Blue Cross Medicare
AdvantageSM




Blue Cross 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 Cross 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 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.
  • 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:

  Choice Plus PPO Choice Premier PPO
Monthly Premium $34 $34 $54 $54
  In
Network
Out of
Network
In
Network
Out of
Network
Maximum
Medical Out-of-Pocket
$3,400 $5,100 $3,400 $5,000
Inpatient Hospital Care $300/Day (1-7) 40% coinsurance $250/Day (1-7) $400/Day (1-7)
Skilled Nursing Facility $0 Copay (days 1-14); $50 (days 15-20);
$100/day (days 21-100)
40% coinsurance $0 Copay (days 1-14); $50 (days 15-20);
$100/day (days 21-100)
30% coinsurance
Emergency Care $65 copay $65 copay $65 copay $65 copay
Annual Physical Exam $0 copay $0 copay $0 copay $0 copay
Doctor Office Visits $10 Primary Care Physician copay
$40 Specialist copay
40% coinsurance Primary Care Physician
40% coinsurance Specialist
$5 Primary Care Physician copay
$35 Specialist copay
30% coinsurance Primary Care Physician
30% coinsurance Specialist
Chiropractic Services $20 copay 40% coinsurance $20 copay 30% coinsurance
X-Rays $15 - $100 copay (POS) 40% coinsurance $15 - $100 copay (POS) 30% coinsurance
Advanced Imaging (MRI, MRA, CT Scan, PET) $200 copay 40% coinsurance $200 copay 30% coinsurance
Diabetes Self-Management Training, Supplies and Services $0 copay training
20% coinsurance supplies and services
$0 copay training
40% coinsurance supplies and services
$0 copay training
20% coinsurance supplies and services
$0 copay training
30% coinsurance supplies and services
Supplemental Education/
Wellness
Programs
$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.
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
Eye Exams $0 copay for one specialist eye exam /$10 copay routine eye exam annually Not Covered $0 copay for one specialist eye exam /$10 copay routine eye exam annually $0 copay for one specialist eye exam /$10 copay routine eye exam annually
Hearing Exams $10 copay for 1 supplemental routine hearing exam each year 40% coinsurance $10 copay for 1 supplemental routine hearing exam each year 30% coinsurance

Prescription Copays and Coinsurances (applies to all plans)

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

 

Evidence of Coverage

English
Y0096_BEN_TX_PPOANOCEOC2014 Accepted 08292013
Espanol
Y0096_BEN_TMP_MAEOCCVR14SPA Approved 08222013

Summary of Benefits English
Y0096_BEN_TX_MAPDSB14 Accepted 10012013

Espanol
Y0096_BEN_TX_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. 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 .

® 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.