Plan Basics
Contract Year 2021
Medicare Type Medicare Advantage Plan (Part C)
CMS Plan ID H3554-009-000
Plan Organization Arkansas Blue Medicare
Plan Type Local PPO
Plan Name BlueMedicare Premier Choice (PPO)
Plan Organization Type Local CCP
Drugs Covered Yes
Doctors Choice Any Doctor
Benefit Type Enhanced Alternative
Special Needs Plan No
Overall Star Rating Plan too new to be measured
Plan Cost Sharing
Premium $49.00
Total Premium (Includes Part B) $184.50
Monthly Part C Premium $49.00
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 $195.00
Annual Drug Deductible $195.00
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) $7000.00
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 50% coinsurance
Endodontics Yes Out-of-Network No No 50% coinsurance
Extractions Yes Out-of-Network No No 50% coinsurance
Non-routine services Yes Out-of-Network No No 50% coinsurance
Periodontics Yes Out-of-Network No No 50% coinsurance
Prosthodontics, other oral/maxillofacial surgery, other services Yes Out-of-Network No No 50% coinsurance
Restorative services Yes Out-of-Network No No 50% coinsurance
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 40% coinsurance
Diagnostic tests and procedures - Out-of-Network Yes No 40% coinsurance
Lab services - Out-of-Network Yes No 40% coinsurance
Outpatient x-rays - Out-of-Network Yes No 40% coinsurance
Doctor Visits
Service Cap Network Auth. Req. Ref. Req. Cost Share
Primary - Out-of-Network - - $20 copay per visit
Specialist - Out-of-Network No No 40% 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 - - - - $5-45 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 40% coinsurance
Routine foot care Yes Out-of-Network No No 40% coinsurance
Ground Ambulance
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network - - $265 copay or 20% coinsurance
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 Yes Out-of-Network No No 40% coinsurance
Hearing aids Yes Out-of-Network No No $0 copay
Hearing exam - Out-of-Network No No 40% coinsurance
Inpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes No 40% per stay
Maximum Out-of-pocket Enrollee Responsibility (does Not Include Prescription Drugs)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $11,300 In and Out-of-network$7,000 In-network
Medical Equipment/supplies
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diabetes supplies - Out-of-Network No - 20% coinsurance per item
Durable medical equipment (e.g., wheelchairs, oxygen) - Out-of-Network Yes - 20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs) - Out-of-Network Yes - 20% coinsurance per item
Medicare Part B Drugs
Service Cap Network Auth. Req. Ref. Req. Cost Share
Chemotherapy - Out-of-Network No - 40% coinsurance
Other Part B drugs - Out-of-Network No - 40% coinsurance
Mental Health Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Inpatient hospital - psychiatric - Out-of-Network Yes No 40% per stay
Outpatient group therapy visit - Out-of-Network No No 40% coinsurance
Outpatient group therapy visit with a psychiatrist - Out-of-Network No No 40% coinsurance
Outpatient individual therapy visit - Out-of-Network No No 40% coinsurance
Outpatient individual therapy visit with a psychiatrist - Out-of-Network No No 40% 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 Yes No 40% coinsurance per visit
Preventive Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network No No 40% coinsurance
Preventive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Cleaning Yes Out-of-Network No No 50% coinsurance
Dental x-ray(s) Yes Out-of-Network No No 50% coinsurance
Fluoride treatment No - - - Not covered
Oral exam Yes Out-of-Network No No 50% coinsurance
Rehabilitation Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Occupational therapy visit - Out-of-Network No No 40% coinsurance
Physical therapy and speech and language therapy visit - Out-of-Network No No 40% coinsurance
Skilled Nursing Facility
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes No 40% 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

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