2017 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | Medicare BlueEnhanced (PPO) | ||||
Location: | Cayuga, New York Click to see other locations | ||||
Plan ID: | H3335 - 015 - 0 Click to see other plans | ||||
Member Services: | 1-877-883-9577 TTY users 1-800-421-1220 | ||||
— 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 Medicare BlueEnhanced (PPO) benefit details
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— Medicare Plan Features — | |||||
Monthly Premium: | $150.00 (see Plan Premium Details below) | ||||
Annual Deductible: | $0 (Tier excluded from the Deductible.) | ||||
Annual Initial Coverage Limit (ICL): | $3,700 | ||||
Health Plan Type: | Local PPO | ||||
Maximum Out-of-Pocket Limit for Parts A & B (MOOP): | $5,000 | ||||
Additional Gap Coverage? | No additional gap coverage, only the Donut Hole Discount | ||||
Total Number of Formulary Drugs: | 4,712 drugs | Browse the Medicare BlueEnhanced (PPO) Formulary | |||
This plan has 5 drug tiers.
See cost-sharing for all pharmacies and tiers.
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Formulary Drug Details: | Tier 1 | Tier 2 | Tier 3 | Tier 4 | Tier 5 |
• Preferred Pharmacy Cost-Sharing during initial coverage phase: | $0.00 | $10.00 | $47.00 | $100.00 | 33% |
• Number of Drugs per Tier: | 183 | 1887 | 608 | 1142 | 892 |
Plan's Pharmacy Search: | http://www.excellusbcbs.comandwww.univerahealthcare.com | ||||
Plan Offers Mail Order? | Yes | ||||
Number of Members enrolled in this plan in (H3335 - 015): | 5,001 members | ||||
Plan’s Summary Star Rating: | 4 out of 5 Stars. | ||||
• Customer Service Rating: | 5 out of 5 Stars. | ||||
• Member Experience Rating: | 3 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 Base Premium | Part D Supplemental Premium | |
$150.00 | $57.40 | $62.90 | $29.70 | ||
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): | $57.40 | $57.40 | $57.40 | $57.40 | |
— Plan Health Benefits — | |||||
** General Plan Information ** | |||||
Choice of Doctors?: Any Doctor | |||||
** Cost ** | |||||
Monthly Health Plan Premium: $57.40 | |||||
Monthly Drug Plan Premium: $92.60 | |||||
Health Plan Deductible: $0 | |||||
Other Health Plan Deductibles?: No | |||||
Maximum Out-of-Pocket Enrollee Responsibility (does not include prescription drugs)
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** Extra Benefits ** | |||||
Prescription Drugs Covered?: Yes | |||||
Optional Supplemental Benefits?: No | |||||
** Outpatient Care and Services ** | |||||
Ambulance:
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Doctor's office visits:
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Durable medical equipment (wheelchairs, oxygen, etc.):
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Emergency care: $75 per visit (always covered) | |||||
Home health care:
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Mental health care:
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Outpatient hospital:
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Renal dialysis:
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** Inpatient Care ** | |||||
Inpatient hospital care:
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Optional Supplemental Benefits?: No | |||||
Skilled Nursing Facility (SNF):
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Prescription Drugs Covered?: Yes | |||||
** Additional Benefits ** | |||||
Optional Supplemental Benefits?: No |