Blue Advantage (HMO)
Medicare Plan Details
2021 Plan
Monthly Premium
| (select county for price) |
by Blue Cross and Blue Shield of Louisiana HMO
Additional Coverage
Hearing
Vision
Dental
Overall Government Star Rating
3.5out of 5 stars
State: Louisiana
Select your county to view the price for this plan
Plan Type
Medicare Advantage (Part C) with Prescription Drug (Part D)
Medicare Advantage combines Part A and Part B. This plan = Part A + Part B + Part D
Plan Details
$0
$0
$0
$0
$6,700 In-network
No
Yes
Yes
Yes
Medical Benefits
Doctor Services
$0 copay
$45 copay per visit
Tests, labs, & imaging
$11 copay
$0 copay
$0-200 copay
$35 copay
$90 copay per visit (always covered)
$40 copay per visit (always covered)
Hospital Services
$100 per day for days 1 through 10
$0 per day for days 11 through 90
$0 per day for days 11 through 90
$200 copay or 20% coinsurance per visit
Skilled nursing facility
$0 per day for days 1 through 20
$165 per day for days 21 through 100
$165 per day for days 21 through 100
Preventive services
$0 copay
Ambulance
$260 copay
Therapy services
$20 copay
$20 copay
Mental health services
$40 copay
$40 copay
$40 copay
$40 copay
Opioid treatment services
Covered
Other services
20% coinsurance per item
20% coinsurance per item
$0 copay
Prescription Drug Benefits
Tier drug costs for: Standard retail pharmacy drug cost for 1-month
| Tiers | Initial coverage phase | Gap coverage phase1 | Catastrophic coverage phase |
|---|---|---|---|
| Preferred Generic | $10.00 copay | $10.00 copay |
Brand-name drugs :
|
| Generic | $18.00 copay | $18.00 copay | |
| Preferred Brand | $47.00 copay | ||
| Non-Preferred Drug | $100.00 copay | ||
| Specialty Tier | 33% | ||
| 1 For all other drugs, you pay 25% for generic drugs and 25% for brand-name drugs. | |||
Part B Drugs
20% coinsurance
20% coinsurance
Extra Benefits
Hearing
$10 copay
$0 copay
$0 copay
Preventive Dental
$0 copay
$0 copay
$0 copay
$0 copay
Comprehensive dental
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Not covered
Vision
$0 copay
$0 copay
Not covered
$0 copay
$0 copay
Not covered
Other benefits
Limited coverage
Limited coverage
Not covered
Not covered
Limited coverage
Not covered
Limited coverage
Health Plan Star Ratings
(government star ratings are out of 5 stars)
Prescription Drug Plan Star Ratings
(government star ratings are out of 5 stars)
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