BlueMedicare Regional PPO Sarasota County, FL Medicare Advantage Plan

BlueMedicare Regional PPO by Blue Cross and Blue Shield of Florida, Inc., a 2016 Medicare Advantage plan available in Sarasota County, FL BlueMedicare Regional PPO is a Medicare Advantage plan from Blue Cross and Blue Shield of Florida, Inc. that's available in Sarasota County, Florida. It is a Preferred Provider Organization (PPO) option, with prescription drug coverage, for people with Medicare Part A and Part B benefits.

You can reach Blue Cross and Blue Shield of Florida, Inc. directly at (855)601-9465 or (800)955-8770 for TTY users.

About PPO Plans with Part D

PPO health insurance allows you to choose your own primary care doctor, specialists and other healthcare providers. If you're on a budget you can lower your out-of-pocket costs by using the plan's provider network.

IMPORTANT: Unlike Original Medicare, your out-of-pocket expenses are capped with this plan. As a result, you won't be vulnerable to excessive medical bills due to an accident or a critical illness.

CRITICAL: The prescription drug coverage included with BlueMedicare Regional PPO has its own deductible and co-pays. If you have prescriptions, make sure your drugs are covered at a favorable price before you join this plan.

Monthly Premium and Deductibles

The premium on this plan is $39.90 per month. That includes your prescription drugs, as well. Plus, you must continue to pay your monthly Medicare Part B premium. Co-payments and/or co-insurances also apply with most healthcare services, except preventive care mandated by CMS (see R3332-001 Summary of Benefits below).

Although the health plan itself does not have a deductible, the prescription drug plan does. It's $260.00 per year. That means you pay 100% of your prescription costs until you've spent $260.00, then the plan will begin paying it's share.

IMPORTANT: When evaluating this plan, look past the monthly premium. Identify the costs of the healthcare services you use most. Only then will you uncover the plan's value for your personal situation.

Maximum Out-of-Pocket (MOOP) Limit for Parts A & B

Unlike Original Medicare, Medicare Advantage plans must set an annual Maximum Out-of-Pocket limit on inpatient and outpatient healthcare services. The BlueMedicare Regional PPO plan MOOP is $6,700 . Once you reach this amount of spending on your co-payments, all of your Medicare Part A and Part B services will be covered at no additional charge.

Plans can set their MOOP at a voluntary level of $0 to $3,400 (for in-network services) or a mandatory $3,401 to $6,700 (in-network). Combined totals for in-network and out-of-network are generally higher.

NOTE: MOOP does not include what you spend on monthly premiums. It also does not apply to your prescription drugs or Part D deductible.

CRITICAL: It is important to evaluate the combined annual MA/MAPD premiums and MOOP versus what you might expect to pay for a Medigap plan in Sarasota County. Some Medicare Supplements offer less overall financial risk than Medicare Advantage.

Plan Ratings

In this section we show you the quality rating for this plan. Each year the Centers for Medicare and Medicaid Services (CMS) rates health plans (Part C) in five broad categories and drug plans (Part D) in four broad categories. We do not recommend joining a plan with an overall rating less than 3.0. The following marks will give you an idea of the level of care you will receive if you join this Blue Cross and Blue Shield of Florida, Inc. plan.

2016 Overall RatingBlueMedicare Regional PPO Overall Rating
Part C Summary RatingBlueMedicare Regional PPO Medicare Part C Rating
Part D Summary RatingBlueMedicare Regional PPO Medicare Part D Rating
Staying Healthy: Screenings, Tests, VaccinesBlueMedicare Regional PPO Staying Healthy Rating
Managing Chronic (Long Term) ConditionsBlueMedicare Regional PPO Managing Chronic Conditions Rating
Member Experience with Health PlanBlueMedicare Regional PPO Member Experience with Health Plan Rating
Complaints and Changes in Plans PerformanceBlueMedicare Regional PPO Complaints Rating
Health Plan Customer ServiceBlueMedicare Regional PPO Health Plan Customer Service Rating
Drug Plan Customer ServiceBlueMedicare Regional PPO Drug Plan Customer Service Rating
Complaints and Changes in the Drug PlanBlueMedicare Regional PPO Drug Plan Member Complaints Rating
Member Experience with the Drug PlanBlueMedicare Regional PPO Drug Plan Member Experience Rating
Drug Safety and Accuracy of Drug PricingBlueMedicare Regional PPO Drug Safety and Accuracy of Drug Pricing Rating

Part D Prescription Drug Benefits

This plan includes Medicare Part D prescription drug benefits. If you have regular prescriptions, it's critical that you evaluate your costs using the plan's formulary.

Annual Rx Deductible:260.00
Initial Coverage Limit (ICL):$3,310
Gap Coverage:No
Plan's Pharmacy Page:http://www.myprime.com
Plan's Formulary Page:http://MyPrime.com
Plan Offers an Online Pharmacy:No

Here's what you'll pay at the pharmacy if you join this plan:

TierDrug ClassCopay
1Preferred Generic$15
2Generic$20
3Preferred Brand$47
4Non-Preferred Brand$100
5Specialty Tier27%

IMPORTANT: Once you and your plan provider have spent $3,310 on covered drugs (combined amount plus your deductible), you will be in the donut hole coverage gap. In this phase, unless the plan offers additional coverage, you will pay 45% for brand-name drugs and 58% on generic drugs. This Blue Cross and Blue Shield of Florida, Inc. plan does not provide additional coverage through the gap.

NOTE: Medicare Advantage plans that include prescription drug coverage (MAPDs) are treated like Medicare Part D plans. Members at higher income levels are subject to the Income Related Monthly Adjustment Amount (IRMAA). In some situations, IRMAA can be appealed. You will need to show SSA evidence of a qualifying event and provide proof of your lower income.

Summary of Benefits (R3332-001)

In this section we outline high-level information about the plan's co-payment and co-insurance costs for inpatient, outpatient, preventive care, transportation and other healthcare services. For complete details, download the BlueMedicare Regional PPO Summary of Benefits.

Outpatient Care and Services

All outpatient health care services (Medicare Part B benefits) have their own co-payment or co-insurance costs. Here's how this plan charges for the basics.

Primary Care Doctor:20% co-insurance
Physician Specialist:$50 co-payment
Chiropractor:$20 co-payment
Occupational Therapist:$30 to $40 co-payment
Physical Therapist:$30 to $40 co-payment
Speech Terapist:$30 to $40 co-payment
Psychotherapist:$40 co-payment
Psychiatrist:$40 co-payment
Podiatrist:$40 co-payment

Lab and Diagnostic Services

Lab and diagnostic services have co-payment or co-insurance costs. Some plans offer these services at no cost, but most do not.

Medicare-covered Diagnostic Procedures/Tests:$0 to $50 co-payment
Medicare-covered Lab Services:$0 to $40 co-payment
Medicare-covered Diagnostic Radiological Services:30% co-insurance
Medicare-covered Therapeutic Radiological Services20% co-insurance
Medicare-covered X-Ray Services30% co-insurance

Urgent Care and Emergency Services

Urgent care and emergency room services (Medicare Part B benefits) have co-payment or co-insurance costs. Some plans waive these costs if you are admitted as an inpatient within a specified amount of time. Also, plans are not required to offer emergency care worldwide.

Urgent Care:$10 to $50 co-payment
Emergency Care:$75 co-payment
Co-insurance waived if admitted within 0 Hours
Worldwide Coverage:Yes
Ambulance:$225 co-payment

Medicare Preventive Care

BlueMedicare Regional PPO covers preventive services, as required by law under Medicare Part B, including:

  • Abdominal aortic aneurysm screening
  • Alcohol misuse counseling
  • Bone mass measurement
  • Breast cancer screening (mammogram)
  • Cardiovascular disease (behavioral therapy)
  • Cardiovascular screenings
  • Cervical and vaginal cancer screening
  • Colorectal cancer screenings
  • Depression screening
  • Diabetes screenings
  • HIV screening
  • Medical nutrition therapy services
  • Obesity screening and counseling
  • Prostate cancer screenings (PSA)
  • Sexually transmitted infections screening and counseling
  • Tobacco use cessation counseling
  • Vaccines including Flu shots Hepatitis B shots Pneumococcal shots
  • "Welcome to Medicare" preventive visit
  • Yearly "Wellness" visit

All preventive healthcare services are provided at no cost to the beneficiary. Any additional preventative services approved by Medicare during the contract year will be covered.

Inpatient Care and Services

When you are admitted into a hospital or skilled nursing facility you will make copayments based on benefit periods. A benefit period begins when you are admitted and ends after not receiving inpatient care for 60 days in a row. If you are admitted again after a benefit period has ended a new benefit period begins.

You are required to pay an inpatient deductible for each benefit period. There are no limits on the the number of benefit periods. Here's how this plan charges:

  • Day 1 to 5 you pay $295 per day
  • See the Summary of Benefits for additional copayment periods.
The hospital benefit period is Per Medicare-covered Stay.

Hospice

You pay nothing for hospice care from a Medicare-approved (certified) hospice facility. You may have to pay some of the cost for drugs and respite care.

Plan Availability

BlueMedicare Regional PPO is available to beneficiaries living in Englewood, Osprey, Sarasota, Laurel, Nokomis, Venice, North Port, and all other areas of Sarasota County, Florida.

For assistance 24 hours a day, call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048 or visit www.medicare.gov

Tips and Disclaimers

The Medicare Advantage plan data on MedicareWire.com comes directly from Medicare.gov and CMS.gov and is subject to change. The Centers for Medicare and Medicaid Services has neither reviewed nor endorsed the information on this site.

The benefit information provided on this page is a brief summary only, not a complete description. Limitations, co-payments, and restrictions may apply. For more information contact the plan directly at (855)601-9465 or (800)955-8770 for TTY users.

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