2020 MEDICARE ADVANTAGE PLANS

39831_Day_04_Shot_01_Row_Boat_1_1160.jpg

Visit a Medicare Center Today

Additional information1. You must receive all care from plan providers,

with limited exceptions.

2. If you see a participating BlueCard® provider outside of the service area, you pay your in-network copay. If you receive care from out-of-network providers, your cost may be higher.

3. Dental premium is in addition to plan and Part B premium.

4. Preventive cleanings do not include periodontal cleanings (commonly referred to by dentists as deep cleaning or scaling and root planing).

5. $25 allowance per quarter up to $100 annually. OTC drugs are obtained through online order or mail-in order from catalog and delivered to the member's home.

6. In order for your service to be in-network you must see an EyeMed participating provider.

7. Our plans cover one routine hearing exam per year with a TruHearing® provider. Please call TruHearing to verify your benefi t and schedule a hearing exam. Coverage is for select models only.

8. Annual wellness visit, breast cancer screening, and colon cancer screening are covered by any doctor in our network as part of your member benefi ts. If other services are performed by your doctor at the same visit, you may have a higher copay.

About usBlueShield of Northeastern New York (BSNENY) is a Medicare Advantage plan with a Medicare contract and enrollment depends on contract renewal. BSNENY is a division of HealthNow New York Inc., an independent licensee of the Blue Cross and Blue Shield Association.

Individuals must have both Parts A and B to enroll in a Medicare Advantage plan. Individuals may enroll in a plan only during specifi c times of the year. There are additional enrollment guidelines. Contact BSNENY for more information. This information is not a complete description of benefi ts. Call 1-877-258-7453 (TTY 711) for more information.

SilverSneakers® is a registered trademark of Tivity Health, Inc. Tivity Health is an independent company that administers the SilverSneakers gym benefi t. Doctor On Demand® is a separate company that provides telemedicine services to BSNENY members. TruHearing® is a registered trademark of TruHearing, Inc. TruHearing is an independent company that administers the hearing-aid benefi t. EyeMed®, an independent company, administers vision benefi ts on behalf of BSNENY. Express Scripts® is a separate company. Other pharmacies/physicians/providers are available in our network. Out-of-network/noncontracted providers are under no obligation to treat BSNENY members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.

BSNENY complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-833-735-4515.

(TTY 711). 注意：如果您使用繁體中文，您可以免費獲得語言 援助服務。請致電 1-833-735-4515 (TTY 711).

Y0086_MRK2679_Mbsneny.com/medicare

Questions about choosing the right Medicare Advantage plan for your needs? Meet one-on-one with our experienced staff at one of our new Medicare Centers! Visit bsneny.com/medicarecenters for more information.

Guilderland1704 Western Avenue(Price Chopper Plaza)

Malta13 Kendall Way(Shops of Malta)

With one of the most robust health care networks in the region, BlueShield Medicare Advantage

connects you to the providers and hospitals you trust the most. When you choose BlueShield,

you carry the confi dence of a card accepted at all Capital Region hospitals and the leading

health systems and medical practices, including:

Get More with BlueShield

You’re covered — wherever life takes you Ring the bell for Blue Concierge

Our exclusive Blue Concierge

service connects you with

a dedicated, local team ready to help

you get the most from your Medicare

coverage. Our Blue Concierge team

can help you understand your benefi ts

and how they work, fi nd providers,

and even help you schedule appointments

with doctors and specialists.

All of our plans provide worldwide

emergency and urgent care, giving

you the peace of mind that comes with

knowing you’re covered at home or on the go.

• $65 copay for urgent care

• $90 copay for emergency care

For convenient nonemergency care, you can

also see a board-certifi ed doctor with

telemedicine hosted by Doctor On Demand®.

• $0 copay for virtual visits.

• Virtual visits take place using your mobile device or computer with a front-facing camera.

• Doctors are available for appointments 24/7.

• Albany Medical Center

• CapitalCare Medical Group

• Community Care Physicians, P.C.

• Ellis Hospital

• Glens Falls Hospital

• Hudson Headwaters

• Irongate

• Samaritan Hospital

• Saratoga Hospital

• St. Peter’s Health Partners

14749_08_19_NENY F11015-A

FEARLESS ISTHE PROTECTION OF THE SHIELD

NEW

VISIT A MEDICARE CENTER TODAY

Premium3 Diagnostic and restorative service cost

Annual max allowance

Basic $13 50% coinsurance $500

Enhanced $24 50% coinsurance $1,000

Our supplemental dental plans provide enhanced dental coverage for an affordable monthly premium.

Optional supplemental dental plans

• Call to enroll over the phone.• Meet one-on-one with a consultant

who can help you fill out and submit an application.

• Fill out an application and mail it in. • Visit bsneny.com/enrollmedicare

to complete the application online.

October 1 – December 31 8 a.m. to 8 p.m., 7 days a weekJanuary 1 – September 30 8 a.m. to 8 p.m., Monday – Friday

How to Enroll Contact UsWe’re here to help. Call us at 1-877-258-7453 (TTY 711) or email SalesCenterNENY@bsneny.com to get in touch.

Preventive dentalPreventive dental coverage includes reimbursement for up to two cleanings, two exams, and one set of X-rays annually.4 This benefit requires no network and can be used at any dental provider.

• $15 copay per service

Over-the-counter (OTC)Up to $100 annual allowance for over-the-counter drugs and supplies with convenient home delivery. Choose from hundreds of items from an online shop or catalog.5

Vision 6

• $100 annual allowance on frames, lenses, and contacts through an EyeMed provider

• $25 annual routine eye exam through an EyeMed provider

HearingSave thousands on hearing aids through TruHearing.

• $699 or $999 per unit 7

• $45 annual routine hearing exam through a TruHearing provider

Fitness SilverSneakers no-cost fitness benefit with access to 16,000+ fitness locations nationwide.

Rewards for preventive servicesEarn up to $60 for annual preventive services including annual wellness visit, colon cancer screening, and breast cancer screening.8 Up to $60 total or one $20 Prepaid Card per service.

Low- or no-cost vaccines• $0 copay for preventive vaccines including flu, pneumonia, and hepatitis

• Coverage for shingles vaccine with Tier 1 copay (copay varies by plan)

Part B diabetic monitoring supplies• $0 Part B diabetic monitoring supplies including lancets, glucose monitors, and test strips

• On all 2020 Medicare Advantage plans

• $0 copay for a 90-day supply of Tier 1 preferred generic medications delivered for free through Express Scripts® mail order

PremiumPremium with EPIC subsidy*

Primary care

doctorSpecialist Drug

deductibles†

Part D prescriptions Tier 1/2/3/4/5 __________________

Preferred pharmacy Standard pharmacy

Inpatient hospital care Ambulance

X-rays/ advanced radiology

(MRI,CAT,PET)

Ambulatory surgery/

outpatient hospital

Laboratoryservices

Physical therapy/ occupational

therapy(PT/OT)

Freedom Value (HMO)1

$0 $0 $0 $40

$0 Tiers 1–2;

$350Tiers 3–5

$3/$10/$42/$94/26%$9/$15/$47/$100/26%

$370 per day for days 1–5

$1,850 OOP max per year

$300 $50/$200 $450/$550 $10 $40

Freedom Plus

(HMO)1$55

As low as

$18.45$10 $35

$0 Tiers 1–2;

$295Tiers 3–5

$2/$8/$42/$94/27%$7/$13/$47/$100/27%

$325 per day for days 1–4

$1,300 OOP max per year

$300 $50/$200 $275/$375 $10 $40

Freedom Premier(HMO)1

$110As low

as $73.45

$5 $30

$0 Tiers 1–2;

$100Tiers 3–5

$0/$5/$42/$94/31%$5/$10/$47/$100/31%

$295 per day for days 1–4

$1,180 OOP max per year

$250 $50/$200 $275/$375 $5 $40

Senior Blue 652(HMO)1

$139As low

as $102.45

$0 $26 $0$4/$10/$42/$94/33%$9/$15/$47/$100/33%

$225 per day for days 1–7

$1,575 OOP max per year

$200 $50/$150 $200/$300 $5 $15

Forever Blue 770(PPO)2

$197As low

as $160.45

$10 $22 $0$2/$12/$42/$94/33%$7/$17/$47/$100/33%

$205 per day for days 1–7

$1,435 OOP max per year

$200 $40/$150 $175/$275 $5 $25

HMO

PPO

2020 MEDICARE ADVANTAGE PLANS All plans are Medicare-approved. NEW BLUE TOTAL HEALTH PACKAGE

Rx

$0 Tier 1 generics with convenient home delivery

Our Blue Total Health package provides you with the additional benefits and preventive services you want and need to help you live a healthy lifestyle. This exclusive benefits package includes:

† Drug deductibles displayed are for non-LIS (Low-Income Subsidy) members. LIS members may pay a lower drug deductible.

Unless otherwise noted, costs shown are for services received in-network.*Enrollees who meet income eligibility requirements may qualify for Extra Help from Medicare.

NEW

Unless otherwise noted, costs shown are for services received in-network.