** Cost ** |
Premium and Other Important Information |
$101 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. |
This plan does not allow providers to balance bill (charging more than your cost share amount). |
$3 400 out-of-pocket limit. |
This limit includes only Medicare-covered services. |
** Doctor and Hospital Choice ** |
Doctor and Hospital Choice |
You may go to any doctor specialist or hospital that accepts the plan's terms and conditions of payment. |
** Extra Benefits ** |
Prescription Drugs |
0% of the cost for Part B-covered drugs (not including Part B-covered chemotherapy drugs). |
20% of the cost for Part B-covered chemotherapy drugs. |
This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at www.bcbst-medicare.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 BlueAdvantage Gold (PFFS) 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 BlueAdvantage Gold (PFFS) approves the exception you will pay Tier 4: Specialty Tier 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: Brand Drugs |
Tier 4: Specialty Tier Drugs |
$7 copay for a one-month (30-day) supply of drugs in this tier |
$30 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 |
$21 copay for a three-month (90-day) supply of drugs in this tier |
$90 copay for a three-month (90-day) supply of drugs in this tier |
$225 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: Brand Drugs |
Tier 4: Specialty Tier Drugs |
$7 copay for a one-month (31-day) supply of drugs in this tier |
$30 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: Brand Drugs |
Tier 4: Specialty Tier Drugs |
$7 copay for a one-month (30-day) supply of drugs in this tier |
$30 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 |
$17.50 copay for a three-month (90-day) supply of drugs in this tier |
$75 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 BlueAdvantage Gold (PFFS). |
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: Brand Drugs |
Tier 4: Specialty Tier Drugs |
$7 copay for a one-month (30-day) supply of drugs in this tier |
$30 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. |
$0 copay for the required Medicare-covered initial preventive physical exam and annual wellness visits. |
Vision Services |
$0 copay for - one pair of eyeglasses or contact lenses after cataract surgery
|
glasses |
contacts |
lenses |
frames |
$0 to $20 copay for exams to diagnose and treat diseases and conditions of the eye. |
$20 copay for up to 1 routine eye exam(s) every year |
$100 plan coverage limit for eye wear every year. |
Dental Services |
$0 copay for Medicare-covered dental benefits. |
$0 copay for the following preventive dental benefits: |
oral exams |
cleanings |
fluoride treatments |
dental x-rays |
Plan offers additional comprehensive dental benefits. |
$100 plan coverage limit for dental benefits every year. |
** Important Information ** |
Premium and Other Important Information |
$101 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. |
This plan does not allow providers to balance bill (charging more than your cost share amount). |
$3 400 out-of-pocket limit. |
This limit includes only Medicare-covered services. |
Doctor and Hospital Choice |
You may go to any doctor specialist or hospital that accepts the plan's terms and conditions of payment. |
** Inpatient Care ** |
Inpatient Hospital Care (Acute) |
You may go to any doctor specialist or hospital that accepts the plan's terms and conditions of payment except in emergencies. |
No limit to the number of days covered by the plan each benefit period. |
For Medicare-covered hospital stays: |
Days 1 - 7: $100 copay per day |
Days 8 - 90: $0 copay per day |
$0 copay for additional hospital days |
$700 out-of-pocket limit every 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: $100 copay per day |
Days 8 - 90: $0 copay per day |
$700 out-of-pocket limit every stay. |
Skilled Nursing Facility (SNF) |
Plan covers up to 100 days each benefit period |
No prior hospital stay is required. |
For SNF stays: |
Days 1 - 20: $0 copay per day |
Days 21 - 100: $75 copay per day |
Home Health Care |
$0 copay for Medicare-covered home health visits. |
Hospice |
You must get care from a Medicare-certified hospice. |
** Outpatient Care ** |
Doctor Office Visits |
You may go to any doctor specialist or hospital that accepts the plan's terms and conditions of payment. |
See 'Welcome to Medicare; and Annual Wellness Visit' for more information. |
$20 copay for each primary care doctor visit for Medicare-covered benefits. |
$35 copay for each specialist visit for Medicare-covered benefits. |
Chiropractic Services |
$20 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. |
Podiatry Services |
$35 copay for each Medicare-covered visit. |
Medicare-covered podiatry benefits are for medically-necessary foot care. |
Outpatient Mental Health Care |
$20 copay for each Medicare-covered individual or group therapy visit. |
Outpatient Substance Abuse Care |
$20 copay for Medicare-covered individual or group visits. |
Outpatient Hospital Services |
$200 copay for each Medicare-covered ambulatory surgical center visit. |
$200 copay for each Medicare-covered outpatient hospital facility visit. |
Emergency Care |
$50 copay for Medicare-covered emergency room visits. |
Worldwide coverage. |
If you are admitted to the hospital within 3-day(s) for the same condition you pay $0 for the emergency room visit |
Outpatient Rehabilitation Services |
$20 copay for Medicare-covered Occupational Therapy visits. |
$20 copay for Medicare-covered Physical and/or Speech and Language Therapy visits. |
$20 copay for Medicare-covered Cardiac Rehab services. |
** Outpatient Medical Services and Supplies ** |
Durable Medical Equipment |
20% of the cost for Medicare-covered items. |
Prosthetic Devices |
20% of the cost for Medicare-covered items. |
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. |
** Preventive Services ** |
Bone Mass Measurement |
$0 copay for Medicare-covered bone mass measurement. |
Separate Office Visit cost sharing of $20 to $35 may apply. |
Colorectal Screening Exams |
$0 copay for Medicare-covered colorectal screenings. |
Separate Office Visit cost sharing of $20 to $35 may apply. |
Immunizations |
$0 copay for Flu and Pneumonia vaccines. |
$0 copay for Hepatitis B vaccine. |
Pap Smears and Pelvic Exams |
$0 copay for Medicare-covered pap smears and pelvic exams |
Separate Office Visit cost sharing of $20 to $35 may apply. |
Prostate Cancer Screening Exams |
$0 copay for Medicare-covered prostate cancer screening. |
Separate Office Visit cost sharing of $20 to $35 may apply. |
** Additional Benefits ** |
Dialysis |
$10 copay for renal dialysis |
$0 copay for Nutrition Therapy for End-Stage Renal Disease. |
Prescription Drugs |
0% of the cost for Part B-covered drugs (not including Part B-covered chemotherapy drugs). |
20% of the cost for Part B-covered chemotherapy drugs. |
This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at www.bcbst-medicare.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 BlueAdvantage Gold (PFFS) 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 BlueAdvantage Gold (PFFS) approves the exception you will pay Tier 4: Specialty Tier 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: Brand Drugs |
Tier 4: Specialty Tier Drugs |
$7 copay for a one-month (30-day) supply of drugs in this tier |
$30 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 |
$21 copay for a three-month (90-day) supply of drugs in this tier |
$90 copay for a three-month (90-day) supply of drugs in this tier |
$225 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: Brand Drugs |
Tier 4: Specialty Tier Drugs |
$7 copay for a one-month (31-day) supply of drugs in this tier |
$30 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: Brand Drugs |
Tier 4: Specialty Tier Drugs |
$7 copay for a one-month (30-day) supply of drugs in this tier |
$30 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 |
$17.50 copay for a three-month (90-day) supply of drugs in this tier |
$75 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 BlueAdvantage Gold (PFFS). |
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: Brand Drugs |
Tier 4: Specialty Tier Drugs |
$7 copay for a one-month (30-day) supply of drugs in this tier |
$30 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 |
$0 copay for Medicare-covered dental benefits. |
$0 copay for the following preventive dental benefits: |
oral exams |
cleanings |
fluoride treatments |
dental x-rays |
Plan offers additional comprehensive dental benefits. |
$100 plan coverage limit for dental benefits every year. |
Hearing Services |
Hearing aids not covered. |
$20 copay for Medicare-covered diagnostic hearing exams |
$20 copay for up to 1 routine hearing test(s) every two years |
Vision Services |
$0 copay for - one pair of eyeglasses or contact lenses after cataract surgery
|
glasses |
contacts |
lenses |
frames |
$0 to $20 copay for exams to diagnose and treat diseases and conditions of the eye. |
$20 copay for up to 1 routine eye exam(s) every year |
$100 plan coverage limit for eye wear every year. |
Physical Exams |
$0 copay for routine exams. |
Limited to 1 exam(s) every year. |
$0 copay for the required Medicare-covered initial preventive physical exam and annual wellness visits. |
Health/Wellness Education |
The plan covers the following health/wellness education benefits: |
Written health education materials including Newsletters |
Nutritional benefit |
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. |
Transportation |
This plan does not cover routine transportation. |
Acupuncture |
This plan does not cover Acupuncture. |