2022 Secure Blue Courage (PPO)

Secure Blue Courage (PPO) H1302-004 is a 2022 Medicare Advantage Plan or Part-C by Blue Cross of Idaho available to residents in Idaho. This plan does not provide additional prescription drug (Part-D) coverage. The Secure Blue Courage (PPO) has a monthly premium of $0 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 Courage (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 Courage (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 you are always covered for urgently needed and emergency care. Plus you receive all 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 Medicare Advantage.

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

2022 Blue Cross of Idaho Medicare Advantage Plan Costs

2021 Secure Blue Courage (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	Not covered
Endodontics	50% coinsurance (Out-of-Network)
Endodontics	50% coinsurance
Extractions	$0 copay
Extractions	50% coinsurance (Out-of-Network)
Non-routine services	50% coinsurance (Out-of-Network)
Non-routine services	$0 copay
Periodontics	50% coinsurance (Out-of-Network)
Periodontics	50% coinsurance
Prosthodontics, other oral/maxillofacial surgery, other services	50% coinsurance
Prosthodontics, other oral/maxillofacial surgery, other services	50% coinsurance (Out-of-Network)
Restorative services	$0 copay
Restorative services	50% coinsurance (Out-of-Network)

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Deductible

$0

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Diagnostic Tests and Procedures

Diagnostic radiology services (e.g., MRI)	$250 copay
Diagnostic radiology services (e.g., MRI)	25% coinsurance (Out-of-Network)
Diagnostic tests and procedures	10% coinsurance
Diagnostic tests and procedures	25% coinsurance (Out-of-Network)
Lab services	$0 copay
Lab services	25% coinsurance (Out-of-Network)
Outpatient x-rays	$0 copay
Outpatient x-rays	25% coinsurance (Out-of-Network)

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Doctor Visits

Primary	$30 copay per visit (Out-of-Network)
Primary	$0 copay
Specialist	$25 copay per visit
Specialist	$30 copay per visit (Out-of-Network)

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Emergency care/Urgent Care

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

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Foot Care (podiatry services)

Foot exams and treatment	$30 copay (Out-of-Network)
Foot exams and treatment	$25 copay
Routine foot care	Not covered

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Ground Ambulance

$175 copay (Out-of-Network)
$175 copay

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Hearing

Fitting/evaluation	Not covered
Hearing aids	$699-999 copay
Hearing aids	$699-999 copay (Out-of-Network)
Hearing exam	$25 copay
Hearing exam	$45 copay (Out-of-Network)

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Inpatient Hospital Coverage

$100 per day for days 1 through 5 $0 per day for days 6 through 90
$200 per day for days 1 through 10 $0 per day for days 11 through 90 (Out-of-Network)

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Medical Equipment/Supplies

Diabetes supplies	$0 copay
Diabetes supplies	20% coinsurance per item (Out-of-Network)
Durable medical equipment (e.g., wheelchairs, oxygen)	10% coinsurance per item
Durable medical equipment (e.g., wheelchairs, oxygen)	20% coinsurance per item (Out-of-Network)
Prosthetics (e.g., braces, artificial limbs)	10% coinsurance per item
Prosthetics (e.g., braces, artificial limbs)	20% coinsurance per item (Out-of-Network)

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Medicare Part B Drugs

Chemotherapy	30% coinsurance (Out-of-Network)
Chemotherapy	20% coinsurance
Other Part B drugs	20% coinsurance
Other Part B drugs	30% coinsurance (Out-of-Network)

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Mental Health Services

Inpatient hospital - psychiatric	$100 per day for days 1 through 5 $0 per day for days 6 through 90
Inpatient hospital - psychiatric	$200 per day for days 1 through 10 $0 per day for days 11 through 90 (Out-of-Network)
Outpatient group therapy visit	$0 copay
Outpatient group therapy visit	25% coinsurance (Out-of-Network)
Outpatient group therapy visit with a psychiatrist	$25 copay
Outpatient group therapy visit with a psychiatrist	25% coinsurance (Out-of-Network)
Outpatient individual therapy visit	$0 copay
Outpatient individual therapy visit	25% coinsurance (Out-of-Network)
Outpatient individual therapy visit with a psychiatrist	$25 copay
Outpatient individual therapy visit with a psychiatrist	25% coinsurance (Out-of-Network)

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MOOP

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

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Option

No

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Optional supplemental benefits

No

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Outpatient Hospital Coverage

20% coinsurance per visit (Out-of-Network)
$175 copay per visit

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Preventive Care

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

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Preventive Dental

Cleaning	Covered under office visit
Dental x-ray(s)	Covered under office visit
Fluoride treatment	Covered under office visit
Office visit	$0.00
Office visit	50% coinsurance (Out-of-Network)
Oral exam	Covered under office visit

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Rehabilitation Services

Occupational therapy visit	$30 copay (Out-of-Network)
Occupational therapy visit	$25 copay
Physical therapy and speech and language therapy visit	$30 copay (Out-of-Network)
Physical therapy and speech and language therapy visit	$25 copay

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Skilled Nursing Facility

$0 per day for days 1 through 20 $180 per day for days 21 through 100
$100 per day for days 1 through 12 $180 per day for days 13 through 100 (Out-of-Network)

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Transportation

Not covered

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Vision

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

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Wellness Programs (e.g. fitness nursing hotline)

Covered

Ready to Enroll?

Click Here

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

Coverage Area for Secure Blue Courage (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.