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2015 PLAN OPTIONS

Personalized plan compare

Senior Blue HMO 601 Senior Blue HMO Select Senior Blue HMO 651
Forever Blue Medicare PPO Value Forever Blue
Medicare
PPO 751
BlueSaver
MSA
2015 Premium* What is 2014 Premium $0 $36.90 $95 $74 $155 $0
Out-of-pocket (OOP) maximum What is Out of Pocket Max $3,400 $3,400 $3,400 $3,400 - $5,100 $3,400 - $5,100 N/A
Primary doctor/specialist What is a primary doctor $25/$45 $35/$50 $20/$40 $35/$50 $20/$40 Use MSA funds
Prescription drugs What are prescription drugs
   Generic
   Brand
   Specialty

Not
covered


$10/$25
$45/$95
33%

$7/$20
$45/$95
33%

$7/$20
$45/$95
33%

$5/$15
$45/$95
33%

A stand- alone drug plan can be purchased.

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Details

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Details

Enroll

Details

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Details





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The benefit information provided is a brief summary, not a complete description of benefits.  For more information, contact the plan.  Limitations, copayments, and restrictions may apply. Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year.

MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.

Medicare MSA Plans don’t cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate Medicare Prescription Drug Plan.

There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan at 1-800-248-9296 (TTY 711) for additional information.

You must file Form 1040, US Individual Income Tax Return, along with Form 8853, “Archer MSA and Long-Term Care Insurance Contracts” with the Internal Revenue Service (IRS) for any distributions made from your Medicare MSA account to ensure you aren’t taxed on your MSA account withdrawals. You must file these tax forms for any year in which an MSA account withdrawal is made, even if you have no taxable income or other reason for filing a Form 1040. MSA account withdrawals for qualified medical expenses are tax free, while account withdrawals for non-medical expenses are subject to both income tax and a fifty (50) percent tax penalty.”

Tax publications are available on the IRS website at http://www.irs.gov or from 1-800-TAX-FORM (1-800-829-3676). 

 

 

 

BlueCross BlueShield of Western New York is a Medicare Advantage plan with a Medicare contract. Enrollment in BlueCross BlueShield of Western New York depends on contract renewal.

Y0086  H9788_MRK1514 Approved 
Content last updated July 6, 2015