2025 BCN Advantage^SM HMO-POS Elements

In-network services: $0
Point of service: $500

This plan doesn't have prescription drug coverage.

$4,500

Optional supplemental benefits and care received through our point-of-service benefit don't count toward your out-of-pocket maximum.

You pay $0.

You pay $35.

You pay $0-$45.

This plan doesn't have prescription drug coverage.

All benefits required by Original Medicare and more, including:

• $0 telehealth visits for primary care and behavioral health
• Advantage Dollars quarterly allowance of $50 for over-the-counter drugs, groceries (for qualified members) and health products
• Worldwide emergency, urgent care and transportation coverage
• Meals benefit following hospital discharge for qualifying members
• One round trip per calendar year to an Annual Physical Exam within the state of Michigan
• Transportation benefit for certain counties following hospital discharge
• SilverSneakers^® fitness program
• Coverage for ambulance services not requiring transportation
• Mobile crisis and crisis stabilization for behavioral health for certain counties
• MyBlue^SM Concierge program
• Coverage while traveling outside of Michigan with the Nationwide network of Blue Plan Providers (PDF)

This is an HMO-POS plan. HMO stands for health maintenance organization. It's a group of health care professionals that provide services to members. You choose a primary care physician from your network who coordinates all your care and refers you to specialists. In most cases, we don’t cover care you get outside our network except in an emergency.

POS stands for point of service. It means you can get care from doctors outside of Michigan under certain conditions. Find a doctor in this plan's network.

Includes services such as:
• Welcome to Medicare exam
• Personalized prevention plan services
• Bone mass measurement
• Screenings for cancer, glaucoma, depression, diabetes and sexually transmitted infections
• Immunizations (including flu, pneumonia and Hepatitis B vaccines)
• Screening mammograms
• Pap smears
• Behavioral counseling to reduce alcohol misuse
• Behavioral therapy for cardiovascular disease and obesity

You pay $0

Primary care physician: You pay a $0 copay.

Specialist: You pay a $35 copay.

Primary Care Physician: You pay a $0 copay.

Behavioral health: You pay a $0 copay.

Ambulatory surgical center: You pay $0-$100 copay.

Hospital: You pay a $200 copay.

Days 1-7: You pay a $205 copay per day.

Days 8-90: You pay $0.

Days 90 and beyond: You pay $0.

You're covered for up to 100 days each benefit period at a Medicare-certified facility.

Days 1-20: You pay $0.

Days 21-100: You pay a $214 copay per day.

You pay a $0-$45 copay.

You pay a $125 copay.

You pay a $45 copay.

There's a combined $50,000 lifetime limit for emergency, urgent care services and worldwide emergency transportation received outside the U.S. and its territories.

You pay a $125 copay.

There's a combined $50,000 lifetime limit for emergency, urgent care services and worldwide emergency transportation received outside the U.S. and its territories.

You pay a $300 copay.

There's a combined $50,000 lifetime limit for emergency, urgent care services and worldwide emergency transportation received outside the U.S. and its territories.

You pay 0-20% of the cost.

Durable medical equipment must be obtained from Northwood Inc.

You pay a $300 copay for air or ground transport.

Spinal manipulation: You pay a $15 copay.

Annual exam: You pay a $35 copay.

Annual X-ray: You pay a $20 copay.

You pay a $35 copay.

Includes individual and group therapy visits.

You pay a $20 copay.

You pay a $30 copay.

You pay 20% of the cost.

The benefit provides a $1,500 annual maximum for combined in-network and out-of-network dental services per calendar year.

This plan covers the following dental services for $0 copay in-network and 50% coinsurance out-of-network (frequencies vary):

• Two oral exams per calendar year
• Two routine cleanings per calendar year
• One full-mouth X-ray every five years
• Up to four bitewing X-rays or up to six periapical films every other calendar year
• Fluoride treatments, one time per calendar year
• Brush biopsies
• Resin and amalgam fillings
• Crowns
• Crown repairs
• Root canals
• Deep cleanings
• Extractions
• Oral surgery
• Original Medicare covered dental care services are covered with a copay of $0-$200 depending on place of service.

What's not covered:

• Dental procedures like dentures, onlays and implants (available in optional supplemental benefit buy-up)

Add more dental and vision coverage (PDF) for an additional cost.

This plan covers these benefits for $0 copay:
• One routine eye exam every year
• If you have cataract surgery, you're covered for one pair of eyeglasses (lenses and frames) or contact lenses.
•Diabetic retinopathy exam

Glasses and contacts

• We'll pay up to $150 once per calendar year for elective contacts or one frame with no copay.
• Standard eyeglass lenses are covered in full once per calendar year.
• Limitations may apply.
• You can choose any provider from the VSP Choice network.

This plan also covers Medicare-covered exams. You'll just have a $35 copay.
• Diabetic Retinopathy Eye Exam has a $0 copay.

What's not covered:
• LASIK or RK (radial keratotomy) surgery

Add more dental and vision coverage (PDF) for an additional cost.

You pay:

• $0 for one hearing aid fitting and evaluation every three years
• $0 to $35 copay for one routine hearing exam each year
• $0 to $35 copay for Medicare-covered diagnostic hearing exams
• New standard hearing aids every three years. We'll cover up to $600 per ear.

How this compares:

• This plan offers more hearing coverage than Original Medicare.

Add more dental and vision coverage (PDF) for an additional cost.

This document lists important features and rules for this plan.

• Summary of Benefits (PDF)

This booklet explains how to use this plan's benefits. It also lists some of the things this plan doesn't cover.

• Evidence of Coverage (PDF)

This brochure gives you an overview of all our Medicare Advantage plans to help you compare.

• 2025 Medicare Advantage Plans Comparison Guide (PDF)

Find a doctor or hospital in this plan's network:

• Find a doctor

This map shows you the counties where BCN Advantage plans are available.

• BCN Advantage Service Area (PDF)

The easiest way to enroll in this plan is online. Or call us at 1-888-563-3307. TTY users call 711. You can also print, fill out and mail this paper application.

• Enrollment Application Form (PDF)

Visit our Forms and Documents section.