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Summary of Benefits (SOB)

The Summary of Benefits tells you some of the features of our plans, but it does not list every service that we cover, nor does it list every limitation or exclusion. To get a complete list of our benefits, please consult the Evidence of Coverage.

Evidence of Coverage (EOC)

The Evidence of Coverage (sometimes called the "EOC") explains how to get your Medicare services. The Evidence of Coverage, together with your enrollment form and any amendments that we may send you, is our contract with you. It explains your rights, benefits and responsibilities as a member, and it also explains our responsibilities to you.

Blue Advantage (HMO)

Blue Advantage (PPO)

Please note that chapter 9, sections 1-10 of the EOC describe our grievance, initial organizational & coverage determination (including exceptions) and appeals processes.

Annual Notice of Change (ANOC)

Each year, prior to the start of the Annual Enrollment Period (AEP), we will mail you an Annual Notice Of Change (ANOC). This notice highlights all of the important plan benefit changes that will take effect on the first day of the following plan year. We also recommend you review our drug formulary to be sure the medicine(s) you take will remain covered in the new plan year. Also, review the Provider Directory to confirm your physician(s) remain contracted with us. If you have any questions about this notice, please contact Customer Service.

Blue Advantage (HMO)

Blue Advantage (PPO)

Y0132_19-529_ITLU - Last updated 01/30/2020