2011 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | BlueMedicare PPO (PPO) | ||||
Location: | Sarasota, Florida Click to see other locations | ||||
Plan ID: | H5434 - 002 - 0 Click to see other plans | ||||
Member Services: | 1-800-926-6565 TTY users 1-800-955-8771 | ||||
— 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 BlueMedicare PPO (PPO) benefit details | |||||
— Medicare Plan Features — | |||||
Monthly Premium: | $150.00 (see Plan Premium Details below) | ||||
Annual Rx Deductible: | $150 | ||||
Annual Rx Initial Coverage Limit (ICL): | $2,840 | ||||
Health Plan Type: | Local PPO | ||||
Maximum Out-of-Pocket Limit for Parts A & B (MOOP): | $6,700 | ||||
Additional Rx Gap Coverage? | No additional gap coverage, only the Donut Hole Discount | ||||
Total Number of Formulary Drugs: | 3,599 drugs | Browse the BlueMedicare PPO (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: | $6.00 | $45.00 | $89.00 | 25% | |
• Number of Drugs per Tier: | 1636 | 357 | 1384 | 222 | |
Plan's Pharmacy Search: | http://www.myprime.com | ||||
Number of Members enrolled in this plan in (H5434 - 002): | 2,476 members | ||||
— Plan Premium Details — | |||||
Monthly Premium with Extra Help Low-Income Subsidy (LIS): ❔ | 100% Subsidy | 75% Subsidy | 50% Subsidy | 25% Subsidy | |
Monthly Part D Premium with LIS: | $0.00 | $0.00 | $0.00 | $0.00 | |
— Plan Health Benefits — | |||||
** Cost ** | |||||
Premium and Other Important Information | |||||
$150 monthly plan premium in addition to your monthly Medicare Part B premium. | |||||
Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However some people will pay higher Part B and Part D premiums because of their yearly income (over $85 000 for singles $170 000 for married couples). For more information about Part B and Part D premiums based on income call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may also call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. | |||||
This plan covers all Medicare-covered preventive services with zero cost sharing. | |||||
$6 700 out-of-pocket limit. | |||||
All plan services included. | |||||
$1 000 yearly deductible. Contact the plan for services that apply. | |||||
$10 000 out-of-pocket limit. | |||||
All plan services included. | |||||
** Doctor and Hospital Choice ** | |||||
Doctor and Hospital Choice | |||||
No referral required for network doctors specialists and hospitals. | |||||
You can go to doctors specialists and hospitals in or out of the network. It will cost more to get out of network benefits. | |||||
Plan covers you when you travel in the U.S. | |||||
** Extra Benefits ** | |||||
Prescription Drugs | |||||
20% of the cost for Part B-covered chemotherapy drugs and other Part B-covered drugs. | |||||
30% of the cost for Part B drugs out-of-network. | |||||
This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at www.myprime.com on the web. | |||||
Different out-of-pocket costs may apply for people who
| |||||
The plan offers national in-network prescription coverage (i.e. this would include 50 states and DC). This means that you will pay the same cost-sharing amount for your prescription drugs if you get them at an in-network pharmacy outside of the plan's service area (for instance when you travel). | |||||
Total yearly drug costs are the total drug costs paid by both you and the plan. | |||||
The plan may require you to first try one drug to treat your condition before it will cover another drug for that condition. | |||||
Some drugs have quantity limits. | |||||
Your provider must get prior authorization from BlueMedicare PPO (PPO) for certain drugs. | |||||
You must go to certain pharmacies for a very limited number of drugs due to special handling provider coordination or patient education requirements that cannot be met by most pharmacies in your network. These drugs are listed on the plan's website formulary printed materials as well as on the Medicare Prescription Drug Plan Finder on Medicare.gov. | |||||
If the actual cost of a drug is less than the normal cost-sharing amount for that drug you will pay the actual cost not the higher cost-sharing amount. | |||||
If you request a formulary exception for a drug and BlueMedicare PPO (PPO) approves the exception you will pay Tier 3: Non-Preferred Brand Drugs cost sharing for that drug. | |||||
$150 yearly deductible. | |||||
After you pay your yearly deductible you pay the following until total yearly drug costs reach $2 840: | |||||
Tier 1: Generic Drugs | |||||
Tier 2: Preferred Brand Drugs | |||||
Tier 3: Non-Preferred Brand Drugs | |||||
Tier 4: Specialty Tier Drugs | |||||
Tier 1: Generic Drugs | |||||
Tier 2: Preferred Brand Drugs | |||||
Tier 3: Non-Preferred Brand Drugs | |||||
Tier 4: Specialty Tier Drugs | |||||
Tier 1: Generic Drugs | |||||
Tier 2: Preferred Brand Drugs | |||||
Tier 3: Non-Preferred Brand Drugs | |||||
Tier 4: Specialty Tier Drugs | |||||
After your total yearly drug costs reach $2 840 you receive a discount on brand name drugs and pay 93% of the plan's costs for all generic drugs until your yearly out-of-pocket drug costs reach $4 550. | |||||
After your yearly out-of-pocket drug costs reach $ 4 550 you pay the greater of:
| |||||
Plan drugs may be covered in special circumstances for instance illness while traveling outside of the plan's service area where there is no network pharmacy. You may have to pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy. In addition you will likely have to pay the pharmacy's full charge for the drug and submit documentation to receive reimbursement from BlueMedicare PPO (PPO). | |||||
After you pay your yearly deductible you will be reimbursed up to the full cost of the drug minus the following for drugs purchased out-of-network until total yearly drug costs reach $2 840: | |||||
Tier 1: Generic Drugs | |||||
Tier 2: Preferred Brand Drugs | |||||
Tier 3: Non-Preferred Brand Drugs | |||||
Tier 4: Specialty Tier Drugs | |||||
You will be reimbursed up to 7% of the plan allowable cost for generic drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 550. | |||||
You will be reimbursed up to the discounted price for brand name drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 550. | |||||
After your yearly out-of-pocket drug costs reach $ 4 550 you will be reimbursed for drugs purchased out-of-network up to the full cost of the drug minus your cost share which is the greater of:
| |||||
Physical Exams | |||||
$0 copay for routine exams. | |||||
Limited to 1 exam(s) every year. | |||||
30% of the cost for routine exams. | |||||
Vision Services | |||||
Non-Medicare-covered eye exams and glasses not covered. | |||||
$0 copay for
| |||||
30% of the cost for eye exams. | |||||
30% of the cost for eye wear. | |||||
Dental Services | |||||
In general preventive dental benefits (such as cleaning) not covered. | |||||
$50 copay for Medicare-covered dental benefits. | |||||
30% of the cost for comprehensive dental benefits. | |||||
** Important Information ** | |||||
Premium and Other Important Information | |||||
$150 monthly plan premium in addition to your monthly Medicare Part B premium. | |||||
Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However some people will pay higher Part B and Part D premiums because of their yearly income (over $85 000 for singles $170 000 for married couples). For more information about Part B and Part D premiums based on income call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may also call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. | |||||
This plan covers all Medicare-covered preventive services with zero cost sharing. | |||||
$6 700 out-of-pocket limit. | |||||
All plan services included. | |||||
$1 000 yearly deductible. Contact the plan for services that apply. | |||||
$10 000 out-of-pocket limit. | |||||
All plan services included. | |||||
Doctor and Hospital Choice | |||||
No referral required for network doctors specialists and hospitals. | |||||
You can go to doctors specialists and hospitals in or out of the network. It will cost more to get out of network benefits. | |||||
Plan covers you when you travel in the U.S. | |||||
** Inpatient Care ** | |||||
Inpatient Hospital Care (Acute) | |||||
No limit to the number of days covered by the plan each benefit period. | |||||
For Medicare-covered hospital stays: | |||||
Days 1 - 7: $225 copay per day | |||||
Days 8 - 90: $0 copay per day | |||||
$0 copay for additional hospital days | |||||
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital. | |||||
30% of the cost for each hospital stay. | |||||
Inpatient Mental Health Care | |||||
You get up to 190 days in a Psychiatric Hospital in a lifetime. | |||||
For Medicare-covered hospital stays: | |||||
Days 1 - 7: $225 copay per day | |||||
Days 8 - 90: $0 copay per day | |||||
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital. | |||||
30% of the cost for each hospital stay. | |||||
Skilled Nursing Facility (SNF) | |||||
Authorization rules may apply. | |||||
Plan covers up to 100 days each benefit period | |||||
No prior hospital stay is required. | |||||
For Medicare-covered SNF stays: | |||||
Days 1 - 6: $0 copay per day | |||||
Days 7 - 25: $50 copay per day | |||||
Days 26 - 100: $0 copay per day | |||||
30% of the cost for each SNF stay. | |||||
Home Health Care | |||||
$0 copay for Medicare-covered home health visits. | |||||
$0 copay for home health visits. | |||||
Hospice | |||||
You must get care from a Medicare-certified hospice. | |||||
** Outpatient Care ** | |||||
Doctor Office Visits | |||||
See 'Welcome to Medicare; and Annual Wellness Visit' for more information. | |||||
$15 copay for each primary care doctor visit for Medicare-covered benefits. | |||||
$15 to $25 copay for each in-area network urgent care Medicare-covered visit. | |||||
$50 copay for each specialist visit for Medicare-covered benefits. | |||||
30% for each primary care doctor visit. | |||||
30% for each specialist visit. | |||||
Chiropractic Services | |||||
$15 to $40 copay for each Medicare-covered visit. | |||||
Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part) if you get it from a chiropractor or other qualified providers. | |||||
30% of the cost for chiropractic benefits. | |||||
Podiatry Services | |||||
$50 copay for each Medicare-covered visit. | |||||
$50 copay for up to 6 routine visit(s) every year | |||||
Medicare-covered podiatry benefits are for medically-necessary foot care. | |||||
30% of the cost for podiatry benefits. | |||||
Outpatient Mental Health Care | |||||
$40 copay for each Medicare-covered individual or group therapy visit. | |||||
30% of the cost for Mental Health benefits. | |||||
30% of the cost for Mental Health benefits with a psychiatrist. | |||||
Outpatient Substance Abuse Care | |||||
$40 copay for Medicare-covered individual or group visits. | |||||
30% of the cost for outpatient substance abuse benefits. | |||||
Outpatient Hospital Services | |||||
$50 copay for each Medicare-covered ambulatory surgical center visit. | |||||
$15 to $150 copay for each Medicare-covered outpatient hospital facility visit. | |||||
30% of the cost for ambulatory surgical center benefits. | |||||
30% of the cost for outpatient hospital facility benefits. | |||||
Emergency Care | |||||
$50 copay for Medicare-covered emergency room visits. | |||||
Worldwide coverage. | |||||
If you are immediately admitted to the hospital you pay $0 for the emergency room visit | |||||
Outpatient Rehabilitation Services | |||||
$15 to $50 copay for Medicare-covered Occupational Therapy visits. | |||||
$15 to $50 copay for Medicare-covered Physical and/or Speech and Language Therapy visits. | |||||
$50 copay for Medicare-covered Cardiac Rehab services. | |||||
30% of the cost for Occupational Therapy benefits. | |||||
30% of the cost for Physical and/or Speech and Language Therapy visits. | |||||
30% of the cost for Cardiac Rehab services. | |||||
** Outpatient Medical Services and Supplies ** | |||||
Durable Medical Equipment | |||||
0% to 20% of the cost for Medicare-covered items. | |||||
30% of the cost for durable medical equipment. | |||||
Prosthetic Devices | |||||
$0 copay for Medicare-covered items. | |||||
30% of the cost for prosthetic devices. | |||||
Diabetes Self-Monitoring Training, Nutrition Therapy, and Supplies | |||||
$0 copay for Diabetes self-monitoring training. | |||||
$0 copay for Nutrition Therapy for Diabetes. | |||||
$0 copay for Diabetes supplies. | |||||
30% of the cost for Diabetes self-monitoring training. | |||||
30% of the cost for Nutrition Therapy for Diabetes. | |||||
30% of the cost for Diabetes supplies. | |||||
** Preventive Services ** | |||||
Bone Mass Measurement | |||||
$0 copay for Medicare-covered bone mass measurement | |||||
30% of the cost for Medicare-covered bone mass measurement. | |||||
Colorectal Screening Exams | |||||
$0 copay for
| |||||
No limit on the number of covered colorectal screenings. | |||||
30% of the cost for colorectal screenings. | |||||
Immunizations | |||||
$0 copay for Flu and Pneumonia vaccines. | |||||
$0 copay for Hepatitis B vaccine. | |||||
No referral needed for Flu and pneumonia vaccines. | |||||
30% of the cost for immunizations. | |||||
Pap Smears and Pelvic Exams | |||||
$0 copay for Medicare-covered pap smears and pelvic exams | |||||
No limit on the number of covered pap smears and pelvic exams. | |||||
30% of the cost for pap smears and pelvic exams. | |||||
Prostate Cancer Screening Exams | |||||
$0 copay for
| |||||
No limit on the number of covered prostate cancer screenings. | |||||
30% of the cost for prostate cancer screening. | |||||
** Additional Benefits ** | |||||
Dialysis | |||||
$25 copay for renal dialysis | |||||
$0 copay for Nutrition Therapy for End-Stage Renal Disease | |||||
$25 copay for renal dialysis. | |||||
30% of the cost for Nutrition Therapy for End-Stage Renal Disease. | |||||
Prescription Drugs | |||||
20% of the cost for Part B-covered chemotherapy drugs and other Part B-covered drugs. | |||||
30% of the cost for Part B drugs out-of-network. | |||||
This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at www.myprime.com on the web. | |||||
Different out-of-pocket costs may apply for people who
| |||||
The plan offers national in-network prescription coverage (i.e. this would include 50 states and DC). This means that you will pay the same cost-sharing amount for your prescription drugs if you get them at an in-network pharmacy outside of the plan's service area (for instance when you travel). | |||||
Total yearly drug costs are the total drug costs paid by both you and the plan. | |||||
The plan may require you to first try one drug to treat your condition before it will cover another drug for that condition. | |||||
Some drugs have quantity limits. | |||||
Your provider must get prior authorization from BlueMedicare PPO (PPO) for certain drugs. | |||||
You must go to certain pharmacies for a very limited number of drugs due to special handling provider coordination or patient education requirements that cannot be met by most pharmacies in your network. These drugs are listed on the plan's website formulary printed materials as well as on the Medicare Prescription Drug Plan Finder on Medicare.gov. | |||||
If the actual cost of a drug is less than the normal cost-sharing amount for that drug you will pay the actual cost not the higher cost-sharing amount. | |||||
If you request a formulary exception for a drug and BlueMedicare PPO (PPO) approves the exception you will pay Tier 3: Non-Preferred Brand Drugs cost sharing for that drug. | |||||
$150 yearly deductible. | |||||
After you pay your yearly deductible you pay the following until total yearly drug costs reach $2 840: | |||||
Tier 1: Generic Drugs | |||||
Tier 2: Preferred Brand Drugs | |||||
Tier 3: Non-Preferred Brand Drugs | |||||
Tier 4: Specialty Tier Drugs | |||||
Tier 1: Generic Drugs | |||||
Tier 2: Preferred Brand Drugs | |||||
Tier 3: Non-Preferred Brand Drugs | |||||
Tier 4: Specialty Tier Drugs | |||||
Tier 1: Generic Drugs | |||||
Tier 2: Preferred Brand Drugs | |||||
Tier 3: Non-Preferred Brand Drugs | |||||
Tier 4: Specialty Tier Drugs | |||||
After your total yearly drug costs reach $2 840 you receive a discount on brand name drugs and pay 93% of the plan's costs for all generic drugs until your yearly out-of-pocket drug costs reach $4 550. | |||||
After your yearly out-of-pocket drug costs reach $ 4 550 you pay the greater of:
| |||||
Plan drugs may be covered in special circumstances for instance illness while traveling outside of the plan's service area where there is no network pharmacy. You may have to pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy. In addition you will likely have to pay the pharmacy's full charge for the drug and submit documentation to receive reimbursement from BlueMedicare PPO (PPO). | |||||
After you pay your yearly deductible you will be reimbursed up to the full cost of the drug minus the following for drugs purchased out-of-network until total yearly drug costs reach $2 840: | |||||
Tier 1: Generic Drugs | |||||
Tier 2: Preferred Brand Drugs | |||||
Tier 3: Non-Preferred Brand Drugs | |||||
Tier 4: Specialty Tier Drugs | |||||
You will be reimbursed up to 7% of the plan allowable cost for generic drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 550. | |||||
You will be reimbursed up to the discounted price for brand name drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 550. | |||||
After your yearly out-of-pocket drug costs reach $ 4 550 you will be reimbursed for drugs purchased out-of-network up to the full cost of the drug minus your cost share which is the greater of:
| |||||
Dental Services | |||||
In general preventive dental benefits (such as cleaning) not covered. | |||||
$50 copay for Medicare-covered dental benefits. | |||||
30% of the cost for comprehensive dental benefits. | |||||
Hearing Services | |||||
In general routine hearing exams and hearing aids not covered. | |||||
30% of the cost for hearing exams. | |||||
Vision Services | |||||
Non-Medicare-covered eye exams and glasses not covered. | |||||
$0 copay for
| |||||
30% of the cost for eye exams. | |||||
30% of the cost for eye wear. | |||||
Physical Exams | |||||
$0 copay for routine exams. | |||||
Limited to 1 exam(s) every year. | |||||
30% of the cost for routine exams. | |||||
Health/Wellness Education | |||||
The plan covers the following health/wellness education benefits: | |||||
$0 copay for each Medicare-covered smoking cessation counseling session. | |||||
$0 copay for each Medicare-covered HIV screening. | |||||
HIV screening is covered for people with Medicare who are pregnant and people at increased risk for the infection including anyone who asks for the test. Medicare covers this test once every 12 months or up to three times during a pregnancy. | |||||
$0 copay for Health and Wellness services. | |||||
Transportation | |||||
This plan does not cover routine transportation. | |||||
Acupuncture | |||||
This plan does not cover Acupuncture. |