Plan Basics
Contract Year 2021
Medicare Type Medicare Advantage Plan (Part C)
CMS Plan ID H0104-012-000
Plan Organization Blue Cross and Blue Shield of Alabama
Plan Type Local PPO
Plan Name Blue Advantage Complete (PPO)
Plan Organization Type Local CCP
Drugs Covered Yes
Doctors Choice Any Doctor
Benefit Type Enhanced Alternative
Special Needs Plan No
Overall Star Rating 4
Plan Cost Sharing
Premium $0.00
Total Premium (Includes Part B) $135.50
Monthly Part C Premium $0.00
Monthly Part D Basic Premium $0.00
Monthly Part D Supplemental Premium $0.00
Monthly Part D Total Premium $0.00
Monthly Part D Premium Full Assistance $0.00
Monthly Part D Premium 75% Assistance $0.00
Monthly Part D Premium 50% Assistance $0.00
Monthly Part D Premium 25% Assistance $0.00
Part D Drug Deductible $150.00
Annual Drug Deductible $150.00
Tiers Excluded From Deductible 1
Part D Initial Coverage Limit $4130.00
Part D Catastrophic Coverage Threshold $6550.00
Maximum Out-of-Pocket Limit for Parts A & B (MOOP) $5100.00
Gap Coverage Yes

Medicare Advantage Plan Health Benefits


Additional Benefits And/or Reduced Cost-sharing For Enrollees With Certain Health Conditions?
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network - - No
Comprehensive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diagnostic services Yes Out-of-Network No No $0 copay
Endodontics Yes Out-of-Network No No $0 copay
Extractions Yes Out-of-Network No No $0 copay
Non-routine services Yes Out-of-Network No No $0 copay
Periodontics Yes Out-of-Network No No $0 copay
Prosthodontics, other oral/maxillofacial surgery, other services Yes Out-of-Network No No $0 copay
Restorative services Yes Out-of-Network No No $0 copay
Diagnostic Procedures/lab Services/imaging
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diagnostic radiology services (e.g., MRI) - Out-of-Network Yes No 50% coinsurance
Diagnostic tests and procedures - Out-of-Network No No 50% coinsurance
Lab services - Out-of-Network No No 50% coinsurance
Outpatient x-rays - Out-of-Network Yes No 50% coinsurance
Doctor Visits
Service Cap Network Auth. Req. Ref. Req. Cost Share
Primary - Out-of-Network - - 50% coinsurance per visit
Specialist - Out-of-Network No No 50% coinsurance per visit
Emergency Care/Urgent Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
Emergency - - - - $90 copay per visit (always covered)
Urgent care - - - - $5-40 copay per visit (always covered)
Foot Care (podiatry Services)
Service Cap Network Auth. Req. Ref. Req. Cost Share
Foot exams and treatment - Out-of-Network No No 50% coinsurance
Routine foot care - - - - Not covered
Ground Ambulance
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network - - $275 copay
Health Plan Deductible
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $0
Hearing
Service Cap Network Auth. Req. Ref. Req. Cost Share
Fitting/evaluation No - - - Not covered
Hearing aids Yes Out-of-Network No No $699-999 copay
Hearing exam - Out-of-Network No No 50% coinsurance
Inpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network No No 50% per stay
Maximum Out-of-pocket Enrollee Responsibility (does Not Include Prescription Drugs)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $7,500 In and Out-of-network$5,100 In-network
Medical Equipment/supplies
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diabetes supplies - Out-of-Network No - 50% coinsurance per item
Durable medical equipment (e.g., wheelchairs, oxygen) - Out-of-Network No - 50% coinsurance per item
Prosthetics (e.g., braces, artificial limbs) - Out-of-Network No - 50% coinsurance per item
Medicare Part B Drugs
Service Cap Network Auth. Req. Ref. Req. Cost Share
Chemotherapy - Out-of-Network No - 50% coinsurance
Other Part B drugs - Out-of-Network No - 50% coinsurance
Mental Health Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Inpatient hospital - psychiatric - Out-of-Network No No 50% per stay
Outpatient group therapy visit - Out-of-Network No No 50% coinsurance
Outpatient group therapy visit with a psychiatrist - Out-of-Network No No 50% coinsurance
Outpatient individual therapy visit - Out-of-Network No No 50% coinsurance
Outpatient individual therapy visit with a psychiatrist - Out-of-Network No No 50% coinsurance
Optional Supplemental Benefits
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - No
Other Health Plan Deductibles?
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network - - No
Outpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network No No 50% coinsurance per visit
Preventive Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network No No 50% coinsurance
Preventive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Cleaning Yes Out-of-Network No No $0 copay
Dental x-ray(s) Yes Out-of-Network No No $0 copay
Fluoride treatment Yes Out-of-Network No No $0 copay
Oral exam Yes Out-of-Network No No $0 copay
Rehabilitation Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Occupational therapy visit - Out-of-Network Yes No 50% coinsurance
Physical therapy and speech and language therapy visit - Out-of-Network Yes No 50% coinsurance
Skilled Nursing Facility
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes No 50% per stay
Transportation
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - Not covered
Vision
Service Cap Network Auth. Req. Ref. Req. Cost Share
Contact lenses Yes Out-of-Network No No 50% coinsurance
Eyeglass frames No - - - Not covered
Eyeglass lenses No - - - Not covered
Eyeglasses (frames and lenses) Yes Out-of-Network No No 50% coinsurance
Other No - - - Not covered
Routine eye exam Yes Out-of-Network No No 50% coinsurance
Upgrades - - - - Not covered
Wellness Programs (e.g., Fitness, Nursing Hotline)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - No No Covered
Plan Drug Info
Formulary Link Drug Formulary Directory
Official Medicare Contact
Medicare Phone 1-800-MEDICARE (1-800-633-4227)
Medicare TTY User 1-877-486-2048
Plan Available in these Counties
Autauga County, Alabama, Barbour County, Alabama, Blount County, Alabama, Bullock County, Alabama, Butler County, Alabama, Calhoun County, Alabama, Chambers County, Alabama, Cherokee County, Alabama, Choctaw County, Alabama, Clarke County, Alabama, Clay County, Alabama, Cleburne County, Alabama, Coffee County, Alabama, Colbert County, Alabama, Conecuh County, Alabama, Coosa County, Alabama, Covington County, Alabama, Crenshaw County, Alabama, Cullman County, Alabama, Dale County, Alabama, Dallas County, Alabama, Dekalb County, Alabama, Elmore County, Alabama, Escambia County, Alabama, Etowah County, Alabama, Fayette County, Alabama, Franklin County, Alabama, Geneva County, Alabama, Greene County, Alabama, Hale County, Alabama, Henry County, Alabama, Houston County, Alabama, Jackson County, Alabama, Lamar County, Alabama, Lauderdale County, Alabama, Lawrence County, Alabama, Lee County, Alabama, Limestone County, Alabama, Lowndes County, Alabama, Macon County, Alabama, Madison County, Alabama, Marengo County, Alabama, Marion County, Alabama, Marshall County, Alabama, Monroe County, Alabama, Montgomery County, Alabama, Morgan County, Alabama, Perry County, Alabama, Pickens County, Alabama, Pike County, Alabama, Randolph County, Alabama, Russell County, Alabama, Saint Clair County, Alabama, Sumter County, Alabama, Talladega County, Alabama, Tallapoosa County, Alabama, Tuscaloosa County, Alabama, Washington County, Alabama, Wilcox County, Alabama, Winston County, Alabama

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