2022 Blue Advantage Premier (PPO)

Blue Advantage Premier (PPO) H0104-015 is a 2022 Medicare Advantage Plan or Part-C by Blue Cross and Blue Shield of Alabama available to residents in Alabama. This plan includes additional prescription drug (Part-D) coverage. The Blue Advantage Premier (PPO) has a monthly premium of $171.00 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.

Blue Advantage Premier (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 and Blue Shield of Alabama works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for Blue Advantage Premier (PPO) you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Blue Cross and Blue Shield of Alabama 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 and Blue Shield of Alabama 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 and Blue Shield of Alabama Medicare Advantage Plan Costs

Blue Advantage Premier (PPO) Part-C Premium

Blue Cross and Blue Shield of Alabama charges a $102.90 Part-C premium. The Part C premium covers Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.

H0104-015 Part-D Deductible and Premium

Blue Advantage Premier (PPO) has a monthly drug premium of $68.10 and a $0.00 drug deductible. This Blue Cross and Blue Shield of Alabama plan offers a $68.10 Part-D Basic Premium that is not below the regional benchmark. This covers the basic prescription benefit only and does not cover enhanced drug benefits such as medical benefits or hospital benefits. The Part D Supplemental Premium is $0.00 this Premium covers any enhanced plan benefits offered by Blue Cross and Blue Shield of Alabama above and beyond the standard PDP benefits. This can include additional coverage in the gap, lower co-payments and coverage of non-Part D drugs. The Part D Total Premium is $68.10 . The Part D Total Premium is the addition of the supplemental and basic premiums for some plans this amount can be lowered due to negative basic or supplemental premiums.

Blue Cross and Blue Shield of Alabama Gap Coverage

In 2022 once you and your plan provider have spent $4430 on covered drugs. (combined amount plus your deductible) You will be in the coverage gap. (AKA "donut hole") You will be required to pay 25% for prescription drugs unless your plan offers additional coverage. This Blue Cross and Blue Shield of Alabama plan does offer additional coverage through the gap.

Premium Assistance

The Low Income Subsidy (LIS) helps people with Medicare pay for prescription drugs, and lowers the costs of Medicare prescription drug coverage. Depending on your income level you may be eligible for full 75%, 50%, 25% premium assistance. The Blue Advantage Premier (PPO) medicare insurance offers a $35.40 premium obligation if you receive a full low-income subsidy (LIS) assistance. And the payment is $43.60 for 75% low income subsidy $51.70 for 50% and $59.90 for 25%.

H0104-015 Formulary or Drug Coverage

Blue Advantage Premier (PPO) formulary is divided into Tiers or levels of coverage based on usage and according to the medication costs. Each tier will have a defined copay that you must pay to receive the drug. Drugs in lower tiers will usually cost less than those in higher tiers. By reviewing different Medicare Drug formularies, you can pick a Medicare Advantage plan that covers your medications. Additionally, you can choose a plan that has your drugs listed at a lower price. You can see complete 2022 Blue Advantage Premier (PPO) H0104-015 Formulary here.

Drug Tier	Copay Preferred Pharmacy	Copay Nonpreferred Pharmacy
Tier 1	$3	$10
Tier 2	$8	$15
Tier 3	$40	$47
Tier 4	42%	47%
Tier 5	33%	33%
Tier 6	$0	$0

*Initial Coverage Phase and 30 day supply

2021 Blue Advantage Premier (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	$0 copay
Diagnostic services	$0 copay (Out-of-Network)
Endodontics	$0 copay (Out-of-Network)
Endodontics	$0 copay
Extractions	$0 copay
Extractions	$0 copay (Out-of-Network)
Non-routine services	$0 copay
Non-routine services	$0 copay (Out-of-Network)
Periodontics	$0 copay
Periodontics	$0 copay (Out-of-Network)
Prosthodontics, other oral/maxillofacial surgery, other services	$0 copay (Out-of-Network)
Prosthodontics, other oral/maxillofacial surgery, other services	$0 copay
Restorative services	$0 copay
Restorative services	$0 copay (Out-of-Network)

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Deductible

$0

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Diagnostic Tests and Procedures

Diagnostic radiology services (e.g., MRI)	$25 copay
Diagnostic radiology services (e.g., MRI)	50% coinsurance (Out-of-Network)
Diagnostic tests and procedures	50% coinsurance (Out-of-Network)
Diagnostic tests and procedures	$0 copay
Lab services	$0 copay
Lab services	50% coinsurance (Out-of-Network)
Outpatient x-rays	50% coinsurance (Out-of-Network)
Outpatient x-rays	$5 copay

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Doctor Visits

Primary	$5 copay per visit
Primary	50% coinsurance per visit (Out-of-Network)
Specialist	$25 copay per visit
Specialist	50% coinsurance per visit (Out-of-Network)

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Emergency care/Urgent Care

Emergency	$120 copay per visit (always covered)
Urgent care	$5-25 copay per visit (always covered)

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Foot Care (podiatry services)

Foot exams and treatment	$20 copay
Foot exams and treatment	50% coinsurance (Out-of-Network)
Routine foot care	Not covered

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Ground Ambulance

$150 copay (Out-of-Network)
$150 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	$10 copay
Hearing exam	50% coinsurance (Out-of-Network)

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Inpatient Hospital Coverage

$175 per day for days 1 through 5 $0 per day for days 6 through 90 $0 per day for days 91 and beyond
50% per stay (Out-of-Network)

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Medical Equipment/Supplies

Diabetes supplies	50% coinsurance per item (Out-of-Network)
Diabetes supplies	$0 copay
Durable medical equipment (e.g., wheelchairs, oxygen)	50% coinsurance per item (Out-of-Network)
Durable medical equipment (e.g., wheelchairs, oxygen)	20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs)	20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs)	50% coinsurance per item (Out-of-Network)

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Medicare Part B Drugs

Chemotherapy	20% coinsurance
Chemotherapy	50% coinsurance (Out-of-Network)
Other Part B drugs	20% coinsurance
Other Part B drugs	50% coinsurance (Out-of-Network)

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Mental Health Services

Inpatient hospital - psychiatric	50% per stay (Out-of-Network)
Inpatient hospital - psychiatric	$175 per day for days 1 through 5 $0 per day for days 6 through 90
Outpatient group therapy visit	$25 copay
Outpatient group therapy visit	50% coinsurance (Out-of-Network)
Outpatient group therapy visit with a psychiatrist	$25 copay
Outpatient group therapy visit with a psychiatrist	50% coinsurance (Out-of-Network)
Outpatient individual therapy visit	$25 copay
Outpatient individual therapy visit	50% coinsurance (Out-of-Network)
Outpatient individual therapy visit with a psychiatrist	50% coinsurance (Out-of-Network)
Outpatient individual therapy visit with a psychiatrist	$25 copay

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MOOP

$5,100 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

$150 copay per visit
50% coinsurance per visit (Out-of-Network)

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Preventive Care

50% coinsurance (Out-of-Network)
$0 copay

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Preventive Dental

Cleaning	$0 copay
Cleaning	$0 copay (Out-of-Network)
Dental x-ray(s)	$0 copay (Out-of-Network)
Dental x-ray(s)	$0 copay
Fluoride treatment	$0 copay (Out-of-Network)
Fluoride treatment	$0 copay
Oral exam	$0 copay (Out-of-Network)
Oral exam	$0 copay

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Rehabilitation Services

Occupational therapy visit	$20 copay
Occupational therapy visit	50% coinsurance (Out-of-Network)
Physical therapy and speech and language therapy visit	50% coinsurance (Out-of-Network)
Physical therapy and speech and language therapy visit	$20 copay

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Skilled Nursing Facility

$0 per day for days 1 through 20 $100 per day for days 21 through 55 $0 per day for days 56 through 100
50% per stay (Out-of-Network)

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Transportation

Not covered

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Vision

Contact lenses	50% coinsurance (Out-of-Network)
Contact lenses	$0 copay
Eyeglass frames	Not covered
Eyeglass lenses	Not covered
Eyeglasses (frames and lenses)	50% coinsurance (Out-of-Network)
Eyeglasses (frames and lenses)	$0 copay
Other	Not covered
Routine eye exam	$0 copay
Routine eye exam	50% coinsurance (Out-of-Network)
Upgrades	Not covered

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Wellness Programs (e.g. fitness nursing hotline)

Covered

CMS Star Ratings for Blue Advantage Premier (PPO) H0104

Staying Healthy, Screening, Testing, & Vaccines

Managing Chronic And Long Term Care for Older Adults

Member Experience with Health Plan

Member Complaints and Changes in Blue Advantage Premier (PPO) Plans Performance

Health Plan Customer Service Rating for Blue Advantage Premier (PPO)

Blue Advantage Premier (PPO) Drug Plan Customer Service Ratings

Ratings For Member Complaints and Changes in the Drug Plans Performance

Member Experience with the Drug Plan

Drug Safety and Accuracy of Drug Pricing

Ready to Enroll?

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

Coverage Area for Blue Advantage Premier (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.