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2022 Annual Notice of Change/Evidence of Coverage

The Evidence of Coverage booklet tells you how to get your Medicare medical care and prescription drugs (if applicable) through a Medicare Advantage plan.

The Evidence of Coverage booklet explains:

  • Member rights and responsibilities
  • What is covered
  • What you will pay as a member of the plan

The benefits listed in the Evidence of Coverage are effective January 1 of the current year. Benefits, formulary, pharmacy network, premium and/or copayments/co-insurance may change on January 1, 2022.

Medicare Advantage HMO Plans

Medicare Advantage PPO Plans

Medicare Advantage HMO Plans

Medicare Advantage PPO Plans

Optional Supplemental Dental Benefit

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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 4, 2021