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Plan Comparison Table

Monthly Premium*
Next steps
? Out-of-pocket Max.
? Medical Deductible
Medical Services
? Primary Care Doctor
? Specialist
Hospital Care
? Inpatient Hospital
Laboratory Services
Advanced Radiology (MRI, CAT, PET)
? Urgent Care (copay waived if admitted)
? Emergency Room (copay waived if admitted)
? Outpatient
? Ambulatory Surgery
? Preventive Services
Annual Routine Eye Exam
Vision Wear (frames/lenses/contact lens)
? Hearing Aid (coverage for specific models only)
? Optional Supplemental Dental Plan
National Coverage
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
Tier 1 Preferred Generic
Tier 2 Generic
Tier 3 Preferred Brand
Tier 4 Non-Preferred Brand
Tier 5 Specialty
Gap Coverage

BlueCross BlueShield of Western New York is a Medicare Advantage plan with a Medicare contract and enrollment depends on contract renewal.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 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. A division of HealthNow New York Inc., an 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 1-800-248-9296 (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 1-833-202-9524 (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 1-833-202-9524 (TTY: 711).

Y0086_MRK2150 Approved
Content Last Updated June 18, 2018