2018 Forever Blue 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 or hospital that accepts Medicare nationwide.

Not sure which plan is right for you?  Call us, visit a Medicare Center, chat online, or click the button below and we'll help you find the right plan.

*If you need a different format of this plan, please view our Multi-Language Interpreter Services

 

PLANS (The copays shown below are for in-network providers)

Forever Blue Focus (PPO)**

(Must reside in Erie or Niagara county to enroll)

Forever Blue Value (PPO) Forever Blue 751 (PPO)
2018 premium* $61 $136 $198
Out-of-pocket (OOP) maximum $6,700 in-network $10,000 in and out-of-network combined $6,700 in-network $10,000 in and out-of-network combined
$6,700 in-network $10,000 in and out-of-network

Medical

Deductible

None None None
Primary doctor/Specialist $20/$40 $15/$35
$5/$27
Inpatient hospital $270 per day
$1,890 OOP limit per year
$250 per day
$1,750 OOP limit per year
$205 per day
$1,435 OOP limit per year
Lab $5 $5 $5
X-rays/advanced radiology $50/$150 $50/$150 $40/$75
Urgent care 
(copay waived if admitted)
$65 $65 $65
Emergency room 
(copay waived if admitted)
$80 $80 $80
Outpatient/Ambulatory surgery $375/$300 $325/$250 $275/$200
Preventive services $0 $0 $0
Annual routine eye exam $40  $35 $27
Vision wear (frames/lenses/contact lens) $100 annual allowance $100 annual allowance $100 annual allowance
Hearing aid (coverage for specific models only; must use a TruHearing provider) $699 or $999/unit $699 or $999/unit $699 or $999/unit
Optional supplemental dental plan*** Add to plan for additional $17 per month for the Basic plan, or $35 a month for the Enhanced plan Add to plan for additional $17 per month for the Basic plan, or $35 a month for the Enhanced plan Add to plan for additional $17 per month for the Basic plan, or $35 a month for the Enhanced plan
Nationwide coverage Yes, for all services 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
Prescription Drug Deductible

$0 Tiers 1-2

$290 Tiers 3-5 

   
Tier 1 - Preferred generic $10 Preferred Pharmacy
$15 Standard Pharmacy
$4 Preferred Pharmacy
$9 Standard Pharmacy
$2 Preferred Pharmacy
$7 Standard Pharmacy
Tier 2 - Non-preferred generic $15 Preferred Pharmacy
$20 Standard Pharmacy
$10 Preferred Pharmacy
$15 Standard Pharmacy
$8 Preferred Pharmacy
$13 Standard Pharmacy
Tier 3 - Preferred brand $42 Preferred Pharmacy
$47 Standard Pharmacy
$42 Preferred Pharmacy
$47 Standard Pharmacy
$42 Preferred Pharmacy
$47 Standard Pharmacy
Tier 4 - Non-preferred brand $94 Preferred Pharmacy
$100 Standard Pharmacy
50% Preferred Pharmacy
50% Standard Pharmacy
$94 Preferred Pharmacy
$99 Standard Pharmacy
Tier 5 - Specialty 27% Preferred Pharmacy
27% Standard Pharmacy
33% Preferred Pharmacy
33% Standard Pharmacy
33% Preferred Pharmacy
33% Standard Pharmacy
Gap Coverage Discounts Discounts Discounts and Tier 1 generic drug coverage through the gap

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

**There is a select facility network with the Forever Blue Focus (PPO) plan. Call us for a full list of participating facilities.

Forever Blue Focus (PPO) covers emergency services at any hospital; however, routine or scheduled medical services at certain facilities, including Kaleida Health and ECMC, will be considered out of network when billed by those facilities and result in a higher cost share. You must reside in Erie or Niagara county to enroll in this plan. 

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

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



To be eligible for enrollment in all our other Medicare Advantage plans, you must live in one of the following Western New York counties (Must reside in Erie or Niagara County to enroll in Forever Blue Focus (PPO)):

  • Allegany
  • Genesee
  • Cattaraugus
  • Niagara
  • Chautauqua
  • Orleans
  • Erie
  • Wyoming

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 or Forever Blue Medicare PPO through the CMS Medicare Online Enrollment Center located at http://www.medicare.gov.

adobe reader icon Senior Blue and Forever Blue Medicare Paper Based Application

 

Need Assistance?

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1-800-248-9296  (TTY 711)

Oct. 1 - Feb. 14, 8 a.m. to 8 p.m., 7 days a week
Feb. 15 - Sept. 30, 8 a.m. - 8 p.m., Mon. - Fri.

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Our Star Rating:

PPO:

PPO: Star Icon

HMO:

PPO: Star Icon

 

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. You must continue to pay your Medicare Part B Premium.

Out-of-network/non-contracted providers are under no obligation to treat BlueCross BlueShield of Western 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.

BlueCross BlueShield of Western 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). BlueCross BlueShield of Western 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_MRK1961 Approved
Content Last Updated October 1, 2017