[<Annual Wellness Visit >] [<Breast Cancer Screening>] [<Colon Cancer Screening>] [<Diabetic Dilated Eye Exam>] Earn at least:

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1 Welcome/Activation FLB-FRM2016 Don t miss your chance! Complete your health care activities by 12/31/16 to earn rewards. <Sample A. Sample> <Address Line 1> <Address Line 2> <City, ST ZIP> Para servicio en español llame al: , TTY 711 Dear <Member Name>, Welcome to Healthy Blue Rewards, a special member program that rewards you for taking better care of your health. By completing health care activities, you can earn gift cards from popular retailers. Florida Blue is partnering with a company called Novu to bring you this program and deliver the gift cards to you. Just complete each activity in the chart below, contact us in the way that s most convenient for you, and we ll send you the reward of your choice. The more activities you complete, the more you earn! Earn rewards for taking care of your health Health Care Activity [<Annual Wellness Visit >] [<Flu Shot>] [<Breast Cancer Screening>] [<Colon Cancer Screening>] [<Diabetic Dilated Eye Exam>] Earn at least: REWARD Choose your reward online, by phone or by mail There are three ways to tell us about your completed health care activities and select your reward. Choose the one that works best for you: $ Gift Card Value [<$xx>] [<$xx>] [<$xx>] [<$xx>] [<$xx>] <$xx> OR OR Online Visit: Choose from more gift card options and get them faster! Mail Mail activity cards to: Healthy Blue Rewards Phone Call us toll-free at: , TTY/TDD 711 Monday-Friday 8 a.m. to 10 p.m. ET, Saturday 10 a.m. to 3 p.m. ET

2 Gift Card Terms and Conditions Walmart Purchase of this card constitutes acceptance of the following terms: The balance on this card is solely a liability of Walmart Stores Inc., in the U.S. and Puerto Rico. To use at SAMS CLUB, the holder must be a SAM S CLUB member or a 10% service fee will apply except where prohibited. Shopping card value may be applied toward annual Membership. This card cannot be redeemed for cash except in those states that require redemption for cash. Lost or stolen cards cannot be replaced without original receipt. Target The Bullseye Design, Target and Target GiftCards are registered trademarks of Target Brands, Inc. Terms and conditions are applied to gift cards. Target is not a participating partner in or sponsor of this offer. Applebee s This gift card is usable up to balance only to purchase goods or services at any Applebee s Grill & Bar in the U.S. and Canada or through applebees.com. Not usable to purchase gift cards. Card is not redeemable for cash unless required by law. Card will not be replaced or replenished if lost, stolen, damaged or used without authorization. ACM Cards, Inc. or the Franchisee of the independently owned restaurant where card was purchased is the card issuer. ACM or Franchisee may delegate its issuer obligations to an assignee. Purchase, use or acceptance of card constitutes acceptance of these terms. Inquiries, complete terms and restaurant location information: visit applebees.com or call Applebee s Restaurants LLC. Disclaimers Your Evidence of Coverage explains how your Florida Blue Medicare plan covers these services. Florida Blue has partnered with Novu to manage our member rewards program. Check with your doctor to see which covered health care services are right for you. Y0011_ C: 08/2016

3 Health Care Activity Annual Wellness Visit Overview: An annual wellness visit is a one-on-one conversation between you and your doctor about your health. By completing this once-a-year visit, you ll be eligible for a reward. What to expect: Your doctor will likely give you a simple vision test and record your height, weight and blood pressure. You ll also have a chance to talk about your medications, eating habits, physical activity and general well-being. You can ask questions, and your doctor will put together a plan of action that s tailored just for you. Health Care Activity Annual Wellness Visit Appointment date: / / Doctor s full name: Dr. (mm/dd/yy) (eligible dates: <01/01/16 12/31/16)> Health Care Activity Flu Shot Overview: A flu shot is a great way to lower your chances of getting the flu. Every flu season is different, so you should get a flu shot once per year in the early fall (before October, if possible). Get your flu shot this year to be eligible for a reward. What to expect: You can get a flu shot from your doctor or nurse, but many other places, such as pharmacies, clinics or health centers, might offer flu shots as well. Health Care Activity Flu Shot Date of vaccination: / / Clinic or location phone number: (mm/dd/yy) (eligible dates: <01/01/16 12/31/16)> - -

4 Health Care Activity Annual Wellness Visit Y0011_ C: 08/2016 Health Care Activity Flu Shot Y0011_ C: 08/2016

5 Health Care Activity Breast Cancer Screening Overview: A breast cancer screening, also called a mammogram, is an X-ray of the breasts to check for cancer. It can help find cancer early, when it may be easier to treat. Based on your family and personal history, your doctor will help you set up a plan for when and how often you should be screened. Complete a breast cancer screening this year to be eligible for a reward. What to expect: On the day of your screening, you will need to remove jewelry and clothing from the waist up prior to being X-rayed. Don t wear deodorant that day because it could be seen on the X-rays and cause confusion. You will feel pressure for a few seconds in your breasts during the screening. Health Care Activity Breast Cancer Screening Appointment date: / / Doctor s full name: Dr. (mm/dd/yy) (eligible dates: <01/01/16 12/31/16)> Health Care Activity Colon Cancer Screening Overview: Although the idea of getting screened for colon cancer can be scary, regular screenings could help find growths (called polyps) before they re cancerous, or catch cancer early when it may be easier to treat. Talk with your doctor to set up a plan for how often you should be screened, the age that you should start and the type of screening that s right for you. Complete a colon cancer screening this year to be eligible for a reward. What to expect: There are different types of colon cancer screenings. Most tests involve a thin tube with a tiny camera used to look inside your colon. Although, based on your doctor s recommendation, you may receive an at-home kit to complete and send back. Health Care Activity Colon Cancer Screening Date of test: / / Doctor s full name: Dr. Name of clinic or location (or write home kit ): (mm/dd/yy) (eligible dates: <01/01/16 12/31/16)>

6 Health Care Activity Breast Cancer Screening Y0011_ C: 08/2016 Health Care Activity Colon Cancer Screening Y0011_ C: 08/2016

7 Health Care Activity Diabetic Dilated Eye Exam Overview: Diabetes can cause damage to your eyes. However, it s possible to catch problems early if you get regular eye exams with an eye doctor. By completing a once-a-year eye exam you ll be eligible for a reward. What to expect: Your eye doctor will use eye drops to make your pupils dilate (enlarge). To see the back of your eye, your doctor will look through a special magnifying glass using a bright light. This lets the doctor see areas that may be damaged by diabetes and check the overall health of your eyes. Health Care Activity Diabetic Dilated Eye Exam Appointment date: Optometrist or Ophthalmologist name: / / (mm/dd/yy) (eligible dates: <01/01/16 12/31/16)> Health Care Activity Diabetic Urine Test for Protein Overview: Diabetes can sometimes damage your kidneys. This damage can lead to kidney disease, which happens when the blood is not being cleaned properly. A test for protein in the urine can help your doctor see if you have the disease. If caught and treated early, diabetic kidney disease can be slowed. By completing one diabetic urine test this year, you ll be eligible for a reward. What to expect: Your doctor will ask you for a urine sample, which will be tested for a certain type of protein. Health Care Activity Diabetic Urine Test for Protein Appointment date: / / Doctor s full name: Dr. (mm/dd/yy) (eligible dates: <01/01/16 12/31/16)>

8 Florida Blue Disclaimer: Florida Blue is a PPO, RPPO and Rx (PDP) Plan with a Medicare contract. Florida Blue HMO and Florida Blue Preferred HMO are HMO plans with a Medicare contract. Enrollment in Florida Blue, Health Care Activity Diabetic Dilated Eye Exam Y0011_ C: 08/2016 Florida Blue Disclaimer: Florida Blue is a PPO, RPPO and Rx (PDP) Plan with a Medicare contract. Florida Blue HMO and Florida Blue Preferred HMO are HMO plans with a Medicare contract. Enrollment in Florida Blue, Health Care Activity Diabetic Urine Test for Protein Y0011_ C: 08/2016

9 Health Care Activity Diabetic Blood Test (A1C) Overview: A diabetic blood test, also called an A1C test, is a simple way to look at your blood sugar level over the past 3 months. It s not the same as testing your blood sugar at home. This test will help you and your doctor see if your diabetes treatment plan is working. Your doctor may send you to get an A1C test 2-4 times per year. Provide the details of one of your A1C tests from this year to be eligible for a reward. What to expect: The A1C test is a simple blood test your doctor performs. You can eat and drink normally before the test. Health Care Activity Diabetic Blood Test (A1C) Appointment date: / / (mm/dd/yy) (eligible dates: <01/01/16 12/31/16)> Doctor s full name: Dr. A1C numeric result:. % (XX.X%)

10 Health Care Activity Diabetic Blood Test (A1C) Y0011_ C: 08/2016

11 Health Care Activity Bone Density Test (Osteoporosis Screening) Overview: Bone density tests measure how strong your bones are. A low score could mean that your bones have weakened over time and could indicate osteoporosis, a condition that can cause bones to break more easily. Talk to your doctor to see if and when you need this test. Complete a bone density test this year to be eligible for a reward. What to expect: A bone density test is usually fast and painless, and it measures the strength of your bones with a special X-ray machine. Your doctor will look at the results to see if your bone density is normal or lower than normal. Health Care Activity Bone Density Test (Osteoporosis Screening) Date of bone density scan: / / (mm/dd/yy) (eligible dates: <01/01/16 12/31/16)> Doctor s full name: Dr. Date of your fracture: / / (mm/dd/yy) Check the box if you were prescribed a medication for osteoporosis and filled it: If you checked the box, at which pharmacy?

12 Health Care Activity Bone Density Test (Osteoporosis Screening) Y0011_ C: 08/2016

renew You can t predict if you will get lower your cancer risk Learn about screenings for colon cancer. See Page 5. Fall

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