2016 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | Blue Medicare Advantage (Medicare-Medicaid Plan) | ||||
Location: | Kane, Illinois Click to see other locations | ||||
Plan ID: | H0927 - 001 - 0 Click to see other plans | ||||
Member Services: | 1-877-723-7702 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 Blue Medicare Advantage (Medicare-Medicaid Plan) benefit details | |||||
— Medicare Plan Features — | |||||
Monthly Premium: | $0.00 (see Plan Premium Details below) | ||||
Annual Rx Deductible: | $0 | ||||
Health Plan Type: | MMP | ||||
Maximum Out-of-Pocket Limit for Parts A & B (MOOP): | $0 | ||||
Additional Rx Gap Coverage? | Yes, some additional gap coverage. | ||||
Total Number of Formulary Drugs: | 3,295 drugs | Browse the Blue Medicare Advantage (Medicare-Medicaid Plan) Formulary | |||
This plan has 3 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: | $0.00 | $0.00 | $0.00 | ||
• Number of Drugs per Tier: | 2137 | 1158 | |||
Plan's Pharmacy Search: | http://www.yourpartd.com | ||||
Plan Offers Mail Order? | Yes | ||||
Number of Members enrolled in this plan in Kane, Illinois: | 615 members | ||||
Number of Members enrolled in this plan in Illinois: | 13,588 members | ||||
Number of Members enrolled in this plan in (H0927 - 001): | 13,796 members | ||||
Plan’s Summary Star Rating: | New plan - No summary rating as of yet. | ||||
• Customer Service Rating: | New plan - not yet rated. | ||||
• Member Experience Rating: | New plan - not yet rated. | ||||
• Drug Cost Accuracy Rating: | New plan - not yet rated. | ||||
— 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 ** | |||||
Monthly premium, deductible, and limits on how much you pay for covered services | |||||
Some services may require a monthly payment amount. | |||||
You pay nothing | |||||
In this plan you will pay nothing for services from any provider. | |||||
Please note that you will still need to pay your 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 | |||||
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 drugs: You pay nothing | |||||
Other Part B drugs: You pay nothing | |||||
You may get your drugs at network retail pharmacies and mail order pharmacies. | |||||
You pay nothing | |||||
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 at the same cost as an in-network pharmacy. | |||||
You pay nothing | |||||
Institutional care | |||||
Institution for mental disease services for individuals 65 or older: You pay nothing | |||||
Nursing home services: You pay nothing | |||||
** Important Information ** | |||||
Monthly premium, deductible, and limits on how much you pay for covered services | |||||
Some services may require a monthly payment amount. | |||||
You pay nothing | |||||
In this plan you will pay nothing for services from any provider. | |||||
Please note that you will still need to pay your 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 | |||||
Not covered | |||||
Additional home care services | |||||
Home and community based services: You pay nothing | |||||
Additional services | |||||
Hospice: You pay nothing | |||||
Behavioral Health Services (MH/Substance Abuse: You pay nothing | |||||
Telehealth Services: You pay nothing | |||||
Emergency Dental: You pay nothing | |||||
Ambulance | |||||
You pay nothing | |||||
Chiropractic care | |||||
Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): You pay nothing | |||||
Dental services | |||||
Limited dental services (this does not include services in connection with care treatment filling removal or replacement of teeth): You pay nothing | |||||
Preventive dental services: | |||||
Diabetes supplies and services | |||||
Diabetes monitoring supplies: You pay nothing | |||||
Diabetes self-management training: You pay nothing | |||||
Therapeutic shoes or inserts: You pay nothing | |||||
Diagnostic tests, lab and radiology services, and x-rays (Costs for these services may be different if received in an outpatient surgery setting) | |||||
Diagnostic radiology services (such as MRIs CT scans): You pay nothing | |||||
Diagnostic tests and procedures: You pay nothing | |||||
Lab services: You pay nothing | |||||
Outpatient x-rays: You pay nothing | |||||
Therapeutic radiology services (such as radiation treatment for cancer): You pay nothing | |||||
Doctor's office visits | |||||
Primary care physician visit: You pay nothing | |||||
Specialist visit: You pay nothing | |||||
Durable medical equipment (wheelchairs, oxygen, etc.) | |||||
You pay nothing | |||||
Durable medical equipment for use outside the home: You pay nothing | |||||
Emergency care | |||||
You pay nothing | |||||
Foot care (podiatry services) | |||||
Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: You pay nothing | |||||
Hearing services | |||||
Exam to diagnose and treat hearing and balance issues: You pay nothing | |||||
Routine hearing exam (for up to 1 every year): You pay nothing | |||||
Hearing aid fitting/evaluation (for up to 1 every three years): You pay nothing | |||||
Hearing aid: You pay nothing | |||||
Home health care | |||||
You pay nothing | |||||
Additional hours of care: You pay nothing | |||||
Mental health care | |||||
Inpatient visit: | |||||
Our plan covers an unlimited number of days for an inpatient hospital stay. | |||||
You pay nothing | |||||
Outpatient group therapy visit: You pay nothing | |||||
Outpatient individual therapy visit: You pay nothing | |||||
Outpatient rehabilitation | |||||
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: You pay nothing | |||||
Non-Medicare Occupational Therapy Services: You pay nothing | |||||
Physical therapy and speech and language therapy visit: You pay nothing | |||||
Non-Medicare Physical Therapy Services: You pay nothing | |||||
Non-Medicare Speech-Therapy Services: You pay nothing | |||||
Outpatient substance abuse | |||||
Group therapy visit: You pay nothing | |||||
Individual therapy visit: You pay nothing | |||||
Outpatient surgery | |||||
Ambulatory surgical center: You pay nothing | |||||
Outpatient hospital: You pay nothing | |||||
Over-the-counter items | |||||
Please visit our website to see our list of covered over-the-counter items. | |||||
Prosthetic devices (braces, artificial limbs, etc.) | |||||
Prosthetic devices: You pay nothing | |||||
Related medical supplies: You pay nothing | |||||
Non-Medicare Prosthetics/Medical Supplies: You pay nothing | |||||
Renal dialysis | |||||
You pay nothing | |||||
Transportation | |||||
You pay nothing | |||||
Urgently needed services | |||||
You pay nothing | |||||
Vision services | |||||
Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): You pay nothing | |||||
Routine eye exam (for up to 1 every year): You pay nothing | |||||
Eyeglasses (frames and lenses) (for up to 1 every two years): You pay nothing | |||||
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:
| |||||
Family planning services: You pay nothing | |||||
Tobacco cessation counseling for pregnant women (for up to 12 sessions every year): You pay nothing. | |||||
** Inpatient Care ** | |||||
Inpatient hospital care | |||||
Our plan covers an unlimited number of days for an inpatient hospital stay. | |||||
You pay nothing | |||||
Inpatient mental health care | |||||
For inpatient mental health care see the "Mental Health Care" section. | |||||
Institutional care | |||||
Institution for mental disease services for individuals 65 or older: You pay nothing | |||||
Nursing home services: You pay nothing | |||||
Skilled Nursing Facility (SNF) | |||||
Our plan covers an unlimited number of days in a SNF. | |||||
You pay nothing | |||||
Outpatient prescription drugs | |||||
For Part B drugs such as chemotherapy drugs: You pay nothing | |||||
Other Part B drugs: You pay nothing | |||||
You may get your drugs at network retail pharmacies and mail order pharmacies. | |||||
You pay nothing | |||||
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 at the same cost as an in-network pharmacy. | |||||
You pay nothing | |||||
Additional home care services | |||||
Home and community based services: You pay nothing | |||||
** Outpatient Care ** | |||||
Diabetes supplies and services | |||||
Diabetes monitoring supplies: You pay nothing | |||||
Diabetes self-management training: You pay nothing | |||||
Therapeutic shoes or inserts: You pay nothing | |||||
Foot care (podiatry services) | |||||
Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: You pay nothing | |||||
Hearing services | |||||
Exam to diagnose and treat hearing and balance issues: You pay nothing | |||||
Routine hearing exam (for up to 1 every year): You pay nothing | |||||
Hearing aid fitting/evaluation (for up to 1 every three years): You pay nothing | |||||
Hearing aid: You pay nothing | |||||
** Outpatient Medical Services and Supplies ** | |||||
Outpatient substance abuse | |||||
Group therapy visit: You pay nothing | |||||
Individual therapy visit: You pay nothing | |||||
Prosthetic devices (braces, artificial limbs, etc.) | |||||
Prosthetic devices: You pay nothing | |||||
Related medical supplies: You pay nothing | |||||
Non-Medicare Prosthetics/Medical Supplies: You pay nothing | |||||
** Additional Benefits ** | |||||
Inpatient mental health care | |||||
For inpatient mental health care see the "Mental Health Care" section. | |||||
Institutional care | |||||
Institution for mental disease services for individuals 65 or older: You pay nothing | |||||
Nursing home services: You pay nothing |