2018 Medicare Advantage PPO Plans

 

Our Forever Blue Medicare PPO Plans offer you the same benefits of the Senior Blue HMO plans, but gives you even more flexibility with the extra benefit of out-of-network coverage. It is designed to give you the freedom to see any doctor who accepts Medicare.  

Not sure which plan is right for you? Call, chat online, or click the button below and we will help you find the right plan.

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*If you need to see this plan information in a different format, view our Multi-Language Interpreter Services

 

  FOREVER BLUE Value (PPO) FOREVER BLUE 770 (PPO)
2018 premium* $85 $184
Out-of-pocket (OOP) maximum $6,700 in-network
$10,000 in and out-of-network combined
$5,500 in-network
$8,500 in and out-of-network
Medical Deductible
None None
Primary doctor/ Specialist
$25/$36 $10/$22
Inpatient hospital
$240 per day
$1,680 OOP limit per year
$205 per day
$1,435 OOP limit per year
Lab $5 $5
X-rays/advanced radiology $50/$125 $40/$100
Urgent care (copay waived if admitted) $65 $60
Emergency room visit (copay waived if admitted) $80 $80
Outpatient/ambulatory surgery $275/$225 $225/$175
Preventive Services $0 $0
Annual routine eye exam $36 $22
Annual eye wear allowance N/A $100
Hearing aid (coverage for specific models only;
must use a Truhearing provider)
$699 or $999/unit $699 or $999/unit
Optional supplemental dental plan** Add to plan for additional $19 per month for the Basic plan, or $38 per month for the Enhanced plan Add to plan for additional $19 per month for the Basic plan, or $38 per month for the Enhanced plan
Nationwide coverage

Yes, for all services

Yes, for all services BlueCard travel included (pay in-network costs for covered services in participating areas)
PRESCRIPTION DRUGS (30-day supply at retail pharmacy)
Preferred pharmacies include Rite Aid and Walmart; see provider directory for a full list.
Tier 1 - Preferred generic $7 Preferred Pharmacy
$12 Standard Pharmacy
$2 Preferred Pharmacy
$7 Standard Pharmacy
Tier 2 - Generic $15 Preferred Pharmacy
$20 Standard Pharmacy
$12 Preferred Pharmacy
$17 Standard Pharmacy
Tier 3 - Preferred brand $42 Preferred Pharmacy
$47 Standard Pharmacy
$42 Preferred Pharmacy
$47 Standard Pharmacy
Tier 4 - Non-preferred brand $94 Preferred Pharmacy
$100 Standard Pharmacy
$94 Preferred Pharmacy
$100 Standard Pharmacy
Tier 5 - Specialty 33% Preferred Pharmacy
33% Standard Pharmacy
33% Preferred Pharmacy
33% Standard Pharmacy
Gap Coverage Discounts and tier 1 generic drug coverage through the coverage gap Discounts and tier 1 generic drug coverage through the coverage gap


*You must continue to pay your Medicare Part B premium.

**Dental premium is in addition to plan and Part B premium.

Our plans cover one routine hearing exam per year with a TruHearingTM provider. Please call TruHearing to verify your benefit and schedule a hearing exam. Coverage is for TruHearing Flyte models only. TruHearingTM is a registered trademark of TruHearing, Inc. TruHearing is an independent company that administers the hearing-aid benefit.

You must live in one of the following Northeastern New York counties to be eligible for enrollment in one of our Medicare Advantage plans:

  • Albany
  • Columbia
  • Fulton
  • Greene
  • Montgomery
  • Rensselaer
  • Saratoga
  • Schenectady
  • Warren
  • Washington

Enrolling is easy! You can use our online enrollment system or print off, complete and mail in the paper-based application. 

Medicare beneficiaries may also enroll in Senior Blue HMO, Forever Blue Medicare PPO or through the CMS Medicare Online Enrollment Center located at: http://www.medicare.gov.

adobe reader icon  2018 Medicare Advantage Application

 




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Feb. 15 - Sept. 30, 8 a.m. - 8 p.m., Mon. - Fri.

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This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or copayments/coinsurance may change January 1 of each year. 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 BlueShield of Northeastern New York members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. 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 evaluates plans based on a 5-star rating system. Star Ratings are calculated each year and may change from one year to the next.

BlueShield of Northeastern New York is a Medicare Advantage plan with a Medicare contract and enrollment depends on contract renewal.

A division of HealthNow New York Inc., and independent licensee of the BlueCross BlueShield Association. A salesperson will be present with information and applications. For accommodations of persons with special needs at sales meetings, please call 1-800-329-2792 (TTY 711). BlueShield of Northeastern New York complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-329-2792 (TTY: 711).

注意:如果您使用繁體中文,您可以免費獲得語言援助服務。請致電 1-800-329-2792 (TTY: 711).

Y0086_MRK1962 Approved
Content Last Updated October 1, 2017