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Medicare Blue Choice Select (HMO)
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MDC-Medicare Blue Choice Select- Plan Features - Even
- NEW for 2020, add Full Comprehensive Dental coverage to your plan for an additional $39 a month. This includes preventive dental coverage (i.e., cleanings and x-rays) and coverage for restorative and major dental services (i.e., crowns, root canals). 4 (View our Supplemental Dental plans)
- NEW for 2020, you pay 50% of the cost for up to 10 acupuncture visits.
- Robust provider network1
- No referrals required
- Worldwide urgent care and emergency coverage
- The Silver&Fit® Fitness Program. $25 annual non-refundable fee for gym membership. Other program options are available. Find a participating fitness center near you.
- Coverage for hearing aids through our partner TruHearing® (a copayment will apply)
MDC-Medicare Blue Choice Select- Benefits - Even
Medicare Blue Choice Select (HMO) provides comprehensive coverage for the health care services you need, including:
- $15 copay per visit for in-network primary care providers
- $50 copay per visit for in-network specialists
- $0 copay for many Medicare-covered preventive services, such as physical exams, smoking cessation and some immunizations
- $15 copay for in-network chiropractic medical visits
- Inpatient Hospital Stay
- $380 copay per day for days 1-5 for each Medicare-covered stay at a network hospital
- Days 6+ covered in full
- $6,700 annual Out-of-Pocket Maximum Protection (In-network services)
Prescription Drug Coverage3
In 2020, you may save on prescription drugs and vaccines when they are filled at our preferred pharmacies. You may pay more at standard pharmacies.
Your prescription drug costs. You pay 2 times the copayment for a 30-day supply of your prescription at the pharmacy or through mail order:
|Tier||Preferred Pharmacy |
|Preferred Pharmacy |
|Standard Pharmacy |
|Standard Pharmacy |
|Tier 1 Preferred Generic Drugs (Includes select vaccines like the shingles vaccine shingrix®)||$0||$0||$5||$10|
|Tier 2 Generic Drugs||$15||$30||$20||$40|
|Tier 3 Preferred Brand Drugs||$42||$84||$47||$94|
|Tier 4 Non-Preferred Drugs||$95||$190||$100||$200|
|Tier 5 Specialty Drugs||26%||26%||26%||26%|
- $380 annual deductible on Tiers 3, 4 and 5 Drugs (you must pay the full cost of your Tiers 3, 4 and 5 drugs until you reach the plan's deductible amount). For all other drugs, you will not have to pay any deductible and will start receiving coverage immediately.
- Additional savings when you take advantage of our mail order and select retail pharmacies that provide lower cost-sharing for a 90-day supply of your prescription drug(s)
- The 5-Tier comprehensive formulary includes Tier 1, 2, 3, 4 and 5 drugs. Follow this link to Search for a Medication and View Drug Tier and Copayment or Coinsurance Information
- Our nationwide network includes thousands of participating pharmacies. Additionally, Excellus BlueCross BlueShield has contracts with pharmacies that equal or exceed the CMS requirements for pharmacy access in your area
MDC-Medicare Blue Choice Select- Learn More - Even
Learn more with these resources:
- Summary of Benefits with Multi-Language FlyerOpen a PDF
- Evidence of CoverageOpen a PDF
- Annual Notice of ChangesOpen a PDF
- Plan Ratings
- Disenrollment Rights & Responsibilities
1 Network Coverage Information - With our Medicare Advantage Health Maintenance Organization (HMO) plans you must use plan providers except in emergency or urgent care situations or for out-of-area renal dialysis or other services. The Point-of-Service (POS) benefit gives extra flexibility to receive some covered services from providers that are not in our network without having to pay the entire cost yourself. The POS benefit has a coverage limit. Once your costs go above this limit, you will be responsible for 100% of the remaining costs for the out-of-network services. For information on how to request reimbursement for Out-of-Network claims, the Point-of-Service (POS) benefit, Out-of-Network Coverage, or Coverage Determinations and Appeals call Customer Care at 1-877-883-9577, Monday - Friday, 8 a.m. to 8 p.m.; From October 1 through March 31, 8 a.m. to 8 p.m., 7 days a week (TTY/TDD 1-800-662-1220). Or, see the Evidence of Coverage using the link above. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.
3 Eligible beneficiaries must use network pharmacies to access their prescription drug benefit, except under non-routine circumstances, and quantity limitations and restrictions may apply.
4 For out-of-network providers, we will pay 100% of the allowance or dentist charges, whichever is less, You will be responsible for the balance.
To the extent of any discrepancy between this web site and the Evidence of Coverage, the Evidence of Coverage terms take priority.
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Monday - Friday:
8 a.m. to 8 p.m.
From Oct. 1 - Dec. 30:
advisors are also available weekends 8 a.m. to 8 p.m.
Closed Thanksgiving Day, Christmas Eve, Christmas Day, New Year’s Eve, and New Year’s Day
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Excellus BlueCross BlueShield contracts with the Federal Government and is an HMO plan and PPO plan with a Medicare contract. Enrollment in Excellus BlueCross BlueShield depends on contract renewal. Submit a complaint about your Medicare plan at www.Medicare.gov or learn about filing a complaint by contacting the Medicare Ombudsman. Y0028_5993.
This page last updated 10-01-2019.