BCN Advantage ConnectedCare (HMO)
Available to residents of Washtenaw County, MI for 2026. Contract H5883, plan 007, segment 0.
- ✉ Email a copy of the plan benefit details
- Plan health benefits
- Benefits in plain text
- Rx cost-sharing for all pharmacies and tiers
- Other plans in Washtenaw County
- Plan website
- Browse the BCN Advantage ConnectedCare (HMO) formulary
Renewed for 2026. CMS carries this plan forward from 2025.
Plan details
| Monthly premium (Part C + D) | $41.00 |
|---|---|
| — medical (Part C) part | $41.00 |
| — drug (Part D) part | $0.00? |
| Monthly premium with full Extra Help (LIS) | $41.00?drug (Part D) part $0.00; Extra Help does not cover the medical (Part C) premium |
| Part B premium reduction (giveback) | None |
| Health plan deductible (in-network) | None |
| In-network out-of-pocket maximum | $4,400.00? |
| Drug deductible | $125.00Tier 1 and 2 exempt |
| Drug out-of-pocket threshold | $2,100.00 |
| Plan type | HMO? |
| Contract / plan | H5883-007-0 |
| Offered by | Blue Care Network |
| Parent organization | Blue Cross Blue Shield of Michigan Mutual Ins. Co. |
| Formulary drugs | 3,083 |
| Formulary exception tier | 4? |
| Pharmacy search | www.bcbsm.com/pharmaciesmedicare |
| Member services | (855)425-7720TTY 711 |
CMS star ratings
- Overall
- 4.5 out of 5 stars for Overall
- Health plan (Part C)
- 4.5 out of 5 stars for Health plan (Part C)
- Drug plan (Part D)
- 3.5 out of 5 stars for Drug plan (Part D)
Published per contract — every plan under contract H5883 shares this rating.
Plan health benefits
| Service | In-network |
|---|---|
| Doctor visits | |
| Primary care doctor | $0 copay |
| Specialist | $35 copay(authorization required) |
| Other health care professional | $0–$35 copay(authorization required) |
| Additional telehealth services | $0 copay |
| Preventive care | |
| Medicare-covered preventive services | $0 copay |
| Annual physical exam | $0 copay |
| Kidney disease education | $0 copay |
| Glaucoma screening | $0 copay |
| Diabetes self-management training | $0 copay |
| Diagnostic tests, labs and imaging | |
| Diagnostic tests and procedures | $0–$20 copay(authorization required) |
| Lab services | $0 copay(authorization required) |
| Diagnostic radiology (e.g. MRI, CT) | $20–$100 copay(authorization required) |
| Therapeutic radiology | $25 copay(authorization required) |
| Outpatient x-rays | $20–$100 copay(authorization required) |
| Emergency and urgent care | |
| Emergency room | $130 copay |
| Urgent care | $0–$45 copay |
| Worldwide emergency coverage | $130 copay · $50,000 plan limit |
| Worldwide urgent care | $45 copay · $50,000 plan limit |
| Worldwide emergency transportation | $230 copay |
| Hospital care | |
| Inpatient hospital stay | $275 per day for days 1–7; $0 per day for days 8–90(authorization required) |
| Outpatient hospital services | $225 copay(authorization required) |
| Outpatient observation | $130 copay |
| Ambulatory surgical center | $0–$100 copay(authorization required) |
| Outpatient blood services | $0 copay |
| Skilled nursing and home health | |
| Skilled nursing facility | $0 per day for days 1–20; $218 per day for days 21–100(authorization required) |
| Home health care | $0 copay |
| Kidney dialysis | 20% coinsurance |
| Rehabilitation | |
| Occupational therapy | $40 copay(authorization required) |
| Physical therapy and speech-language therapy | $40 copay(authorization and referral required) |
| Cardiac rehabilitation | $15 copay(authorization required) |
| Pulmonary rehabilitation | $10 copay(authorization required) |
| Mental health and substance use | |
| Inpatient psychiatric hospital stay | $275 per day for days 1–7; $0 per day for days 8–90(authorization required) |
| Outpatient mental health, individual session | $20 copay |
| Outpatient mental health, group session | $20 copay |
| Psychiatrist, individual session | $20 copay |
| Psychiatrist, group session | $20 copay |
| Partial hospitalization | $55 copay(authorization required) |
| Intensive outpatient program | $55 copay |
| Outpatient substance use, individual session | $35 copay |
| Outpatient substance use, group session | $35 copay |
| Opioid treatment program | $0 copay |
| Ambulance and transportation | |
| Ground ambulance | $230 copay |
| Air ambulance | $230 copay |
| Transportation to plan-approved locations | Not covered |
| Medical equipment and supplies | |
| Durable medical equipment (e.g. wheelchairs, oxygen) | 0%–20% coinsurance(authorization required) |
| Prosthetics (e.g. braces, artificial limbs) | 20% coinsurance(authorization required) |
| Medical supplies | 20% coinsurance(authorization required) |
| Diabetes supplies | 0%–20% coinsurance(authorization required) |
| Diabetic therapeutic shoes or inserts | $0 copay(authorization required) |
| Chiropractic, acupuncture and foot care | |
| Chiropractic (Medicare-covered) | $15 copay(authorization required) |
| Routine chiropractic care | $35 copay(authorization required, limits apply) |
| Acupuncture | Not covered |
| Foot exams and treatment (Medicare-covered) | $35 copay(authorization required) |
| Routine foot care | Not covered |
| Dental? | |
| Preventive dental plan limit | $1,500 plan limit every year |
| Oral exams | $0 copay(limits apply) |
| Cleanings | $0 copay(limits apply) |
| Fluoride treatment | $0 copay(limits apply) |
| Dental x-rays | $0 copay(limits apply) |
| Other diagnostic dental services | Not covered |
| Other preventive dental services | Not covered |
| Restorative services (fillings, crowns) | $0 copay(limits apply) |
| Endodontics (root canals) | $0 copay(limits apply) |
| Periodontics (gum disease) | $0 copay(limits apply) |
| Dentures and other removable prosthodontics | Optional supplemental benefit (extra premium) |
| Maxillofacial prosthetics | Not covered |
| Implants | Optional supplemental benefit (extra premium) |
| Bridges and other fixed prosthodontics | Optional supplemental benefit (extra premium) |
| Oral and maxillofacial surgery | $0 copay(limits apply) |
| Orthodontics | Not covered |
| Adjunctive general services | Optional supplemental benefit (extra premium) |
| Vision? | |
| Eye exam (Medicare-covered) | $0–$35 copay |
| Routine eye exam | $0 copay(limits apply) |
| Eyewear after cataract surgery (Medicare-covered) | $0 copay |
| Contact lenses | Not covered |
| Eyeglasses (frames and lenses) | Not covered |
| Eyeglass lenses | Not covered |
| Eyeglass frames | Not covered |
| Eyewear upgrades | Not covered |
| Hearing? | |
| Hearing exam (Medicare-covered) | $0–$35 copay |
| Routine hearing exam | $0 copay(limits apply) |
| Hearing aid fitting and evaluation | $0 copay |
| Hearing aids (all types) | $495–$1,695 copay(limits apply) |
| Hearing aids, inner ear | Not covered |
| Hearing aids, outer ear | Not covered |
| Hearing aids, over the ear | Not covered |
| Medicare Part B drugs | |
| Part B insulin | 0%–20% coinsurance(authorization required, step therapy may apply) |
| Chemotherapy and radiation drugs | 0%–20% coinsurance(authorization required, step therapy may apply) |
| Other Part B drugs | 0%–20% coinsurance(authorization required, step therapy may apply) |
| Other extra benefits? | |
| Over-the-counter (OTC) allowance | $50 allowance every three months |
| Meals after a hospital stay or for a chronic condition | $0 copay |
| Fitness benefit | $0 copay |
| Health education | Not covered |
| Nutritional / dietary benefit | $0 copay |
| Extra smoking and tobacco cessation counseling | $0 copay |
| Enhanced disease management | Not covered |
| Telemonitoring | Not covered |
| Remote access technologies (web/phone, nurse line) | $0 copay |
| Home and bathroom safety devices | Not covered |
| Counseling services | Not covered |
| In-home safety assessment | Not covered |
| Personal emergency response system (PERS) | Not covered |
| Medical nutrition therapy | Not covered |
| Post-discharge in-home medication reconciliation | Not covered |
| Re-admission prevention | Not covered |
| Wigs for hair loss from chemotherapy | Not covered |
| Weight management programs | Not covered |
| Alternative therapies | Not covered |
| Therapeutic massage | Not covered |
| Adult day health services | Not covered |
| Home-based palliative care | Not covered |
| In-home support services | Not covered |
| Support for caregivers | Not covered |
In-network cost-sharing as the plan filed it with CMS (CMS plan benefit package (PBP) files, CY2026). A range means the cost depends on the service or setting. Rows the filing does not state are left out rather than guessed. Contact the plan for the full Evidence of Coverage.
Drug tiers — preferred pharmacy, initial coverage
| Tier | Cost-sharing |
|---|---|
| Tier 1 | $0.00 |
| Tier 2 | $2.00 |
| Tier 3 | 20% |
| Tier 4 | 25% |
| Tier 5 | 31% |
Rx cost-sharing by coverage phase
| Tier | 30-day supply | 90-day supply | ||||
|---|---|---|---|---|---|---|
| Preferred | Standard | Mail Order | Preferred | Standard | Mail Order | |
| Initial deductible phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $5.00 | $0.00 | $0.00 | $15.00 | $0.00 |
| Tier 2: Generic | $2.00 | $7.00 | $2.00 | $0.00 | $21.00 | $0.00 |
| Initial coverage phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $5.00 | $0.00 | $0.00 | $15.00 | $0.00 |
| Tier 2: Generic | $2.00 | $7.00 | $2.00 | $0.00 | $21.00 | $0.00 |
| Tier 3: Preferred Brand | 20% | 20% | 20% | 20% | 20% | 20% |
| Tier 4: Non-Preferred Drug | 25% | 25% | 25% | 25% | 25% | 25% |
| Tier 5: Specialty Tier | 31% | 31% | 31% | n/a | n/a | n/a |
| Catastrophic coverage phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 2: Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 3: Preferred Brand | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 4: Non-Preferred Drug | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 5: Specialty Tier | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
Also available in 10 other MI counties
Benefits in plain text
BCN Advantage ConnectedCare (HMO) (H5883-007-0) is a 2026 HMO Medicare Advantage plan offered by Blue Care Network, available to residents of Washtenaw County, MI.
The monthly premium is $41.00 (Part C and Part D together).
With full Extra Help (the Low-Income Subsidy), the total monthly premium is $41.00.
There is no in-network deductible for health services.
Its in-network out-of-pocket maximum is $4,400.00.
The drug deductible is $125.00. Tier 1 and 2 exempt.
The plan's formulary lists 3,083 drugs.
At a preferred pharmacy in the initial coverage phase, a 30-day supply costs tier 1: $0.00; tier 2: $2.00; tier 3: 20%; tier 4: 25%; tier 5: 31%.
CMS gives the plan's contract (H5883) an overall rating of 4.5 out of 5 stars.
Email a copy of the plan benefit details
Plan facts come from the CMS quarterly prescription drug plan public use files; the premium split, Extra Help premium, MOOP and plan type from the CMS Landscape file; the Part B giveback and health benefits from the CMS plan benefit package (PBP) files.