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2022 Plan Comparison Table

Plan Tier
Monthly Premium*
Next steps
? Out-of-pocket Max.
? Medical Deductible
Medical Services
? Primary Care Doctor
? Specialist
Hospital Care
? Inpatient Hospital
Laboratory Services
X-Rays
Advanced Radiology (MRI, CAT, PET)
? Urgent Care
? Emergency Room
? Outpatient Hospital
? 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
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 Drug
Tier 5 Specialty
Gap Coverage

Highmark Blue Cross Blue Shield of Western New York (Highmark BCBSWNY) is a trade name of Highmark Western and Northeastern New York Inc., an independent licensee of the Blue Cross Blue Shield Association. Highmark BCBSWNY is a Medicare Advantage plan with a Medicare contract and enrollment depends on contract renewal. Highmark BCBSWNY 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 1-833-735-4515 (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 1-833-735-4515 (TTY 711).

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Content last updated: October 1, 2021