Blue Medicare AdvantageSM




Blue Medicare Advantage 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 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 Medicare Advantage.

  • Be sure you are eligible for Medicare. Your primary residence must be in Bastrop, Burnet, Caldwell, Collin, Dallas, Denton, Fayette, Fort Bend, Harris, Hays, Lee, Montgomery, Tarrant, Travis, or Williamson counties to enroll in Blue 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 2013 Blue 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.

In Network Out of Network
Monthly Premium $69.90 $69.90
Maximum Medical Out-of-Pocket $3,400 $5,000
Doctor Office Visits

$15 copay for each Medicare-covered primary care doctor visit

$45 copay for each Medicare-covered specialist visit

30% coinsurance for each Medicare-covered primary care doctor visit

30% coinsurance for each Medicare-covered specialist visit
Inpatient Hospital Care

Days 1- 7: $250 copay per day

Days 8 – 100: $0 copay per day

Days 1- 7:$250 copay per day

Days 8 – 100: $0 copay per day

2013 Blue Medicare Advantage built-in drug coverage:
Prescription deductible $325 for tiers 3, 4 & 5 only
Copay Tier 1 Preferred Generic Drugs $3.00
Copay Tier 2 Non-preferred Generic Drugs $10.00
Copay Tier 3 Preferred Brand Drugs $43.00
Copay Tier 4 Non-preferred Brand Drugs $95.00
Coinsurance Tier 5 Specialty Drugs 25%
Copay gap coverage After your total yearly drug costs reach $2,970, you receive limited coverage by the plan on certain drugs. You will also receive a discount on brand name drugs and generally pay no more than 47.5% for the plan’s costs for brand drugs and 79% of the plan’s costs for generic drugs until your yearly out-of-pocket drug costs reach $4,750.


Evidence of Coverage - Plan 001
H1666_BEN_TX_EOC0012013 Accepted 09042012


Evidence of Coverage - Plan 001 en Espanol
H1666_BEN_TX_EOC0012013SPA


Evidence of Coverage - Plan 002
H1666_BEN_TX_EOC0022013 Accepted 09042012


Evidence of Coverage - Plan 002 en Espanol
H1666_BEN_TX_EOC0022013SPA


Evidence of Coverage - Plan 003
H1666_BEN_TX_EOC0032013 Accepted 09042012


Evidence of Coverage - Plan 003 en Espanol
H1666_BEN_TX_EOC0032013SPA Accepted 09042012


Summary of Benefits
H1666_TX_BEN_BNFTSMRY13 Accepted 09152012


Summary of Benefits en Espanol
H1666_TX_BEN_BNFTSMRY13SPA Approved 09152012


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, premium and/or copayments/coinsurance may change on January 1 of each year. Limitations, copayments, and restrictions may apply. Find more information here . If you would like to submit feedback directly to Medicare, please use the Medicare Complaint Form  or contact the Office of the Medicare Ombudsman .