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Simply Blue (PPO)
A PPO plan that offers flexibility to access providers that are in-network and out-of-network as long as they accept Medicare, as well as Blue Benefit Bucks for use on health-related services all at a $0 monthly premium.
Plan Overview
Simply Blue (PPO) is our most flexible plan with a $0 monthly premium, $0 medical and prescription drug deductibles, and a low maximum out-of-pocket of $4,800 you get the coverage you need with confidence for your budget.
Blue KC makes it flexible for you to use your plan as you decide. The new Blue Benefit Bucks works like a debit card so it’s simple to use and you have the power to spend it based on your personal needs.
The Simply Blue plan Blue Benefit Bucks card comes loaded with $1,000 for use on health-related services for dental, eyewear, hearing, and transportation. You can visit any dentist you like without the worry of a network. This plan’s flexibility gives you the power to decide where and how you’d like to use it. This card also comes loaded with a generous OTC allowance of $500 per year and we’ll add your healthy activity rewards1 on the same card as you earn them.
Advantages Include
- $0 monthly premium
- $0 medical and prescription drug deductibles
- $0 Primary care physician copay
- $0 Tier 1 and Tier 2 Prescription Drugs, up to 100-day supply
- $500 over-the-counter items allowance, every year
- $1,000 Blue Benefit Bucks, flexible benefits for dental, hearing aids, eyewear and transportation combined
- 40 hours per year for Member and Caregiver support for help to appointments or around the house
- Low $4,800 annual out-of-pocket maximum in and out of network
- SilverSneakers® fitness membership at no additional cost
You won't need to choose a Primary Care Physician (PCP) or get a referral to see a specialist. You have the freedom to go out-of-network with the same cost share to either in or out-of-network partners. You have worldwide emergency and urgent care coverage plus access to national BCBS network of providers.
To join, you must be entitled to Medicare Part A, be enrolled in Medicare Part B, and live in our service area. The Blue KC service area includes these counties in Kansas: Johnson and Wyandotte. And these counties in Missouri: Andrew, Bates, Buchanan, Cass, Clay, Clinton, Jackson, Johnson, Lafayette, Platte and Ray.
1Rewards for healthy activities may not be used for any benefit cost sharing.
Plan Resources
- Evidence of Coverage
- Extra Help - Low Income Subsidy Information
- Summary of Benefits
- Comprehensive Prescription Drug Formulary Search – Blue Medicare Advantage
- Comprehensive Prescription Drug Formulary - Blue Medicare Advantage
- Drug Pricing Tool - Simply Blue
- Blue Medicare Advantage PPO Provider Search
- Other Plan Information
Plan Benefits
At-A-Glance
| Total Premium |
$0 |
|
|---|---|---|
| Blue National Network |
Covered |
|
| Plan Deductible |
$0 |
|
| Maximum Out of Pocket (MOOP) |
$4,800 |
|
Inpatient Services |
||
| Inpatient Hospital - Acute |
In-Network$300/day, Days 1-5 |
Out-of-Network$300/day, Days 1-5 |
| Skilled Nursing Facility |
In-Network$0, Days 1-20 |
Out-of-Network$0, Days 1-20 |
Emergency Care/Urgent Care |
||
| Emergency Care (Worldwide) |
In-Network$90 |
Out-of-Network$90 |
| Urgently Needed Care (Worldwide) |
In-Network$50 |
Out-of-Network$50 |
| Ambulance Services (Worldwide) |
In-Network$300 |
Out-of-Network$300 |
Professional Services |
||
| PCP Visit |
In-Network$0 |
Out-of-Network$0 |
| Specialist Visit |
In-Network$35 |
Out-of-Network$35 |
| Telehealth |
In-Network$0 |
Out-of-NetworkN/A |
Diagnostic Testing Services |
||
| Diagnostic Procedures/Tests |
In-Network$0 |
Out-of-Network$0 |
| Lab Services |
In-Network$0 |
Out-of-Network$0 |
| X-Ray Services |
In-Network$0 |
Out-of-Network$0 |
| MRI/CT at physicians office or free standing |
In-Network$100 |
Out-of-Network$100 |
| MRI/CT at other facility |
In-Network$250 |
Out-of-Network$250 |
Outpatient Services |
||
| Observation |
In-Network$300 |
Out-of-Network$300 |
| Outpatient Hospital & ASC (Minor surgical; other services) |
In-Network20% |
Out-of-Network20% |
| Surgery (Ambulatory Surgical Center) |
In-Network$250 |
Out-of-Network$250 |
| Surgery (Outpatient Hospital) |
In-Network$300 |
Out-of-Network$300 |
Supplemental Services |
||
| Dental, Eyewear and Transportation |
$1,000 Blue Benefit Bucks allowance for dental, hearing services, transportation and eyewear combined |
|
| Hearing and Hearing Aids |
$1,000 Blue Benefit Bucks allowance for dental, hearing services, transportation and eyewear combined |
|
| Over-the-counter allowance |
$500 per year |
|
*After 90 days, our plan covers an unlimited number of additional days for an inpatient hospital stay at $0 copay.
Prescription Drug Benefits
| Annual Deductible |
$0 |
|
|---|---|---|
| Preferred Generics (Tier 1) |
30-day Supply$0 copay |
100-day Supply$0 copay |
| Generics (Tier 2) |
30-day Supply$10 copay |
100-day Supply$0 copay |
| Preferred Brands (Tier 3) |
30-day Supply$47 copay |
90-day Supply$141 copay |
| Non-Preferred Drugs (Tier 4) |
30-day Supply$100 copay |
90-day Supply$300 copay |
| Specialty Drugs (Tier 5) |
30-day Supply33% |
90-day SupplyN/A |
| Gap Coverage |
Original Medicare Standard: 25% for all Tiers |
|
| $35 Insulin Program |
Yes |
|
We offer a 100-day mail order and retail drug benefit with a $0 copay for all Tier 1 and Tier 2 prescription drugs.
This information is not a complete description of benefits.
Sheri Blue KC Medicare Expert
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