Plan Overview

Simply Blue Advantage has a $0 monthly premium, $0 medical and prescription drug deductibles and a combined in-network and out-of-network maximum out-of-pocket limit of $7,250.

Simple Blue Advantage also offers a $75 per month Part B giveback meaning you receive up to $75 reduction of your monthly Part B premium. This premium reduction applies only to amounts you pay towards your Medicare Part B premium.

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Advantages Include

  • $0 monthly premium
  • $75 per month Part B giveback
  • $0 medical and prescription drug deductibles
  • $0 Primary care physician copay
  • $0 Tier 1 and Tier 2 Prescription Drugs, up to 100-day supply
  • Annual out-of-pocket maximum of $7,250 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.

Plan Benefits
At-A-Glance

Total Premium

$0

Blue National Network

Covered

Plan Deductible

$0

Maximum Out of Pocket (MOOP)

$7,250

Inpatient Services
Inpatient Hospital - Acute
In-Network

$500/day, Days 1-4
$0, Days 5-90*

Out-of-Network

$500/day, Days 1-4
$0, Days 5-90

Skilled Nursing Facility
In-Network

$0, Days 1-20
$188/day, Days 21-100

Out-of-Network

$0, Days 1-20
$188/day, Days 21-100

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

$30

Out-of-Network

$30

Telehealth
In-Network

$0

Out-of-Network

N/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

$150

Out-of-Network

$150

MRI/CT at other facility
In-Network

$300

Out-of-Network

$300

Outpatient Services
Observation
In-Network

$500

Out-of-Network

$500

Outpatient Hospital & ASC (Minor surgical; other services)
In-Network

20%

Out-of-Network

20%

Surgery (Ambulatory Surgical Center)
In-Network

$300

Out-of-Network

$300

Surgery (Outpatient Hospital)
In-Network

$500

Out-of-Network

$500

Supplemental Services
Dental

Not covered

Eyewear

Not covered

Transportation

Not covered

Hearing and Hearing Aids

Not covered

Over-the-counter allowance

Not covered

*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 Supply

33%

90-day Supply

N/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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