Blue Cross Medicare Advantage Basic (HMO-POS)

by Blue Cross and Blue Shield of Illinois

2027 Medicare Advantage plan available in Illinois

Plan ID H3822-001-0

Additional coverage:

RxHearingVisionDental

Medicare Advantage HMO

Monthly plan premium $29 / mo

Annual deductible $0 / yr

Max out-of-pocket · in-network $5,500 / yr

Drug deductible $500 / yr

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Plan Overview

Blue Cross Medicare Advantage Basic (HMO-POS) is a Medicare Advantage Plan With Part D Prescription Drug Coverage, which is available in Illinois and offered by the health insurance company Blue Cross and Blue Shield of Illinois. This plan's network type is HMO, which determines the in-network doctors who accept the plan and whether a referral is needed.

Plan Name Blue Cross Medicare Advantage Basic (HMO-POS)

Insurance Carrier Blue Cross and Blue Shield of Illinois

Plan Type Medicare Advantage Plan With Part D Prescription Drug Coverage

Network Type HMO

Cost Summary

Blue Cross Medicare Advantage Basic (HMO-POS) has a monthly premium cost of $29 per month, with an annual deductible of $0 and a maximum out-of-pocket cost sharing of $5,500. The most common costs people evaluate when choosing a plan are listed here; a full list of benefit costs is defined below.

Monthly Premium $29 / mo

Health portion of premium $29

Drug portion of premium $0

Annual Deductible $0 / yr

Max Out-of-Pocket · in-network $5,500 / yr

Primary doctor visit $0 copay

Specialist visit $20 copay

ER visit $130 copay

Ambulance $250 copay

Additional Benefits and Coverage

Blue Cross Medicare Advantage Basic (HMO-POS) is a Medicare Advantage plan which includes Medicare Part D prescription drug coverage. Other common benefits included with Medicare Advantage plans are coverage for dental, vision, and hearing. Blue Cross Medicare Advantage Basic (HMO-POS) includes coverage for hearing, vision, dental.

Part D Prescription Drug Coverage Yes

Dental Yes

Vision Yes

Hearing Yes

Nationwide Coverage No

Other benefits

Fitness benefit Limited coverage

Over-the-counter drug benefits Limited coverage

In-home support services Not covered

Home & bathroom safety devices Not covered

Meals for short duration Not covered

Annual physical exams Limited coverage

Telehealth Limited coverage

Medical Benefits

Doctor Services

Primary doctor visit In-network: $0 copay
Out-of-network: $0 copay

Specialist visit In-network: $20 copay
Out-of-network: $20 copay

Tests, labs & imaging

Diagnostic tests & procedures In-network: $0-$50 copay
Out-of-network: $0-$50 copay

Lab services In-network: $0-$50 copay
Out-of-network: $0-$50 copay

Diagnostic radiology services (like MRI) In-network: $0-$250 copay
Out-of-network: $0-$250 copay

Outpatient x-rays In-network: $0-$100 copay
Out-of-network: $0-$100 copay

Emergency care $130 copay

Urgent care $50 copay

Hospital Services

Inpatient hospital coverage In-network:
  Tier 1
  $250 per day for days 1-7
  $0 per day for days 8-90
  $0 per stay

Outpatient hospital coverage In-network: $0-$300 copay
Out-of-network: $0-$300 copay

Skilled nursing facility

Skilled nursing facility In-network:
  Tier 1
  $10 per day for days 1-20
  $221 per day for days 21-39
  $0 per day for days 40-100

Preventive services

Preventive services In-network: $0 copay
Out-of-network: $0 copay

Ambulance

Ground ambulance In-network: $250 copay
Out-of-network: $250 copay

Therapy services

Occupational therapy visit In-network: $50 copay
Out-of-network: $50 copay

Physical therapy & speech & language therapy visit In-network: $20 copay
Out-of-network: $20 copay

Mental health services

Outpatient group therapy with a psychiatrist In-network: $30 copay
Out-of-network: $30 copay

Outpatient individual therapy with a psychiatrist In-network: $30 copay
Out-of-network: $30 copay

Outpatient group therapy visit In-network: $30 copay
Out-of-network: $30 copay

Outpatient individual therapy visit In-network: $30 copay
Out-of-network: $30 copay

Opioid treatment services

Opioid treatment services Covered

Other services

Durable medical equipment (like wheelchairs & oxygen) In-network: 20% coinsurance
Out-of-network: 20% coinsurance

Prosthetics (like braces, artificial limbs) In-network: 20% coinsurance
Out-of-network: 20% coinsurance

Diabetes supplies In-network: 0%-20% coinsurance
Out-of-network: 0%-20% coinsurance

Prescription drugs (Part D benefits)

Drug tier standard retail · 1-month supply Initial coverage Catastrophic

Preferred Generic $0.00 copay $0 copay

Generic $1.00 copay $0 copay

Preferred Brand 25% coinsurance $0 copay

Non-Preferred Drug 25% coinsurance $0 copay

Specialty Tier 28% coinsurance $0 copay

Part B drugs

Chemotherapy drugs In-network: 0%-20% coinsurance
Out-of-network: 0%-20% coinsurance

Other Part B drugs In-network: 0%-20% coinsurance
Out-of-network: 0%-20% coinsurance

Extra Benefits

Hearing

Hearing exam In-network: $0 copay
Out-of-network: $0 copay

Fitting/evaluation In-network: $0 copay
Out-of-network: $0 copay

Hearing aids - prescription In-network: $699-$999 copay
Out-of-network: $699-$999 copay

Hearing aids - over the counter Not covered

Preventive dental

Oral exam In-network: $0 copay
Out-of-network: 0%-50% coinsurance

Cleaning In-network: $0 copay
Out-of-network: 0%-50% coinsurance

Fluoride treatment Not covered

Dental x-rays In-network: $0 copay
Out-of-network: 0%-50% coinsurance

Comprehensive dental

Restorative services In-network: 0%-50% coinsurance
Out-of-network: 0%-50% coinsurance

Endodontics Not covered

Periodontics In-network: $0 copay
Out-of-network: 0%-50% coinsurance

Prosthodontics, removable Not covered

Prosthodontics, fixed Not covered

Maxillofacial prosthetics Not covered

Implant services In-network: $0 copay
Out-of-network: 0%-50% coinsurance

Oral and maxillofacial surgery In-network: 50% coinsurance
Out-of-network: 0%-50% coinsurance

Orthodontics Not covered

Adjunctive general services In-network: 0%-50% coinsurance
Out-of-network: 0%-50% coinsurance

Vision

Routine eye exam In-network: $0 copay
Out-of-network: $0 copay

Contact lenses In-network: $0 copay
Out-of-network: $0 copay

Eyeglasses (frames & lenses) In-network: $0 copay
Out-of-network: $0 copay

Eyeglass frames (only) In-network: $0 copay
Out-of-network: $0 copay

Eyeglass lenses (only) In-network: $0 copay
Out-of-network: $0 copay

Upgrades Not covered

Plan documents & tools

Plan details (carrier site)Provider directory Drug list (formulary)

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