Blue Advantage (PPO)
H1248 - 005 - 0
(3.5 / 5)
Blue Advantage (PPO) is a Medicare Advantage (Part C) Plan by Blue Cross and Blue Shield of Louisiana.
This page features plan details for 2022 Blue Advantage (PPO) H1248 – 005 – 0 available in Northwest Parishes.
IMPORTANT: This page features the 2022 version of this plan. See the 2024 version using the link below:
No 2024 version found. You can use the location links below to find 2024 plans in your area.
Locations
Blue Advantage (PPO) is offered in the following locations.
Plan Overview
Blue Advantage (PPO) offers the following coverage and cost-sharing.
| Insurer: | Blue Cross and Blue Shield of Louisiana |
| Health Plan Deductible: | $1,000 |
| MOOP: | $4,200.00 |
| Drugs Covered: | Yes |
Please Note:
- This plan's deductible only applies to out-of-network services.
Ready to sign up for Blue Advantage (PPO) ?
Premium Breakdown
Blue Advantage (PPO) has a monthly premium of $37.3. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.| Part B | Part C | Part D | Part B Give Back | Total |
|---|---|---|---|---|
| $170.10 | $62.70 | $37.30 | $0.00 | $270.10 |
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
- You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.
Drug Info
Blue Advantage (PPO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
| Drug Deductible: | $0.00 |
| Initial Coverage Limit: | $4,430.00 |
| Catastrophic Coverage Limit: | $7,050.00 |
| Drug Benefit Type: | Enhanced |
| Gap Coverage: | Yes |
| Formulary Link: | Formulary Link |
Part D Premium Reduction
The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs. The table below shows how the LIS impacts the Part D premium of this plan.| Part D | LIS 25% | LIS 50% | LIS 75% | LIS Full |
|---|---|---|---|---|
| $37.30 | $28.20 | $19.10 | $10.00 | $0.90 |
Initial Coverage Phase
After you pay your $0.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $4,430.00. Once you reach that amount, you will enter the next coverage phase.
30 Day
60 Day
90 Day
30 Day
60 Day
90 Day
Gap Coverage Phase
After your total drug costs (including what this plan has paid and what you have paid) reach $4,430.00, you will pay no more than the amounts below for any drug tier until you reach $7,050.00.
30 Day
90 Day
30 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $3.00 copay | $10.00 copay | $3.00 copay | $10.00 copay |
| 2 (Generic) | $12.00 copay | $18.00 copay | $12.00 copay | $18.00 copay |
90 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $0.00 copay | $30.00 copay | $0.00 copay | $30.00 copay |
| 2 (Generic) | $36.00 copay | $54.00 copay | $36.00 copay | $54.00 copay |
| Tier | Cost |
|---|---|
| All other tiers (Generic) | 25% |
| All other tiers (Brand-name) | 25% |
Catastrophic Coverage Phase
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $7,050.00, you will pay no more than the greater of the two amounts listed below for generic and brand-name drugs.
| Tier | Cost |
|---|---|
| Generic | $4.15 copay or 5% (whichever costs more) |
| Brand-name | $10.35 copay or 5% (whichever costs more) |
Additional Benefits
Blue Advantage (PPO) also provides the following benefits.
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?
| In-Network: Yes, contact plan for further details |
Dental (comprehensive)
| Diagnostic services: | In-Network: 50% coinsurance (limits may apply) |
| Diagnostic services: | Out-of-Network: 50% coinsurance (limits may apply) |
| Endodontics: | In-Network: 50% coinsurance (limits may apply) |
| Endodontics: | Out-of-Network: 50% coinsurance (limits may apply) |
| Extractions: | In-Network: 50% coinsurance (limits may apply) |
| Extractions: | Out-of-Network: 50% coinsurance (limits may apply) |
| Non-routine services: | In-Network: 50% coinsurance (limits may apply) |
| Non-routine services: | Out-of-Network: 50% coinsurance (limits may apply) |
| Periodontics: | Not covered |
| Prosthodontics, other oral/maxillofacial surgery, other services: | Not covered |
| Restorative services: | In-Network: 50% coinsurance (limits may apply) |
| Restorative services: | Out-of-Network: 50% coinsurance (limits may apply) |
Dental (preventive)
| Cleaning: | In-Network: $0 copay (limits may apply) |
| Cleaning: | Out-of-Network: 50% coinsurance (limits may apply) |
| Dental x-ray(s): | In-Network: $0 copay (limits may apply) |
| Dental x-ray(s): | Out-of-Network: 50% coinsurance (limits may apply) |
| Fluoride treatment: | Not covered |
| Oral exam: | In-Network: $0 copay (limits may apply) |
| Oral exam: | Out-of-Network: 50% coinsurance (limits may apply) |
Diagnostic procedures/lab services/imaging
| Diagnostic radiology services (e.g., MRI): | In-Network: $0-135 copay (authorization required) |
| Diagnostic radiology services (e.g., MRI): | Out-of-Network: 50% coinsurance (authorization required) |
| Diagnostic tests and procedures: | In-Network: $0-30 copay (authorization required) |
| Diagnostic tests and procedures: | Out-of-Network: 50% coinsurance (authorization required) |
| Lab services: | In-Network: $0 copay (authorization required) |
| Lab services: | Out-of-Network: 50% coinsurance (authorization required) |
| Outpatient x-rays: | In-Network: $75 copay (authorization required) |
| Outpatient x-rays: | Out-of-Network: 50% coinsurance (authorization required) |
Doctor visits
| Primary: | In-Network: $0 copay |
| Primary: | Out-of-Network: 50% coinsurance per visit |
| Specialist: | In-Network: $40 copay per visit |
| Specialist: | Out-of-Network: 50% coinsurance per visit |
Emergency care/Urgent care
| Emergency: | $90 copay per visit (always covered) |
| Urgent care: | $35 copay per visit (always covered) |
Foot care (podiatry services)
| Foot exams and treatment: | In-Network: $40 copay |
| Foot exams and treatment: | Out-of-Network: 50% coinsurance |
| Routine foot care: | Not covered |
Ground ambulance
| In-Network: $260 copay | |
| Out-of-Network: $260 copay |
Health plan deductible
| $1,000 annual deductible |
Health plan deductibles (other)
| In-Network: No |
Hearing
| Fitting/evaluation: | In-Network: $0 copay (limits may apply) |
| Fitting/evaluation: | Out-of-Network: 50% coinsurance (limits may apply) |
| Hearing aids: | In-Network: $0 copay (limits may apply) |
| Hearing aids: | Out-of-Network: $0 copay (limits may apply) |
| Hearing exam: | In-Network: $10 copay |
| Hearing exam: | Out-of-Network: 50% coinsurance |
Hospital coverage (inpatient)
| In-Network: $135 per day for days 1 through 10 $0 per day for days 11 through 90 (authorization required) | |
| Out-of-Network: 50% per stay (authorization required) |
Hospital coverage (outpatient)
| In-Network: $75-200 copay per visit (authorization required) | |
| Out-of-Network: 50% coinsurance per visit (authorization required) |
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
| $8,400 In and Out-of-network $4,200 In-network |
Medical equipment/supplies
| Diabetes supplies: | In-Network: $0 copay (authorization required) |
| Diabetes supplies: | Out-of-Network: 50% coinsurance per item (authorization required) |
| Durable medical equipment (e.g., wheelchairs, oxygen): | In-Network: 20% coinsurance per item (authorization required) |
| Durable medical equipment (e.g., wheelchairs, oxygen): | Out-of-Network: 50% coinsurance per item (authorization required) |
| Prosthetics (e.g., braces, artificial limbs): | In-Network: 20% coinsurance per item (authorization required) |
| Prosthetics (e.g., braces, artificial limbs): | Out-of-Network: 50% coinsurance per item (authorization required) |
Medicare Part B drugs
| Chemotherapy: | In-Network: 20% coinsurance (authorization required) |
| Chemotherapy: | Out-of-Network: 50% coinsurance (authorization required) |
| Other Part B drugs: | In-Network: 20% coinsurance (authorization required) |
| Other Part B drugs: | Out-of-Network: 50% coinsurance (authorization required) |
Mental health services
| Inpatient hospital – psychiatric: | In-Network: $175 per day for days 1 through 7 $0 per day for days 8 through 90 (authorization required) |
| Inpatient hospital – psychiatric: | Out-of-Network: 50% per stay (authorization required) |
| Outpatient group therapy visit with a psychiatrist: | In-Network: $40 copay (authorization required) |
| Outpatient group therapy visit with a psychiatrist: | Out-of-Network: 50% coinsurance (authorization required) |
| Outpatient group therapy visit: | In-Network: $40 copay (authorization required) |
| Outpatient group therapy visit: | Out-of-Network: 50% coinsurance (authorization required) |
| Outpatient individual therapy visit with a psychiatrist: | In-Network: $40 copay (authorization required) |
| Outpatient individual therapy visit with a psychiatrist: | Out-of-Network: 50% coinsurance (authorization required) |
| Outpatient individual therapy visit: | In-Network: $40 copay (authorization required) |
| Outpatient individual therapy visit: | Out-of-Network: 50% coinsurance (authorization required) |
Optional supplemental benefits
| No |
Preventive care
| In-Network: $0 copay | |
| Out-of-Network: 50% coinsurance |
Rehabilitation services
| Occupational therapy visit: | In-Network: $20 copay (authorization required) |
| Occupational therapy visit: | Out-of-Network: 50% coinsurance (authorization required) |
| Physical therapy and speech and language therapy visit: | In-Network: $20 copay (authorization required) |
| Physical therapy and speech and language therapy visit: | Out-of-Network: 50% coinsurance (authorization required) |
Skilled Nursing Facility
| In-Network: $0 per day for days 1 through 20 $165 per day for days 21 through 100 (authorization required) | |
| Out-of-Network: 50% per stay (authorization required) |
Transportation
| Not covered |
Vision
| Contact lenses: | In-Network: $0 copay (limits may apply) |
| Contact lenses: | Out-of-Network: $40-225 copay (limits may apply) |
| Eyeglass frames: | In-Network: $0 copay (limits may apply) |
| Eyeglass frames: | Out-of-Network: $40-225 copay (limits may apply) |
| Eyeglass lenses: | In-Network: $0 copay (limits may apply) |
| Eyeglass lenses: | Out-of-Network: $40-225 copay (limits may apply) |
| Eyeglasses (frames and lenses): | Not covered |
| Other: | Not covered |
| Routine eye exam: | In-Network: $0 copay (limits may apply) |
| Routine eye exam: | Out-of-Network: $40 copay (limits may apply) |
| Upgrades: | Not covered |
Wellness programs (e.g., fitness, nursing hotline)
| Covered |
Ready to sign up for Blue Advantage (PPO) ?