2022 NextBlue Classic PPO (PPO)

NextBlue Classic PPO (PPO) H6202-001 is a 2022 Medicare Advantage Plan or Part-C by NextBlue of North Dakota available to residents in North Dakota. This plan includes additional prescription drug (Part-D) coverage. The NextBlue Classic PPO (PPO) has a monthly premium of $0 and has an in-network maximum out-of-pocket limit of $6,000 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $6,000 out-of-pocket. This can be a extremely nice safety net.

NextBlue Classic PPO (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.

NextBlue of North Dakota works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for NextBlue Classic PPO (PPO) you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from NextBlue of North Dakota 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 NextBlue of North Dakota except hospice care. Original Medicare still provides you with hospice care even if you sign up for Medicare Advantage.

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2022 NextBlue of North Dakota Medicare Advantage Plan Costs

NextBlue Classic PPO (PPO) Part-C Premium

NextBlue of North Dakota 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.

H6202-001 Part-D Deductible and Premium

NextBlue Classic PPO (PPO) has a monthly drug premium of $0.00 and a $250.00 drug deductible. This NextBlue of North Dakota 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 NextBlue of North Dakota 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.

NextBlue of North Dakota 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 NextBlue of North Dakota plan does not offer additional coverage through the gap.

H6202-001 Formulary or Drug Coverage

NextBlue Classic PPO (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 NextBlue Classic PPO (PPO) H6202-001 Formulary here.

Drug Tier	Copay Preferred Pharmacy	Copay Nonpreferred Pharmacy
Tier 1	$2	$12
Tier 2	$8	$18
Tier 3	$37	$47
Tier 4	$100	$100
Tier 5	28%	28%

*Initial Coverage Phase and 30 day supply

2021 NextBlue Classic PPO (PPO) Summary of Benefits

*This will be updated with 2022 data when available.

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Additional Benefits

No

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Comprehensive Dental

Diagnostic services	25% coinsurance
Diagnostic services	0-25% coinsurance (Out-of-Network)
Endodontics	25% coinsurance
Endodontics	0-25% coinsurance (Out-of-Network)
Extractions	0-25% coinsurance (Out-of-Network)
Extractions	25% coinsurance
Non-routine services	Not covered
Periodontics	0-25% coinsurance (Out-of-Network)
Periodontics	25% coinsurance
Prosthodontics, other oral/maxillofacial surgery, other services	25% coinsurance
Prosthodontics, other oral/maxillofacial surgery, other services	0-25% coinsurance (Out-of-Network)
Restorative services	0-25% coinsurance (Out-of-Network)
Restorative services	25% coinsurance

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Deductible

$0

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Diagnostic Tests and Procedures

Diagnostic radiology services (e.g., MRI)	$150-350 copay
Diagnostic radiology services (e.g., MRI)	$150-350 copay (Out-of-Network)
Diagnostic tests and procedures	$20-350 copay
Diagnostic tests and procedures	$20-350 copay (Out-of-Network)
Lab services	$10-30 copay
Lab services	$10-30 copay (Out-of-Network)
Outpatient x-rays	$20-350 copay
Outpatient x-rays	$20-350 copay (Out-of-Network)

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Doctor Visits

Primary	$20 copay per visit (Out-of-Network)
Primary	$20 copay per visit
Specialist	$40 copay per visit (Out-of-Network)
Specialist	$40 copay per visit

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Emergency care/Urgent Care

Emergency	$90 copay per visit (always covered)
Urgent care	$50 copay per visit (always covered)

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Foot Care (podiatry services)

Foot exams and treatment	$40 copay (Out-of-Network)
Foot exams and treatment	$40 copay
Routine foot care	Not covered

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Ground Ambulance

$0-300 copay (Out-of-Network)
$250 copay

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Hearing

Fitting/evaluation	$0 copay
Fitting/evaluation	$10-40 copay (Out-of-Network)
Hearing aids	$0 copay
Hearing aids	$0 copay (Out-of-Network)
Hearing exam	$10-40 copay (Out-of-Network)
Hearing exam	$10-40 copay

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Inpatient Hospital Coverage

$425 per day for days 1 through 4 $0 per day for days 5 through 90
$425 per day for days 1 through 4 $0 per day for days 5 through 90 (Out-of-Network)

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Medical Equipment/Supplies

Diabetes supplies	20-35% coinsurance per item (Out-of-Network)
Diabetes supplies	20% coinsurance per item
Durable medical equipment (e.g., wheelchairs, oxygen)	20% coinsurance per item
Durable medical equipment (e.g., wheelchairs, oxygen)	50% coinsurance per item (Out-of-Network)
Prosthetics (e.g., braces, artificial limbs)	20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs)	50% coinsurance per item (Out-of-Network)

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Medicare Part B Drugs

Chemotherapy	20% coinsurance
Chemotherapy	20-35% coinsurance (Out-of-Network)
Other Part B drugs	20-35% coinsurance (Out-of-Network)
Other Part B drugs	0-20% coinsurance

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Mental Health Services

Inpatient hospital - psychiatric	$425 per day for days 1 through 4 $0 per day for days 5 through 90 (Out-of-Network)
Inpatient hospital - psychiatric	$425 per day for days 1 through 4 $0 per day for days 5 through 90
Outpatient group therapy visit	$40 copay (Out-of-Network)
Outpatient group therapy visit	$40 copay
Outpatient group therapy visit with a psychiatrist	$40 copay
Outpatient group therapy visit with a psychiatrist	$40 copay (Out-of-Network)
Outpatient individual therapy visit	$40 copay
Outpatient individual therapy visit	$40 copay (Out-of-Network)
Outpatient individual therapy visit with a psychiatrist	$40 copay (Out-of-Network)
Outpatient individual therapy visit with a psychiatrist	$40 copay

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MOOP

$6,000 In and Out-of-network $6,000 In-network

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Option

No

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Optional supplemental benefits

No

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Outpatient Hospital Coverage

$200-300 copay per visit
$0-300 copay per visit (Out-of-Network)

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Preventive Care

$0 copay
$0 copay (Out-of-Network)

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Preventive Dental

Cleaning	50% coinsurance (Out-of-Network)
Cleaning	$0 copay
Dental x-ray(s)	$0 copay
Dental x-ray(s)	50% coinsurance (Out-of-Network)
Fluoride treatment	50% coinsurance (Out-of-Network)
Fluoride treatment	$0 copay
Oral exam	$0 copay
Oral exam	50% coinsurance (Out-of-Network)

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Rehabilitation Services

Occupational therapy visit	$40 copay
Occupational therapy visit	$40 copay (Out-of-Network)
Physical therapy and speech and language therapy visit	$40 copay (Out-of-Network)
Physical therapy and speech and language therapy visit	$40 copay

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Skilled Nursing Facility

$0 per day for days 1 through 20 $150 per day for days 21 through 55 $0 per day for days 56 through 100 (Out-of-Network)
$0 per day for days 1 through 20 $150 per day for days 21 through 55 $0 per day for days 56 through 100

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Transportation

Not covered

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Vision

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

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Wellness Programs (e.g. fitness nursing hotline)

Covered

Ready to Enroll?

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1-855-778-4180
Mon-Fri 8am-8pm EST
Sat 8am-8pm EST

Coverage Area for NextBlue Classic PPO (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.