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Plan Comparison Table

Copays displayed are for in-network services only. Some services are excluded from coverage under the out-of-network POS benefit. Services such as emergency room, urgent care, and ambulance coverage are always covered out-of-network separately from the POS benefit with different copays. Contact the plan for full details on exclusions. 

 

Monthly Premium*
Next steps
? Out-of-pocket Max.
(individual/family)
? Medical Deductible
Medical Services
? Primary Care Doctor
? Specialist
Hospital Care
? Inpatient Hospital
Laboratory Services
X-Rays
Advanced Radiology (MRI, CAT, PET)
? Urgent Care (copay waived if admitted)
? Emergency Room (copay waived if admitted)
? Outpatient
? Ambulatory Surgery
? Preventive Services
Annual Routine Eye Exam
Vision Wear (frames/lenses/contact lens)
? Hearing Aid (coverage for specific models only)
? Optional Supplemental Dental Plan
Worldwide Coverage - Emergency and Urgent Care
Prescription Drugs
(30-day supply at a retail pharmacy) Preferred pharmacies include Rite Aid and Walmart; see Provider Directory for a full list.
Prescription Drug Deductible
Tier 1 Preferred Generic
Our plans cover Tier 1 generics through the coverage gap, so you would pay a copay for those drugs.
Tier 2 Generic
Tier 3 Preferred Brand
Tier 4 Non-Preferred Brand
Tier 5 Specialty
Gap Coverage

A division of HealthNow New York Inc., an independent licensee of the Blue Cross and Blue Shield Association. BlueShield of Northeastern New York is a Medicare Advantage plan with a Medicare contract and enrollment depends on contract renewal. This information is not a complete description of benefits. Call 1-800-329-2792 (TTY: 711) for more information. BlueShield of Northeastern New York 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). 

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Content Last Updated October 1, 2018