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Medicare Advantage Plans

You are newly eligible for Medicare and want Medicare Part C or you are switching during Annual Enrollment Period from Oct. 15 to Dec. 7.

Medicare Supplement Plans

You want to add a Medicare Supplement plan to your Original Medicare Parts A and B.

3 Medicare Part D Plans

You are newly eligible for Medicare Part D or you are switching during Annual Enrollment Period from Oct. 15 to Dec. 7.

There are no Medicare Advantage plans in your area.

Topeka Region (Douglas, Jackson, Jefferson, Osage, Pottawatomie, Shawnee, Wabaunsee)	Blue Medicare Advantage (PPO)		Blue Medicare Advantage Comprehensive (PPO)
	Enroll in Blue Medicare Advantage (PPO)		Enroll in Blue Medicare Advantage Comprehensive (PPO)
General Costs*
Monthly Premium	$0		$50
Deductible	No annual deductible
Out of Pocket Maximum (In Network)	$6,700		$6,200
Out of Pocket Maximum (In Network and Out of Network)	$10,000		$9,000
Medical Benefit Copays	Blue Medicare Advantage (PPO)		Blue Medicare Advantage Comprehensive (PPO)
Primary Care Visit	$10 copay		$5 copay
Specialist Visit	$50 copay		$40 copay
Emergency Care	$90 copay		$80 copay
Urgent Care	$30 copay		$25 copay
Ambulance	$250 copay
Inpatient Hospital - Acute	$300 copay per day for days 1 to 5
Outpatient/Ambulatory Surgery	$250 copay
Diagnostic Procedures/Tests/Lab	$0 copay
Diagnostic X-Rays	$0 copay
Advanced Imaging (CTs/MRIs)	$50 to $250 copay		$40 to $250 copay
Mental Health Services	$40 copay
Standard Out-of-Network†	40% coinsurance		30% coinsurance
Supplemental Benefits	Blue Medicare Advantage (PPO)		Blue Medicare Advantage Comprehensive (PPO)
Dental	$500 annual allowance for preventive services + comprehensive services		$800 annual allowance for preventive services + comprehensive services
Optional: Comprehensive Dental	Add $21 premium - $1,000 allowance for minor comprehensive services Include dental option for additional $21/month
Vision	One routine eye exam + $150 eyewear allowance
Fitness	SilverSneakers® gym membership
Over-the-Counter (OTC) retail allowance	$160 per year ($40 per quarter)		$360 per year ($90 per quarter)
Hearing	One routine hearing exam + discount on hearing aids
Meals & Nutrition	Not offered		14 home delivered meals over 7-day period post hospital discharge
Prescription Benefits	Blue Medicare Advantage (PPO)		Blue Medicare Advantage Comprehensive (PPO)
Retail	Preferred	Standard	Preferred	Standard
Tier 1	$3 copay	$10 copay	$3 copay	$10 copay
Tier 2	$5 copay	$12 copay	$5 copay	$12 copay
Tier 3	$45 copay		$45 copay
Tier 4	$100 copay		$100 copay
Tier 5	30% coinsurance		30% coinsurance
Mail Order	Preferred	Standard	Preferred	Standard
Tier 1	Not Applicable	$3 copay	Not Applicable	$3 copay
Tier 2		$5 copay		$5 copay
Tier 3		$45 copay		$45 copay
Tier 4		$100 copay		$100 copay
Tier 5		30% coinsurance		30% coinsurance
	Medicare Advantage plans will be available starting October 15.
	Enroll in Blue Medicare Advantage (PPO)		Enroll in Blue Medicare Advantage Comprehensive (PPO)
Summary of Benefits (PDF)	Medicare Advantage 2021 Summary of Benefits
Evidence of Coverage (PDF)	Blue Medicare Advantage (PPO) Evidence of Coverage		Blue Medicare Advantage Comprehensive (PPO) Evidence of Coverage

*Medicare Advantage benefits are based on a January 1, 2021 effective date.
†Certain exceptions apply. Please reference the Evidence of Coverage for additional information.

Wichita Region (Butler, Cowley, Harvey, Kingman, Reno, Sedgwick, Sumner)	Blue Medicare Advantage (PPO)		Blue Medicare Advantage Comprehensive (PPO)
	Enroll in Blue Medicare Advantage (PPO)		Enroll in Blue Medicare Advantage Comprehensive (PPO)
General Costs*
Monthly Premium	$0		$40
Deductible	No annual deductible
Out of Pocket Maximum (In Network)	$6,400		$5,900
Out of Pocket Maximum (In Network and Out of Network)	$10,000		$9,000
Medical Benefit Copays	Blue Medicare Advantage (PPO)		Blue Medicare Advantage Comprehensive (PPO)
Primary Care Visit	$10 copay		$5 copay
Specialist Visit	$45 copay		$40 copay
Emergency Care	$90 copay		$80 copay
Urgent Care	$30 copay		$25 copay
Ambulance	$250 copay		$200 copay
Inpatient Hospital - Acute	$300 copay per day for days 1 to 5
Outpatient/Ambulatory Surgery	$250 copay
Diagnostic Procedures/Tests/Lab	$0 copay
Diagnostic X-Rays	$0 copay
Advanced Imaging (CTs/MRIs)	$45 to $250 copay		$40 to $250 copay
Mental Health Services	$40 copay
Standard Out-of-Network†	40% coinsurance		30% coinsurance
Supplemental Benefits	Blue Medicare Advantage (PPO)		Blue Medicare Advantage Comprehensive (PPO)
Dental	$1,000 allowance for preventive services + comprehensive services		$2,000 allowance for preventive services + comprehensive services
Vision	One routine eye exam + $150 eyewear allowance
Fitness	SilverSneakers® gym membership
Over-the-Counter (OTC) retail allowance	$160 per year ($40 per quarter)		$360 per year ($90 per quarter)
Hearing	One routine hearing exam + discount on hearing aids
Meals & Nutrition	Not offered		14 home delivered meals over 7-Day period post hospital discharge
Prescription Benefits	Blue Medicare Advantage (PPO)		Blue Medicare Advantage Comprehensive (PPO)
Retail	Preferred	Standard	Preferred	Standard
Tier 1	$3 copay	$10 copay	$3 copay	$10 copay
Tier 2	$5 copay	$12 copay	$5 copay	$12 copay
Tier 3	$45 copay		$45 copay
Tier 4	$100 copay		$100 copay
Tier 5	30% coinsurance		30% coinsurance
Mail Order	Preferred	Standard	Preferred	Standard
Tier 1	Not Applicable	$3 copay	Not Applicable	$3 copay
Tier 2		$5 copay		$5 copay
Tier 3		$45 copay		$45 copay
Tier 4		$100 copay		$100 copay
Tier 5		30% coinsurance		30% coinsurance
	Medicare Advantage plans will be available starting October 15.
	Enroll in Blue Medicare Advantage (PPO)		Enroll in Blue Medicare Advantage Comprehensive (PPO)
Summary of Benefits (PDF)	Medicare Advantage 2021 Summary of Benefits
Evidence of Coverage (PDF)	Blue Medicare Advantage (PPO) Evidence of Coverage		Blue Medicare Advantage Comprehensive (PPO) Evidence of Coverage

*Medicare Advantage benefits are based on a January 1, 2021 effective date.
†Certain exceptions apply. Please reference the Evidence of Coverage for additional information.

Benefits	Plan A	Plan G	Plan G (HDHP)	Plan G Select	Plan K	Plan K Select	Plan L	Plan N	Plan N Select
Monthly Sample Premium*	$111.21	$136.68	$59.04	$99.40	$63.82	$47.78	$86.11	$105.26	$76.17
	Get your quote and enroll now If you are a current Plan 65 member and would like to change plans, please call us direct at 866-749-8290.
Medicare Part A coinsurance and hospital coverage (up to an additional 365 days after Medicare benefits are used up)	✔	✔	✔	✔	✔	✔	✔	✔	✔
Medicare Part B coinsurance or copayment	✔	✔	✔	✔	50%	50%	75%	✔	✔
Blood (first three pints each year)	✔	✔	✔	✔	50%	50%	75%	✔	✔
Part A hospice care coinsurance or copayment	✔	✔	✔	✔	50%	50%	75%	✔	✔
Skilled nursing facility coinsurance		✔	✔	✔	50%	50%	75%	✔	✔
Medicare Part A deductible		✔	✔	✔	50%	50%	75%	✔	✔
Medicare Part B excess charges		✔	✔	✔
Foreign travel emergency (up to plan limits)		✔	✔	✔				✔	✔
Out-of-pocket limit					$6,220	$6,220	$3,110
After you pay this deductible			$2,370
	Plan A	Plan G	Plan G (HDHP)	Plan G Select	Plan K	Plan K Select	Plan L	Plan N	Plan N Select
Monthly Sample Premium*	$111.21	$136.68	$59.04	$99.40	$63.82	$47.78	$86.11	$105.26	$76.17
	Get accurate quote and enroll in a Medicare Supplement plan

*Medicare Supplement sample premiums are based on a 65-year-old female, non-tobacco user with household discount eligibility for January 1, 2021 effective date.
**For Medicare Supplement Plans sold on or after January 1, 2020, only applicants first eligible for Medicare before 2020 may purchase Plans C and F.

Here is a list of key services not covered by any Medicare Supplement Plan:

Custodial nursing home care.
Intermediate nursing home care costs.
Most dental care and hospital admissions for such care. Examples are treatment, filling, removal or replacement of teeth, root canal therapy, surgery for impacted teeth, and other surgical procedures involving the teeth or structures directly supporting the teeth.
Routine physical examinations and tests, routine foot care, and immunizations except injection of pneumococcal vaccine, mammograms and prostate exams.
Hearing aids and examinations for them, or consultations about them.
Eyeglasses or contact lenses and examinations for them, or consultations about them, unless for replacement of the lens following cataract surgery.
Benefits considered medically unnecessary by a committee of doctors representing Medicare and Blue Cross and Blue Shield of Kansas will not be paid.

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Call now 866-627-6705 (TTY 711)

Medicare Advantage: 8 a.m. to 8 p.m. Monday-Friday

All other inquiries: 8 a.m. to 4:30 p.m. Monday-Friday

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Blue Cross and Blue Shield of Kansas is a PPO plan with a Medicare contract. Enrollment in Blue Cross and Blue Shield of Kansas Medicare Advantage depends on contract renewal. This information is not a complete description of benefits. Call 800-222-7645 (TTY:711) for more information.

1133 S.W. Topeka Blvd. Topeka, KS 66629-0001

H7063_E19Web_M CMS Approved 06122019
Last updated 06/12/2019