Important Information

• Individual Members
• Group Members

Important Information Regarding MedicareBlue^SM PPO (Regional PPO) and MedicareBlue Rx (PDP)

Coverage is available to residents of the service area and separately issued by one of the following plans: Wellmark Blue Cross and Blue Shield of Iowa,* Blue Cross and Blue Shield of Minnesota,* Blue Cross and Blue Shield of Montana,* Blue Cross and Blue Shield of Nebraska,* Blue Cross Blue Shield of North Dakota,* Wellmark Blue Cross and Blue Shield of South Dakota,* and Blue Cross Blue Shield of Wyoming.*

*Independent licensees of the Blue Cross and Blue Shield Association.

Medicare beneficiaries may enroll in MedicareBlue PPO (Regional PPO) or MedicareBlue Rx (PDP) through the Centers for Medicare & Medicaid Services Online Enrollment Center, located at www.medicare.gov. For more information, contact MedicareBlue Rx (PDP) toll-free at 1-866-434-2037 or MedicareBlue PPO (Regional PPO) toll free at 1-866-434-2038, daily, 8 a.m. to 8 p.m. Central and Mountain Time. TTY users call 1-866-456-1550.

You may be able to get extra help to pay for your prescription drug premiums and costs. To see if you qualify for getting extra help, call:

• MedicareBlue PPO (Regional PPO) or MedicareBlue Rx (PDP) Customer Service, or
• 1-800-MEDICARE (1-800-633-4227). TTY users call 1-877-486-2048, 24 hours a day/7 days a week, or
• The Social Security Office at 1-800-722-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users call 1-800-325-0778, or
• Your State Medicaid Office

MedicareBlue PPO (Regional PPO) and MedicareBlue Rx (PDP) members must use contracted network pharmacies to access their prescription drug benefit, except under non-routine circumstances when they cannot reasonably use network pharmacies. Members who use pharmacies outside the network will pay any difference in the non-network pharmacy’s charge and the plan’s allowable charge. Types of network pharmacies include: retail, mail order, long-term care, and Indian/Tribal/Urban. For more information about mail-order service, contact 1-866-434-2037 8 a.m. to 8 p.m., daily, Central and Mountain Time. TTY users should call 1-866-456-1550. The pharmacies in our network can change at any time. To obtain additional network pharmacy information, call 1-866-434-2037 8 a.m. to 8 p.m., daily, Central and Mountain Time. TTY users call 1-866-456-1550. Or send a request in writing to MedicareBlue PPO (Regional PPO) Customer Service, P.O. Box 155845, Fort Worth, TX 76155-0845 or MedicareBlue Rx (PDP), P.O. Box 155845, Fort Worth, TX 76155-0845.

Benefits, formulary, network pharmacies, premium, and/or copayments/coinsurance may change on January 1, 2011. Please contact MedicareBlue PPO (Regional PPO) or MedicareBlue Rx (PDP) for details.

Members may enroll in Medicare Blue PPO (Regional PPO) or MedicareBlue Rx (PDP) only during specific times of the year. For more information about enrollment periods, please contact MedicareBlue PPO (Regional PPO) or MedicareBlue Rx (PDP) Customer Service.

MedicareBlue PPO (Regional PPO) and MedicareBlue Rx’s (PDP) contracts with CMS are renewed annually, so enrollment in MedicareBlue PPO (Regional PPO) or MedicareBlue Rx (PDP) after 2010 cannot be guaranteed.

If you have special needs, this document is available in alternative formats. Please call Customer Service at the phone numbers listed below for more information.

MedicareBlue PPO (Regional PPO)

MedicareBlue PPO (Regional PPO) is a Medicare-approved regional PPO plan. You are eligible to enroll in MedicareBlue PPO (Regional PPO) if you are entitled to Medicare Part A and enrolled in Medicare Part B and live in the plan service area. You must continue to pay your Medicare Part B premiums (and Part A, if applicable) if not otherwise paid for by Medicaid or another third party. The MedicareBlue PPO (Regional PPO) prescription drug benefit is only available to members of the MedicareBlue PPO (Regional PPO) plan. If you are already enrolled in a Medicare Advantage Prescription Drug plan, you must receive your Medicare prescription drug benefit through that Plan. MedicareBlue PPO (Regional PPO) has formed a network of doctors, specialists and hospitals. You can use any provider who is part of our network or you may go to doctors out of the network. However, you may have to pay more for services received out of the network, except in emergency/urgent care situations. MedicareBlue PPO (Regional PPO) provides reimbursement for all covered benefits regardless of whether they are received in- or out-of-network as long as they are medically necessary. The providers in our network can change at any time. For a current Provider Directory, contact MedicareBlue PPO (Regional PPO) Customer Service, or visit our web site at YourMedicareSolutions.com.

MedicareBlue PPO (Regional PPO)’s contract with CMS is renewed annually, so enrollment in MedicareBlue PPO (Regional PPO) after 2010 cannot be guaranteed.

MedicareBlue PPO (Regional PPO) Customer Service:

For members: 1-888-457-3009, daily, 8 a.m. to 8 p.m. Central and Mountain Time. TTY users call 1-888-457-3005.

For prospective members: 1-866-434-2038, daily 8 a.m. to 8 p.m. Central and Mountain Time. TTY users call 1-866-456-1550. You have the option to speak with a licensed sales representative when you call this number.

MedicareBlue Rx (PDP)

MedicareBlue Rx (PDP) is Medicare-approved Part D sponsor. You are eligible to enroll in MedicareBlue Rx (PDP) if you are entitled to Medicare benefits under Part A or enrolled in Medicare Part B and live in the plan service area. You must continue to pay your Medicare Part B premium if not otherwise paid for under Medicaid or by another third party. You may be enrolled in only one Part D plan at a time. If you are enrolled in a Medicare Advantage (MA) coordinated care (HMO or PPO) plan or an MA private fee-for-service (PFFS) plan that includes Medicare prescription drugs, you may not enroll in a prescription drug plan unless you disenroll from the HMO, PPO or MA PFFS plan. You may enroll in a prescription drug plan if you are a member of a PFFS plan that does not provide Medicare prescription drug coverage, or a MA Medicare Savings Account (MSA) plan, or an 1876 Cost Plan. You cannot enroll in MedicareBlue Rx (PDP) Premier if your current or former employer or union helps pay for your drugs.

MedicareBlue Rx (PDP) Customer Service:

For members: 1-888-832-0075, daily, 8 a.m. to 8 p.m. Central and Mountain Time. TTY users call 1-800-693-3819.

For prospective members: 1-866-434-2037, daily 8 a.m. to 8 p.m. Central and Mountain Time. TTY users call 1-866-456-1550. You have the option to speak with a licensed sales representative when you call this number.