Premera Blue Cross Medicare Advantage Peak + Rx (HMO) H9302-011 is a 2023 Medicare Advantage Plan or Part-C by Premera Blue Cross Medicare Advantage available to residents in Washington. This plan includes extra prescription drug (Part-D) coverage. Premera Blue Cross Medicare Advantage Premera Blue Cross Medicare Advantage Peak + Rx (HMO) has a monthly premium of $0 and has an in-network maximum out-of-pocket limit of $6,700 (MOOP). This means that if you get sick or need a high-cost procedure the co-pays are capped once you pay $6,700 out-of-pocket. This can be an extremely nice safety net.

Premera Blue Cross Medicare Advantage works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for Premera Blue Cross Medicare Advantage Peak + Rx (HMO) you still retain Original Medicare. But you will get extra Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Premera Blue Cross Medicare Advantage and not Original Medicare. With 2023 Medicare Advantage Plan you are always covered for urgently needed and emergency care. Plus, you receive all the benefits of Original Medicare from Premera Blue Cross Medicare Advantage except hospice care. Original Medicare still provides you with hospice care if you sign up for Medicare Advantage in Washington.

2023 Premera Blue Cross Medicare Advantage Medicare Advantage Plan Overview

What type of plan is Premera Blue Cross Medicare Advantage Peak + Rx (HMO)

Premera Blue Cross Medicare Advantage Peak + Rx (HMO) is a Local HMO. With a health maintenance organization (HMO) you will be required to receive most of your health care from an in-network provider. Health maintenance organizations require that you select a primary care physician (PCP). Your primary care physician will serve as your personal doctor to provide all of your basic healthcare services. If you require specialized care or a physician specialist, your primary care physician will make the arrangements and inform you where you can go in the network. You will need your primary care physician approval, called a referral. Services received from an out-of-network provider are not typically covered.

How much does Premera Blue Cross Medicare Advantage Peak + Rx (HMO) cost?

Monthly Premium

A monthly premium is the fee you pay to the plan in exchange for coverage. Premera Blue Cross Medicare Advantage charges a $0 consolidated premium. The Part C premium is $0 this charge covers Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.

Part-D Deductible and Premium

An annual deductible is the amount you pay out-of-pocket for your prescription drugs before your plan begins to pay. Premera Blue Cross Medicare Advantage Peak + Rx (HMO) has a monthly drug premium of $0 and a $160.00 drug deductible. This Premera Blue Cross Medicare Advantage plan offers a $0 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. This Premium covers any enhanced plan benefits offered by Premera Blue Cross Medicare Advantage above and beyond the standard PDP benefits. This can include extra coverage in the gap, lower co-payments, and coverage of non-Part D drugs. The Part D Total Premium is $0. The Part D Total Premium is the addition of supplemental and basic premiums for some plans this amount can be lowered due to negative basic or supplemental premiums.

Premera Blue Cross Medicare Advantage Gap Coverage

In 2023 once you and your plan provider have spent $4660 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 extra coverage. This Premera Blue Cross Medicare Advantage plan does not offer extra coverage through the gap.

MOOP

The maximum out-of-pocket (MOOP) is a yearly limit on your out-of-pocket costs. Premera Blue Cross Medicare Advantage Peak + Rx (HMO) by Premera Blue Cross Medicare Advantage MOOP is $6,700. Once you spend $6,700 you will pay nothing for Part A or Part B covered services. Copayments and coinsurance for Medicare approved services apply toward your out-of-pocket limit. Remember Original Medicare (Parts A and B) doesn’t have a MOOP.

Formulary and Drug Coverage

Premera Blue Cross Medicare Advantage Peak + Rx (HMO) 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.

Drug Tier	Copay Preferred Pharmacy	Copay Nonpreferred Pharmacy
Tier 1	NA	$3
Tier 2	NA	$12
Tier 3	NA	$42
Tier 4	NA	$100
Tier 5	NA	30%

The complete Premera Blue Cross Medicare Advantage Peak + Rx (HMO) Formulary.
*Initial Coverage Phase and 30 day supply

2023 Summary of Benefits

The benefit information provided is a summary of what Premera Blue Cross Medicare Advantage Peak + Rx (HMO) covers and what you pay (such as copayments and coinsurance amounts) for certain common medical events. The Summary of Benefits from Premera Blue Cross Medicare Advantage helps get an idea of how much financial protection the plan is generally expected to provide for common health conditions. This section also contains information on coverage for in-network and out-of-network providers.

Wellness programs (e.g., fitness, nursing hotline)	Covered

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Contact lenses

Vision	$0 copay

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Eyeglass frames

Vision	$0 copay

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Eyeglass lenses

Vision	$0 copay

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Eyeglasses (frames and lenses)

Vision	$0 copay

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Other

Vision	Not covered

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Routine eye exam

Vision	$20 copay

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Upgrades

Vision	$0 copay

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Transportation	Not covered
Skilled Nursing Facility	$0 per day for days 1 through 20 $160 per day for days 21 through 60 $0 per day for days 61 through 100

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Occupational therapy visit

Rehabilitation services	$20 copay

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Physical therapy and speech and language therapy visit

Rehabilitation services	$20 copay

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Cleaning

Preventive dental	$0 copay

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Dental x-ray(s)

Preventive dental	$0 copay

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Fluoride treatment

Preventive dental	$0 copay

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Oral exam

Preventive dental	$0 copay

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Preventive care	$0 copay
Outpatient hospital coverage	$350 copay per visit
In-Network Other health plan deductibles?	Yes
Optional supplemental benefits	No

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Inpatient hospital - psychiatric

Mental health services	$595 per day for days 1 through 2 $0 per day for days 3 through 90

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Outpatient group therapy visit

Mental health services	$30 copay

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Outpatient group therapy visit with a psychiatrist

Mental health services	$30 copay

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Outpatient individual therapy visit

Mental health services	$30 copay

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Outpatient individual therapy visit with a psychiatrist

Mental health services	$30 copay

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Chemotherapy

Medicare Part B drugs	20% coinsurance

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Other Part B drugs

Medicare Part B drugs	20% coinsurance

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Diabetes supplies

Medical equipment/supplies	$0 copay

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Durable medical equipment (e.g., wheelchairs, oxygen)

Medical equipment/supplies	20% coinsurance per item

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Prosthetics (e.g., braces, artificial limbs)

Medical equipment/supplies	20% coinsurance per item

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Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)	$6,700 In-network
Inpatient hospital coverage	$450 per day for days 1 through 4 $0 per day for days 5 through 90 $0 per day for days 91 and beyond

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Fitting/evaluation

Hearing	Not covered

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Hearing aids

Hearing	$0 copay

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Hearing exam

Hearing	$35 copay

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Health plan deductible	$0
Ground ambulance	$280 copay

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Foot exams and treatment

Foot care (podiatry services)	$40 copay

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Routine foot care

Foot care (podiatry services)	$40 copay

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Emergency

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

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Urgent care

Emergency care/Urgent care	$35 copay per visit (always covered)

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Primary

Doctor visits	$5 copay per visit

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Specialist

Doctor visits	$40 copay per visit

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Diagnostic radiology services (e.g., MRI)

Diagnostic procedures/lab services/imaging	$180 copay

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Diagnostic tests and procedures

Diagnostic procedures/lab services/imaging	$60 copay

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Lab services

Diagnostic procedures/lab services/imaging	$10 copay

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Outpatient x-rays

Diagnostic procedures/lab services/imaging	$15 copay

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Diagnostic services

Comprehensive dental	$0 copay

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Endodontics

Comprehensive dental	$0 copay

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Extractions

Comprehensive dental	$0 copay

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Non-routine services

Comprehensive dental	$0 copay

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Periodontics

Comprehensive dental	$0 copay

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Prosthodontics, other oral/maxillofacial surgery, other services

Comprehensive dental	$0 copay

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Restorative services

Comprehensive dental	$0 copay

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In-Network Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?	No

Premera Blue Cross Medicare Advantage Peak + Rx (HMO) Reviews

Is Premera Blue Cross Medicare Advantage Peak + Rx (HMO) a good plan? Premera Blue Cross Medicare Advantage Peak + Rx (HMO) received a 3 overall star rating from the CMS. The CMS uses a Star Rating System to measure how well Medicare Advantage and Part D plans perform. Plans are rated on a one-to-five scale, with one star representing poor performance and five stars representing excellent performance. Medicare Advantage with prescription drug (Part D) coverage (MA-PD) contracts are rated on up to 38 unique quality and performance measures. You can use the CMS star rating to compare Premera Blue Cross Medicare Advantage Peak Rx Reviews among several different plans.

Staying Healthy, Screening, Testing, & Vaccines

Managing Chronic And Long Term Care for Older Adults

Member Experience with H9302-011 Health Plan

Member Complaints and Changes in Plans Performance

Health Plan Customer Service Rating for Premera Blue Cross Medicare Advantage

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

Coverage Area

(Click county or state to compare all available Advantage plans)

The availability of Medicare Advantage Plans will vary according to your region. This is why the Coverage Area matters in terms of Medicare eligibility. You will always be eligible for Original Medicare, but eligibility for Premera Blue Cross Medicare Advantage Peak + Rx (HMO) requires you to live in that plan’s service area. The service area is listed below:

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Source:CMS. Data as of Oct 1, 2022.

Last updated on December 03, 2022

Notes: Data are subject to change as contracts are finalized. For 2023, enhanced alternative may offer extra cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part-D benefit. Includes 2023 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.