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2011 Blue Medicare Access Value (Regional PPO) in Anderson, Kentucky

Medicare Advantage Plan Benefit Details in Plain Text

The following Medicare Advantage plan benefits apply to the Blue Medicare Access Value (Regional PPO) (R5941 - 009) in Anderson, Kentucky .

This plan is administered by . To switch to a different Medicare Advantage plan or to change your location, click here.

Click here to see the Blue Medicare Access Value (Regional PPO) health and prescription benefit details in chart format

or email and view benefits chart

Plan Premium

This plan has a $0.00 monthly premium. Although you pay no additional monthly premium, you must continue to pay your Medicare Part B premium. If you have a premium penalty, your premium will be higher. Or if you have a higher income you would be subject to the Income Related Adjustment Amount (IRMAA).

This Medicare Advantage Plan with Prescription Drug Coverage is a Regional PPO plan.

Prescription Drug Coverage: Deductible, Cost-sharing, Formulary

This plan does NOT have a deductible for the prescription drug coverage. That means that you have first dollar coverage. Some plans have a deductible that must be paid (in full) prior to the prescription coverage assisting in your prescription costs (see cost-sharing below). The maximum deductible for 2011 is $310. This plan (Blue Medicare Access Value (Regional PPO)) has no deductible.

The Initial Coverage Phase (ICP) can be thought of as the cost-sharing phase of the plan. During this phase, you and the insurance company share your prescription costs. Since this plan has no deductible, your coverage (initial coverage phase) will start right away. All medication are divided into tiers within the plans formulary. This helps the plan to organize and manage the prescription cost-sharing. The Blue Medicare Access Value (Regional PPO)’s formulary is divided into 6 tiers. Every plan can name their tiers differently, and can place medications on any tier. The cost-sharing for this plan is divided as follows:

Tier 1 (Generic Drugs) contains 0 drugs and has a co-payment of $7.00.
Tier 2 (Preferred Brand Drugs) contains 0 drugs and has a co-payment of $43.00.
Tier 3 (Non-Preferred Brand Drugs) contains 0 drugs and has a co-payment of $85.00.
Tier 4 (Injectable Drugs) contains 0 drugs and has a co-insurance of 33% of the drug cost.
Tier 5 (Specialty Tier Drugs) contains 0 drugs and has a co-insurance of 33% of the drug cost.
Tier 6 (Supplemental Drugs) contains drugs and has a co-payment of $7.00.

Click here to browse the Blue Medicare Access Value (Regional PPO) Formulary.

The Coverage Gap, which is also known as the Donut (Doughnut) Hole is the phase of your Medicare Part D plan where you are responsible for 100% of your medication costs. Healthcare Reform mandates that the insurance carrier pay 7% of your generic drug prescription costs in the donut hole on your behalf.

The brand-name drug manufacturer will pay 50% and your plan will pay an additional 0% of the cost of your brand-name drugs purchased in the Donut Hole, for a total of 50% discount. The 50% paid by the brand-name drug manufacturer is paid on your behalf and therefore counts toward your TrOOP (or True Out-of-Pocket) costs. The portion paid by your plan, does not count toward TrOOP. Some Medicare Part D plans offer coverage during the Coverage Gap that is beyond the mandated discounts. Any drug not covered by the plan’s Gap Coverage will still receive the discounts noted above -- even if the plan has "No Gap Coverage". This plan (Blue Medicare Access Value (Regional PPO)) offers Coverage for Many Generics during the Coverage Gap phase. This means that many (65% to 100%) of the generic drugs on the plans formulary (or drug list) and no brand-name drugs will be covered through the coverage gap (or donut hole).

The Blue Medicare Access Value (Regional PPO) offers many Health and Prescription Drug Coverage Benefits. The following section will describe these benefits in detail.

** Cost **

Premium and Other Important Information

$0 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.

$3 900 out-of-pocket limit.

All plan services included.

$3 900 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.

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 www.anthem.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 Blue Medicare Access Value (Regional 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 Access Value (Regional 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: Injectable Drugs

Tier 5: Specialty Tier Drugs

Tier 6: Supplemental Drugs

$7 copay for a one-month (30-day) supply of drugs in this tier

$43 copay for a one-month (30-day) supply of drugs in this tier

$85 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

$7 copay 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

$129 copay for a three-month (90-day) supply of drugs in this tier

$255 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

$21 copay 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: Injectable Drugs

Tier 5: Specialty Tier Drugs

Tier 6: Supplemental Drugs

$7 copay for a one-month (34-day) supply of drugs in this tier

$43 copay for a one-month (34-day) supply of drugs in this tier

$85 copay for a one-month (34-day) supply of drugs in this tier

33% coinsurance for a one-month (34-day) supply of drugs in this tier

$7 copay for a one-month (34-day) supply of drugs in this tier

Tier 1: Generic Drugs

Tier 2: Preferred Brand Drugs

Tier 3: Non-Preferred Brand Drugs

Tier 4: Injectable Drugs

Tier 5: Specialty Tier Drugs

Tier 6: Supplemental Drugs

33% coinsurance for a one-month (30-day) supply of drugs in this tier

$10.50 copay for a three-month (90-day) supply of drugs in this tier

$107.50 copay for a three-month (90-day) supply of drugs in this tier

$212.50 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

$10.50 copay for a three-month (90-day) supply of drugs in this tier

The plan covers many formulary generics (65%-99% of formulary generic drugs) through the coverage gap.

You pay the following:

Tier 1: Generic Drugs

Tier 6: Supplemental Drugs

$7 copay for a one-month (30-day) supply of all drugs covered in this tier

$21 copay for a three-month (90-day) supply of all drugs covered in this tier

Tier 1: Generic Drugs

Tier 6: Supplemental Drugs

$7 copay for a one-month (34-day) supply of all drugs covered in this tier

Tier 1: Generic Drugs

Tier 6: Supplemental Drugs

$10.50 copay for a three-month (90-day) supply of all drugs covered in this tier

After your total yearly drug costs reach $2 840 you receive limited coverage by the plan on certain drugs. You will also receive a discount on brand name drugs and generally pay no more than 93% of the plan's costs for 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 following:

Tier 1: Generic Drugs

Tier 2: Preferred Brand Drugs

Tier 3: Non-Preferred Brand Drugs

Tier 4: Injectable Drugs

Tier 5: Specialty Tier Drugs

Tier 6: Supplemental Drugs

$2.50 copay or 5% coinsurance [whichever costs more] for drugs in this tier

$6.30 copay or 5% coinsurance [whichever costs more] for drugs in this tier

$3.25 copay or 5% coinsurance [whichever costs more] for drugs in this tier

$6.30 copay or 5% coinsurance [whichever costs more] for drugs in this tier

$7 copay for drugs in this tier

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 Access Value (Regional 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: Injectable Drugs

Tier 5: Specialty Tier Drugs

Tier 6: Supplemental Drugs

$7 copay for a one-month (30-day) supply of drugs in this tier

$43 copay for a one-month (30-day) supply of drugs in this tier

$85 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

$7 copay 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 for these drugs purchased out-of-network up to the full cost of the drug minus the following:

Tier 1: Generic Drugs

Tier 6: Supplemental Drugs

Tier 2: Preferred Brand Drugs

Tier 3: Non-Preferred Brand Drugs

Tier 4: Injectable Drugs

Tier 5: Specialty Tier Drugs

$7 copay for a one-month (30-day) supply of all drugs covered in this tier

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 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 the following:

Tier 1: Generic Drugs

Tier 2: Preferred Brand Drugs

Tier 3: Non-Preferred Brand Drugs

Tier 4: Injectable Drugs

Tier 5: Specialty Tier Drugs

Tier 6: Supplemental Drugs

$2.50 copay or 5% coinsurance [whichever costs more] for drugs in this tier

$6.30 copay or 5% coinsurance [whichever costs more] for drugs in this tier

$3.25 copay or 5% coinsurance [whichever costs more] for drugs in this tier

$6.30 copay or 5% coinsurance [whichever costs more] for drugs in this tier

$7 copay for 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.

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.

$0 copay for routine exams.

Vision Services

In general routine eye exams and eye wear not covered. However this plan covers some vision benefits for an extra cost (see 'Optional Benefits').

$0 copay for one pair of eyeglasses or contact lenses after cataract surgery.

$0 to $35 copay for exams to diagnose and treat diseases and conditions of the eye.

$45 copay for eye exams.

$0 copay for eye wear.

Dental Services

In general preventive dental benefits (such as cleaning) not covered. However this plan covers preventive dental benefits for an extra cost (see 'Optional Benefits.')

0% of the cost for Medicare-covered dental benefits.

$0 copay for comprehensive dental benefits.

** Important Information **

Premium and Other Important Information

$0 monthly plan premium in addition to your monthly Medicare Part B premium.

This plan covers all Medicare-covered preventive services with zero cost sharing.

$3 900 out-of-pocket limit.

All plan services included.

$3 900 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: $210 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.

20% of the cost for each hospital stay.

Inpatient Mental Health Care

Contact the plan for details about coverage in a Psychiatric Hospital beyond 190 days.

For Medicare-covered hospital stays:

Days 1 - 7: $210 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.

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 SNF stays:

Days 1 - 20: $0 copay per day

Days 21 - 100: $128 copay per day

30% of the cost for each SNF stay.

Home Health Care

Authorization rules may apply.

$0 copay for each Medicare-covered home health visit.

$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.

$25 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.

$35 copay for each primary care doctor visit.

$45 copay for each specialist visit.

Chiropractic Services

Authorization rules may apply.

$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.

$45 copay for chiropractic benefits.

Podiatry Services

$40 copay for each Medicare-covered visit.

Medicare-covered podiatry benefits are for medically-necessary foot care.

$45 copay for podiatry benefits.

Outpatient Mental Health Care

Authorization rules may apply.

$40 copay for each Medicare-covered individual or group therapy visit.

$50 copay for Mental Health benefits.

$50 copay for Mental Health benefits with a psychiatrist.

Outpatient Substance Abuse Care

Authorization rules may apply.

$40 copay for Medicare-covered individual or group visits.

$50 copay for outpatient substance abuse benefits.

Outpatient Hospital Services

Authorization rules may apply.

$250 copay for each Medicare-covered ambulatory surgical center visit.

$40 to $250 copay for each Medicare-covered outpatient hospital facility visit.

$350 copay for ambulatory surgical center benefits.

$45 to $350 copay 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 72-hour(s) for the same condition you pay $0 for the emergency room visit

Outpatient Rehabilitation Services

Authorization rules may apply.

$40 to $60 copay for Medicare-covered Occupational Therapy visits.

$40 to $60 copay for Medicare-covered Physical and/or Speech and Language Therapy visits.

$0 copay for Medicare-covered Cardiac Rehab services.

$45 to $100 copay for Occupational Therapy benefits.

$45 to $100 copay Physical and/or Speech and Language Therapy visits.

$0 copay 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.

$0 copay for Diabetes supplies.

20% of the cost for Diabetes self-monitoring training.

20% 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.

Colorectal Screening Exams

$0 copay for Medicare-covered colorectal screenings.

$0 copay for colorectal screenings.

Immunizations

$0 copay for Flu and Pneumonia vaccines.

No referral needed for Flu and pneumonia vaccines.

$0 copay for Hepatitis B vaccine.

$0 copay for immunizations.

Pap Smears and Pelvic Exams

$0 copay for Medicare-covered pap smears and pelvic exams

$0 copay for pap smears and pelvic exams.

Prostate Cancer Screening Exams

$0 copay for Medicare-covered prostate cancer screening.

$0 copay for prostate cancer screening.

** Additional Benefits **

Dialysis

20% of the cost for renal dialysis

$0 copay for Nutrition Therapy for End-Stage Renal Disease.

20% of the cost 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 www.anthem.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).