2016 Blue Advantage Complete (PPO) H0104-012 By Blue Advantage (PPO)

2016 Medicare Advantage Blue Advantage Complete (PPO)

Blue Advantage Complete (PPO) H0104-012 is a 2016 Medicare Advantage or Medicare Part-C plan by Blue Advantage (PPO) available to residents in Alabama. This plan includes additional Medicare prescription drug (Part-D) coverage. The Blue Advantage Complete (PPO) has a monthly premium of $75.00 and has a in-network Maximum Out-of-Pocket limit of $5,000 (MOOP). This means that if you get sick or need a high cost procedure your co-pays are capped once you pay out of pocket $5,000 this can be a very nice safety net.

Blue Advantage Complete (PPO) is a Local PPO. A preferred provider organization (PPO) is a medicare plan that has created contracts with a network of "preferred" providers for you to choose from at reduced rates. You do not need to select a primary care physician and you do not need referrals to see other providers in the network. Offering you a little more flexibility overall. You can get medical attention from a provider outside of the network but you will have to pay the difference between the out-of-network bill and the PPOs discounted rate.

This plan from Blue Advantage (PPO) works with Medicare to give you significant coverage beyond Part A and Part B benefits. If you decide to sign up for Blue Advantage Complete (PPO) you still retain Original Medicare. But you will get additional Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) coverage from Blue Advantage (PPO) and not Original Medicare. With Medicare Advantage plans your always covered for urgently needed and emergency care and you receive all of the benefits of Original Medicare from this plan except hospice care. Original Medicare still provides you with hospice care even if you sign up for a Medicare Advantage Plan.



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2016 Blue Advantage (PPO) Medicare Advantage Plan Details

Plan Name:
Blue Advantage Complete (PPO)
Plan ID:
H0104-012
Provider:Blue Advantage (PPO)
Parent:BlueCross BlueShield of Alabama
Plan Year:2016
Plan Type: Local PPO
Monthly Premium C+D: $75.00
MOOP: $5,000




Plan Services



Monthly premium deductible and limits on how much you pay for covered services


$75 per month. In addition you must keep paying your Medicare Part B premium. This plan has deductibles for some hospital and medical services and Part D prescription drugs. $2 000 per year for out-of-network services. $360 per year for Part D prescription drugs except for drugs listed on Tier 1 Tier 2 and Tier 6 which are excluded from the deductible. Yes. Like all Medicare health plans our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care. Your yearly limit(s) in this plan:
  • $5 000 for services you receive from in-network providers.
  • $7 500 for services you receive from any provider. Your limit for services received from in-network providers will count toward this limit.
If you reach the limit on out-of-pocket costs you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year.

Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs. Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply.


Doctor's office visits


Primary care physician visit:
  • In-network:  $20 copay
  • Out-of-network:  40% of the cost
Specialist visit:
  • In-network:  $40 copay
  • Out-of-network:  40% of the cost


Durable medical equipment (wheelchairs oxygen etc.)


  • In-network:  20% of the cost
  • Out-of-network:  40% of the cost


Emergency care


$75 copay If you are admitted to the hospital within 24 hours you do not have to pay your share of the cost for emergency care. See the "Inpatient Hospital Care" section for other costs.


Foot care (podiatry services)


Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions:
  • In-network:  $40 copay
  • Out-of-network:  40% of the cost


Hearing services


Exam to diagnose and treat hearing and balance issues:
  • In-network:  $10 copay
  • Out-of-network:  40% of the cost


Home health care


  • In-network:  You pay nothing
  • Out-of-network:  40% of the cost


Mental health care


Inpatient visit: Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital. The copays for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you're admitted as an inpatient and ends when you haven't received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There's no limit to the number of benefit periods. Our plan covers 90 days for an inpatient hospital stay. Our plan also covers 60 "lifetime reserve days." These are "extra" days that we cover. If your hospital stay is longer than 90 days you can use these extra days. But once you have used up these extra 60 days your inpatient hospital coverage will be limited to 90 days.
  • In-network:  
    • $195 copay per day for days 1 through 7
    • You pay nothing per day for days 8 through 90
    • Out-of-network:  
      • 40% of the cost per stay
      Outpatient group therapy visit:
      • In-network:  $40 copay
      • Out-of-network:  40% of the cost
      Outpatient individual therapy visit:
      • In-network:  $40 copay
      • Out-of-network:  40% of the cost


Outpatient rehabilitation


Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks):
  • In-network:  $40 copay
  • Out-of-network:  40% of the cost
Occupational therapy visit:
  • In-network:  $40 copay
  • Out-of-network:  40% of the cost
Physical therapy and speech and language therapy visit:
  • In-network:  $40 copay
  • Out-of-network:  40% of the cost


Outpatient substance abuse


Group therapy visit:
  • In-network:  $40 copay
  • Out-of-network:  40% of the cost
Individual therapy visit:
  • In-network:  $40 copay
  • Out-of-network:  40% of the cost


Outpatient surgery


Ambulatory surgical center:
  • In-network:  $300 copay
  • Out-of-network:  40% of the cost
Outpatient hospital:
  • In-network:  $300 copay
  • Out-of-network:  40% of the cost


Acupuncture


Not covered


Over-the-counter items


Not Covered


Prosthetic devices (braces artificial limbs etc.)


Prosthetic devices:
  • In-network:  20% of the cost
  • Out-of-network:  40% of the cost
Related medical supplies:
  • In-network:  20% of the cost
  • Out-of-network:  40% of the cost


Renal dialysis


  • In-network:  20% of the cost
  • Out-of-network:  40% of the cost


Transportation


Not covered


Urgently needed services


$40 copay


Vision services


Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening):
  • In-network:  $30 copay
  • Out-of-network:  40% of the cost
Routine eye exam (for up to 1 every year):
  • In-network:  You pay nothing
  • Out-of-network:  You pay nothing
Our plan pays up to $45 every year for routine eye exams from any provider. Eyeglasses or contact lenses after cataract surgery:
  • In-network:  You pay nothing
  • Out-of-network:  40% of the cost


Preventive care


  • In-network:  You pay nothing
  • Out-of-network:  40% of the cost
Our plan covers many preventive services including:
  • Abdominal aortic aneurysm screening
  • Alcohol misuse counseling
  • Bone mass measurement
  • Breast cancer screening (mammogram)
  • Cardiovascular disease (behavioral therapy)
  • Cardiovascular screenings
  • Cervical and vaginal cancer screening
  • Colorectal cancer screenings (Colonoscopy Fecal occult blood test Flexible sigmoidoscopy)
  • Depression screening
  • Diabetes screenings
  • HIV screening
  • Medical nutrition therapy services
  • Obesity screening and counseling
  • Prostate cancer screenings (PSA)
  • Sexually transmitted infections screening and counseling
  • Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease)
  • Vaccines including Flu shots Hepatitis B shots Pneumococcal shots
  • "Welcome to Medicare" preventive visit (one-time)
  • Yearly "Wellness" visit
Any additional preventive services approved by Medicare during the contract year will be covered.


Hospice


You pay nothing for hospice care from a Medicare-certified hospice. You may have to pay part of the cost for drugs and respite care.


Inpatient hospital care


The copays for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you're admitted as an inpatient and ends when you haven't received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There's no limit to the number of benefit periods. Our plan covers an unlimited number of days for an inpatient hospital stay.
  • In-network:  
    • $225 copay per day for days 1 through 7
    • You pay nothing per day for days 8 through 90
    • You pay nothing per day for days 91 and beyond
    • Out-of-network:  
      • 40% of the cost per stay


Inpatient mental health care


For inpatient mental health care see the "Mental Health Care" section.


Skilled Nursing Facility (SNF)


Our plan covers up to 100 days in a SNF.
  • In-network:  
    • You pay nothing per day for days 1 through 20
    • $150 copay per day for days 21 through 54
    • You pay nothing per day for days 55 through 100
    • Out-of-network:  
      • 40% of the cost per stay


Outpatient prescription drugs


For Part B drugs such as chemotherapy drugs:
  • In-network:  20% of the cost
  • Out-of-network:  40% of the cost
Other Part B drugs:
  • In-network:  20% of the cost
  • Out-of-network:  40% of the cost
After you pay your yearly deductible you pay the following until your total yearly drug costs reach $3 310. Total yearly drug costs are the total drug costs paid by both you and our Part D plan. You may get your drugs at network retail pharmacies and mail order pharmacies. Standard Retail Cost-Sharing
TierOne-month supplyThree-month supply
Tier 1 (Preferred Generic)$4 copay$12 copay
Tier 2 (Generic)$20 copay$60 copay
Tier 3 (Preferred Brand)$47 copay$141 copay
Tier 4 (Non-Preferred Brand)$100 copay$300 copay
Tier 5 (Specialty Tier)25% of the cost25% of the cost
Tier 6 (Select Care Drugs)$2 copay$6 copay
Preferred Retail Cost-Sharing
TierOne-month supplyThree-month supply
Tier 1 (Preferred Generic)$4 copay$8 copay
Tier 2 (Generic)$20 copay$40 copay
Tier 3 (Preferred Brand)$47 copay$94 copay
Tier 4 (Non-Preferred Brand)$100 copay$200 copay
Tier 5 (Specialty Tier)25% of the cost25% of the cost
Tier 6 (Select Care Drugs)$2 copay$4 copay
Standard Mail Order Cost-Sharing
TierOne-month supplyThree-month supply
Tier 1 (Preferred Generic)$4 copay$8 copay
Tier 2 (Generic)$20 copay$40 copay
Tier 3 (Preferred Brand)$47 copay$94 copay
Tier 4 (Non-Preferred Brand)$100 copay$200 copay
Tier 5 (Specialty Tier)25% of the cost25% of the cost
Tier 6 (Select Care Drugs)$2 copay$4 copay
If you reside in a long-term care facility you pay the same as at a retail pharmacy.
You may get drugs from an out-of-network pharmacy but may pay more than you pay at an in-network pharmacy.
Most Medicare drug plans have a coverage gap (also called the "donut hole"). This means that there's a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $3 310.

After you enter the coverage gap you pay 45% of the plan's cost for covered brand name drugs and 58% of the plan's cost for covered generic drugs until your costs total $4 850 which is the end of the coverage gap. Not everyone will enter the coverage gap.

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4 850 you pay the greater of:
  • 5% of the cost or
  • $2.95 copay for generic (including brand drugs treated as generic) and a $7.40 copayment for all other drugs.


Ambulance


  • In-network:  $200 copay
  • Out-of-network:  $200 copay


Chiropractic care


Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position):
  • In-network:  $20 copay
  • Out-of-network:  40% of the cost


Dental services


Limited dental services (this does not include services in connection with care treatment filling removal or replacement of teeth):
  • In-network:  $40 copay
  • Out-of-network:  40% of the cost


Diabetes supplies and services


Diabetes monitoring supplies:
  • In-network:  You pay nothing
  • Out-of-network:  40% of the cost
Diabetes self-management training:
  • In-network:  You pay nothing
  • Out-of-network:  40% of the cost
Therapeutic shoes or inserts:
  • In-network:  You pay nothing
  • Out-of-network:  40% of the cost


Diagnostic tests lab and radiology services and x-rays (Costs for these services may be different if received in an outpatient surgery setting)


Diagnostic radiology services (such as MRIs CT scans):
  • In-network:  $100 copay
  • Out-of-network:  40% of the cost
Diagnostic tests and procedures:
  • In-network:  You pay nothing
  • Out-of-network:  40% of the cost
Lab services:
  • In-network:  You pay nothing
  • Out-of-network:  40% of the cost
Outpatient x-rays:
  • In-network:  $20 copay
  • Out-of-network:  40% of the cost
Therapeutic radiology services (such as radiation treatment for cancer):
  • In-network:  $50 copay
  • Out-of-network:  40% of the cost




Coverage Area for Blue Advantage Complete (PPO)

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Ratings for Blue Advantage Complete (PPO) H0104

2016 Overall Rating
Part C Summary Rating
Part D Summary Rating
Staying Healthy: Screenings, Tests, Vaccines
Managing Chronic (Long Term) Conditions
Member Experience with Health Plan
Complaints and Changes in Plans Performance
Health Plan Customer Service
Drug Plan Customer Service
Complaints and Changes in the Drug Plan
Member Experience with the Drug Plan
Drug Safety and Accuracy of Drug Pricing


Member Experience with Health Plan

Total Experience Rating
Getting Needed Care
Timely Care and Appointments
Customer Service
Health Care Quality
Rating of Health Plan
Care Coordination


Member Complaints and Changes in Blue Advantage Complete (PPO) Plans Performance

Total Rating
Members Leaving the Plan
Complaints about Health Plan
Beneficiary Access
Health Plan Quality Improvement


Health Plan Customer Service Rating for Blue Advantage Complete (PPO)

Total Customer Service Rating
Timely Decisions About Appeals
Reviewing Appeals Decisions
Call Center, TTY, Foreign Language


Staying Healthy, Screening, Testing, & Vaccines

Total Preventative Rating
Breast Cancer Screening
Colorectal Cancel Screening
Annual Flu Vaccine
Improving Physical
Improving Mental Health
Monitoring Physical Activity
Adult BMI Assessment


Managing Chronic And Long Term Care for Older Adults

Total Rating
SNP Care Management
Medication Review
Functional Status Assessment
Pain Screening
Osteoporosis Management
Diabetes Care - Eye Exam
Diabetes Care - Kidney Disease
Diabetes Care - Blood Sugar
Controlling Blood Pressure
Rheumatoid Arthritis
Improving Bladder Control
Reducing Risk of Falling
Plan - Cause Readmissions


Member Experience with the Drug Plan

Total Rating
Rating of Drug Plan
Getting Needed Prescription Drugs


Drug Safety and Accuracy of Drug Pricing

Total Rating
MPF Price Accuracy
High Risk Medication
Drug Adherence for Diabetes Medications
Drug Adherence for Hypertension (RAS antagonists)
Drug Adherence for Cholesterol (Statins)
MTM Program Completion Rate for CMR


Ratings For Member Complaints and Changes in the Drug Plans Performance

Total Rating
Complaints about the Drug Plan
Members Choosing to Leave the Plan
Beneficiary Access
Drug Plan Quality Improvement


Blue Advantage Complete (PPO) Drug Plan Customer Service ratings

Total Rating
Appeals Auto Forward
Appeals Upheld
Call Center, TTY, Foreign Language


Part-C Premium

Blue Advantage (PPO) plan charges a $51.00 Part-C premium. The Part C premium covers Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.



Part-D Deductible and Premium

The Blue Advantage Complete (PPO) plan has a monthly drug premium of $24.00 and a $360.00 drug deductible. This Blue Advantage (PPO) plan offers a $24.00 Part D Basic Premium that is not below the regional benchmark. This covers the basic prescription benefit only and does not cover enhanced drug benefits such as medical benefits or hospital benefits. The Part D Supplemental Premium is $0.00 this Premium covers any enhanced plan benefits offered by Blue Advantage (PPO) above and beyond the standard PDP benefits. This can include additional coverage in the gap, lower co-payments and coverage of non-Part D drugs. The Part D Total Premium is $24.00. The Part D Total Premium is the addition of the supplemental and basic premiums for some plans this amount can be lower due to negative basic or supplemental premiums.



Premium Assistance

Depending on your income level you may be eligible for full 75%, 50%, 25% premium assistance. The Blue Advantage Complete (PPO) medicare insurance plan offers a $0.00 premium obligation if you receive a full low-income subsidy (LIS) assistance. And the payment is $6.00 for 75% low income subsidy $12.00 for 50% and $18.00 for 25%.



Part C Premium: $51.00
Part D (Drug) Premium: $24.00
Part D Supplemental Premium $0.00
Total Part D Premium: $24.00
Drug Deductible: $360.00
Tiers with No Deductible: 1
Benchmark: not below the regional benchmark
Type of Medicare Health Plan: Enhanced Alternative
Drug Benefit Type: Enhanced
Full LIS Premium: $0.00
75% LIS Premium: $6.00
50% LIS Premium: $12.00
25% LIS Premium: $18.00
Gap Coverage: No


Gap Coverage

In 2016 once you and your plan provider have spent $3,310 on covered drugs. (combined amount plus your deductible) You will be in the coverage gap. (AKA "donut hole") You will be required to pay 45% for brand-name drugs and 58% on generic drugs unless your plan offers additional coverage. This Blue Advantage (PPO) plan does not offer additional coverage through the gap.





Source: CMS.

Plans as of September 9, 2015.

Star Rating as of September 30, 2015.

For More Information on Ratings Please See the CMS Tech Notes Here.

Notes: Data are subject to change as contracts are finalized. For 2016, enhanced alternative plans may offer additional cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part D benefit

Includes 2016 approved contracts/plans. Employer sponsored 800 series plans and plans under sanction are excluded.

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