2021 Plan Highlights Medical, prescriptions and more in one easy-to-use plan - with in/out-of-network flexibility - Medicare
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2021 Plan Highlights
Medical, prescriptions and more
in one easy-to-use plan — with
in/out-of-network flexibility.
H0104_BRO21_M
NEW FOR 2021!
Comprehensive dental coverage with increased annual allowance
Lower doctor copays — now just $5 on Complete plan
Lower copays for Physical, Occupational and Speech Therapy
Glucometers and test strips for $0 copay at retail pharmacies or through
mail-order service††
14 home-delivered meals with $0 copay***
Expanded Preferred Pharmacy Network now including Costco, Kroger, Publix,
Walgreens, Walmart, Winn-Dixie and hundreds of new local, independent
neighborhood pharmacies
$0 copay on hundreds of Tier-6 Select Care drugs
Blue Advantage® (PPO) AT-A-GLANCE
Blue Advantage is an all-in-one Medicare Advantage plan that combines hospital, doctor,
prescription drug coverage and more — including dental, vision, hearing and fitness.
• Choice of plans including a $0 monthly plan premium option.
• Large provider network — with more than 90% of all doctors and 100% of Alabama
hospitals.
• Freedom to use providers outside the network.
• NO REFERRALS required to see specialists.
SUMMARY OF WHAT YOU WILL PAY IN 2021
Blue Advantage Blue Advantage
2021 MONTHLY COMPLETE PREMIER
PLAN PREMIUM $
0 $
170
Primary Care Doctor
NEW 5 5
$ $
(copay per visit)
Specialist (copay per visit) $
40 NEW $25
Lab Services $
0 $
0
X-rays $
15 $
5
Diagnostic Radiology
(MRI, CT scans)
$
75 25
$
Outpatient Hospital $
250 $
150
Physical, Occupational, and
NEW 30 NEW 20
$ $
Speech Therapy Sessions
Ambulance Services $
275 $
150
Inpatient Hospital
$
225 per day for days 1 – 7; 175 per day for days 1 – 5;
$
$
0 for days 8 – 365 $
0 for days 6 – 365
Post-Discharge Meals
(for members with two of the following NEW $0 NEW $0
chronic conditions: COPD, diabetes, CHF, 14 meals delivered for FREE 14 meals delivered for FREE
vascular disease, rheumatoid arthritis)
$
0 per day for days 1 – 20; 0 per day for days 1 – 20;
$
Skilled Nursing Facility
(prior hospital stay not required)
$
160 per day for days 21 – 80 $
100 per day for days 21 – 55;
$
0 per day for days 81 – 100 $
0 per day for days 56 – 100
Medicare Part B Drugs
(injectable and infused drugs like 20% 20%
chemo, etc.)
Emergency Room Visit
$
90 $
120
(waived if admitted within 24 hours) (waived if admitted within 24 hours)
Diabetes Supplies
(Glucometer, test strips*)
$
0 $
0
Comprehensive Dental Allowance NEW $500 per calendar year NEW $750 per calendar year
Annual Routine Vision and
Hearing Exam
$
0 $
0
Eyewear Allowance 100 per calendar year
$
100 per calendar year
$
$
699/$999 $
699/$999
Hearing Aids
(One per Ear, per Year)
(two high-tech TruHearing™-branded (two high-tech TruHearing™-branded
hearing aids) hearing aids)
MOOP: (Maximum 5,100 in-network;
$
3,400 in-network;
$
Out-Of-Pocket) Amount $
7,500 combined in/out-of-network $
5,100 combined in/out-of-network
You must continue to pay your Medicare Part B premium. The benefits/costs shown above represent in-network services unless otherwise
stated. Please refer to the Blue Advantage (PPO) Evidence of Coverage for a full list of benefits.
*Glucometer and test strip brands include Ascensia (CONTOUR™ NEXT & PLUS) and LifeScan (OneTouch®).WHAT YOU WILL PAY FOR PRESCRIPTION DRUGS IN 2021
2021 Prescription
Blue Advantage Complete Blue Advantage Premier
Drug Benefits:
Tiers 1, 2 & 6: You pay $0 deductible
Part D Deductible Tiers 3, 4 & 5: You pay $150 annual All Tiers: You pay $0 deductible
deductible
After deductible, you pay… You pay…
At PREFERRED Cost-Sharing Pharmacies At PREFERRED Cost-Sharing Pharmacies
Tier 1_Preferred Generic...........$4 Tier 1_Preferred Generic...........$3
Tier 2_Generic......................... $13 Tier 2_Generic......................... $8
Tier 3_Preferred Brand............. $40 Tier 3_Preferred Brand............. $40
Tier 4_Non-Preferred Brand......45% Tier 4_Non-Preferred Brand......45%
Tier 5_Specialty Tier................. 25% Tier 5_Specialty Tier................. 33%
Part D Drug Copays/ Tier 6_Select Care Drugs.......... $0 Tier 6_Select Care Drugs.......... $0
Coinsurance
At STANDARD Cost-Sharing Pharmacies At STANDARD Cost-Sharing Pharmacies
Tier 1_Standard Generic........... $11 Tier 1_Standard Generic........... $10
Tier 2_Generic......................... $20 Tier 2_Generic......................... $15
Tier 3_Standard Brand............. $47 Tier 3_Standard Brand............. $47
Tier 4_Non-Preferred Brand......50% Tier 4_Non-Preferred Brand......50%
Tier 5_Specialty Tier................. 25% Tier 5_Specialty Tier................. 33%
Tier 6_Select Care Drugs.......... $0 Tier 6_Select Care Drugs.......... $0
You pay $0 for Tier 6 Select Care drugs. You pay 25% of generic drug costs
Part D Coverage Gap
(Tiers 1 & 2) and 25% of brand-name drug costs (Tiers 3, 4, 5). Starts when total drug cost
(also known as the “donut hole”)
(what you and the plan spend) reaches $4,130 in 2021.
You pay the greater of $3.70 for generic drugs (Tiers 1, 2, 6) and $9.20 for brand-name
Part D Catastrophic drugs (Tiers 3, 4, 5) OR 5% coinsurance per prescription for the rest of the year.
Coverage Blue Advantage pays the rest. Starts when your annual out-of-pocket cost reaches
$
6,550 in 2021.
3 great reasons to use a Preferred Retail Pharmacy:
1.) Your copays are lowest at Preferred pharmacies.
2.) There are now over 800 Preferred pharmacies throughout Alabama including Costco, Kroger, Publix,
Walgreens, Walmart, Winn-Dixie and HUNDREDS of local independent neighborhood pharmacies!
3.) You can get a 90-day supply of routine medication but pay only the copay for a 60-day supply.
Visit BCBSALMedicare.com/PreferredPharmacies to find Preferred pharmacies near you.
Home Delivery Pharmacy Service is also available.
Get your routine medication without leaving home! When you use our mail-order Home Delivery Pharmacy Service
you can get a 90-day supply but pay only the copay for a 60-day supply. That’s one month at no cost to you…
along with free standard shipping!
*NOTE: The network pharmacies listed may change at any time. Blue Advantage members will receive notice when necessary.Blue Advantage plans also include these valuable
health and wellness features:
FREE SilverSneakers® fitness membership‡
Get fit, have fun and make friends! Work out when, where and how
you want with SilverSneakers, the nation’s leading exercise program
for active older adults.
Preventive Services and Screenings
Many health screenings, immunizations and other Medicare-
recommended preventive services are covered at no cost to you.
TruHearing® Services*
Enjoy a $0 copay for an annual routine hearing exam through
TruHearing. You can also get state-of-the-art technology on hearing
aids at a substantial discount (one per ear, per year). Pay just $699
or $999, depending on the model you choose.
24-Hour Nurse Hotline
Specially trained nurses are “on call” to answer your questions
24 hours a day, 365 days a year.
FREE Mobile Apps for Your Smartphone or Tablet
Enjoy 24-hour online access to your account plus other medical
and wellness care online tools.
Disease Management Program
Our nurses are available to help you manage a variety of chronic
conditions — through early intervention, appropriate treatments
and lifestyle changes — at no cost to you.
AirMed International**
If you’re hospitalized more than 150 miles from your home, AirMed
International will provide an air ambulance to bring you to your local
hospital. There is no cost to you for this service.You can enroll in Blue Advantage® (PPO) if you are both:
• An Alabama resident; and
• Enrolled in Medicare Part A and Part B
Question about Blue Advantage or need help enrolling?
Call toll free 1-888-873-4707 (TTY 711)
8 a.m. to 8 p.m., 7 days a week.†
Or visit us online anytime at:
BCBSALMedicare.com
Blue Cross also offers traditional, supplemental coverage through
our C PlusSM Medicare Select plans. If you are interested in
C Plus, let us know when you call.
This information is not a complete description of benefits. This is a summary of drug and health services covered by Blue Advantage (PPO). It
doesn’t list every service that we cover or list every limitation or exclusion. If you would like a detailed Evidence of Coverage, you may call us at
1-888-873-4707 (TTY 711) or visit BCBSALMedicare.com.
†From April 1 to September 30, on weekends and holidays, you may be required to leave a message. Calls will be returned the next business day
.
‡
SilverSneakers and the SilverSneakers shoe logotype are registered trademarks of Tivity Health, Inc. © 2020 Tivity Health, Inc. All rights reserved. The
SilverSneakers fitness program is provided by Tivity Health, Inc., an independent company.
*©2020 TruHearing, Inc. All Rights Reserved. TruHearing® is a registered trademark of TruHearing, Inc. All appointments must be performed by a TruHearing
network provider. TruHearing is an independent company offering exclusive hearing aid savings for Blue Cross and Blue Shield of Alabama members.
**Air medical transport services are provided through a contract with AirMed International, LLC. AirMed International, LLC is an independent company that does
not provide Blue Cross and Blue Shield of Alabama products. Blue Cross is not responsible for any mistakes, errors or omissions that AirMed, its employees or staff
members make. Air medical services terminate if coverage by your plan ends.
††
Glucometer and test strip brands include Ascensia ( CONTOUR™ NEXT & PLUS) and LifeScan (OneTouch®).
***You may qualify for a maximum of 14 home-delivered meals from an approved vendor upon each hospital discharge when diagnosed with a minimum of two of
the following chronic conditions: COPD, Congestive Heart failure, Diabetes, Rheumatoid Arthritis or Vascular disease.
BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of
independent Blue Cross and Blue Shield Plans that includes Blue Cross and Blue Shield of Alabama.
Blue Advantage® (PPO) is a Medicare-approved PPO plan. Enrollment in Blue Advantage (PPO) depends on CMS contract renewal. You must continue to pay your
Medicare Part B premium. Out-of-network/non-contracted providers are under no obligation to treat Blue Cross and Blue Shield of Alabama 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. Medicare beneficiaries may also enroll in Blue Advantage (PPO) through the CMS Medicare Online Enrollment Center located at
www.medicare.gov. This is a solicitation of insurance. Contact may be made by an issuer or insurance producer. C PlusSM is a Medicare Select Plan and is a private
insurance plan regulated by the Alabama Department of Insurance. It is not connected with or endorsed by the U.S. government or the federal Medicare program.
Blue Cross and Blue Shield of Alabama is an independent licensee of the Blue Cross and Blue Shield Association. 9655(10/20)BRO-BAYou can also read
