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2011 Medicare Advantage Plan Benefit Details for the Blue Medicare PPO Enhanced (PPO) - H3404-001-0
This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.

2011 Medicare Advantage Plan Details
Medicare Plan Name:Blue Medicare PPO Enhanced (PPO)
Location:Person, North Carolina     Click to see other locations
Plan ID:H3404 - 001 - 0     Click to see other plans
Member Services:1-877-494-7647 TTY users 1-888-451-9957
— 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
Email a copy of the Blue Medicare PPO Enhanced (PPO) benefit details
— Medicare Plan Features —
Monthly Premium:$62.00 (see Plan Premium Details below)
Annual Deductible:$0
Annual Initial Coverage Limit (ICL):$2,840
Health Plan Type:Local PPO
Maximum Out-of-Pocket Limit for Parts A & B (MOOP):$3,400
Additional Gap Coverage?No additional gap coverage, only the Donut Hole Discount
Total Number of Formulary Drugs:4,880 drugsBrowse the Blue Medicare PPO Enhanced (PPO) Formulary
This plan has 4 drug tiers. See cost-sharing highlights below.
Formulary Drug Details:Tier 1Tier 2Tier 3Tier 4Tier 5
• Preferred Pharmacy
  Cost-Sharing during
  initial coverage phase:		$7.00$40.00$80.0033% 
• Number of Drugs per
  Tier:		18786981927377
Plan's Pharmacy Search:http://www.bcbsnc.com/medicare/pharmacy-search.cfm
Number of Members enrolled in this plan in (H3404 - 001):5,945 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
$62 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.
$3 400 out-of-pocket limit.
This limit includes only Medicare-covered services.
$5 100 out-of-pocket limit.
In-Network: This limit includes only Medicare-covered services.
Out-Of-Network: This limit includes only Medicare-covered services.
** 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.
20% 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 http://www.bcbsnc.com/medicare/drug-search.cfm on the web.
Different out-of-pocket costs may apply for people who
  • have limited incomes
  • live in long term care facilities or
  • have access to Indian/Tribal/Urban (Indian Health Service).
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 Blue Medicare PPO Enhanced (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 Blue Medicare PPO Enhanced (PPO) approves the exception you will pay Tier 3: Non-Preferred Brand Drugs cost sharing for that drug.
$0 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
  • $7 copay for a one-month (30-day) supply of drugs in this tier
  • $40 copay for a one-month (30-day) supply of drugs in this tier
  • $80 copay for a one-month (30-day) supply of drugs in this tier
  • 33% coinsurance for a one-month (30-day) supply of drugs in this tier
  • $21 copay for a three-month (90-day) supply of drugs in this tier
  • $120 copay for a three-month (90-day) supply of drugs in this tier
  • $240 copay for a three-month (90-day) supply of drugs in this tier
  • 33% coinsurance for a three-month (90-day) supply of drugs in this tier
  • $14 copay for a 60-day supply of drugs in this tier
  • $80 copay for a 60-day supply of drugs in this tier
  • $160 copay for a 60-day supply of drugs in this tier
  • 33% coinsurance for a 60-day supply of drugs in this tier
    • Tier 1: Generic Drugs
    Tier 2: Preferred Brand Drugs
    Tier 3: Non-Preferred Brand Drugs
    Tier 4: Specialty Tier Drugs
  • $7 copay for a one-month (31-day) supply of drugs in this tier
  • $40 copay for a one-month (31-day) supply of drugs in this tier
  • $80 copay for a one-month (31-day) supply of drugs in this tier
  • 33% coinsurance for a one-month (31-day) supply of drugs in this tier
    • Tier 1: Generic Drugs
    Tier 2: Preferred Brand Drugs
    Tier 3: Non-Preferred Brand Drugs
    Tier 4: Specialty Tier Drugs
  • $0 copay for a one-month (30-day) supply of drugs in this tier from a preferred mail order pharmacy.
  • $40 copay for a one-month (30-day) supply of drugs in this tier from a preferred mail order pharmacy.
  • $80 copay for a one-month (30-day) supply of drugs in this tier from a preferred mail order pharmacy.
  • 33% coinsurance for a one-month (30-day) supply of drugs in this tier from a preferred mail order pharmacy.
  • $0 copay for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy.
  • $100 copay for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy.
  • $200 copay for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy.
  • 33% coinsurance for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy.
  • $0 copay for a 60-day supply of drugs in this tier from a preferred mail order pharmacy.
  • $80 copay for a 60-day supply of drugs in this tier from a preferred mail order pharmacy.
  • $160 copay for a 60-day supply of drugs in this tier from a preferred mail order pharmacy.
  • 33% coinsurance for a 60-day supply of drugs in this tier from a preferred mail order pharmacy.
  • $7 copay for a one-month (30-day) supply of drugs in this tier from a non-preferred mail order pharmacy.
  • $40 copay for a one-month (30-day) supply of drugs in this tier from a non-preferred mail order pharmacy.
  • $80 copay for a one-month (30-day) supply of drugs in this tier from a non-preferred mail order pharmacy.
  • 33% coinsurance for a one-month (30-day) supply of drugs in this tier from a non-preferred mail order pharmacy.
  • $21 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred mail order pharmacy.
  • $120 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred mail order pharmacy.
  • $240 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred mail order pharmacy.
  • 33% coinsurance for a three-month (90-day) supply of drugs in this tier from a non-preferred mail order pharmacy.
  • $14 copay for a 60-day supply of drugs in this tier from a non-preferred mail order pharmacy.
  • $80 copay for a 60-day supply of drugs in this tier from a non-preferred mail order pharmacy.
  • $160 copay for a 60-day supply of drugs in this tier from a non-preferred mail order pharmacy.
  • 33% coinsurance for a 60-day supply of drugs in this tier from a non-preferred mail order pharmacy.
    • 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:
    • A $ 2.50 copay for generic (including brand drugs treated as generic) and a $ 6.30 copay for all other drugs or
    • 5% coinsurance.
    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 Blue Medicare PPO Enhanced (PPO).
    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
  • $7 copay for a one-month (30-day) supply of drugs in this tier
  • $40 copay for a one-month (30-day) supply of drugs in this tier
  • $80 copay for a one-month (30-day) supply of drugs in this tier
  • 33% coinsurance for a one-month (30-day) supply of drugs in this tier
    • You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount.
    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.
    You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount.
    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:
    • A $ 2.50 copay for generic (including brand drugs treated as generic) and a $ 6.30 copay for all other drugs or
    • 5% coinsurance.
    You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount.
    Physical Exams
    $0 copay for routine exams.
    Limited to 1 exam(s).
    20% of the cost for routine exams.
    Vision Services
  • 20% of the cost for one pair of eyeglasses or contact lenses after cataract surgery.
  • $0 to $40 copay for exams to diagnose and treat diseases and conditions of the eye.
  • $40 copay for up to 1 routine eye exam(s)
    • $100 plan coverage limit for eye exams.
    20% of the cost for eye exams.
    20% of the cost for eye wear.
    Dental Services
    In general preventive dental benefits (such as cleaning) not covered.
    $40 copay for Medicare-covered dental benefits.
    20% of the cost for comprehensive dental benefits.
    ** Important Information **
    Premium and Other Important Information
    $62 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.
    $3 400 out-of-pocket limit.
    This limit includes only Medicare-covered services.
    $5 100 out-of-pocket limit.
    In-Network: This limit includes only Medicare-covered services.
    Out-Of-Network: This limit includes only Medicare-covered services.
    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 - 6: $195 copay per day
    Days 7 - 90: $0 copay per day
    $0 copay for each additional hospital day.
    Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital.
    20% 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 - 6: $195 copay per day
    Days 7 - 90: $0 copay per day
    Plan covers 60 lifetime reserve days. Cost per lifetime reserve day:
    Days 1 - 60: $0 copay per day
    Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital.
    20% 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 - 10: $0 copay per day
    Days 11 - 100: $100 copay per day
    For each SNF stay:
    Days 1 - 10: $0 copay per SNF day
    Days 11 - 100: $100 copay per SNF day
    Home Health Care
    Authorization rules may apply.
    $0 copay for Medicare-covered home health visits.
    20% 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.
    $20 copay for each primary care doctor visit for Medicare-covered benefits.
    $40 copay for each in-area network urgent care Medicare-covered visit.
    $40 copay for each specialist visit for Medicare-covered benefits.
    20% for each primary care doctor visit.
    20% for each specialist visit.
    Chiropractic Services
    $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.
    20% of the cost for chiropractic benefits.
    Podiatry Services
    $40 copay for each Medicare-covered visit.
    Medicare-covered podiatry benefits are for medically-necessary foot care.
    20% of the cost for podiatry benefits.
    Outpatient Mental Health Care
    Authorization rules may apply.
    $40 copay for each Medicare-covered individual or group therapy visit.
    20% of the cost for Mental Health benefits.
    20% of the cost for Mental Health benefits with a psychiatrist.
    Outpatient Substance Abuse Care
    Authorization rules may apply.
    $40 copay for Medicare-covered individual or group visits.
    20% of the cost for outpatient substance abuse benefits.
    Outpatient Hospital Services
    Authorization rules may apply.
    $100 copay for each Medicare-covered ambulatory surgical center visit.
    $0 to $100 copay for each Medicare-covered outpatient hospital facility visit.
    20% of the cost for ambulatory surgical center benefits.
    20% of the cost for outpatient hospital facility benefits.
    Emergency Care
    $50 copay for Medicare-covered emergency room visits.
    Worldwide coverage.
    If you are admitted to the hospital within 48-hour(s) for the same condition you pay $0 for the emergency room visit
    Outpatient Rehabilitation Services
    $40 copay for Medicare-covered Occupational Therapy visits.
    $40 copay for Medicare-covered Physical and/or Speech and Language Therapy visits.
    $0 copay for Medicare-covered Cardiac Rehab services.
    20% of the cost for Occupational Therapy benefits.
    20% of the cost for Physical and/or Speech and Language Therapy visits.
    20% of the cost for Cardiac Rehab services.
    ** Outpatient Medical Services and Supplies **
    Durable Medical Equipment
    Authorization rules may apply.
    20% of the cost for Medicare-covered items.
    20% of the cost for durable medical equipment.
    Prosthetic Devices
    Authorization rules may apply.
    20% of the cost for Medicare-covered items.
    20% 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.
    20% of the cost for Diabetes supplies.
    20% of the cost for Diabetes self-monitoring training.
    20% of the cost for Nutrition Therapy for Diabetes.
    20% of the cost for Diabetes supplies.
    ** Preventive Services **
    Bone Mass Measurement
    $0 copay for Medicare-covered bone mass measurement
    20% of the cost for Medicare-covered bone mass measurement.
    Colorectal Screening Exams
    $0 copay for Medicare-covered colorectal screenings.
    20% 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.
    20% of the cost for immunizations.
    Pap Smears and Pelvic Exams
    $0 copay for Medicare-covered pap smears and pelvic exams
  • up to 1 additional pap smear(s) and pelvic exam(s)
    • 20% of the cost for pap smears and pelvic exams.
    Prostate Cancer Screening Exams
    $0 copay for
    • Medicare-covered prostate cancer screening
    20% of the cost for prostate cancer screening.
    ** Additional Benefits **
    Dialysis
    $0 copay for renal dialysis
    $0 copay for Nutrition Therapy for End-Stage Renal Disease
    $0 copay for renal dialysis.
    20% 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.
    20% 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 http://www.bcbsnc.com/medicare/drug-search.cfm on the web.
    Different out-of-pocket costs may apply for people who
    • have limited incomes
    • live in long term care facilities or
    • have access to Indian/Tribal/Urban (Indian Health Service).
    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 Blue Medicare PPO Enhanced (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 Blue Medicare PPO Enhanced (PPO) approves the exception you will pay Tier 3: Non-Preferred Brand Drugs cost sharing for that drug.
    $0 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
  • $7 copay for a one-month (30-day) supply of drugs in this tier
  • $40 copay for a one-month (30-day) supply of drugs in this tier
  • $80 copay for a one-month (30-day) supply of drugs in this tier
  • 33% coinsurance for a one-month (30-day) supply of drugs in this tier
  • $21 copay for a three-month (90-day) supply of drugs in this tier
  • $120 copay for a three-month (90-day) supply of drugs in this tier
  • $240 copay for a three-month (90-day) supply of drugs in this tier
  • 33% coinsurance for a three-month (90-day) supply of drugs in this tier
  • $14 copay for a 60-day supply of drugs in this tier
  • $80 copay for a 60-day supply of drugs in this tier
  • $160 copay for a 60-day supply of drugs in this tier
  • 33% coinsurance for a 60-day supply of drugs in this tier
    • Tier 1: Generic Drugs
    Tier 2: Preferred Brand Drugs
    Tier 3: Non-Preferred Brand Drugs
    Tier 4: Specialty Tier Drugs
  • $7 copay for a one-month (31-day) supply of drugs in this tier
  • $40 copay for a one-month (31-day) supply of drugs in this tier
  • $80 copay for a one-month (31-day) supply of drugs in this tier
  • 33% coinsurance for a one-month (31-day) supply of drugs in this tier
    • Tier 1: Generic Drugs
    Tier 2: Preferred Brand Drugs
    Tier 3: Non-Preferred Brand Drugs
    Tier 4: Specialty Tier Drugs
  • $0 copay for a one-month (30-day) supply of drugs in this tier from a preferred mail order pharmacy.
  • $40 copay for a one-month (30-day) supply of drugs in this tier from a preferred mail order pharmacy.
  • $80 copay for a one-month (30-day) supply of drugs in this tier from a preferred mail order pharmacy.
  • 33% coinsurance for a one-month (30-day) supply of drugs in this tier from a preferred mail order pharmacy.
  • $0 copay for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy.
  • $100 copay for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy.
  • $200 copay for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy.
  • 33% coinsurance for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy.
  • $0 copay for a 60-day supply of drugs in this tier from a preferred mail order pharmacy.
  • $80 copay for a 60-day supply of drugs in this tier from a preferred mail order pharmacy.
  • $160 copay for a 60-day supply of drugs in this tier from a preferred mail order pharmacy.
  • 33% coinsurance for a 60-day supply of drugs in this tier from a preferred mail order pharmacy.
  • $7 copay for a one-month (30-day) supply of drugs in this tier from a non-preferred mail order pharmacy.
  • $40 copay for a one-month (30-day) supply of drugs in this tier from a non-preferred mail order pharmacy.
  • $80 copay for a one-month (30-day) supply of drugs in this tier from a non-preferred mail order pharmacy.
  • 33% coinsurance for a one-month (30-day) supply of drugs in this tier from a non-preferred mail order pharmacy.
  • $21 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred mail order pharmacy.
  • $120 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred mail order pharmacy.
  • $240 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred mail order pharmacy.
  • 33% coinsurance for a three-month (90-day) supply of drugs in this tier from a non-preferred mail order pharmacy.
  • $14 copay for a 60-day supply of drugs in this tier from a non-preferred mail order pharmacy.
  • $80 copay for a 60-day supply of drugs in this tier from a non-preferred mail order pharmacy.
  • $160 copay for a 60-day supply of drugs in this tier from a non-preferred mail order pharmacy.
  • 33% coinsurance for a 60-day supply of drugs in this tier from a non-preferred mail order pharmacy.
    • 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:
    • A $ 2.50 copay for generic (including brand drugs treated as generic) and a $ 6.30 copay for all other drugs or
    • 5% coinsurance.
    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 Blue Medicare PPO Enhanced (PPO).
    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
  • $7 copay for a one-month (30-day) supply of drugs in this tier
  • $40 copay for a one-month (30-day) supply of drugs in this tier
  • $80 copay for a one-month (30-day) supply of drugs in this tier
  • 33% coinsurance for a one-month (30-day) supply of drugs in this tier
    • You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount.
    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.
    You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount.
    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:
    • A $ 2.50 copay for generic (including brand drugs treated as generic) and a $ 6.30 copay for all other drugs or
    • 5% coinsurance.
    You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount.
    Dental Services
    In general preventive dental benefits (such as cleaning) not covered.
    $40 copay for Medicare-covered dental benefits.
    20% of the cost for comprehensive dental benefits.
    Hearing Services
    In general routine hearing exams and hearing aids not covered.
  • $40 copay for Medicare-covered diagnostic hearing exams
    • 20% of the cost for hearing exams.
    Vision Services
  • 20% of the cost for one pair of eyeglasses or contact lenses after cataract surgery.
  • $0 to $40 copay for exams to diagnose and treat diseases and conditions of the eye.
  • $40 copay for up to 1 routine eye exam(s)
    • $100 plan coverage limit for eye exams.
    20% of the cost for eye exams.
    20% of the cost for eye wear.
    Physical Exams
    $0 copay for routine exams.
    Limited to 1 exam(s).
    20% of the cost for routine exams.
    Health/Wellness Education
    The plan covers the following health/wellness education benefits:
  • Health Club Membership/Fitness Classes
  • Nursing Hotline
  • Other Wellness 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.




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    Tips & Disclaimers
    • Q1Medicare®, Q1Rx®, and Q1Group® are registered Service Marks of Q1Group LLC and may not be used in any advertising, publicity, or for commercial purposes without the express authorization of Q1Group.
    • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
    • Medicare has neither reviewed nor endorsed the information on our site.
    • We provide our Q1Medicare.com site for educational purposes and strive to present unbiased and accurate information. However, Q1Medicare is not intended as a substitute for your lawyer, doctor, healthcare provider, financial advisor, or pharmacist. For more information on your Medicare coverage, please be sure to seek legal, medical, pharmaceutical, or financial advice from a licensed professional or telephone Medicare at 1-800-633-4227.
    • We are an independent education, research, and technology company. We are not affiliated with any Medicare plan, plan carrier, healthcare provider, or insurance company. We are not compensated for Medicare plan enrollments. We do not sell leads or share your personal information.
    • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDPCompare.com and MACompare.com provide highlights of annual plan benefit changes.
    • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
    • Limitations, copayments, and restrictions may apply.
    • We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area. However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
      Statement required by Medicare:
      "We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options."
    • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
    • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
    • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
    • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
    • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
    • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
    • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
    • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
    • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
    • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
    • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
    • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
    • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
    • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
    • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.
    .