2010 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | BlueCross BlueShield Forever Blue Medicare PPO 755 (PPO) | ||||
Location: | Wyoming, New York Click to see other locations | ||||
Plan ID: | H5526 - 010 - 0 Click to see other plans | ||||
Member Services: | |||||
— This plan information is for research purposes only. — Click here to see plans for the current plan year | |||||
Medicare Contact Information: | Please go to Medicare.gov or call 1-800-MEDICARE (1-800-633-4227) to get information on all of your options. TTY users 1-877-486-2048 or contact your local SHIP for assistance |
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Email a copy of the BlueCross BlueShield Forever Blue Medicare PPO 755 (PPO) benefit details | |||||
— Medicare Plan Features — | |||||
Monthly Premium: | $265.00 | ||||
Annual Rx Deductible: | $0 | ||||
Annual Rx Initial Coverage Limit (ICL): | $2,830 | ||||
Health Plan Type: | Local PPO | ||||
Rx Gap Coverage? | Many Generics, Many Brand | ||||
Total Number of Formulary Drugs: | 3,061 drugs | Browse the BlueCross BlueShield Forever Blue Medicare PPO 755 (PPO) Formulary | |||
This plan has 4 drug tiers. See cost-sharing highlights below. | |||||
Formulary Drug Details: | Tier 1 | Tier 2 | Tier 3 | Tier 4 | Tier 5 |
• Preferred Pharmacy Cost-Sharing during initial coverage phase: | $5.00 | $25.00 | $40.00 | 30% | |
• Number of Drugs per Tier: | 1768 | 898 | 232 | 163 | |
Number of Members enrolled in this plan in (H5526 - 010): | 1,319 members |