2021 Annual Notice of Change & Evidence of Coverage
The Evidence of Coverage booklet tells you how to get your Medicare medical care and prescription drugs (if applicable) through a Medicare Advantage plan.
The Evidence of Coverage booklet explains:
- Member rights and responsibilities
- What is covered
- What you will pay as a member of the plan
The benefits listed in the Evidence of Coverage are effective January 1st of the current year. Benefits, formulary, pharmacy network, premium and/or copayments/co-insurance may change on January 1, 2021.
Medicare Advantage HMO Plans
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2021 Freedom No RX (HMO) Evidence of Coverage Last updated October 1, 2020
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Freedom Value (HMO) Annual Notice of Change Last updated October 1, 2020
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2021 Freedom Value (HMO) Evidence of Coverage Last updated October 1, 2020
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Freedom Plus (HMO) Annual Notice of Change Last updated October 1, 2020
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2021 Freedom Plus (HMO) Evidence of Coverage Last updated October 1, 2020
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Freedom Premier (HMO) Annual Notice of Change Last updated October 1, 2020
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2021 Freedom Premier (HMO) Evidence of Coverage Last updated October 1, 2020
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Senior Blue 652 (HMO) Annual Notice of Change Last updated October 1, 2020
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2021 Senior Blue (HMO) Evidence of Coverage Last updated October 1, 2020
Medicare Advantage PPO Plans
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2021 Freedom Nation (PPO) Evidence of Coverage Last updated October 1, 2020
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Forever Blue 770 (PPO) Annual Notice of Change Last updated October 1, 2020
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2021 Forever Blue 770 (PPO) Evidence of Coverage Last updated October 1, 2020
Optional Supplemental Dental Benefit
Medicare Questions?
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1-833-735-4512 (TTY 711)
Oct. 1 - Dec. 31, 8 a.m. - 8 p.m., 7 days a week
Jan. 1 - Sept. 30, 8 a.m. - 8 p.m., Monday - Friday
BlueShield of Northeastern New York (BSNENY) is a Medicare Advantage plan with a Medicare contract and enrollment depends on contract renewal. 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)
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Content last updated: March 6, 2021