2021 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | Blue Advantage (PPO) | ||||
Location: | West Carroll, Louisiana Click to see other locations | ||||
Plan ID: | H1248 - 006 - 0 Click to see other plans | ||||
Member Services: | 1-866-508-7145 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 Blue Advantage (PPO) benefit details
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— Medicare Plan Features — | |||||
Monthly Premium: | $85.00 (see Plan Premium Details below) | ||||
Annual Deductible: | $0 | ||||
Annual Initial Coverage Limit (ICL): | $4,130 | ||||
Health Plan Type: | Local PPO | ||||
Maximum Out-of-Pocket Limit for Parts A & B (MOOP): | $3,700 | ||||
Additional Gap Coverage? | Yes, some additional gap coverage. | ||||
Total Number of Formulary Drugs: | 3,697 drugs | Browse the Blue Advantage (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: | $3.00 | $12.00 | $45.00 | $100.00 | 33% |
• Number of Drugs per Tier: | 388 | 1730 | 428 | 359 | 792 |
Plan's Pharmacy Search: | http://www.bcbsla.com/blueadvantage | ||||
Plan Offers Mail Order? | Yes | ||||
Number of Members enrolled in this plan in West Carroll, Louisiana: | less than 10 members | ||||
Number of Members enrolled in this plan in Louisiana: | 193 members | ||||
Number of Members enrolled in this plan in (H1248 - 006): | 253 members | ||||
Plan’s Summary Star Rating: | New plan - No summary rating as of yet. | ||||
• Customer Service Rating: | 5 out of 5 Stars. | ||||
• Member Experience Rating: | New plan - not yet rated. | ||||
• 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 Base Premium | Part D Supplemental Premium | |
$85.00 | $29.20 | $55.80 | $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: | $21.50 | $30.10 | $38.70 | $47.20 | |
Total Monthly Premium with LIS (Parts C & D): | $50.70 | $59.30 | $67.90 | $76.40 |
— Plan Health Benefits — | |||||
** Base Plan ** | |||||
Premium | |||||
• Total monthly premium: $85.00 | |||||
• Health plan premium: $29.20 | |||||
• Drug plan premium: $55.80 | |||||
• You must continue to pay your Part B premium. | |||||
• Part B premium reduction: No | |||||
Deductible | |||||
• Health plan deductible: $1,000 annual deductible | |||||
• Other health plan deductibles: In-network: No | |||||
• Drug plan deductible: No annual deductible | |||||
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs) | |||||
• $7,400 In and Out-of-network $3,700 In-network | |||||
Optional supplemental benefits | |||||
• No | |||||
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions? | |||||
• In-network: Yes, contact plan for further details | |||||
Doctor visits | |||||
• Primary In-network: $0 copay | |||||
• Primary Out-of-network: 30% coinsurance per visit | |||||
• Specialist In-network: $35 copay per visit | |||||
• Specialist Out-of-network: 30% coinsurance per visit | |||||
Diagnostic procedures/lab services/imaging | |||||
• Diagnostic tests and procedures In-network: $11 copay (authorization required) | |||||
• Diagnostic tests and procedures Out-of-network: 30% coinsurance (authorization required) | |||||
• Lab services In-network: $0 copay (authorization required) | |||||
• Lab services Out-of-network: 30% coinsurance (authorization required) | |||||
• Diagnostic radiology services (e.g., MRI) In-network: $0-75 copay (authorization required) | |||||
• Diagnostic radiology services (e.g., MRI) Out-of-network: 30% coinsurance (authorization required) | |||||
• Outpatient x-rays In-network: $75 copay (authorization required) | |||||
• Outpatient x-rays Out-of-network: 30% coinsurance (authorization required) | |||||
Emergency care/Urgent care | |||||
• Emergency: $90 copay per visit (always covered) | |||||
• Urgent care: $35 copay per visit (always covered) | |||||
Inpatient hospital coverage | |||||
• In-network: $170 per day for days 1 through 10 $0 per day for days 11 through 90 (authorization required) | |||||
• Out-of-network: 30% per stay (authorization required) | |||||
Outpatient hospital coverage | |||||
• In-network: $75-175 copay per visit (authorization required) | |||||
• Out-of-network: 30% coinsurance per visit (authorization required) | |||||
Skilled Nursing Facility | |||||
• In-network: $0 per day for days 1 through 20 $165 per day for days 21 through 100 (authorization required) | |||||
• Out-of-network: 30% per stay (authorization required) | |||||
Preventive care | |||||
• In-network: $0 copay | |||||
• Out-of-network: 30% coinsurance | |||||
Ground ambulance | |||||
• In-network: $260 copay | |||||
• Out-of-network: $260 copay | |||||
Rehabilitation services | |||||
• Occupational therapy visit In-network: $20 copay (authorization required) | |||||
• Occupational therapy visit Out-of-network: 30% coinsurance (authorization required) | |||||
• Physical therapy and speech and language therapy visit In-network: $20 copay (authorization required) | |||||
• Physical therapy and speech and language therapy visit Out-of-network: 30% coinsurance (authorization required) | |||||
Mental health services | |||||
• Inpatient hospital - psychiatric In-network: $175 per day for days 1 through 7 $0 per day for days 8 through 90 (authorization required) | |||||
• Inpatient hospital - psychiatric Out-of-network: 30% per stay (authorization required) | |||||
• Outpatient group therapy visit with a psychiatrist In-network: $40 copay (authorization required) | |||||
• Outpatient group therapy visit with a psychiatrist Out-of-network: 30% coinsurance (authorization required) | |||||
• Outpatient individual therapy visit with a psychiatrist In-network: $40 copay (authorization required) | |||||
• Outpatient individual therapy visit with a psychiatrist Out-of-network: 30% coinsurance (authorization required) | |||||
• Outpatient group therapy visit In-network: $40 copay (authorization required) | |||||
• Outpatient group therapy visit Out-of-network: 30% coinsurance (authorization required) | |||||
• Outpatient individual therapy visit In-network: $40 copay (authorization required) | |||||
• Outpatient individual therapy visit Out-of-network: 30% coinsurance (authorization required) | |||||
Medical equipment/supplies | |||||
• Durable medical equipment (e.g., wheelchairs, oxygen) In-network: 20% coinsurance per item (authorization required) | |||||
• Durable medical equipment (e.g., wheelchairs, oxygen) Out-of-network: 30% coinsurance per item (authorization required) | |||||
• Prosthetics (e.g., braces, artificial limbs) In-network: 20% coinsurance per item (authorization required) | |||||
• Prosthetics (e.g., braces, artificial limbs) Out-of-network: 30% coinsurance per item (authorization required) | |||||
• Diabetes supplies In-network: $0 copay (authorization required) | |||||
• Diabetes supplies Out-of-network: 30% coinsurance per item (authorization required) | |||||
Hearing | |||||
• Hearing exam In-network: $10 copay | |||||
• Hearing exam Out-of-network: 30% coinsurance | |||||
• Fitting/evaluation In-network: $0 copay (limits apply) | |||||
• Fitting/evaluation Out-of-network: 30% coinsurance (limits apply) | |||||
• Hearing aids In-network: $0 copay (limits apply) | |||||
• Hearing aids Out-of-network: $0 copay (limits apply) | |||||
Preventive dental | |||||
• Oral exam In-network: $0 copay (limits apply) | |||||
• Oral exam Out-of-network: 50% coinsurance (limits apply) | |||||
• Cleaning In-network: $0 copay (limits apply) | |||||
• Cleaning Out-of-network: 50% coinsurance (limits apply) | |||||
• Fluoride treatment In-network: $0 copay (limits apply) | |||||
• Fluoride treatment Out-of-network: 50% coinsurance (limits apply) | |||||
• Dental x-ray(s) In-network: $0 copay (limits apply) | |||||
• Dental x-ray(s) Out-of-network: 50% coinsurance (limits apply) | |||||
Comprehensive dental | |||||
• Non-routine services In-network: 50% coinsurance (limits apply) | |||||
• Non-routine services Out-of-network: 50% coinsurance (limits apply) | |||||
• Diagnostic services In-network: 50% coinsurance (limits apply) | |||||
• Diagnostic services Out-of-network: 50% coinsurance (limits apply) | |||||
• Restorative services In-network: 50% coinsurance (limits apply) | |||||
• Restorative services Out-of-network: 50% coinsurance (limits apply) | |||||
• Endodontics In-network: 50% coinsurance (limits apply) | |||||
• Endodontics Out-of-network: 50% coinsurance (limits apply) | |||||
• Periodontics In-network: 50% coinsurance (limits apply) | |||||
• Periodontics Out-of-network: 50% coinsurance (limits apply) | |||||
• Extractions In-network: 50% coinsurance (limits apply) | |||||
• Extractions Out-of-network: 50% coinsurance (limits apply) | |||||
• Prosthodontics, other oral/maxillofacial surgery, other services: Not covered | |||||
Vision | |||||
• Routine eye exam In-network: $0 copay (limits apply) | |||||
• Routine eye exam Out-of-network: $40 copay (limits apply) | |||||
• Other: Not covered | |||||
• Contact lenses In-network: $0 copay (limits apply) | |||||
• Contact lenses Out-of-network: $40-225 copay (limits apply) | |||||
• Eyeglasses (frames and lenses): Not covered | |||||
• Eyeglass frames In-network: $0 copay (limits apply) | |||||
• Eyeglass frames Out-of-network: $40-225 copay (limits apply) | |||||
• Eyeglass lenses In-network: $0 copay (limits apply) | |||||
• Eyeglass lenses Out-of-network: $40-225 copay (limits apply) | |||||
• Upgrades: Not covered | |||||
Wellness programs (e.g., fitness, nursing hotline) | |||||
• Covered | |||||
Transportation | |||||
• Not covered | |||||
Foot care (podiatry services) | |||||
• Foot exams and treatment In-network: $30 copay | |||||
• Foot exams and treatment Out-of-network: 30% coinsurance | |||||
• Routine foot care: Not covered | |||||
Medicare Part B drugs | |||||
• Chemotherapy In-network: 20% coinsurance (authorization required) | |||||
• Chemotherapy Out-of-network: 30% coinsurance (authorization required) | |||||
• Other Part B drugs In-network: 20% coinsurance (authorization required) | |||||
• Other Part B drugs Out-of-network: 30% coinsurance (authorization required) |