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2011 benefits, copays and premiums

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Select your county to view a summary of 2011 BCN Advantage HMO-POS℠ benefits, premiums and copayments. The benefits provided are subject to plan terms and conditions. For more information or to obtain a complete list of benefits, call us.

Please select your county for monthly premiums:



Benefit for Medicare-covered services Option 1 BASIC Option 2 Option 3
Out-of-pocket maximum for Medicare-covered medical services $3,400 $4,000 $3,200 $3,000
The plan covers 100% after the out-of-pocket maximums are reached
Out-of-pocket maximum for durable medical equipment and prosthetic and orthotic devices $1,000 $1,000 $1,000 $1,000
Deductible $150 $200 $100 $0
Inpatient hospital care Days 1-5: $175 per day Days 6+: $0 copay Days 1-5: $225 per day Days 6+: $0 copay Days 1-5: $125 per day Days 6+: $0 copay Days 1-5: $80 per day Days 6+: $0 copay
Skilled nursing facility (in a Medicare-certified skilled nursing facility) Days 1-20: $0 copay per day Days 21-100: $130 copay per day Days 1-20: $0 copay per day Days 21-100: $130 copay per day Days 1-20: $0 copay per day Days 21-100: $130 copay per day Days 1-20: $0 copay per day Days 21-100: $130 copay per day
Outpatient services $35 to $125 copay $35 to 125 copay $30 to $100 copay $25 to $75 copay
Office visits: primary care physicians $20 copay $25 copay $15 copay $10 copay
Office visits: specialists $35 copay $40 copay $30 copay $20 copay
Outpatient surgery $75 copay ambulatory; $125 copay hospital; $50 copay doctor office $75 copay ambulatory; $125 copay hospital; $50 copay doctor office $60 copay ambulatory; $100 copay hospital; $40 copay doctor office $45 copay ambulatory; $75 copay hospital; $30 copay doctor office
Ambulance services $50 copay $50 copay $50 copay $50 copay
Urgent care – worldwide $35 copay $35 copay $35 copay $35 copay
Emergency care – worldwide $50 copay $50 copay $50 copay $50 copay
Durable medical equipment 20% coinsurance 20% coinsurance 20% coinsurance 20% coinsurance
Preventive services $0 copay $0 copay $0 copay $0 copay
Preventive services such as Welcome to Medicare exam, Personalized Prevention Plan Services, bone mass measurement, colorectal screening, glaucoma screening, immunizations (including flu, pneumonia and Hepatitis B vaccines), mammograms, Pap smears and prostate screening.
Other physical exams $20 copay $25 copay $15 copay $10 copay
Chiropractic $35 copay $40 copay $30 copay $20 copay
Podiatry $35 copay $40 copay $30 copay $20 copay
Preventive dental $0 copay Up to two exams every year, two cleanings every year and dental X-rays every two years. Not included $0 copay Up to two exams every year, two cleanings every year and dental X-rays every two years. $0 copay Up to two exams every year, two cleanings every year and dental X-rays every two years.
Enhanced vision benefit Not included Not included Included Included
One routine eye exam every year, contact lenses or eye glasses every two years; $100 limit for contact lenses every two years; $100 limit for eyeglass frames or contact lenses every two years. Copays apply.
Hearing Included Up to two hearing aids every three years, one hearing test every year, one hearing aid fitting evaluation every three years. $500 per ear limit for hearing aids every three years. Copays apply. Not included Included Up to two hearing aids every three years, one hearing test every year, one hearing aid fitting evaluation every three years. $500 per ear limit for hearing aids every three years. Copays apply. Included Up to two hearing aids every three years, one hearing test every year, one hearing aid fitting evaluation every three years. $500 per ear limit for hearing aids every three years. Copays apply.
SilverSneakers® Fitness Program Not included Included Included Not included
Safety bars $75 combined annual maximum, 50% coinsurance. Installation not covered. Shower grab bar, bathtub bar and commode rails. Must use network vendor. Not included $75 annual maximum, 50% coinsurance. Installation not covered. Shower grab bar, bathtub bar and commode rails. Must use network vendor. $75 annual maximum, 50% coinsurance. Installation not covered. Shower grab bar, bathtub bar and commode rails. Must use network vendor.
Transportation $0 copay. Up to 12 round trips to plan-approved locations. Must use network vendor. Not included $0 copay. Up to 12 round trips to plan-approved locations. Must use network vendor. $0 copay. Up to 12 round trips to plan-approved locations. Must use network vendor.
Part D prescription drugs—initial coverage period (until your total drug costs reach $2,840) Not included $310 deductible, 25% coinsurance Tier 1 Preferred generic: $4 Tier 2 Preferred brand: $35 Tier 3 Non-preferred generic/brand: $75 Tier 4 Specialty: 25%* Tier 5 Injectable: 25%*
*of plan’s approved amount		 Tier 1 Preferred generic: $3 Tier 2 Preferred brand: $30 Tier 3 Non-preferred generic/brand: $65 Tier 4 Specialty: 25%* Tier 5 Injectable: 25%*
*of plan’s approved amount
Part D prescription drugs—gap period (after your drug costs reach $2,840 until they reach $4,550) Not included Discount on brand name drugs; pay no more than 93% coinsurance on all generic drugs Generic drugs covered with a 50% coinsurance Generic drugs covered with a $5 copay
Part D prescription drugs— catastrophic period (after your drug costs reach $4,550) Not included $2.50 copay for generic drugs and $6.30 copay for other drugs or 5% coinsurance, whichever is greater

You have the right to make a complaint if you have concerns related to your medical or prescription drug coverage or care. “Appeals” and “grievances” are the two types of complaints you can make. An “appeal” is the type of complaint you make when you want us to reconsider a decision we made about what services are covered for you or what we will pay for a service or benefit. A “grievance” is the type of complaint you make if you have any other type of problem with BCN Advantage or one of our plan providers. If you believe you need a drug that is not on our formulary or you believe you should get a drug at a lower copayment, you have the right to ask for an “exception.” There are specific steps you may take to request an exception, appeal or grievance. See Chapter 7 for Option 1 or Chapter 9 for Basic, Option 2 or Option 3 of your Evidence of Coverage for complete details.

Network Explanation

BCN Advantage has formed a network of doctors, specialists and hospitals. You can only use doctors who are part of our network for routine care. To find a doctor, visit our Physician Search Tool.

You may go to any emergency room, anywhere in the world, if you reasonably believe you need emergency care. You pay a copayment for each Medicare-covered emergency room visit. The copayment is waived if you are admitted to the hospital within one day for the same condition.

For urgently needed care (non-emergency) from a non-BCN Advantage provider anywhere in the world, you pay a copayment for each Medicare-covered urgently needed care visit.

You must use plan providers except in emergent or urgent care situations or for out-of-area renal dialysis. If you obtain routine care from out-of-network providers neither Medicare nor BCN Advantage will be responsible for the costs.

Important information about this plan

A health plan with a Medicare contract.

H5883_BCNAdvantageWebR2 CMS Approved 05242011

page modified 09/23/2011