2020 Blue Advantage (PPO) H1248-001 By Blue Cross and Blue Shield of Louisiana.

2020 Medicare Advantage Plan Services for
Blue Advantage (PPO)


Blue Advantage (PPO) H1248-001 is a 2020 Medicare Advantage Plan or Medicare Part-C plan by Blue Cross and Blue Shield of Louisiana available to residents in Louisiana. This plan includes additional Medicare prescription drug (Part-D) coverage. The Blue Advantage (PPO) has a monthly premium of $75.00 and has an in-network Maximum Out-of-Pocket limit of $3,500 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $3,500 out of pocket. This can be a extremely nice safety net.

Blue Advantage (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.

Blue Cross and Blue Shield of Louisiana works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for Blue Advantage (PPO) you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Blue Cross and Blue Shield of Louisiana and not Original Medicare. With Medicare Advantage Plans you are always covered for urgently needed and emergency care. Plus you receive all of the benefits of Original Medicare from Blue Cross and Blue Shield of Louisiana except hospice care. Original Medicare still provides you with hospice care even if you sign up for a Medicare Advantage Plan.





2020 Blue Cross and Blue Shield of Louisiana Medicare Advantage Plan Details

Name:
Blue Advantage (PPO)
ID:
H1248-001
Provider:Blue Cross and Blue Shield of Louisiana
Year:2020
Type: Local PPO
Monthly Premium C+D: $75.00
Part C Premium:$39.00
MOOP: $3,500
Part D (Drug) Premium:$36.00
Part D Supplemental Premium$0.00
Total Part D Premium:$36.00
Drug Deductible:$0.00
Tiers with No Deductible:0
Gap Coverage:Yes
Benchmark:not below the regional benchmark
Type of Medicare Health:Enhanced Alternative
Drug Benefit Type:Enhanced




Part-C Premium

Blue Cross and Blue Shield of Louisiana plan charges a $39.00 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

Blue Advantage (PPO) has a monthly drug premium of $36.00 and a $0.00 drug deductible. This Blue Cross and Blue Shield of Louisiana plan offers a $36.00 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 Cross and Blue Shield of Louisiana 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 $36.00. 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 (PPO) medicare insurance offers a $3.80 premium obligation if you receive a full low-income subsidy (LIS) assistance. And the payment is $11.80 for 75% low income subsidy $19.90 for 50% and $27.90 for 25%.



Full LIS Premium:$3.80
75% LIS Premium:$11.80
50% LIS Premium:$19.90
25% LIS Premium:$27.90


Gap Coverage

In 2020 once you and your plan provider have spent $4020 on covered drugs. (combined amount plus your deductible) You will be in the coverage gap. (AKA "donut hole") You will be required to pay 25% for prescription drugs unless your plan offers additional coverage. This Blue Cross and Blue Shield of Louisiana plan does offer additional coverage through the gap.



Blue Cross and Blue Shield of Louisiana Drug Coverage and Formulary

A formulary is divided into tiers or levels of coverage based on the type or usage of your medication or benefit categories, according to drug costs. Each tier will have a defined out-of-pocket cost that you must pay before receiving the drug. You can see complete 2020 Blue Advantage (PPO) H1248-001 Formulary here.

Drug Tier Copay
Preferred
Copay
Nonpreferred
1 $3 $10
2 $12 $18
3 $45 $47
4 $100 $100
5 33% 33%
*Initial Coverage Phase and 30 day supply

See the 2020 Blue Cross and Blue Shield of Louisiana Formulary





2019 Plan Services

(*2020 Plan services will be added when available)




Health plan deductible


$1,000 annual deductible



Emergency care/Urgent care


Emergency $90 per visit (always covered)
Urgent care $35 per visit (always covered)



Diagnostic procedures/lab services/imaging


Diagnostic tests and procedures Out-of-Network 30%
Diagnostic tests and procedures In-Network $11
Lab services Out-of-Network 30%
Lab services In-Network $0 copay
Diagnostic radiology services (e.g., MRI) Out-of-Network 30%
Diagnostic radiology services (e.g., MRI) In-Network $0-75
Outpatient x-rays Out-of-Network 30%
Outpatient x-rays In-Network $75



Hearing


Hearing exam Out-of-Network 30%
Hearing exam In-Network $10
Fitting/evaluation Out-of-Network 30%
Fitting/evaluation In-Network $0 copay
Hearing aids Out-of-Network 30%
Hearing aids In-Network $0 copay



Preventive dental


Oral exam Out-of-Network 30%
Oral exam In-Network $0 copay
Cleaning Out-of-Network 30%
Cleaning In-Network $0 copay
Fluoride treatment Out-of-Network 30%
Fluoride treatment In-Network $0 copay
Dental x-ray(s) Out-of-Network 30%
Dental x-ray(s) In-Network $0 copay



Comprehensive dental


Non-routine services Out-of-Network 30%
Non-routine services In-Network 50%
Diagnostic services Out-of-Network 30%
Diagnostic services In-Network 50%
Restorative services Out-of-Network 30%
Restorative services In-Network 50%
Endodontics Out-of-Network 30%
Endodontics In-Network 50%
Periodontics Out-of-Network 30%
Periodontics In-Network 50%
Extractions Out-of-Network 30%
Extractions In-Network 50%
Prosthodontics, other oral/maxillofacial surgery, other services Not covered



Vision


Routine eye exam Out-of-Network 30%
Routine eye exam In-Network $0 copay
Other Not covered
Contact lenses Out-of-Network 30%
Contact lenses In-Network $0 copay
Eyeglasses (frames and lenses) Not covered
Eyeglass frames Out-of-Network 30%
Eyeglass frames In-Network $0 copay
Eyeglass lenses Out-of-Network 30%
Eyeglass lenses In-Network $0 copay
Upgrades Not covered



Mental health services


Inpatient hospital - psychiatric Out-of-Network 30% per stay
Inpatient hospital - psychiatric In-Network $175 per day for days 1 through 7
$0 per day for days 8 through 90
Outpatient group therapy visit with a psychiatrist Out-of-Network 30%
Outpatient group therapy visit with a psychiatrist In-Network $40
Outpatient individual therapy visit with a psychiatrist Out-of-Network 30%
Outpatient individual therapy visit with a psychiatrist In-Network $40
Outpatient group therapy visit Out-of-Network 30%
Outpatient group therapy visit In-Network $40
Outpatient individual therapy visit Out-of-Network 30%
Outpatient individual therapy visit In-Network $40



Skilled Nursing Facility


Out-of-Network 30% per stay
In-Network $0 per day for days 1 through 20
$165 per day for days 21 through 100



Rehabilitation services


Occupational therapy visit Out-of-Network 30%
Occupational therapy visit In-Network $20
Physical therapy and speech and language therapy visit Out-of-Network 30%
Physical therapy and speech and language therapy visit In-Network $20



Ground ambulance


Out-of-Network 30%
In-Network $275



Other health plan deductibles?


In-Network No



Transportation


Not covered



Foot care (podiatry services)


Foot exams and treatment Out-of-Network 30%
Foot exams and treatment In-Network $30
Routine foot care Not covered



Medical equipment/supplies


Durable medical equipment (e.g., wheelchairs, oxygen) Out-of-Network 30% per item
Durable medical equipment (e.g., wheelchairs, oxygen) In-Network 20% per item
Prosthetics (e.g., braces, artificial limbs) Out-of-Network 30% per item
Prosthetics (e.g., braces, artificial limbs) In-Network 20% per item
Diabetes supplies Out-of-Network 30% per item
Diabetes supplies In-Network $0 copay



Wellness programs (e.g., fitness, nursing hotline)


Covered



Medicare Part B drugs


Chemotherapy Out-of-Network 30%
Chemotherapy In-Network 20%
Other Part B drugs Out-of-Network 30%
Other Part B drugs In-Network 20%



Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)


$10,000 In and Out-of-network
$5,000 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



Inpatient hospital coverage


Out-of-Network 30% per stay
In-Network $175 per day for days 1 through 10
$0 per day for days 11 through 90



Outpatient hospital coverage


Out-of-Network 30% per visit
In-Network $75-175 per visit



Doctor visits


Primary Out-of-Network 30% per visit
Primary In-Network $0 copay
Specialist Out-of-Network 30% per visit
Specialist In-Network $40 per visit



Preventive care


Out-of-Network 30%
In-Network $0 copay




Coverage Area for Blue Advantage (PPO)

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Source: CMS.
Data as of September 4, 2019.
Star Rating as of October 10, 2019.
Plan Services are 2019 information as reference. 2020 information will be added when released.
Notes: Data are subject to change as contracts are finalized. For 2020, enhanced alternative may offer additional cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part D benefit. Includes 2020 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.

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