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BCN Advantage HMO-POS Prime Value (HMO-POS) - H5883-014-001
$0.00
Monthly Premium
BCN Advantage HMO-POS Prime Value (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by Blue Cross Blue Shield of Michigan
Plan ID: H5883-014-001
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.
$0.00
Monthly Premium
Michigan 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 Michigan 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 | $0.00 |
| Out-of-pocket maximum | $4,200.00 |
| Initial drug coverage limit | $0.00 |
| Catastrophic drug coverage limit | $2,000.00 |
| Primary care doctor visit | In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $0 |
| Specialty doctor visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $35 Prior Authorization Required for Doctor Specialty Visit |
| Inpatient hospital care | In-Network: Medicare Covered Acute Hospital Services: $300 per day for days 1 to 7 $0 per day for days 8 to 90 $0 per day for days 90 and beyond Out-of-Network: Medicare Covered Acute Hospital Services: $300 per day for days 1 to 7 $0 per day for days 8 to 90 $0 per day for days 90 and beyond Prior Authorization Required for Acute Hospital Services |
| Urgent care | Urgent Care: Copayment for Urgent Care $0 to $45 Emergency Services $125 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $45 Worldwide Emergency Coverage $125 Worldwide Emergency Transportation $310 Maximum Plan Benefit of $50,000 Minimum copayment amount applies to services provided in a PCP office. Maximum copayment amount applies to services provided in an urgent care facility. |
| Emergency room visit | Emergency Care: Copayment for Emergency Care $125 Urgently Needed Services / Urgent Care Centers (min copay services in PCP office; max copay services in Urgent Care) $0-$45 Worldwide Coverage: Copayment for Worldwide Emergency Coverage $125 Worldwide Urgent Coverage $45 Copayment for Worldwide Emergency Transportation $310 Maximum Plan Benefit of $50,000 |
| Ambulance transportation | Out-of-Network: Ambulance Services: Copayment for Ambulance Services - Ground $310 Copayment for Ambulance Services - Air $310 Please see Evidence of Coverage for details |
Health Care Services and Medical Supplies
BCN Advantage HMO-POS Prime Value (HMO-POS) covers a range of additional benefits. Learn more about BCN Advantage HMO-POS Prime Value (HMO-POS) 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 $15 Copayment for Routine Care $35
Chiropractic X-rays (1 visit/year) $20 Out-of-Network: Chiropractic Services: Copayment for Routine Care $35
Chiropractic X-rays (1 visit/year) $20 |
| Diabetes supplies, training, nutrition therapy and monitoring | In-Network: Diabetic Supplies and Services: Copayment for Medicare-covered Diabetic Supplies $0 Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0 Out-of-Network: Diabetic Supplies and Services: Copayment for Medicare-covered Diabetic Supplies $0 Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0 |
| Durable medical equipment (DME) | In-Network: Durable Medical Equipment: Coinsurance for Medicare-covered Durable Medical Equipment 0% to 20% Prior Authorization Required for Durable Medical Equipment Out-of-Network: Medicare Covered Durable Medical Equipment Services: Coinsurance for Medicare Covered Durable Medical Equipment 0% to 20% |
| 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 to $20 Copayment for Medicare-covered Lab Services $0 Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services $0 cost share applies to COVID-19 testing. The maximum applies to other outpatient diagnostic tests and procedures. Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $20 to $100 Copayment for Medicare-covered Therapeutic Radiological Services $25 Copayment for Medicare-covered X-Ray Services $20 to $100 Out-of-Network: Medicare Covered Diagnostic Procedures/Tests Services: Copayment for Medicare Covered Diagnostic Procedures/Tests $0 to $20 Copayment for Medicare Covered Lab Services $0 Copayment for Medicare Covered Diagnostic Radiological Services $20 to $100 Copayment for Medicare Covered Therapeutic Radiological Services $25 Copayment for Medicare Covered Outpatient X-Ray Services $20 to $100 $0 cost share applies to COVID-19 testing. The maximum applies to other outpatient diagnostic tests and procedures. |
| Home health care | In-Network: Home Health Services: Copayment for Medicare-covered Home Health Services $0 Prior Authorization Required for Home Health Services |
| Mental health inpatient care | In-Network: Medicare Covered Hospital Psychiatric: $300 per day for days 1 to 7 $0 per day for days 8 to 90 $0 per day for days 90 and beyond Out-of-Network: Medicare Covered Hospital Psychiatric: $300 per day for days 1 to 7 $0 per day for days 8 to 90 $0 per day for days 90 and beyond |
| Mental health outpatient care | In-Network: Outpatient Mental Health Services: Copayment for Medicare-covered Individual Sessions $20 Copayment for Medicare-covered Group Sessions $20 |
| Outpatient services/surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $275 Prior Authorization Required for Outpatient Hospital Services Outpatient Observation Services: Copayment for Medicare Covered Observation Services $0 Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $0 to $240 Prior Authorization Required for Ambulatory Surgical Center Services Minimum copay applies to arthroplasty knee and hip. Maximum copay applies to services performed in an ambulatory surgical center. Out-of-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $275 Prior Authorization Required for Outpatient Hospital Services Outpatient Observation Services: Copayment for Medicare Covered Observation Services $0 Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $0 to $240 Prior Authorization Required for Ambulatory Surgical Center Services Minimum copay applies to arthroplasty knee and hip. Maximum copay applies to services performed in an ambulatory surgical center.
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| Outpatient substance abuse care | In-Network: Outpatient Substance Abuse Services: Copayment for Medicare-covered Individual Sessions $35 Copayment for Medicare-covered Group Sessions $35 Out-of-Network: Copayment for Medicare-covered Individual Sessions $35 Copayment for Medicare-covered Group Sessions $35 |
| Over-the-counter items | In-Network: Over-The-Counter (OTC) Items: Allowance benefit of $60.00 every three months for Over-The-Counter (OTC) Items The benefit is administered through a plan approved network of retail and mail order partners.(No Rollover) |
| Podiatry services | In-Network: Podiatry Services: Copayment for Medicare-Covered Podiatry Services $35 Prior Authorization Required for Podiatry Services |
| Skilled Nursing Facility (SNF) care | In-Network: Skilled Nursing Facility Services: $0 per day for days 1 to 20 $214 per day for days 21 to 100 Prior Authorization Required for Skilled Nursing Facility Services Out-of-Network: Skilled Nursing Facility Services: $0 per day for days 1 to 20 $214 per day for days 21 to 100 Prior authorization may apply to certain 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 | $1,500 combined in-network and out-of-network allowance for preventive and comprehensive dental services. Preventive dental services: Oral Exams (2 visits per calendar year): In-network: You pay nothing Point-of-service: 50% of the cost Cleaning (2 visits per calendar year): In-network: You pay nothing Point-of-service: 50% of the cost Fluoride Treatment (1 visit per calendar year): In-network: You pay nothing Point-of-service: 50% of the cost Dental X-rays (One set of up to 4 bitewings or 6 periapical films every 2 calendar years): In-network: You pay nothing Point-of-service: 50% of the cost Medicare Covered Dental Services: In-network: $0-$275 Point-of-service: $0-$275 Comprehensive Dental services :$0 copay In-network and 50% coinsurance for Point-of-service for the following services: Diagnostic: Exams - 2 per calendar year; X-rays - once every 2 calendar years of either 1 set of up to 4 bitewings OR up to 6 periapical Restorative: Fillings once per tooth/surface every 48 months, Crown repairs (3 per permanent tooth per calendar year), Crowns (once per permanent tooth every 84 months) Endodontic: Root canal once per tooth per lifetime Periodontics: Deep Cleaning 1 per quadrant per 24 months Extractions: Once per tooth per lifetime Prosthodontics/Other/Oral Maxiofacial Surgery, and Other services: Oral Surgery (2 per tooth per lifetime), Brush Biopsy (2 per calendar year) Please see Evidence of Coverage for details |
Vision Benefits
The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage
| Coverage | Details |
|---|---|
| Vision care | In-Network: Eye Exams: Copayment for Medicare Covered Benefits $0 to $35 Copayment for Routine Eye Exams $0
Eyewear: Copayment for Medicare-Covered Benefits $0 Copayment for Contact Lenses $0 Copayment for Eyeglass Lenses $0
Out-of-Network: Medicare Covered Eye Exams Services: Copayment for Medicare Covered Eye Exams $0 to $35 Copayment for Medicare Covered Eyewear $0 Please see Evidence of Coverage for details |
Hearing Benefits
The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Hearing care | In-Network: Hearing Exams: Copayment for Medicare Covered Benefits $0 to $35 Copayment for Routine Hearing Exams $0 to $35
Hearing Aids: Copayment for Hearing Aids $0
Hearing aids are covered up to a $1200 maximum benefit ($600 per ear) every three years. Excludes hearing aid repairs, adjustments or reconfigurations. Out-of-Network: Medicare Covered Hearing Exams Services: Copayment for Medicare Covered Hearing Exams $0 to $35 |
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 Medicare-covered Preventive Services: Copayment for Medicare Covered Medicare-covered Preventive Services $0 |
When reviewing Michigan 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 Michigan 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 |
Michigan Counties Served
We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.