BCN Advantage HMO-POS Prime Value (HMO-POS)

4.5 out of 5 stars* for plan year 2023
$0.00 Monthly Premium

BCN Advantage HMO-POS Prime Value (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by Blue Cross Blue Shield of Michigan

Plan ID: H5883-014-003

$0.00 Monthly Premium

Michigan Medicare beneficiaries may want to consider reviewing their Medicare Advantage (Medicare Part C) plan options. A Medicare Advantage plan combines your Original Medicare (Part A and Part B) benefits into a single plan.

Most Medicare Advantage plans cover prescription drugs, and many plans may offer other extra benefits Original Medicare doesn’t cover.

Learn more about Michigan Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price.

Basic Costs and Coverage

Coverage Details
Monthly plan premium$0.00
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible$0.00
Out-of-pocket maximum$0.00
Initial drug coverage limit$0.00
Catastrophic drug coverage limit$7,400.00
Primary care doctor visit
POS (Out-of-Network):

Doctor Office Visit:
Copayment for Medicare Covered Primary Care Office Visit $0.00
Specialty doctor visitIn-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $45.00
Prior Authorization Required for Doctor Specialty Visit
Inpatient hospital care
Out-of-Network:
$325.00 per day for days 1 to 6
$0.00 per day for days 7 to 90
Urgent care
Urgent Care:
Copayment for Urgent Care $0.00 to $45.00

Minimum copayment amount applies to services provided in a PCP office. Maximum copayment amount applies to services provided in an urgent care facility.

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $45.00
Maximum Plan Benefit of $50,000
Emergency room visit
Emergency Care:
Copayment for Emergency Care $90.00
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 3 days

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $90.00
Copayment for Worldwide Emergency Transportation $275.00
Maximum Plan Benefit of $50,000
Ambulance transportationIn-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $275.00

Air Ambulance:
Copayment for Air Ambulance Services $275.00

Health Care Services and Medical Supplies

BCN Advantage HMO-POS Prime Value (HMO-POS) covers a range of additional benefits. Learn more about BCN Advantage HMO-POS Prime Value (HMO-POS) benefits, some of which may not be covered by Original Medicare (Part A and Part B).

Coverage Details
Chiropractic services
POS (Out-of-Network):

Chiropractic Services:
Copayment for Medicare Covered Chiropractic Services $0.00 to $45.00
Chiropractic Services:
Copayment for Non-Medicare Covered Chiropractic Services $0.00 to $45.00
Diabetes supplies, training, nutrition therapy and monitoringIn-Network:

Diabetic Supplies and Services:
Copayment for Medicare-covered Diabetic Supplies $0.00
Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0.00
Prior Authorization Required for Diabetic Supplies and Services
Diabetic Supplies and Services limited to those from specified manufacturers(Please see Evidence of Coverage)
Durable medical equipment (DME)In-Network:

Durable Medical Equipment:
Coinsurance for Medicare-covered Durable Medical Equipment 0% to 20%
Prior Authorization Required for Durable Medical Equipment
This Plan has preferred Vendors/Manufacturers - Please see Evidence of Coverage
Diagnostic tests, lab and radiology services, and X-rays
POS (Out-of-Network):

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare Covered Diagnostic Procedures/Tests
$0.00 to $20.00
Copayment for Medicare Covered Lab Services
$0.00
Copayment for Medicare Covered Diagnostic Radiological Services $20.00 to $100.00
Copayment for Medicare Covered Therapeutic Radiological Services $25.00
Copayment for Medicare Covered Outpatient X-Ray Services $20.00 to $100.00
Home health care
POS (Out-of-Network):

Home Health Services:
Copayment for Medicare Covered Home Health $0.00
Mental health inpatient careIn-Network:

Psychiatric Hospital Services:
$300.00 per day for days 1 to 6
$0.00 per day for days 7 to 90
Prior Authorization Required for Psychiatric Hospital Services
Mental health outpatient care
POS (Out-of-Network):

Outpatient Mental Health Services:
Copayment for Medicare Covered Individual Sessions $40.00
Copayment for Medicare Covered Group Sessions $40.00
Outpatient services/surgery
POS (Out-of-Network):

Outpatient Hospital and ASC Services:
Copayment for Medicare Covered Outpatient Hospital Services $0.00 to $275.00
Copayment for Medicare Covered Ambulatory Surgical Center Services $0.00 to $275.00
Outpatient substance abuse careIn-Network:

Outpatient Substance Abuse Services:
Copayment for Medicare-covered Individual Sessions $45.00
Copayment for Medicare-covered Group Sessions $45.00
Over-the-counter items In-Network:

Over-The-Counter (OTC) Items:
Copayment for Over-The-Counter (OTC) Items $0.00
Maximum Plan Benefit of $85.00 every three months. Unused amounts will carry
forward into the next quarter.

Nicotine Replacement Therapy (NRT) offered as a
Part C OTC benefit

Podiatry services
POS (Out-of-Network):

Podiatry Services:
Copayment for Medicare Covered Podiatry Services $45.00
Skilled Nursing Facility (SNF) careIn-Network:

Skilled Nursing Facility Services:
$0.00 per day for days 1 to 20
$188.00 per day for days 21 to 100
Prior Authorization Required for Skilled Nursing Facility Services

Dental Benefits

The following dental services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage Details
Dental careIn-Network:

Preventive Dental:
Copayment for Oral Exams $0.00
  • Maximum 2 visits every year
Copayment for Prophylaxis (Cleaning) $0.00
  • Maximum 2 visits every year
Copayment for Fluoride Treatment $0.00
  • Maximum 1 visit every year
Copayment for Dental X-Rays $0.00
  • Maximum 1 visit every two years
Maximum Plan Benefit of $1500.00 every year for Preventive and Non-Medicare Covered Comprehensive combined

Comprehensive Dental:
Copayment for Medicare-covered Benefits $0.00 to $275.00
Copayment for Diagnostic Services $0.00
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Restorative Services $0.00
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Endodontics $0.00
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Periodontics $0.00
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Extractions $0.00
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services $0.00
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Maximum Plan Benefit of $1500.00 every year for Preventive and Non-Medicare Covered Comprehensive combined

Vision Benefits

The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage Details
Vision benefits
POS (Out-of-Network):

Medicare Covered Vision Services:
Copayment for Medicare Covered Eye Exams $0.00 to $45.00
Copayment for Medicare Covered Eyewear $0.00

Hearing Benefits

The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage Details
Hearing benefits
POS (Out-of-Network):

Medicare Covered Hearing Services:
Copayment for Medicare Covered Hearing Exams $45.00

Preventive Services and Health/Wellness Education Programs

The following services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage Details
Preventive services and health/wellness education programs
POS (Out-of-Network):

Medicare-covered Zero Dollar Preventive Services:
Copayment for Medicare Covered Medicare-covered Preventive Services $0.00

When reviewing Michigan Medicare plans, be sure to find out if your doctors are part of the plan network. If a Medicare Advantage plan covers prescription drugs, make sure the plan formulary (list of drugs covered by the plan) includes your drugs.

You may be able to find plans in your part of Michigan that offer similar benefits at similar or lower prices than the plan above. Call 1-800-557-6059 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.

Plan Documents

Links to plan documents

Michigan Counties Served

Alcona Alpena Arenac Bay Charlevoix Cheboygan Clare Crawford Gladwin Huron Iosco Kalkaska Luce Mackinac Montmorency Ogemaw Oscoda Presque Isle Roscommon Saginaw Sanilac Schoolcraft Shiawassee Tuscola
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