2023 BCN AdvantageSM HMO ConnectedCare
This Blue Care Network plan is for residents of Arenac, Genesee, Iosco, Kalamazoo, Livingston, Macomb, Oakland, Saginaw, St. Clair, Washtenaw or Wayne County. It's a good fit if you don't travel much and want to choose from a network of local doctors.
NETWORK SIZE
MONTHLY PREMIUM
$
MEDICAL DEDUCTIBLE
$0
$0.00 monthly payment for 48002
$0
$0
$3,800
Optional supplemental benefits don't count toward your maximum out-of-pocket.
You pay $0.
You pay $40.
You pay $0-$45.
Starts at $0 for certain generic drugs filled at a preferred pharmacy. Certain drugs may cost more if you choose a pharmacy in our standard network.
See if this plan covers your medication. Find your prescription (PDF).
All benefits required by Original Medicare and more, including:
• $0 telehealth visits for primary care and behavioral health
• Advantage Dollars quarterly allowance for over-the-counter drugs and health products with rollover within the calendar year
• Annual allowance for preventive and comprehensive dental
• Worldwide emergency, urgent care and transportation coverage
• Meals benefit following hospital discharge for qualifying members
• One round trip per calendar year to an Annual Wellness Visit within the state of Michigan
• Transportation benefit for certain counties following hospital discharge
• SilverSneakers® fitness program
• MyBlueSM Concierge program
This is an HMO plan with a network that was created just for people who live in Arenac, Genesee, Iosco, Kalamazoo, Livingston, Macomb, Oakland, Saginaw, St. Clair, Washtenaw and Wayne counties. HMO stands for health maintenance organization. It's a group of health care professionals that provide services to members. You choose a Primary care physician from a select network who coordinates all your care and refers you to specialists. In most cases, we don’t cover care you get outside our network except in an emergency. Find a doctor in this plan's network.
Includes services such as:
• Welcome to Medicare exam
• Personalized prevention plan services
• Bone mass measurement
• Screenings for cancer, glaucoma, depression, diabetes and sexually transmitted infections
• Immunizations (including flu, pneumonia and Hepatitis B vaccines)
• Screening mammograms
• Pap smears
• Behavioral counseling to reduce alcohol misuse
• Behavioral therapy for cardiovascular disease and obesity
You pay $0.
Primary care physician: You pay a $0 copay.
Specialist: You pay a $40 copay.
Primary care physician: You pay a $0 copay.
Behavioral health: You pay a $0 copay.
Ambulatory surgical center: You pay a $0-$100 copay.
Hospital: You pay a $0-$225 copay.
Days 1-6: You pay a $225 copay per day.
Days 7-90: You pay $0.
Days 90 & beyond: You pay $0.
You're covered for up to 100 days each benefit period at a Medicare-certified facility.
Days 1-20: You pay $0.
Days 21-100: You pay a $188 copay per day.
You pay a $0-$45 copay.
You pay a $90 copay.
You pay a $45 copay.
There's a combined $50,000 lifetime limit for emergency, urgent care services and worldwide transportation received outside the U.S. and its territories.
You pay a $90 copay.
There's a combined $50,000 lifetime limit for emergency, urgent care services and worldwide transportation received outside the U.S. and its territories.
You pay a $230 copay.
There's a combined $50,000 lifetime limit for emergency, urgent care services and worldwide transportation received outside the U.S. and its territories.
You pay 20% of the cost.
You pay a $230 copay.
Spinal manipulation: You pay a $15 copay.
Annual exam: You pay a $40 copay.
Annual X-ray: You pay a $20 copay.
You pay a $40 copay.
Includes individual and group therapy visits.
You pay a $20 copay.
You pay a $30 copay.
You pay 20% of the cost.
Commonly prescribed generic versions of brand medications. You’ll pay the least for these drugs at the pharmacy.
Preferred pharmacy: You pay $0.
Standard pharmacy: You pay $5.
Although you’ll pay more at the pharmacy for these generic drugs, they're more cost-effective than brand medications.
Preferred pharmacy: You pay $10.
Standard pharmacy: You pay $18.
Brand drugs that aren’t available yet as a generic.
Preferred pharmacy: You pay $42.
Standard pharmacy: You pay $47.
Because there are alternatives for the drugs in this tier, you’ll pay more for them at the pharmacy.
Preferred pharmacy: You pay 46% of the cost.
Standard pharmacy: You pay 46% of the cost.
Specialty drugs are used to treat complex conditions like cancer and multiple sclerosis. Although they can be generic or brand, they usually need special handling and approval. You may have to order them through a specialty pharmacy.
Preferred pharmacy: You pay 33% of the cost.
Standard pharmacy: You pay 33% of the cost.
Tier 1: You also receive some coverage for generic drugs. You pay no more than 25% of the cost for generic drugs and the plan pays the rest.
All other drugs: You pay 25% of the cost.
Generic drugs: You pay a $4.15 copay or 5% of the cost, whichever is greater.
Other drugs: You pay a $10.35 copay or 5% of the cost, whichever is greater.
The benefit provides a $1,500 annual maximum for in-network dental services per calendar year.
This plan covers the following dental services for $0 copay in-network:
• Two oral exams every year
• Two routine cleanings every year
• Up to four bitewing x-rays or up to six periapical films every other calendar year
• Fluoride treatments
• Brush biopsies
• Resin and amalgam fillings
• Crowns
• Crown repairs
• Root canals
• Deep cleanings
• Extractions
• Oral surgery
• Original Medicare covered dental care services are covered with a copay of $0-$225 depending on place of service.
What's not covered:
• Dental procedures like dentures, onlays and implants
Add more dental, vision and hearing coverage for an additional cost.
This plan covers these benefits for $0 copay:
• One routine eye exam every year
• A diabetic retinopathy exam
• One pair of Medicare-covered glasses or contact lenses after cataract surgery.
• You can choose from any provider from the VSP Choice network.
This plan also covers:
• Medicare-covered exam for a $40 copay.
• Diabetic Retinopathy Eye Exam has a $0 copay.
What's not covered:
• Glasses or contact lenses
• LASIK or RK (radial keratotomy) surgery
Add more dental, vision and hearing coverage for an additional cost.
You pay:
• $0 to $40 for Medicare-covered diagnostic only hearing exams. These are tests your doctor orders for you to see if you need medical treatment. Your Primary care physician or specialist copay applies.
What's not covered:
• Routine hearing exams
• Hearing aids or exams for fitting hearing aids
Add more dental, vision and hearing coverage for an additional cost.
This document lists important features and rules for this plan.
This booklet explains how to use this plan's benefits. It also lists some of the things this plan doesn't cover.
This brochure gives you an overview of all our Medicare Advantage plans to help you compare.
Find a doctor or hospital in this plan's network:
Find a pharmacy in this plan's network:
This map shows you the counties where BCN Advantage plans are available.
If you meet certain income and resource limits, you may qualify for help paying for your prescription drug costs through the low-income subsidy.
If you're eligible, see what your monthly premium would be:
The easiest way to enroll in this plan is online. Or call us at 1-888-563-3307. TTY users call 711. You can also print, fill out and mail this paper application.
$0
$0
$3,800
Optional supplemental benefits don't count toward your maximum out-of-pocket.
You pay $0.
You pay $40.
You pay $0-$45.
Starts at $0 for certain generic drugs filled at a preferred pharmacy. Certain drugs may cost more if you choose a pharmacy in our standard network.
See if this plan covers your medication. Find your prescription (PDF).
All benefits required by Original Medicare and more, including:
• $0 telehealth visits for primary care and behavioral health
• Advantage Dollars quarterly allowance for over-the-counter drugs and health products with rollover within the calendar year
• Annual allowance for preventive and comprehensive dental
• Worldwide emergency, urgent care and transportation coverage
• Meals benefit following hospital discharge for qualifying members
• One round trip per calendar year to an Annual Wellness Visit within the state of Michigan
• Transportation benefit for certain counties following hospital discharge
• SilverSneakers® fitness program
• MyBlueSM Concierge program
This is an HMO plan with a network that was created just for people who live in Arenac, Genesee, Iosco, Kalamazoo, Livingston, Macomb, Oakland, Saginaw, St. Clair, Washtenaw and Wayne counties. HMO stands for health maintenance organization. It's a group of health care professionals that provide services to members. You choose a Primary care physician from a select network who coordinates all your care and refers you to specialists. In most cases, we don’t cover care you get outside our network except in an emergency. Find a doctor in this plan's network.
Includes services such as:
• Welcome to Medicare exam
• Personalized prevention plan services
• Bone mass measurement
• Screenings for cancer, glaucoma, depression, diabetes and sexually transmitted infections
• Immunizations (including flu, pneumonia and Hepatitis B vaccines)
• Screening mammograms
• Pap smears
• Behavioral counseling to reduce alcohol misuse
• Behavioral therapy for cardiovascular disease and obesity
You pay $0.
Primary care physician: You pay a $0 copay.
Specialist: You pay a $40 copay.
Primary care physician: You pay a $0 copay.
Behavioral health: You pay a $0 copay.
Ambulatory surgical center: You pay a $0-$100 copay.
Hospital: You pay a $0-$225 copay.
Days 1-6: You pay a $225 copay per day.
Days 7-90: You pay $0.
Days 90 & beyond: You pay $0.
You're covered for up to 100 days each benefit period at a Medicare-certified facility.
Days 1-20: You pay $0.
Days 21-100: You pay a $188 copay per day.
You pay a $0-$45 copay.
You pay a $90 copay.
You pay a $45 copay.
There's a combined $50,000 lifetime limit for emergency, urgent care services and worldwide transportation received outside the U.S. and its territories.
You pay a $90 copay.
There's a combined $50,000 lifetime limit for emergency, urgent care services and worldwide transportation received outside the U.S. and its territories.
You pay a $230 copay.
There's a combined $50,000 lifetime limit for emergency, urgent care services and worldwide transportation received outside the U.S. and its territories.
You pay 20% of the cost.
You pay a $230 copay.
Spinal manipulation: You pay a $15 copay.
Annual exam: You pay a $40 copay.
Annual X-ray: You pay a $20 copay.
You pay a $40 copay.
Includes individual and group therapy visits.
You pay a $20 copay.
You pay a $30 copay.
You pay 20% of the cost.
Commonly prescribed generic versions of brand medications. You’ll pay the least for these drugs at the pharmacy.
Preferred pharmacy: You pay $0.
Standard pharmacy: You pay $5.
Although you’ll pay more at the pharmacy for these generic drugs, they're more cost-effective than brand medications.
Preferred pharmacy: You pay $10.
Standard pharmacy: You pay $18.
Brand drugs that aren’t available yet as a generic.
Preferred pharmacy: You pay $42.
Standard pharmacy: You pay $47.
Because there are alternatives for the drugs in this tier, you’ll pay more for them at the pharmacy.
Preferred pharmacy: You pay 46% of the cost.
Standard pharmacy: You pay 46% of the cost.
Specialty drugs are used to treat complex conditions like cancer and multiple sclerosis. Although they can be generic or brand, they usually need special handling and approval. You may have to order them through a specialty pharmacy.
Preferred pharmacy: You pay 33% of the cost.
Standard pharmacy: You pay 33% of the cost.
Tier 1: You also receive some coverage for generic drugs. You pay no more than 25% of the cost for generic drugs and the plan pays the rest.
All other drugs: You pay 25% of the cost.
Generic drugs: You pay a $4.15 copay or 5% of the cost, whichever is greater.
Other drugs: You pay a $10.35 copay or 5% of the cost, whichever is greater.
The benefit provides a $1,500 annual maximum for in-network dental services per calendar year.
This plan covers the following dental services for $0 copay in-network:
• Two oral exams every year
• Two routine cleanings every year
• Up to four bitewing x-rays or up to six periapical films every other calendar year
• Fluoride treatments
• Brush biopsies
• Resin and amalgam fillings
• Crowns
• Crown repairs
• Root canals
• Deep cleanings
• Extractions
• Oral surgery
• Original Medicare covered dental care services are covered with a copay of $0-$225 depending on place of service.
What's not covered:
• Dental procedures like dentures, onlays and implants
Add more dental, vision and hearing coverage for an additional cost.
This plan covers these benefits for $0 copay:
• One routine eye exam every year
• A diabetic retinopathy exam
• One pair of Medicare-covered glasses or contact lenses after cataract surgery.
• You can choose from any provider from the VSP Choice network.
This plan also covers:
• Medicare-covered exam for a $40 copay.
• Diabetic Retinopathy Eye Exam has a $0 copay.
What's not covered:
• Glasses or contact lenses
• LASIK or RK (radial keratotomy) surgery
Add more dental, vision and hearing coverage for an additional cost.
You pay:
• $0 to $40 for Medicare-covered diagnostic only hearing exams. These are tests your doctor orders for you to see if you need medical treatment. Your Primary care physician or specialist copay applies.
What's not covered:
• Routine hearing exams
• Hearing aids or exams for fitting hearing aids
Add more dental, vision and hearing coverage for an additional cost.
This document lists important features and rules for this plan.
This booklet explains how to use this plan's benefits. It also lists some of the things this plan doesn't cover.
This brochure gives you an overview of all our Medicare Advantage plans to help you compare.
Find a doctor or hospital in this plan's network:
Find a pharmacy in this plan's network:
This map shows you the counties where BCN Advantage plans are available.
If you meet certain income and resource limits, you may qualify for help paying for your prescription drug costs through the low-income subsidy.
If you're eligible, see what your monthly premium would be:
The easiest way to enroll in this plan is online. Or call us at 1-888-563-3307. TTY users call 711. You can also print, fill out and mail this paper application.
You can add an optional supplemental package to your Medicare Advantage plan for an additional monthly cost.
This package will enhance your dental and vision benefits including: