0 2020 Secure Blue no Rx (PPO) H1302-004 By Blue Cross of Idaho.
2020 Secure Blue no Rx (PPO) H1302-004 By Blue Cross of Idaho.

2020 Medicare Advantage Plan Services for
Secure Blue no Rx (PPO)


Secure Blue no Rx (PPO) H1302-004 is a 2020 Medicare Advantage Plan or Medicare Part-C plan by Blue Cross of Idaho available to residents in Idaho. This plan does not provide additional Medicare prescription drug (Part-D) coverage. The Secure Blue no Rx (PPO) has a monthly premium of $29.00 and has an in-network Maximum Out-of-Pocket limit of $3,400 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $3,400 out of pocket. This can be a extremely nice safety net.

Secure Blue no Rx (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 of Idaho works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for Secure Blue no Rx (PPO) you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Blue Cross of Idaho 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 of Idaho except hospice care. Original Medicare still provides you with hospice care even if you sign up for a Medicare Advantage Plan.





2020 Blue Cross of Idaho Medicare Advantage Plan Details

Name:
Secure Blue no Rx (PPO)
ID:
H1302-004
Provider:Blue Cross of Idaho
Year:2020
Type: Local PPO *
Monthly Premium C+D: $29.00
Part C Premium:
MOOP: $3,400






2019 Plan Services

(*2020 Plan services will be added when available)




Health plan deductible


$0



Emergency care/Urgent care


Emergency $90 per visit (always covered)
Urgent care $25 per visit (always covered)



Diagnostic procedures/lab services/imaging


Diagnostic tests and procedures Out-of-Network 25%
Diagnostic tests and procedures In-Network 10%
Lab services Out-of-Network 25%
Lab services In-Network 10%
Diagnostic radiology services (e.g., MRI) Out-of-Network 25%
Diagnostic radiology services (e.g., MRI) In-Network 10%
Outpatient x-rays Out-of-Network 25%
Outpatient x-rays In-Network 10%



Hearing


Hearing exam Out-of-Network $45
Hearing exam In-Network $45
Fitting/evaluation Not covered
Hearing aids Out-of-Network $699-999
Hearing aids In-Network $699-999



Preventive dental


Office visit Out-of-Network 50%
Office visit In-Network $10.00
Oral exam Covered under office visit
Cleaning Covered under office visit
Fluoride treatment Not covered
Dental x-ray(s) Covered under office visit



Comprehensive dental


Non-routine services Not covered
Diagnostic services Not covered
Restorative services Not covered
Endodontics Not covered
Periodontics Not covered
Extractions Not covered
Prosthodontics, other oral/maxillofacial surgery, other services Not covered



Vision


Routine eye exam Out-of-Network $20
Routine eye exam In-Network $20
Other Not covered
Contact lenses Out-of-Network $35
Contact lenses In-Network $0-35
Eyeglasses (frames and lenses) Out-of-Network $35
Eyeglasses (frames and lenses) In-Network $35
Eyeglass frames Not covered
Eyeglass lenses Not covered
Upgrades Out-of-Network $35
Upgrades In-Network $0 copay



Mental health services


Inpatient hospital - psychiatric Out-of-Network $200 per day for days 1 through 10
$0 per day for days 11 through 90
Inpatient hospital - psychiatric In-Network $175 per day for days 1 through 5
$0 per day for days 6 through 90
Outpatient group therapy visit with a psychiatrist Out-of-Network 25%
Outpatient group therapy visit with a psychiatrist In-Network $25
Outpatient individual therapy visit with a psychiatrist Out-of-Network 25%
Outpatient individual therapy visit with a psychiatrist In-Network $25
Outpatient group therapy visit Out-of-Network 25%
Outpatient group therapy visit In-Network $25
Outpatient individual therapy visit Out-of-Network 25%
Outpatient individual therapy visit In-Network $25



Skilled Nursing Facility


Out-of-Network $100 per day for days 1 through 12
$150 per day for days 13 through 100
In-Network $0 per day for days 1 through 20
$150 per day for days 21 through 100



Rehabilitation services


Occupational therapy visit Out-of-Network $30
Occupational therapy visit In-Network $25
Physical therapy and speech and language therapy visit Out-of-Network $30
Physical therapy and speech and language therapy visit In-Network $25



Ground ambulance


Out-of-Network $175
In-Network $175



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 $25
Routine foot care Not covered



Medical equipment/supplies


Durable medical equipment (e.g., wheelchairs, oxygen) Out-of-Network 20% per item
Durable medical equipment (e.g., wheelchairs, oxygen) In-Network 10% per item
Prosthetics (e.g., braces, artificial limbs) Out-of-Network 20% per item
Prosthetics (e.g., braces, artificial limbs) In-Network 10% per item
Diabetes supplies Out-of-Network 20% 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)


$5,000 In and Out-of-network
$3,400 In-network



Optional supplemental benefits


Yes



Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?


In-Network No



Inpatient hospital coverage


Out-of-Network $200 per day for days 1 through 10
$0 per day for days 11 and beyond
In-Network $175 per day for days 1 through 5
$0 per day for days 6 through 90



Outpatient hospital coverage


Out-of-Network 20% per visit
In-Network $175 per visit



Doctor visits


Primary Out-of-Network $30 per visit
Primary In-Network $15 per visit
Specialist Out-of-Network $30 per visit
Specialist In-Network $25 per visit



Preventive care


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




Coverage Area for Secure Blue no Rx (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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