Basic Benefits:
*In order to receive full benefits, dental services must be performed by a United Concordia contracted dental provider in the Advantage Plus network. To find a dentist in the United Concordia contracted dental provider network, visit www.bcbsla.com/findcare and search the dental directory.
Options of BlueChoice 65:
Benefits and Premium Information:
Benefit Chart
Plan Name |
A |
B |
F |
G** |
N |
|---|---|---|---|---|---|
| Here are the basics | |||||
| Basic, including 100% Part B coinsurance |  |
|
|
|
Basic, including 100% Part B coinsurance, except up to $20 copayment for office visit, and up to $50 copayment for ER |
| Skilled nursing facility coinsurance |  |
|
|
||
| Part A deductible | |
|
|
|
|
| Part B deductible | |
||||
| Part B excess (100%) | |
|
|||
| Foreign Travel Emergency (80%) | |
|
|
||
Plan Name |
A |
||
|---|---|---|---|
| Here are the basics | |||
| Basic, including 100% Part B coinsurance | |
||
| Skilled nursing facility coinsurance | |||
| Part A deductible | |||
| Part B deductible | |||
| Part B excess (100%) | |||
| Foreign Travel Emergency | |||
Plan Name |
B |
||
|---|---|---|---|
| Here are the basics | |||
| Basic, including 100% Part B coinsurance | |
||
| Skilled nursing facility coinsurance | |||
| Part A deductible |
|
||
| Part B deductible | |||
| Part B excess (100%) | |||
| Foreign Travel Emergency | |||
Plan Name |
F |
||
|---|---|---|---|
| Here are the basics | |||
| Basic, including 100% Part B coinsurance | |
||
| Skilled nursing facility coinsurance | |
||
| Part A deductible | |
||
| Part B deductible | |
||
| Part B excess (100%) | |
||
| Foreign Travel Emergency | |
||
Plan Name |
G |
||
|---|---|---|---|
| Here are the basics | |||
| Basic, including 100% Part B coinsurance | |
||
| Skilled nursing facility coinsurance | |
||
| Part A deductible | |
||
| Part B deductible | |||
| Part B excess (100%) | |
||
| Foreign Travel Emergency | |
||
Plan Name |
N |
||
|---|---|---|---|
| Here are the basics | |||
| Basic, including 100% Part B coinsurance | Basic, including 100% Part B coinsurance, except up to $20 copayment for office visit, and up to $50 copayment for ER | ||
| Skilled nursing facility coinsurance | |
||
| Part A deductible | |
||
| Part B deductible | |||
| Part B excess (100%) | |||
| Foreign Travel Emergency | |
||
2023-24 Monthly Premium Rates
BlueChoice 65 SELECT PLUS Rates effective May 1, 2023
Plan Name |
G |
|---|---|
Age:Under 65 |
$369.90 |
| 65 | $118.60 |
| 66-68 | $126.90 |
| 69-71 | $136.40 |
| 72-74 | $143.60 |
| 75-77 | $52.60 |
| 78-80 | $158.50 |
| 81+ | $162.40 |
Plan Name |
G |
|---|---|
Age:Under 65 |
$423.60 |
| 65 | $133.40 |
| 66-68 | $143.10 |
| 69-71 | $154.10 |
| 72-74 | $162.40 |
| 75-77 | $172.80 |
| 78-80 | $179.30 |
| 81+ | $183.90 |
BlueChoice 65, BlueChoice 65 SELECT, BlueChoice 65 PLUS Plan G, and BlueChoice 65 SELECT PLUS Plan G are not connected with or endorsed by the U.S. government or the federal Medicare program. Please see your agent for benefit exclusions, limitations and reductions.
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