Blue Cross Medicare Advantage Dental Premier (PPO)

Medicare Plan Details (2023 Plan)


Monthly Premium

 

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

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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

 

$0
$0
$0
$0
$11,300 In and Out-of-network
$6,900 In-network
$11,300 Out-of-network
No
Yes
Yes
Yes

Doctor Services

In-network: $0 copay
Out-of-network: $30 copay per visit
In-network: $45 copay per visit
Out-of-network: $75 copay per visit

Tests, labs, & imaging

In-network: $0-100 copay
Out-of-network: $200 copay
In-network: $5 copay
Out-of-network: $200 copay
In-network: $0-300 copay
Out-of-network: $400 copay
In-network: 20% coinsurance
Out-of-network: $200 copay
$90 copay per visit (always covered)
$40 copay per visit (always covered)

Hospital Services

In-network: $370 per day for days 1 through 6
$0 per day for days 7 through 90
Out-of-network: $500 per day for days 1 and beyond
In-network: $375 copay per visit
Out-of-network: $400 copay per visit

Skilled nursing facility

In-network: $0 per day for days 1 through 20
$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

In-network: $0 copay
Out-of-network: $0 copay

Ambulance

In-network: $350 copay
Out-of-network: $350 copay

Therapy services

In-network: $40 copay
Out-of-network: $75 copay
In-network: $40 copay
Out-of-network: $75 copay

Mental health services

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

Opioid treatment services

Covered

Other services

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

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

TiersInitial coverage phaseGap coverage phaseCatastrophic coverage phase
Preferred Generic$15.00 copay


Generic drugs :
25%

Brand-name drugs :
25%


Generic drugs :
$4.15 copay or 5% (whichever costs more)

Brand-name drugs :
$10.35 copay or 5% (whichever costs more)

Generic$20.00 copay
Preferred Brand$47.00 copay
Non-Preferred Drug$100.00 copay
Specialty Tier25%

Part B Drugs

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

Hearing

In-network: $40 copay
Out-of-network: $75 copay
In-network: $0 copay
Out-of-network: 50% coinsurance
In-network: $0 copay
Out-of-network: $0 copay

Preventive Dental

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

Comprehensive dental

In-network: 0% coinsurance
Out-of-network: 0-20% coinsurance
Not covered
In-network: 0% coinsurance
Out-of-network: 0-20% coinsurance
In-network: 20% coinsurance
Out-of-network: 0-20% coinsurance
In-network: 20% coinsurance
Out-of-network: 0-20% coinsurance
In-network: 20% coinsurance
Out-of-network: 0-20% coinsurance
In-network: 20% coinsurance
Out-of-network: 0-20% coinsurance

Vision

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

Other benefits

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

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