Benefits Comparison Chart

Blue Medicare Advantage Plans At-A-Glance

Essential (PPO)

Counties Covered

Buchanan, MO
Cass, MO
Clay, MO
Clinton, MO
Jackson, MO
Johnson, KS
Lafayette, MO
Platte, MO
Ray, MO
Wyandotte, KS

Total Premium

$0

Visitor Travel

Covered

Plan Deductible

$500*

Maximum Out of Pocket (MOOP)

$4,000

Inpatient Services

Inpatient Hospital - Acute

In-Network

$250, Days 1-5; $0, Days 6-90**

Out-of-Network

45% per stay

Skilled Nursing Facility

In-Network

$0, Days 1-20; $184, Days 21-100

Out-of-Network

45%, Days 1-100

Emergency Care/Urgent Care

Emergency Care (Worldwide)

In-Network

$90

Out-of-Network

$90

Urgently Needed Care (Worldwide)

In-Network

$50

Out-of-Network

$50

Ambulance Services (Worldwide *NEW* 2021)

In-Network

$300

Out-of-Network

$300

Professional Services

PCP Visit

In-Network

$5

Out-of-Network

45%

Specialist Visits

In-Network

$25

Out-of-Network

45%

Podiatry & Routine Foot Care 6/year

In-Network

$25

Out-of-Network

45%

Diagnostic Testing Services

Other Diagnostic Procedures/Tests

In-Network

$0

Out-of-Network

45%

Lab Services

In-Network

$0

Out-of-Network

45%

X-Ray Services

In-Network

$0

Out-of-Network

45%

MRI/CT at physicians office or free standing

In-Network

$150

Out-of-Network

45%

MRI/CT at other facility

In-Network

$250

Out-of-Network

45%

Outpatient Services

Outpatient Hospital (Non-Surgical)

In-Network

20%

Out-of-Network

45%

Observation

In-Network

$250

Out-of-Network

45%

Surgery (ASC or Outpatient Hospital)

In-Network

$250

Out-of-Network

45%

Supplemental Services

Dental Services (DentaQuest) 1

In-Network

$0 Copay, 2 Exams/Cleaning, 1 X-ray/Fluoride; 50% Coinsurance for Comprehensive;

Out-of-Network

45% Coinsurance, 2 Exams/Cleaning, 1 X-ray/Fluoride; 45% Coinsurance for Comprehensive;

$1,000 Benefit Maximum Combined

Vision Eyewear Benefits (EyeMed) 2

$300 Every Year

Hearing Aid (TruHearing)

$699-$999

Access (PPO)

Counties Covered

Cass, MO
Clay, MO
Clinton, MO
Jackson, MO
Johnson, KS
Lafayette, MO
Platte, MO
Ray, MO
Wyandotte, KS

Total Premium

$60

Visitor Travel

Covered

Plan Deductible

$0

Maximum Out of Pocket (MOOP)

$5,900

Inpatient Services

Inpatient Hospital - Acute

In-Network

$285, Days 1-5; $0, Days 6-90**

Out-of-Network

$500, Days 1-5; $0, Days 6-90

Skilled Nursing Facility

In-Network

$0, Days 1-20; $184, Days 21-100

Out-of-Network

$0, Days 1-20; $184, Days 21-100

Emergency Care/Urgent Care

Emergency Care (Worldwide)

In-Network

$90

Out-of-Network

$90

Urgently Needed Care (Worldwide)

In-Network

$50

Out-of-Network

$50

Ambulance Services (Worldwide *NEW* 2021)

In-Network

$285

Out-of-Network

$285

Professional Services

PCP Visit

In-Network

$5

Out-of-Network

$10

Specialist Visits

In-Network

$35

Out-of-Network

$70

Podiatry & Routine Foot Care 6/year

In-Network

$35

Out-of-Network

$70

Diagnostic Testing Services

Other Diagnostic Procedures/Tests

In-Network

$0

Out-of-Network

50%

Lab Services

In-Network

$0

Out-of-Network

50%

X-Ray Services

In-Network

$0

Out-of-Network

50%

MRI/CT at physicians office or free standing

In-Network

$185

Out-of-Network

50%

MRI/CT at other facility

In-Network

$285

Out-of-Network

50%

Outpatient Services

Outpatient Hospital (Non-Surgical)

In-Network

20%

Out-of-Network

$500

Observation

In-Network

$285

Out-of-Network

$500

Surgery (ASC or Outpatient Hospital)

In-Network

$285

Out-of-Network

$500

Supplemental Services

Dental Services (DentaQuest) 1

In-Network

$0 Copay, 2 Exams/Cleaning, 1 X-ray/Fluoride; 50% Coinsurance for Comprehensive;

Out-of-Network

50% Coinsurance, 2 Exams/Cleaning, 1 X-ray/Fluoride; 50% Coinsurance for Comprehensive;

$1,000 Benefit Maximum Combined

Vision Eyewear Benefits (EyeMed) 2

$300 Every Year

Hearing Aid (TruHearing)

$399-$699

Flex (PPO)

Counties Covered

Cass, MO
Clay, MO
Clinton, MO
Jackson, MO
Johnson, KS
Lafayette, MO
Platte, MO
Ray, MO
Wyandotte, KS

Total Premium

$0

Visitor Travel

Not Applicable

Plan Deductible

$0

Maximum Out of Pocket (MOOP)

$4,000

Inpatient Services

Inpatient Hospital - Acute

In-Network

$285, Days 1-6; $0, Days 7-90**

Out-of-Network

$285, Days 1-6; $0, Days 7-90**

Skilled Nursing Facility

In-Network

$0, Days 1-20; $184, Days 21-100

Out-of-Network

$0, Days 1-20; $184, Days 21-100

Emergency Care/Urgent Care

Emergency Care (Worldwide)

In-Network

$90

Out-of-Network

$90

Urgently Needed Care (Worldwide)

In-Network

$50

Out-of-Network

$50

Ambulance Services (Worldwide *NEW* 2021)

In-Network

$285

Out-of-Network

$285

Professional Services

PCP Visit

In-Network

$5

Out-of-Network

$5

Specialist Visits

In-Network

$20

Out-of-Network

$20

Podiatry & Routine Foot Care 6/year

In-Network

$20

Out-of-Network

$20

Diagnostic Testing Services

Other Diagnostic Procedures/Tests

In-Network

$0

Out-of-Network

$0

Lab Services

In-Network

$0

Out-of-Network

$0

X-Ray Services

In-Network

$0

Out-of-Network

$0

MRI/CT at physicians office or free standing

In-Network

$185

Out-of-Network

20%

MRI/CT at other facility

In-Network

$285

Out-of-Network

20%

Outpatient Services

Outpatient Hospital (Non-Surgical)

In-Network

20%

Out-of-Network

20%

Observation

In-Network

$285

Out-of-Network

$285

Surgery (ASC or Outpatient Hospital)

In-Network

$285

Out-of-Network

$285

Supplemental Services

Dental Services (DentaQuest) 1

$0 Copay, 2 Exams/Cleaning, 1 X-ray/Fluoride; 50% Coinsurance for Comprehensive;

$1,000 Benefit Maximum Combined

Vision Eyewear Benefits (EyeMed) 2

$300 Every Year

Hearing Aid (TruHearing)

$699-$999

Complete (HMO)

Counties Covered

Cass, MO
Clay, MO
Clinton, MO
Jackson, MO
Johnson, KS
Lafayette, MO
Platte, MO
Ray, MO
Wyandotte, KS

Total Premium

$0

Optional supplemental benefit for Dental and Vision:
Additional $25 per month.

Visitor Travel

Not Covered

Plan Deductible

$0

Maximum Out of Pocket (MOOP)

$6,200

Inpatient Services

Inpatient Hospital - Acute

In-Network

$325, Days 1-5; $0, Days 6-90**

Skilled Nursing Facility

In-Network

$0, Days 1-20; $184, Days 21-100

Emergency Care/Urgent Care

Emergency Care (Worldwide)

In-Network

$90

Urgently Needed Care (Worldwide)

In-Network

$50

Ambulance Services (Worldwide *NEW* 2021)

In-Network

$325

Professional Services

PCP Visit

In-Network

$5

Specialist Visits

In-Network

$45

Podiatry & Routine Foot Care 6/year

In-Network

$45

Diagnostic Testing Services

Other Diagnostic Procedures/Tests

In-Network

$0

Lab Services

In-Network

$0

X-Ray Services

In-Network

$0

MRI/CT at physicians office or free standing

In-Network

$225

MRI/CT at other facility

In-Network

$325

Outpatient Services

Outpatient Hospital (Non-Surgical)

In-Network

20%

Observation

In-Network

Not Applicable

Surgery (ASC or Outpatient Hospital)

In-Network

$325

Supplemental Services

Dental Services (DentaQuest) 1

$0 Copay, 2 Exams/Cleaning, 1 X-ray/Fluoride

Optional Supplemental benefit:

20%-50% Coinsurance for Comprehensive
Our plan pays up to $2,000 every year for Comprehensive Dental Services.

$25/Additional Monthly premium buy-up for Dental and Vision.

Vision Eyewear Benefits (EyeMed) 2

Optional Supplemental benefit:

Our plan pays up to $250 every year for eyewear.

$25/Additional Monthly premium buy-up for Dental and Vision.

Hearing Aid (TruHearing)

$699-$999

Plus (HMO)

Counties Covered

Cass, MO
Clay, MO
Clinton, MO
Jackson, MO
Johnson, KS
Lafayette, MO
Platte, MO
Ray, MO
Wyandotte, KS

Total Premium

$45

Visitor Travel

Not Covered

Plan Deductible

$0

Maximum Out of Pocket (MOOP)

$5,200

Inpatient Services

Inpatient Hospital - Acute

In-Network

$285, Days 1-6; $0, Days 7-90**

Skilled Nursing Facility

In-Network

$0, Days 1-20; $184, Days 21-100

Emergency Care/Urgent Care

Emergency Care (Worldwide)

In-Network

$90

Urgently Needed Care (Worldwide)

In-Network

$40

Ambulance Services (Worldwide *NEW* 2021)

In-Network

$285

Professional Services

PCP Visit

In-Network

$5

Specialist Visits

In-Network

$40

Podiatry & Routine Foot Care 6/year

In-Network

$45

Diagnostic Testing Services

Other Diagnostic Procedures/Tests

In-Network

$0

Lab Services

In-Network

$0

X-Ray Services

In-Network

$0

MRI/CT at physicians office or free standing

In-Network

$185

MRI/CT at other facility

In-Network

$285

Outpatient Services

Outpatient Hospital (Non-Surgical)

In-Network

20%

Observation

In-Network

Not Applicable

Surgery (ASC or Outpatient Hospital)

In-Network

$285

Supplemental Services

Dental Services (DentaQuest) 1

$0 Copay, 2 Exams/Cleaning, 1 X-ray/Fluoride; 50% Coinsurance for Comprehensive;

$1,000 Benefit Maximum Combined

Vision Eyewear Benefits (EyeMed) 2

$250 Every Year

Hearing Aid (TruHearing)

$399-$699

Spira Care (HMO)

Counties Covered

Johnson, KS
Wyandotte, KS

Total Premium

$0

Optional supplemental benefit for Dental and Vision:
Additional $25 per month.

Visitor Travel

Not Covered

Plan Deductible

$0

Maximum Out of Pocket (MOOP)

$4,800

Inpatient Services

Inpatient Hospital - Acute

In-Network

$300, Days 1-5; $0, Days 6-90**

Skilled Nursing Facility

In-Network

$0, Days 1-20; $184, Days 21-100

Emergency Care/Urgent Care

Emergency Care (Worldwide)

In-Network

$90

Urgently Needed Care (Worldwide)

In-Network

$50

Ambulance Services (Worldwide *NEW* 2021)

In-Network

$300

Professional Services

PCP Visit

In-Network

$0

Specialist Visits

In-Network

$30

Podiatry & Routine Foot Care 6/year

In-Network

$30

Diagnostic Testing Services

Other Diagnostic Procedures/Tests

In-Network

$0

Lab Services

In-Network

$0

X-Ray Services

In-Network

$0

MRI/CT at physicians office or free standing

In-Network

$200

MRI/CT at other facility

In-Network

$300

Outpatient Services

Outpatient Hospital (Non-Surgical)

In-Network

20%

Observation

In-Network

Not Applicable

Surgery (ASC or Outpatient Hospital)

In-Network

$300

Supplemental Services

Dental Services (DentaQuest) 1

$0 Copay, 2 Exams/Cleaning, 1 X-ray/Fluoride

Optional Supplemental benefit:

20%-50% Coinsurance for Comprehensive
Our plan pays up to $2,000 every year for Comprehensive Dental Services.

$25/Additional Monthly premium buy-up for Dental and Vision.

Vision Eyewear Benefits (EyeMed) 2

Optional Supplemental benefit:

Our plan pays up to $250 every year for eyewear.

$25/Additional Monthly premium buy-up for Dental and Vision.

Hearing Aid (TruHearing)

$399-$699

* 2021 Deductible applies to these In-network services: dialysis services, inpatient acute & psychiatric hospital, partial hospitalization, outpatient hospital services, observation services, and ambulatory surgical center (ASC) services. All out-of-network Medicare-covered services, except zero-dollar preventive services, apply to the deductible.

** After 90 days, our plan covers an unlimited number of additional days for an inpatient hospital stay at $0 copay.

1 Member is responsible for charges over the Dental Benefit Maximum.

2 Member is responsible for charges over the Eyewear Benefit Maximum.

This information is not a complete description of benefits.

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