Blue Cross Medicare Advantage Saver Plus (PPO) H8634-020-000 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	$0.00
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible	$505.00
Out-of-pocket maximum	$6,900.00
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 $30.00
Specialty doctor visit	In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $45.00 Prior Authorization Required for Doctor Specialty Visit
Inpatient hospital care	In-Network: Acute Hospital Services: $370.00 per day for days 1 to 6 $0.00 per day for days 7 to 90 Prior Authorization Required for Acute Hospital Services
Urgent care	Urgent Care: Copayment for Urgent Care $40.00 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $90.00
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
Ambulance transportation	In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $225.00 Air Ambulance: Coinsurance for Air Ambulance Services 20% Please see Evidence of Coverage for Prior Authorization rules

Health Care Services and Medical Supplies

Blue Cross Medicare Advantage Saver Plus (PPO) covers a range of additional benefits. Learn more about Blue Cross Medicare Advantage Saver Plus (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 $20.00 Prior Authorization Required for Chiropractic Services
Diabetes supplies, training, nutrition therapy and monitoring	Out-of-Network: Diabetic Supplies and Services: Coinsurance for Medicare Covered Diabetic Supplies and Services 20%
Durable medical equipment (DME)	Out-of-Network: Durable Medical Equipment: Coinsurance for Medicare Covered Durable Medical Equipment 20%
Diagnostic tests, lab and radiology services, and X-rays	Out-of-Network: Outpatient Diag Procs/Tests/Lab Services: Copayment for Medicare Covered Diagnostic Procedures/Tests $200.00 Copayment for Medicare Covered Lab Services $200.00 Copayment for Medicare Covered Diagnostic Radiological Services $400.00 Coinsurance for Medicare Covered Therapeutic Radiological Services 50% Copayment for Medicare Covered Outpatient X-Ray Services $200.00
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: $500.00 per day for days 1 to 999
Mental health outpatient care	In-Network: Outpatient Mental Health Services: Copayment for Medicare-covered Individual Sessions $40.00 Copayment for Medicare-covered Group Sessions $40.00 Prior Authorization Required for Outpatient Mental Health Services
Outpatient services/surgery	In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $375.00 Prior Authorization Required for Outpatient Hospital Services Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per stay $370.00 Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $300.00 Prior Authorization Required for Ambulatory Surgical Center Services
Outpatient substance abuse care	Out-of-Network: Outpatient Substance Abuse Services: Copayment for Medicare Covered Individual or Group Sessions $100.00
Podiatry services	Out-of-Network: Podiatry Services: Copayment for Medicare Covered Podiatry Services $75.00
Skilled Nursing Facility (SNF) care	Out-of-Network: $250.00 per day for days 1 to 999

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	Out-of-Network: Medicare Covered Dental Services: Copayment for Medicare Covered Comprehensive Dental $75.00 Non-Medicare Covered Dental Services: Copayment for Non-Medicare Covered Preventive Dental $0.00 Coinsurance for Non-Medicare Covered Comprehensive Dental 0% to 50%

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	Out-of-Network: Medicare Covered Vision Services: Copayment for Medicare Covered Eye Exams $75.00 Copayment for Medicare Covered Eyewear $75.00 Non-Medicare Covered Vision Services: Copayment for Non-Medicare Covered Eye Exams $0.00 Copayment for Non-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	In-Network: Hearing Exams: Copayment for Medicare Covered Benefits $40.00 Copayment for Routine Hearing Exams $0.00 Maximum 1 visit every year Copayment for Fitting/Evaluation for Hearing Aid $0.00 Hearing Aids: Copayment for Hearing Aids $0.00 Maximum 2 Hearing Aids every three years Maximum Plan Benefit of $1000.00 every three years both ears combined for in and out of network services combined

Coverage

Details

Hearing benefits

In-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $40.00
Copayment for Routine Hearing Exams $0.00

Maximum 1 visit every year

Copayment for Fitting/Evaluation for Hearing Aid $0.00

Hearing Aids:
Copayment for Hearing Aids $0.00

Maximum 2 Hearing Aids every three years

Maximum Plan Benefit of $1000.00 every three years both ears combined for in and out of network services combined

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 Saver Plus (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

Blue Cross Medicare Advantage Saver Plus (PPO)