MAPD Plan Comparison Chart

	Blue Cross Medicare Advantage Value (HMO) ^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
Plan Premium	$0	$0		$62
Doctors Office Visits
Primary Care Provider	$0 copay	$10 copay	50% coinsurance	$15 copay	50% coinsurance
Specialist	$20 copay	$50 copay		$45 copay
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
Prescription Drug Deductible	$200 Deductible Tiers 4 & 5	$435 Deductible Tiers 3, 4 & 5		$435 Deductible Tiers 3, 4 & 5
Extra Health & Wellness Benefits
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
Comprehensive	50% Basic Restorative; 70% Major Restorative $1,000 Annual Maximum	not covered		50% Basic Restorative; 70% Major Restorative $1,000 Annual Maximum
Vision
Eye Exam	$0 copay	$0 copay	$40 allowance	$0 copay	$40 allowance
Eyewear	$150 two-year maximum	not covered	not covered	$100 two-year maximum	$100 two-year maximum
Hearing
Hearing Exam	$10 copay	not covered		$10 copay
Hearing Aids	$1,000 three-year maximum	not covered		$1,000 three-year maximum
Over-the-Counter (OTC) Purchase Allowance	$50 / quarterly	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	not covered		not covered
Rewards & Incentives	✓	✓		✓

Get more from your Medicare with the Benefit of Blue^SM. Enroll today.

With multiple options from which to choose, there’s a Blue Cross Medicare Advantage plan for you. Need help deciding? Talk to your licensed, authorized agent or call one of our product specialists.