2010 Plan information
For more information call:
1-877-469-2583
TTY 1-800-481-8704
Seven days a week
8 a.m. to 8 p.m. Eastern Time
Select your county to view a summary of 2010 BCN Advantage HMO benefits, premiums and copayments. The benefits provided are subject to plan terms and conditions. For more information or to obtain a complete list of benefits, call us.
Please select your county for monthly premiums:
| OPTION 1 Without prescription drugs | OPTION 2 With prescription drugs | OPTION 3 With prescription drugs | |
| Deductible | $150 | $100 | $0 |
| Out-of-pocket maximum | $3,400 | $3,200 | $3,000 |
| Outpatient care | |||
| Doctor office visits, primary care physician | $20 copay | $15 copay | $10 copay |
| Doctor office visits, specialists | $35 copay | $30 copay | $25 copay |
| Chiropractic | $35 copay | $30 copay | $25 copay |
| Podiatry services | $35 copay | $30 copay | $25 copay |
| Ambulance services (medically necessary) | $50 copay | $50 copay | $50 copay |
| Emergency care | $50 waived if admitted within 1 day | $50 waived if admitted within 1 day | $50 waived if admitted within 1 day |
| Urgent care | $35 copay | $35 copay | $35 copay |
| Diabetes monitoring Supplies | $0 copay | $0 copay | $0 copay |
| Lab/Diagnostic tests | $20 copay | $20 copay | $10 copay |
| X-ray | $0 for Medicare-covered lab services, $0 for Medicare therapeutic radiology services, $20 for Medicare-covered diagnostic radiology services. | $0 for Medicare-covered lab services, $0 for Medicare therapeutic radiology services, $20 for Medicare-covered diagnostic radiology services. | $0 for Medicare-covered lab services, $0 for Medicare therapeutic radiology services, $10 for Medicare-covered diagnostic radiology services. |
| X-ray PET, CT, MRI | $40 copay | $40 copay | $20 copay |
| Durable medical equipment | 20% coinsurance | 20% coinsurance | 20% coinsurance |
| Physical therapy, occupational therapy, speech therapy | $35 copay | $30 copay | $25 copay |
| Inpatient hospital care | |||
| Hospital care (includes substance abuse and rehabilitation services) | $700 per Medicare-covered admission (unlimited days of coverage in each benefit period) | $500 per Medicare-covered admission (unlimited days of coverage in each benefit period) | $300 per Medicare-covered admission (unlimited days of coverage in each benefit period) |
| Skilled nursing (in a Medicare-certified skilled nursing facility) | $0 for days 1-20, $130 for days 21-100 (100 days per benefit period) | $0 for days 1-20, $130 for days 21-100 (100 days per benefit period) | $0 for days 1-20, $130 for days 21-100 (100 days per benefit period) |
| Preventive services | |||
| Bone mass measurement | $0 copay | $0 copay | $0 copay |
| Colorectal screening exams* | Medicare-covered screening plus up to one additional per year. $0 copay/no age limit. | Medicare-covered screening plus up to one additional per year. $0 copay/no age limit. | Medicare-covered screening plus up to one additional per year. $0 copay/no age limit. |
| Immunizations | $0 copay | $0 copay | $0 copay |
| Mammograms (annual screening)* | Medicare-covered screening plus up to one additional per year. $0 copay/no age limit. | Medicare-covered screening plus up to one additional per year. $0 copay/no age limit. | Medicare-covered screening plus up to one additional per year. $0 copay/no age limit. |
| Pap smears and pelvic exams** | Medicare-covered screening plus up to one additional per year. $0 copay/no age limit. | Medicare-covered screening plus up to one additional per year. $0 copay/no age limit. | Medicare-covered screening plus up to one additional per year. $0 copay/no age limit. |
| Prostate cancer screening* | Medicare-covered screening plus up to one additional per year. $0 copay/no age limit. | Medicare-covered screening plus up to one additional per year. $0 copay/no age limit. | Medicare-covered screening plus up to one additional per year. $0 copay/no age limit. |
| *One per year, no age limit. **One per year. | |||
| Additional benefits | |||
| Hearing exams | $25 copay (1 exam/year) | $25 copay (1 exam/year) | $25 copay (1 exam/year) |
| Hearing aids | $500 toward one hearing aid for each ear (one right, one left) every three years | $500 toward one hearing aid for each ear (one right, one left) every three years | $500 toward one hearing aid for each ear (one right, one left) every three years |
| Health education, wellness programs | $0 copay | $0 copay | $0 copay |
| Routine physical exams | $20 copay | $15 copay | $10 copay |
| Preventive dental | $0 copay (2 oral exams/year, 2 prophylaxis-cleanings/year, 1 set of bite-wing X-rays/2 years) | $0 copay (2 oral exams/year, 2 prophylaxis-cleanings/year, 1 set of bite-wing X-rays/2 years) | $0 copay (2 oral exams/year, 2 prophylaxis-cleanings/year, 1 set of bite-wing X-rays/2 years) |
| Prescription drug coverage (Prescription drug benefits subject to exclusions and limitations.) |
Not covered | Deductible – $0
Initial coverage limit – $2,830 Copayments after deductible and up to coverage limit: Tier 1 – $4; Tier 2 – $35; Tier 3 – $75; Tiers 4 and 5 – 25% coinsurance Once the coverage limit is met, members pay 100% of prescription drug costs until out-of-pocket expenses reach $4,550. After $4,550 out-of-pocket, copayments are: $2.50 for generics, $6.30 for brand-name drugs or 5%, whichever is greater. |
Deductible – $0
Initial coverage limit – $2,830 Copayments after deductible and up to coverage limit: Tier 1 – $3; Tier 2 – $30; Tier 3 – $65; Tiers 4 and 5 – 25% coinsurance Once the coverage limit is met and until the member has paid $4,550 out-of-pocket, copayments are: $5 for generics and 100% for brand-name drugs. After $4,550 out-of-pocket, copayments are: $2.50 for generics, $6.30 for brand-name drugs or 5%, whichever is greater. |
| Tier 1: Formulary preferred (mostly generics) | |||
| Tier 2: Formulary options (most brand name medications) | |||
| Tier 3: Non-preferred drugs (Tier 1 and Tier 2 drugs offer better value) | |||
| Tier 4: High cost/specialty drugs | |||
| Tier 5: Drugs administered by a health care professional | |||
| You have the right to make a complaint if you have concerns related to your medical or prescription drug coverage or care. “Appeals” and “grievances” are the two types of complaints you can make. An “appeal” is the type of complaint you make when you want us to reconsider a decision we made about what services are covered for you or what we will pay for a service or benefit. A “grievance” is the type of complaint you make if you have any other type of problem with BCN Advantage or one of our plan providers. If you believe you need a drug that is not on our formulary or you believe you should get a drug at a lower copayment, you have the right to ask for an “exception.” There are specific steps you may take to request an exception, appeal or grievance. See Section 7 for Option 1 or Section 8 for Option 2 or 3 of your Evidence of Coverage for complete details. | |||
BCN Advantage has formed a network of doctors, specialists and hospitals. You can only use doctors who are part of our network for routine care. To find a doctor, visit our Physician Search Tool.
You may go to any emergency room, anywhere in the world, if you reasonably believe you need emergency care. You pay a copayment for each Medicare-covered emergency room visit. The copayment is waived if you are admitted to the hospital within one day for the same condition.
For urgently needed care (non-emergency) from a non-BCN Advantage provider anywhere in the world, you pay a copayment for each Medicare-covered urgently needed care visit.
You must use plan providers except in emergent or urgent care situations or for out-of-area renal dialysis. If you obtain routine care from out-of-network providers neither Medicare nor BCN Advantage will be responsible for the costs.
BCN Advantage HMOSM is a health plan with a Medicare contract.
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page modified 09/29/2009