date of this Agreement. Monthly charges are payable on the first day of each following month during the time this Agreement is in effect. J. Retroactive Premium Adjustment The monthly charge will be determined from our records by the number of Covered Retirees who have been confirmed through the CMS enrollment transaction process. Retroactive adjustments will be made for additions and terminations of Covered Retirees and for Covered Retirees who have been confirmed through the CMS enrollment transaction process after the initial billing statement. Any refund that is owed to a Covered Retiree must come from the Group, unless the Covered Retiree is billed directly by us. Florida Blue will only adjust the amount due of a Group and will not refund Premium(s) paid to a Covered Retiree, unless we mutually agree that a Covered Retiree is to be directly billed by Florida Blue. You must refund to Covered Retirees any amounts received from us that are due to Covered Retirees in a timely manner. SECTION 6: HOST BLUE PLANS A. Out -of -Area Services — Medicare Advantage We have relationships with other Blue Cross and/or Blue Shield Licensees ("Host Blues") referred to generally as the "Inter -Plan Medicare Advantage Program" This Program operates under rules and procedures issued by the Blue Cross Blue Shield Association ("Association"). When members access FJ healthcare services outside the geographic area we serve, the claim for those services will be processed through the Inter -Plan Medicare Advantage Program. The Inter -Plan Medicare Advantage Program available to members under this agreement is described generally below. B. Member Liability Calculation When you receive Covered Services outside of our service area from a Medicare Advantage PPO network provider, the cost of the service, on which member liability (copayment/coinsurance) is based, will be either. • The Medicare allowable amount for covered services; or • The amount either we negotiate with the provider or the Host Blue negotiates with its provider on behalf of our members, if applicable. The amount negotiated may be either higher than, lower than, or equal to the Medicare allowable amount. C. Nonparticipating Healthcare Providers Outside Our Service Area When Covered Services are provided outside of our service area by nonparticipating healthcare providers, the amount(s) a member pays for such services will be based on either the payment arrangements, described above, for Medicare Advantage PPO network providers, Medicare's limiting charge where applicable or the provider's billed charge. In these situations, the member may be responsible for the difference between the amount that the nonparticipating healthcare provider bills and the payment we will make for the covered services as set forth in this paragraph. Payments for out -of -network emergency services will be governed by applicable federal and state law. SECTION 7: GENERAL PROVISIONS A. Administration and Record Retention You must provide us with any information we need to administer the coverage and/or benefits to be provided or needed to compute the Premium due. While this coverage is in force, we have the right, at any reasonable time, to examine your records on any issues necessary to verify information provided by you. You must retain all records relating to this Agreement, including but not limited to those relating to LIS administration, for the current calendar year plus an additional ten (10) years. B. Assignment and Delegation You may not assign, delegate or otherwise transfer this Agreement and the obligations hereunder without our written consent. Any assignment, delegation, or transfer made in violation of this provision shall be void. We may assign, delegate, or otherwise transfer this Agreement to our successor in interest or an affiliated entity without your consent at any time. C. Authorization Where this Agreement requires that an act involving the administration of coverage and/or benefits be authorized or approved by us, such authorization or approval shall be considered given when provided in writing by a duly authorized officer of Florida Blue or his or her designee. D. Evidence of Coverage We will provide an Evidence of Coverage and ID Card for each Covered Retiree. The Evidence of Coverage will describe the coverage and benefits to be provided to Covered Persons by us. You agree that, if requested by us, you will distribute the Evidence of Coverage (and any Endorsements to it) and other coverage materials to Covered Persons. E. Grievance and Appeals Process We have established and will maintain a process for hearing and resolving Grievances and Appeals raised by Covered Persons in accordance with CMS requirements. Details regarding this process are provided in the Evidence of Coverage. F. Changes to the Agreement Florida Blue may make any changes to this Agreement that are necessary to meet CMS Requirements ("CMS Mandated Amendments") with sixty (60) calendar days advanced written notice to you. Such changes shall become effective as amendments to this Agreement upon expiration of this sixty (60) calendar day notice period. Except in the case of (a) CMS Mandated Amendments or (b) Renewal Notices as described in Section 4.A., no person may change, modify, or revise the written terms or provisions of this Agreement unless such change is made by a written amendment signed by one of our duly authorized officers. For example, no Eligible Retiree or agent of Florida Blue or the Group can change or waive the written terms or provisions of this Agreement except as stated in the first sentence of this paragraph. G. Furnishing and Maintaining Enrollment Records You must provide any information required by us for the purpose of creating and maintaining enrollment records, processing terminations, and recording changes in family status. In addition, you and each Eligible Retiree must submit accurate and complete Enrollment Forms on a timely basis. You are responsible for collecting the Enrollment Forms, reviewing them for accuracy and completeness, and forwarding them to us, along with the applicable Premium payment. All enrollment record information which is relevant to the eligibility or coverage status of any individual must be made available to us for inspection and copying upon request. A. Errors or Delays Clerical errors or delays by us in maintaining enrollment records regarding Covered Persons will not invalidate coverage which would otherwise be validly in force or continue coverage which would otherwise be validly terminated, provided you have furnished us with timely and accurate enrollment information. Errors or delays by you in furnishing accurate enrollment information to us will not affect our right to strictly enforce any and all eligibility requirements. I. Entire Agreement This Agreement sets forth the exclusive and entire understanding and agreement between the parties and shall be binding upon the Covered Persons, the parties, and any of their subsidiaries, affiliates, successors, 9 heirs, and permitted assigns. All prior negotiations, agreements, and understandings are superseded hereby. No oral statements, representations, or understanding by any person can change, alter, delete, add or otherwise modify the express written terms of this Agreement, which includes the terms of coverage and/or benefits set forth in the Evidence of Coverage, the Schedule of Benefits, and any other attachments, amendments or riders. J. Financial Responsibilities of the Group We reserve the right to recover any benefit payments made to or on behalf of any individual whose coverage has been terminated. Our recovery efforts may relate to benefit payments made for health care services rendered subsequent to the Covered Person's termination date and prior to the date notice of coverage termination is required to be made by you. Your cooperation with and support such recovery efforts is required. In the event that you do not comply with the notice requirements set forth in Subsection 5.A (Monthly Invoice), you shall be solely liable to us for Premium due until the effective date established by CMS for a Covered Person's disenrollment. K. Indemnification You shall hold harmless and indemnify Florida Blue, against all claims, demands, liabilities, or expenses (including reasonable attorney fees and court costs), which are related to, arise out of, or are in connection with any of your acts or omissions, or acts or omissions of any of your employees, retirees or agents, in the performance of your obligations under this Agreement. We are not your agent, nor are you our agent, for any purpose. This paragraph shall only apply to the extent allowed under Florida Statutes § 768.28. L. Representations on the Group Application and the Enrollment Forms We rely on the information you and your Eligible Retirees provide to determine whether to issue coverage; the appropriate Premium and financing method; and eligibility for coverage. All such information must be accurate, truthful, and complete. Statements made on the Enrollment Forms are representations and not warranties. We may cancel, terminate, or void this Agreement if the information which you provide is fraudulent, or if you make an intentional misrepresentation. M. Reservation of Right to Contract We reserve the right to contract with any individuals, corporations, associations, partnerships, or other entities for assistance with the servicing of coverage and benefits to be provided by us or obligations due, under this Agreement. N. Service Mark You, on behalf of the Group and its Covered Retirees, hereby expressly acknowledge your understanding that this Agreement constitutes a contract solely between you and Florida Blue. We are an independent corporation operating under a license with the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans, (the "Association") permitting us to use the Blue Cross and Blue Shield Service Mark in the state of Florida and that we are not contracting as the agent of the 10 Association. You fiuther acknowledge and agree that you have not entered into this contract based upon representations by any person other than us and that no person, entity, or organization other than us shall be held accountable or liable to you for any of our obligations created under this Agreement. This paragraph shall not create any additional obligations whatsoever on our part other than those obligations created under other provisions of this Agreement. O. Third Party Beneficiary This Agreement was entered into solely and specifically for the benefit of Florida Blue and the Group. The terms and provisions of the Agreement shall be binding solely upon, and inure solely to the benefit of, Florida Blue and the Group, and no other person shall have any rights, interest or claims under this Agreement, including the Evidence of Coverage, or be entitled to sue for a breach thereof as a third -party beneficiary or otherwise. Florida Blue and the Group hereby specifically express their intent that health care providers that have not entered into contracts with Florida Blue to participate in Florida Blue's provider networks shall not be third -party beneficiaries under this Agreement, including the Evidence of Coverage. P. Inspection and Audit You shall permit CMS, The U.S. Department of Health and Human Services, the Comptroller General, or their designees, to inspect, evaluate, and audit any of your books, contracts, medical records, patient care documentation, documents, papers, and other records pertaining to coverage by providing records to Florida Blue, which will submit the records to CMS. This right to inspect, evaluate, and audit shall extend ten (10) years from the expiration or termination of the Agreement or completion of final audit, whichever is later, unless otherwise required by applicable law. Q. Benefit Administrator Guide We will provide you with a Benefit Administrator Guide, which provides details related to how your plan is administered and your responsibilities as a benefit administrator. R Member Communications and Campaigns We may send CMS required or Florida Blue member communications without your consent. Samples of all required materials are available upon request for informational purposes. We may also contact Covered Persons by telephone regarding any Florida Blue campaign and any campaign approved by the Florida Office of Insurance Regulation and/or CMS, as applicable. We will notify you of the campaign prior to making contact with members. S. COBRA You are solely responsible for determining when individuals are eligible for coverage under a Medicare Plan pursuant to the Consolidated Omnibus Budget Reconciliation Act ("COBRA"). You will notify us promptly of any COBRA elections. For more information on your COBRA responsibilities refer to the Benefit Administrator Guide. 11 In consideration of the payment of Premiums when due and subject to all of the terms of this Agreement, Blue Cross Blue Shield of Florida, Inc, hereby agrees to provide each enrollee of Indian River County BOCC. The benefits of this Agreement as set forth in the Evidence of Coverage beginning on each enrollee's effective date. The Group has selected the following plan and premium: Advanced/Platinum PPO fv/DHV $337.99 The Group's Agreement is effective as of 10/01/2025 IN WITNESS WHEREOF, the parties have executed this Agreement as of dates listed below. Blue Cross Blue Shield of Florida, Inc. (DBA Florida Blue) (Signature) Indian River County BOCC #90000 0 OUI Name: Andrea Davis Name: Joseph E. Flescher (Please Print or Type) (Please Print or Type) Title: Vice President, Medicare Product Grwmh & Ups. 9-4-2025 Date: Date: September 2, 2025 12 APPROVED AS TO FORM AND S ICI'ENCY BY C�GA CHRtZTOJHER A, HICKS ASSIST T C LINTY ATTORNEY Attest: Ryan L. Butler, Cleric of Circuit Court and Comptroller F14r4& B&(e OU I MEDICARE Your Health Solutions Partner 2025 Summary of Benefits Medicare Advantage Plan with Part D Prescription Drug Coverage BlueMedicare Group PPO (Employer PPO) Advanced PPO w DHV + Platinum Rx Indian River County BOCC #90000 The plan's service area includes; Nationwide Y0011_FBM2082 2024 EGWP_M 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 Important Information Our plans group each medication into a tier. The number of tiers may vary based on the plan you choose. You will need to use your formulary to locate what tier your drug is on to determine how much it will cost you. The amount you pay depends on the drug's tier and what stage of the benefit you have reached. Through this document you will see the "0" symbol. Services with this symbol may require prior authorization from the plan before you receive the services from network providers. If you do not get a prior authorization when required, you may have to pay out -of -network cost-sharing, even though you received services from a network provider. Please contact your doctor or refer to the "Evidence of Coverage (EOC)" for more information about services that require a prior authorization from the plan. 3 Monthly Premium, Deductible and Limits Monthly Plan $337.99 Premium You must continue to pay your Medicare Part B premium. Deductible ■ $0 per year for In -Network healthcare services ■ $2,000 per year for Out -of -Network health care services ■ $0 per year for Part D prescription drugs. There is no deductible for insulins. Maximum ■ $1,000 is the most you pay for copays, coinsurance, and other costs for Out -of -Pocket Medicare -covered medical services from in -network providers for the Responsibility year. ■ $3,000 is the most you pay for copays, coinsurance, and other costs for Medicare -covered medical services you receive from in- and out -of -network providers. Medical and Hospital Benefits In1,1%orl 0 f=levi'►r ! Inpatient ■ $200 copay per day, for days 1-7 40% of the Medicare -allowed Hospital ■ $0 copay per day, after day 7 amount after $2,000 Coverage 0 out -of -network deductible (Authorization applies to in -network services only.) Outpatient ■ $75 copay per visit for Hospital Medicare -covered observation Coverage services ■ $250 copay for all other services 0 ■ $0 copay for diagnostic colonoscopy G! ■ 40% of the Medicare -allowed amount after $2,000 out -of -network deductible In -Network Out -of -Network Ambulatory • $200 copay for surgery services 40% of the Medicare -allowed Surgical Center provided at an Ambulatory amount after $2,000 (ASC) Services Surgical Center 0 out -of -network deductible • $0 copay for diagnostic colonoscopy Doctor Visits • $25 copay per provider of choice visit • $45 copay per specialist visit ■ 40% of the Medicare -allowed amount after $2,000 out -of -network deductible Preventive Care - $0 copay - 40% of the Medicare -allowed • Abdominal aortic aneurysm amount screening • Annual wellness visit • Bone mass measurement • Breast cancer screening (mammograms) • Cardiovascular disease risk reduction visit (therapy for cardiovascular disease) • Cardiovascular disease testing • Cervical and vaginal cancer screening • Colorectal cancer screening • Depression screening • Diabetes screening • Diabetes self-management training, diabetic services and supplies • Health and wellness education programs • Hepatitis C Screening • HIV screening • Immunizations • Medical nutrition therapy • Medicare Diabetes Prevention Program (MDPP) • Obesity screening and therapy to promote sustained weight loss 5 In -Network • Prostate cancer screening exams • Screening and counseling to reduce alcohol misuse • Screening for lung cancer with low dose computed tomography (LDCT) • Screening for sexually transmitted infections (ST1s) and counseling to prevent STIs • Smoking and tobacco use cessation (counseling to stop smoking or tobacco use) • Vision care: Glaucoma screening • "Welcome to Medicare" preventive visit Emergency Care Medicare -Covered Emergency Care ■ $75 copay per visit, in- or out -of -network Out -of -Network This copay is waived if you are admitted to the hospital within 48 hours of an emergency room visit, Worldwide Emergency Care Services ■ $75 copay for Worldwide Emergency Care ■ $25,000 combined yearly limit for Worldwide Emergency Care and Worldwide Urgently Needed Services Does not include emergency transportation. Urgently Needed Medicare -Covered Urgently Needed Services Services Urgently needed services are provided to treat a non -emergency, unforeseen medical illness, injury or condition that requires immediate medical attention. ■ $30 copay at an Urgent Care Center, in- or out -of -network Convenient Care Services are outpatient services for non -emergency injuries and illnesses that need treatment when most family physician offices are closed. ■ $30 copay at a Convenient Care Center, in- or out -of -network Worldwide Urgently Needed Services ■ $75 copay for Worldwide Urgently Needed Services .. .... ......... .... .. 0 X -Rays ■ $50 copay at a physician's office or at an IDTF ■ $150 copay at an outpatient hospital facility Advanced Imaging Services Includes services such as Magnetic Resonance Imaging (MRI), Magnetic Resonance Angiography (MRA), Positron Emission Tomography (PET), Computer Tomography (CT) scan or Nuclear Medicine testing. ■ $75 copay at a physician's office ■ $100 copay at an IDTF ■ $150 copay at an outpatient hospital facility Radiation Therapy ■ 20% of the Medicare -allowed amount N In-Network Out-of-Network • $25,000 combined yearly limit for Worldwide Emergency Care and Worldwide Urgently Needed Services Does not include emergency transportation. Diagnostic Diagnostic Procedures and Tests 40% of the Medicare-allowed Services/ ■ $30 copay at an Independent amount after $2,000 Labs/Imaging 0 Diagnostic Testing Facility (IDTF) out-of-network deductible (Authorization ■ $100 copay at an outpatient applies to hospital facility in-network ■ $0 copay for allergy testing services only.) Laboratory Services ■ $0 copay at an Independent Clinical Laboratory ■ $30 copay at an outpatient hospital facility X -Rays ■ $50 copay at a physician's office or at an IDTF ■ $150 copay at an outpatient hospital facility Advanced Imaging Services Includes services such as Magnetic Resonance Imaging (MRI), Magnetic Resonance Angiography (MRA), Positron Emission Tomography (PET), Computer Tomography (CT) scan or Nuclear Medicine testing. ■ $75 copay at a physician's office ■ $100 copay at an IDTF ■ $150 copay at an outpatient hospital facility Radiation Therapy ■ 20% of the Medicare -allowed amount N In -Network Out -of -Network ._.. .. Hearing Services Medicare -Covered Hearing Services Medicare -Covered Hearing Services ■ $45 copay for specialist exams to ■ 40% of the Medicare -allowed diagnose and treat hearing and amount after $2,000 balance issues out -of -network deductible Additional Hearing Services ■ $0 copay for one routine hearing exam per year. ■ $0 copay for evaluation and fitting of hearing aids ■ $350 per ear. You pay a $0 copay for up to 2 hearing aids every year with a maximum benefit allowance of $350 per ear. NOTE: Hearing aids must be purchased through our participating provider to receive in -network benefits, ■ Member is responsible for any amount after the benefit allowance has been applied. Subject to benefit maximum. Additional Hearing Services ■ Member must submit receipts for reimbursement at 50% of maximum allowed for a routine hearing exam per year. • Member must submit receipts for reimbursement at 50% of maximum allowed for evaluation and fitting of hearing aids. ■ Member must submit receipts for reimbursement at 50% of maximum allowed for up to 2 hearing aids every year. Subject to benefit maximum. Dental Services Medicare -Covered Dental Services 0 Medicare -Covered Dental Services ■ $45 copay for specialist 40% of the Medicare -allowed non -routine dental care amount after $2,000 out -of -network deductible for non -routine dental Additional Dental Services Additional Dental Services ■ $0 copay for covered preventive Member pays up front and is dental services reimbursed 50% of ■ $0 copay for covered non -participating rates for covered preventive dental comprehensive dental services services. 0 In-Network Vision Services Medicare -Covered Vision Services ■ $45 copay for specialist to diagnose and treat eye diseases and conditions ■ $0 copay for glaucoma screening (once per year for members at high risk of glaucoma) • $0 copay for one diabetic retinal exam per year • $0 copay for one pair of eyeglasses or contact lenses after each cataract surgery Additional Vision Services In -Network ■ $0 copay for an annual routine eye examination 1 every 12 months. ■ $0 copay for lenses, frames or contacts. Member responsible for any amount in excess of annual maximum plan benefit allowance. • $250 maximum allowance per year towards the purchase of lenses, frames or contacts. Out -of -Network • Member pays up front and is reimbursed 50% of non -participating rates for covered comprehensive dental services. Medicare -Covered Vision Services ■ 40% of the Medicare -allowed amount for glaucoma screening ■ 40% of the Medicare -allowed amount after $2,000 out -of -network deductible for Medicare -covered specialist services to diagnose and treat diseases and conditions of the eye and diabetic retinal exams • 40% of the Medicare -allowed amount after $2,000 out -of -network deductible for eyeglasses or contact lenses after cataract surgery Additional Vision Services Out -of -Network • Member must pay 100% of the charges and submit the itemized receipt(s) for reimbursement of 50% of the in -network allowed amount for an annual routine eye examination 1 every 12 months. In -Network Mental Health Inpatient Mental Health Services Services 0 • $200 copay per day for days 1-7 (Authorization ■ $0 copay per day for days 8-90 applies to 190 -day lifetime benefit maximum in in -network a psychiatric hospital. services only) Outpatient Mental Health Services ■ $40 copay Skilled Nursing Facility (SNF) 0 (Authorization applies to in -network services only.) Physical Therapy ■ $0 copay per day for days 1-20 ■ $100 copay per day for days 21-100 Out -of -Network ■ Member must pay 100% of the charges and submit the itemized receipt(s) for reimbursement of 50% of the in -network allowed amount for lenses, frames, contacts or upgrades. Member is responsible for all amounts in excess of the 500/o of the in -network allowed amount and/or any amounts in excess of the annual maximum plan benefit allowance for lenses, frames, contacts or upgrades. ■ Total reimbursement is subject to the annual maximum plan benefit _ allowance. Inpatient Mental Health Services ices ■ 40% of the Medicare -allowed amount after $2,000 out -of -network deductible 190 -day lifetime benefit maximum in a psychiatric hospital. Outpatient Mental Health Services ■ 40% of the Medicare -allowed amount after $2,000 out -of -network deductible ■ 40% of the Medicare -allowed amount after $2,000 out -of -network deductible Our plan covers up to 100 days in a SNF per benefit period. ■ $35 copay per visit 0 ■ $0 copay for Lymphedema Therapy 10 • 40% of the Medicare -allowed amount after $2,000 out -of -network deductible in -Network Ambulance $200 copay for each Medicare -covered trip (one-way) 0 Out -of -Network ■ $200 for each Medicare- covered trip (one-way) Transportation ■ Not Covered ■ Not Covered Medicare Part B ■ $0 Copay copay for allergy Drugs injections ■ Up to 20% of the Medicare -allowed amount for chemotherapy drugs and other Medicare Part B -covered drugs 0 ■ 20% up to $35 per month for insulin if you use an insulin pump that's covered under Part B's durable medical equipment benefit 0 ■ 40% of the Medicare -allowed amount after $2,000 out -of -network deductible Additional Benefits `lei-Netir-jor Out-of-Networ f (y Diabetic Supplies $0 copay at a Florida Blue 40% of the Medicare -allowed Medicare contracted network amount after $2,000 retail or mail-order pharmacy for out -of -network deductible Diabetic Supplies such as: 0 Lifescan (One Touch@) and Ascensia (Contour @) glucose meters and test strips are preferred. Other brands will require prior authorization 0 • Lancets 11 • Continuous Glucose Monitors (CGMs) such as Freestyle Libre and Dexcom, (and supplies) are preferred. Other brands may require prior authorization 0 Important Note: • Insulin, alcohol swabs, insulin syringes and needles for self -administration in the home are obtained from an in -network retail or mail order pharmacy and are covered under your Medicare Part D pharmacy benefit. Applicable Part D co -pays and deductibles apply. Please note: Medical supplies i.e. alcohol swabs, gauze, and/or syringes are not coverable if not used for the administration of insulin. The initial fill of a CGM or insulin when being used with an insulin pump can be obtained through our participating DME provider. Medicare Diabetes ■ $0 copay for Medicare -covered • 40% of the Medicare -allowed Prevention services amount Program Podiatry ■ $45 copay for each ■ 40% of the Medicare -allowed Medicare -covered podiatry visit amount after $2,000 out -of -network deductible Chiropractic ■ $20 copay for each a 40% of the Medicare -allowed Medicare -covered chiropractic amount after $2,000 service out -of -network deductible 12 1 7111"y; Medical 20% of the Medicare -allowed 40% of the Medicare -allowed Equipment and amount for all plan approved, amount after $2,000 Supplies 0 Medicare -covered motorized out -of -network deductible wheelchairs and electric scooters (Authorization applies to 0% of the Medicare -allowed in -network services amount for all other plan only.) approved, Medicare -covered durable medical equipment Occupational and ■ $35 copay per visit 0 40% of the Medicare -allowed Speech Therapy amount after $2,000 out -of -network deductible Telehealth 0 ■ $30 copay for Urgently Needed 40% of the Medicare -allowed Services amount after $2,000 (Authorization . $25 copay for Primary Care out -of -network deductible applies to Services in -network services . $35 copay for Occupational only) Therapy/Physical Therapy/Speech Therapy at all locations ■ $45 copay for Dermatology Services ■ $40 copay for individual sessions for outpatient Mental Health Specialty Services ■ $40 copay for individual sessions for outpatient Psychiatry Specialty Services ■ $40 copay for Opioid Treatment Program Services ■ $40 copay for individual sessions for outpatient Substance Abuse Specialty Services in an office setting x $0 copay for Diabetes Self -Management Training ■ $0 copay for Dietician Services 13 MasterCard® Prepaid Card NOTE. See Healthy Blue Rewards Sliver5neakers® Fitness Program HealthyBlue Rewards n u 71 amounts, funds will be loaded on your Blue Dollars Card automatically. Use your Blue Dollars card for easy access to rewards and select allowance benefits that may be part of your plan. Benefits, coverage and amounts vary by plan. Limitations, exclusions, and restrictions may apply. The Blue Dollars card will be mailed directly to you. Reward dollars must be used by 12/31. Any unused allowance will not be rolled over. Gym membership and classes available at fitness locations across the country, including national chains and local gyms. Access to exercise equipment and other amenities, classes for all levels and abilities, social events, and more. ■ Your BlueMedicare plan rewards you for taking care of your health. Reward dollars will be loaded to your Blue Dollars card for completing and/or reporting preventive care and screenings. ■ Rewards are available after opting in to the program. 14 U Ij n will be loaded on your Blue Dollars Card automatically. Use your Blue Dollars card for easy access to rewards and select allowance benefits that may be part of your plan. Benefits, coverage and amounts vary by plan. Limitations, exclusions, and restrictions may apply. The Blue Dollars card will be mailed directly to you. Reward dollars must be used by 12/31. Any unused allowance will not be rolled over. • Gym membership and classes available at fitness locations across the country, including national chains and local gyms. ■ Access to exercise equipment and other amenities, classes for all levels and abilities, social events, and more. ■ Your BlueMedicare plan rewards you for taking care of your health. Reward dollars will be loaded to your Blue Dollars card for completing and/or reporting preventive care and screenings. ■ Rewards are available after opting in to the program. Part D Prescription Drug Benefits Deductible Stage This plan does not have a prescription drug deductible. Initial Coverage Stage You begin in this stage when you fill your first prescription of the year. During this stage, the plan pays its share of the cost of your drugs, and you pay your share of the cost (your copayment -or coinsurance amount). You stay in the Initial Coverage Stage until your total out-of-pocket costs reach $2,000. You then move on to the Catastrophic Coverage Stage. You may get your drugs at network retail pharmacies and mail order pharmacies. Tier 1 - Preferred Generic Tier 2 - Generic Tier 3 - Preferred Brand i ier 4 - ivon-Nreterrea vrug tailsl, Standard Retail Standard Retail Mail Order"(90 to ' (31 -day supply) (90 to 100 -day 100 -day supply) �...�? supply) $3 copay $9 copay $0 copay $8 copay $24 copay $8 copay $35 copay $105 copay $70 copay $65 copay $195 copay $195 copay Tier 5 - Specialty Tier 33% of the cost N/A NIA i You won't pay more than $35 for a one-month supply of each covered insulin product regardless of the cost-sharing tier. Catastrophic Coverage Stage You enter the Catastrophic Coverage Stage when your out-of-pocket costs have reached the $2,000 limit for the calendar year. During the Catastrophic Coverage Stage, you pay nothing for your covered Part D drugs. You will stay in this payment stage until the end of the calendar year. Additional Drug Coverage Please call us or see the plan's "Evidence of Coverage" on our website (www,floridablue.com/medicare/forms) for complete information about your costs for covered drugs. If you request and the plan approves a formulary exception, you will pay Tier 4 (Non -Preferred Drug) cost-sharing. 15 Your cost-sharing may be different if you use a Long -Term Care (LTC) pharmacy, a home infusion pharmacy, or an out -of -network pharmacy, or if you purchase a long-term supply (up to 90 days) of a drug. ■ Our plan covers most Part D vaccines at no cost to you including shingles, tetanus and travel vaccines. Disclaimers Florida Blue is a PPO plan with a Medicare contract. Enrollment in Florida Blue depends on contract renewal. Out-of-network/non-contracted providers are under no obligation to treat Florida Blue members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out -of -network services. If you have any questions, please contact our Member Services number at 1-800-926-6565 (TTY users should call 1-800-955-8770). Our hours are 8:00 a.m. to 8:00 p.m. local time, seven days a week, from October 1 through March 31, except for Thanksgiving and Christmas. From April 1 through September 30, our hours are 8:00 a.m. to 8:00 p.m. local time, Monday through Friday, except for major holidays. PPO coverage is offered by Blue Cross and Blue Shield of Florida, Inc., DBA Florida Blue, an Independent Licensee of the Blue Cross and Blue Shield Association. Plans may offer supplemental benefits in addition to Part C benefits and Part D benefits. The Blue Dollars Benefits Mastercard® Prepaid Card is issued by The Bancorp Bank N.A., Member FDIC, pursuant to license by Mastercard International Incorporated. Card can be used for eligible expenses wherever Mastercard is accepted. valid only in the U.S. No cash access. Mastercard and the circles design is a trademark of Mastercard International Incorporated. © 2024 Blue Cross and Blue Shield of Florida, Inc., DBA Florida Blue. All rights reserved. We comply with applicable Federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability or sex. View the Discrimination and Accessibility Notice at floridablue.com/ndnoticeplus information on our free language assistance services. Or call 1-800-352-2583 (TTY: 1-800-955-8770). Puede ver la notificaci6n de no discriminaci6n y accesibilidad, ademas de informaci6n sobre nuestros servicios gratuitos de asistencia linguistica en floridablue.com/es/ndnotice. 0 Ilame al 1-800-352-2583 (TTY: 1-877-955-8773). 16 Form Approved OMB# 0938-1421 Multi -language Interpreter Services English: We have free interpreter services to answer any questions you may have about our health or drug plan. To get an interpreter, just call us at 1-800-926-6565. (TTY users should call 1-800-955-8770). Someone who speaks English/Language can help you. This is a free service. Spanish: Tenemos servicios de intdrprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos. Para hablar con un intdrprete, por favor Mame al 1-800-926-6565 (TTY: 1-877-955-8773). Alguien que hable espaiiol le pods ayudar. Este es un servicio gratuito. Chinese Mandarin:�17�� if i sib r ° ijaRt 1-800-926-6565 Chinese Cantonese: IM09RH'RIE 1-800-926-6565 ° Tagalog: Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot. Upang makakuha ng tagasaling-wika, tawagan lamang kami sa 1-800-926-6565. Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog. Ito ay libreng serbisyo. French: Nous proposons des services gratuits d'interprdtation pour rdpondre a toutes vos questions relatives i notre regime de santd ou d'assurance-mddicaments. Pour accdder au service d'interprdtation, it vous suit de nous appeler au 1-800-926-6565. Un interlocuteur parlant Frangais pours vous aider. Ce service est gratuit. Vietnamese: Chu'nff toi co dich v -V th6ng dick mien phi de tri 16i cic cau h6i ve chuong s*c kh6e vi chuomg trinh thuoc men. 4u qui vi can th6ng dich vien xin g(?i 1-800-926-6565. s8 c6 nhan vidn n6i titng Vigt giup d6 qui vi. Day li dich vV mien phi. German: Unser kostenloser Dolmetscherservice beantwortet Ihren Fragen zu unserem Gesundheits- and Arzneimittelplan. Unsere Dolmetscher erreichen Sie unter 1-800-926-6565. Man wird Ihnen dort auf Deutsch weiterhelfen. Dieser Service ist kostenlos. Korean: o Al- L °I _Y_ o g ` 0-11 Es _Y_ o Oil Oil B oil C al 2 zf TT 9-a' AI Ul'L 42 Jail o of R LIQ . 9-a' Ai U I L O 0 (l of z1 °1 `i O 1-800-926-6565.a c °i oN T � AI 4 . 0 � Oi � of o9JCf7f EZ cU :-:,H91LIGf. 01 AHI -A-I T.�.= _221 =`oTJLlQ. Russian: EcJIH y sac B03HHKHYT BOnpOCLI OTHOCHTenhHO CTpaxoBoro wm McAHxameirrHorO nmaxa, Bm MO)KeTe BOCnOJIb3OBaTbCA HamHmH 6ecnnaTHUMH yCnyramH nepeBoAgRKOB. LITo6bl BOCHOAIMBaThwl ycnyramH nepeBOAmIKa, H03BOHHTe Ham no Tene(DoHy 1-800-926-6565. Bam OKaxeT nomo Ijb COTpyAHHIC, xoTop6IH rOBOpHT no-pyccKH. AaHHax ycnyra 6ecrmaTHaA. Form CMS -10802 (Expires 12/31/25) 17 Form Approved OMB# 0938-1421 Arabic: J j ..SII .L4-il a,Zn-- l 61-M ZII-1 41 �p a :?,N :Ate wi L151 a.yj �+ L,— 1-800-926-6565 „k cji.oSYl Ls-- 4& 01 'c;js9 Z",� Hindi: TTft 7; TMg gT,dT ,4i t�jR �; 4T� �4 3ffq2� * ASC �5 � �4 �j � Vpft -qM jqU ? TTi W t 7' qIH IN qT WE-cf WT4 2�c�T, -if i4 1-800-926-6565. W lq;�ff qT�. up� � fo7ift Q -dT t 3{Tqqft Tf&qZR""q�t.�vw-iw 4CIT t Italian: E disponibile un servizio di interpretariato gratuito per rispondere a eventuali domande sul nostro piano sanitario e farmaceutico. Per un interprete, contattare it numero 1-800-926-6565. Un nostro incaricato the parla Italianovi fornirA 1'assistenza necessaria. E un servizio gratuito. Portuguese: Dispomos de servigos de interpretag5o gratuitos para responder a qualquer questao que tenha acerca do nosso piano de sande ou de medicagao. Para obter um interprete, contacte-nos atraves do numero 1-800-926-6565. Ird encontrar alguem que fate o idioma Portugues para o ajudar. Este servigo 6 gratuito. French Creole: Nou genyen s6vis ent6pret gratis you reponn tout kesyon ou to genyen kons6nan plan medikal oswa dw6g nou an. Pou jwenn yon ent6pr6t, jis rcle nou nan 1-800-926-6565. Yon moue ki pale Kreyol kapab ede w. Sa a se yon s6vis ki gratis. Polish: UmoAiwiamy bezplatne skorzystanie z usfug tiumacza ustnego, ktory pomo2e w uzyskaniu odpowiedzi na temat planu zdrowotnego lub dawkowania lek6w. Aby skorzysta6 z pornocy tfumacza znajgcego jgzyk polski, nalezy zadzwonic pod numer 1-800-926-6565. Ta usfuga jest bezpfatna. Japanese: h4f0)Q* M*f� MLAc3 �L7� �� �(� %i(� A x gat_- (z, "90) 1-800-926-6565 iZ13oV tIt Form CMS -10802 (Expires 12/31/25)