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Medicare Blue Choice Platinum (HMO-POS)
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MDC-Medicare Blue Choice Platinum - Plan Features - Odd
- Robust provider network1
- No referrals required
- $125 annual eyewear allowance
- Worldwide urgent care and emergency coverage
- Silver&Fit® Fitness Program
- $25 annual non-refundable fee to enroll in a participating fitness club or exercise center;
- $10 annual non-refundable fee to enroll in the home fitness program; or
- $150 annual allowance for out-of-network facilities.
MDC-Medicare Blue Choice Platinum - Benefits - Odd
Medicare Blue Choice Platinum (HMO-POS) provides comprehensive coverage for the health care services you need, including:
- Out-of-Network coverage under the point of service benefit: 30% coinsurance; $3,000 annual maximum.
- $15 copay per visit for an in-network primary care providers
- $40 copay per visit for in-network specialists
- $0 copay for many Medicare-covered preventive services in-network, such as physical exams, smoking cessation and some immunizations
- $15 copay for in-network chiropractic medical visits
- Inpatient Hospital Stay
- $260 copay per day for days 1-5 for each Medicare-covered stay at a network hospital
- Days 6+ covered in full
- $5,500 annual Out-of-Pocket Maximum Protection (In-network services)
MDC-Medicare Blue Choice Platinum - Learn More - Odd
Learn more with these resources:
- Summary of Benefits with Multi-Language FlyerOpen a PDF
- Evidence of CoverageOpen a PDF
- Annual Notice of ChangeOpen 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 1-800-421-1220). 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.
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 - Mar. 31:
advisors are also available weekends 8 a.m. to 8 p.m.
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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_5966_M.
This page last updated 08-03-2019.