2018 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | Medicare Plus Blue PPO Signature (PPO) | ||||
Location: | Antrim, Michigan Click to see other locations | ||||
Plan ID: | H9572 - 001 - 4 Click to see other plans | ||||
Member Services: | 1-877-241-2583 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 Medicare Plus Blue PPO Signature (PPO) benefit details | |||||
— Medicare Plan Features — | |||||
Monthly Premium: | $179.50 (see Plan Premium Details below) | ||||
Annual Rx Deductible: | $105 (Tier 1 and 2 excluded from the Deductible.) | ||||
Annual Rx Initial Coverage Limit (ICL): | $3,750 | ||||
Health Plan Type: | Local PPO | ||||
Maximum Out-of-Pocket Limit for Parts A & B (MOOP): | $4,700 | ||||
Additional Rx Gap Coverage? | No additional gap coverage, only the Donut Hole Discount | ||||
Total Number of Formulary Drugs: | 3,988 drugs | Browse the Medicare Plus Blue PPO Signature (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: | $1.00 | $10.00 | $42.00 | 48% | 30% |
• Number of Drugs per Tier: | 465 | 1397 | 349 | 1079 | 698 |
Plan's Pharmacy Search: | http://www.bcbsm.com/pharmaciesmedicare | ||||
Plan Offers Mail Order? | Yes | ||||
Number of Members enrolled in this plan in Antrim, Michigan: | 111 members | ||||
Number of Members enrolled in this plan in (H9572 - 001): | 38,934 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 Basic Premium | Part D Supplemental Premium | |
$179.50 | $103.10 | $54.50 | $21.90 | ||
Monthly Premium with Extra Help Low-Income Subsidy (LIS): ❔ | 100% Subsidy | 75% Subsidy | 50% Subsidy | 25% Subsidy | |
Monthly Part D Premium with LIS: | $43.10 | $51.40 | $59.80 | $68.10 | |
Total Monthly Premium with LIS (Parts C & D): | $146.20 | $154.50 | $162.90 | $171.20 |
— Plan Health Benefits — |