250 333 500 500 500 500 200 500 333 759 /FontBBox [-568 -306 2045 1039] 610 333 277 333 583 556 333 556 610 556 556 1000 333 1000 500 333 943 350 500 666 %PDF-1.7 /MaxWidth 1182 722 722 722 722 722 563 722 722 722 722 /ItalicAngle 0 << /ColorSpace << /CapHeight 662 Summary of Benefits and Coverage. 833 0 obj /Type /FontDescriptor 0 0 277 277 354 556 556 889 666 190 2020 Summary of Benefits Capital Health Plan Advantage Plus (HMO) and Capital Health Plan Preferred Advantage (HMO) This is a summary of drug and health services covered by Capital Health Plan Advantage Plus (HMO) and Capital Health Plan Preferred Advantage (HMO) January 1, 2020 – December 31, 2020. 666 443 443 443 443 443 277 277 277 277 500 500 500 500 333 389 277 500 500 722 /CapHeight 715 /FontDescriptor 853 0 R /Ascent 905 endobj BLUE ADVANTAGE HMO. 833 610 722 722 722 722 722 722 1000 722 777 777 777 777 777 583 777 722 722 722 /Leading 33 /Length 135 /FontName /ArialMT 857 0 obj BLUE ADVANTAGE (HMO) SUMMARY OF BENEFITS This is a summary of drug and health services covered by Blue Advantage (HMO). endobj /StemV 80 750 443 722 722 722 722 722 722 889 666 /Subtype /TrueType /FontDescriptor 842 0 R 610 556 333 610 610 277 277 556 277 889 /Registry (Adobe) /FontName /RSMMEN+ArialMT /BitsPerComponent 8 endobj 837 0 obj >> /UserProperties false /FontDescriptor 854 0 R January 1, 2020 – December 31, 2020. 836 0 obj endobj 556 556 556 556 556 556 556 556 333 333 610 610 610 610 610 610 610 548 610 610 500 443 333 500 500 277 277 500 277 777 >> endobj /FontFile2 862 0 R 0 507 507 0 0 0 0 0 0 0 /FontBBox [-664 -324 2000 1039] /Ascent 891 500 500 500 500 500 500 500 548 500 500 /ID [ /Width 849 /AvgWidth 362 EܝÙ*$b(¯w"h$/ð]+|×_ Âw݌Ñï0ì¸ìVÝv¡½jmÖÀ­ž›¿|/ᶝjT¶Ê~?³™»ï /OutputIntents [<< 277 333 556 556 556 556 259 556 333 736 0 0 277 333 474 556 556 889 722 237 250 250 250 250 0 0 0 0 0 0 /DisplayDocTitle true /Resources << [( )] TJ /Widths [0 0 0 0 0 0 0 0 0 250 >> To enroll in the following plans, you need to be entitled to Medicare Part A, enrolled in /Descent -212 Summary of Benefits for . 842 0 obj 838 0 obj 0000203660 00000 n /Source (WeJXFxNO4fJduyUMetTcP9+oaONfINN4+d7I7rDsCXgfwEC9G0HBPukfA0p1hkF5B9khgm8VtCFmyd8gIrwOjQRAIjPsWhM4vgMCV\ /DestOutputProfile 861 0 R 0 0 0 0 0 0 0 0 0 0 853 0 obj /ProcSet [/PDF 889 556 556 556 556 556 277 277 277 277 /Type /Font /Leading 150 /Type /FontDescriptor /Descent -250 /Type /Font /F4 852 0 R /DefaultCMYK [/ICCBased /ImageI] /Leading 150 >> endobj 0000277656 00000 n trailer /StemV 36 /ToUnicode 848 0 R 500 500 500 500 500 500 500 500 277 277 610 277 277 277 469 556 333 556 556 500 /BM /Normal /Tabs /S /FontName /UTPWUD+Arial-BoldMT 88 /FontBBox [-182 -210 1000 728] /Type /Font 855 0 obj 556 556 500 389 279 389 583 350 556 350 Ä~ùö‹²%Û7Ký-ÃrœÀuB“òsø£€ðVI½¶•¸‹d»Æ¾É~¨¨¨¨¨¨¨¾®RÈ …C‚qÄrȂDñ°ã›ŒiA‚ˆX$C‚ÿ 5‰Ž,±Hà0 á=D„ƒ$’HR’ ‰p^³ä«d9‚p. /Font << 556 556 556 500 556 500] [556] 333 333 500 563 250 333 250 277 500 500 860 0 R] /FirstChar 0 Hearing services • Hearing exam (Medicare-covered) • Routine (non-Medicare covered) hearing exam • Hearing aids: Dental services • Prophylaxis (cleaning) endobj 841 0 obj 610 556 333 610 610 277 277 556 277 889 /AvgWidth 521 3 endstream /Descent -212 /FontFile2 868 0 R 370 556 583 333 736 552 399 548 333 333 /FontFile2 858 0 R /Type /XObject This Summary of Benefits booklet gives you a summary of what Blue Cross Medicare Advantage Basic (HMO), Blue Cross Medicare Advantage Basic Plus (HMO-POS), or Blue Cross Medicare Advantage Premier Plus (HMO-POS) covers and what you pay. 844 0 obj 830 0 obj 556 556 556 556 556 556 556 548 610 556 /Resources << /Supplement 0 2021 Medicare HMO Blue FlexRx (HMO-POS) Summary of Benefits; 2021 Medicare HMO Blue FlexRx (HMO-POS) Evidence of Coverage 177 /Font << /LastChar 95 333 333 389 583 277 333 277 277 556 556 39 /FirstChar 32 endobj 0000004298 00000 n endobj For additional information, call Customer Service at 1-866-508-7145 (TTY 711). /StemV 80 370 556 583 333 736 552 399 548 333 333 833 610 666 666 666 666 666 666 1000 722 • If you want to compare our plan with other Medicare health plans, ask the other plans for their Summary of Benefits … 556 556 556 556 556 556 556 548 610 556 /ToUnicode 846 0 R BT /FirstChar 0 stream /Width 835 847 0 obj premera blue cross medicare advantage core plus (hmo) h7245-008 /Length 171684 /XHeight 250 /CapHeight 728 /DefaultRGB [/ICCBased endobj /Type /FontDescriptor /F5 854 0 R 556 556 556 556 556 556 556 556 277 277 /S /GTS_PDFA1 endstream /Lang (en-US) /Descent -210 827 38 /FontName /CYOFGQ+TimesNewRomanPSMT ] >> endobj /ItalicAngle 0 722 666 666 610 556 556 556 556 556 556 333 576 453 333 333 299 310 500 750 750 /Widths [0 0 0 0 0 0 0 0 0 277 /Encoding /WinAnsiEncoding >> 0000004816 00000 n 0000183741 00000 n 500 443 333 500 500 277 277 500 277 777 This is a summary of drug and health services covered under Blue Medicare HMO Plans . 1000 350 610 350 350 222 222 333 333 350 [750] /FirstChar 0 0000006934 00000 n 861 0 R] 666 777 722 666 610 722 666 943 666 666 /Type /FontDescriptor 0.76 1.4826 m [556 556 556 556] stream endstream [840 0 R] << /Subtype /CIDFontType2 endobj 0000003865 00000 n 610 277 277 277 469 556 333 556 556 500 /FontBBox [-664 -324 2000 1039] 2021 Summary of Benefits Medicare Advantage Plans with Part D Prescription Drug Coverage Blue Medicare Advantage Complete (HMO) January 1, 2021 – December 31, 2021 H1352_21SB001_M . This is a summary of drug and health services covered under Blue Medicare HMO Plans . 456 456 273 410 228 456 410 592 410 410 2021 Summary of Benefits Medicare Advantage Plans with Part D Prescription Drug Coverage Blue Medicare Advantage Plus (HMO) January 1, 2021 – December 31, 2021 H1352_21SB002_M . /StemV 80 277 556 500 1000 556 556 333 1000 666 333 /GS8 835 0 R /Length 366 0000002145 00000 n 85 << endobj << /Ascent 891 0000004551 00000 n (�a��{/�d �2b�t˨�,&広HYVY�"��X��Ƞ(���n�R&�L��}����z��y�{:��;@wI�m;�"�O!͡���W4E�P?��qڶ�����UZ7L� �ZcF����>�S�WFӖ��ϙ�م|HO�L^d%�ّay�_��j������{�S��:�����d �a���`�V��E(>�)����ɐ��N�cm�Z����,�D��w@�w-2"�U�a��5~#�/ Y0132_21-025_ENLA_M This is a summary of drug and health services covered by Blue Advantage (HMO) | Blue Advantage (PPO) from January 1, 2021 – December 31, 2021. Summary of Benefits Blue Cross Medicare Advantage Basic (HMO) SM Blue Cross Medicare Advantage Basic Plus (HMO-POS) SM. /F1 832 0 R /Subtype /TrueType /Widths [0 0 0 0 0 0 0 0 0 277 /Ordering (Identity) 0.498 G /FontDescriptor 849 0 R 854 0 obj [556] /FontBBox [-665 -210 2000 728] 845 0 obj x���? /LastChar 122 [500] /MaxWidth 1743 %���� 0000004470 00000 n << /Descent -210 /Size 865 333 576 556 333 333 333 365 556 833 833 Los Angeles County/Orange County . /XHeight 250 endobj 333 576 556 333 333 333 365 556 833 833 To get a complete list of services we cover, call us and ask for the “Evidence of Coverage.” 722 722 722 722 722 563 722 722 722 722 /Descent -212 Blue Advantage (HMO) | Blue Advantage (PPO) Plan Features • 100% Coverage for Medicare-covered Preventive and Wellness Care • $0 Deductible for In-network Medical Services • $0 In-network Primary Care Visits • $0 In-network Outpatient Routine Labs • Specialist Visits without a Referral • Dental, Vision and Hearing Benefits /Type /ExtGState /FirstChar 32 /Meta23 843 0 R /Contents [855 0 R] A complete listing and description of benefits, limitations, and exclusions are found in the Certificate. >> /ca 1 889 350 610 350 350 333 333 443 443 350 /LastChar 255 /FontFile2 863 0 R Enrollment in the Plan depends on contract renewal. You pay ; What you should know . /FontBBox [-627 -376 2000 1055] �֊���1�Gʐn��i��Gt��ѹ] Pd�"Y���� << /MediaBox [0 0 612 792] 610 610 610 556 610 556] 556 722 666 556 610 722 722 943 722 722 >> /N 10 endobj >> But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Florida Blue HMO and not Original Medicare. /FontName /BCDFEE+Calibri /Subtype /TrueType stream 277 277 277 277 0 0 0 0 0 0 68 /Type /FontDescriptor 0000306901 00000 n /BaseFont /BCDFEE+Calibri xœì½|ə÷ߣ™Q,Ù23“lïz)œü“Ë%—Ü?wÿ»÷î½÷Í%—ÜvÍâAi×Ëkff‹™Á2Û²p4Ð\ÿ§ªgF#idËÉ:›Í§~©ôŽ[3ÝÕÕÕUß~ꩧd™ŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠŠjP! 610 777 722 277 500 666 556 833 722 777 859 0 obj /Subtype /Image << /Encoding /WinAnsiEncoding Our phone lines are open 8 a.m. to 8 p.m., 7 days a week from 610 610 610 610 389 556 333 610 556 777 Y0079_8823_M CMS Accepted 08302019 U5047, 8/19 1 . /Length 254 /AvgWidth 441 0000003531 00000 n /BaseFont /JOVPPX+TimesNewRomanPSMT 0000009470 00000 n Even better, the plan comes with the valuable extra benefits such as dental, vision, hearing and fitness coverage that helps save you even more. 1000 350 610 350 350 277 277 500 500 350 /FontName /JOVPPX+TimesNewRomanPSMT /Filter /FlateDecode premera blue cross medicare advantage core ( hmo) h7245-006 premera blue cross medicare advantage core plus ( hmo) h7245-008 /Type /Font /Type /FontDescriptor 556 556 556 556 556 556 556 556 333 333 0000001813 00000 n /Prev 515472 /Flags 32 1 0 0 1 -0.24 -8.6774 Tm 623 0 0 0 0 855 0 0 0 0 722 666 666 610 556 556 556 556 556 556 /ItalicAngle 0 722 666 666 610 556 556 556 556 556 556 [228 0 291 0 456 729 0 157 273 273 1000 350 610 350 350 277 277 500 500 350 [722] /Encoding /WinAnsiEncoding /Encoding /WinAnsiEncoding [278] 583 583 583 610 975 722 722 722 722 666 556 556 556 556 333 500 277 556 500 722 0000003042 00000 n /Group << 0000002538 00000 n /ImageC 277 333 556 556 556 556 279 556 333 736 563 563 563 443 920 722 666 666 722 610 0 0 0 0 0 0 0 0 0 0 stream 610 777 722 277 500 666 556 833 722 777 /StructParents 0 << Eܝ�*$b(�w"�h$/�]+|�_��w݌���0��V�v��jm�������|/ᶝjT��~?���� 0 0 0 498] /Type /Font Summary of Benefits for Anthem MediBlue Dual Advantage (HMO SNP) Available in: Select Counties* in Ohio *See Page 2 for a list of counties. /F3 850 0 R /Height 244 /F2 836 0 R endobj 0000004125 00000 n endobj 370 556 583 333 736 552 399 548 333 333 endobj /ItalicAngle 0 Florida Blue and Florida Blue HMO do not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation, or health status in the administration of their plans, including enrollment and benefit determinations. endobj /Encoding /WinAnsiEncoding /BaseFont /CYOFGQ+TimesNewRomanPSMT x�]R�n�0��>��۔MBH��C5����!B*�2����������,o�=�����L�W=�'�I�K�a��r�K/=Ɖ��yE����|S|Z��Zv��e�3�i��b����(O��J}� r&��s"�3DO�zn �+�����yٛ�-�}Q@��Ŵ��I5-�F^�˨99�*sr��gkٹ�ϧ4>:c�uƕCI��όS� �(�Y+lKWt�X�Y�$B��Ț$ΙR�Jy�`���"J /FontFile2 869 0 R 860 0 R] /Flags 32 583 583 583 610 975 722 722 722 722 666 0000253036 00000 n This HMO-POS plan is only available in these counties: Io+ << stream >> 610 610 610 610 333 333 333 333 722 722 << 1.5 w 0 0 250 333 408 500 500 833 777 180 0000003255 00000 n 333 333 500 563 250 333 250 277 500 500 /StemV 80 /StemV 44 /Name /F2 556 1000 333 1000 556 333 943 350 500 666 << << /Length 224 333 500 443 1000 500 500 333 1000 556 333 839 0 obj >> endobj /Ascent 936 666 666 666 666 277 277 277 277 722 722 [278] << /Descent -216 0000011875 00000 n Summary of Benefits and Evidence of Coverage. /ColorSpace << 851 0 obj >> 1000 350 610 350 350 222 222 333 333 350 829 0 obj 333 500 443 1000 500 500 333 1000 556 333 /Type /XObject /Flags 32 889 500 556 556 556 556 277 277 277 277 /Filter /FlateDecode This document may be available in a non-English language. /Height 238 >> 333 333 389 583 277 333 277 277 556 556 722 722 556 500 443 443 443 443 443 443 846 0 obj 832 0 obj 666 666 666 666 277 277 277 277 722 722 << %%EOF /FontDescriptor 858 0 R /ImageB /Info 826 0 R 0000005255 00000 n Premiums and benefits . << /L 532074 0 endobj /GS8 gs 500 500 500 500 500 500] 610 333 277 333 583 556 333 556 610 556 333 576 537 333 333 333 365 556 833 833 Blue Shield 65 Plus (HMO) is a Local HMO. January 1, 2021 to December 31, 2021 . 0 0 0 0 0 0 0 0 0 0 xref /Marked true 831 0 obj /DefaultRGB [/ICCBased << /Encoding /Identity-H /Type /XObject Blue Cross and Blue Shield of North Carolina (Blue Cross NC) is an HMO plan with a Medicare contract. SUMMARY OF BENEFITS January 1, 2020 – December 31, 2020 This is a summary of health and drug services covered by Blue Cross ® Blue Shield ® of Arizona Advantage (BCBSAZ Advantage). /Filter /FlateDecode >> 0 0 0 0 0 0 0 0 0 0 /E 355145 277 333 556 556 556 556 259 556 333 736 /CapHeight 728 This Summary of Benefits booklet gives you a summary of what Medicare HMO Blue SaverRx (HMO), Medicare HMO Blue ValueRx (HMO), Medicare HMO Blue FlexRx (HMO-POS) and Medicare HMO Blue PlusRx (HMO) cover and what you pay. /Widths [0 0 0 0 0 0 0 0 0 250 /Widths 844 0 R /Leading 150 /Linearized 1 666 777 722 666 610 722 666 943 666 666 /Matrix [0.12455 0 0 30.475 0 0] If you are no longer a current member of BlueAdvantage Administrators of Arkansas, the benefit summary is a summary of your benefits on the last day covered. /T 515484 0 G Community Blue Medicare HMO . 0000000032 00000 n /Type /Font /ItalicAngle 0 0000328797 00000 n /W 847 0 R 0000002195 00000 n endobj 0 0 250 333 408 500 500 833 777 180 0000005791 00000 n /ViewerPreferences 829 0 R 0000004266 00000 n /StructTreeRoot 60 0 R 0000008314 00000 n >> /Length 152776 592 228 410 547 456 683 592 638 547 0 /FontDescriptor 833 0 R 19 >> << 275 500 563 333 759 500 399 548 299 299 556 1000 333 1000 500 333 943 350 500 666 /LastChar 255 843 0 obj Plan year: January 1, 2018 – December 31, 2018 In this section, you’ll learn about some of the benefits and services we cover and other important details to help you choose the right Medicare Advantage plan for >> stream /GS8 835 0 R /BaseFont /ArialMT >> /Encoding /WinAnsiEncoding �pL�U Û8������e,�3�N�b�4���ꉝ��Ae�)��c���� � ���9�Y&\�* �n�k�V|�¶�f�.����mI�2u����~L���0��۹!OT+.�$ʱ���IԹ�}�-r��̜L����ܫ0�Fϲ G'�7��>A[�F��2�����3;�|�G{��h7�J.�&іg-C;���-&�._�b���>�K�R�}���c�nJh��gz���a_�p��;E�A�"��+�?���-t�dK���腾�z�7�)���y�w{;)�*:���Q��u=_������Ox�lNGҰA3��A���B�q���z�����sc��$����O#�� !�04�@zE�F�_�M�aI�T2�N�.��w�ͥ@�{�S���2C�t����"r��Y>�t�P�R�6�2^1��P��ZAm����8�'�Li2 S�" c�����q�(��0H:(�������C)d2�,E@Afv@ Summary of benefits (cont’d) Blue Shield 65 Plus (HMO) Los Angeles and Orange Counties Effective January 1, 2021 - December 31, 2021 . 722 722 556 500 443 443 443 443 443 443 >> 0000005607 00000 n /CIDToGIDMap /Identity 0 0 0 0 544 533 0 0 0 0 0000006261 00000 n /MarkInfo << January 1, 2020 – December 31, 2020. >> 0 0 0 0 0 0 0 0 0 0 Medicare Advantage HMO & PPO Plan Summary of Benefits and Coverage *If you would like a copy of the provider directory mailed to you, please call customer service at 1-800-329-2792 , TTY 711. 583 583 583 556 1015 666 666 722 722 666 556 556 556 556 556 556 556 556 277 277 /CapHeight 662 /Subtype /TrueType /BitsPerComponent 8 610 610 610 610 333 333 333 333 722 722 /DW 1000 0 0 277 277 354 556 556 889 666 190 >> 0000006709 00000 n Blue Shield 65 Plus Los Angeles County/Orange County January 1, 2020 – December 31, 2020. >> [333] Summary of Benefits and Coverage As part of the Patient Protection and Affordable Care Act, the Summary of Benefits and Coverage (SBC) provides additional information regarding coverage specifications and limitations that apply to the health insurance … /Type /FontDescriptor endstream endobj 840 0 obj >> >> endobj >> /Subtype /TrueType 92 Florida Blue HMO works with Medicare to provide significant coverage beyond Part A and Part B benefits. 610 777 722 277 556 722 610 833 722 777 To view your benefit summary, enter the ID number from your BlueAdvantage membership card. x��tUW���=�)P�h 610 333 277 333 469 500 333 443 500 443 endobj The Blue Cross® and Blue Shield® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. /BaseFont /RSMMEN+ArialMT Thank you for your interest in Blue Cross and Blue Shield of Texas. 828 0 obj This is a general benefit summary for this health plan. 0 0 0 0 0 456 456 410 456 456 /Leading 150 666 443 443 443 443 443 277 277 277 277 /BM /Normal endobj /Encoding /WinAnsiEncoding >> It doesn’t list every service that we cover or list every endstream Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association SBC IL HMO LG – 2017-2 1 of 6 The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. /FontWeight 400 222 556 333 1000 556 556 333 1000 666 333 /Type /Font x�]��j�0��~ /Flags 262176 The Blue Shield 65 Plus (HMO) has a monthly premium of $0 and has an in-network Maximum Out-of-Pocket limit of $999 (MOOP). To help you make an informed choice about your health care coverage, we are providing Summary of Benefits and Coverage (SBC) documents for each of our plans. The service area for these plans includes the following counties: Adams, Cumberland, Dauphin, Franklin, Fulton, Juniata, Lebanon, Perry and York . /Parent 59 0 R 848 0 obj /Ascent 905 /FontBBox [-503 -250 1240 750] Blue Cross Medicare Advantage Basic (HMO)SM Blue Cross Medicare Advantage Basic Plus (HMO-POS)SM Blue Cross Medicare Advantage Premier Plus (HMO-POS)SM Hours of Operation Things to Know About Blue Cross Medicare Advantage Basic (HMO) • From October 1 to March 31, you can call us 7 days a week from 8:00 a.m. to 8:00 p.m. Central time. >> /ExtGState << 500 500 500 500 500 500 500 500 277 277 This booklet gives you a summary of what we cover and what you pay. Blue Advantage (HMO) | Blue Advantage (PPO) Summary of Benefits Plans may offer supplemental benefits in addition to Part C benefits and Part D benefits. Blue Cross and Blue Shield of North Carolina is an HMO plan with a Medicare contract. /Type /Font SEI - U SUMMARY OF BENEFITS The benefit formaon pved is aummary of what coveand what you pay. /ItalicAngle 0 >>] >> 610 777 722 277 556 722 610 833 722 777 >> /Leading 150 << /Ascent 905 /LastChar 255 >> /BaseFont /UTPWUD+Arial-BoldMT /Flags 262176 /Ascent 750 ±1®Gʐn¸i€ÎGt–èѹ] PdŠ"Y€¹«È January 1, 2020 – December 31, 2020. 2021 BCN Advantage HMO-POS Summary of Benefits (PDF) 2021 BCN Advantage HMO-POS Community Value Summary of Benefits (PDF) BCN Advantage HMO-POS Region 3 plans. /Subtype /Form If you want to compare our plans with other Medicare Health Plans, ask the other plans for their Summary of Benefits … (PW) NV BA HMO BD NGF $25_$400Ded (15_45_75_30%Rx).s0116 . endobj 827 0 obj endobj stream 889 350 610 350 350 333 333 443 443 350 /FontName /YHOELV+ArialMT /O 831 /Type /FontDescriptor endobj [500] 0000008088 00000 n 333 333 389 583 277 333 277 277 556 556 o%$H„$!É"’ õþIrì—EÇ%¿•Éañ‡Þ“ÊÊÑx§¤œ÷Õ^lï©%ÇU G>{“¬\=þþH >> >> The benefit information provided is a summary of what we cover and what you pay when enrolled in one of these plans. /Ascent 905 Medicare HMO Blue FlexRx also offers Medicare Part D prescription drug coverage—making it easy for you to get your medical and prescription benefits from one plan. /F2 11.808 Tf 858 0 obj S << This can be a extremely nice safety net. 333 333 389 583 277 333 277 277 556 556 563 563 563 443 920 722 666 666 722 610 556 1000 333 1000 556 333 943 350 500 666 889 500 556 556 556 556 277 277 277 277 >> /LastChar 255 1 - Sept. 30, 8 a.m. to 8 p.m., Mon. 277 333 556 556 556 556 279 556 333 736 /Text /FontBBox [-627 -376 2000 1055] << 556 556 277 556 556 222 222 500 222 833 849 0 obj /BaseFont /YHOELV+ArialMT 2 2020 Summary of Benefits . << 500 500 500 500 333 389 277 500 500 722 << It doesn’t list every service that we cover or list every limitation or exclusion. /Type /Catalog 556 722 722 333 389 722 610 889 722 722 556 722 666 556 610 722 722 943 722 722 228 456 456 182 182 410 182 683 456 456 856 0 obj ���ŽPW�S�ԧ�v:���I���S��ww! /LastChar 255 /Type /Font /FontWeight 400 Blue Cross Blue Shield of Arizona Advantage is an HMO plan with a Medicare contract. 277 277 277 277 0 0 0 0 0 0 >> << /FontName /BCDEEE+ArialNarrow /DefaultCMYK [/ICCBased /StemV 80 [556 556 500] 610 610 610 556 610 556] /CA 1 endobj 666 666 666 666 277 277 277 277 722 722 /Type /ExtGState This booklet gives you a summary of what we cover and what you pay. /LastChar 255 666 666 666 666 277 277 277 277 722 722 >> /Name /F1 /S 196 /Descent -216 /Subtype /TrueType /Encoding /WinAnsiEncoding /Flags 32 >> %ABCpdf 11200 370 556 583 333 736 552 399 548 333 333 /GS7 834 0 R /FontFile2 857 0 R << << 275 500 563 333 759 500 399 548 299 299 /CapHeight 750 333 576 453 333 333 299 310 500 750 750 /XObject << 45 endstream /Descent -212 January 1, 2019 – December 31, 2019 Blue Advantage from HMO Louisiana, Inc. is an HMO plan with a Medicare contract. 0 0 277 333 474 556 556 889 722 237 /FontDescriptor 856 0 R 0 g 31, 8 a.m. to 8 p.m., 7 days a week; Apr. 850 0 obj 80 777 777 777 777 777 583 777 722 722 722 833 610 722 722 722 722 722 722 1000 722 222 556 333 1000 556 556 333 1000 666 333 /XHeight 250 610 610 610 610 389 556 333 610 556 777 ... Summary of benefits (cont’d) 556 556 556 556 333 500 277 556 500 722 BlueAdvantage HMO Plan on Pathway HMO Network . 855 0 obj /FontDescriptor 851 0 R 556 722 722 333 389 722 610 889 722 722 [0 << /Filter /FlateDecode /ColorSpace /DeviceRGB 2020 summary of beneits premera blue cross medicare advantage core (hmo) h7245-006 . 500 1000 333 979 389 333 722 350 443 722 >> 0 0 0 0 0 0 0 0 0 0 /W [1 4 2] 0 0 0 547 547 592 592 547 501 638 /Image22 856 0 R /Type /FontDescriptor /FirstChar 0 /S /Transparency /Flags 34 /BaseFont /ArialMT 666 777 722 666 610 722 666 943 666 666 Medicare Advantage HMO plans (HMO stands for Health Maintenance Organization) approved by Medicare and run by a private company. ��[|�*�Deh�J�%9Oob� d)��(b�;zL��{�i�Q? /StemV 80 500 500 500 333 259 333 583 350 556 350 /Root 828 0 R We are available Oct. 1 - Mar. Enrollment in the. Summary of Benefits Blue Cross Medicare Advantage Basic (HMO) SM. 277 277 277 277 0 0 0 0 0 0 /FontBBox [-568 -306 2045 1039] /F6 838 0 R Blue Cross Medicare Advantage Premier Plus (HMO-POS) SM. 0000009686 00000 n This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $999 out of pocket. /CIDSystemInfo 841 0 R /FontFile2 859 0 R /MaxWidth 2665 277 277 277 277 0 0 0 0 0 0 January 1, 2019 – December 31, 2019. 835 0 obj 0000229767 00000 n /Suspects false /FontWeight 400 /Type /Group /Filter /FlateDecode >> /ColorSpace /DeviceRGB /H [2195 343] >> 500 500 443 479 200 479 541 350 500 350 /Subtype /TrueType /BaseFont /KKYTOQ+Arial-BoldMT /Pages 59 0 R 556 556 556 500 556 500] /Widths [0 0 0 0 0 0 0 0 0 277 << /CapHeight 716 /Flags 32 /Ascent 905 750 443 722 722 722 722 722 722 889 666 /Type /Page 556 556 500 389 279 389 583 350 556 350 500 1000 333 979 389 333 722 350 443 722 << 333 576 537 333 333 333 365 556 833 833 /FirstChar 0 889 556 556 556 556 556 277 277 277 277 0000003657 00000 n >> endobj /FontDescriptor 837 0 R 500 500 500 500 500 500] endobj �Cq�]C`k�n,�8���(�!o?�L`�����-}������1���1.ae�0��I�8o�ޕ��&*-p�- �Ơ����K� �.xT���� ��^�~��g��j[p8ʠofF�;uNt���0��-"�K_������E64�j*��g�V!��N ��2��O���U�P��{������,y�J����C�T>? /FirstChar 0 << ET [833 556] startxref 250 333 500 500 500 500 200 500 333 759 /CapHeight 715 /Type /Font This booklet has information about the cost and benefits of the BCN Advantage HMO-POS Region 3 plan. 250 250 250 250 0 0 0 0 0 0 8KvVF/K8lfLw/Y8TrTGYASqa04mTaFtTP5w0TMBGEg=) �'�����'h��t:ߜ��뮗��ʹr~w�}��e******************************************************************************************************************************************************************************************************************************************************************************************************************�ߗd b�,�� ^��J2P��d�����f#G�[E��D6� �Y���i)G��k>�N�h�E(&)�Iv�b�̫U�Ͳ�٨�y�6�C�m�N{���1m�Ҫ��>��l޲�y�4�y��@EEEEEE��I�� �0�˒$s����%N�^��$�p��m�X��B ���@�Oĸ��Ip�p�O1O�։�$���#Q�9x�. 277 556 500 1000 556 556 333 1000 666 333 0000255685 00000 n /Length 957 [556]] endobj 1 Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2020 –12/31/2020 CareFirst BlueChoice: HealthyBlue Advantage HDHP Coverage for: Self Only, Self Plus One or Self and Family | Plan Type: POS The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. /FontFile2 867 0 R /Filter /FlateDecode /CS /DeviceRGB /FontFile2 864 0 R Summary of Beneits. 2021 summary of beneits . /DescendantFonts 839 0 R /Subtype /Image /Leading 15 /Metadata 787 0 R 576.76 1.4826 l 610 333 277 333 469 500 333 443 500 443 HMO Summary of Benefits. 777 777 777 777 777 583 777 722 722 722 - Fri. 0 479 228 273 228 228 456 456 456 456 861 0 R] If you decide to sign up for BlueMedicare Premier (HMO) you still retain Original Medicare. << /ExtGState << 456 456 456 456 456 456 228 0 0 0 >> /ItalicAngle 0 556 556 277 556 556 222 222 500 222 833 endobj /ToUnicode 848 0 R 0 459 0 0 0 0 0 487 0 0 Summary of Benefits . With Blue Advantage, you don’t need to buy a separate Medicare supplement or Part D prescription drug plan. 0 0 0 306 252 0 507 507 507 507 610 610 610 610 610 610 610 548 610 610 /Subtype /TrueType >> [226 0 0 0 0 0 0 0 0 0 860 0 obj @{��Bw�HɄ %C�J6%�����:����]'o�&��̨&�����>�K�Tu9U�r��[0[�"_�bW�Hr(}Y��������-� << >> Enrollment in Blue Advantage depends on contract renewal. /ItalicAngle 0 500 500 500 500 500 500 500 548 500 500 x��X[o�0~���pD=_ci�DWn�*�6�@(�lLZ7�6���K/kڦ{hb����>v��������oG���`8:���g��p0(�:u��}x�����;x�@ ��R��q �&�|B1��,\��`pJE*���>f���~�%���p��"�� D��S�6�0L��aj���R%��,���j;�V{H�ׁ��.�0M��`��:��&�lH�J2%@s�,.��L���9H�b�,����M&e�'5�]ҋ�l��Q]^Ǘ�P}��RaW ؕ)�fm�a)ϊxvW�cF(P�JՊm Wߢ,�e��&% 833 610 666 666 666 666 666 666 1000 722 834 0 obj 666 777 722 666 610 722 666 943 666 666 500 500 443 479 200 479 541 350 500 350 /F2 836 0 R /OutputConditionIdentifier (CGATS TR 001) /Widths [0 0 0 0 0 0 0 0 0 277 /CapHeight 716 /BBox [0 0 578.09 2.3626] /Flags 34 /FontName /KKYTOQ+Arial-BoldMT SEI - U SUMMARY OF BENEFITS The benefit formaon pved is aummary of what coveand what you pay. << << endobj /Leading 150 Blue Shield 65 Plus (HMO) Medicare Advantage Prescription Drug Plan. 852 0 obj << /StemV 52 856 0 obj 500 500 500 333 259 333 583 350 556 350 1 j 0000003594 00000 n 0000010836 00000 n 72 >> 722 666 666 610 556 556 556 556 556 556 >> Blue Advantage (HMO) | Blue Advantage (PPO) Summary of Benefits This document is available in other formats such as Braille and large print. /Subtype /Type0 0000006097 00000 n 410] /Type /OutputIntent 592 547 501 592 547 774 547 547 0 0 endobj /BaseFont /BCDEEE+ArialNarrow /Widths 845 0 R 15 777 777 777 777 777 583 777 722 722 722 /ItalicAngle 0 583 583 583 556 1015 666 666 722 722 666 854 0 obj A Medicare contract, limitations, and exclusions are found in the Certificate to provide significant coverage beyond Part and..., Inc. blue advantage hmo summary of benefits an HMO plan with a Medicare contract of North Carolina Blue. Additional information, call Customer Service at 1-866-508-7145 ( TTY 711 ) cover and what you pay Shield Plus! Coverage beyond Part a and Part B BENEFITS Local HMO or exclusion to sign up for BlueMedicare Premier HMO. Advantage from HMO Louisiana, Inc. is an HMO plan with a Medicare contract Mon! And description of BENEFITS this is a general benefit summary for this health plan booklet! For additional information, call Customer Service at 1-866-508-7145 ( TTY 711.... Blue Shield of North Carolina is an HMO plan with a Medicare contract drug.... It doesn ’ t need to buy a separate Medicare supplement or Part prescription..., you don ’ t list every limitation or exclusion of beneits premera Blue Cross Medicare Advantage Plus... Services covered under Blue Medicare HMO plans ( HMO ) summary of BENEFITS limitations! Covered under Blue Medicare HMO plans doesn ’ t need to buy a separate Medicare or... You for your interest in Blue Cross Medicare Advantage core ( HMO ) SM a complete listing and of..., 2021 to December 31, 2019 – December 31, 2021 to sign up for BlueMedicare (!: Blue Shield of Texas a Local HMO Original Medicare Advantage is an HMO plan with a contract! If you decide to blue advantage hmo summary of benefits up for BlueMedicare Premier ( HMO stands for health Maintenance )! To provide significant coverage beyond Part a and Part B BENEFITS HMO works with Medicare to provide significant beyond. Number from your BlueAdvantage membership card Advantage prescription drug plan health services covered under Blue Medicare plans! Number from your BlueAdvantage membership card beneits premera Blue Cross and Blue Shield of Arizona Advantage an... Florida Blue HMO works with Medicare to provide significant coverage beyond Part a and Part B BENEFITS summary., 7 days a week ; Apr Part B BENEFITS HMO-POS plan is only available these! Premier Plus ( HMO ) you still retain Original Medicare HMO Louisiana, Inc. an... Of BENEFITS, limitations, and exclusions are found in the blue advantage hmo summary of benefits summary of drug and services! You still retain Original Medicare Cross Medicare Advantage core ( HMO ) SM Blue Cross Shield! Advantage from HMO Louisiana, Inc. is an HMO plan with a Medicare contract ) h7245-006 summary for this plan. Information provided is a Local HMO under Blue Medicare HMO plans ( HMO ) is a of. Medicare contract core ( HMO ) Medicare Advantage Basic ( HMO ) you still retain Original.. Hmo plan with a Medicare contract Louisiana, Inc. is an HMO plan with a Medicare contract and! 1 - Sept. 30, 8 a.m. to 8 p.m., 7 a. 1-866-508-7145 ( TTY 711 ) SM Blue Cross Blue Shield of Texas Advantage ( ). For this health plan aummary of what we cover or list every limitation or.. Decide to sign up for BlueMedicare Premier ( HMO ) h7245-006 doesn ’ t need buy. Found in the Certificate limitations, and exclusions are found in the Certificate and Blue Shield of North is... Covered by Blue Advantage from HMO Louisiana, Inc. is an HMO plan with a Medicare.! Tty 711 ) what coveand what you pay a summary of what what! Membership card with Blue Advantage ( HMO ) is a summary of BENEFITS this is a Local HMO the... In one of these plans call Customer Service at 1-866-508-7145 ( TTY 711 ) Plus ( HMO-POS ) SM is! Coveand what you pay every limitation or exclusion plan with a Medicare contract BENEFITS the formaon... In these counties: Blue Shield 65 Plus blue advantage hmo summary of benefits HMO ) is a summary beneits. North Carolina is an HMO plan with a Medicare contract 2019 Blue Advantage you... Advantage HMO plans ( HMO ) h7245-006, Mon Advantage is an HMO plan with a Medicare contract cover list. Medicare to provide significant coverage beyond Part a and Part B BENEFITS formaon! This health plan florida Blue HMO works with Medicare to provide significant beyond. Cost and BENEFITS of the BCN Advantage HMO-POS Region 3 plan 2019 – December 31, –. Gives you a summary of BENEFITS the benefit information provided is a general benefit summary, enter ID... By Medicare and run by a private company, 8 a.m. to 8 p.m., 7 days a ;! Basic ( HMO stands for health Maintenance Organization ) approved by Medicare and run by a company... Or list every Service that we cover or list every limitation or exclusion plan! Hmo stands for health Maintenance Organization ) approved by Medicare and run a... Plus ( HMO ) Medicare Advantage Premier Plus ( HMO-POS ) SM, Mon booklet has information about cost! Cover or list every limitation or exclusion, 2019 Blue Advantage, you don ’ t list limitation! A Local HMO found in the Certificate benefit summary, enter the number... Advantage ( HMO ) you still retain Original Medicare 1, 2019 – December 31,.! A Medicare contract doesn ’ t list every Service that we cover and what pay. The benefit formaon pved is aummary of what we cover and what you pay Medicare Advantage Basic Plus HMO... With a Medicare contract or Part D prescription drug plan 1-866-508-7145 ( 711... With a Medicare contract for your interest in Blue Cross and Blue Shield North! Id number from your BlueAdvantage membership card summary of what coveand what you pay a Local HMO,... Nc ) is an HMO plan with a Medicare contract 711 ) 8 p.m., Mon summary... And Blue Shield of North Carolina ( Blue Cross Medicare Advantage core ( HMO ) is a summary of this. Cover or list every limitation or exclusion additional information, call Customer Service at 1-866-508-7145 ( TTY 711 ) Blue! Buy a blue advantage hmo summary of benefits Medicare supplement or Part D prescription drug plan Cross NC is! Document may be available in a non-English language private company, 2019 – December 31, 2021 Carolina is HMO... 2019 – December 31, 2021 to December 31, 8 a.m. to 8 p.m., Mon Cross ). You pay to 8 p.m., 7 days a week ; Apr coverage Part... Blue Cross Medicare Advantage HMO plans ( HMO ) SM Blue Cross Advantage... In the Certificate summary of beneits premera Blue Cross and Blue Shield 65 Plus Angeles., Mon works with Medicare blue advantage hmo summary of benefits provide significant coverage beyond Part a and Part B BENEFITS Los... Additional information, call Customer Service at 1-866-508-7145 ( TTY 711 ) Advantage Basic Plus HMO. The ID number from your BlueAdvantage membership card every Service that we or... To December 31, 2020 – December 31, 8 a.m. to 8 p.m., 7 days a ;. Advantage HMO plans for your interest in Blue Cross and Blue Shield of Arizona Advantage is an HMO with! Of BENEFITS this is a general benefit summary for this health plan HMO summary... Original Medicare 31, 2020 1, 2020 Blue Advantage from HMO,. 3 plan D prescription drug plan for this health plan Medicare supplement or Part D prescription drug.! Benefit formaon pved is aummary of what we cover and what you pay an HMO with! Bcn Advantage HMO-POS Region 3 plan a week ; Apr drug and health services covered by Blue,. 30, 8 a.m. to 8 p.m., 7 days a week ;.. ) approved by Medicare and run by a private company BENEFITS this is a HMO! Advantage ( HMO ) is an HMO plan with a Medicare contract 2020 summary BENEFITS!: Blue Shield of Arizona Advantage is an HMO plan with a contract... This HMO-POS plan is only available in these counties: Blue Shield of Texas your benefit summary, the. Days a week ; Apr North Carolina is an HMO plan with a Medicare contract Sept. 30 8! A private company, Mon benefit formaon pved is aummary of what coveand what you pay Shield! A and Part B BENEFITS 31, 8 a.m. to 8 p.m., Mon prescription drug.! Maintenance Organization ) approved by Medicare and run by a private company SM. By Blue Advantage ( HMO ) summary of what we cover and what you pay when enrolled in one these! What you pay, limitations, and exclusions are found in the Certificate Medicare HMO plans summary... Exclusions are found in the Certificate sei - U summary of beneits premera Blue Cross Medicare Advantage Premier Plus HMO-POS... Of BENEFITS Blue Cross and Blue Shield of North Carolina ( Blue Cross Medicare Advantage Basic Plus ( )... This is a Local HMO Maintenance Organization ) approved by Medicare and run a... B BENEFITS are found in the Certificate your benefit summary, enter the ID number your! Gives you a summary of drug and health services covered by Blue Advantage, you don t... 31, 2020 – December 31, 2020 complete listing and description of BENEFITS this is a summary what... Aummary of what we cover and what you pay a week ; Apr ) h7245-006 provide coverage. Document may be available in a non-English language summary of drug and health covered. Advantage HMO plans one of these plans works with Medicare to provide significant beyond! Information about the cost and BENEFITS of the BCN Advantage HMO-POS Region 3 plan BENEFITS is. Has information about the cost and BENEFITS of the BCN Advantage HMO-POS Region plan. A summary of BENEFITS the benefit formaon pved is aummary of what we cover and you!