Blue Cross Medicare
AdvantageSM

Blue Medicare Advantage

Blue Cross Medicare Advantage, a plan that offers all of the coverage of Original Medicare — plus benefits not covered by Medicare or most Medicare Supplement insurance plans, including built-in prescription drug coverage. Think of it is as an all-in-one plan.

Whether you’re new to Medicare or thinking about switching plans, here are some important things to consider before choosing Blue Cross Medicare Advantage.

  • Be sure you are eligible for Medicare. Your primary residence must be in Cook, DuPage, Kane or Will counties to enroll in Blue Cross Medicare Advantage.
  • If you're eligible for Medicare and planning to retire, speak with your benefits administrator at work about your benefit options.
  • Learn how Medicare Advantage works.
  • Review the 2014 Blue Cross Medicare Advantage plan benefits and built-in drug coverage below.
  • If you’d like to enroll in a Medicare Advantage plan, make sure you're aware of enrollment periods. Members may enroll in the plan only during specific times of the year.


2014 Blue Cross Medicare Advantage Plans

  Basic
HMO
Basic Plus
(HMO-POS)
Premier Plus
(HMO-POS)
Monthly Premium $0 $0 $38
    In
Network
Out of
Network
In
Network
Out of
Network
Maximum
Medical Out-of-Pocket
$3,400 $3,800 No Maximum
Out-of-Pocket
$3,500 No Maximum
Out-of-Pocket
Inpatient Hospital Care $225/day (days 1-7) $250/day (days 1-7) $400/day $225/day (days 1-7) $400/day
Skilled Nursing Facility

$0/day
(days 1-7);
$50/day
(days 8-20);
$100/day
(days 21-100)

$0/day
(days 1-7);
$25/day
(days 8-20);
$125/day
(days 21-100)
40%
coinsurance
$0/day
(days 1-7);
$25/day
(days 8-20);
$125/day
(days 21-100)
40%
coinsurance
Emergency Care $65 copay $65 copay $65 copay $65 copay $65 copay
Annual Physical Exam $0 copay

$0 copay

Not covered $0 copay Not covered
Doctor Office Visits $5 Primary Care Physician copay
$35 Specialist copay
$10 Primary Care Physician copay
$45 Specialist copay
$75 Primary Care Physician copay
$75 Specialist copay
$5 Primary Care Physician copay
$40 Specialist copay
$75 Primary Care Physician copay
$75 Specialist copay
Chiropractic Services $20 copay $20 copay 40% coinsurance $20 copay 40% coinsurance
X-Rays $0 copay $0 copay 40% coinsurance $0 copay 40% coinsurance
Advanced Imaging (MRI, MRA, CT Scan, PET) $150 copay $200 copay $400 copay $200 copay $400 copay
Diabetes Self-Management Training, Supplies and Services $0 copay training
0% coinsurance supplies and services
$0 copay training
20% coinsurance supplies and services
40% coinsurance training
40% coinsurance supplies and services
$0 copay training
20% coinsurance supplies and services
40% coinsurance training
40% coinsurance supplies and services
Supplemental Education/
Wellness
Programs
$0 copay
(SilverSneakers)
$0 copay
(SilverSneakers)
$0 copay
(SilverSneakers)
$0 copay
(SilverSneakers)
$0 copay
(SilverSneakers)
Travel Benefit Available for members that are out of the service area for up to 6 months. Available for members that are out of the service area for up to 6 months. Available for members that are out of the service area for up to 6 months. Available for members that are out of the service area for up to 6 months. Available for members that are out of the service area for up to 6 months.
Worldwide Emergency Urgent/Emergent Care only; No annual limit; $65 copay Urgent/Emergent Care only; No annual limit; $65 copay Urgent/Emergent Care only; No annual limit; $65 copay Urgent/
Emergent Care only; No annual limit; $65 copay
Urgent/
Emergent Care only; No annual limit; $65 copay
Eye Exams $0 copay for one specialist eye exam $0 copay for one specialist eye exam Medicare covered at 40% $0 copay for one specialist eye exam Medicare covered at 40%
Hearing Exams $5 copay for 1 supplemental routine hearing exam each year $5 copay for 1 supplemental routine hearing exam each year Medicare covered at 40% $5 copay for 1 supplemental routine hearing exam each year Medicare covered at 40%

Prescription Copays and Coinsurances (applies to all plans)

  Preferred Non
Preferred
Preferred Non
Preferred
Not
Covered
Preferred Non
Preferred
Not
Covered
Deductible $0 $0 $0
Tier 1 - Preferred Generic Drugs
$0 $5
$0 $5  
$0 $5  
Tier 2 - Non-Preferred Generic Drugs
$2 $7
$2 $7  
$2 $7  
Tier 3 - Preferred Brand Drugs
$39 $44
$39 $44  
$39 $44  
Tier 4 - Non-Preferred Brand Drugs
$85 $95
$85 $95  
$85 $95  
Tier 5 - Specialty Drugs
33% 33%
33% 33%  
33% 33%  

2014 Blue Cross Medicare Advantage built-in drug coverage:

Evidence of Coverage

English
Y0096_
BEN_IL_
HMOANOCE
OC2014
Accepted
08282013

Espanol
Y0096_
Y0096_BEN_TMP_
MAEOCCVR14SPA
Approved
08222013

English
Y0096_
BEN_IL_
HMOPOSE
OC2014a
Accepted
09272013

Espanol
Y0096_
Y0096_BEN_TMP_
MAEOCCVR14SPA
Approved
08222013
English
Y0096_
BEN_IL_
HMOPOSE
OC2014a
Accepted
09272013

Espanol
Y0096_
Y0096_BEN_TMP_
MAEOCCVR14SPA
Approved
08222013
Summary of Benefits English
Y0096_BEN_IL_MAPDSB14 Accepted 10012013
Espanol
Y0096_BEN_IL_MAPDSB14SPA Accepted 10012013

You must continue to pay your Medicare Part B premium. The benefit information provided is a brief summary, not a complete description of benefits. For more information, contact the plan. Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Limitations, co-payments, and restrictions may apply. If you would like to submit feedback directly to Medicare, please use the Medicare Complaint Form  or contact the Office of the Medicare Ombudsman .

® Registered Service Marks of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans
† SilverSneakers® is a registered mark of Healthways, Inc.
Healthways SilverSneakers® Fitness Program is a wellness program owned and operated by Healthways, Inc, an independent company.