BlueCross BlueShield of Western New York

Plan Comparison Chart

  Senior BlueSaver (HMO) Senior Blue 601 (HMO) Senior Blue Select (HMO) Senior Blue 651 (HMO) Forever Blue Focus (PPO)**
Forever Blue Value (PPO) Forever Blue 751 (PPO)
2018 Monthly Premium* $0/mo. $0/mo. $46/mo. $117/mo. $61/mo. $136/mo. $198/mo.
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Out-of-pocket max.
$6,700 $6,700 $6,700 $6,700

$6,700 in-network 

$10,000 in and out-of-network combined

$6,700 in-network 

$10,000 in and out-of-network combined

$6,700 in-network 

$10,000 in and out-of-network 

Medical deductible
None None None None None None None
Medical Services
Primary Doctor/Specialist
$15/$41 $10/$45 $10/$30 $0/$25 $20/$40 $15/$35 $5/$27
Hospital Care
Inpatient Hospital

$360 per day

$1,800 max per year

$280 per day

$1,960 max per year

$280 per day

$1,960 max per year

$225 per day

$1,575 max per year

$270 per day

$1,890 max per year

$250 per day

$1,750 max per year

$205 per day

$1,435 max per year

Lab  $10 $0 $10 $5 $5 $5 $5
X-Rays/Advanced Radiology (MRI, CAT, PET) $50/$175 $45/$75  $50/$175 $40/$75 $50/$150 $50/$150 $40/$75
Urgent Care (copay waived if admitted)
$65 $65 $65 $65 $65 $65 $65
Emergency Room (copay waived if admitted)
$80 $80 $80 $80 $80 $80 $80
Outpatient/
Ambulatory Surgery
$500/$450 $300/$225 $375/$300 $300/$225 $375/$300 $325/$250 $275/$200
Preventive Services
$0 $0 $0 $0 $0 $0 $0
Annual Routine Eye Exam $41  $50   $30 $25  $40 $35  $27
Vision Wear (frames/lenses/contact lens) Not Covered $100 annual allowance $100 annual allowance $100 annual allowance $100 annual allowance $100 annual allowance $100 annual allowance
Hearing Aid
(coverage for specific models only)
$699 or $999/unit $699 or $999/unit $699 or $999/unit $699 or $999/unit $699 or $999/unit $699 or $999/unit $699 or $999/unit
Optional Supplemental Dental Plan
Add to plan for additional $17 per month for the Basic plan, or $35 a month for the Enhanced plan Add to plan for additional $17 per month for the Basic plan, or $35 a month for the Enhanced plan Add to plan for additional $17 per month for the Basic plan, or $35 a month for the Enhanced plan Add to plan for additional $17 per month for the Basic plan, or $35 a month for the Enhanced plan Add to plan for additional $17 per month for the Basic plan, or $35 a month for the Enhanced plan Add to plan for additional $17 per month for the Basic plan, or $35 a month for the Enhanced plan Add to plan for additional $17 per month for the Basic plan, or $35 a month for the Enhanced plan
National Coverage ER, urgent care, and dialysis ER, urgent care, and dialysis ER, urgent care, and dialysis ER, urgent care, and dialysis Yes, for all covered services Yes, for all covered services  Yes, for all services BlueCard travel included (pay in-network costs for covered services in participating areas)
Prescription Drugs (30-day supply at a retail pharmacy) Preferred pharmacies include Rite Aid and Walmart; see Provider Directory for a full list. 
Prescription Drug Deductible $0 Tiers 1-2
$290 Tiers 3-5
  $0 Tiers 1-2
$180 Tiers 3-5
  $0 Tiers 1-2
$290 Tiers 3-5
   
Tier 1 Preferred Generic

$2 Preferred Pharmacy

$7 Standard Pharmacy

Not Covered

$2 Preferred Pharmacy

$7 Standard Pharmacy

$4 Preferred Pharmacy

$9 Standard Pharmacy

$10 Preferred Pharmacy

$15 Standard Pharmacy

$4 Preferred Pharmacy

$9 Standard Pharmacy

$2 Preferred Pharmacy

$7 Standard Pharmacy

Tier 2 Generic $12 Preferred Pharmacy

$17 Standard Pharmacy

Not Covered

$10 Preferred Pharmacy

$15 Standard Pharmacy

 $10 Preferred Pharmacy

$15 Standard Pharmacy 

$15 Preferred Pharmacy

$20 Standard Pharmacy

$10 Preferred Pharmacy

$15 Standard Pharmacy

$8 Preferred Pharmacy

$13 Standard Pharmacy

Tier 3 Preferred Brand

 $42 Preferred Pharmacy

$47 Standard Pharmacy

Not Covered

$42 Preferred Pharmacy

$47 Standard Pharmacy

$42 Preferred Pharmacy 

$47 Standard Pharmacy

$42 Preferred Pharmacy

$47 Standard Pharmacy

$42 Preferred Pharmacy

$47 Standard Pharmacy

$42 Preferred Pharmacy

$47 Standard Pharmacy

Tier 4 Non-Preferred Brand

$85 Preferred Pharmacy

$90 Standard Pharmacy

Not Covered

$94 Preferred Pharmacy

$100 Standard Pharmacy

$94 Preferred Pharmacy

$100 Standard Pharmacy

$94 Preferred Pharmacy

$100 Standard Pharmacy

50% Preferred Pharmacy

50% Standard Pharmacy

$94 Preferred Pharmacy

$99 Standard Pharmacy

Tier 5 Specialty

27% Preferred Pharmacy

27% Standard Pharmacy

Not Covered

29% Preferred Pharmacy

29% Standard Pharmacy

 

33% Preferred Pharmacy

33% Standard Pharmacy

27% Preferred Pharmacy

27% Standard Pharmacy

33% Preferred Pharmacy

33% Standard Pharmacy

33% Preferred Pharmacy

33% Standard Pharmacy

Gap Coverage Discounts Not covered Discounts

Discounts and tier 1 generic coverage through the gap

Discounts Discounts

Discounts and Tier 1 generic coverage through the gap

 

*You must continue to pay your Medicare Part B premium.

**There is a select facility network with the Forever Blue Focus (PPO) plan. Call us for a full list of participating facilities.
***Dental premium is in addition to plan and Part B premium.

PPO Plans: Cost shown are for services received in-network.

Forever Blue Focus covers emergency services at any hospital; however, routine or scheduled medical services at certain facilities, including Kaleida Health and ECMC, will be considered out of network when billed by those facilities and result in a higher cost share.  Must be a resident of Erie or Niagara County to enroll in this plan.

Our plans cover one routine hearing exam per year with a TruHearing™ provider. Please call TruHearing to verify your benefit and schedule a hearing exam. Coverage is for TruHearing™ Flyte models only. TruHearing is a registered trademark of TruHearing, Inc. TruHearing is an independent company that administers the hearing-aid benefit. 

 

This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or copayments/coinsurance may change January 1 of each year. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. You must continue to pay your Medicare Part B Premium.

Out-of-network/non-contracted providers are under no obligation to treat BlueCross BlueShield of Western New York members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.

Medicare evaluates plans based on a 5-star rating system. Star Ratings are calculated each year and may change from one year to the next. 

BlueCross BlueShield of Western New York is a Medicare Advantage plan with a Medicare contract and enrollment depends on contract renewal.

A division of HealthNow New York Inc., and independent licensee of the BlueCross BlueShield Association. A salesperson will be present with information and applications. For accommodations of persons with special needs at sales meetings, please call 1-800-329-2792 (TTY 711). BlueCross BlueShield of Western New York complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-329-2792 (TTY: 711).

注意:如果您使用繁體中文,您可以免費獲得語言援助服務。請致電 1-800-329-2792 (TTY: 711).

Y0086_MRK1961 Approved
Content Last Updated October 1, 2017