2022 Empire MediBlue Access (PPO)

Empire MediBlue Access (PPO) H3342-023 is a 2022 Medicare Advantage Plan or Part-C by Empire BlueCross BlueShield available to residents in New York. This plan includes additional prescription drug (Part-D) coverage. The Empire MediBlue Access (PPO) has a monthly premium of $91.00 and has an in-network maximum out-of-pocket limit of $6,200 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $6,200 out-of-pocket. This can be a extremely nice safety net.

Empire MediBlue Access (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.

Empire BlueCross BlueShield works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for Empire MediBlue Access (PPO) you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Empire BlueCross BlueShield 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 Empire BlueCross BlueShield except hospice care. Original Medicare still provides you with hospice care even if you sign up for Medicare Advantage.

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2022 Empire BlueCross BlueShield Medicare Advantage Plan Costs

Empire MediBlue Access (PPO) Part-C Premium

Empire BlueCross BlueShield charges a $50.10 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.

H3342-023 Part-D Deductible and Premium

Empire MediBlue Access (PPO) has a monthly drug premium of $39.90 and a $310.00 drug deductible. This Empire BlueCross BlueShield plan offers a $39.90 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 Empire BlueCross BlueShield 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 $39.90 . 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.

Empire BlueCross BlueShield 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 Empire BlueCross BlueShield 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 Empire MediBlue Access (PPO) medicare insurance offers a $0.00 premium obligation if you receive a full low-income subsidy (LIS) assistance. And the payment is $10.00 for 75% low income subsidy $19.90 for 50% and $29.90 for 25%.

H3342-023 Formulary or Drug Coverage

Empire MediBlue Access (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 Empire MediBlue Access (PPO) H3342-023 Formulary here.

Drug Tier	Copay Preferred Pharmacy	Copay Nonpreferred Pharmacy
Tier 1	$3	$8
Tier 2	$10	$15
Tier 3	$38	$43
Tier 4	$88	$93
Tier 5	27%	27%
Tier 6	$0	$0

*Initial Coverage Phase and 30 day supply

2021 Empire MediBlue Access (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	Not covered
Endodontics	Not covered
Extractions	Not covered
Non-routine services	Not covered
Periodontics	Not covered
Prosthodontics, other oral/maxillofacial surgery, other services	Not covered
Restorative services	Not covered

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Deductible

$0

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Diagnostic Tests and Procedures

Diagnostic radiology services (e.g., MRI)	40% coinsurance (Out-of-Network)
Diagnostic radiology services (e.g., MRI)	$50-150 copay
Diagnostic tests and procedures	40% coinsurance (Out-of-Network)
Diagnostic tests and procedures	$0-80 copay
Lab services	$0-20 copay
Lab services	40% coinsurance (Out-of-Network)
Outpatient x-rays	$40-80 copay
Outpatient x-rays	40% coinsurance (Out-of-Network)

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Doctor Visits

Primary	$50 copay per visit (Out-of-Network)
Primary	$10 copay per visit
Specialist	$50 copay per visit
Specialist	$75 copay per visit (Out-of-Network)

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Emergency care/Urgent Care

Emergency	$90 copay per visit (always covered)
Urgent care	$65 copay per visit (always covered)

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Foot Care (podiatry services)

Foot exams and treatment	$75 copay (Out-of-Network)
Foot exams and treatment	$50 copay
Routine foot care	Not covered

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Ground Ambulance

$275 copay
$275 copay (Out-of-Network)

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Hearing

Fitting/evaluation	Not covered
Hearing aids - inner ear	Not covered
Hearing aids - outer ear	Not covered
Hearing aids - over the ear	Not covered
Hearing exam	$50 copay
Hearing exam	$75 copay (Out-of-Network)

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Inpatient Hospital Coverage

$372 per day for days 1 through 5 $0 per day for days 6 through 90
40% per stay (Out-of-Network)

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Medical Equipment/Supplies

Diabetes supplies	$0 copay
Diabetes supplies	40% coinsurance per item (Out-of-Network)
Durable medical equipment (e.g., wheelchairs, oxygen)	40% coinsurance per item (Out-of-Network)
Durable medical equipment (e.g., wheelchairs, oxygen)	0-20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs)	20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs)	40% coinsurance per item (Out-of-Network)

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Medicare Part B Drugs

Chemotherapy	20% coinsurance
Chemotherapy	40% coinsurance (Out-of-Network)
Other Part B drugs	20% coinsurance
Other Part B drugs	40% coinsurance (Out-of-Network)

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Mental Health Services

Inpatient hospital - psychiatric	40% per stay (Out-of-Network)
Inpatient hospital - psychiatric	$395 per day for days 1 through 4 $0 per day for days 5 through 90
Outpatient group therapy visit	$40 copay
Outpatient group therapy visit	$75 copay (Out-of-Network)
Outpatient group therapy visit with a psychiatrist	$75 copay (Out-of-Network)
Outpatient group therapy visit with a psychiatrist	$40 copay
Outpatient individual therapy visit	$40 copay
Outpatient individual therapy visit	$75 copay (Out-of-Network)
Outpatient individual therapy visit with a psychiatrist	$75 copay (Out-of-Network)
Outpatient individual therapy visit with a psychiatrist	$40 copay

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MOOP

$9,000 In and Out-of-network $6,200 In-network

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Option

No

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Optional supplemental benefits

Yes

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Outpatient Hospital Coverage

$0 copay or 20% coinsurance per visit
40% coinsurance per visit (Out-of-Network)

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Package #1

Deductible
Monthly Premium	$19.00

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Package #2

Deductible
Monthly Premium	$30.00

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Package #3

Deductible
Monthly Premium	$54.00

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Preventive Care

$0 copay
40% coinsurance (Out-of-Network)

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Preventive Dental

Cleaning	Not covered
Dental x-ray(s)	Not covered
Fluoride treatment	Not covered
Oral exam	Not covered

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Rehabilitation Services

Occupational therapy visit	$40 copay
Occupational therapy visit	$75 copay (Out-of-Network)
Physical therapy and speech and language therapy visit	$75 copay (Out-of-Network)
Physical therapy and speech and language therapy visit	$40 copay

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Skilled Nursing Facility

$0 per day for days 1 through 20 $184 per day for days 21 through 100
40% per stay (Out-of-Network)

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Transportation

Not covered

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Vision

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

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Wellness Programs (e.g. fitness nursing hotline)

Covered

Ready to Enroll?

Click Here

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

Coverage Area for Empire MediBlue Access (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.