2023 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | BlueAdvantage Ruby (PPO) | ||||
Location: | Bedford, Tennessee Click to see other locations | ||||
Plan ID: | H7917 - 013 - 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: | $107.00 (see Plan Premium Details below) | ||||
Annual Rx Deductible: | $0 | ||||
Annual Rx Initial Coverage Limit (ICL): | $4,660 | ||||
Health Plan Type: | Local PPO | ||||
Maximum Out-of-Pocket Limit for Parts A & B (MOOP): | $4,400 | ||||
Additional Rx Gap Coverage? | Yes, some additional gap coverage. | ||||
Total Number of Formulary Drugs: | 3,690 drugs | Browse the BlueAdvantage Ruby (PPO) Formulary | |||
This plan has 5 drug tiers. See cost-sharing for all pharmacies and tiers. | |||||
Insulin on a Medicare Part D plan's formulary will have a monthly copay of $35 or less. | |||||
Formulary Drug Details: | Tier 1 | Tier 2 | Tier 3 | Tier 4 | Tier 5 |
• Preferred Pharmacy Cost-Sharing during initial coverage phase: | $0.00 | $5.00 | $28.00 | $65.00 | 33% |
• Number of Drugs per Tier: | 562 | 1305 | 367 | 552 | 904 |
Plan Offers Mail Order? | Yes | ||||
Medicare Plan Pharmacy Numbers: | BIN: 004336 PCN: MEDDADV See BIN/PCNs for all plans | ||||
Number of Members enrolled in this plan in Bedford, Tennessee: | 78 members | ||||
Number of Members enrolled in this plan in Tennessee: | 1,886 members | ||||
Number of Members enrolled in this plan in (H7917 - 013): | 1,903 members | ||||
Plan’s Summary Star Rating: | 5 out of 5 Stars. This plan qualifies for the 5-star rating Special Enrollment period. Read more. | ||||
• Customer Service Rating: | 5 out of 5 Stars. | ||||
• Member Experience Rating: | 5 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 | |
$107.00 | $77.90 | $29.10 | $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: | $0.00 | $7.30 | $14.50 | $21.80 | |
Total Monthly Premium with LIS (Parts C & D): | $77.90 | $85.20 | $92.40 | $99.70 |
— Plan Health Benefits — | |||||
** Base Plan ** | |||||
Premium | |||||
• Total monthly premium: $107.00 | |||||
• Health plan premium: $77.90 | |||||
• Drug plan premium: $29.10 | |||||
• You must continue to pay your Part B premium. | |||||
• Part B premium reduction: No | |||||
Deductible | |||||
• Drug plan deductible: No annual deductible | |||||
Medically-approved non-opioid pain management services | |||||
• Chiropractic services: Not covered | |||||
• Acupuncture: Not covered | |||||
• Therapeutic Massage: Not covered | |||||
• Alternative Therapies: Not covered | |||||
More benefits | |||||
• Over-the-counter drug benefits: Some coverage | |||||
• Meals for short duration: Some coverage | |||||
• Annual physical exams: Some coverage | |||||
• Telehealth: Some coverage | |||||
• WorldWide emergency transportation: Some coverage | |||||
• WorldWide emergency coverage: Some coverage | |||||
• WorldWide emergency urgent care: Some coverage | |||||
• Fitness Benefit: Some coverage | |||||
• In-Home Support Services: Not covered | |||||
• Bathroom Safety Devices: Not covered | |||||
• Health Education: Some coverage | |||||
• In-Home Safety Assessment: Not covered | |||||
• Personal Emergency Response System (PERS): Not covered | |||||
• Medical Nutrition Therapy (MNT): Not covered | |||||
• Post discharge In-Home Medication Reconciliation: Not covered | |||||
• Re-admission Prevention: Not covered | |||||
• Wigs for Hair Loss Related to Chemotherapy: Not covered | |||||
• Weight Management Programs: Not covered | |||||
• Adult Day Health Services: Not covered | |||||
• Nutritional/Dietary Benefit: Some coverage | |||||
• Home-Based Palliative Care: Not covered | |||||
• Support for Caregivers of Enrollees: Not covered | |||||
• Additional Sessions of Smoking and Tobacco Cessation Counseling: Not covered | |||||
• Enhanced Disease Management: Some coverage | |||||
• Telemonitoring Services: Some coverage | |||||
• Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline): Some coverage | |||||
• Counseling Services: Not covered |