Blue Cross Medicare Advantage Classic (PPO)


Medicare Plan Details

2021 Plan
Monthly Premium
(select county for price)

 

by Blue Cross and Blue Shield of Montana
Additional Coverage
Hearing Vision
Overall Government Star Rating
 4.0
out of 5 stars

State: Montana

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

 

$40
$11
$30
$0
$10,000 In and Out-of-network
$6,700 In-network
$10,000 Out-of-network
No
Yes
Yes
No

Medical Benefits

Doctor Services

In-network: $10 copay per visit
Out-of-network: 50% coinsurance per visit
In-network: $45 copay per visit
Out-of-network: 50% coinsurance per visit

Tests, labs, & imaging

In-network: $0-50 copay
Out-of-network: 50% coinsurance
In-network: $5 copay
Out-of-network: 50% coinsurance
In-network: $180-250 copay
Out-of-network: 50% coinsurance
In-network: 20% coinsurance
Out-of-network: 50% coinsurance
$90 copay per visit (always covered)
$25 copay per visit (always covered)

Hospital Services

In-network: $360 per day for days 1 through 5
$0 per day for days 6 through 90
Out-of-network: 50% per stay
In-network: $275 copay per visit
Out-of-network: 50% coinsurance per visit

Skilled nursing facility

In-network: $0 per day for days 1 through 20
$184 per day for days 21 through 100
Out-of-network: 50% per stay

Preventive services

In-network: $0 copay
Out-of-network: 50% coinsurance

Ambulance

In-network: $275 copay
Out-of-network: $275 copay

Therapy services

In-network: $40 copay
Out-of-network: 50% coinsurance
In-network: $40 copay
Out-of-network: 50% coinsurance

Mental health services

In-network: $30 copay
Out-of-network: 50% coinsurance
In-network: $30 copay
Out-of-network: 50% coinsurance
In-network: $30 copay
Out-of-network: 50% coinsurance
In-network: $30 copay
Out-of-network: 50% coinsurance

Opioid treatment services

Covered

Other services

In-network: 20% coinsurance per item
Out-of-network: 30% coinsurance per item
In-network: 20% coinsurance per item
Out-of-network: 50% coinsurance per item
In-network: 0-20% coinsurance per item
Out-of-network: 50% coinsurance per item

Prescription Drug Benefits

Tier drug costs for: Standard retail pharmacy drug cost for 1-month

TiersInitial coverage phaseGap coverage phase1Catastrophic coverage phase
Preferred Generic$7.00 copay$7.00 copay


Generic drugs :
$3.70 copay or 5% (whichever costs more)

Brand-name drugs :
$9.20 copay or 5% (whichever costs more)

Generic$20.00 copay
Preferred Brand$47.00 copay
Non-Preferred Drug$100.00 copay
Specialty Tier25%
1 For all other drugs, you pay 25% for generic drugs and 25% for brand-name drugs.

Part B Drugs

In-network: 20% coinsurance
Out-of-network: 50% coinsurance
In-network: 20% coinsurance
Out-of-network: 50% coinsurance

Extra Benefits

Hearing

In-network: $45 copay
Out-of-network: 50% coinsurance
Not covered
Not covered
Not covered
Not covered

Preventive Dental

Not covered
Not covered
Not covered
Not covered

Comprehensive dental

Not covered
Not covered
Not covered
Not covered
Not covered
Not covered
Not covered

Vision

In-network: $0 copay
Out-of-network: $0 copay
Not covered
Not covered
Not covered
Not covered
Not covered

Other benefits

Limited coverage
Limited coverage
Not covered
Not covered
Limited coverage
Limited coverage
Limited coverage
 4
 4
 3
 4
 5
 4
 4
 4
 5
 3
 4

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