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Medicare BluePlus (PPO)
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MDC-Medicare BluePlus - Plan Features - Odd
- Dedicated Customer Care department
- No referrals required
- Worldwide urgent care and emergency coverage
- For a 90-day supply, you pay 2 times the copayment for a 30-day supply of your prescription
- Silver&Fit® Fitness Program
- $25 annual non-refundable fee to enroll in a participating fitness club or exercise center;
- $10 annual non-refundable fee to enroll in the home fitness program; or
- $150 annual allowance for out-of-network facilities.
MDC-Medicare BluePlus - Benefits - Odd
Medicare BluePlus (PPO) provides comprehensive coverage for the health care services you need, including:
- $5 copay per visit for an in-network primary care providers
- $50 copay per visit for in-network specialists
- $0 copay for many Medicare-covered preventive services, such as in-network physical exams, smoking cessation and some immunizations
- $5 copay for in-network chiropractic medical visits
- Inpatient Hospital Stay
- $360 copay per day for days 1-5 for each Medicare-covered stay at a network hospital
- Days 6+ covered in full
Prescription Drug Coverage2
Our prescription drug coverage features:
|Tier||30-Day Supply||90-Day Supply|
|Tier 1 Preferred Generic Drugs||$4||$8|
|Tier 2 Generic Drugs||$20||$40|
|Tier 3 Preferred Brand Drugs||$45||$90|
|Tier 4 Non-Preferred Drugs||$95||$190|
|Tier 5 Specialty Drugs||25%||25%|
- $410 annual deductible (this is the amount you must pay for prescriptions before we begin to pay)
- Additional savings when you take advantage of our mail order and select retail pharmacies that provide lower cost-sharing for a 90-day supply of your prescription drug(s)
- The 5-Tier basic, alternative comprehensive formulary includes Tier 1, 2, 3, 4 and 5 drugs. Follow this link to Search for a Medication and View Drug Tier and Copayment or Coinsurance Information
- Our nationwide network includes thousands of participating pharmacies. Additionally, Excellus BlueCross BlueShield has contracts with pharmacies that equal or exceed the CMS requirements for pharmacy access in your area
MDC-Medicare BluePlus - Learn More - Odd
Learn more with these resources:
- Summary of Benefits with Multi-Language FlyerOpen a PDF
- Evidence of CoverageOpen a PDF
- Annual Notice of ChangeOpen a PDF
- Plan Ratings
- Disenrollment Rights & Responsibilities
2 Eligible beneficiaries must use network pharmacies to access their prescription drug benefit, except under non-routine circumstances, and quantity limitations and restrictions may apply.
Network Coverage Information - With our Medicare Advantage Preferred Provider Organization (PPO) plans you have access to both In- and Out-of-Network providers and you may see any Medicare participating provider. However, your out-of-pocket costs may be higher when you use an Out-of-Network provider, except in limited cases such as emergencies and urgently needed care. For information on how to request reimbursement for Out-of-Network claims, and information on Out-of-Network Coverage or Coverage Determinations and Appeals call Customer Care at 1-877-883-9577, Monday - Friday, 8 a.m. to 8 p.m.; From October 1 through March 31, 8 a.m. to 8 p.m., 7 days a week (TTY/TDD 1-800-421-1220). Or, see the Evidence of Coverage using the link above. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.
Out-of-network/non-contracted providers are under no obligation to treat Excellus BlueCross BlueShield members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.
To the extent of any discrepancy between this web site and the Evidence of Coverage, the Evidence of Coverage terms take priority.
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Monday - Friday:
8 a.m. to 8 p.m.
From Oct. 1 - Mar. 31:
advisors are also available weekends 8 a.m. to 8 p.m.
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Excellus BlueCross BlueShield contracts with the Federal Government and is an HMO plan and PPO plan with a Medicare contract. Enrollment in Excellus BlueCross BlueShield depends on contract renewal. Submit a complaint about your Medicare plan at www.Medicare.gov or learn about filing a complaint by contacting the Medicare Ombudsman. Y0028_5966_M.
This page last updated 08-03-2019.