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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2022 Blue Cross of Idaho Medicare Advantage Plan Costs

Name:
Secure Blue Courage (PPO)
Plan ID:
H1302-004
Provider:Blue Cross of Idaho
Year:2022
Type: Local PPO *
Monthly Premium C+D: $0
Part C Premium:
MOOP: $3,400
Similar Plan: H1302-004




2021 Secure Blue Courage (PPO) Summary of Benefits

*This will be updated with 2022 data when available.



Additional Benefits


No



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)



Deductible


$0



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)



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)



Emergency care/Urgent Care


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



Foot Care (podiatry services)


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



Ground Ambulance


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



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)



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)



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)



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)



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)



MOOP


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



Option


No



Optional supplemental benefits


No



Outpatient Hospital Coverage


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



Preventive Care


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



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



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



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)



Transportation


Not covered



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)



Wellness Programs (e.g. fitness nursing hotline)


Covered





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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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