Plan Comparison Chart

  BlueSaver (HMO) Senior Blue 650 (HMO-POS)*** Senior Blue 652 (HMO) Forever Blue Value (PPO) Forever Blue 770 (PPO)
2018 Monthly Premium* $16/mo. $46/mo. $129/mo. $85/mo. $184/mo.
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Out-of-pocket Max.

$6,700

$5,500

$6,700

$6,700 in-network

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

$5,500 in-network

$8,500 in and out-of-network

Medical Deductible

None

None

None

None

None

Medical Services
Primary Doctor/Specialist

$15/$45

$15/$50

$0/$26

$25/$36

$10/$22

Hospital Care
Inpatient Hospital

$360 per day

$1,800 OOP limit per year

$325 per day

$1,300 OOP limit per year

$225 per day

$1,575 OOP limit per year

$240 per day

$1,680 OOP limit per year

$205 per day

$1,435 OOP limit per year

Lab

$10

$5

$5

$5

$5

X-Rays/Advanced Radiology

$50/$175

$50/$175

$50/$75

$50/$125

$40/$100

Urgent Care (copay waived if admitted)

$65

$65

$65

$65

$60

Emergency Room (copay waived if admitted)

$80

$80

$80

$80

$80

Outpatient/Ambulatory Surgery

$500/$450

$325/$275

$250/$200

$275/$225

$225/$175

Preventive Services

$0

$0

$0

$0

$0

Annual Routine Eye Exam $45 $50 $26 $36 $22
Annual Eye Wear Allowance  N/A N/A $100 N/A $100
Hearing Aid
(Coverage for specific models only. Must use a Truehearing provider.)
$699 or $999/unit $699 or $999/unit $699 or $999/unit $699 or $999/unit  $699 or $999/unit
Optional Supplemental Dental**
Add to plan for additional $19 per month for the Basic plan, or $38 a month for the Enhanced plan Add to plan for additional $19 per month for the Basic plan, or $38 a month for the Enhanced plan Add to plan for additional $19 per month for the Basic plan, or $38 a month for the Enhanced plan Add to plan for additional $19 per month for the Basic plan, or $38 a month for the Enhanced plan Add to plan for additional $19 per month for the Basic plan, or $38 a month for the Enhanced plan
National Coverage ER, urgent care, and dialysis ER, urgent care, dialysis, and other specific services (Cost-share is 50% up to $1,500) ER, urgent care and dialysis  Yes, for all services Yes, for all services BlueCard travel included (Pay in-network costs 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

Tiers 1-2

$290 Tiers 3-5

N/A

N/A

N/A

N/A

Tier 1 Preferred Generic

$2 Preferred Pharmacy

$7 Standard Pharmacy

$3 Preferred Pharmacy

$8 Standard Pharmacy

$4 Preferred Pharmacy

$9 Standard Pharmacy

$7 Preferred Pharmacy

$12 Standard Pharmacy

$2 Preferred Pharmacy

$7 Standard Pharmacy

Tier 2 Generic

$12 Preferred Pharmacy

$17 Standard Pharmacy

$15 Preferred Pharmacy

$20 Standard Pharmacy

$10 Preferred Pharmacy

$15 Standard Pharmacy

$15 Preferred Pharmacy

$20 Standard Pharmacy

$12 Preferred Pharmacy

$17 Standard Pharmacy

Tier 3 Preferred Brand

$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

$94 Preferred Pharmacy

$100 Standard Pharmacy

50% Preferred Pharmacy

50% Standard Pharmacy

$94 Preferred Pharmacy

$100 Standard Pharmacy

$94 Preferred Pharmacy

$100 Standard Pharmacy

Tier 5 Specialty

27% Preferred Pharmacy

27% Standard Pharmacy

33% Preferred Pharmacy

33% Standard Pharmacy

33% Preferred Pharmacy

33% Standard Pharmacy

33% Preferred Pharmacy

33% Standard Pharmacy

33% Preferred Pharmacy

33% Standard Pharmacy

Gap Coverage

Discounts

Discounts and Tier 1 drug coverage through the coverage gap

Discounts and Tier 1 drug coverage through the coverage gap

Discounts and Tier 1 drug coverage through the coverage gap

Discounts and Tier 1 drug coverage through the coverage gap

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

**Dental premium is in addition to plan and Part B premium. 

***Coverage out-of-network for specialists, x-rays, diagnostic tests and procedures, lab, occupational and physical therapy, and speech-language pathology services only. The cost-share out-of-network is 50%, up to $1,500 annually.


Our plans cover one routine hearing exam per year with a TruHearingTM provider. Please call TruHearing to verify your benefit and schedule a hearing exam. Coverage is for TruHearing Flyte models only. TruHearingTM 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. 

Out-of-network/non-contracted providers are under no obligation to treat BlueShield of Northeastern 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.

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

Y0086_MRK1962 Approved
Content Last Updated October 1, 2017