2019 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | BlueAdvantage Ruby (PPO) | ||||
Location: | Smith, Tennessee Click to see other locations | ||||
Plan ID: | H7917 - 014 - 0 Click to see other plans | ||||
Member Services: | 1-800-831-2583 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 BlueAdvantage Ruby (PPO) benefit details | |||||
— Medicare Plan Features — | |||||
Monthly Premium: | $91.00 (see Plan Premium Details below) | ||||
Annual Rx Deductible: | $0 | ||||
Annual Rx Initial Coverage Limit (ICL): | $3,820 | ||||
Health Plan Type: | Local PPO | ||||
Maximum Out-of-Pocket Limit for Parts A & B (MOOP): | $4,300 | ||||
Additional Rx Gap Coverage? | Yes, some additional gap coverage. | ||||
Total Number of Formulary Drugs: | 3,617 drugs | Browse the BlueAdvantage Ruby (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 | $5.00 | $28.00 | $65.00 | 33% |
• Number of Drugs per Tier: | 614 | 1234 | 450 | 576 | 743 |
Plan's Pharmacy Search: | http://bcbstmedicare.com | ||||
Plan Offers Mail Order? | Yes | ||||
Number of Members enrolled in this plan in Smith, Tennessee: | 17 members | ||||
Number of Members enrolled in this plan in Tennessee: | 5,737 members | ||||
Number of Members enrolled in this plan in (H7917 - 014): | 5,744 members | ||||
Plan’s Summary Star Rating: | 4 out of 5 Stars. | ||||
• Customer Service Rating: | 3 out of 5 Stars. | ||||
• Member Experience Rating: | 5 out of 5 Stars. | ||||
• Drug Cost Accuracy Rating: | 3 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 | |
$91.00 | $31.10 | $59.90 | $0.00 | ||
Monthly Premium with Extra Help Low-Income Subsidy (LIS): ❔ | 100% Subsidy | 75% Subsidy | 50% Subsidy | 25% Subsidy | |
Monthly Part D Premium with LIS: | $28.50 | $36.30 | $44.20 | $52.00 | |
Total Monthly Premium with LIS (Parts C & D): | $59.60 | $67.40 | $75.30 | $83.10 |
— Plan Health Benefits — | |||||
** Benefit Highlights ** | |||||
Health plan deductible | |||||
• $0 | |||||
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs) | |||||
• $10,000 In and Out-of-network $4,300 In-network | |||||
Optional supplemental benefits | |||||
• No | |||||
Other health plan deductibles? | |||||
• In-Network: No | |||||
Preventive care | |||||
• In-Network: $0 copay | |||||
Outpatient hospital coverage | |||||
• In-Network: $260 per visit | |||||
Inpatient hospital coverage | |||||
• In-Network: $260 per day for days 1 through 4 $0 per day for days 5 through 90 | |||||
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions? | |||||
• In-Network: No | |||||
Inpatient hospital coverage | |||||
• Out-of-Network: 50% per stay | |||||
Outpatient hospital coverage | |||||
• Out-of-Network: 50% per visit | |||||
Preventive care | |||||
• Out-of-Network: 50% | |||||
Doctor visits | |||||
• Primary: In-Network: $15 per visit | |||||
• Primary: Out-of-Network: 50% per visit | |||||
• Specialist: In-Network: $35 per visit | |||||
• Specialist: Out-of-Network: 50% per visit | |||||
Emergency care/Urgent care | |||||
• Emergency: $85 per visit (always covered) | |||||
• Urgent care: $55 per visit (always covered) | |||||
Wellness programs (e.g., fitness, nursing hotline) | |||||
• Covered | |||||
Transportation | |||||
• Not covered | |||||
Skilled Nursing Facility | |||||
• In-Network: $0 per day for days 1 through 20 $172 per day for days 21 through 100 | |||||
Ground ambulance | |||||
• In-Network: $150 | |||||
Skilled Nursing Facility | |||||
• Out-of-Network: 50% per stay | |||||
Ground ambulance | |||||
• Out-of-Network: $150 or 20% | |||||
Vision | |||||
• Routine eye exam: In-Network: $40 | |||||
• Routine eye exam: Out-of-Network: $40 | |||||
• Other: Not covered | |||||
• Contact lenses: In-Network: $0 copay | |||||
• Contact lenses: Out-of-Network: $0 copay | |||||
• Eyeglasses (frames and lenses): In-Network: $0 copay | |||||
• Eyeglasses (frames and lenses): Out-of-Network: $0 copay | |||||
• Eyeglass frames: Not covered | |||||
• Eyeglass lenses: Not covered | |||||
• Upgrades: Not covered | |||||
Mental health services | |||||
• Inpatient hospital - psychiatric: In-Network: $260 per day for days 1 through 4 $0 per day for days 5 through 90 | |||||
• Inpatient hospital - psychiatric: Out-of-Network: 50% per stay | |||||
• Outpatient group therapy visit with a psychiatrist: In-Network: $20 | |||||
• Outpatient group therapy visit with a psychiatrist: Out-of-Network: 50% | |||||
• Outpatient individual therapy visit with a psychiatrist: In-Network: $30 | |||||
• Outpatient individual therapy visit with a psychiatrist: Out-of-Network: 50% | |||||
• Outpatient group therapy visit: In-Network: $20 | |||||
• Outpatient group therapy visit: Out-of-Network: 50% | |||||
• Outpatient individual therapy visit: In-Network: $30 | |||||
• Outpatient individual therapy visit: Out-of-Network: 50% | |||||
Rehabilitation services | |||||
• Occupational therapy visit: In-Network: $40 | |||||
• Occupational therapy visit: Out-of-Network: 50% | |||||
• Physical therapy and speech and language therapy visit: In-Network: $40 | |||||
• Physical therapy and speech and language therapy visit: Out-of-Network: 50% | |||||
Foot care (podiatry services) | |||||
• Foot exams and treatment: In-Network: $25 | |||||
• Foot exams and treatment: Out-of-Network: 50% | |||||
• Routine foot care: Not covered | |||||
Medical equipment/supplies | |||||
• Durable medical equipment (e.g., wheelchairs, oxygen): In-Network: 20% per item | |||||
• Durable medical equipment (e.g., wheelchairs, oxygen): Out-of-Network: 50% per item | |||||
• Prosthetics (e.g., braces, artificial limbs): In-Network: 20% per item | |||||
• Prosthetics (e.g., braces, artificial limbs): Out-of-Network: 50% per item | |||||
• Diabetes supplies: In-Network: $0 copay | |||||
• Diabetes supplies: Out-of-Network: 20% per item | |||||
Medicare Part B drugs | |||||
• Chemotherapy: In-Network: 20% | |||||
• Chemotherapy: Out-of-Network: 50% | |||||
• Other Part B drugs: In-Network: 20% | |||||
• Other Part B drugs: Out-of-Network: 50% | |||||
** Benefits Services ** | |||||
Diagnostic procedures/lab services/imaging | |||||
• Diagnostic tests and procedures: In-Network: $10-100 | |||||
• Diagnostic tests and procedures: Out-of-Network: 50% | |||||
• Lab services: In-Network: $0-40 or 20% | |||||
• Lab services: Out-of-Network: 50% | |||||
• Diagnostic radiology services (e.g., MRI): In-Network: $200 | |||||
• Diagnostic radiology services (e.g., MRI): Out-of-Network: 50% | |||||
• Outpatient x-rays: In-Network: $15-50 | |||||
• Outpatient x-rays: Out-of-Network: 50% | |||||
Hearing | |||||
• Hearing exam: In-Network: $10 | |||||
• Hearing exam: Out-of-Network: $10 | |||||
• Fitting/evaluation: Not covered | |||||
• Hearing aids: In-Network: $599-899 | |||||
• Hearing aids: Out-of-Network: $599-899 | |||||
Preventive dental | |||||
• Oral exam: In-Network: $0 copay | |||||
• Oral exam: Out-of-Network: $0 copay | |||||
• Cleaning: In-Network: $0 copay | |||||
• Cleaning: Out-of-Network: $0 copay | |||||
• Fluoride treatment: Not covered | |||||
• Dental x-ray(s): In-Network: $0 copay | |||||
• Dental x-ray(s): Out-of-Network: $0 copay | |||||
Comprehensive dental | |||||
• Non-routine services: In-Network: $0 copay | |||||
• Non-routine services: Out-of-Network: $0 copay | |||||
• Diagnostic services: In-Network: $0 copay | |||||
• Diagnostic services: Out-of-Network: $0 copay | |||||
• Restorative services: In-Network: $0 copay | |||||
• Restorative services: Out-of-Network: $0 copay | |||||
• Endodontics: In-Network: $0 copay | |||||
• Endodontics: Out-of-Network: $0 copay | |||||
• Periodontics: In-Network: $0 copay | |||||
• Periodontics: Out-of-Network: $0 copay | |||||
• Extractions: In-Network: $0 copay | |||||
• Extractions: Out-of-Network: $0 copay | |||||
• Prosthodontics, other oral/maxillofacial surgery, other services: In-Network: $0 copay | |||||
• Prosthodontics, other oral/maxillofacial surgery, other services: Out-of-Network: $0 copay |