q1medicare.com
Powered by Q1Group LLC
A non-government resource for the Medicare community
Powered by Q1Group LLC
A non-government Medicare community resource
  • Menu ☰
  • Home
  • Contact
  • MAPD
  • PDP
  • 2024
  • 2025
  • FAQs
  • Articles
  • Search ⌕
  • Contact
  • 2024
  • 2025
  • FAQs
  • Articles
  • Latest Medicare News
  • Search ⌕

2016 Medicare Advantage Plan Benefit Details for the AR Blue Cross - Medi-Pak Advantage MA (PFFS) - H4213-016-2
This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.

2016 Medicare Advantage Plan Details
Medicare Plan Name:AR Blue Cross - Medi-Pak Advantage MA (PFFS)
Location:Crittenden, Arkansas     Click to see other locations
Plan ID:H4213 - 016 - 2     Click to see other plans
Member Services:1-877-233-7022 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
Email a copy of the AR Blue Cross - Medi-Pak Advantage MA (PFFS) benefit details
— Medicare Plan Features —
Monthly Premium:$31.00 (see Plan Premium Details below)
Annual Deductible:no drug coverage
Health Plan Type:PFFS *
Maximum Out-of-Pocket Limit for Parts A & B (MOOP):$0
Number of Members enrolled in this plan in Crittenden, Arkansas:27 members
Number of Members enrolled in this plan in Arkansas:6,902 members
Number of Members enrolled in this plan in (H4213 - 016):6,945 members
Plan’s Summary Star Rating: 3 out of 5 Stars.
• Customer Service Rating: 4 out of 5 Stars.
• Member Experience Rating: 3 out of 5 Stars.
• Drug Cost Accuracy Rating: 4 out of 5 Stars.
— 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
$31.00 per month. In addition you must keep paying your Medicare Part B premium.
This plan has deductibles for some hospital and medical services.
$500 per year for out-of-network services.
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:
  • $6 700 for services you receive from any provider.
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.
No. There are no limits on how much our plan will pay.
** 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:
  • In-network:  20% of the cost
  • Out-of-network:  20-40% of the cost depending on the drug
Other Part B drugs:
  • In-network:  20% of the cost
  • Out-of-network:  20-40% of the cost depending on the drug
Our plan does not cover Part D prescription drug.
** Important Information **
Monthly premium, deductible, and limits on how much you pay for covered services
$31.00 per month. In addition you must keep paying your Medicare Part B premium.
This plan has deductibles for some hospital and medical services.
$500 per year for out-of-network services.
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:
  • $6 700 for services you receive from any provider.
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.
No. There are no limits on how much our plan will pay.
** Outpatient Care and Services **
Acupuncture
Not covered
Ambulance
  • In-network:  $350 copay
  • Out-of-network:  $350 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):
  • In-network:  $20 copay
  • Out-of-network:  $20 copay or 40% of the cost depending on the service
Dental services
Limited dental services (this does not include services in connection with care treatment filling removal or replacement of teeth):
  • In-network:  $50 copay
  • Out-of-network:  $50 copay or 40% of the cost depending on the service
Diabetes supplies and services
Diabetes monitoring supplies:
  • In-network:  20% of the cost
  • Out-of-network:  20-40% of the cost depending on the supply
Diabetes self-management training:
  • In-network:  You pay nothing
  • Out-of-network:  0-40% of the cost depending on the service
Therapeutic shoes or inserts:
  • In-network:  20% of the cost
  • Out-of-network:  20-40% of the cost depending on the supply
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):
  • In-network:  $315 copay
  • Out-of-network:  $315 copay or 40% of the cost depending on the service
Diagnostic tests and procedures:
  • In-network:  20% of the cost
  • Out-of-network:  20-40% of the cost depending on the service
Lab services:
  • In-network:  You pay nothing
  • Out-of-network:  0-40% of the cost depending on the service
Outpatient x-rays:
  • In-network:  20% of the cost
  • Out-of-network:  20-40% of the cost depending on the service
Therapeutic radiology services (such as radiation treatment for cancer):
  • In-network:  20% of the cost
  • Out-of-network:  20-40% of the cost depending on the service
Doctor's office visits
Primary care physician visit:
  • In-network:  $20 copay
  • Out-of-network:  $20 copay or 40% of the cost depending on the service
Specialist visit:
  • In-network:  $50 copay
  • Out-of-network:  $50 copay or 40% of the cost depending on the service
Durable medical equipment (wheelchairs, oxygen, etc.)
  • In-network:  20% of the cost
  • Out-of-network:  20-40% of the cost depending on the equipment
Emergency care
$75 copay
Foot care (podiatry services)
Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions:
  • In-network:  $50 copay
  • Out-of-network:  $50 copay or 40% of the cost depending on the service
Hearing services
Exam to diagnose and treat hearing and balance issues:
  • In-network:  $50 copay
  • Out-of-network:  $50 copay or 40% of the cost depending on the service
Home health care
  • In-network:  You pay nothing
  • Out-of-network:  0-40% of the cost depending on the service
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.
The copays for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you're admitted as an inpatient and ends when you haven't received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There's no limit to the number of benefit periods.
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.
  • In-network:  
    • $295 copay per day for days 1 through 5
    • You pay nothing per day for days 6 through 90
      • Out-of-network:  
        • 40% of the cost per stay
        • $295 copay per day for days 1 through 5
        • You pay nothing per day for days 6 through 90
          • Outpatient group therapy visit:
          • In-network:  $25-40 copay depending on the service
          • Out-of-network:  $25-40 copay or 40% of the cost depending on the service
          Outpatient individual therapy visit:
          • In-network:  $25-40 copay depending on the service
          • Out-of-network:  $25-40 copay or 40% of the cost depending on the service
          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):
          • In-network:  $45 copay
          • Out-of-network:  $45 copay or 40% of the cost depending on the service
          Occupational therapy visit:
          • In-network:  $25-40 copay depending on the service
          • Out-of-network:  $25-40 copay or 40% of the cost depending on the service
          Physical therapy and speech and language therapy visit:
          • In-network:  $25-40 copay depending on the service
          • Out-of-network:  $25-40 copay or 40% of the cost depending on the service
          Outpatient substance abuse
          Group therapy visit:
          • In-network:  $25-40 copay depending on the service
          • Out-of-network:  $25-40 copay or 40% of the cost depending on the service
          Individual therapy visit:
          • In-network:  $25-40 copay depending on the service
          • Out-of-network:  $25-40 copay or 40% of the cost depending on the service
          Outpatient surgery
          Ambulatory surgical center:
          • In-network:  $75 copay
          • Out-of-network:  $75 copay or 40% of the cost depending on the service
          Outpatient hospital:
          • In-network:  $75-315 copay depending on the service
          • Out-of-network:  $75-315 copay or 40% of the cost depending on the service
          Over-the-counter items
          Not Covered
          Prosthetic devices (braces, artificial limbs, etc.)
          Prosthetic devices:
          • In-network:  20% of the cost
          • Out-of-network:  20-40% of the cost depending on the device
          Related medical supplies:
          • In-network:  20% of the cost
          • Out-of-network:  20-40% of the cost depending on the supply
          Renal dialysis
          • In-network:  20% of the cost
          • Out-of-network:  20-40% of the cost depending on the service
          Transportation
          Not covered
          Urgently needed services
          $35 copay
          Vision services
          Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening):
          • In-network:  $0-50 copay depending on the service
          • Out-of-network:  $50 copay or 40% of the cost depending on the service
          Eyeglasses or contact lenses after cataract surgery:
          • In-network:  $50 copay
          • Out-of-network:  $50 copay or 40% of the cost depending on the service
          ** 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
          • In-network:  You pay nothing
          • Out-of-network:  0-40% of the cost depending on the service
          Our plan covers many preventive services including:
          • Abdominal aortic aneurysm screening
          • Alcohol misuse counseling
          • Bone mass measurement
          • Breast cancer screening (mammogram)
          • Cardiovascular disease (behavioral therapy)
          • Cardiovascular screenings
          • Cervical and vaginal cancer screening
          • Colorectal cancer screenings (Colonoscopy Fecal occult blood test Flexible sigmoidoscopy)
          • Depression screening
          • Diabetes screenings
          • HIV screening
          • Medical nutrition therapy services
          • Obesity screening and counseling
          • Prostate cancer screenings (PSA)
          • Sexually transmitted infections screening and counseling
          • Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease)
          • Vaccines including Flu shots Hepatitis B shots Pneumococcal shots
          • "Welcome to Medicare" preventive visit (one-time)
          • Yearly "Wellness" visit
          Any additional preventive services approved by Medicare during the contract year will be covered.
          ** Inpatient Care **
          Inpatient hospital care
          Our plan covers an unlimited number of days for an inpatient hospital stay.
          • In-network:  
            • $275 copay per day for days 1 through 6
            • You pay nothing per day for days 7 through 90
            • You pay nothing per day for days 91 and beyond
              • Out-of-network:  
                • 40% of the cost per stay
                • $275 copay per day for days 1 through 6
                • You pay nothing per day for days 7 through 90
                  • 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.
                  • In-network:  
                    • You pay nothing per day for days 1 through 20
                    • $160 copay per day for days 21 through 100
                      • Out-of-network:  
                        • 40% of the cost per stay
                        • You pay nothing per day for days 1 through 20
                        • $160 copay per day for days 21 through 100
                          • Outpatient prescription drugs
                          For Part B drugs such as chemotherapy drugs:
                          • In-network:  20% of the cost
                          • Out-of-network:  20-40% of the cost depending on the drug
                          Other Part B drugs:
                          • In-network:  20% of the cost
                          • Out-of-network:  20-40% of the cost depending on the drug
                          Our plan does not cover Part D prescription drug.
                          ** Outpatient Care **
                          Diabetes supplies and services
                          Diabetes monitoring supplies:
                          • In-network:  20% of the cost
                          • Out-of-network:  20-40% of the cost depending on the supply
                          Diabetes self-management training:
                          • In-network:  You pay nothing
                          • Out-of-network:  0-40% of the cost depending on the service
                          Therapeutic shoes or inserts:
                          • In-network:  20% of the cost
                          • Out-of-network:  20-40% of the cost depending on the supply
                          Foot care (podiatry services)
                          Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions:
                          • In-network:  $50 copay
                          • Out-of-network:  $50 copay or 40% of the cost depending on the service
                          Hearing services
                          Exam to diagnose and treat hearing and balance issues:
                          • In-network:  $50 copay
                          • Out-of-network:  $50 copay or 40% of the cost depending on the service
                          ** Outpatient Medical Services and Supplies **
                          Outpatient substance abuse
                          Group therapy visit:
                          • In-network:  $25-40 copay depending on the service
                          • Out-of-network:  $25-40 copay or 40% of the cost depending on the service
                          Individual therapy visit:
                          • In-network:  $25-40 copay depending on the service
                          • Out-of-network:  $25-40 copay or 40% of the cost depending on the service
                          Prosthetic devices (braces, artificial limbs, etc.)
                          Prosthetic devices:
                          • In-network:  20% of the cost
                          • Out-of-network:  20-40% of the cost depending on the device
                          Related medical supplies:
                          • In-network:  20% of the cost
                          • Out-of-network:  20-40% of the cost depending on the supply
                          ** Additional Benefits **
                          Inpatient mental health care
                          For inpatient mental health care see the "Mental Health Care" section.




                          Medicare Supplements
                          fill the gaps in your
                          Original Medicare
                          1. Enter Your ZIP Code:
                          » Medicare Supplement FAQs




                          © Q1Group LLC 2005 - 2024  



                          Tips & Disclaimers
                          • Q1Medicare®, Q1Rx®, and Q1Group® are registered Service Marks of Q1Group LLC and may not be used in any advertising, publicity, or for commercial purposes without the express authorization of Q1Group.
                          • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
                          • Medicare has neither reviewed nor endorsed the information on our site.
                          • We provide our Q1Medicare.com site for educational purposes and strive to present unbiased and accurate information. However, Q1Medicare is not intended as a substitute for your lawyer, doctor, healthcare provider, financial advisor, or pharmacist. For more information on your Medicare coverage, please be sure to seek legal, medical, pharmaceutical, or financial advice from a licensed professional or telephone Medicare at 1-800-633-4227.
                          • We are an independent education, research, and technology company. We are not affiliated with any Medicare plan, plan carrier, healthcare provider, or insurance company. We are not compensated for Medicare plan enrollments. We do not sell leads or share your personal information.
                          • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDPCompare.com and MACompare.com provide highlights of annual plan benefit changes.
                          • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
                          • Limitations, copayments, and restrictions may apply.
                          • We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area. However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
                            Statement required by Medicare:
                            "We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options."
                          • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
                          • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
                          • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
                          • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
                          • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
                          • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
                          • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
                          • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
                          • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
                          • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
                          • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
                          • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
                          • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
                          • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
                          • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.
                          .