2015 Medicare Advantage Plan Details | |||||||||||||||||||||||
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Medicare Plan Name: | Community Blue Medicare Signature (HMO) | ||||||||||||||||||||||
Location: | Allegheny, Pennsylvania Click to see other locations | ||||||||||||||||||||||
Plan ID: | H3957 - 038 - 0 Click to see other plans | ||||||||||||||||||||||
Member Services: | 1-888-234-5397 TTY users 711 | ||||||||||||||||||||||
— This plan information is for research purposes only. — Click here to see plans for the current plan year | |||||||||||||||||||||||
Medicare Contact Information: | Please go to Medicare.gov or call 1-800-MEDICARE (1-800-633-4227) to get information on all of your options. TTY users 1-877-486-2048 or contact your local SHIP for assistance |
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Email a copy of the Community Blue Medicare Signature (HMO) benefit details | |||||||||||||||||||||||
— Medicare Plan Features — | |||||||||||||||||||||||
Monthly Premium: | $0.00 (see Plan Premium Details below) | ||||||||||||||||||||||
Annual Rx Deductible: | $0 | ||||||||||||||||||||||
Annual Rx Initial Coverage Limit (ICL): | $2,960 | ||||||||||||||||||||||
Health Plan Type: | Local HMO | ||||||||||||||||||||||
Maximum Out-of-Pocket Limit for Parts A & B (MOOP): | $6,700 | ||||||||||||||||||||||
Additional Rx Gap Coverage? | No additional gap coverage, only the Donut Hole Discount | ||||||||||||||||||||||
Total Number of Formulary Drugs: | 4,839 drugs | Browse the Community Blue Medicare Signature (HMO) Formulary | |||||||||||||||||||||
This plan has 5 drug tiers. See cost-sharing for all pharmacies and tiers. | |||||||||||||||||||||||
Formulary Drug Details: | Tier 1 | Tier 2 | Tier 3 | Tier 4 | Tier 5 | ||||||||||||||||||
• Preferred Pharmacy Cost-Sharing during initial coverage phase: | $4.00 | $15.00 | $45.00 | $95.00 | 33% | ||||||||||||||||||
• Number of Drugs per Tier: | 649 | 1758 | 482 | 1400 | 550 | ||||||||||||||||||
Plan's Pharmacy Search: | http://www.highmarkbcbs.com/medicare | ||||||||||||||||||||||
Plan Offers Mail Order? | Yes | ||||||||||||||||||||||
Number of Members enrolled in this plan in Allegheny, Pennsylvania: | 2,400 members | ||||||||||||||||||||||
Number of Members enrolled in this plan in Pennsylvania: | 6,678 members | ||||||||||||||||||||||
Number of Members enrolled in this plan in (H3957 - 038): | 6,713 members | ||||||||||||||||||||||
Plan’s Summary Star Rating: | 4 out of 5 Stars. | ||||||||||||||||||||||
• Customer Service Rating: | 3 out of 5 Stars. | ||||||||||||||||||||||
• Member Experience Rating: | 5 out of 5 Stars. | ||||||||||||||||||||||
• Drug Cost Accuracy Rating: | 4 out of 5 Stars. | ||||||||||||||||||||||
— Plan Premium Details — | |||||||||||||||||||||||
The Monthly Premium is Split as Follows: ❔ | Total Premium | Part C Premium | Part D Basic Premium | Part D Supplemental Premium | |||||||||||||||||||
$0.00 | $0.00 | $0.00 | $0.00 | ||||||||||||||||||||
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 | |||||||||||||||||||
Total Monthly Premium with LIS (Parts C & D): | $0.00 | $0.00 | $0.00 | $0.00 | |||||||||||||||||||
— Plan Health Benefits — | |||||||||||||||||||||||
** Cost ** | |||||||||||||||||||||||
Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services | |||||||||||||||||||||||
$0 per month. In addition you must keep paying your Medicare Part B premium. | |||||||||||||||||||||||
Keystone Health Plan West Inc. will reduce your Medicare Part B premium by up to $6. | |||||||||||||||||||||||
This plan does not have a deductible. | |||||||||||||||||||||||
Yes. Like all Medicare health plans our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care. | |||||||||||||||||||||||
Your yearly limit(s) in this plan: | |||||||||||||||||||||||
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If you reach the limit on out-of-pocket costs you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year. Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs. | |||||||||||||||||||||||
Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply. | |||||||||||||||||||||||
** Doctor and Hospital Choice ** | |||||||||||||||||||||||
Acupuncture and Other Alternative Therapies | |||||||||||||||||||||||
Not covered | |||||||||||||||||||||||
** Extra Benefits ** | |||||||||||||||||||||||
Inpatient Mental Health Care | |||||||||||||||||||||||
For inpatient mental health care see the "Mental Health Care" section. | |||||||||||||||||||||||
Outpatient Prescription Drugs | |||||||||||||||||||||||
For Part B drugs such as chemotherapy drugs1: 0-20% of the cost depending on the drug | |||||||||||||||||||||||
Other Part B drugs1: 0-20% of the cost depending on the drug | |||||||||||||||||||||||
You pay the following until your total yearly drug costs reach $2 960. Total yearly drug costs are the total drug costs paid by both you and our Part D plan. | |||||||||||||||||||||||
You may get your drugs at network retail pharmacies and mail order pharmacies. | |||||||||||||||||||||||
Standard Retail Cost-Sharing
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Standard Mail Order Cost-Sharing
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If you reside in a long-term care facility you pay the same as at a retail pharmacy. | |||||||||||||||||||||||
You may get drugs from an out-of-network pharmacy but may pay more than you pay at an in-network pharmacy. | |||||||||||||||||||||||
Most Medicare drug plans have a coverage gap (also called the "donut hole"). This means that there's a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $2 960. After you enter the coverage gap you pay 45% of the plan's cost for covered brand name drugs and 65% of the plan's cost for covered generic drugs until your costs total $4 700 which is the end of the coverage gap. Not everyone will enter the coverage gap. | |||||||||||||||||||||||
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4 700 you pay the greater of:
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** Important Information ** | |||||||||||||||||||||||
Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services | |||||||||||||||||||||||
$0 per month. In addition you must keep paying your Medicare Part B premium. | |||||||||||||||||||||||
Keystone Health Plan West Inc. will reduce your Medicare Part B premium by up to $6. | |||||||||||||||||||||||
This plan does not have a deductible. | |||||||||||||||||||||||
Yes. Like all Medicare health plans our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care. | |||||||||||||||||||||||
Your yearly limit(s) in this plan: | |||||||||||||||||||||||
| |||||||||||||||||||||||
If you reach the limit on out-of-pocket costs you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year. Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs. | |||||||||||||||||||||||
Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply. | |||||||||||||||||||||||
** Outpatient Care and Services ** | |||||||||||||||||||||||
Acupuncture and Other Alternative Therapies | |||||||||||||||||||||||
Not covered | |||||||||||||||||||||||
Ambulance Services | |||||||||||||||||||||||
$250 copay | |||||||||||||||||||||||
Chiropractic Care | |||||||||||||||||||||||
Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): $20 copay | |||||||||||||||||||||||
Dental Services | |||||||||||||||||||||||
Limited dental services (this does not include services in connection with care treatment filling removal or replacement of teeth): $40-300 copay depending on the service | |||||||||||||||||||||||
Preventive dental services: | |||||||||||||||||||||||
Dental services: $30 copay for a single office visit that includes: | |||||||||||||||||||||||
Diabetes Supplies and Services | |||||||||||||||||||||||
Diabetes monitoring supplies: 0-20% of the cost depending on the supply | |||||||||||||||||||||||
Diabetes self-management training: You pay nothing | |||||||||||||||||||||||
Therapeutic shoes or inserts: 20% of the cost | |||||||||||||||||||||||
Diagnostic Tests, Lab and Radiology Services, and X-Rays | |||||||||||||||||||||||
Diagnostic radiology services (such as MRIs CT scans): $200 copay | |||||||||||||||||||||||
Diagnostic tests and procedures: $5-15 copay depending on the service | |||||||||||||||||||||||
Lab services: $5-15 copay depending on the service | |||||||||||||||||||||||
Outpatient x-rays: $50 copay | |||||||||||||||||||||||
Therapeutic radiology services (such as radiation treatment for cancer): You pay nothing | |||||||||||||||||||||||
Doctor’s Office Visits | |||||||||||||||||||||||
Primary care physician visit: $10 copay | |||||||||||||||||||||||
Specialist visit: $40 copay | |||||||||||||||||||||||
Durable Medical Equipment (wheelchairs, oxygen, etc.) | |||||||||||||||||||||||
20% of the cost | |||||||||||||||||||||||
Emergency Care | |||||||||||||||||||||||
$65 copay | |||||||||||||||||||||||
If you are admitted to the hospital within 3 days you do not have to pay your share of the cost for emergency care. See the "Inpatient Hospital Care" section for other costs. | |||||||||||||||||||||||
Foot Care (podiatry services) | |||||||||||||||||||||||
Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: $40 copay | |||||||||||||||||||||||
Hearing Services | |||||||||||||||||||||||
Exam to diagnose and treat hearing and balance issues: $40 copay | |||||||||||||||||||||||
Routine hearing exam (for up to 1 every year): $40 copay | |||||||||||||||||||||||
Hearing aid: You pay nothing | |||||||||||||||||||||||
Our plan pays up to $500 every three years for hearing aids. | |||||||||||||||||||||||
Home Health Care | |||||||||||||||||||||||
You pay nothing | |||||||||||||||||||||||
Mental Health Care | |||||||||||||||||||||||
Inpatient visit: | |||||||||||||||||||||||
Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital. | |||||||||||||||||||||||
Our plan covers 90 days for an inpatient hospital stay. | |||||||||||||||||||||||
Our plan also covers 60 "lifetime reserve days." These are "extra" days that we cover. If your hospital stay is longer than 90 days you can use these extra days. But once you have used up these extra 60 days your inpatient hospital coverage will be limited to 90 days. | |||||||||||||||||||||||
Outpatient group therapy visit: $40 copay | |||||||||||||||||||||||
Outpatient individual therapy visit: $40 copay | |||||||||||||||||||||||
Outpatient Rehabilitation Services | |||||||||||||||||||||||
Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): You pay nothing | |||||||||||||||||||||||
Occupational therapy visit: $40 copay | |||||||||||||||||||||||
Physical therapy and speech and language therapy visit: $40 copay | |||||||||||||||||||||||
Outpatient Substance Abuse | |||||||||||||||||||||||
Group therapy visit: $40 copay | |||||||||||||||||||||||
Individual therapy visit: $40 copay | |||||||||||||||||||||||
Outpatient Surgery | |||||||||||||||||||||||
Ambulatory surgical center: $300 copay | |||||||||||||||||||||||
Outpatient hospital: $300 copay | |||||||||||||||||||||||
Over-the-Counter Items | |||||||||||||||||||||||
Not Covered | |||||||||||||||||||||||
Prosthetic Devices (braces, artificial limbs, etc.) | |||||||||||||||||||||||
Prosthetic devices: 20% of the cost | |||||||||||||||||||||||
Related medical supplies: 20% of the cost | |||||||||||||||||||||||
Renal Dialysis | |||||||||||||||||||||||
You pay nothing | |||||||||||||||||||||||
Transportation | |||||||||||||||||||||||
$40 copay | |||||||||||||||||||||||
Urgently Needed Care | |||||||||||||||||||||||
$50 copay | |||||||||||||||||||||||
Vision Services | |||||||||||||||||||||||
Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): $0-40 copay depending on the service | |||||||||||||||||||||||
Routine eye exam (for up to 1 every year): You pay nothing | |||||||||||||||||||||||
Contact lenses (for up to 1 every year): You pay nothing | |||||||||||||||||||||||
Our plan pays up to $100 every year for contact lenses. | |||||||||||||||||||||||
Eyeglass frames (for up to 1 every year): You pay nothing | |||||||||||||||||||||||
Our plan pays up to $100 every year for eyeglass frames. | |||||||||||||||||||||||
Eyeglass lenses (for up to 1 every year): You pay nothing | |||||||||||||||||||||||
Our plan pays up to $100 every year for eyeglass lenses. | |||||||||||||||||||||||
Eyeglasses or contact lenses after cataract surgery: You pay nothing | |||||||||||||||||||||||
** Hospice ** | |||||||||||||||||||||||
Hospice | |||||||||||||||||||||||
You pay nothing for hospice care from a Medicare-certified hospice. You may have to pay part of the cost for drugs and respite care. | |||||||||||||||||||||||
** Preventive Care ** | |||||||||||||||||||||||
Preventive Care | |||||||||||||||||||||||
You pay nothing | |||||||||||||||||||||||
Our plan covers many preventive services including:
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** Inpatient Care ** | |||||||||||||||||||||||
Inpatient Hospital Care | |||||||||||||||||||||||
Our plan covers an unlimited number of days for an inpatient hospital stay. | |||||||||||||||||||||||
Inpatient Mental Health Care | |||||||||||||||||||||||
For inpatient mental health care see the "Mental Health Care" section. | |||||||||||||||||||||||
Skilled Nursing Facility (SNF) | |||||||||||||||||||||||
Our plan covers up to 100 days in a SNF. | |||||||||||||||||||||||
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Outpatient Prescription Drugs | |||||||||||||||||||||||
For Part B drugs such as chemotherapy drugs1: 0-20% of the cost depending on the drug | |||||||||||||||||||||||
Other Part B drugs1: 0-20% of the cost depending on the drug | |||||||||||||||||||||||
You pay the following until your total yearly drug costs reach $2 960. Total yearly drug costs are the total drug costs paid by both you and our Part D plan. | |||||||||||||||||||||||
You may get your drugs at network retail pharmacies and mail order pharmacies. | |||||||||||||||||||||||
Standard Retail Cost-Sharing
| |||||||||||||||||||||||
Standard Mail Order Cost-Sharing
| |||||||||||||||||||||||
If you reside in a long-term care facility you pay the same as at a retail pharmacy. | |||||||||||||||||||||||
You may get drugs from an out-of-network pharmacy but may pay more than you pay at an in-network pharmacy. | |||||||||||||||||||||||
Most Medicare drug plans have a coverage gap (also called the "donut hole"). This means that there's a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $2 960. After you enter the coverage gap you pay 45% of the plan's cost for covered brand name drugs and 65% of the plan's cost for covered generic drugs until your costs total $4 700 which is the end of the coverage gap. Not everyone will enter the coverage gap. | |||||||||||||||||||||||
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4 700 you pay the greater of:
| |||||||||||||||||||||||
** Outpatient Care ** | |||||||||||||||||||||||
Diabetes Supplies and Services | |||||||||||||||||||||||
Diabetes monitoring supplies: 0-20% of the cost depending on the supply | |||||||||||||||||||||||
Diabetes self-management training: You pay nothing | |||||||||||||||||||||||
Therapeutic shoes or inserts: 20% of the cost | |||||||||||||||||||||||
Foot Care (podiatry services) | |||||||||||||||||||||||
Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: $40 copay | |||||||||||||||||||||||
Hearing Services | |||||||||||||||||||||||
Exam to diagnose and treat hearing and balance issues: $40 copay | |||||||||||||||||||||||
Routine hearing exam (for up to 1 every year): $40 copay | |||||||||||||||||||||||
Hearing aid: You pay nothing | |||||||||||||||||||||||
Our plan pays up to $500 every three years for hearing aids. | |||||||||||||||||||||||
** Outpatient Medical Services and Supplies ** | |||||||||||||||||||||||
Outpatient Substance Abuse | |||||||||||||||||||||||
Group therapy visit: $40 copay | |||||||||||||||||||||||
Individual therapy visit: $40 copay | |||||||||||||||||||||||
Prosthetic Devices (braces, artificial limbs, etc.) | |||||||||||||||||||||||
Prosthetic devices: 20% of the cost | |||||||||||||||||||||||
Related medical supplies: 20% of the cost | |||||||||||||||||||||||
** Additional Benefits ** | |||||||||||||||||||||||
Inpatient Mental Health Care | |||||||||||||||||||||||
For inpatient mental health care see the "Mental Health Care" section. |