2022 Blue Advantage Complete (PPO)


Blue Advantage Complete (PPO) H0104-012 is a 2022 Medicare Advantage Plan or Part-C by Blue Cross and Blue Shield of Alabama available to residents in Alabama. This plan includes additional prescription drug (Part-D) coverage. The Blue Advantage Complete (PPO) has a monthly premium of $0 and has an in-network maximum out-of-pocket limit of $5,100 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $5,100 out-of-pocket. This can be a extremely 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.

Blue Cross and Blue Shield of Alabama works with Medicare to provide 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 Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Blue Cross and Blue Shield of Alabama and not Original Medicare. With Medicare Advantage you are always covered for urgently needed and emergency care. Plus you receive all the benefits of Original Medicare from Blue Cross and Blue Shield of Alabama except hospice care. Original Medicare still provides you with hospice care even if you sign up for Medicare Advantage.




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2022 Blue Cross and Blue Shield of Alabama Medicare Advantage Plan Costs

Name:
Blue Advantage Complete (PPO)
Plan ID:
H0104-012
Provider:Blue Cross and Blue Shield of Alabama
Year:2022
Type: Local PPO
Monthly Premium C+D: $0
Part C Premium:$0.00
MOOP: $5,100
Part D (Drug) Premium:$0.00
Part D Supplemental Premium$0.00
Total Part D Premium:$0.00
Drug Deductible:$150.00
Tiers with No Deductible:1
Gap Coverage:Yes
Benchmark:not below the regional benchmark
Type of Medicare Health:Enhanced Alternative
Drug Benefit Type:Enhanced
Similar Plan: H0104-014




Blue Advantage Complete (PPO) Part-C Premium

Blue Cross and Blue Shield of Alabama charges a $0.00 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.



H0104-012 Part-D Deductible and Premium

Blue Advantage Complete (PPO) has a monthly drug premium of $0.00 and a $150.00 drug deductible. This Blue Cross and Blue Shield of Alabama plan offers a $0.00 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 Alabama 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 $0.00 . The Part D Total Premium is the addition of the supplemental and basic premiums for some plans this amount can be lowered due to negative basic or supplemental premiums.



Blue Cross and Blue Shield of Alabama Gap Coverage

In 2022 once you and your plan provider have spent $4430 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 Alabama plan does offer additional coverage through the gap.



H0104-012 Formulary or Drug Coverage

Blue Advantage Complete (PPO) formulary is divided into Tiers or levels of coverage based on usage and according to the medication costs. Each tier will have a defined copay that you must pay to receive the drug. Drugs in lower tiers will usually cost less than those in higher tiers. By reviewing different Medicare Drug formularies, you can pick a Medicare Advantage plan that covers your medications. Additionally, you can choose a plan that has your drugs listed at a lower price. You can see complete 2022 Blue Advantage Complete (PPO) H0104-012 Formulary here.

Drug Tier Copay
Preferred
Pharmacy
Copay
Nonpreferred
Pharmacy
Tier 1 $4 $11
Tier 2 $13 $20
Tier 3 $40 $47
Tier 4 32% 37%
Tier 5 30% 30%
Tier 6 $0 $0
*Initial Coverage Phase and 30 day supply





2021 Blue Advantage Complete (PPO) Summary of Benefits

*This will be updated with 2022 data when available.



Additional Benefits


No



Comprehensive Dental


Diagnostic services $0 copay
Diagnostic services $0 copay (Out-of-Network)
Endodontics $0 copay (Out-of-Network)
Endodontics $0 copay
Extractions $0 copay
Extractions $0 copay (Out-of-Network)
Non-routine services $0 copay
Non-routine services $0 copay (Out-of-Network)
Periodontics $0 copay
Periodontics $0 copay (Out-of-Network)
Prosthodontics, other oral/maxillofacial surgery, other services $0 copay (Out-of-Network)
Prosthodontics, other oral/maxillofacial surgery, other services $0 copay
Restorative services $0 copay
Restorative services $0 copay (Out-of-Network)



Deductible


$0



Diagnostic Tests and Procedures


Diagnostic radiology services (e.g., MRI) $75 copay
Diagnostic radiology services (e.g., MRI) 50% coinsurance (Out-of-Network)
Diagnostic tests and procedures 50% coinsurance (Out-of-Network)
Diagnostic tests and procedures $0 copay
Lab services $0 copay
Lab services 50% coinsurance (Out-of-Network)
Outpatient x-rays 50% coinsurance (Out-of-Network)
Outpatient x-rays $15 copay



Doctor Visits


Primary $5 copay per visit
Primary 50% coinsurance per visit (Out-of-Network)
Specialist $40 copay per visit
Specialist 50% coinsurance per visit (Out-of-Network)



Emergency care/Urgent Care


Emergency $90 copay per visit (always covered)
Urgent care $5-40 copay per visit (always covered)



Foot Care (podiatry services)


Foot exams and treatment $20 copay
Foot exams and treatment 50% coinsurance (Out-of-Network)
Routine foot care Not covered



Ground Ambulance


$275 copay (Out-of-Network)
$275 copay



Hearing


Fitting/evaluation Not covered
Hearing aids $699-999 copay
Hearing aids $699-999 copay (Out-of-Network)
Hearing exam $10 copay
Hearing exam 50% coinsurance (Out-of-Network)



Inpatient Hospital Coverage


$225 per day for days 1 through 7
$0 per day for days 8 through 90
$0 per day for days 91 and beyond
50% per stay (Out-of-Network)



Medical Equipment/Supplies


Diabetes supplies 50% coinsurance per item (Out-of-Network)
Diabetes supplies $0 copay
Durable medical equipment (e.g., wheelchairs, oxygen) 50% coinsurance per item (Out-of-Network)
Durable medical equipment (e.g., wheelchairs, oxygen) 20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs) 20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs) 50% coinsurance per item (Out-of-Network)



Medicare Part B Drugs


Chemotherapy 20% coinsurance
Chemotherapy 50% coinsurance (Out-of-Network)
Other Part B drugs 20% coinsurance
Other Part B drugs 50% coinsurance (Out-of-Network)



Mental Health Services


Inpatient hospital - psychiatric 50% per stay (Out-of-Network)
Inpatient hospital - psychiatric $225 per day for days 1 through 7
$0 per day for days 8 through 90
Outpatient group therapy visit $40 copay
Outpatient group therapy visit 50% coinsurance (Out-of-Network)
Outpatient group therapy visit with a psychiatrist $40 copay
Outpatient group therapy visit with a psychiatrist 50% coinsurance (Out-of-Network)
Outpatient individual therapy visit $40 copay
Outpatient individual therapy visit 50% coinsurance (Out-of-Network)
Outpatient individual therapy visit with a psychiatrist 50% coinsurance (Out-of-Network)
Outpatient individual therapy visit with a psychiatrist $40 copay



MOOP


$7,500 In and Out-of-network
$5,100 In-network



Option


No



Optional supplemental benefits


No



Outpatient Hospital Coverage


$250 copay per visit
50% coinsurance per visit (Out-of-Network)



Preventive Care


50% coinsurance (Out-of-Network)
$0 copay



Preventive Dental


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



Rehabilitation Services


Occupational therapy visit $30 copay
Occupational therapy visit 50% coinsurance (Out-of-Network)
Physical therapy and speech and language therapy visit 50% coinsurance (Out-of-Network)
Physical therapy and speech and language therapy visit $30 copay



Skilled Nursing Facility


$0 per day for days 1 through 20
$160 per day for days 21 through 80
$0 per day for days 81 through 100
50% per stay (Out-of-Network)



Transportation


Not covered



Vision


Contact lenses 50% coinsurance (Out-of-Network)
Contact lenses $0 copay
Eyeglass frames Not covered
Eyeglass lenses Not covered
Eyeglasses (frames and lenses) 50% coinsurance (Out-of-Network)
Eyeglasses (frames and lenses) $0 copay
Other Not covered
Routine eye exam $0 copay
Routine eye exam 50% coinsurance (Out-of-Network)
Upgrades Not covered



Wellness Programs (e.g. fitness nursing hotline)


Covered




CMS Star Ratings for Blue Advantage Complete (PPO) H0104



2021 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


Staying Healthy, Screening, Testing, & Vaccines

Total Preventative Rating
Breast Cancer Screening
Colorectal Cancer Screening
Annual Flu Vaccine
Monitoring Physical Activity


Managing Chronic And Long Term Care for Older Adults

Total Rating
SNP Care Management
Medication Review
Functional Status Assessment
Osteoporosis Management
Diabetes Care - Eye Exam
Diabetes Care - Kidney Disease
Diabetes Care - Blood Sugar
Rheumatoid Arthritis
Reducing Risk of Falling
Improving Bladder Control
Medication Reconciliation
Statin Therapy


Member Experience with Health Plan

Total Experience Rating
Getting Needed Care
Getting 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
Complaints about Health Plan
Members Leaving the Plan
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


Blue Advantage Complete (PPO) Drug Plan Customer Service Ratings

Total Rating
Call Center, TTY, Foreign Language


Ratings For Member Complaints and Changes in the Drug Plans Performance

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


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
Drug Adherence for Diabetes Medications
Drug Adherence for Hypertension (RAS antagonists)
Drug Adherence for Cholesterol (Statins)
MTM Program Completion Rate for CMR
Statin with Diabetes



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Coverage Area for Blue Advantage Complete (PPO)

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Source: CMS.
Data as of September 1, 2021.
Notes: Data are subject to change as contracts are finalized. For 2022, 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 2022 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.

*Licensed Agent Disclaimer: We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE (TTY users should call 1-877-486-2048) 24 hours a day/7 days a week to get information on all of your options.

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