Blue Advantage Complete (PPO)

BlueCross BlueShield of Alabama
Blue Advantage Complete (PPO) H0104-012 Plan Details
4 out of 5 stars

Blue Advantage Complete (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by BlueCross BlueShield of Alabama.
Plan ID: H0104-012.

$0.00
Monthly Premium

Blue Advantage Complete (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by BlueCross BlueShield of Alabama.
Plan ID: H0104-012.

BlueCross BlueShield of Alabama
Blue Advantage Complete (PPO) H0104-012 Plan Details
4 out of 5 stars

Blue Advantage Complete (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by BlueCross BlueShield of Alabama.
Plan ID: H0104-012.

$0.00
Monthly Premium

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $150
Out of Pocket Max In-Network: $5100
Out-of-Network: 7500
Initial Coverage Limit $4430
Catastrophic Coverage Limit $7,050
Primary Care Doctor Visit
In-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $5.00
Out-of-Network:

Doctor Office Visit:
Coinsurance for Medicare Covered Primary Care Office Visit 50%
Specialty Doctor Visit
In-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $40.00
Out-of-Network:

Doctor Specialty Visit:
Coinsurance for Medicare Covered Physician Specialist Office Visit 50%
Inpatient Hospital Care
In-Network:

Acute Hospital Services:
$290.00 per day for days 1 to 7
$0.00 per day for days 8 to 90
Maximum out of Pocket $2030.00 (Please see Evidence of Coverage fo
Out-of-Network:
Coinsurance for Acute Hospital Services per Stay 50%
Urgent Care
Copayment for Urgent Care $5.00 to $40.00

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $5.00 to $40.00
Maximum Plan Benefit of $50,000
Emergency Room Visit
Copayment for Emergency Care $90.00
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $90.00
Copayment for Worldwide Emergency Transportation $275.00
Maximum Plan Benefit of $50,000
Ambulance Transportation
In-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $275.00

Air Ambulance:
Copayment for Air Ambulance Services $275.00
Out-of-Network:

Ambulance Services:
Copayment for Medicare Covered Ambulance Services - Ground $275.00
Copayment for Medicare Covered Ambulance Services - Air $275.00

Health Care Services and Medical Supplies

Blue Advantage Complete (PPO) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).

Coverage Cost
Chiropractic Services
In-Network:
Copayment for Medicare-covered Chiropractic Services $15.00
Out-of-Network:
Coinsurance for Medicare Covered Chiropractic Services 50%
Diabetes Supplies, Training, Nutrition Therapy and Monitoring
In-Network:
Copayment for Medicare-covered Diabetic Supplies $0.00
Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0.00
Out-of-Network:
Coinsurance for Medicare Covered Diabetic Supplies and Services 50%
Durable Medical Eqipment (DME)
In-Network:
Coinsurance for Medicare-covered Durable Medical Equipment 20%
Out-of-Network:
Coinsurance for Medicare Covered Durable Medical Equipment 50%
Diagnostic Tests, Lab and Radiology Services, and X-Rays
In-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $0.00
Copayment for Medicare-covered Lab Services $0.00

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $75.00
Copayment for Medicare-covered Therapeutic Radiological Services $50.00
Copayment for Medicare-covered X-Ray Services $15.00
Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services
Prior authorization required
Out-of-Network:

Outpatient Diag Procs/Tests/Lab Services:
Coinsurance for Medicare Covered Diagnostic Procedures/Tests 50%
Coinsurance for Medicare Covered Lab Services 50%
Coinsurance for Medicare Covered Diagnostic Radiological Services 50%
Coinsurance for Medicare Covered Therapeutic Radiological Services 50%
Coinsurance for Medicare Covered Outpatient X-Ray Services 50%
Home Health Care
In-Network:
Copayment for Medicare-covered Home Health Services $0.00
Out-of-Network:
Coinsurance for Medicare Covered Home Health 50%
Mental Health Inpatient Care
In-Network:

Psychiatric Hospital Services:
$265.00 per day for days 1 to 7
$0.00 per day for days 8 to 90
Maximum out of Pocket $1855.00 (Please see Evidence of Coverage fo
Out-of-Network:
Coinsurance for Psychiatric Hospital Services per Stay 50%
Mental Health Outpatient Care
In-Network:
Copayment for Medicare-covered Individual Sessions $40.00
Copayment for Medicare-covered Group Sessions $40.00
Out-of-Network:
Coinsurance for Medicare Covered Individual Sessions 50%
Coinsurance for Medicare Covered Group Sessions 50%
Outpatient Services / Surgery
In-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $250.00

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $250.00

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $250.00
Out-of-Network:

Outpatient Hospital and ASC Services:
Coinsurance for Medicare Covered Outpatient Hospital Services 50%
Coinsurance for Medicare Covered Ambulatory Surgical Center Services 50%
Outpatient Substance Abuse Care
In-Network:
Copayment for Medicare-covered Individual Sessions $40.00
Copayment for Medicare-covered Group Sessions $40.00
Out-of-Network:
Coinsurance for Medicare Covered Individual or Group Sessions 50%
Podiatry Services
In-Network:
Copayment for Medicare-Covered Podiatry Services $20.00
Out-of-Network:
Coinsurance for Medicare Covered Podiatry Services 50%
Skilled Nursing Facility Care
In-Network:

Skilled Nursing Facility Services:
$0.00 per day for days 1 to 20
$188.00 per day for days 21 to 100
Prior Authorization Required for Skilled Nursing Facility Services
Prior authorization required
Out-of-Network:
Coinsurance for Skilled Nursing Facility Services per Stay 50%

Dental Benefits

The following dental services are covered from in-network providers.

Coverage Cost
Dental Care
In-Network:

Preventive Dental:
Maximum Plan Allowance of $1000.00 every year for in and out of network services combined for Preventive and Non-Medicare Covered Comprehensive combined

Comprehensive Dental:
Copayment for Medicare-covered Benefits $40.00
Maximum Plan Allowance of $1000.00 every year for in and out of network services combined for Preventive and Non-Medicare Covered Comprehensive combined
Out-of-Network:

Medicare Covered Dental Services:
Coinsurance for Medicare Covered Comprehensive Dental 50%
Non-Medicare Covered Dental Services:
Copayment for Non-Medicare Covered Preventive Dental $0.00
Copayment for Non-Medicare Covered Comprehensive Dental $0.00

Vision Benefits

The following vision services are covered from in-network providers.

Coverage Cost
Vision Benefits
In-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $30.00
Copayment for Routine Eye Exams $0.00
  • Maximum 1 Routine Eye Exam every year

Eyewear:
Copayment for Medicare-Covered Benefits $0.00
Copayment for Contact Lenses $0.00
Copayment for Eyeglasses (lenses and frames) $0.00
Maximum Plan Benefit of $100.00 every year for all Non-Medicare covered eyewear for in and out of network services combined
Out-of-Network:

Medicare Covered Vision Services:
Coinsurance for Medicare Covered Eye Exams 50%
Coinsurance for Medicare Covered Eyewear 50%
Non-Medicare Covered Vision Services:
Coinsurance for Non-Medicare Covered Eye Exams 50%
Coinsurance for Non-Medicare Covered Eyewear 50%

Hearing Benefits

The following hearing services are covered from in-network providers.

Coverage Cost
Hearing Benefits
In-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $10.00
Copayment for Routine Hearing Exams $0.00
  • Maximum 1 visit every year
Copayment for Fitting/Evaluation for Hearing Aid $0.00

Hearing Aids:
Copayment for Hearing Aids $699.00 to $999.00
  • Maximum 2 Hearing Aids every year
TruHearing Advanced ($699) and Premium ($999). There is a $50 additional cost per aid for optional hearing aid rechargeability.
Out-of-Network:

Medicare Covered Hearing Services:
Coinsurance for Medicare Covered Hearing Exams 50%
Non-Medicare Covered Hearing Services:
Copayment for Non-Medicare Covered Hearing Exams $0.00
Copayment for Non-Medicare Covered Hearing Aids $699.00 to $999.00

Preventive Services and Health/Wellness Education Programs

The following services are covered from in-network providers.

Coverage Cost
Preventive Services and Health/Wellness Education Programs
In-Network:
$0.00 copay for Medicare Covered Preventive Services:

Abdominal aortic aneurysm screening
Alcohol misuse screenings & counseling
Bone mass measurements (bone density)
Cardiovascular disease screenings
Cardiovascular disease (behavioral therapy)
Cervical & vaginal cancer screening
Colorectal cancer screenings
Depression screenings
Diabetes screenings
Diabetes self-management training
Glaucoma tests
Hepatitis B (HBV) infection screening
Hepatitis C screening test
HIV screening
Lung cancer screening
Mammograms (screening)
Nutrition therapy services
Obesity screenings & counseling
One-time Welcome to Medicare preventive visit
Prostate cancer screenings(PSA)
Sexually transmitted infections screening & counseling
Shots:
  • COVID-19 shots
  • Flu shots
  • Hepatitis B shots
  • Pneumococcal shots
  • Tobacco use cessation
    Yearly "Wellness" visit
    Out-of-Network:

    Medicare-covered Zero Dollar Preventive Services:
    Coinsurance for Medicare Covered Medicare-covered Preventive Services 50%

    Prescription Drug Costs and Coverage

    The Blue Advantage Complete (PPO) plan offers the following prescription drug coverage, with an annual drug deductible of $150 (excludes Tiers 1, 2 and 6) per year.

    Coverage
    Cost
    Coverage & Cost
    Annual Drug Deductible $150 (excludes Tiers 1, 2 and 6)
    Preferred Generic
    • Preferred retail $4.00
    • Standard retail $11.00
    • Standard mail order $4.00
    Generic
    • Preferred retail $13.00
    • Standard retail $20.00
    • Standard mail order $13.00
    Select Care Drugs
    • Preferred retail $0.00
    • Standard retail $0.00
    • Standard mail order $0.00
    Annual Drug Deductible $150 (excludes Tiers 1, 2 and 6)
    Preferred Generic
    • Preferred retail N/A
    • Standard retail N/A
    • Standard mail order N/A
    Generic
    • Preferred retail N/A
    • Standard retail N/A
    • Standard mail order N/A
    Select Care Drugs
    • Preferred retail N/A
    • Standard retail N/A
    • Standard mail order N/A
    Annual Drug Deductible $150 (excludes Tiers 1, 2 and 6)
    Preferred Generic
    • Preferred retail $8.00
    • Standard retail $33.00
    • Standard mail order $8.00
    Generic
    • Preferred retail $26.00
    • Standard retail $60.00
    • Standard mail order $26.00
    Select Care Drugs
    • Preferred retail $0.00
    • Standard retail $0.00
    • Standard mail order $0.00