Blue Cross Medicare Advantage Flex (PPO) H8634-014-000 2023 Plan Details and Costs

Illinois 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 Illinois 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	$187.00
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible	$505.00
Out-of-pocket maximum	($1.00)
Initial drug coverage limit	$0.00
Catastrophic drug coverage limit	$7,400.00
Primary care doctor visit	Out-of-Network: Doctor Office Visit: Copayment for Medicare Covered Primary Care Office Visit $0.00
Specialty doctor visit	In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $0.00 Prior Authorization Required for Doctor Specialty Visit
Inpatient hospital care	In-Network: Acute Hospital Services: Copayment for Acute Hospital Services per Stay $0.00 Your plan covers an unlimited number of days for an inpatient stay. Prior Authorization Required for Acute Hospital Services
Urgent care	Urgent Care: Copayment for Urgent Care $0.00 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $0.00
Emergency room visit	Emergency Care: Copayment for Emergency Care $0.00 Worldwide Coverage: Copayment for Worldwide Emergency Coverage $0.00
Ambulance transportation	Out-of-Network: Ambulance Services: Copayment for Medicare Covered Ambulance Services - Ground $0.00 Copayment for Medicare Covered Ambulance Services - Air $0.00

Health Care Services and Medical Supplies

Blue Cross Medicare Advantage Flex (PPO) covers a range of additional benefits. Learn more about Blue Cross Medicare Advantage Flex (PPO) benefits, some of which may not be covered by Original Medicare (Part A and Part B).

Coverage	Details
Chiropractic services	In-Network: Chiropractic Services: Copayment for Medicare-covered Chiropractic Services $0.00 Prior Authorization Required for Chiropractic Services
Diabetes supplies, training, nutrition therapy and monitoring	Out-of-Network: Diabetic Supplies and Services: Copayment for Medicare Covered Diabetic Supplies and Services $0.00
Durable medical equipment (DME)	In-Network: Durable Medical Equipment: Copayment for Medicare-covered Durable Medical Equipment $0.00 Prior Authorization Required for Durable Medical Equipment
Diagnostic tests, lab and radiology services, and X-rays	In-Network: Outpatient Diag Procs/Tests/Lab Services: Copayment for Medicare-covered Diagnostic Procedures/Tests $0.00 Copayment for Medicare-covered Lab Services $0.00 Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $0.00 Copayment for Medicare-covered Therapeutic Radiological Services $0.00 Copayment for Medicare-covered X-Ray Services $0.00 Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services
Home health care	In-Network: Home Health Services: Copayment for Medicare-covered Home Health Services $0.00 Prior Authorization Required for Home Health Services
Mental health inpatient care	Out-of-Network: Copayment for Psychiatric Hospital Services per Stay $0.00
Mental health outpatient care	Out-of-Network: Outpatient Mental Health Services: Copayment for Medicare Covered Individual Sessions $0.00 Copayment for Medicare Covered Group Sessions $0.00
Outpatient services/surgery	In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0.00 Prior Authorization Required for Outpatient Hospital Services Outpatient Observation Services: Copayment for Medicare Covered Observation Services $0.00 Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $0.00 Prior Authorization Required for Ambulatory Surgical Center Services
Outpatient substance abuse care	In-Network: Outpatient Substance Abuse Services: Copayment for Medicare-covered Individual Sessions $0.00 Copayment for Medicare-covered Group Sessions $0.00 Prior Authorization Required for Outpatient Substance Abuse Services
Podiatry services	Out-of-Network: Podiatry Services: Copayment for Medicare Covered Podiatry Services $0.00
Skilled Nursing Facility (SNF) care	In-Network: Skilled Nursing Facility Services: Copayment for Skilled Nursing Facility Services per Stay $0.00 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 care	In-Network: Comprehensive Dental: Copayment for Medicare-covered Benefits $0.00

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	In-Network: Eye Exams: Copayment for Medicare Covered Benefits $0.00 Copayment for Routine Eye Exams $0.00 Maximum 1 Routine Eye Exam every year Eyewear: Copayment for Medicare-Covered Benefits $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	Out-of-Network: Medicare Covered Hearing Services: Copayment for Medicare Covered Hearing Exams $0.00

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

Prescription Drug Costs and Coverage

The Blue Cross Medicare Advantage Flex (PPO) offers prescription drug coverage, with an annual drug deductible of $505.00 (excludes Tiers 1 and 2)

Coverage	Cost
Coverage & Cost
Annual drug deductible	$505.00 (excludes Tiers 1 and 2)
Tier 1	Preferred retail $0.00 Standard retail $15.00 Preferred mail order $0.00 Standard mail order $15.00
Tier 2	Preferred retail $5.00 Standard retail $20.00 Preferred mail order $5.00 Standard mail order $20.00
Annual drug deductible	$505.00 (excludes Tiers 1 and 2)
Tier 1	Preferred retail $0.00 Standard retail $30.00 Preferred mail order $0.00 Standard mail order $30.00
Tier 2	Preferred retail $10.00 Standard retail $40.00 Preferred mail order $10.00 Standard mail order $40.00
Annual drug deductible	$505.00 (excludes Tiers 1 and 2)
Tier 1	Preferred retail $0.00 Standard retail $45.00 Preferred mail order $0.00 Standard mail order $45.00
Tier 2	Preferred retail $15.00 Standard retail $60.00 Preferred mail order $15.00 Standard mail order $60.00

When reviewing Illinois 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 Illinois 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	Summary of benefits Evidence of coverage Star ratings

Links to plan documents

Illinois Counties Served

Adams Alexander Bond Boone Brown Bureau Calhoun Carroll Cass Christian Clark Clay Clinton Coles Cook Crawford Cumberland Dekalb Dewitt Douglas Dupage Edgar Edwards Effingham Fayette Ford Franklin Fulton Gallatin Greene Grundy Hamilton Hancock Hardin Henderson Henry Iroquois Jackson Jasper Jefferson Jersey Johnson Kane Kankakee Kendall Knox La Salle Lake Lawrence Lee Livingston Logan Macon Macoupin Madison Marion Marshall Mason Mcdonough Mchenry Mclean Menard Mercer Monroe Montgomery Morgan Moultrie Ogle Peoria Perry Piatt Pike Pope Pulaski Putnam Randolph Richland Rock Island Saint Clair Saline Sangamon Schuyler Scott Shelby Stark Stephenson Tazewell Union Warren Washington Wayne White Whiteside Will Williamson Winnebago Woodford