** Cost ** |
Premium and Other Important Information |
$73 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. |
$3 500 out-of-pocket limit. |
All plan services included. |
$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. |
** 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.excellusbcbs.com and www.univerahealthcare.com 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 Medicare Blue PPO - THREE (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. |
You pay $0 the first time you fill a prescription for certain drugs. These drugs will be listed as 'free first fill' on the plan's website formulary printed materials and on the Medicare Prescription Drug Plan Finder on Medicare.gov. |
If you request a formulary exception for a drug and Medicare Blue PPO - THREE (PPO) approves the exception you will pay Tier 3: Non-Preferred Brand Drugs cost sharing for that drug. |
$0 deductible. |
Supplemental drugs don't count toward your out-of-pocket drug costs. |
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 |
$6 copay for a one-month (30-day) supply of drugs in this tier |
$35 copay for a one-month (30-day) supply of drugs in this tier |
$75 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 |
$15 copay for a three-month (90-day) supply of drugs in this tier |
$87.50 copay for a three-month (90-day) supply of drugs in this tier |
$187.50 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 |
Tier 1: Generic Drugs |
Tier 2: Preferred Brand Drugs |
Tier 3: Non-Preferred Brand Drugs |
Tier 4: Specialty Tier Drugs |
$6 copay for a one-month (31-day) supply of drugs in this tier |
$35 copay for a one-month (31-day) supply of drugs in this tier |
$75 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 |
$15 copay for a three-month (90-day) supply of drugs in this tier |
$87.50 copay for a three-month (90-day) supply of drugs in this tier |
$187.50 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 |
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 Medicare Blue PPO - THREE (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 |
$6 copay for a one-month (30-day) supply of drugs in this tier |
$35 copay for a one-month (30-day) supply of drugs in this tier |
$75 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) every year. |
Separate Office Visit cost sharing of $10 to $25 may apply. |
30% of the cost for routine exams. |
Vision Services |
$25 copay for one pair of eyeglasses or contact lenses after cataract surgery. |
$0 to $25 copay for exams to diagnose and treat diseases and conditions of the eye. |
$0 to $25 copay for up to 1 routine eye exam(s) every year |
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. |
$25 copay for Medicare-covered dental benefits. |
30% of the cost for comprehensive dental benefits. |
** Important Information ** |
Premium and Other Important Information |
$73 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. |
$3 500 out-of-pocket limit. |
All plan services included. |
$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. |
** Inpatient Care ** |
Inpatient Hospital Care (Acute) |
No limit to the number of days covered by the plan each benefit period. |
$100 copay for each Medicare-covered hospital stay |
$0 copay for additional hospital days |
$300 out-of-pocket limit every year. |
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. |
$100 copay for each Medicare-covered hospital stay. |
The maximum out-of-pocket limit is covered under 'Inpatient Hospital Care'. |
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 - 100: $25 copay per day |
30% of the cost for each SNF stay. |
Home Health Care |
Authorization rules may apply. |
$0 copay for Medicare-covered home health visits. |
30% 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. |
$10 copay for each primary care doctor visit for Medicare-covered benefits. |
$25 copay for each in-area network urgent care Medicare-covered visit. |
$25 copay for each specialist visit for Medicare-covered benefits. |
30% for each primary care doctor visit. |
30% for each specialist visit. |
Chiropractic Services |
$10 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 |
$25 copay for each Medicare-covered visit. |
Medicare-covered podiatry benefits are for medically-necessary foot care. |
30% of the cost for podiatry benefits. |
Outpatient Mental Health Care |
$25 copay for each Medicare-covered individual or group therapy visit. |
50% of the cost for Mental Health benefits. |
50% of the cost for Mental Health benefits with a psychiatrist. |
Outpatient Substance Abuse Care |
$25 copay for Medicare-covered individual or group visits. |
50% of the cost for outpatient substance abuse benefits. |
Outpatient Hospital Services |
Authorization rules may apply. |
$35 copay for each Medicare-covered ambulatory surgical center visit. |
$0 to $35 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 admitted to the hospital within 23-hour(s) for the same condition you pay $0 for the emergency room visit |
Outpatient Rehabilitation Services |
Authorization rules may apply. |
$25 copay for Medicare-covered Occupational Therapy visits. |
$25 copay for Medicare-covered Physical and/or Speech and Language Therapy visits. |
$25 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 |
Authorization rules may apply. |
20% of the cost for Medicare-covered items. |
30% of the cost for durable medical equipment. |
Prosthetic Devices |
Authorization rules may apply. |
20% of the cost 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. |
20% of the cost for Diabetes supplies. |
Separate Office Visit cost sharing of $10 to $25 may apply. |
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 |
Separate Office Visit cost sharing of $10 to $25 may apply. |
30% of the cost for Medicare-covered bone mass measurement. |
Colorectal Screening Exams |
$0 copay for Medicare-covered colorectal screenings. |
Separate Office Visit cost sharing of $10 to $25 may apply. |
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. |
Separate Office Visit cost sharing of $10 to $25 may apply. |
30% of the cost for pap smears and pelvic exams. |
Prostate Cancer Screening Exams |
$0 copay for - Medicare-covered prostate cancer screening
|
Separate Office Visit cost sharing of $10 to $25 may apply. |
30% 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. |
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.excellusbcbs.com and www.univerahealthcare.com 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 Medicare Blue PPO - THREE (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. |
You pay $0 the first time you fill a prescription for certain drugs. These drugs will be listed as 'free first fill' on the plan's website formulary printed materials and on the Medicare Prescription Drug Plan Finder on Medicare.gov. |
If you request a formulary exception for a drug and Medicare Blue PPO - THREE (PPO) approves the exception you will pay Tier 3: Non-Preferred Brand Drugs cost sharing for that drug. |
$0 deductible. |
Supplemental drugs don't count toward your out-of-pocket drug costs. |
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 |
$6 copay for a one-month (30-day) supply of drugs in this tier |
$35 copay for a one-month (30-day) supply of drugs in this tier |
$75 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 |
$15 copay for a three-month (90-day) supply of drugs in this tier |
$87.50 copay for a three-month (90-day) supply of drugs in this tier |
$187.50 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 |
Tier 1: Generic Drugs |
Tier 2: Preferred Brand Drugs |
Tier 3: Non-Preferred Brand Drugs |
Tier 4: Specialty Tier Drugs |
$6 copay for a one-month (31-day) supply of drugs in this tier |
$35 copay for a one-month (31-day) supply of drugs in this tier |
$75 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 |
$15 copay for a three-month (90-day) supply of drugs in this tier |
$87.50 copay for a three-month (90-day) supply of drugs in this tier |
$187.50 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 |
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 Medicare Blue PPO - THREE (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 |
$6 copay for a one-month (30-day) supply of drugs in this tier |
$35 copay for a one-month (30-day) supply of drugs in this tier |
$75 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. |
$25 copay for Medicare-covered dental benefits. |
30% of the cost for comprehensive dental benefits. |
Hearing Services |
Hearing aids not covered. |
$25 copay for Medicare-covered diagnostic hearing exams |
$25 copay for up to 1 routine hearing test(s) every year |
30% of the cost for hearing exams. |
Vision Services |
$25 copay for one pair of eyeglasses or contact lenses after cataract surgery. |
$0 to $25 copay for exams to diagnose and treat diseases and conditions of the eye. |
$0 to $25 copay for up to 1 routine eye exam(s) every year |
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. |
Separate Office Visit cost sharing of $10 to $25 may apply. |
30% of the cost for routine exams. |
Health/Wellness Education |
The plan covers the following health/wellness education benefits: |
Written health education materials including Newsletters |
Nutritional Training |
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% to 30% of the cost for Health and Wellness services. |
Transportation |
This plan does not cover routine transportation. |
Acupuncture |
This plan does not cover Acupuncture. |