Florida Blue Medicare Advantage
BlueMedicare Value (PPO)
Florida Blue Medicare Advantage
BlueMedicare Premier (HMO)
Coverage Summary
|
Is My Doctor In-Network? Is My Doctor In-Network? |
||
|---|---|---|
|
Primary Care Doctor Visit |
Level 1 $0 Copayment in-network |
$0 copay |
|
Specialist Visit |
Level 1 $30 Copayment in-network |
$10 copay |
|
Inpatient Hospital Care |
$295 copay per day for days 1-5 in-network |
$125 copay per day for days 1-6 |
|
Emergency Services (In and out-of-network) |
$90 copay; ER copay waived if admitted |
$115 copay; ER copay waived if admitted |
|
Urgent Care Services |
$40 copay in and out-of-network |
$10 copay in and out-of-network |
Prescription Drug Coverage
|
Prescription Drug Deductible |
$150 (applies to Tiers 3,4,5 only) |
$0 |
|---|---|---|
|
In-Network Prescription Drug Coverage - Initial Coverage |
Tier 1 - Preferred Generics |
Tier 1 - Preferred Generics |
|
Coverage Gap |
This plan has coverage in the Part D coverage gap. Tier 1 (preferred generic drugs) and Tier 6 (select care) medications are covered in the coverage gap. For these tiers, you continue to pay the same cost-sharing amounts as in the Initial Coverage Stage. You pay no more than $0 for Tier 1 medications at a network retail pharmacy. You pay no more than $0 for Tier 6 medications at a network retail pharmacy. You will pay no more than 25% of the costs for generics in all other tiers. For all brand drugs you pay no more than 25% of the costs. |
This plan has coverage in the Part D coverage gap. Tier 1 (preferred generic drugs) and Tier 2 (generics) medications are covered in the coverage gap. For these tiers, you continue to pay the same cost-sharing amounts as in the Initial Coverage Stage. You pay no more than $0 for Tier 1 medications at a preferred pharmacy. You pay no more than $0 for Tier 2 medications at a preferred pharmacy. You will pay no more than 25% of the costs for generics in all other tiers. For all brand drugs you pay no more than 25% of the costs. |
|
Catastrophic Coverage |
You pay the greater of $3.95 or 5% for generic drugs and drugs treated like generics. You pay the greater of $9.85 or 5% for brand name drugs. |
You pay the greater of $3.95 or 5% for generic drugs and drugs treated like generics. You pay the greater of $9.85 or 5% for brand name drugs. |
Extra Coverage
|
Extra Benefits |
Routine Dental |
Routine Dental |
|---|
Out of Network Coverage
|
Medical Services/Supplies |
If you receive care from an out-of-network provider, your out-of-pocket costs will usually be higher than if you use a network provider. There are three exceptions: emergency care, urgently needed care and dialysis services. For details about the plan's coverage of out-of-network care, please refer to the Summary of Benefits or the Evidence of Coverage. (See "Plan Documents" below.) |
If you receive care from an out-of network provider without prior authorization from our plan, the care will not be covered except for emergency care, urgently needed care and dialysis services. |
|---|---|---|
|
Prescription Drugs |
We generally cover drugs filled at an out-of-network pharmacy only if you are not able to use one of our network pharmacies (for example, because you are traveling, need emergency or urgent care, or need a drug that it not available at an accessible network pharmacy). Chapter 5 of the Evidence of Coverage provides a full list of situations in which we may cover drugs from an out-of-network pharmacy. |
We generally cover drugs filled at an out-of-network pharmacy only if you are not able to use one of our network pharmacies (for example, because you are traveling, need emergency or urgent care, or need a drug that it not available at an accessible network pharmacy). Chapter 5 of the Evidence of Coverage provides a full list of situations in which we may cover drugs from an out-of-network pharmacy. |
Plan Documents
| Summary of Benefits (PDF) |
|
|
|---|---|---|
| Evidence of Coverage (PDF) |
|
|
| Plan Rating (PDF) |
|
|
| General Transition Notice (PDF) |
|
|
| Low Income Subsidy Premium Summary Table for Those Receiving Extra Help (PDF) |
|
|
| Comprehensive Formulary (PDF) |
|
|
| Service Area Map | ||
| Annual Notice of Change |
|
|
| Enrollment Forms |
|
|