2018 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | BlueShield Forever Blue Value (PPO) | ||||
Location: | Schenectady, New York Click to see other locations | ||||
Plan ID: | H5526 - 017 - 0 Click to see other plans | ||||
Member Services: | 1-800-329-2792 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 BlueShield Forever Blue Value (PPO) benefit details | |||||
— Medicare Plan Features — | |||||
Monthly Premium: | $85.00 (see Plan Premium Details below) | ||||
Annual Deductible: | $0 | ||||
Annual Initial Coverage Limit (ICL): | $3,750 | ||||
Health Plan Type: | Local PPO | ||||
Maximum Out-of-Pocket Limit for Parts A & B (MOOP): | $6,700 | ||||
Additional Gap Coverage? | Yes, some additional gap coverage. | ||||
Total Number of Formulary Drugs: | 4,065 drugs | Browse the BlueShield Forever Blue Value (PPO) 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: | $7.00 | $15.00 | $42.00 | $94.00 | 33% |
• Number of Drugs per Tier: | 387 | 2065 | 594 | 249 | 770 |
Plan's Pharmacy Search: | http://www.bcbswny.com | ||||
Plan Offers Mail Order? | No | ||||
Number of Members enrolled in this plan in (H5526 - 017): | 1,790 members | ||||
Plan’s Summary Star Rating: | 4.5 out of 5 Stars. | ||||
• Customer Service Rating: | 5 out of 5 Stars. | ||||
• Member Experience Rating: | 4 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 | |
$85.00 | $16.20 | $47.80 | $21.00 | ||
Monthly Premium with Extra Help Low-Income Subsidy (LIS): ❔ | 100% Subsidy | 75% Subsidy | 50% Subsidy | 25% Subsidy | |
Monthly Part D Premium with LIS: | $29.80 | $39.60 | $49.30 | $59.10 | |
Total Monthly Premium with LIS (Parts C & D): | $46.00 | $55.80 | $65.50 | $75.30 |
— Plan Health Benefits — |