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.
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 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 Advantage
- 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) |
$7,250 |
|
Inpatient Services |
||
Inpatient Hospital - Acute |
In-Network$500/day, Days 1-4 |
Out-of-Network$500/day, Days 1-4 |
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$30 |
Out-of-Network$30 |
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$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-Network20% |
Out-of-Network20% |
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 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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