Premera Blue Cross Medicare Advantage (HMO) | Medicare Shopping
Premera Blue Cross Medicare Advantage (HMO) 2021
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A primary care provider (PCP) is the doctor you see first for most health issues. He or she makes sure you get the care you need to keep you healthy. With many Medicare Advantage Plans, you must see your primary care doctor before you see any other health care provider.
A doctor who only practices one branch of medicine. Your family physician may refer you to this type of doctor or speak with them about your care.
Care provided in a hospital when you have been admitted to the facility. An overnight stay does not automatically mean the patient is considered as inpatient.
$0 per day for days 5+
Emergency Services (In and out-of-network)
Care that you get outside of your Medicare health plan's service area for a sudden illness or injury that needs medical care right away, but isn't life-threatening. If it's not safe to wait until you get home to get care from a plan doctor, the health plan must pay for the care.
$75 Copayment;
ER copayment waived if admitted
ER Facility Services
Care provided when you believe your health is in serious jeopardy and immediate attention is required. Emergency rooms treat more serious issues than urgent care facilities.
A non-life-threatening injury or illness that requires immediate attention. For instance, if you cut your finger and need stitches, that's considered urgent care.
Rider available at $26 Premeium per month
The amount you must pay before our plan begins to pay its share of your covered drugs. Example, if a drug plan has a $350 deductible, you must pay the first $350 of covered drug expenses before the plan begins to pay its portion of your cost.
Preferred: $5 Copayment
Non-Preferred: $15 Copayment
Preferred: $15 Copayment
Tier 4 - Non Preferred Drugs
Coverage in the Coverage Gap
Also known as the “donut hole” or coverage gap, this is a Medicare Part D Prescription Drug plan benefit level that's reached when total costs for covered drugs reach a specified amount in any given calendar year. Total costs include those paid by the member and the insurance carrier. The coverage gap ends when catastrophic coverage is reached or the calendar year ends, whichever is first.
You pay only 35% of the costs of brand name drugs and 44% of the costs of generic drugs. You stay in this stage until your out-of-pocket costs reach $5,000.
Free benefits included in this plan
If you receive care from an out-of-network provider, your out-of-pocket costs will usually be higher than if you use a network provider. There are 3 exceptions: emergency care, urgently needed care, and dialysis services you receive while temporarily outside the plan service area. For details about the plan’s coverage of out-of-network care, please refer to the summary of benefits or the evidence of coverage. (View plan documents.)
If you receive care from an out-of-network provider without prior authorization from our plan, the care will not be covered except for emergency care, urgently needed care and dialysis services you receive while temporarily outside the plan service area.
We generally cover drugs filled at an out-of-network pharmacy only if you aren't able to use an in-network pharmacies. (For example, because you are traveling, need emergency or urgent care, or need a drug that it not available at an nearby in-network pharmacy.) Chapter 5 of the Evidence of Coverage provides a full list of situations in which we may cover drugs from an out-of-network pharmacy.
We generally cover drugs filled at an out-of-network pharmacy only if you are not able to use one of our network pharmacies (for example, because you are traveling, need emergency or urgent care, or need a drug that it not available at an accessible network pharmacy). Chapter 5 of the Evidence of Coverage provides a full list of situations in which we may cover drugs from an out-of-network pharmacy.
Plan Rating (PDF)
Drug Transition Policy (PDF)
Low Income Subsidy Premium Summary Table for Those Receiving Extra Help (PDF)
Call our FREE and CONFIDENTIAL 24-Hour NurseLine to speak to a registered nurse who will ask the right questions, listen to your concerns, and help you determine where and when to seek treatment. The 24-Hour NurseLine number is listed on the back of your ID card.