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BlueCross Medicare Advantage

BlueCare Plus (HMO SNP) 2019

$0.00
per month

Medical Coverage

Benefit You Pay:
Annual Deductible

$0

Maximum Out Of Pocket

$6,700

PCP Office Visits

$0 copay

Specialist Office Visits

$0 copay

Inpatient Hospital Facility Services

0% coinsurance

Dental Services

Cleaning(s): $0 copay
Dental bitewing x-ray(s): $0 copay
Oral exam(s): $0 copay
$5,000 allowance for combined preventive and comprehensive dental services

Ambulance

0% coinsurance

Chiropractic Services

0% coinsurance for 20 routine visits per year

Diabetes Self-Monitoring Training, Nutrition Therapy, and supplies

$0 copay

Diagnostic Tests, X-Rays, Lab Services, and Radiology Services

Advanced imaging services (such as MRIs, CT scans): 0% coinsurance
Diagnostic tests and procedures: 0% coinsurance
Lab services: 0% coinsurance
X-rays: 0% coinsurance
Therapeutic radiology services: 0% coinsurance

Durable Medical Equipment

0% coinsurance

Emergency Services (In and out-of-network)

0% coinsurance

Hearing Services

$2,500 allowance for a routine hearing exam, hearing aid fitting/evaluation, and hearing aid, combined.

Home Health Care

$0 copay

Dialysis

0% coinsurance

Meals

Up to 2 meals for up to 7 days after an Inpatient Hospital stay1
May require prior authorization

Outpatient Surgery

Outpatient hospital: 0% coinsurance
Ambulatory surgical center: 0% coinsurance

Rehabilitation and Therapy Services

Covered¹

Personal Emergency Response System (PERS)

Covered¹

Preventive Services

$0 copay

Prosthetic Devices

0% coinsurance

SilverSneakers Fitness Benefit

SilverSneakers membership included at no cost

Skilled Nursing Facility (SNF)

0% coinsurance per day for days 1 through 100

Urgent Care Facility

0% coinsurance

Transportation

Up to 100 one-way trips

Over-the-Counter (OTC) Benefit

$300 quarterly allowance

Vision Services

Routine exam (for up to 1 per year): $0 copay
Contact lenses/Eyeglasses (frames and lenses): $350 allowance

Prescription Drug Coverage

Benefit You Pay:
Deductible (applies to all drugs)

$0.00

Tier 1 - Preferred Generics

$0 - $3.40
The amount you pay is determined by the covered Part D prescription and your low-income subsidy coverage.

Tier 2 - Generics

$0 - $3.40
The amount you pay is determined by the covered Part D prescription and your low-income subsidy coverage.

Tier 3 - Preferred Brands

$0 - $8.50
The amount you pay is determined by the covered Part D prescription and your low-income subsidy coverage.

Tier 4 - Non Preferred Brands

$0 - $3.40
The amount you pay is determined by the covered Part D prescription and your low-income subsidy coverage.

Tier 5 - Specialty Drugs

$0 - $3.40
The amount you pay is determined by the covered Part D prescription and your low-income subsidy coverage.

Coverage in the Coverage Gap

There is no coverage gap. Once you leave the Initial Coverage Stage, you move on to the Catastrophic Coverage Stage.

Extra Coverage

Benefit
Extra Benefits

Routine Preventive and Comprehensive Dental
Routine Vision and Eyewear
Routine Hearing and Limited Hearing Aid Benefit
Transportation Benefit
Personal Emergency Response System (PERS)
Over-The-Counter (OTC) Medication and Products
Meals (Post In-patient Hospital Stay)
Chiropractic Benefit

Out of Network Coverage

Benefit
Medical Services/Supplies

It is important to know which providers are part of our network because, with limited exceptions, while you are a member of our plan you must use network providers to get your medical care and services. The only exceptions are emergencies, urgently needed services when the network is not available (generally, when you are out of the area), out-of-area dialysis services, and cases in which BlueCare Plus (HMO SNP) authorizes use of out-of-network providers. See Chapter 3 (Using the plan’s coverage for your medical services) of the Evidence of Coverage (EOC) for more specific information about emergency, out-of-network, and out-of-area coverage.

Prescription Drugs

You should always try to obtain urgently needed services from network providers. However, if providers are temporarily unavailable or inaccessible and it is not reasonable to wait to obtain care from your network provider when the network becomes available, we will cover urgently needed services that you get from an out-of-network provider. Generally, if you cannot use a network provider during a disaster, your plan will allow you to obtain care from out-of-network providers at in-network cost-sharing. If you cannot use a network pharmacy during a disaster, you may be able to fill your prescription drugs at an out-of –network pharmacy. Please see Chapter 5, Section 2.5 of the Evidence of Coverage (EOC) for more information.

Plan Documents

 Summary of Benefits (PDF)
 Evidence of Coverage
 Plan Rating
 General Transition Notice (PDF)
 Low Income Subsidy Premium Summary Table for Those Receiving Extra Help (PDF)
 Annual Notice of Change
 Find a Doctor, Hospital, and Pharmacy

Value Added Benefits

Member Account

BlueAccess Member Portal - Access your health care information here. Online access is an easy way to get up-to-date information about your plan.

Fitness membership through SilverSneakers®

SilverSneakers® Fitness, an exercise program designed just for you, is available to our members at 14,000+ fitness locations across the state and throughout the country, including national chains, local gyms, and women-only sites!

Member Perks

BlueCross members can save money on health and wellness products and services with Blue365® – our discount program. Get weekly emails filled with new discounts on leading national brands and be sure to check the local deals in your area!