MAPD Plan Comparison Chart

	Blue Cross Medicare Advantage Basic (HMO) ^SM	Blue Cross Medicare Advantage Basic Plus (HMO‑POS)^SM		Blue Cross Medicare Advantage Premier Plus (HMO‑POS)^SM		Blue Cross Medicare Advantage Choice Plus (PPO) ^SM		Blue Cross Medicare Advantage Choice Premier (PPO) ^SM
		In-Network	Out-of-Network	In-Network	Out-of-Network	In-Network	Out-of-Network	In-Network	Out-of-Network
Plan Premium	$0	$0		$83		$79		$141.10
Doctors Office Visits
Primary Care Provider	$0 copay	$10 copay	$60 copay	$5 copay	$60 copay	$25 copay	50% coinsurance	$15 copay	50% coinsurance
Specialist	$30 copay	$40 copay	$75 copay	$35 copay	$75 copay	$40 copay	50% coinsurance	$50 copay	50% coinsurance
Prescription Drug Copay	Tier 1: $0 – $5 copay Full coverage of Tier 1 in gap	Tier 1: $0 – $5 copay Full coverage of Tier 1 in gap		Tier 1: $0 – $5 copay Full coverage of Tier 1 in gap		Tier 1: $3 – $8 copay Full coverage of Tier 1 in gap		Tier 1: $0 – $5 copay Full coverage of Tier 1 in gap
Prescription Drug Deductible	$0 Deductible	$0 Deductible		$0 Deductible		$435 Deductible Tiers 4 & 5		$0 Deductible
Extra Health & Wellness Benefits
Optional Supplemental Benefits Premium	not available	$27.10^*		not available		$32.30^*		not available
Dental
Preventive	$0 copay per visit; 2 exams, 2 cleanings, 1 X-ray	^* $0 copay per visit; 2 exams, 2 cleanings, 1 X-ray		$0 copay per visit; 2 exams, 2 cleanings, 1 X-ray	not covered	^*$0 copay per visit; 2 exams, 2 cleanings, 1 X-ray		$0 copay per visit; 2 exams, 2 cleanings, 1 X-ray
Comprehensive	$500 Annual Maximum	^* 50% Basic Restorative; 70% Major Restorative $1,000 Annual Maximum		$500 Annual Maximum		^* 50% Basic Restorative; 70% Major Restorative $1,000 Annual Maximum		not covered
Vision
Eye Exam	$0 copay	$0 copay		$0 copay $25 copay lenses	not covered	$0 copay	$40 allowance	$0 copay	$40 allowance
Eyewear	$150 two-year maximum	^* $150 per year allowance		$100 two-year maximum		^* $150 per year allowance	^* $150 per year allowance
Hearing
Hearing Exam	not covered	^* $5 copay		^* $5 copay	not covered	^* $5 copay		not covered
Hearing Aids		^*$1,000 three-year maximum		^*$1,000 three-year maximum		^*$1,000 three-year maximum
Over-the-Counter (OTC) Purchase Allowance	$75 / quarterly	not available		not available		not available		not available
Free SilverSneakers^® Fitness Program	✓	✓		✓		✓		✓
24/7 NurseLine	✓	✓		✓		✓		✓
Transportation	$0 copay / up to 12 one-way trips every year to plan-approved locations	$0 copay / up to 12 one-way trips every year to plan-approved locations	not covered	$0 copay / up to 12 one-way trips every year to plan-approved locations	not covered	not covered		not covered

^* These benefits only available with Optional Supplemental Benefit package and additional premium.

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