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Blue Cross Medicare Advantage Basic (HMO)

H3822 - 012 - 0

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Blue Cross Medicare Advantage Basic (HMO) is a Medicare Advantage Plan by Blue Cross and Blue Shield of IL, NM.

This page features plan details for 2025 Blue Cross Medicare Advantage Basic (HMO) H3822 – 012 – 0 available in Central & Southern IL Markets.

Locations

Blue Cross Medicare Advantage Basic (HMO) is offered in the following locations.

Alexander County, Illinois

Brown County, Illinois

Cass County, Illinois

Click to see more locations

Plan Overview

Blue Cross Medicare Advantage Basic (HMO) offers the following coverage and cost-sharing.

Insurer:	Blue Cross and Blue Shield of IL, NM
Health Plan Deductible:	$0
MOOP:	$5,500 In-network
Drugs Covered:	Yes

Ready to sign up for Blue Cross Medicare Advantage Basic (HMO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

Premium Breakdown

Blue Cross Medicare Advantage Basic (HMO) has a monthly premium of $0.00. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.

Part B	Part C	Part D	Part B Give Back	Total
$185.00	$0.00	$0.00	$	$

Please Note:

Your Part B premium may differ based on factors including late enrollment, income, and disability status.
You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.

Drug Info

Blue Cross Medicare Advantage Basic (HMO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

Drug Deductible:	$0.00
Drug Out-Of-Pocket maximum:	$2,000.00
Drug Benefit Type:	Enhanced Alternative

Part D Premium Reduction

The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs.

The table below shows how the LIS impacts the Part D premium of this plan.

Part D	LIS Full
$0.00	$0.00

Initial Coverage Phase

After you pay your $0.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $2,000.00. Once you reach that amount, you will enter the next coverage phase.

30 Day

60 Day

90 Day

30 Day

Tier	Pref. Pharm	Std. Pharm	Pref. Mail	Std. Mail
1) Preferred Generic		$18.00 Copay		$18.00 Copay
2) Generic	$10.00 Copay	$20.00 Copay	$10.00 Copay	$20.00 Copay
3) Preferred Brand	$47.00 Copay	$47.00 Copay	$47.00 Copay	$47.00 Copay
4) Non-Preferred Drug	50.00% Coinsurance	50.00% Coinsurance	50.00% Coinsurance	50.00% Coinsurance
5) Specialty Tier	33.00% Coinsurance	33.00% Coinsurance	33.00% Coinsurance	33.00% Coinsurance

60 Day

Tier	Pref. Pharm	Std. Pharm	Pref. Mail	Std. Mail
1) Preferred Generic		$36.00 Copay		$36.00 Copay
2) Generic	$20.00 Copay	$40.00 Copay	$20.00 Copay	$40.00 Copay
3) Preferred Brand	$94.00 Copay	$94.00 Copay	$94.00 Copay	$94.00 Copay
4) Non-Preferred Drug	50.00% Coinsurance	50.00% Coinsurance	50.00% Coinsurance	50.00% Coinsurance
5) Specialty Tier

90 Day

Tier	Pref. Pharm	Std. Pharm	Pref. Mail	Std. Mail
1) Preferred Generic		$54.00 Copay		$36.00 Copay
2) Generic	$30.00 Copay	$60.00 Copay	$20.00 Copay	$40.00 Copay
3) Preferred Brand	$141.00 Copay	$141.00 Copay	$94.00 Copay	$94.00 Copay
4) Non-Preferred Drug	50.00% Coinsurance	50.00% Coinsurance	50.00% Coinsurance	50.00% Coinsurance
5) Specialty Tier

Catastrophic Coverage Phase

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $2,000.00, you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit. Please note, that this plan has a Enhanced Alternative benefit type.

Additional Benefits

Blue Cross Medicare Advantage Basic (HMO) also provides the following benefits.

Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?

- In-Network: No

Comprehensive Dental

Adjunctive General Services
- In-Network: 0 Coins – No Co pay (Limits Apply)
Endodontics
- In-Network: 20 Coins – No Co pay (Limits Apply)
Maxillofacial Prosthetics
- In-Network: 20 Coins – No Co pay (Limits Apply)
Oral and Maxillofacial Surgery
- In-Network: 0-20 Coins – No Co pay (Limits Apply)
Periodontics
- In-Network: 0-20 Coins – No Co pay (Limits Apply)
Prosthodontics, fixed
- In-Network: 20 Coins – No Co pay (Limits Apply)
Prosthodontics, removable
- In-Network: 20 Coins – No Co pay (Limits Apply)
Restorative Services
- In-Network: 0 Coins – No Co pay (Limits Apply)

Diagnostic and Preventive Dental

Dental X-Rays
- In-Network: No Coins – 0.00 Copay
Oral Exams
- In-Network: No Coins – 0.00 Copay
Prophylaxis (cleaning)
- In-Network: No Coins – 0.00 Copay

Diagnostic procedures/lab services/imaging

Diagnostic radiology services (e.g., MRI)
- $0-250 copay (Authorization Required, Referral Required)
Diagnostic tests and procedures
- $0-50 copay (Authorization Required, Referral Required)
Lab services
- $0 copay (Authorization Required, Referral Required)
Outpatient x-rays
- $0 copay (Authorization Required, Referral Required)

Doctor visits

Specialist
- $25 copay per visit (Authorization Required, Referral Required)
Primary
- $0 copay

Emergency care/Urgent care

Emergency
- $125 copay per visit (always covered)
Urgent care
- $50 copay per visit (always covered)

Foot care (podiatry services)

Foot exams and treatment
- $40 copay (Authorization Required, Referral Required)
Routine foot care
- Not covered

Ground ambulance

- $250 copay

Health plan deductible

- $0

Hearing

Hearing aids OTC
- Not covered
Medicare-Covered Hearing Exam
- $25 copay
Fitting/evaluation
- $0 copay
Hearing aids
- $699-999 copay (Limits Apply)

Inpatient hospital coverage

- $325 per day for days 1 through 8
  $0 per day for days 9 through 90 (Authorization Required, Referral Required)

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)

- $5,500 In-network

Medical equipment/supplies

Diabetes supplies
- 0-20% coinsurance per item (Authorization Required)
Durable medical equipment (e.g., wheelchairs, oxygen)
- 20% coinsurance per item (Authorization Required)
Prosthetics (e.g., braces, artificial limbs)
- 20% coinsurance per item (Authorization Required)

Medicare Part B drugs

Other Part B drugs
- 0-20% coinsurance (Authorization Required)
Chemotherapy
- 0-20% coinsurance (Authorization Required)

Mental health services

Outpatient individual therapy visit
- $40 copay (Authorization Required, Referral Required)
Outpatient group therapy visit with a psychiatrist
- $40 copay (Authorization Required, Referral Required)
Inpatient hospital – psychiatric
- $250 per day for days 1 through 7
  $0 per day for days 8 through 90 (Authorization Required, Referral Required)
Outpatient group therapy visit
- $40 copay (Authorization Required, Referral Required)
Outpatient individual therapy visit with a psychiatrist
- $40 copay (Authorization Required, Referral Required)

Optional supplemental benefits

- No

Other health plan deductibles?

- In-Network: No

Outpatient hospital coverage

- $250 copay per visit (Authorization Required, Referral Required)

Preventive care

- $0 copay

Rehabilitation services

Occupational therapy visit
- $40 copay (Authorization Required, Referral Required)
Physical therapy and speech and language therapy visit
- $40 copay (Authorization Required, Referral Required)

Skilled Nursing Facility

- $0 per day for days 1 through 20
  $214 per day for days 21 through 49
  $0 per day for days 50 through 100 (Authorization Required, Referral Required)

Transportation

- Not covered

Vision

Eyeglasses (frames and lenses)
- Not covered
Upgrades
- Not covered
Eyeglass frames
- $0 copay (Limits Apply)
Eyeglass lenses
- $0 copay (Limits Apply)
Routine eye exam
- $0 copay (Limits Apply)
Contact lenses
- $0 copay (Limits Apply)
Other
- Not covered

Wellness programs (e.g., fitness, nursing hotline)

- Covered