2017 Annual Notice of Change/Evidence of Coverage

The Evidence of Coverage booklet tells members how to get their Medicare medical care and prescription drugs (if applicable) through our plan, a Medicare Advantage Plan. The Evidence of Coverage booklet explains member’s rights and responsibilities, what is covered, and what you will pay as a member of the plan.

The benefits listed in the Evidence of Coverage are effective January 1st of the current year. Benefits, formulary, pharmacy network, premium and/or copayments/co-insurance may change on January 1, 2018.

 

Senior Blue HMO

Forever Blue PPO Medicare

Optional Supplemental Dental Benefit



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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.

Y0086_MRK1717 Approved
Content Last Updated December 15, 2016