Plan Basics
Contract Year 2021
Medicare Type Medicare Advantage Plan (Part C)
CMS Plan ID H5883-001-005
Plan Organization Blue Care Network
Plan Type Local HMO *
Plan Name BCN Advantage HMO-POS Elements (HMO-POS)
Drugs Covered No
Doctors Choice Plan Doctors Only (some exceptions)
Overall Star Rating 4
Plan Cost Sharing
Premium $30.00
Total Premium (Includes Part B) $165.50
Monthly Part C Premium $30.00
Maximum Out-of-Pocket Limit for Parts A & B (MOOP) $4500.00

Medicare Advantage Plan Health Benefits


Additional Benefits And/or Reduced Cost-sharing For Enrollees With Certain Health Conditions?
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network - - No
Comprehensive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diagnostic services No - - - Not covered
Endodontics No - - - Not covered
Extractions No - - - Not covered
Non-routine services No - - - Not covered
Periodontics No - - - Not covered
Prosthodontics, other oral/maxillofacial surgery, other services No - - - Not covered
Restorative services No - - - Not covered
Diagnostic Procedures/lab Services/imaging
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diagnostic radiology services (e.g., MRI) - Out-of-Network Yes No $20-100 copay
Diagnostic tests and procedures - Out-of-Network Yes No $20 copay
Lab services - Out-of-Network Yes No $0 copay
Outpatient x-rays - Out-of-Network Yes No $20-100 copay
Doctor Visits
Service Cap Network Auth. Req. Ref. Req. Cost Share
Primary - Out-of-Network - - $40 copay per visit
Specialist - Out-of-Network Yes No $40 copay per visit
Emergency Care/Urgent Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
Emergency - - - - $90 copay per visit (always covered)
Urgent care - - - - $0-45 copay per visit (always covered)
Foot Care (podiatry Services)
Service Cap Network Auth. Req. Ref. Req. Cost Share
Foot exams and treatment - Out-of-Network Yes No $40 copay
Routine foot care - - - - Not covered
Ground Ambulance
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network - - $250 copay
Health Plan Deductible
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $160 In-network
Hearing
Service Cap Network Auth. Req. Ref. Req. Cost Share
Fitting/evaluation Yes In-Network No No $0 copay
Hearing aids Yes In-Network No No $0 copay
Hearing exam - Out-of-Network No No $40 copay
Inpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes No $205 per day for days 1 through 6$0 per day for days 7 through 90
Maximum Out-of-pocket Enrollee Responsibility (does Not Include Prescription Drugs)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $4,500 In and Out-of-network$4,500 In-network
Medical Equipment/supplies
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diabetes supplies - Out-of-Network Yes - $0 copay
Durable medical equipment (e.g., wheelchairs, oxygen) - Out-of-Network Yes - 20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs) - Out-of-Network Yes - 20% coinsurance per item
Medicare Part B Drugs
Service Cap Network Auth. Req. Ref. Req. Cost Share
Chemotherapy - Out-of-Network Yes - 0-20% coinsurance
Other Part B drugs - Out-of-Network Yes - 0-20% coinsurance
Mental Health Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Inpatient hospital - psychiatric - Out-of-Network Yes No $205 per day for days 1 through 6$0 per day for days 7 through 90
Outpatient group therapy visit - Out-of-Network No No $40 copay
Outpatient group therapy visit with a psychiatrist - Out-of-Network No No $40 copay
Outpatient individual therapy visit - Out-of-Network No No $40 copay
Outpatient individual therapy visit with a psychiatrist - Out-of-Network No No $40 copay
Optional Supplemental Benefits
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - Yes
Other Health Plan Deductibles?
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network - - No
Outpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes No $0-200 copay per visit
Preventive Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network No No $0 copay
Preventive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Cleaning Yes In-Network No No $0 copay
Dental x-ray(s) Yes In-Network No No $0 copay
Fluoride treatment No - - - Not covered
Oral exam Yes In-Network No No $0 copay
Rehabilitation Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Occupational therapy visit - Out-of-Network Yes No $30 copay
Physical therapy and speech and language therapy visit - Out-of-Network Yes No $30 copay
Skilled Nursing Facility
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes No $0 per day for days 1 through 20$178 per day for days 21 through 100
Transportation
Service Cap Network Auth. Req. Ref. Req. Cost Share
No In-Network No Yes $0 copay
Vision
Service Cap Network Auth. Req. Ref. Req. Cost Share
Contact lenses No - - - Not covered
Eyeglass frames No - - - Not covered
Eyeglass lenses No - - - Not covered
Eyeglasses (frames and lenses) No - - - Not covered
Other No - - - Not covered
Routine eye exam Yes In-Network No No $0 copay
Upgrades - - - - Not covered
Wellness Programs (e.g., Fitness, Nursing Hotline)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - No Yes Covered

Medicare Plan Packages


Package #1
Category Cost Sharing Type Cost Share
Comprehensive dental Monthly Premium $20.40
Eye exams Monthly Premium $20.40
Eyewear Monthly Premium $20.40
Preventive dental Monthly Premium $20.40
Package #2
Category Cost Sharing Type Cost Share
Comprehensive dental Monthly Premium $37.40
Eye exams Monthly Premium $37.40
Eyewear Monthly Premium $37.40
Preventive dental Monthly Premium $37.40
Plan Drug Info
Formulary Link Drug Formulary Directory
Official Medicare Contact
Medicare Phone 1-800-MEDICARE (1-800-633-4227)
Medicare TTY User 1-877-486-2048

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