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MediBlue (HMO) Plans and Benefits

PW_B135974
2011 Medicare Advantage Summary of Benefits (SOB) and Evidence of Coverage (EOC) for Individual Medicare Advantage Products. If the product you are searching for is not on the list below, then please call the number on the back of the member’s ID card for EOC and SOB information. 

Empire Blue Cross 
     
HMO 
     
Empire MediBlue Plus 
SOB 
EOC 
Empire MediBlue Essential*
*No Part D Coverage 
SOB  
EOC 
 
       
PPO 
     
Empire MediBlue Freedom I 
SOB 
EOC 
Empire MediBlue Freedom II 
SOB 
EOC 
Empire MediBlue Freedom III 
SOB 
EOC 
Additional Part D Forms 
     
     
     
       
Empire Blue Cross and Blue Shield 
     
HMO 
     
Empire MediBlue Plus (A) 
SOB 
EOC 
Empire MediBlue Plus (D) 
SOB 
EOC 
Empire MediBlue Plus (F) 
SOB 
EOC 
Empire MediBlue Select (G)  
SOB 
EOC 
Empire MediBlue Select (D)  
SOB 
EOC 
Empire MediBlue Essential* (H)  
*No Part D Coverage 
SOB 
EOC  
 
       
PPO 
     
Empire MediBlue Freedom I (B)
Empire MediBlue Freedom I (C)
Empire MediBlue Freedom I (A)
Empire MediBlue Freedom II (A)
Empire MediBlue Freedom II (B)
Empire MediBlue Freedom II (C)
Empire MediBlue Freedom III (B)
Empire MediBlue Freedom III (C)
 
Empire MediBlue Freedom III (A) 
Empire MediBlue Freedom III (A) 
SOB
 
SOB
 
SOB
 
SOB
 
SOB
 
SOB
 
SOB
 
SOB
 
SOB 
EOC
 
EOC
 
EOC
 
EOC
 
EOC
 
EOC
 
EOC
 
EOC
 
EOC 
       
Additional Part D Forms 
     
     
     
Express Scripts, Inc. is a separate company that provides pharmacy services and pharmacy benefit management services on behalf of health plan members. 
     
 
(A) Suffolk County 
(B) Bronx, Kings, Nassau, New York, Queens, and Richmond Counties 
(C) Columbia, Delaware, Dutchess, Greene, Orange, Putnam, Rockland, Sullivan, Ulster, and Westchester 
(D) Nassau  
(E) Dutchess, Orange, Putnam, Rockland, Sullivan, Ulster, and Westchester 
(F) Bronx, Kings, New York, Queens, and Richmond Counties 
(G) Rockland, Westchester and Mid-Hudson Valley 
(H) New York City, Nassau, Rockland, Westchester, and Mid-Hudson Vally 
©2014 Empire BlueCross BlueShield

Services provided by Empire HealthChoice HMO, Inc. and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans, serving residents and businesses in the 28 eastern and southeastern counties of New York State. All external sites will open in a new browser window. Please view our Website Privacy Policy for more information.