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Topeka Region (Douglas, Jackson, Jefferson, Osage, Pottawatomie, Shawnee, Wabaunsee) Blue Medicare Advantage (PPO) 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 $800 annual allowance for preventive services
Optional: Comprehensive Dental Add $21 premium - $1,000 allowance for minor comprehensive services
Vision One routine eye exam + $150 eyewear allowance
Fitness SilverSneakers® gym membership
Over-the-Counter (OTC) Not offered $25 quarterly retail and mail-order allowance
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 $5 copay $12 copay $3 copay $10 copay
Tier 2 $7 copay $14 copay $5 copay $12 copay
Tier 3 $47 copay $45 copay
Tier 4 $100 copay $100 copay
Tier 5 33% coinsurance 30% coinsurance
Mail Order Preferred Standard Preferred Standard
Tier 1 Not Applicable $5 copay Not Applicable $3 copay
Tier 2 $7 copay $5 copay
Tier 3 $47 copay $45 copay
Tier 4 $100 copay $100 copay
Tier 5 33% coinsurance 30% coinsurance
  Medicare Advantage plans will be available starting October 15.
Summary of Benefits (PDF) Medicare Advantage 2020 Summary of Benefits
Planes de salud 2020 resumen de beneficios
Evidence of Coverage (PDF) Blue Medicare Advantage (PPO) Evidence of Coverage Blue Medicare Advantage Comprehensive (PPO) Evidence of Coverage

†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)
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 + minor comprehensive services $2,000 allowance for preventive services + minor comprehensive services
Vision One routine eye exam + $150 eyewear allowance
Fitness SilverSneakers® gym membership
Over-the-Counter (OTC) $25 quarterly retail and mail-order allowance
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 $5 copay $12 copay $3 copay $10 copay
Tier 2 $7 copay $14 copay $5 copay $12 copay
Tier 3 $47 copay $45 copay
Tier 4 $100 copay $100 copay
Tier 5 33% coinsurance 30% coinsurance
Mail Order Preferred Standard Preferred Standard
Tier 1 Not Applicable $5 copay Not Applicable $3 copay
Tier 2 $7 copay $5 copay
Tier 3 $47 copay $45 copay
Tier 4 $100 copay $100 copay
Tier 5 33% coinsurance 30% coinsurance
  Medicare Advantage plans will be available starting October 15.
Summary of Benefits (PDF) Medicare Advantage 2020 Summary of Benefits
Planes de salud 2020 resumen de beneficios
Evidence of Coverage (PDF) Blue Medicare Advantage (PPO) Evidence of Coverage Blue Medicare Advantage Comprehensive (PPO) Evidence of Coverage

†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* $105.31 $129.43 $55.91 $94.13 $60.44 $47.78 $81.54 $99.68 $72.13
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         $5,560 $5,560 $2,780    
After you pay this deductible     $2,180            
  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* $105.31 $129.43 $55.91 $94.13 $60.44 $47.78 $81.54 $99.68 $72.13
  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, 2020 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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Upcoming Seminars


We are currently planning our 2020 seminars. Please check back in January for our 2020 Medicare & You seminar schedule.

Call now 866-627-6705 (TTY 711)

Medicare Advantage: 8 a.m. to 8 p.m. Sunday-Saturday

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

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