Medicare Blue Choice Value Plus (HMO-POS)

For Coverage January 1, 2019 to December 31, 2019

Plan Features

  • Robust provider network1
  • No referrals required
  • $0 copay for all Tier 1 Preferred Generic drugs
  • For a 90-day supply, you pay 2 times the copayment for a 30-day supply of your prescription
  • Coverage for preventive dental care including 2 oral exams, 2 cleanings, and 2 x-rays per year2
  • $75 annual eyewear allowance
  • Worldwide urgent care and emergency coverage
  • Silver&Fit® Fitness Program (learn more)
    • $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.

Benefits3

Medical Coverage
Medicare Blue Choice Value Plus (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.
  • $10 copay per visit for an in-network primary care doctor
  • $45 copay per visit for in-network specialists
  • $0 copay for many Medicare-covered preventive services, such as physical exams, smoking cessation and some immunizations
  • $9 copay for in-network chiropractic medical visits
  • Inpatient Hospital Stay
    • $310 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 Coverage4
Our prescription drug coverage features:

Tier 30-Day Supply 90-Day Supply
Tier 1 Preferred Generic Drugs $0 $0
Tier 2 Generic Drugs $15 $30
Tier 3 Preferred Brand Drugs $47 $94
Tier 4 Non-Preferred Drugs $100 $200
Tier 5 Specialty Drugs 33% 33%
 
  • $0 annual deductible (this is the amount you must pay for prescriptions before we begin to pay)
  • 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

Learn more with these resources:

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. If you obtain routine care from Out-of-Network providers neither Medicare nor Excellus BlueCross BlueShield will be responsible for the costs. For information on how to request reimbursement for Out-of-Network claims from emergency, urgent or other services, 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.

2 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.

3 This information is not a complete description of benefits. Call 1-800-671-6081 (TDD/TTY 1-800-421-1220) for more information.

4 Eligible beneficiaries must use network pharmacies to access their prescription drug benefit, except under non-routine circumstances, and quantity limitations and restrictions may apply.

To the extent of any discrepancy between this web site and the Evidence of Coverage, the Evidence of Coverage terms take priority.

 

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. .
This page last updated .