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Want help? Call 855-339-5205 (TTY/TDD: 711)

Medicare Advantage

Premera Blue Cross Medicare Advantage (HMO) 2021

$0.00
per month

Coverage Summary

Are your Providers In-Network?

Benefit You Pay:
PCP Office Visits

$15 Copayment

Specialist Office Visits

$45 Copayment

Inpatient Hospital Facility Services

$450 per day for days 1-4
$0 per day for days 5+

Emergency Services (In and out-of-network)

$75 Copayment;
ER copayment waived if admitted

ER Facility Services

$75 Copayment

Urgent Care Facility

$50 Copayment

Dental Coverage

Rider available at $26 Premeium per month

Vision Coverage

Not Covered

Prescription Drug Coverage

Benefit You Pay:
Deductible

$340

Tier 1 - Preferred Generics

Preferred: $5 Copayment
Non-Preferred: $15 Copayment

Tier 2 - Generics

Preferred: $15 Copayment
Non-Preferred: $20 Copayment

Tier 3 - Preferred Brands

Preferred: $42 Copayment
Non-Preferred: $47 Copayment

Tier 4 - Non Preferred Drugs

35% Coinsurance

Tier 5 - Specialty Drugs

26% Coinsurance

Coverage in the Coverage Gap

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.

Extra Coverage

Benefit
Extra Benefits

24/7 Nurseline access
Annual Physical Exam

Out of Network Coverage

Benefit
Medical Services/Supplies

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.

Prescription Drugs

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 Documents

 Summary of Benefits (PDF)
 Evidence of Coverage (PDF)
 Plan Rating (PDF)
 Drug Transition Policy (PDF)
 Low Income Subsidy Premium Summary Table for Those Receiving Extra Help (PDF)
 Annual Notice of Change
 Find a Doctor

Value Added benefits

24 hour Nurseline

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.

© 2020 Premera Blue Cross is an Independent Licensee of the Blue Cross Blue Shield Association serving businesses and residents of Alaska and Washington state, excluding Clark County. Premera Blue Cross is an HMO plan with a Medicare contract. Enrollment in Premera Blue Cross depends on contract renewal. ATTENTION: If you speak Spanish, language assistance services, free of charge, are available to you. Call 888-850-8526 (TTY: 711), April 1 - September 30, Monday - Friday, 8 a.m. - 8 p.m.; October 1 - March 31, 7 days a week, 8 a.m. to 8 p.m.To join a Premera Blue Cross Medicare Advantage Plan, you must have Medicare Part A and Part B and live in the Premera Blue Cross Medicare Advantage service area (Cowlitz, Island, King, Kitsap, Pierce, Lewis, San Juan, Skagit, Snohomish, Spokane, Stevens, Thurston, Walla Walla, and Whatcom counties in Washington). Members must select a Primary Care Provider (PCP) from the Premera Blue Cross Medicare Advantage Plans provider network. For accommodation of persons with special needs at sales meetings, call 888-868-7767 (TTY/TDD: 711), April 1 - September 30, Monday - Friday, 8 a.m. - 8 p.m.; October 1 - March 31, 7 days a week, 8 a.m. to 8 p.m.