Blue Cross Medicare Advantage Dental Premier (PPO)
Medicare Plan Details (2023 Plan)
Monthly Premium
by Blue Cross and Blue Shield of Montana
Additional Coverage
Overall Government Star Rating
4.0Ready to Enroll Online?
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
$6,900 In-network
$11,300 Out-of-network
Medical Benefits
Doctor Services
Out-of-network: $30 copay per visit
Out-of-network: $75 copay per visit
Tests, labs, & imaging
Out-of-network: $200 copay
Out-of-network: $200 copay
Out-of-network: $400 copay
Out-of-network: $200 copay
Hospital Services
$0 per day for days 7 through 90
Out-of-network: $500 per day for days 1 and beyond
Out-of-network: $400 copay per visit
Skilled nursing facility
$196 per day for days 21 through 59
$0 per day for days 60 through 100
Out-of-network: $250 per day for days 1 and beyond
Preventive services
Out-of-network: $0 copay
Ambulance
Out-of-network: $350 copay
Therapy services
Out-of-network: $75 copay
Out-of-network: $75 copay
Mental health services
Out-of-network: $50 copay
Out-of-network: $50 copay
Out-of-network: $50 copay
Out-of-network: $50 copay
Opioid treatment services
Other services
Out-of-network: 20% coinsurance per item
Out-of-network: 20% coinsurance per item
Out-of-network: 20% coinsurance per item
Prescription Drug Benefits
Tier drug costs for: Standard retail pharmacy drug cost for 1-month
| Tiers | Initial coverage phase | Gap coverage phase | Catastrophic coverage phase |
|---|---|---|---|
| Preferred Generic | $15.00 copay |
Brand-name drugs :
|
Brand-name drugs :
|
| Generic | $20.00 copay | ||
| Preferred Brand | $47.00 copay | ||
| Non-Preferred Drug | $100.00 copay | ||
| Specialty Tier | 25% |
Part B Drugs
Out-of-network: 50% coinsurance
Out-of-network: 50% coinsurance
Extra Benefits
Hearing
Out-of-network: $75 copay
Out-of-network: 50% coinsurance
Out-of-network: $0 copay
Preventive Dental
Out-of-network: $0 copay
Out-of-network: $0 copay
Out-of-network: $0 copay
Comprehensive dental
Out-of-network: 0-20% coinsurance
Out-of-network: 0-20% coinsurance
Out-of-network: 0-20% coinsurance
Out-of-network: 0-20% coinsurance
Out-of-network: 0-20% coinsurance
Out-of-network: 0-20% coinsurance
Vision
Out-of-network: $0 copay
Out-of-network: $0 copay
Out-of-network: $0 copay
Out-of-network: $0 copay
Other benefits
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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